De-projection of the nasal tip

De-projection of the Nasal Tip

D.J. Menger

International Course in Modern Rhinoplasty Techniques
The Netherlands

www.rhinoplastycourse.nl

Dear colleague,

This presentation illustrates the difference between nasal tip projection and tip rotation, it shows the
mechanisms that provide stability to the nasal tip and what happens if these support mechanisms fail.
Anatomical features that cause over-projection of the tip are discussed in addition to how de-projection
of the tip can be achieved; which surgical techniques are available, how and when should you use them
in order to reach the desired esthetical outcome.

CAUTION: This lecture contains pictures taken during surgery, which might be shocking. The lecture is
intended for colleagues and is part of the "International Course in Modern Rhinoplasty Techniques".

Dirk Jan Menger, MD
Course Director

The Netherlands


In the assessment of the nasal tip there are two important factors to keep in mind:
1. The distance between the alar groove and the tip defining point, known as nasal tip projection. This
length should be in harmony with the length of the nose. On average the length of the nose should be 1,8
times longer than this nasal tip projection.
2. Nasal tip rotation or the nasolabial angle. In woman his angle should be between 90 and 120 degrees in
man 90 to 105 degrees.
Both rotation and projection should be in harmony with the rest of the face and with the height of the
nasal dorsum in particular.


There are a couple of mechanisms that keep the nasal tip in place and provide stability and support. These
mechanisms can be divided into major and minor tip support mechanisms. The major support mechanisms
include the size, shape and resilience of the lower cartilages (LL) , they play an important role.

• Size, shape, and resilience of the lower lateral
cartilages

• Fibrous attachment of:
– the medial crura to the nasal septum
– the lateral crura to the upper laterals


The fibrous attachments between the medial crura (MC) and the nasal septum and the attachments between
the lateral crura (LC) and the upper laterals (UL) are also part of the major support mechanisms.

• Size, shape, and resilience of the lower lateral
cartilages

• Fibrous attachment of:
– the medial crura to the nasal septum
– the lateral crura to the upper laterals


Minor Tip Support Mechanisms: these include:
the septal dorsum, the interdomal ligament, the membranous septum, the nasal spine, the minor alar cartilages
and the attachments of the lower laterals (LL) to the soft tissue envelope.

• septal dorsum
• interdomal ligament
• membranous septum
• nasal spine
• minor alar cartilages of the LL
• attachments of the LL to the soft tissue envelope


Loss of tip support mechanisms:
When one or more of the major or minor support mechanisms are disturbed due to rhinoplasty, trauma or
other causes: than the tip can drop downward causing de-projection and downward rotation.


Some patients are born with insufficient nasal tip projection, like in this patient. There was under-projection of
the tip, a fleshy bulbous columella and a relative high nasal dorsum.


Such a deformity of the nasal tip can easily be resorted and brought into better proportions with the use of
structural grafts to lengthen the tip, increasing its projection using a columellar strut graft, a shield-and tip onlay
grafts.

In this case also a bony- and cartilaginous hump reduction was performed in combination with spreader grafts and
micro-osteotomies


pre- and post operative lateral view


Iatrogenic de-projection/amputation:
Sometimes surgery itself causes de-projection or amputation of the nasal tip. This case illustrates a patient who
was referred due to multiple rhinoplasties in the past.


In this case I had to remove all the scar tissue and remnants of grafts that were brought into the nose
in previous surgeries elsewhere, only the soft tissue envelope could be preserved. The entire
cartilaginous skeleton was rebuild using rib grafts and auricular composite grafts.


This is an exceptional case, it shows that one should be careful when disrupting or manipulating major and minor
tip support mechanisms. During the surgical procedure they should always be restored in order to avoid
problems as outlined in this case.

pre- and postoperative frontal view.


pre- and postoperative lateral view.


Back to the over-projected nasal tip:
Over-projection of the nasal tip is often caused by a combination of three features:
1. a strong nasal spine
2. long medial- and lateral crura
3. a high nasal septum
In general: in most patients with over projection of the nasal tip the cause is multi factorial and
therefore the surgical techniques to lower the tip too are multistep procedures. In the next up coming
slides surgical techniques to de-project the nasal tip will be discussed.

2 3
1

Surgical Solutions:
complete transfixion
One of the easiest procedures is the complete transfixion incision. Due to this incision the attachment between
the medial crura and the septum is disturbed which causes de-projection of the tip.


Surgical Solutions:
reduction of the anterior nasal spine
Another solution might be the reduction of the anterior nasal spine. Especially in patients with a strong spine in
combination with a short upper lip, this can give just enough de-projection to bring the tip in better harmony
with the rest of the nose and face.


Surgical Solutions:
lowering the nasal septum
Some patients with too much tip projection have a very high nasal septum. By lowering the cartilaginous part of
the septum, the tip will de-projection as a result.


Surgical Solutions:
Tripod Theory
The LL can be altered too, this is the basis for the tripod concept. The middle leg of the tripod is the MC,
the LC are the other two legs. One can imagine what happens if one or more legs are shortened:
shortening the middle leg will cause de-projection and downward rotation of the tip.
When only the lateral legs are shortened: the tip will de-project and rotate upwards.

H. Tschopp


Surgical Solutions:
lateral crural overlay
Shortening of the lateral crura can be achieved using an interrupted strip, or a lateral crural overlay technique in
which the lateral crus is cut and sutured side to side.


Surgical Solutions:
lateral- and medial crural overlay
The medial crura, they too can be shortened and placed side-to-side, medial crural overlay, or the so-called
“Lipsett maneuver”. The effect is twofold; downward rotation and de-projection of the nasal tip. When both LC -
and MC-overlay is performed, the rotation of the tip will not change, only de-projection will be achieved.


Surgical Solutions
dome amputation with onlay tip graft
A more aggressive method to de-project the tip is to amputate the domes, suture them together and
camouflage the area with a small onlay graft.


De-projection of the nasal tip, a multistep procedure:
As mentioned before, in many patients a multi-step procedure is necessary to achieve the desired post-operative
result.
For example this male patient with breathing problems. In this case a complete transfixion incision was
made, the nasal spine was reduced and the lateral- and medial crura were shortened using the crural overlay
technique as described earlier.


The deviated and over-projected nose:
This patient had an over-projected tip and a strong deviation of the bony and cartilaginous dorsum to the right
due to nasal trauma.
External approach rhinoplasty: osteotomies, including intermediate on the left, septal
correction, spreader/splint on the left side, lateral- and medial crural overlay, reduction of the anterior nasal
spine.


pre- and postoperative frontal view.


The deviated tension nose
This patient had breathing problems on the right side due to collapse of the mid-nasal third, hence the concave
area just cephalic of the LC. The dorsum was deviated to the left side, bifidity of the domes, over-projection of
the bony- and cartilaginous dorsum and nasal tip.


The reason for this over-projection was threefold and caused by the combination of:
a strong nasal spine, relative long medial crura and

2
1


a high nasal dorsum.
In the assessment of the surgical steps to be taken in order to reduce the over-projection in this case, again
multiple surgical procedures will be necessary:

• hump reduction / reduction of cartilaginous
septum
• osteotomies
– lateral / oblique

3 •
•
•
spreader graft right side
reduction anterior nasal spine
medial crural overlay
• tip refinement
– cephalic resection
– sutures trans- and interdomal


1. Lowering the nasal dorsum (hump reduction) and the nasal septum.

septum
• osteotomies
• spreader graft right side
• reduction anterior nasal spine
• medial crural overlay
• tip refinement


2. Oblique- and lateral osteotomies, for realignment and infraction of the nasal bones.

septum
• osteotomies
• tip refinement


3. A spreader graft only on the right side to camouflage the concavity in the mid nasal third.

septum
• osteotomies
• tip refinement


4. Reduction of the anterior nasal spine to reduce the "short and crowded upper-lip".

septum
• osteotomies
• tip refinement


5. De-projection of the nasal tip was performed using medial crural overlay, the medial crura are sutured side to
side. Between the MC's a columellar strut is placed to stabilize the columellar complex.

septum
• osteotomies
• tip refinement


6. Minimal cephalic resection of the LC followed by trans- and interdomal sutures to to camouflage the bifidity
of the nasal tip and to refine the tip defining region.

septum
• osteotomies
• tip refinement


7. Finally a small radix graft (diced cartilage) is placed in the fronto-nasal angle, augmentation of this area gives
the illusion that the nasal bridge is less prominent.

septum
• osteotomies
• tip refinement
• small radix graft


pre- and postoperative views.
A less crowded upper-lip, de-projection and “softening” of the nasal tip, a slightly lower nasal dorsum that fits
better in her profile and minimal augmentation of the nasofronatal angle.


This Patient had functional- and esthetic problems of the nose. Especially in the lateral view her nose was too
prominent. She had a short upper lip, too much projection of her nasal tip and a cartilaginous dorsum that was
relatively high.


Pre- and postoperative lateral view after an external approach rhinoplasty. Hump reduction, oblique- and lateral
osteotomies, thin spreader grafts, reduction of the anterior nasal spine and caudal septum, de-projection of the
tip using medial- and lateral crural overlay, columellar strut and tip sutures.


pre- and postoperative views


This patient had complaints of an irregular and over-projected nasal dorsum and tip. There was a concavity in
the mid nasal third on the right side and breathing problems due to a strong deviation of caudal nasal septum.


A multi step procedure was performed using an external approach rhinoplasty:
hump reduction, oblique- and lateral osteotomies, spreader graft on the right side, septal correction, de-
projection of the tip using medial- and lateral crural overlay, columellar strut and tip sutures.

pre- and postoperative lateral view.


pre- and postoperative basal view.
The septal deviation was reconstructed using a caudal septal splint graft.


Caudal septal splint graft. This graft can be used to straighten severe septal deviations. The deviated area of the
nasal septum is first weakened by "scoring the cartilage" with a blade, than the graft is sutured to this area in
order to straighten and support the caudal septum.


pre- and postoperative oblique view.


A long over-projected nose
This patient had a nose that was too long. There was over-projection and downward rotation of the nasal tip
and too much columellar show. She had previous rhinoplasty performed elsewhere, a hump was removed
trough an endonasal approach. Hence the open roof deformity due to insufficient osteotomies and infraction of
the nasal bones. There was a deviation of the mid nasal third to the left side and a concavity on the right side.
There was also bifidity and asymmetry of the tip defining points.


Assessment:
Shortening of the nose by removing a strip of the caudal septum and upper laterals. A limited hump
removal, oblique- and lateral osteotomies to close the open roof. A spreader/splint graft on the right
side of the nasal septum to camouflage the concavity and to straighten the mid nasal third. De-
projected of the tip using a medial- and lateral crural overlay, a columellar strut graft, tip sutures to
smoothen her asymmetric tip.


Another goal of surgery was to improve the eyebrow esthetic line to the tip defining points.


pre- and postoperative oblique view.
A shorter nose, upward rotation of the nasal tip, de-projection of the tip and a smooth nasal dorsum.


Conclusions, over-projection of the nasal tip is often multi-factorial.
The anatomical structures that are involved are the anterior nasal spine, the nasal septum and the
lower lateral cartilages.

• Over-projection of the nasal tip is often multi-factorial:
– nasal spine
– nasal septum
– lower lateral cartilages


De-projection of the nasal tip requires a multistep procedure:
A rhinoplasty with detachment of tip support mechanisms and reduction of the anterior nasal spine,
the nasal septum and/or medial- and lateral crura. At the end of surgery the tip support mechanisms
should be restored in order to reach a balanced and stable long-term postoperative result.

• De-projection of the nasal tip requires a multistep procedure:
– detachment of tip support mechanisms
– reduction
• spine
• septum
• medial- and lateral crura


Join us at the International Course in Modern Rhinoplasty Techniques!



De-projection of the nasal tip

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