Rhinoplasty Dr Bashar Bizrah Article on: Principles of Tip Surgery Part 5: Tip Underprojection

Definition:

As Sheen stated, the nose looks as if it is pressed against the window (Fig. 8 – 38). The tip may be round or flat below the level of the dorsum, the columella may be short, the nostrils may be small or flared, which may be associated with acute nasolabial angle (less then 85°). (Figs. 8 – 2,43,45,46,51,56,57,58,65,71,73,75,77,78)

Aetiologies:

These may be combined or single:

1. Underdeveloped alar cartilage:
   Short intermediate crura, short broad lateral crura and an ill-defined dome.
2. Short caudal septum:
   This causes loss of tip projection.
3. Short nasal spine:
   Underdeveloped or short nasal spine affects tip projection.
4. Iatrogenic loss of tip projection following poor technique used in rhinoplasty as in excessive trimming of lateral crura, caudal septum, superior septal angle or nasal spine trimming, poorly applied sutures and lack of use of columellar and tip grafts. Our routine incision and excision divide the anatomical factors that support the tip, resulting in loss of tip support and its unpleasant effects such as dropped tip, hanging columella and wider nares. Therefore, supportive means to compensate for the loss of tip support are mandatory to maintain or improve tip projection.
5. False hump: The underprojected tip with acceptable dorsum height may give the impression of hump (false hump). This should be clearly assessed and identified, because what is needed in this case is only to elevate and project the tip without any dorsum reduction. Lowering the dorsum in such a patient leads to saddling and requires a major augmentation procedure.
6. Associated deformities:
   Low radix, high dorsum, low dorsum and/ or alar flare .
7. Retruded maxilla.

Management:

The aim is to achieve tip projection, elevation, definition and refinement with balanced dorsum and nasal sidewalls.

Fig. 8 - 24. Correction of tip underprojection by new dome creation, scoring, suture fixation, columellar strut and tip gralts. Double or triple tip gralts may be needed.

Fig. 8 - 25. Septocolumellar suture will increase and preserve tip projection.

The main tip techniques which were explained before in this text (new dome creation/ suture fixation/ dome division/ columellar strut and tip grafts unit) are applied. Septocolumellar sutures are essential in order to preserve and increase tip projection. (Figs. 8 – 24,25 and Figs. 17 -13,14,15,16)

These manoeuvres are applied, considering the following hints:

1. Borrowing two to three mm of lateral crura.
2. If lateral crura is short and when borrowing too much of the lateral crura, this may cause dimpling on the alar sidewalls, caused by the distal lateral crus pulling tension on the skin. To avoid this, following vertical division of the dome cartilage, undermine medially the borrowed portion of the lateral crura with preservation of the vestibular skin. Then, insert the columellar strut and stitch the two medial crura with the borrowed part with columellar strut in the middle together in a sandwichlike manner. This manoeuvre of undermining the borrowed portion of lateral crura, will reduce the dimpling caused by the pulling tension of the intact posterior lateral
   crura portion on the skin of the alar sidewall.
3. Use a long tip graft (20mm x 5mm) in order to augment the acute nasolabial angle. This graft will help to achieve rotation, elevation, projection and definition. Double or triple tip grafts may be needed for more projection. (Fig. 8 – 24 and Fig. 17 -16)
4. Correct combined deformities such as true hump, low dorsum, deviated septum, alar flare.
5. Rarely, premaxillary augmentation is needed by using an allograft.

New Advances

Modified vertical dome division without delivery of the lateral crus (Bizrah Modification). The author has developed this technique (p. 137) which is largely based on the Goldman’s Tip and the I-beam of medial crura but without lateral crus delivery (Figs. 8 -18,19). This is in order to keep an intact alar rim and avoid any problems along the alar rim such as notching, retraction, collapse or asymmetry. The author has been applying this technique for the last two years (Figs. 17 – 28,29). In his opinion this technique is very useful in order to achieve tip projection, definition and refinement in the following situations:

1. Tip underprojection
2. Short columella
3. Mild tip bulbousity
4. In revision cases: when lateral crus delivery is technically difficult.