Rhinoplasty Dr Bashar Bizrah Article on: Principles of Tip Surgery Part 6: Tip Overprojection

Definition and aetiology:

It is a case where the tip projects unpleasantly too far forward in the anterior plane of the face resulting in gross disproportion on nasal anatomy components. (Figs 8 – 55,61)

Aetiologies:

These are always combined and rarely single. (Fig. 8 – 26)

1. Alar cartilage overdevelopment
   – The lateral crura are long and wide with variable concavity or convexity.
   – The dome may be sharply angulated, twisted, or buckled which is usually associated with thin skin.
   – Elongated medial crura:
   Over long medial crura may coexist with large elongated vertical nostrils and thin alar sidewalls.
2. Nasal spine overdevelopment
   Often coexist with blunting of the nasolobial angle, which may appear full, webbed or obtuse. The upper lip may appear short. (Fig. 17 – 19)
3. Caudal septum overdevelopment
   Causes obliteration of the nasolobial angle, which should be accurately differentiated from nasal spine overdevelopment. If the caudal septum is dislocated this shows up as asymmetrical nares and projecting dome.
4. Septal cartilagenous dorsum overdevelopment
   A high superior septal angle and high dorsum septum may elevate the tip.
5. Combined abnormalities
   This includes thin skin, deep nasofrontal angle, high dorsum, overdeveloped alar cartilage, alar flare and large noses.
6. Iatrogenic overprojection:
   Excessive borrowing of lateral crura, long columellar strut, or unnecessarily long or multiple tip grafts.

Management:

The aim is to achieve proportion and balance among nasal anatomic components. Accurate anatomical diagnosis is mandatory for correct surgical plan. Lateral and medial crura overlay technique, dome trimming, and reduction of overdeveloped nasal spine are

Fig. 8 - 26. Nose overprojection could be due to the following single or combined overdevelopments of the alar cartilage, nasal spine, caudal septum and or dorsum septum.

Fig. 8 - 27. Lateral crura overlay technique: The lateral crus is incised at the mid-portion with preservation of vestibu_lar skin.

Fig. 8 - 28. Medial crura overlay technique: The cartilage is incised at the junction of medial to intermediate crura with preservation of vestibular skin. The medial crura will overlap the intermediate crura resulting in further correction of tip overprojection.

necessary. Dorsal septum lowering, caudal septum shortening, dorsum and nasofrontal grafts and alar reduction, some or all of these mentioned manoeuvres may need to be considered in order to achieve balanced surgery.

Special Techniques:

1. Lateral crura overlay technique in order to reduce the volume and shorten the lateral crura with preservation of cartilage and intact rim. (Figs. 8 – 27,28 and Fig. 17 – 17)
2. Medial crura overlay technique:
   If correction of overprojection is still insufficient after the lateral overlay technique, a cartilage incision is made near the junction of the intermediate crura to medial crura with preservation of the vestibular skin, allowing the medial crura to overlap the intermediate crura. This manoeuvre will slightly drop the tip. Remember that one mm may be enough to achieve satisfactory results.
3. Dome trimming:
   If dome cartilages are still asymmetrical or if further reduction is needed, the domal cartilage above the mattress suture fixation at the site of dome scoring or division is trimmed symmetrically with preservation of underlying vestibular skin. In a thin skinned patient, crushed or soft shaved edged tip graft cartilage should be considered to avoid the showing of the sharp edges.
4. Reduction of overdeveloped nasal spine:
   This is performed by a sublabial incision, the nasal spine is identified and an appropriate portion is trimmed by using bone nippler forceps. (Fig. 17 -19)
5. Other combined balancing procedures:
   Dorsal septum lowering, caudal septum shortening, dorsum and nasofrontal grafts and alar wedge excision.
6. Modified vertical dome division without delivery of lateral crus (Bizrah Modification) (p. 137). This technique maybe applied in order to correct the overprojected tip. Following vertical dome division and the I-beam medial crura, the proximal ends of the lateral crura and the superior ends of I-beam medial crura are conservatively trimmed. This will lower the dome and shorten the alar sidewalls.
   (Figs. 17 -28,29)