Nasal tip projection — Diagnosis and surgical planning
Over-projected tip, tension nose, suspended tip and under-projected tip: which structure fails in each and which manoeuvre corrects it.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Projection depends on the length of the support structures: medial and intermediate crura, anterior nasal spine and alar cartilages. Long gives excess; short, deficit.
- It is far commoner than it seems: two out of three primary rhinoplasties present inadequate projection.
- Before diagnosing, rule out false readings: a high radix, a retruded maxilla or a small chin alter apparent projection without anything being wrong with the tip.
- Reducing projection is difficult; increasing it is relatively simple. Hence the value of being conservative with resections that reduce it inadvertently.
- Major reduction requires shortening all three legs of Anderson’s tripod, and that is only done well through an open approach.
First branch: too much or too little projection?
Does projection exceed cutaneous upper lip height (Simons) and Goode exceed 0.60?
Over-projected tip: the Pinocchio nose
Over-projection is produced by exaggerated length of the intermediate crura, medial crura, anterior nasal spine and alar cartilages. The markedly prominent tip is called the Pinocchio nose or Cyrano de Bergerac, and is usually associated with a recognisable picture: thin skin, elongated nostrils and an insufficient infratip lobule. In operated noses it appears when excess medial or intermediate crura, anterior nasal spine or alar cartilage was not adequately addressed. And two factors accentuate it without being its cause: excessive dorsal lowering and a small chin.
Tension nose: the pedestal effect
The tension nose results from excess anterior nasal spine or caudal septum, producing the so-called pedestal effect: the structure beneath pushes the tip forward. The visible consequence is a shortened lip and an open nasolabial angle. Understanding it matters, because the problem is not where it appears: the alar cartilages may be normal, hypertrophic or even hypotrophic, and correction lies in reducing the pedestal, not in touching the tip.
How to recognise a tension nose
- Short lip and open nasolabial angle.
- Narrow nostrils and flattening of the alar curvature.
- Medial crura pushed downward, with increased columellar show.
- Abnormal gum show on smiling. At rest, normal is 3-4 mm of incisor in women and 2-3 mm in men.
Tip suspended on the septal angle
The third form of over-projection. Here the tip hangs from the anterior septal angle, and its projection is determined by the height of the septal cartilage, not by the alar cartilages. This produces a deceptive combination: tip over-projection with alar cartilage under-projection. It is the mirror image of the tension nose, where the pedestal over-projects deficient alar cartilages; in both, treating the tip without correcting the structure that supports it leaves the problem where it was.
Reducing projection: why it is difficult
It is a deformity that is hard to resolve, and the plan depends on two things: how much projection is excessive and what the cause is. If the excess comes from a long caudal septum, the septal angle or a hypertrophic anterior nasal spine, correction is selective: the specific anatomical alteration is addressed and the tip need not be dismantled. Only when the problem lies in the cartilage length itself do shortening techniques come into play.
Mild cases: manoeuvres that reduce projection
- Partial or total resection of the tip support mechanisms.
- Resection of the medial crural footplates and release of the alar cartilages.
- Dorsal augmentation: it does not reduce real projection, but creates the optical illusion of doing so.
- Tip refinement by reducing alar width, or repositioning with sutures or grafts.
- Reducing cartilage strength by crushing the domes.
Major reduction: shortening the tripod
- 1. ApproachOpen approach: the longitudinal continuity of the cartilages must be interrupted under direct vision
- 2. DivisionDivide medial and alar crura and set them back towards the face as required
- 3. ColumellaTelescoping: the upper fragments of the medial crura slide between the lower ones
- 4. Alar cruraThe medial fragments are overlapped onto the lateral ones
- 5. Domal alternativeDivision of the alar cartilages at the dome and overlapping advancement onto the intermediate crura, creating a new dome
- 6. FixationNon-absorbable 5/0 or 6/0 sutures at every overlap
- 7. RedrapingWide skin and mucosal degloving: without it, the envelope will not follow the new volume
Under-projected nose
A nose that does not project forward looks flattened. The origin may be genetic — African and Asian biotypes, mixed-ancestry noses, and conditions such as Binder syndrome with a flat face and maxillary hypoplasia — or acquired: traumatic noses, boxer’s nose, and rhinoplasties with collapse of the nasal pyramid. Anatomically, the deficit lies in small or hypotrophic alar cartilages or a short columella from short medial or intermediate crura, or crura so weak they cannot support the tip. The result is accompanied by an acute nasolabial angle.
The illusion of under-projection
Before indicating a projection graft, rule out that the tip is fine and the surroundings are at fault. A high radix or maxillary retrusion produce apparent under-projection with nothing wrong at the tip. In those cases, projecting the tip corrects the measurement but not the face: what needs treating is the radix or the skeleton. It is the exact counterpart of the error made with a retruded chin in over-projected tips.
Increasing projection: grafts and sutures
| Resource | How |
|---|---|
| Columellar strut | The commonest. Graft between the medial crura, from the anterior nasal spine to the footplates or to the domes; fixed to the medial crura and the septum |
| Tip grafts | Interdomal or predomal (Sheen): they simulate the domes, creating a new tip at a more anterior level |
| Approximation sutures | Between intermediate or medial crura: they approximate the domes, narrow the tip and increase projection at once |
| Septum-to-crus stitch | 5/0 suture from the upper caudal septum to the lower medial crus |
| Optical effect | Lowering the dorsum or augmenting the maxilla project the tip without touching it |
Under-projected, drooping tip with a wide base
This is a frequent combination — especially with a bulbous or amorphous tip — and has an elegant solution: lengthening the medial crura at the expense of the lateral. Through an open approach, after degloving the vestibular skin at the domes, the lateral crus adjacent to the dome is advanced medially and transdomal and interdomal sutures are placed, with the knots between the two domes. Repositioning the tip superiorly and anteriorly achieves three effects at once: it increases projection, rotates the tip upward and narrows it.
References
- 1.Arquero P. Alteraciones nasales: proyección. rinoplastia.eu.
- 2.Constantian MB. The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients. Plast Reconstr Surg. 2004;114(6):1571-1581.
- 3.Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol. 1984;110(6):349-358.
- 4.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
Related specialty: Rhinoplasty