Our approach to decrease tip projection is presented. These techniques may be applied to the three degrees of overprojection, namely the relative, moderate, and ultraprojecting tip. We feel that our techniques will apply to all clinical situations where decrease in projection is desirable. Our concepts have emerged from review of previous techniques and have evolved over our past 1000 rhinoplasties. Excess nasal septum including the nasal spine area, redundancy in the feet of the medial crura, and soft tissue excess may all contribute to the overprojecting tip. However it is excess in the lower lateral cartilage complex, specifically in the medial crus, that requires the most surgical attention and alteration. Our technique in reducing the medial crus to decrease projection is patterned after the Universal Tip Technique described by Parkes and Kanodia. This endonasal technique utilizes a laterally based unipedicled lower lateral cartilage flap, which is freely rotational, but does not violate the continuity of the vestibular skin. With development of our laterally based unipedicle lower lateral cartilage flap, the number of millimeters desired to reduce the projection is removed from the medial crus and eliminated in the final adjustment of tip projection and, in this way, decreases tip projection. In the moderate case, approximately 3 mm of medial crus is excised. In the more severe or ultraprojecting tip, ≥5 is removed from the medial crus. In extreme overprojecting noses, excess soft tissue is addressed by excision of an ellipse of mucosa at the intercartilaginous incision at the septal angle. In the ultraprojecting tip, in addition to resection of redundant cephalic lower lateral cartilage and a ≥5-mm segment of medial crus, it may be necessary to also resect the lateralmost extension of the lower lateral cartilage, the feet of the medial crura, and alar bases. Septal modification, including an inferior strip resection of septum including the nasal spine, may also contribute to decreasing projection. We have found this technique to be effective and predictable over the last 10 years.
The T- Graft to Control Nasal Length and Nasal Tip Position
