Tip rotation and projection

What repeats

Five findings that hold across the literature.

The two words are two measurements on a profile photograph

Rotation is read as the nasolabial angle, between the columella and the upper lip. Projection is read as the Goode ratio, tip height divided by nasal length. One series of closed rhinoplasties recorded both at four moments: mean rotation ran 100.58 degrees before surgery, 116.19 on the operating table, 113.73 in the short term and 108.49 in the long term, while the Goode ratio ran 0.61, 0.77, 0.68 and 0.64. Projection settled early, rotation kept settling late. Goode is one of six published projection ratios, alongside those of Simons, Baum, Powell and Crumley. Measured on 300 morphed portraits rated by 78 people with no medical training, none of the six tracked facial attractiveness, and the Goode and Crumley ideals were the two that moved the rating most. Population averages are a separate thing from those ideals: in 100 Caucasian volunteers the nasolabial angle matched the published ideal and tip projection sat higher than it.

Rests on: Celikal et al., membranous tongue-in-groove · Apaydin, projection and deprojection · Devcic et al., six projection ratios · Ballin et al., population norms.

A septal extension graft holds the new position better than a columellar strut

In 133 consecutive primary rhinoplasties, projection loss at one year was 4.7% with a columellar strut and 0.2% with a septal extension graft, and mean rotation loss was 4.9 degrees against 1.3 degrees. A strut carried a 5.1-fold risk of losing more than 4% of projection. A meta-analysis of 8 studies covering 256 strut patients and 371 septal extension graft patients favoured the graft on long-term nasolabial angle. The graft was described in 1997 for noses at risk of losing projection, after 20 such patients were reviewed and projection was lost in all but one, the exception being the patient whose columellar strut had been fixed to the caudal septum. Applied to a further 20 patients, projection was maintained or increased in all but one.

Rests on: Byrd et al., the septal extension graft described · Bellamy and Rohrich, long-term tip stability · Ozgenc et al., meta-analysis · Vaghardoost et al., durability at one year.

Sutures alone hold as well as a short floating strut

Forty-four primary open rhinoplasties were split in half. With two septocolumellar sutures and basic tip work, projection loss from the first month to the first year was 3.8%; with a short floating strut added it was 3.5%, and rotation loss was 4.6 degrees in both arms. Across 237 open cases, tongue-in-groove held the nasolabial angle and the Goode ratio better than a strut.

Rests on: Sirinoglu, septocolumellar suture · Erdal et al., 237 cases · and tip sutures.

Every technique gives some of the change back

Eighty-six primary patients were divided between a strut graft and a preservation technique using the Pitanguy ligament. Time had a significant effect on projection and on rotation in both arms, in the same downward direction, with no difference between the techniques at 3, 6 or 9 months. The tip that leaves the operating room is not the tip the patient keeps. Serial measurement before surgery, on the table and at 6 months in 51 primary rhinoplasties reached the same finding: measured projection falls after surgery unless the medial crural segment is lengthened or strengthened.

Rests on: Farhadi et al., structural against preservation · Celikal et al. · Petroff et al., quantitative changes.

The tripod is a teaching model, and the medial crura decide what it does

The tripod concept describes the tip as three legs, the two lateral crura and the conjoined medial crura, and the current review sets out where it stops predicting the result. Cadaver dissection found three shapes of medial crura. Lifting the skin alone changed projection differently between them, the flared symmetric type losing a mean of 1.0 mm, and suture techniques returned two of the three types to their starting projection.

Rests on: Mattos et al., positioning the nasal tip · Patel et al., medial crura · and tip support.

By what the operation is asked to change

The same frame is moved in four directions.

The tip needs to stand out further

Projection is added by fixing the medial crura to a graft that runs off the caudal septum, or by suturing them onto the septum directly. The comparative series put the septal extension graft ahead for holding that gain past a year.

Rests on: Bellamy and Rohrich · Apaydin · and rib cartilage grafts.

The tip stands out too far

Deprojection shortens the legs of the tripod. A systematic review of 5 studies of vertical dome division and vertical alar resection reports projection changed by 15.8%, satisfaction above 90%, projection held beyond 7 years with the graft-reinforced version, and revision of 2% to 6%. The named methods shorten the legs at different points. Alar setback shortens the medial and lateral crura together through an open approach, described in 20 patients, 16 of them by low setback and 4 by high setback, with no revision at a mean of 18 months. Medial crural overlay was introduced in an algorithm covering 120 patients, of whom 2.5% had a dorsal revision and 4.2% a tip revision. Medial crural resection combined with lateral crural steal and a strut, in 447 patients followed a mean of 22.4 months, gave a revision rate of 3.8%. A randomised trial split 54 patients between lateral crural and medial crural cut and overlay, found rotation and projection equal at 12 months, and found cosmetic satisfaction higher after medial crural overlay.

Rests on: Alhajress et al., vertical division and resection · Foda, the alar setback technique · Soliemanzadeh and Kridel, medial crural overlay · Datta et al., tip deprojection · Darzi et al., randomised overlay trial · and the polly beak.

The tip points down

Rotation is raised by shortening the caudal septum, by setting the medial crura higher on it, or by suture. Tongue-in-groove raised the nasolabial angle and held it better than a strut across 237 cases.

Rests on: Erdal et al. · and the drooping tip.

The position is already right and has to survive the operation

Opening the nose divides the tip supports, so a nose that only needs a hump removed still needs its tip position rebuilt. Rotation settles for months afterwards, projection settles within weeks.

Rests on: Celikal et al. · Farhadi et al. · and open against closed.

What to ask about tip position

Questions the evidence supports asking.

What angle and what ratio are you aiming for

Ask for the numbers rather than the adjectives. The published series state a nasolabial angle in degrees and a Goode ratio, and state them again at one year.

Rests on: Celikal et al. · Sirinoglu.

Will you use a strut, a septal extension graft, or sutures

They are not equivalent for holding position. Ask which one the surgeon uses, how often, and what their own one-year photographs show. A graft fixed to the septum is firmer to the touch than a strut floating between the crura.

Rests on: Bellamy and Rohrich · Ozgenc et al. · Erdal et al..

How much of the change will I lose

Ask for the settling figure. Both arms of the preservation comparison lost projection and rotation over 9 months, and the closed tongue-in-groove series lost most of its rotation late.

Rests on: Farhadi et al. · Celikal et al..

Is my cartilage the kind that holds

Medial crural shape predicts how much projection survives the approach itself. Ask what the surgeon finds on examination and what the plan is if the cartilage is weak.

Rests on: Patel et al. · Mattos et al. · and the anatomy of the nose.

The terms, defined

The words used about tip position.

• Tip projection: how far the tip stands forward from the plane of the face. [26616703]
• Tip rotation: the angle the long axis of the tip sits at, measured up from the lip. [40968171]
• Nasolabial angle: the angle between the columella and the upper lip, the usual number for rotation. [28032151]
• Goode ratio: tip height divided by nasal length, the usual number for projection. [34644278]
• Columellar strut: cartilage set between the medial crura, not fixed to the septum. [36728586]
• Septal extension graft: cartilage fixed to the caudal septum, with the medial crura sutured onto it. [40854551]
• Tongue-in-groove: suturing the medial crura onto the caudal septum itself. [40968171]
• Vertical dome division: cutting the lower lateral cartilage at the dome and rebuilding it to reset projection. [42517059]
• Alar setback: shortening the medial and lateral crura together and rebuilding the cartilage, to lower projection with the rotation controlled. [11701071]
• Medial crural overlay: cutting the medial crus and overlapping the cut ends, which shortens the front leg of the tripod. [16301456]
• Medial crura: the cartilage legs inside the columella that carry the tip. [24076670]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function after rhinoplasty sets what a surgeon should record before operating and what should be documented afterwards. Its plain language summary is written for patients.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on tip contour and support and on reducing an overprojected tip.

• Nasal Tip Contour and Support Management
• Overprojected Nasal Tip: Technique To Decrease The Nasal Tip Projection

The reference summary

Rhinoplasty Tip-Shaping Surgery in StatPearls, on the National Library of Medicine's Bookshelf, gives the tip anatomy, the named manoeuvres and the complications in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

• Evaluation Of Cloumella Strut Effect In Tip Rotation, completed, 92 participants.

What is not settled

• The comparisons of strut against septal extension graft are single-surgeon retrospective series and a meta-analysis of them, with the technique chosen case by case. [36728586] [40854551]
• Follow-up stops early. The durability study reports 6 and 12 months and the preservation comparison stops at 9 months. [41629470] [42045684]
• Suture-only fixation matched a floating strut in one study of 44 patients. Whether that holds for weak cartilage, thick skin or a revision nose is untested. [28032151]
• The vertical division evidence is retrospective and heterogeneous by the reviewers' own account, and the review found only 5 studies. [42517059]
• The projection ratios in daily use were not built from outcome data. None of the six correlated with rated facial attractiveness across 300 portraits, and population averages differ from the published ideals. [21647903] [28728950]
• The deprojection series are single-surgeon and retrospective, from 20 patients up to 447. The one randomised comparison enrolled 54 patients and found the two overlay methods equal on rotation and projection. [11701071] [39212968] [34274173]
• Loss of projection after surgery was measured in 51 patients in 1991 and is still being measured the same way, on profile photographs, one practice at a time. [1863446]
• The tripod model is still the teaching frame while its limits are being written about. No measurement study has replaced it. [40996913] [24076670]