This is Dr David W Kim and today’s rhinoplasty video blog is about one method to reduce the over projected tip. Projection usually refers to how much a tip sticks out from the nose in a horizontal direction. One of the most common techniques is to free up the tip cartilages and set them back and fix them onto a stable structure in the midline. This doesnt always work when the tip is very stiff or very strong and the cartilages are resistant to moving or when the tip is overly projected making it hard to move the tip more than a couple of mm. The technique that I am going to show involves dividing and overlapping the limbs of the tip structure in order to set it back more than 2-3mm. This slide shows the demonstration of the tip tripod. This is on side view and it shows the outer and inner limbs of the tripod. This is the tip cartilage on one side of the nose and there is a tip cartilage on the other side which has the same orientation. This is an intra operative photograph of an open rhinoplasty. You can see the tip is formed by these two paired cartilages. The come together in the middle between the nostrils and they flare towards the outside of the nose to form the base of the tip of the nose. Going back to the initial slide when the limbs of the tripod are cut and overlapped they are effectively shortened allowing for some change in the position of the tip. When both limbs of the tripod are reduced the tip goes back in a horizontal direction without changing the vertical position of the tip. This was done in this case. The first step was to trim a small amount of cartilage in the upper border of each lateral crux which is the outer limb of each of the tip cartilages.
The next phase of the surgery was to cut and overlap the outer limbs of the tripod. So the cartilage has been divided here. It has been overlapped and sutured together. The final phase was to divide and overlap the middle limbs of the tripod, the aspect called the medial crux between the nostrils. This was also done on both sides. And this effectively led to a scenario where the tip was pushed back horizontally. This is a patient with such a technique. The tip is too projected for simply sliding the tripod back. If the entire tripod was attempted to be repositioned in that manner, because the cartilages are so stiff, strong and long it would resist that repositioning. However, since the actual limbs of the tripod were cut and overlapped the actual dimensions of the tripod were shortened or truncated allowing for this degree of reduction. You can see that this creates a much better profile, it creates better shadowing from all angles including this ¾ view. It get rid of the shadow that is created by the ledge of the tip sticking out much further than the bridge of the nose and it creates a base view that is more triangular and symmetric.
The medial crural and lateral overlay technique is a very powerful method used to decrease tip projection more than a couple of mm. In the case example I just showed the tip structures are too stiff, too over projected to simply be slid back into the appropriate position. This overlap technique is another example of a structural rhinoplasty method which can be used to improve the features of the nose while maintaining strength and support.