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ACHIEVING MORE NASAL TIP PROJECTION BY THE USE OF A SMALL AUTOGENOUS VOMER OR SEPTAL CARTILAGE GRAFT A Preliminary Report JACK H. SHEEN, M.D. Los Angeles, Calif. Projection of the nasal tip past the dorsal profile line is important for the best appearance. Unfortunately, in many patients the tissues are inadequate in substance and/or quantity to allow the surgeon to achieve this effect. In a secondary rhinoplasty, after tissues have becn removed, there may not be enough left to obtain the desired amount of projection. The nasal tip configuration is a focal point in facial appearance; to be accept- able, ihc following relationships or fea- tures should be found—as noted in most standard works on rhinoplasty. 1. The nasal tip must be the most forward point in the profile 2. There must be a good difterentiation of the tip from the dorsum 3. A triangle should bottom view 4. The line from the nasal tip to the base of the columella should be broken at the lowest point of the colurnellar-alar junction 5. The angle must than 90? 6. The subnasion should be neither too full nor oo sharp 7. The columella must be more than two mm inferior to the alar rim, and parallel to it 8. The basal perímeter must [orm a sort ol triangle be visible on the masolabial be greater Autogenous bone or cartilage grafts have heen used in the nose and nasal tip* and have been reported by many surgeons for more than 75 years. Phcir use in the nose is, of course, quite safe. We believe even small grafts in the tip can be effcctive in attaining more for- ward projection ol the tip, if certain objectives are met. A. Mobility In smiling, the nasal tip is brought down toward the maxilla by the action ol the zygomaticus muscles. We must preserve this changing relationship of the tip to the maxilla. To be good, a graft in the nasal tip must (we belicve) be freefloating and not supported by the maxilla (to climinate a possible “tent pole” effect). B. Acceptable Quality The material nust be [airly rigid and must allow shaping with a scalpel or a bonc-biting rongeur. lt should not elicit too much tissue reactión, and it must not be absorbed or change its shape after insertion. lt must be suitable to place in areas with very little soft tissue cover. C. Effect on Contour lt must effect the desired contour and projection of the nasal tip without dis- turbing the delicate balance of the rela- tionships in the nasal tip. The natural angulation at the columellar-alar junc- tion must be preserved. (This area may be compromised by external excisions in Presented at the Annual Mecting ol the American Society for Aesthetic Plastic Surgery on May 6, 1975 in Vancouver, B.C., Canada. 35 36 PLASTIC K RECONSTRUCTIVE SURGERY, July 1975 the columella, or by struts placed in the columella across this junction.) We believe the material best suited to meet these criteria is cartilage or bone from the nasal vault—quadrangular car- tilage, vomer, or perpendicular plate. THE PREFERRED DESIGN Our design for nasal tip gralts pro- duces, we believe, a more natural-ap- pearing tip, maintains the acceptable details in contour, and (with proper placement) produces forward projection of the tip without interlering with tip mobility. Figure ] illustrates some of the var- lons possibilities for placement of bone or cartilage grafts in the nasal tip, and my opinions of them. To be effective, I [eel the gralt should be placed ante- riorly in the colwmella, resting on the columellaralar junction, with a slight (85%) cephalic tilt (Fig. l, above). No additional projection of the nasal tip will result if the graft is allowed to tilt Loo tar cephalad (Fig. L, center left). (This 1 PROPER PROJECTION OF TIP Foundotion at columellar - lobular Junction. Caio, 2 SUPERIOR SLIP INFERIOR SLIP Dissection Slides down 100 high; no colamella, no -— projechion -— base for ot tip, ds 7 projection Patti 4 5 TIP "BUTTON" TENT POLE No projection Too much potential. projection — cone , perforation har or blanching. Fr grafts 1. Various placements of bone or cartilago nm (he nasal ip. A graft ready for placement in the nasal ip. possibility is increased if the lower lateral cartilages are dissccted free.) Placing a short bone or cartilage graft in the columella does little to increase the projection of the tip, because ulti- mately the gralt will be forced down into the tissues ol the columella and the tip will assume its prior shape (Fig. 1, center right). A “button” of cartilage or bone has been advocated to “fill out” the tip shape, and it is an eflective modality for ihiat purpose (Fig. 1, below left). How- ever, in my experience it does not increase the lorward projection of the nasal tip. A long vertical strut of cartilage or bone in the columella may obliterate the desired break in the tip-columellar line at the columellaralar junction. If the strut is long enough to push the tip lorward, it usually causes blanching (Fig. 1, below right). Furthermore, if the strut is too long and the tension is too great, the strut may perforate the skin of the nasal tip. MY PREFERENCES IN SOURCES FOR TIP GRAFTS Suitable autogenous materia] may be obtained from the septal cartilage and vomer. The characteristics of each of these will not be discussed. However, 38 PLASTIC £ RECONSTRUCTIVE SURGERY, July 1975 Developing packet o rosal tp ye grati place Fra. 6. Placing the gralt in the pocket, Next we place the graft through the incisión, up toward the dome of the alar cartilages (Fig. 6). TT it is dillicult to so place the graft, the wound is opened more laterally (but not jufe- riorly, so the footing for the graft will not be disturbed). When the graft is inserted, the extent of (he final trimming and the length of the graft arc determined (Fig. 6). Then the inferior end of the grafc is notched, after which the graft is secured with one 6-0 nylon suture placed percutaneously. Tbe wound is closed with interrupted 50 plain catgut sutures. The placement is retained by placing an adhesive tape dressing over the dorsum and the tip, as for a rhitoplasty. This tape is leít in place for one weck.* * Editorial note, Perhaps the veader shovid be cautioned to follow tc authors placement exactly —not to place a strap of adhesive fupe across the tip and another úghtiy under the tip and leave them for one week, for this has resulted in sloughs of the nasal tip. DISCUSSION During the past 3 years, we have used more than 75 autogenous cartilage or vomer grafts successlully in nasal tips (Figs. 7-9) . On two patients where bone was used, some of the bone presented later through the wound. The projecting part was trimmed hack with a bone rongeur, atd the wound then closed uneventfully over the remainder, Problems arose only in thin-skinned individuals, where blanching occurred with smiling or wherc the graft gave the nasal tip a surgical look. In all cases, however, the postoperative appearance was more desirable than that prior to surgery. Improper placement of the graft can cause perforation of the skin, Care must Vol. 56, No. 1 [ NASAL TIP PROJECTION Fi. 7. (ef) Oriental nose, (righf Correction 1he nasal spine, A tip graft was used as described. P RA pati by using cartilage to the dorsam over Lot nt with thick skin and a dependent nasal tip. More projection was achieved by insorting a septal cartilage graft into the tip. 39 
