Decreasing Nasal Tip Projection in Rhinoplasty Special Topic

41e Patients undergoing rhinoplasty occasionally require a decrease in nasal tip projection. Accomplishing such an objective requires a comprehensive working knowledge of nasal anatomy and function. Maneuvers executed to simply gain exposure during open or closed rhinoplasty can influence final position of the nasal tip. Failure to recognize and account for any alterations in tip support structures may lead to an unpleasant result. Equally relevant is an awareness of the evolving surgical philosophy as it pertains to rhinoplasty. Antiquated techniques relied on aggressive weakening or resection of the nasal substructure. Subsequently, patients developed problematic results both aesthetically and functionally. Although more aggressive techniques are occasionally required, a graduated approach should be used when decreasing tip projection. Such a conservative approach reserves the most aggressive and precarious maneuvers to be used only when they are unavoidable. HISTORY AND EVOLUTION OF TECHNIQUE Over the past century, many authors have described techniques and modifications to decrease nasal tip projection. Joseph1 is credited with the original description in which he performed a transverse resection of the cartilaginous dome. Noting limitations to Joseph’s technique, Safian2,3 modified the method to include a variable-sized triangular resection of the dome through a similar endonasal approach. Truncation of the dome, as seen with Goldman’s technique,4 was prone to result in sharp edges and contour deformities of the nasal tip. As a result, many authors further altered their techniques to circumvent such untoward corollary. Modification by Smith5 stressed the preservation of underlying vestibular skin. Brennan6 overlapped the medial ends of the lateral crura after splitting the dome but did not perform suture fixation. It is now accepted that failure to overlap the abutting cartilage ends results in a less stable