**2. Nasal tip deformities**

### **2.1. Under-projected tip**

Many techniques are known to increase tip projection all of which may be effectively used according to patient's special needs and indications:


oversized graft is incrementally trimmed and tailored until the ideal tip projection and contour is achieved (Figure 3).[1,8]

**Figure 1.** Tip spanning suture

**Figure 2.** Cap graft

**Figure 3.** Shield graft (Sheen graft)

#### **2.2. Over-projected tip**

oversized graft is incrementally trimmed and tailored until the ideal tip projection and

contour is achieved (Figure 3).[1,8]

770 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 1.** Tip spanning suture

**Figure 2.** Cap graft

An over-projected nasal tip is a common finding that must be detected in preoperative assessments. Two general groups of techniques are applied to decrease the projection for all over-projected noses. In the first group it is tried to sever normal tip support mechanisms that will result in small decrease in tip projection. In the second group lower lateral cartilages are interrupted in some parts. A few millimeters of cartilage are resected and a new tripod with smaller limbs is formed.


#### **2.3. Drooping tip**

There are many modalities to correct the drooping tip or acute nasolabial angle.

**1. A wedge is sometimes resected** from the caudal part of the septum to provide enough space for tip rotation (Figure 5).

**Figure 4.** Transfixion incision

#### **2. Cephalic trimming of lower lateral cartilages and**

#### **3. Collumellar strut insertion**

These are other modalities that are basically done to increase nasolabial angle. In case basic techniques fail to provide the ideal result, the following techniques may be effectively applied [14,16]

#### **4. Tip rotating suture**

This is an effective method to increase and hold the nasolabial angle. In this technique a mattress suture is used to anchor lower lateral cartilages to the nasal septum, by incremental tightening of the suture, ideal nasolabial angle is achieved, then with several subsequent ties this nasolabial angle is fixed and stabilized.

#### **2.4. Important points**

Tip rotating suture easily changes the tip position, though it is clear that a single suture suspension may lose its effect gradually and will not lead to permanent results; to achieve stable results, tip support mechanisms should be improved (i.e. application of collumellar strut) and appropriate space be provided for new tip position (i.e. conservative cephalic trimming and caudal resection of septum) [17,18]

**Figure 5.** A wedge is resected from caudal part of the septum to provide enough space for tip rotation.
