Overprojected Nasal Tip

Following dorsal hump, overprojected tip is perhaps the second most common complaint of patients seeking rhinoplasty. The tip should not project away from the face in a way that is disproportionate to the rest of the nose (or the rest of the face!). Patients often describe an overprojected tip as “I have a big nose!” While a large tip can go along with a dorsal hump and a wide nasal base, all of which contribute to a “big nose,” these are separate and distinct features that are addressed during rhinoplasty.

Rhinoplasty surgeons have used various anatomical guidelines to help determine ideal tip projection. These measured ratios and lengths are helpful for training purposes and for didactic discussion;however, experienced surgeons rarely take measurements. A trained eye will know intuitively that tip projection is too large, too small, or adequate for that particular face. Similarly, patients generally have a good common sense understanding that this part of their nose is simply too big. But how much smaller should it be?

An informed patient is usually a good patient, and for that reason it is helpful for patients to have a rough guideline when analyzing their tip projection or perhaps when analyzing other before and after photos.  In the picture below are two lines, A and B. Line A measures from the nasal tip to the center of the ala (nostril region). Line B represents the upper lip. If line A is much larger than line B, the tip projection is probably too large, as in this case:

In this after photo, the two lines are much more congruent. The tip has been modestly de-projected, and the nose is more in balance. Note that the overall length of line B has increased! This is because an overly projected tip “pulls up” on the upper lip- effectively shortening it. This is called “tenting.” De-projecting the tip has allowed the upper lip to settle into a more aesthetic position:

It is important for patients to understand that the tip can only be de-projected to an extent that is allowed by the patient’s own tissues. For example, if one were to de-project a tip excessively in a very thick-skinned individual, there is a chance that the nasal tip would then lose some of its shape or become amorphous, possibly looking worse than when it was larger. Also, the rest of the nose in most cases MUST be made smaller in a similar if not proportionate fashion to the tip. If the bridge for some reason cannot come down far enough, then reducing tip projection can create a dorsal hump where there wasn’t one before! It is the rhinoplasty surgeon’s job to give patients a reality check with regard to nasal tip de-projection.  In most cases, however, even a subtle change in projection can make quite a difference.

Tip de-projection rhinoplasty can be done through either an open or a closed approach. The surgeon has a choice of dividing and partially resected the dome of the tip, or preserving the dome intact and shortening the three supporting “legs” of the tip.

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