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Open rhinoplasty: Effectiveness of different tipplasty techniques to increase nasal tip projection
Open Rhinoplasty: Effectiveness of Different Tipplasty Techniques to Increase Nasal Tip Projection Sameer Ali Bafaqeeh, MD, Fachartz Purpose: To study the effectiveness of 3 different tipplasty techniques to increase nasal tip projection (NTP). Materials and Methods: NTP of 61 patients who underwent open rhinoplasty were retrospectively studied in 3 different tipplasty techniques used to increase NTP. Using a standard measurement technique, the preoperative and postoperative NTP ratio was measured for every patient preoperatively and at least 1 year after surgery. The study population of 61 patients was divided into 3 groups. Group 1 (n-32) underwent the author’s routine nasal tip procedure (columellar strut, conservative cephalic trim of the lateral crura, and transdomal mattress sutures). Group 2 (n 5 10) underwent the routine procedure and, in addition, has further medical recruitment of the lateral crura. Group 3 (n 5 19) underwent the routine procedure and, in addition, has a tip cartilage graft. Results and Conclusion: The mean gain NTP postoperatively was highest in group 3 and lowest in group 1, and this was statistically significant. Causes of these differences in the NTP gain are discussed. (Am J Otolaryngol 2000;21:231-237. Copyright r 2000 by W.B. Saunders Company)
The effectiveness of 3 different tipplasty techniques to increase nasal tip projection (NTP) was retrospectively studied in 61 patients who underwent open rhinoplasty. In all patients, the surgeon’s objective was to increase the preoperative NTP. Using a standard measurement technique, the preoperative and postoperative NTP ratio was measured for every patient preoperatively and at least 1 year after surgery. The study population of 61 patients was divided into 3 groups. Group 1 (n 5 32) underwent the author’s routine nasal tip procedure (columellar strut, conservative cephalic trim of the lateral crura, and transdomal mattress sutures). Group 2 (n 5 10) underwent the routine procedure and, in addition, had further medial recruitment of the lateral crura. Group 3 (n 5 19) underwent the routine procedure and, in addition, had a tip cartilage graft. The mean gain in NTP postopFrom the Department of Otorhinolaryngology, King Abdul Aziz University Hospital, Riyadh, Saudi Arabia. Address reprint requests to Sameer Ali Bafaqeeh, Fachartz, King Saud University, Faculty of Medicine, Ear Nose Throat Department, King Abdul Aziz University Hospital, PO Box 245, Riyadh 11411 Saudi Arabia. Copyright r 2000 by W.B. Saunders Company 0196-0709/00/2104-0002$10.00/0 doi:10.1035/AJOT.2000.8377
eratively was highest in group 3 and lowest in group 1, and this was statistically significant. Causes of these differences in the NTP gain are discussed. The open approach in rhinoplasty for the correction of nasal tip deformities carries several advantages when compared with the endonasal approach. It provides an undistorted exposure of the cartilage complex, reduces the chance of asymmetric cartilage cuts, and allows accurate suturing of cartilage grafts.1,2 Nasal tip projection (NTP) is defined as that distance that the tip-defining point projects anterior to the facial plane.3 An accurate diagnosis of the nasal tip deformity necessitates a complete facial analysis as well as analysis of specific parts of the nose. When the diagnosis is made, the goals of surgery are determined. Furthermore, the surgeon will have a clear objective to maintain, increase, or decrease the preoperative NTP. This article investigates the effectiveness of different open tipplasty technique to increase the preoperative NTP. PATIENTS AND METHODS Out of a series of 580 open rhinoplasties performed by the author between 1990 and
American Journal of Otolaryngology, Vol 21, No 4 (July-August), 2000: pp 231-237
231
232
SAMEER ALI BAFAQEEH
1997, 61 patients were studied. There were 28 men and 33 women with a mean age of 28 years old, ranging from 17 to 35 years. The criteria for selection of patients include a primary open rhinoplasty procedure, the surgeon’s objective to increase the preoperative NTP, adequate pre- and postoperative documentation, and follow-up of more than 1 year after surgery. Analysis of NTP was limited to measurements of preoperative and postoperative photographs as outlined by Rich et al,4 a modification4 of the method described by Crumley and Lanser.5 The pre- and postoperative photographs of nonsmiling patients were analyzed with 3 lines superimposed on the face (Fig 1). One line drawn from the superior aspect of the external auditory canal through the lateral canthus and extended over the nasal root was used to define the nasofrontal angle. A second line was drawn from the defined nasofrontal angle (A) to the vermillion cutaneous junction of the upper lip (B). A third line, drawn perpendicular to the second, meets the most projecting part of the nasal tip (C-D). The 2 lines A-B and C-D were measured, and the length of second line C-D was divided by the length of the first line A-B, yielding the projection length ratio. This ratio is a unitless number and provides the quantification of nasal
Fig 1. ratio.
Schematic for determining projection length
tip projection as it relates to midface length. Differences in photograph sizes do not affect the calculations, as both lines A-B and C-D are similarly altered, having no net effect on the proportions. The projection length ratio were measured pre- and postoperatively for every patient, and the results compared according to the specific nasal tip procedure. Three methods of nasal tip surgery were reviewed in the study and, accordingly, the study population of 61 patients were divided into 3 groups: Group 1 (n 5 32 patients) Patients who underwent the author’s ‘‘routine’’ nasal tip procedure (columellar strut, conservative cephalic trim of the lateral crura, and transdomal mattress sutures). Group 2 (n 5 10 patients) Patients who underwent the ‘‘routine’’ procedure and, in addition, had further medial recruitment of the lateral crura. Group 3 (n 5 19 patients) Patients who underwent the ‘‘routine’’ procedure and, in addition, had a tip cartilage graft. The criteria for selecting 1 procedure over the other was based on the desired gain in NTP. If the desired gain in NTP was greater than 3 mm, the surgeon performed tip cartilage graft (group 3). This explains the fact that the preoperative NTP ratio in group 3 (Table 1) was significantly (P , .05) less than the other groups. The selection of a procedure over the other in the first 2 groups of patients was not based on any specific criteria. In both groups (groups 1 and 2), the surgeon’s aim was to mildly increase NTP (less than 3 mm). During the first 6 years of the study, the surgeon performed only the routine nasal tip procedure (group 1), but the surgeon was not completely satisfied with the long-term tip projection results. During the last 2 years of the study, the surgeon added the medical recruitment (group 2) to the standard technique.
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TABLE 1. The NTP Ratio in the 3 Groups Studied
Group 1 (n 5 32) Group 2 (n 5 10) Group 3 (n 5 19)
Preoperative NTP Ratio (mean 6 SD)
Postoperative NTP Ratio (mean 6 SD)
The Mean Gain in NTP Ratio
0.2428 6 0.0352 0.2475 6 0.0317 0.2139 6 0.0298
0.2446 6 0.0353 0.2687 6 0.0335 0.2600 6 0.0356
0.0018 0.0212 0.0461
The technique of these tip procedures is described below. Sutured-in-place columellar strut. A piece of autogenous cartilage graft is placed in a well-defined pocket dissected between the medial crura 2 mm above the nasal spine. The graft does not reach the nasal spine in order to avoid clicking of the graft on the spine when the patient smiles.6 The graft is fixed with a single absorbable mattress suture (Fig 2). Conservative cephalic trim of the lateral crura. The author leaves a minimum of 7 mm cartilage width in the female patient and 8 mm in the male patient. This maintains a strong lateral crus and prevents buckling that is frequently associated with more aggressive cartilage resections. Transdomal mattress sutures (Fig 3). A single mattress suture approximates the domes above the columellar strut. Nonabsorbable 5-0 nylon sutures are used.
Fig 2.
Columellar strut.
Further medial recruitment of the lateral crura. After tying the transdomal sutures, further suturing of lateral crura is made in the midline and, hence, the crura are recruited more medially as shown in Figure 4. Tip cartilage grafts. These are autogenous grafts sutured in place with nonabsorbable 5-0 nylon sutures. RESULTS In all of the 61 patients studied, the preoperative goal was to increase the NTP. In group 1 (routine procedure; n 5 32), the NTP was unchanged in 12 patients. The remaining 20 patients had an increase in their NTP postoperatively. In group 2 (further medial recruitment of the lateral crura; n 5 10), all patients showed an increase in the NTP after surgery. In group 3 (the addition of tip cartilage graft; n 5 19), all patients showed an increase in the NTP postoperatively. The mean NTP ratio for each group before
234
SAMEER ALI BAFAQEEH
Fig 3.
and after surgery is shown in Table 1. The mean gain in NTP postoperatively was highest in group 3 and lowest in group 1. The difference in this gain between the 3 groups was statistically significant (ANOVA; P , .05). Furthermore, using the match pair t-test to compare between preoperative and postoperative NTP ratio for each group, it was found that the gain in NTP was significant (P , .05) in all 3 groups.
Fig 4. Further medial recruitment of the lateral crura.
Transdomal suture.
Representative clinical photographs are shown in Figures 5 through 8. DISCUSSION Nasal tip surgery is the most challenging aspect of rhinoplasty and should appear natural, not having an ‘‘operated’’ look. There are several nasal tip support mechanisms that exist in the preoperative state.7-10
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235
the ligamentous attachment of the superior septal angle to the domes of the lower lateral cartilages. Most of these support mechanisms are disrupted during the course of a routine rhinoplasty. Nasal tip dynamics and the ability to apply these to the anatomical nasal tip support mechanisms and functional reconstruction of
Fig 5. NTP maintenance 1 year after the author’s routine open rhinoplasty (group 1). (A) Preoperative. (B) Postoperative.
These include the telescoping attachment of the upper and lower lateral cartilage, length and direction of the lateral crura, medial crural feet attachment to the caudal septum, and
Fig 6. Mild NTP length ratio increase 16 months after the author’s routine open rhinoplasty (group 1). (A) Preoperative. (B) Postoperative.
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SAMEER ALI BAFAQEEH
plasty, the author adds a columellar strut and reapproximates the domes. These latter 2 techniques compensates for the previous disruptions and, hence, none of the patients had any loss of NTP postoperatively. In fact, these 2 techniques appear to slightly increase the NTP in almost two thirds of the patients undergoing the routine rhinoplasty (group 1).
Fig 7. Moderate NTP length ratio increase 2 years after further medial recruitment of the lateral crura (group 2). (A) Preoperative. (B) Postoperative.
the nasal tip, which is still the most important element of successful rhinoplasty. In the author’s routine open rhinoplasty, conservative resection of the cephalic part of the lateral crura will not disrupt the attachment of the upper and lower lateral cartilages as the vestibular skin connection is still intact. Dissection of the medial crura and domes disrupt the attachments at the caudal septum and superior septal angle respectively. However, during the course of the routine rhino-
Fig 8. Marked NTP length ratio increase 18 months after adding tip cartilage graft (group 3). (A) Preoperative. (B) Postoperative.
OPEN RHINOPLASTY
The study also shows that a moderate increase in the NTP can be obtained with further medial recruitment of lower lateral cartilages (group 2). This further increase in NTP appears to be stable with long-term follow-up with the use of nonabsorbable sutures. Finally, the greatest increase in NTP was accomplished with the use of tip cartilage grafts (group 3). The tip grafting achieved greater tip projection compared with medial recruitment of the lateral crura, because the recruitment technique is dependent on many factors that contribute in limitation of the procedure such as the degree of recruitment and resilience of the lateral crura. ACKNOWLEDGMENT I would like to express my appreciation to my wife Fawziah Al-Kandari, MD, Medical Labor, for her valuable advice, collection of patient data for my study, and she also provided me with references that I needed to complete my work. Acknowledgment must also be given to Dr. Mohammad Al-Qattan, MD, FRCS(C), for his fruitful review, and to
237
Ms. Connie Unisa-Marfil for her secretarial work. REFERENCES 1. Bafaqeeh SA, Al-Qattan MM: Open rhinoplasty: Columellar scar analysis in an Arabian population. Plastic and Reconstructive Surgery 102:1226-1228, 1998 2. Bafaqeeh SA, Al-Qattan MM: Alterations in nasal sensibility following open rhinoplasty. Br J Plast Surg 51:508-511, 1998 3. Petroff MA, McCollough EG, Hom D, et al: Nasal tip projection quantitative changes following rhinoplasty. Arch Otolaryngol Head Neck Surg 117:783-788, 1991 4. Rich JS, Friedman WH, Pearlman SJ: The effect of lower lateral cartilage excision on nasal tip projection. Arch Otolaryngol Head Neck Surg 117:56-59, 1991 5. Crumley RL, Lanser M: Quantitative analysis of nasal tip projection. Laryngoscope 98:202-208, 1988 6. Vuyk HD, Oldekalter P: Open Septorhinoplasty experiences in 200 patients. Rhinology 31:175-182, 1993 7. Janeke JB, Wright WK: Studies of the support of the nasal tip. Arch Otolaryngol 93:458-464, 1971 8. Anderson JR: The dynamics of Rhinoplasty In Proceeding of the Ninth International Congress of Otorhinolaryngology. Excerpta Medica International Congress Series, No. 206. Amsterdam, The Netherlands, Excerpta Medica, pp 708-710, 1969 9. Vuyk HD, Oakenfull C, Plant R: A quantitative appraisal of change in nasal tip projection after open rhinoplasty. Rhinology 3:124-129, 1997 10. McColough EG, Mangat D: Systemic approach to correction of the nasal tip in rhinoplasty. Arch Otolaryngol 107:12-16, 1981
The effectiveness of 3 different tipplasty techniques to increase nasal tip projection (NTP) was retrospectively studied in 61 patients who underwent open rhinoplasty. In all patients, the surgeon’s objective was to increase the preoperative NTP. Using a standard measurement technique, the preoperative and postoperative NTP ratio was measured for every patient preoperatively and at least 1 year after surgery. The study population of 61 patients was divided into 3 groups. Group 1 (n 5 32) underwent the author’s routine nasal tip procedure (columellar strut, conservative cephalic trim of the lateral crura, and transdomal mattress sutures). Group 2 (n 5 10) underwent the routine procedure and, in addition, had further medial recruitment of the lateral crura. Group 3 (n 5 19) underwent the routine procedure and, in addition, had a tip cartilage graft. The mean gain in NTP postopFrom the Department of Otorhinolaryngology, King Abdul Aziz University Hospital, Riyadh, Saudi Arabia. Address reprint requests to Sameer Ali Bafaqeeh, Fachartz, King Saud University, Faculty of Medicine, Ear Nose Throat Department, King Abdul Aziz University Hospital, PO Box 245, Riyadh 11411 Saudi Arabia. Copyright r 2000 by W.B. Saunders Company 0196-0709/00/2104-0002$10.00/0 doi:10.1035/AJOT.2000.8377
eratively was highest in group 3 and lowest in group 1, and this was statistically significant. Causes of these differences in the NTP gain are discussed. The open approach in rhinoplasty for the correction of nasal tip deformities carries several advantages when compared with the endonasal approach. It provides an undistorted exposure of the cartilage complex, reduces the chance of asymmetric cartilage cuts, and allows accurate suturing of cartilage grafts.1,2 Nasal tip projection (NTP) is defined as that distance that the tip-defining point projects anterior to the facial plane.3 An accurate diagnosis of the nasal tip deformity necessitates a complete facial analysis as well as analysis of specific parts of the nose. When the diagnosis is made, the goals of surgery are determined. Furthermore, the surgeon will have a clear objective to maintain, increase, or decrease the preoperative NTP. This article investigates the effectiveness of different open tipplasty technique to increase the preoperative NTP. PATIENTS AND METHODS Out of a series of 580 open rhinoplasties performed by the author between 1990 and
American Journal of Otolaryngology, Vol 21, No 4 (July-August), 2000: pp 231-237
231
232
SAMEER ALI BAFAQEEH
1997, 61 patients were studied. There were 28 men and 33 women with a mean age of 28 years old, ranging from 17 to 35 years. The criteria for selection of patients include a primary open rhinoplasty procedure, the surgeon’s objective to increase the preoperative NTP, adequate pre- and postoperative documentation, and follow-up of more than 1 year after surgery. Analysis of NTP was limited to measurements of preoperative and postoperative photographs as outlined by Rich et al,4 a modification4 of the method described by Crumley and Lanser.5 The pre- and postoperative photographs of nonsmiling patients were analyzed with 3 lines superimposed on the face (Fig 1). One line drawn from the superior aspect of the external auditory canal through the lateral canthus and extended over the nasal root was used to define the nasofrontal angle. A second line was drawn from the defined nasofrontal angle (A) to the vermillion cutaneous junction of the upper lip (B). A third line, drawn perpendicular to the second, meets the most projecting part of the nasal tip (C-D). The 2 lines A-B and C-D were measured, and the length of second line C-D was divided by the length of the first line A-B, yielding the projection length ratio. This ratio is a unitless number and provides the quantification of nasal
Fig 1. ratio.
Schematic for determining projection length
tip projection as it relates to midface length. Differences in photograph sizes do not affect the calculations, as both lines A-B and C-D are similarly altered, having no net effect on the proportions. The projection length ratio were measured pre- and postoperatively for every patient, and the results compared according to the specific nasal tip procedure. Three methods of nasal tip surgery were reviewed in the study and, accordingly, the study population of 61 patients were divided into 3 groups: Group 1 (n 5 32 patients) Patients who underwent the author’s ‘‘routine’’ nasal tip procedure (columellar strut, conservative cephalic trim of the lateral crura, and transdomal mattress sutures). Group 2 (n 5 10 patients) Patients who underwent the ‘‘routine’’ procedure and, in addition, had further medial recruitment of the lateral crura. Group 3 (n 5 19 patients) Patients who underwent the ‘‘routine’’ procedure and, in addition, had a tip cartilage graft. The criteria for selecting 1 procedure over the other was based on the desired gain in NTP. If the desired gain in NTP was greater than 3 mm, the surgeon performed tip cartilage graft (group 3). This explains the fact that the preoperative NTP ratio in group 3 (Table 1) was significantly (P , .05) less than the other groups. The selection of a procedure over the other in the first 2 groups of patients was not based on any specific criteria. In both groups (groups 1 and 2), the surgeon’s aim was to mildly increase NTP (less than 3 mm). During the first 6 years of the study, the surgeon performed only the routine nasal tip procedure (group 1), but the surgeon was not completely satisfied with the long-term tip projection results. During the last 2 years of the study, the surgeon added the medical recruitment (group 2) to the standard technique.
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233
TABLE 1. The NTP Ratio in the 3 Groups Studied
Group 1 (n 5 32) Group 2 (n 5 10) Group 3 (n 5 19)
Preoperative NTP Ratio (mean 6 SD)
Postoperative NTP Ratio (mean 6 SD)
The Mean Gain in NTP Ratio
0.2428 6 0.0352 0.2475 6 0.0317 0.2139 6 0.0298
0.2446 6 0.0353 0.2687 6 0.0335 0.2600 6 0.0356
0.0018 0.0212 0.0461
The technique of these tip procedures is described below. Sutured-in-place columellar strut. A piece of autogenous cartilage graft is placed in a well-defined pocket dissected between the medial crura 2 mm above the nasal spine. The graft does not reach the nasal spine in order to avoid clicking of the graft on the spine when the patient smiles.6 The graft is fixed with a single absorbable mattress suture (Fig 2). Conservative cephalic trim of the lateral crura. The author leaves a minimum of 7 mm cartilage width in the female patient and 8 mm in the male patient. This maintains a strong lateral crus and prevents buckling that is frequently associated with more aggressive cartilage resections. Transdomal mattress sutures (Fig 3). A single mattress suture approximates the domes above the columellar strut. Nonabsorbable 5-0 nylon sutures are used.
Fig 2.
Columellar strut.
Further medial recruitment of the lateral crura. After tying the transdomal sutures, further suturing of lateral crura is made in the midline and, hence, the crura are recruited more medially as shown in Figure 4. Tip cartilage grafts. These are autogenous grafts sutured in place with nonabsorbable 5-0 nylon sutures. RESULTS In all of the 61 patients studied, the preoperative goal was to increase the NTP. In group 1 (routine procedure; n 5 32), the NTP was unchanged in 12 patients. The remaining 20 patients had an increase in their NTP postoperatively. In group 2 (further medial recruitment of the lateral crura; n 5 10), all patients showed an increase in the NTP after surgery. In group 3 (the addition of tip cartilage graft; n 5 19), all patients showed an increase in the NTP postoperatively. The mean NTP ratio for each group before
234
SAMEER ALI BAFAQEEH
Fig 3.
and after surgery is shown in Table 1. The mean gain in NTP postoperatively was highest in group 3 and lowest in group 1. The difference in this gain between the 3 groups was statistically significant (ANOVA; P , .05). Furthermore, using the match pair t-test to compare between preoperative and postoperative NTP ratio for each group, it was found that the gain in NTP was significant (P , .05) in all 3 groups.
Fig 4. Further medial recruitment of the lateral crura.
Transdomal suture.
Representative clinical photographs are shown in Figures 5 through 8. DISCUSSION Nasal tip surgery is the most challenging aspect of rhinoplasty and should appear natural, not having an ‘‘operated’’ look. There are several nasal tip support mechanisms that exist in the preoperative state.7-10
OPEN RHINOPLASTY
235
the ligamentous attachment of the superior septal angle to the domes of the lower lateral cartilages. Most of these support mechanisms are disrupted during the course of a routine rhinoplasty. Nasal tip dynamics and the ability to apply these to the anatomical nasal tip support mechanisms and functional reconstruction of
Fig 5. NTP maintenance 1 year after the author’s routine open rhinoplasty (group 1). (A) Preoperative. (B) Postoperative.
These include the telescoping attachment of the upper and lower lateral cartilage, length and direction of the lateral crura, medial crural feet attachment to the caudal septum, and
Fig 6. Mild NTP length ratio increase 16 months after the author’s routine open rhinoplasty (group 1). (A) Preoperative. (B) Postoperative.
236
SAMEER ALI BAFAQEEH
plasty, the author adds a columellar strut and reapproximates the domes. These latter 2 techniques compensates for the previous disruptions and, hence, none of the patients had any loss of NTP postoperatively. In fact, these 2 techniques appear to slightly increase the NTP in almost two thirds of the patients undergoing the routine rhinoplasty (group 1).
Fig 7. Moderate NTP length ratio increase 2 years after further medial recruitment of the lateral crura (group 2). (A) Preoperative. (B) Postoperative.
the nasal tip, which is still the most important element of successful rhinoplasty. In the author’s routine open rhinoplasty, conservative resection of the cephalic part of the lateral crura will not disrupt the attachment of the upper and lower lateral cartilages as the vestibular skin connection is still intact. Dissection of the medial crura and domes disrupt the attachments at the caudal septum and superior septal angle respectively. However, during the course of the routine rhino-
Fig 8. Marked NTP length ratio increase 18 months after adding tip cartilage graft (group 3). (A) Preoperative. (B) Postoperative.
OPEN RHINOPLASTY
The study also shows that a moderate increase in the NTP can be obtained with further medial recruitment of lower lateral cartilages (group 2). This further increase in NTP appears to be stable with long-term follow-up with the use of nonabsorbable sutures. Finally, the greatest increase in NTP was accomplished with the use of tip cartilage grafts (group 3). The tip grafting achieved greater tip projection compared with medial recruitment of the lateral crura, because the recruitment technique is dependent on many factors that contribute in limitation of the procedure such as the degree of recruitment and resilience of the lateral crura. ACKNOWLEDGMENT I would like to express my appreciation to my wife Fawziah Al-Kandari, MD, Medical Labor, for her valuable advice, collection of patient data for my study, and she also provided me with references that I needed to complete my work. Acknowledgment must also be given to Dr. Mohammad Al-Qattan, MD, FRCS(C), for his fruitful review, and to
237
Ms. Connie Unisa-Marfil for her secretarial work. REFERENCES 1. Bafaqeeh SA, Al-Qattan MM: Open rhinoplasty: Columellar scar analysis in an Arabian population. Plastic and Reconstructive Surgery 102:1226-1228, 1998 2. Bafaqeeh SA, Al-Qattan MM: Alterations in nasal sensibility following open rhinoplasty. Br J Plast Surg 51:508-511, 1998 3. Petroff MA, McCollough EG, Hom D, et al: Nasal tip projection quantitative changes following rhinoplasty. Arch Otolaryngol Head Neck Surg 117:783-788, 1991 4. Rich JS, Friedman WH, Pearlman SJ: The effect of lower lateral cartilage excision on nasal tip projection. Arch Otolaryngol Head Neck Surg 117:56-59, 1991 5. Crumley RL, Lanser M: Quantitative analysis of nasal tip projection. Laryngoscope 98:202-208, 1988 6. Vuyk HD, Oldekalter P: Open Septorhinoplasty experiences in 200 patients. Rhinology 31:175-182, 1993 7. Janeke JB, Wright WK: Studies of the support of the nasal tip. Arch Otolaryngol 93:458-464, 1971 8. Anderson JR: The dynamics of Rhinoplasty In Proceeding of the Ninth International Congress of Otorhinolaryngology. Excerpta Medica International Congress Series, No. 206. Amsterdam, The Netherlands, Excerpta Medica, pp 708-710, 1969 9. Vuyk HD, Oakenfull C, Plant R: A quantitative appraisal of change in nasal tip projection after open rhinoplasty. Rhinology 3:124-129, 1997 10. McColough EG, Mangat D: Systemic approach to correction of the nasal tip in rhinoplasty. Arch Otolaryngol 107:12-16, 1981