Tip Projection

Tip projection is a complex and critical concept in both surgical and nonsurgical rhinoplasty. Goode’s ratio has been used to describe ideal tip projection relative to the distance from the nasion to the subnasale. The ratio of tip projection to this nasion/columellar base distance should be 0.55 to 0.6, approximating a perfect 3-4-5 right triangle. Increasing tip projection in medium- or thicker-skinned patients can offer a significant improvement in tip definition. A rounder tip can be made more triangular. A firmer, prominent tip structure can be thought of as pushing into a thicker skin envelope.

Filler placement at the tip is achieved by placing 0.1 to 0.15 mL of filler in front of the tip-defining points, precisely in the midline. The optimal approach is from an entry point in the infratip, using a 29-gauge needle. The skin and soft tissue envelope can be tented up to reduce risk of intravascular injection. Aspiration is important, of course. The filler should be placed very slowly, immediately upon the perichondrium of the tip cartilages. The filler can then be shaped with the fingers. If desired, the infratip can be slightly lengthened using this technique as well, if the filler is in the form of a shield graft. A small amount of additional filler in the supratip may be advisable, if the increased projection accentuates the supratip break.

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