Unhooking the hook: sculpting the nasal tip by replanting the medial crura.

A great challenge of rhinoplasty is the tip with insufficient projection or the hooked nose. Tip grafting is the standard method used to correct this. The open rhinoplasty technique provides exposure of nasal structures not afforded by the closed approach. We have used this approach to sculpt the nasal tip. Successful "unhooking of the hooked nose" by gaining tip projection has been achieved by completely replanting the medial crura. In the operation, the medial crura are freed in their entirety. The lateral alae of the lower cartilages are trimmed. The medial crura are then advanced dorsally until adequate nasal tip projection is obtained. They are secured to each other and to the septum in their new position with interrupted sutures. More tip definition can be obtained, if needed, by suturing the medial crura together near the tip. The dome can be sculpted to an appropriate width in a similar manner. This technique is advantageous because exact symmetry and positioning of the cartilages can be obtained under direct vision. It contours the tip structures to achieve more nasal tip projection, obviating the need for tip grafting. The technique is particularly useful in the patient with a low dorsum and acute nasolabial angle who will benefit from tip augmentation and elevation. The technique simultaneously thins the tip, adds nasal tip projection of 4 to 6 mm, and corrects the nasolabial angle. We have used this technique with good results in 15 patients. The technique and results were illustrated.