Incisor Show-based Selection of Tip Augmentation Rhinoplasty Technique

Our recent studies show that the majority of patients seeking rhinoplasty have inadequate incisor show. Furthermore, some rhinoplasty maneuvers, such as a columella strut, can alter the lip position and consequently the incisor show. We report the senior author's (B.G.) algorithm for tip augmentation technique based on our previous studies and 44 years of keen observation in the field of rhinoplasty. The 5 most common scenarios are described. When there is a short columella with inadequate incisor show, bilateral extended spreader grafts and columella strut with a tapered posterior portion are recommended, serving as a reliable midline septal extension graft supporting the medial crura in a more anterior position with sutures and a positive effect on incisor show. When there is an optimal lip-incisor relationship, a columella strut with a tapered posterior end fixed to the septum, with or without extended spreader grafts, is a better choice to prevent a change in smile. If there is excessive gum show, the optimal tip augmentation technique is a columella strut without tapering or even wider posterior end, with fixation of the columella strut to the septum, with or without extended spreader grafts that will push the upper lip caudally. The remaining scenarios are described in detail. Tip augmentation maneuvers in rhinoplasty can have a significant influence on upper lip position, which is often detrimental to the smile. The preoperative position of the upper lip during smile should play an integral role in the selection of tip augmentation technique.