As the lower part of the nose meets the face, it naturally creates an angle with the upper lip. Noses that are considered attractive are usually turned up, even if only very subtly. Noses are considered most attractive when this angle is greater than 90 degrees. In most individuals, and to a greater degree with women than with men, the nose should be turned upward slightly to avoid a more aged appearance. Exactly how much depends on a number of factors and must be well planned prior to surgery.
Notice how the angle of this patient’s nose affects her appearance before and after rhinoplasty.
There are a variety of factors that can cause the nose to droop downward, including:
• Prior trauma
• Genetic inheritance
• Outdated rhinoplasty techniques
It is crucial to evaluate true nasal tip ptosis versus patients who have retracted nostrils which can mimic a long nose but the patients do not have true tip ptosis. If the septum is causing the long tip, the septal cartilage can be trimmed at the caudal edge. Patients who have tip ptosis who have long lower lateral cartilages may require trimming and repositioning of these cartilages to rotate the nose. If the tip ptosis is related to loss of medial support of the tip cartilages, a cartilage graft called columellar strut may be required. The contribution of the depressor septi muscle to nasal tip ptosis is also important and should be addressed by cutting this muscle. This is why it is important to ask the patient to smile pre-operatively to assess dynamic movement of the tip down. These alterations of the nasal tip position by strengthening the nasal tip support mechanisms may also improve breathing and function of the nasal airway. To further define and alter the nasal tip, specific cartilage grafts may be needed such as shield grafts, cap grafts, plumping grafts or other tip grafts. In addition to these maneuvers, it is very important, to excise the membraneous septum. Failure to excise the membraneous septum may result in recurrence of nasal tip ptosis. Both an open and endonasal rhinoplasty approach may be used to correct nasal tip ptosis (drooping nasal tip) depending on the patient and the comfort and experience of the surgeon with the techniques. It is important to evaluate nasal length as well as tip projection and nasolabial and nasofrontal angles with a drooping nasal tip. All these factors are interdependent and manipulation of the drooping nasal tip affects nasal length as well. Also inadequate tip projection and drooping nose deformity very commonly coexist.
1. Caudal Septum: If the caudal edge of the septum is elongated, it should be addressed first to correct a long nose with a drooping nasal tip. Various excisions of the caudal septum can be performed. To rotate the nose, the anterior caudal septum needs to be reduced. Usually I do not reduce the posteior caudal septum which could weaken tip support further. A proportionate amount of membranous septum is also excised to eliminate soft tissue redundancy which can cause post-operative tip ptosis. By reducing the septum in this location, it rotates the tip and columella cephalically.
2. Tip Modification: The lower lateral cartilages (alar cartilages) which form the tip consist of both a medial crura (medial arm in the columella) and a lateral arm (forms the side portion of the nasal tip). The medial crura support is usually deficient in patients with tip ptosis because the medial crura are usually soft and weak and separated. This is commonly corrected with approximation of medial crura using a columellar strut graft. The columellar strut is placed in a pocket between the medial crura. If an overactive depressor septi muscle is noted, it is cut or resected. If the tip is also underprojected an onlay graft in addition to the columellar strut may be needed to increase tip projection. These grafts are fashioned and harvested from septal cartilage. Single or even multiple onlay grafts may be needed to augment the tip projection. In addition, both interdomal as well as transdomal sutures may be necessary to improve tip support and definition. The lateral crura may also be modified with a conservative cephalic trim to further define the tip of the nose. This cephalic trim also rotates the nose up and improves nasal tip ptosis. It is necessary to leave at least 6-7 mm of lateral crura to prevent collapse of the external nasal valve and nasal airway obstruction. In cases where the lower lateral cartilages are weak and floppy, a lateral crura strut graft may be necessary to support and change the shape of the lateral crura and define the nasal tip. A lateral crura strut graft can convert a convex bulbous crura to a straighter more angular crura, thereby giving tip definition