Rhinoplasty Dr Bashar Bizrah Article on: Principles of Tip Surgery Part 4: The Drooping Tip

Definition:

It is a clinical case when we have a vertical long nose, drooped and with a long tip. Nasal tip ptosis is an unpleasant facial feature and adversely affects nasal airways. (Figs. 8 – l,33,37,39,40,49,69,72)

Aetiology:

1. Congenital:
   A. Long, vertically oriented lateral crura that force or push the tip inferiorly.
   B. Hypertrophy of the nasolabalis muscle that pulls the nasal down.
   C. Thick, heavy skin over the nasal tip that is pulled down by gravity.
2. Iatrogenic:
   Loss of tip support mechanism due to poorly performed rhinoplasty or septoplasty.
3. Aging:
   Causes progressive stretching of the nasal tip fibrous suspensory ligaments and
   atrophy of subcutaneous fat at the nasolabial angle.

Surgical Principles:

1. To achieve tip rotation, projection, elevation and refinement by considering manoeuvres that augment the medial crura, shorten and rotate the lateral crura.
2. To shorten the nose.

Surgical Techniques:

A. Vertical shortening of the nose:

1. Trimming of cephalic margin of lateral crura.
2. Trimming of caudal end of upper lateral cartilage.
3. Trimming of the caudal margin of the septum and superior septal angle.

B. Achievement of tip rotation, projection, elevation and refinement:
This is best achieved by the following three steps:

1. New dome creation/ scoring/ suture fixation/ columellar strut and tip graft units:
   These key manoeuvres lengthen medial crus and shorten the lateral crus
   with dome cartilage support. (Fig. 8 – 23)

Fig. 8 - 23. A. Preoperative drooping tip
B. Postoperative: following new dome creation, scoring, suture fixation, columellar strut, tip graft and lateral crura overlay technique.

2. Lateral crura overlay technique:
   Overlay technique has been already explained in full detail (Figs. 8-16,17). In drooped noses we need more rotation of the dome segments, therefore, the nasal tip is rotated more superiorly to the desired position, then, the free undermined crura segments of the overlay cartilage is sutured firmly to the distal lateral crura segment, in order to lock the tip into the desired rotated position. As a result of rotation of the overlayed crura segment, an irregular triangle of cartilage results along the inferior crural margin, which should be trimmed to avoid alar rim irregularity. (Fig. 17 – 17)
3. Sublabial division of the nasolabalis muscle:
   It enhances rotation and releases tension on the tip. This manoeuvre is also useful in patients whose tip moves up and down while talking or the tip drops too much while laughing. (Fig. 17 -19)