You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Rhinoplasty, Tip PtosisArticle Last Updated: Aug 8, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Eric Moore, MD, Residency Director, Assistant Professor, Department of Otorhinolaryngology/Head and Neck Surgery, Mayo Graduate School of Medicine Eric Moore is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, and American Rhinologic Society Editors: Anthony P Sclafani, MD, Director, Professor, Department of Otolaryngology, Division of Facial Plastic Surgery, New York Eye and Ear Infirmary, New York Medical College; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David Stepnick, MD, Vice Chairman, Department of Otolaryngology-Head and Neck Surgery, Associate Professor, University Hospitals of Cleveland, Case Western Reserve University; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: nasal tip ptosis, plastic surgery, nose job, rhinoplasty, tip ptosis, nasal shape, nasal tip asymmetry, nasal tip rotation INTRODUCTIONSection 2 of 9
  Nasal shape profoundly influences facial appearance because of the central position and anterior projection of the nose on the face. The shape and rotation of the nasal tip are of utmost importance in nasal assessment. Variation in nasal tip asymmetry is the most common complaint of patients requesting rhinoplastic surgery, and the goal of nearly every rhinoplasty is to achieve lower nasal third rotation. Because of the importance of nasal tip rotation in function and cosmesis of the nose, the nasal surgeon must possess the knowledge and skill to prevent and correct nasal tip ptosis. ProblemTip rotation is most commonly assessed on the profile view of the nose by measuring the nasolabial angle (see Image 1). The nasolabial angle is measured by a line from the subnasale to the superior vermilion and by a tangent of the columella from the subnasale. The aesthetic ideal for the nasolabial angle is defined by a range of 90-100° in men and 100-110° in women. This aesthetic ideal must be considered in light of the other physical characteristics of the patient. For instance, shorter people usually can tolerate greater tip rotation without sacrificing cosmesis, while greater tip rotation should especially be avoided in taller people to avoid excessive nostril show. Multiple factors, such as prominence of the anterior nasal spine, maxillary retrusion or prognathism, and asymmetry of the medial crura, may influence the inclination of the columella without correspondingly affecting the inclination of the nasal tip or long axis of the columella. Because of this, use of the nasolabial angle in assessing tip ptosis may be misleading. A more accurate assessment uses measurement of the long axis of the nostril rim with the Frankfort plane (see Image 2). In this assessment, the aesthetically ideal angle ranges from 10-30° in women and 0-15° in men. The long axis of the columella should be parallel to the long axis of the nostril rim, and the alar rim should form a smooth arch 2-4 mm above the edge of the columella. Nasal tip ptosis is then defined as a more acute angle between the long axis of the nostril and the Frankfort plane than the aesthetic ideals mentioned above. FrequencyNasal tip ptosis is often observed following nasal trauma. As a part of the aging face, tip ptosis is the predominant feature of nasal aging (see Image 3). In addition, it is one of the most common findings in patients presenting for primary rhinoplasty. Nearly every rhinoplasty involves maneuvers to achieve and maintain adequate tip rotation. Nasal tip ptosis is also one of the most common findings in patients presenting for secondary rhinoplasty, and iatrogenic destruction of nasal tip support is a common finding in late development of tip ptosis following rhinoplasty. EtiologyThe tripod concept of nasal tip support and the major and minor tip support mechanisms must be considered in nasal tip ptosis. If the lower lateral cartilages of the nose are compared to a tripod, with the medial crura as one leg and the lateral crura as the other two supporting legs, envisioning changes in tip rotation with alterations in the tip supporting structures is easy (see Image 4). In addition, the integrity of the medial and lateral crura, the attachment of the medial crural feet to the caudal end of the quadrangular cartilage, and the scroll-like attachment of the caudal end of the upper lateral cartilage to the cephalic margins of the lateral crura are the major tip support structures to consider. The minor tip support mechanisms include (1) the dorsal cartilaginous septum, (2) the interdomal ligaments, (3) the nasal spine, (4) the membranous septum, and (5) the alar attachments to the skin. Alterations in the size, shape, and integrity of the limbs of the tripod, together with the disruption of the major and minor tip support mechanisms, result in profound alteration in tip rotation. If medial crural integrity is compromised, the nasal tip rotates inferiorly as the supporting limb of the tripod buckles under the weight of the overlying skin-soft tissue envelope. This is the most common factor in tip ptosis secondary to trauma, including iatrogenic insult. Additionally, noses with congenitally short or flimsy medial crura display this type of tip ptosis. Loss of the supporting attachment of the lateral crura and the upper lateral cartilage results in tip ptosis. Trauma, including excessive trimming of the lower lateral cartilage during rhinoplasty, can result in this type of inferior collapse of the nasal tip as the major tip support mechanisms are compromised. Senile ptosis of the nose can also be explained by this factor, as the ligamentous attachments of the upper and lower lateral cartilages lose their integrity with age. Excessive length of the lateral crura depresses the tip inferiorly, as does excessive caudal projection of the cartilaginous septum. This is a common finding in patients with the tension nose. Finally, the tethering of the columella, as in clefting of the palate (particularly with bilateral clefts) or in contracture following nasal or lip trauma, can result in nasal ptosis. In short, nasal ptosis commonly results from a discrepancy between the tip support and the downward force of gravity on the overlying skin soft-tissue envelope. ClinicalPatients presenting for rhinoplasty frequently do not recognize the presence of nasal ptosis and how it affects their nasal aesthetic appearance. Tip ptosis is most pronounced on lateral view, and it may have to be demonstrated to patients during part of their surgical workup by using their photos. Elderly patients with senile tip ptosis may present to the surgeon experiencing nasal obstruction. Elevating the tip of the nose may improve nasal airflow in these patients. RELEVANT ANATOMYSection 3 of 9
The lower lateral cartilages of the nose can be compared to a tripod, with the medial crura as one leg and the lateral crura as the other two supporting legs. The integrity of the medial and lateral crura, the attachment of the medial crural feet to the caudal end of the quadrangular cartilage, and the scroll-like attachment of the caudal end of the upper lateral cartilage to the cephalic margins of the lateral crura are the major tip support structures. The minor tip support mechanisms include (1) the dorsal cartilaginous septum, (2) the interdomal ligaments, (3) the nasal spine, (4) the membranous septum, and (5) the alar attachments to the skin. CONTRAINDICATIONSSection 4 of 9
Correction of nasal tip ptosis requires an adequate well-vascularized skin and soft tissue envelope to redrape over the nasal skeleton, as well as adequate cartilaginous skeletal support. In patients with extensive nasal trauma or previous surgical manipulation, these structures can be insufficient to withstand aggressive surgical manipulation. Consider conservative measures, and sometimes avoiding surgical manipulation altogether, for patients with poorly vascularized soft tissue, extensive loss of cartilaginous support, or other factors that would adversely affect cosmetic and functional outcome. In addition, avoid extensive manipulation of the nasal skeleton in infants and young children to prevent scarring and strictures that may affect nasal and midfacial growth. TREATMENTSection 5 of 9
Surgical therapyCorrection of nasal tip ptosis requires careful preoperative analysis with identification of the structural pathophysiology, followed by surgical alteration of the tip structures. Minor alterations of the caudal septum and lateral crura can be performed adequately through intranasal rhinoplasty maneuvers. Significant alterations of the tip supporting structures, particularly in patients having revision rhinoplasty, are more easily and effectively performed through open septorhinoplasty. Surgical therapy typically involves strengthening of the medial feet, conservative trimming of the lateral crura, and conservative shortening of the caudal end of the nasal septum. Maneuvers are individualized to the patient's pathology, and strengthening of the tip support mechanisms is crucial to a desirable postoperative result. Preoperative detailsThe patient workup for nasal tip ptosis involves a careful history with particular attention to the details of previous trauma, previous surgery of the nose, and the presence of nasal obstruction. Physical examination of the nose should include palpation of the nasal tip to assess integrity of the tip support mechanisms. Uniform nasal photography with frontal, lateral, oblique, basal, and dorsal views of the nose is an integral part of the evaluation and documentation process. Views of the patient smiling help identify the role of the depressor septa muscle in the etiology of tip ptosis. Perform nasal analysis with photos or computer images in the presence of the patient so that preoperative pathology, desires and preconceptions of the patient, and surgical goals are well understood. For every patient, outline a methodical and orderly identification of the nasal pathology and the maneuvers to be undertaken to correct the problem. The surgeon and the patient should be prepared for the possibility of deficient septal and tip cartilage. A discussion of the need for harvesting autologous cartilage grafts, using irradiated cartilage or, uncommonly, artificial graft material should be an integral portion of the preoperative workup. Intraoperative detailsSeptal surgery Septal surgery is usually the initial maneuver in treatment of nasal tip ptosis. A hemitransfixion incision can be used to gain access to the caudal end of the septum. Caudal septum excision may be needed in a nose with excess septal cartilage. Occasionally, excision of membranous septum may be needed. Graft material to augment the tip support may be harvested from the mid cartilaginous septum following elevation of submucoperichondrial tunnels. Take care to preserve adequate continuous dorsal caudal septal support. Resection of the nasal spine and division of the depressor septa muscle can be performed at this time if necessary. Correct septal deviation, securely fixate the septum in the midline, and carefully close the intranasal incisions with absorbable sutures. Medial crura surgery Deficient medial crura support is commonly found in patients with nasal tip ptosis. Placement of a medial crura strut graft of septal cartilage is the criterion standard therapy for this finding. The graft can be placed through an intranasal or external approach, although precise placement and fixation are more easily accomplished through external exposure, particularly in the patient with previous surgery. The graft is sutured between the medial crura with absorbable sutures on a straight needle (see Image 5). Take care to precisely align the caudal edges of the medial crura and the domes. The graft should lie above the nasal spine to avoid deviation of the nasal tip. Absence of septal cartilage as a donor graft requires an alternative source. Conchal cartilage may be sufficient, but its natural curvature requires remodeling prior to placement. In patients with severe tip ptosis and buckling of the medial crura, autogenous rib grafts provide a straight and structurally sound strut graft. Avoid using bone and artificial material in the nasal tip to prevent extrusion and excessive rigidity. Lateral crura surgery Conservative resection of the caudal margin of the lateral crura is another maneuver that can provide minimal-to-moderate tip rotation. Conservatism cannot be overemphasized in this maneuver. Perform the resection at the medial segment of the cephalic lateral crus up to the dome, and take care to leave a minimum of 7 mm of width of intact lateral crus to prevent alar retraction and tip collapse (see Image 6). Another tip rotating maneuver includes shortening the length of the lateral crura. This can be accomplished by dome division, by resection of the overlapping cartilage, and by permanent suture reconstitution of the intact strip with 6-0 nylon sutures. This maneuver narrows the nasal tip as well as providing tip rotation. Again, perform conservative resection. Resection of the redundant membranous septum may be necessary with these maneuvers to preserve tip rotation. If increased tip projection is required in addition to tip rotation, a "lateral crural steal" maneuver can be performed. This maneuver is accomplished by adding to the medial crural length by borrowing from the lateral crura. The nasal tip cartilages can be restructured with either vertical mattress suturing or dome division just lateral to the dome and reconstruction of the tip with increased length of the medial crura. These maneuvers increase the length of the medial leg of the tip tripod and increase the tip projection. Tip grafting Onlay grafting of the nasal tip may be necessary to achieve adequate tip rotation. Tip grafts are usually carved from septal cartilage, but auricular or costal cartilage grafts may be used in the absence of adequate septal graft material. Desired tip rotation can be achieved by altering the positioning of the graft (see Image 7). More cephalad placement results in greater rotation but decreased projection. Securely fix the graft to the stable and symmetric lower lateral cartilage base with multiple 6-0 nylon sutures. Double or even triple stacked grafts may be necessary to achieve the desired projection and rotation. Sufficiently thin and bevel the graft to prevent sharp edges from showing through in patients with thin skin. Subcutaneous thinning of the supratip skin may be necessary in patients with thick or fatty tip skin. Adjunctive maneuvers In rare circumstances, additional maneuvers may be necessary to correct nasal tip ptosis. In elderly patients with senile tip ptosis, a "rhino-lift" may be performed by undermining the nasal dorsal skin and excising a horizontal ellipse of tissue over the glabella. In certain postoperative patients with nasal tip ptosis, reattaching the lower lateral cartilages and suspending them from the upper lateral cartilage may be necessary. In patients with a deficient columella, such as in a cleft rhinoplasty, rotating soft tissue or recruiting it into the columellar area may be necessary to correct nasal tip ptosis. The surgeon should develop a flexible operative approach and should be prepared to perform a combination of surgical maneuvers to fully rotate the nasal tip. Postoperative detailsPostoperatively, a nasal tape and thermasplint dressing is applied to aid in proper redraping and healing of the skin and soft tissue envelope to the newly modified nasal skeleton. The tip is supported by a tape sling. The patient is instructed in wound cleansing and application of antibiotic ointment, and saline nasal irrigations are performed for removal of clots and crusts in the nose. The patient is instructed to avoid situations that could result in nasal trauma for 6 weeks following surgery. Postoperative visits include periodic examination of the healing process, assessment of soft-tissue edema resolution, and postoperative photographic documentation. COMPLICATIONSSection 6 of 9
Postoperative complications include infection, bleeding, hypertrophic or irregular scar formation, nasal asymmetry, and the recurrence of tip ptosis. Most minor complications can be handled with conservative medical therapy and straightforward communication with the patient. The most effective prevention against complications is careful preoperative preparation and meticulous operative technique. Occasionally, revision surgery is necessary to correct postoperative nasal asymmetry. Inform the patient of this possibility preoperatively and remind the patient that most revision surgery should not be undertaken prior to 6 months following the original surgery to allow ample time for assessment of healing. TEST QUESTIONSSection 7 of 9
MULTIMEDIASection 8 of 9
REFERENCESSection 9 of 9
Rhinoplasty, Tip Ptosis excerpt Article Last Updated: Aug 8, 2007 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
