Tip Ptosis Rhinoplasty 

Updated: Jan 22, 2016
Author: Eric J Moore, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA 

Overview

Background

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.

Problem

Tip rotation is most commonly assessed on the profile view of the nose by measuring the nasolabial angle (see the image below). 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.

Rhinoplasty, tip ptosis. Tip rotation can be asses Rhinoplasty, tip ptosis. Tip rotation can be assessed by measuring the nasolabial angle. The aesthetic ideal for this measurement is 90-100° in men and 100-115° in women.

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 the image below). 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.

Rhinoplasty, tip ptosis. Nasal tip rotation can be Rhinoplasty, tip ptosis. Nasal tip rotation can be assessed more accurately by measuring the angle between the long axis of the nostril rim and the Frankfort plane. The aesthetic ideal for this measurement is 0-15° in men and 10-30° in women.

Epidemiology

Frequency

Nasal 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 the image below). 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.

Rhinoplasty, tip ptosis. Nasal tip ptosis is a pro Rhinoplasty, tip ptosis. Nasal tip ptosis is a prominent feature of the aging face. Tip ptosis in this setting results from senile changes in the major and minor tip support mechanisms.

Etiology

The 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 the image below). 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.

Rhinoplasty, tip ptosis. Tip support can be concep Rhinoplasty, tip ptosis. Tip support can be conceptualized as a tripod with the medial crura as 1 supporting leg and the lateral crura as the other 2 legs. Using this model, changes in tip rotation can be predicted when the integrity of the supporting limbs is altered.

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.

Presentation

Patients 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 Anatomy

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.

For more information, see the eMedicine topic Nose Anatomy.

Contraindications

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.

 

Treatment

Surgical Therapy

Correction 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 Details

The 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.[1]

Intraoperative Details

Septal 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

Patients with nasal tip ptosis commonly suffer from medial crura support deficiency. The criterion standard for treating this problem is the use of a medial crura strut graft fashioned from septal cartilage. Either an intranasal or external approach can be used for graft placement, but external exposure, particularly in patients who have previously undergone surgery, allows the graft to more easily be precisely placed and fixed. Absorbable sutures on a straight needle are used to suture the graft between the medial crura (see the image below).[2]

Rhinoplasty, tip ptosis. Tip support and rotation Rhinoplasty, tip ptosis. Tip support and rotation are increased by suturing a cartilaginous strut graft between the medial crura. The graft should be placed above the anterior nasal spine to prevent lateral displacement and subsequent tilting of the nasal tip.

Take care to precisely align the caudal edges of the medial crura and the domes. Nasal tip deviation can be avoided by locating the graft above the nasal spine. If septal cartilage is absent, an alternative donor source is needed. While conchal cartilage may serve the purpose, preplacement remodeling is required owing to the natural curvature of this cartilage. If tip ptosis is severe and the medial crura is buckled, a straight, structurally sound strut graft may be obtained via autogenous rib material. Avoid using bone and artificial material in the nasal tip to prevent extrusion and excessive rigidity.[2]

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 the image below).

Rhinoplasty, tip ptosis. Conservative resection of Rhinoplasty, tip ptosis. Conservative resection of the cephalad border of the lower lateral cartilage can be an effective means of attaining tip rotation. Care should be taken to preserve adequate lateral crus (minimum of 7 mm) to prevent alar collapse and nasal obstruction.

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.[3, 4]

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.

Tuğrul et al reported good results from split cartilage resection of the nasal dome (27 patients), with postoperative outcomes for nasolabial, nasofacial, and rotation angles, as well as Goode’s index, being comparable to those for lateral crura overlap surgery (26 patients).[5]

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 the image below). 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.

Rhinoplasty, tip ptosis. Rotation of the nasal tip Rhinoplasty, tip ptosis. Rotation of the nasal tip can be achieved with the addition of an onlay cartilaginous tip graft. Further degrees of rotation are achieved by more cephalad positioning and fixation of the graft.

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.[6] 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 Details

Postoperatively, 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.

Complications

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.