Tip Ptosis Rhinoplasty Treatment & Management

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.

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. ^[4]

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). ^[5]

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. ^[5]

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).

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. ^{[6, 7]}

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). ^[8]

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.

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. ^[9] 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.

Lip lifting

A study by Pascali et al found that in patients with tip ptosis, good results with regard to profile rejuvenation can be achieved by combining primary closed rhinoplasty with indirect subnasal lip lifting. In this way, the report indicates, the effects of aging on the nose and the upper lip region (such as loss of vermilion height) can both be addressed. The investigators found at 1-year’s follow-up that the overall average nasolabial angle width was reduced by 10.9% and the lip length was shortened by 23.5%, in patients who had undergone the combined procedure. When “before” and “after” photographs were compared, an overall satisfaction rating of 4.4 out of 5 was derived using the Subjective Global Aesthetic Improvement Scale. ^[10]

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.

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.