Nasal Tip Ptosis Or A Drooping Nose (Long Nose) occurs if the tip of the nose is longer than what is deemed ideal. Ideal varies between male and female noses. An elongated nose gives the appearance of an older person and may occur from excessive tip cartilages, elongated shape of the tip cartilages, lack of bony support to the tip, osteoporosis of the maxilla (supporting bone of the nasal tip and upper teeth), or loosening of the ligaments and connective tissue which occur with age.
The loss of maxillary support may enhance or worsen nasal tip ptosis. A previous rhinoplasty may cause loss of nasal tip support and this may become worse as the person ages. Sometimes this drooping nasal tip can have a functional implication as well and cause nasal obstruction. A test one can do is to push up on the nasal tip in the nasal examination and the patient's breathing improves. Dr. Sam Rizk, a New York Facial plastic surgeon and rhinoplasty expert, discusses the functional and cosmetic implications of nasal tip ptosis in his recent teaching at the Brazilian Society of Plastic Surgeons where he lectured on "rhinoplasty in the 21st century future direction and advances".
The first step is to diagnose this condition. Nasal tip angle and rotation is determined by drawing a line from the tip-defining points to the alar crease and measuring this angle in relation to the vertical facial plane. The preferred angle is 90-115 degrees but varies between men and women. In women, it should ideally be 100 degrees and in men 90 degrees. The tip cartilages (lower lateral cartilages) create an arch that begins medially in the columella and extend laterally. The curvature, strength, resiliency and size of the lower lateral cartilages, as well as their association with the nasal septum determine the shape of the nasal tip. The position of the nasal tip is also determined by the connective tissue attachments to the nasal septum as well as the upper lateral cartilage (the upper lateral cartilage forms the middle part of the nose above the nasal tip). A long septum or upper lateral cartilage may push the tip down towards the upper lip. The depressor septi muscle also acts to pull the nasal tip down and this event usually happens with smiling. It is important to ask the patient to smile during the consultation to evaluate this muscle. It is also important to ask the patient if they have difficulty breathing to determine if a functional issue is involved in addition to a cosmetic deformity. Some ethnic noses such as the Middle eastern/Mediterranean noses tend to have a drooping nasal tip.
The diagnosis of the tip ptosis involves measuring nasal angles and facial proportions. We divide the face into 3 zones horizontally. The first line is drawn horizontally at the hairline, the second above the eyebrows, the third at the nasal base, and the fourth line at the bottom of the chin. These 4 lines divide the face into 3 zones. These three zones should ideally be equal in height to each other. The nasofrontal angle (radix) also needs to be evaluated as it connects the forehead and top part (dorsum) of the nose. The deepest part of this angle should ideally lie in a horizontal line drawn from the upper lid eyelashes. The ideal nasal dorsum should lie about 2mm behind and parallel to a line from the radix to the tip-defining points of the nasal tip in women and 1mm in men. This distance is defined as nasal length from the radix to tip defining points. The nasolabial angle (ideally 90 degrees in men and 100 degrees in women) is used to determine the degree of tip rotation and thus tip ptosis. Tip projection is evaluated by looking at the nose from the lateral (profile view). The projection is measured by drawing a line from the nostril-cheek junction to the tip of the nose. The tip projection is considered normal if 50 percent of the tip is in front of a vertical line drawn vertically through the most projecting part of the upper lip. In other words the tip of the nose has to lie significantly in front of the upper lip. Lastly in the nasal examination, the surgeon should evaluate the overall projection, rotation, and definition of the nasal tip in relation to other parts of the nose such as the nostrils and the nasal dorsum.
How to Correct Nasal Tip Ptosis
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, in my opinion 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.
- 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.
- 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.
Nasal tip ptosis is commonly seen in Dr. Sam Rizk's practice and is a condition that affects both the appearance and the function of the nose, since marked tip ptosis can significantly increase upper airway resistance by impeding airflow through the nares. Treating the nasal tip ptosis can correct both the cosmetic and functional deformities by improving the aesthetics of the nasal tip and resolving nasal obstruction. Various techniques have been discussed here for correction of nasal tip ptosis. The techniques discussed here are only a framework for evaluation and need to be individualized to the patient. If a patient had a rhinoplasty without making the nasal tip stronger with grafting techniques, that tip will drop and the patient will require a revision rhinoplasty. Therefore, it is important to reestablish tip support during the first operation with cartilage grafting, as some of the tip techniques to define the nasal tip can also weaken it.
75 yo male interested in improving his drooping nose and loose neck. Patient wants a very natural procedure. Patient underwent endonasal rhinoplasty to lift nose tip and bump reduction conservatively as well as a lower facelift and necklift. Patient is shown 6 months postoperatively.
55 year old female who underwent endonasal revision rhinoplasty for bump reduction to soften her features and improvement in her skin with laser resurfacing. Also note the nasal tip was subtly lifted to improve a slight droop.