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The Drooping Tip
Pertinent anatomy and etiology
The cartilaginous framework and the skin and soft tissue envelope are the primary influences of nasal tip shape, position, and definition. Tip support has been classically divided into the major and minor tip support mechanisms. The three major tip support mechanisms include the cartilage of the medial and lateral crura, the fibrous attachments of the medial crural footplates to the posterior caudal septum, and the fibrous attachments between the lateral crura to the upper lateral cartilages. Minor tip support mechanisms include the interdomal ligaments, the dorsal cartilaginous septum, the fibrous attachments of the lower lateral crura to the pyriform aperture, the attachments of the alar cartilage to the overlying skin and soft tissue envelope, the membranous septum, and the nasal spine.
Primary rhinoplasty whether endonasal or external typically disrupts one or more of the tip support mechanisms. A post rhinoplasty drooping tip usually results from unanticipated or uncompensated loss of the tip support mechanisms. The rhinoplasty surgeon must be able to anticipate, plan, and compensate for the destabilized nasal tip. The standard transcolumellar, intercartilaginous, transfixion, and marginal incisions serve to interrupt tip support mechanisms and must be accounted for by the rhinoplasty surgeon. Examples of destabilizing maneuvers include aggressive resection of the lower lateral cartilage, unnecessary complete transfixion incisions, aggressive reduction of the nasal spine or anterior septal angle, and overzealous interrupted strip techniques. In addition, in accordance with the tripod theory of nasal tip position, failure to recognize and address excessively long lateral crura or weak and short medial crura can result in a ptotic nasal tip post-operatively if corrective measures are not implemented.
Surgical Evaluation and Management
Careful inspection and palpation is of paramount importance when evaluating the ptotic nasal tip. Valuable information such as the size, strength, shape, position, and integrity of the lower lateral cartilages is obtained. The surgeon will also be able to ascertain the amount of scar tissue as well. The rhinoplasty surgeon must also evaluate the projection, rotation, tip definition, and symmetry of the alar cartilages, the nasolabial angle, alar base width, and nasal length. Typically, the patient with tip ptosis after rhinoplasty will have an underprojected, underrotated tip with an acute nasolabial angle. In addition, it is not uncommon for there to be a concomitant polybeak deformity present, either related to inadequate reduction of the cartilaginous dorsum, loss of tip projection and support, or excessive scar tissue formation. Also, excessive long lateral crura or weak and short medial crura must be recognized during the preoperative evaluation to allow for appropriate surgical planning.
The specific cause of the ptotic nasal tip will dictate the approach for management. Commonly, adjustments in projection and rotation will have to be made along with re-establishing the tip support mechanisms that have been disrupted in the previous operation. The external rhinoplasty approach is most commonly used by the senior author to address the drooping tip in revision rhinoplasty. The external approach allows for a more accurate diagnosis, excellent exposure for suturing multiple grafts including tip grafts, batten grafts, columellar struts, cap grafts, and onlay grafts. This is especially helpful in cases of tip asymmetries. One notable exception to the external approach for tip ptosis in revision rhinoplasty is in cases of a redundant anterior membranous septum with posterior maxillary recession as the etiology of the acute nasolabial angle. In that case if tip support is adequate, an endonasal approach is used , and through the complete transfixion incision the anterior membranous septum is resected and plumping grafts are placed followed by the placement of septocolumellar sutures to maintain tip support and position.
That exception aside, the external approach is most commonly used. Cartilage grafts are harvested initially. Auricular cartilage, if necessary is harvested through a posterior auricular incision. Septal cartilage, if present is harvested usually through a hemitransfixtion incision so as to not further disrupt a major tip support mechanism if possible. If there is a caudal septal deviation, it is addressed at this time, freeing it from the nasal spine, re-positioning it, and suturing it to the nasal spine periosteum with a 5.0 polydioxanone (PDS) suture. At least a 1 cm caudal and dorsal septal strut is left in place , more if the cartilage is weak. Irradiated costal cartilage is utilized if the septal or auricular cartilage is insufficient.
The external approach is made by connecting bilateral marginal incisions to an inverted "v" transcolumellar incision. The dissection plane proceeds immediately superficial to the alar cartilages to avoid thinning of the skin flap or fenestration of the skin especially in cases where there is excessive scar tissue. If the dorsum needs modification, the dissection continues to the radix. Once the skin and soft tissue envelope has been elevated, a detailed analysis ensues. The lower lateral cartilages are examined for strength, integrity, symmetry, and scar tissue with specific attention to the lateral crura, domes, and medial crura. Also, the skin and soft tissue envelope is evaluated for thickness and the anterior septal angle is evaluated for its role in tip support.
Excessive scar bands and contractures are released to allow for complete mobilization of the lower lateral cartilages. The lower lateral cartilages are then carefully inspected for integrity, symmetry, excessive resection, malposition, or for cartilage splitting techniques. Displaced cartilage fragments are realigned if possible after freeing them from the vestibular skin. Excessive height of the lateral crura is managed by cephalic trim if necessary always using care to preserve at least 7mm of lateral crural vertical height if the cartilage is strong, 8mm if it is weak. Over resected lateral crura often require alar batten grafts to prevent airway collapse. Septal cartilage and auricular cartilage grafts are carefully sculpted and sutured onto the remnant alar cartilages using meticulous technique to ensure symmetry with 5.0 PDS sutures. Inter and intradomal sutures are placed as necessary using horizontal mattress sutures of 4.0 or 5.0 PDS. These are placed for increased tip definition, projection, and to correct excessive dome separation or biphidity.
Lateral crural overlay is an effective technique 2 to address the excessively long lateral crura as a cause for the drooping nasal tip. It can result in increase rotation, deprojection, and increased tip support. The lower lateral cartilages are freed from the underlying vestibular skin in the middle of the lateral crus. Then a vertical incision is made in the lateral crus approximately 8 to 10mm lateral to the dome. The tip is then re-positioned and the overlapped margins of the lateral crura are sutured with two transcartilaginous horizontal mattress 5.0 PDS sutures.
A columellar strut is often used to reinforce the medial crural component of the nasal tripod in patients who have tip ptosis after rhinoplasty. It stabilizes weak medial crura and can straighten medial crura that are buckled. The strut is positioned between the medial crura in a precise pocket that extends from just superficial to the anterior nasal spine to the junction of the medial crura and intermediate crura. It is typically sutured to the medial crura with 2 or 3 5.0 PDS horizontal mattress sutures. It is important to preserve the natural divergence of the intermediate crura that forms the infratip break.
Caudal septal extension grafts can be used to enhance tip support and correct a retracted columella in patients who underwent an overaggressive resection of the caudal septum. Plumping grafts are also helpful in patients with an acute nasolabial angle to augment the premaxilla.
Tip grafting is an important technique to enhance tip definition or support when there are deficiencies or weaknesses in the alar cartilages. Shield grafts can be helpful in augmenting tip projection and stabilizing the ptotic tip. The graft must be carefully beveled to avoid any visible edges especially in thin-skinned patients. The shield graft is typically placed after the suture stabilization of the columellar strut. Occasionally, the caudal margins of the medial and intermediate crura must be shaved to provide a smooth surface for the graft. Also, the graft ideally has a curvature to accommodate the transition from the medial crura to the intermediate crura so as to avoid effacement of the infratip break. The graft typically requires three sets of sutures, each to the caudal margins of the medial, intermediate, and lateral crura. If additional projection is required, the superior edge of the shield graft can project above the domes as necessary. Additional refinement can be performed with the graft in situ as necessary to correct any irregularities or asymmetries.
It is important to also address the supratip. If supratip fullness or a polybeak persists after repositioning maneuvers to increase projection are performed, the etiology of the persistent polybeak must be ascertained and corrected. Cartilaginous polybeak deformities determined by palpation are addressed by incremental shaving of the dorsal septal cartilage in the supratip region. In patients with thick skin or excessive scar tissue in the supratip after the previous rhinoplasty, scar tissue or fibro fatty tissue can be debulked albeit with great care to avoid visible cartilage graft edges.