Dr. Rizk frequently consults with patients in New York and New Jersey who are dissatisfied with their appearance due to a drooping nose, which is a common complaint heard by nose job surgeons. Also known as nasal tip ptosis, this condition can be caused by a variety of factors. As such, there are a number of techniques that NYC plastic surgeon Dr. Rizk utilizes to address a drooping nose.
Causes of Nasal Tip Ptosis
Some of the common causes of tip droopiness include:
- An elongated nasal septum or bridge
- Excessive cartilage in the tip of the nose
- Age (with age, the connective tissue and ligaments of the nose begin to lose their elasticity causing the tip of the nose to droop)
- Abnormally strong muscles below the nose that pull the tip down when smiling
- A previous nose surgery (in some cases, a poorly performed rhinoplasty may result in loss of adequate nasal tip support)
- Trauma due to an accident or sports injury
Dr. Rizk will determine if you suffer from nasal tip ptosis by taking measurements of your nose, in particular, the nasolabial angle (the angle formed between the nasal tip and upper lip). In men, the angle that is considered cosmetically ideal is about 90°. In women, the nasolabial angle should ideally be between 95 and 105°. If you decide to undergo rhinoplasty to correct a drooping tip, one of the main objectives will be to correct the nose so that the nasolabial angle is closer to the ideal degree.
Rhinoplasty Before & After - Plastic Surgeon New York
*Results may vary.
How to Improve a Droopy Nasal Tip
Dr. Rizk can improve the appearance of a drooping nose by utilizing a variety of techniques. Some patients see great improvement through non-surgical treatments, such as the use of Botox or injectable fillers (e.g. Radiesse or Restylane).
The use of injectables provides an alternative to invasive nose surgery, but the treatment must be repeated to maintain results. Patients seeking a more permanent solution or who require a greater amount of revision may opt to undergo a nose job. After carefully examining your nose, Dr. Rizk will plan a unique approach to improve your nose through rhinoplasty.
The following are some of the techniques Dr. Rizk frequently utilizes during rhinoplasty to correct nasal tip ptosis:
- Reduction and/or repositioning of the lower lateral cartilage of the nose
- Placement of grafts to lift and redefine the nasal tip
- Implantation of a columella strut to lift and support the nasal tip
- Suture techniques to correct over, or under-projection of the nasal tip
- Trimming the septal cartilages
There is no single approach that universally corrects a drooping nose, as each nose is unique and there are a variety of causes of nasal tip ptosis. Therefore, it is important to work with a doctor who is highly experienced in correcting this issue.
When looking for a doctor in NYC, you should view before and after photos of patients who have undergone a nose job to correct nasal tip ptosis before making a decision. Dr. Rizk is one of the most experienced doctors in Manhattan and has been helping his patients correct the form and function of their nose for many years. To learn more about how Dr. Rizk can help correct your nasal tip ptosis, please contact our New York office today.
Pertinent Anatomy and Etiology
The tip, shape, position, and definition of the nose are determined primarily by a framework of cartilage, skin and a soft tissue envelope. The “mechanisms” that support the tip of the nose are generally split into two categories: “major” and “minor” tip support mechanisms.
The three mechanisms that fall within the major category 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 and 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 between the alar cartilage and the overlying skin and soft tissue envelope, the membranous septum, and the nasal spine.
Whether endonasal or external, rhinoplasty procedures tend to disrupt at least one of the nasal tip’s many support mechanisms, creating risks for unintended outcomes. One of the possible outcomes is a post-rhinoplasty “drooping tip.”
To avoid this scenario, surgeons must exercise caution by anticipating and compensating for a destabilized tip, which can result from a variety of incisions (standard transcolumellar, intercartilaginous, transfixion, and marginal incisions). Common rhinoplasty maneuvers that tend to destabilize nasal support can include aggressive or overzealous resectioning of the lower lateral cartilage, reduction of the nasal spine or anterior septal angle, and interrupted strip techniques. A ptotic, or drooping, nasal tip can also be caused by gratuitous transfixion incisions.
Furthermore, if a surgeon fails to manage excessively long lateral crura or weak and short medial crura, the postoperative result could likewise be a sudden loss of tip support.
Surgical Evaluation and Management
Evaluating a ptotic nasal tip requires an extremely thorough examination and palpation to assess the firmness and condition of the tip and determine the size, strength, shape, position, and integrity of the lower lateral cartilages. It is also important to identify the level of scar tissue incurred from previous surgery. In addition, the nose must be evaluated for its projection, rotation, tip definition, and symmetry of the alar cartilages, the nasolabial angle, alar base width, and nasal length.
Patients with postoperative ptosis will commonly have an underprojected, under-rotated tip with an acute nasolabial angle. Another typical feature of a ptotic nose is a pollybeak deformity, which happens when a patient has excessive scar tissue or cartilaginous dorsum. To allow the surgeon to plan prior to the surgery, the pre-operative evaluation should also determine whether the patient has excessive long lateral crura or weak and short medial crura that must be addressed.
How to Improve a Droopy Nasal Tip
Deciding how best to correct a ptotic nasal tip depends primarily on the source of the condition. However, in most cases, the surgeon will have to adjust the nasal projection and rotation and restore the tip support mechanisms that were lost in a previous operation. To do this, Dr. Rizk will usually opt to perform an external rhinoplasty, which provides greater exposure when suturing the tip, batten, columellar struts, cap, and onlay grafts. It also enables a more precise diagnosis and is particularly useful in cases involving asymmetrical nasal tips.
There are some cases, however, when external surgery may not the best option for managing tip ptosis. For example, cases in which the acute nasolabial angle is caused by a redundant anterior membranous septum resulting from a previous rhinoplasty. To treat this problem, an endonasal approach is preferable to resect the anterior membranous septum through a complete transfixion incision and to place plumping grafts and septocolumellar sutures to maintain tip support and position.
Overview of External Droopy Nasal Tip Repair
Aside from the cases mentioned above, the external approach is generally the preferred method for treating drooping tips. To begin, various cartilage grafts are harvested from different parts of the patient’s nose to replace tissue that may have been damaged or missing from previous surgery.
A posterior auricular incision is made to harvest auricular cartilage. Septal cartilage is harvested through a hemitransfixion incision, if possible, to avoid further instability to any major tip support mechanisms. If a caudal septal deviation is present, Dr. Rizk will free it from the nasal spine, reposition it, and use a 5.0 polydioxanone (PDS) suture to stitch it to the nasal spine periosteum. If the cartilage is weak, more than 1 cm of the caudal and dorsal septal strut is left in place. If the septal or auricular cartilage is not enough, irradiated costal cartilage is used in its place.
The external rhinoplasty then proceeds with bilateral marginal incisions that connect in an inverted "v" transcolumellar incision. When excessive scar tissue exists, the dissection plane proceeds just short of the alar cartilages, to avoid thinning of the skin tissue.
The dissection continues to the radix, if the dorsum also needs to be modified. When the skin and soft tissue envelope is lifted, a detailed analysis then takes place. Excessive scar bands and contractures are released to mobilize the lower lateral cartilages, which the surgeon will evaluate for strength, integrity, symmetry, and scar tissue, paying close attention to the lateral crura, domes, and medial crura. The skin and soft tissue envelope are also assessed for their thickness. Additionally, the anterior septal angle is assessed for its function in supporting the nasal tip.
The Importance of a Custom Approach to Nasal Tip Droopiness
Customizing the procedure for each patient is the best way to improve the chances of success. The examination of the lower lateral cartilages will determine their integrity, symmetry, excessive resection, or malposition. Any cartilage fragments that have been displaced are freed from the vestibular skin and are realigned, wherever possible. A cephalic trim may be used to correct excessive height in the lateral crura. If the cartilage is strong, at least 7mm of lateral crural vertical height should be preserved; at least 8mm should be preserved if the cartilage is weak.
To maintain open airways, alar batten grafts may be used to address over resected lateral crura. Septal cartilage and auricular cartilage grafts are meticulously molded and sutured onto the remnant alar cartilages to ensure symmetry with 5.0 PDS sutures. As needed, inter and intradomal sutures are placed using horizontal mattress sutures (4.0 or 5.0 PDS) to improve tip definition and projection and to correct excessive dome separation or bifidity.
As aforementioned, the lateral crural overlay is an effective technique for correcting excessively long lateral crura that may cause the nasal tip to droop. Overlays can provide increased rotation, deprojection, and increased tip support. After the lower lateral cartilages are freed from the vestibular skin in the middle of the lateral crus, a vertical incision is made in the lateral crus approximately 8mm to 10mm lateral to the dome. The surgeon then repositions the tip and sutures the overlapped margins of the lateral crura with two transcartilaginous horizontal mattress 5.0 PDS sutures.
For patients who develop tip ptosis after rhinoplasty, a columellar strut is often used to reinforce the medial crural component of the nasal tripod, by stabilizing weak medial crura and straightening medial crura that have curled. The strut is positioned in a pocket between the medial crura, extending from just short of the anterior nasal spine to the junction of the medial crura and intermediate crura. The strut is usually stitched to the medial crura using two or three 5.0 PDS horizontal mattress sutures. Preserving the natural divergence of the intermediate crura that forms the infratip break is key to success.
Determining the Best Approach for Droopy Nasal Tip
For nasal tip ptosis patients who experienced an overaggressive resection of the caudal septum in a previous operation, caudal septal extension grafts can help enhance tip support and correct a retracted columella. For those with an acute nasolabial angle, plumping grafts are also helpful to augment the premaxilla.
Tip grafting is a highly effective technique for enhancing the definition of the nasal tip, particularly when there are deficiencies in the alar cartilages. Shield grafts, which are typically placed after the columellar strut is stabilized with sutures, can support tip projection and stabilize a drooping tip. Though for thin-skinned patients the graft must be carefully beveled to create a smooth appearance and avoid any unsightly edges.
Sometimes the caudal margins of the medial and intermediate crura must be shaved to create a smooth surface for the graft. Additionally, an ideal graft will have a curve that avoids damaging the infratip in the transition from the medial crura to the intermediate crura. The graft typically requires three sets of sutures, one for each of the caudal margins of the medial, intermediate, and lateral crura. If additional projection is needed, the superior edge of the shield graft can project above the domes. While the graft is in place, continued refinements can be made to address misalignments or asymmetries.
Careful attention must be paid to the supratip. If repositioning maneuvers cause supratip fullness or a pollybeak to persist, it is imperative to identify the etiology of the pollybeak and correct it. Pollybeak deformities are managed by shaving the dorsal septal cartilage in the supratip region. For thick-skinned patients or those who may have developed scar tissue in the supratip from a previous rhinoplasty, measures can be taken to debulk the scar or fibro-fatty tissue. This must be performed with caution to avoid visible cartilage graft edges.
What causes a nose to droop or appear elongated?
Also known as nasal tip ptosis, a drooping nose can be caused by a variety of factors. In the case of nasal tip ptosis, the nasal tip is elongated or droops disproportionately. In some cases, an elongated septum or nasal bridge may cause the nose to appear elongated.
The effects of aging, such as a decreased amount of bony support and loosening of connective tissues and ligaments, may also cause the nose to droop. In other cases, some people have an abnormally strong muscle above their lip that pulls down the tip of their nose, causing the appearance of a drooping nose. Furthermore, often a previous rhinoplasty has weakened or deformed the nose so that it can no longer properly support itself.
How will my doctor determine that nasal tip ptosis should be corrected?
During your initial consultation, Dr. Rizk will take measurements of your nose. He will measure your nasolabial angle, which is the angle between the nasal tip and upper lip. If the angle is determined to be less than ideal (about 90° in men and 95 to 105° in women), he may suggest that you undergo rhinoplasty to correct a drooping nose.
How can nose surgery help improve the appearance of a drooping nose?
With offices located near New Jersey, our NY expert rhinoplasty surgeon understands that the shape and rotation of the nasal tip plays an important role in your overall appearance. Rhinoplasty can be performed to correct a drooping nose, as well as any other cosmetic or functional concerns you may have.
By correcting the size and angle of your nasal tip, the shape of your nose will be improved and your face will appear more harmonious. When patients only require nasal tip correction, the procedure does not typically require the breaking of the nasal bones, thus reducing discomfort during the recovery period.
What factors will the surgeon take into consideration when correcting nasal tip ptosis?
A major factor that your surgeon will take into consideration is your age. As we age, the nasal tip naturally begins to droops. When correcting nasal tip ptosis on an older patient, Dr. Rizk will take care to shape a tip that is appropriate for the patient’s age. Another key factor is whether or not you have undergone a previous rhinoplasty.
What problems are associated with a drooping nose?
In addition to creating the appearance of a disproportionate nose, severe nasal tip ptosis can actually cause breathing problems. If your breathing seems to improve when you lift the tip of your nose, it is possible that a drooping nose is impacting your ability to breathe through your nose. If this is the case, it is especially important to seek help from a qualified plastic surgeon.
What qualifications should I look for in a surgeon to correct nasal tip ptosis?
Nasal tip asymmetry is one of the most common complaints heard by Dr. Rizk. Successful correction of a drooping nose is important both for cosmetic and functional reasons, so it is important to find a surgeon who can demonstrate success in performing the surgery. Nasal tip correction is one of the most challenging aspects of rhinoplasty.
Dr. Rizk is highly experienced and remains one of the leading rhinoplasty surgeons in NYC. He has been helping patients correct and refine drooping tips for many years. To learn more about how rhinoplasty can help improve your drooping nose, please contact our New York office today. Our office is located in central Manhattan with easy access to New Jersey and surrounding areas.
Written by Dr. Sam Rizk
Last Modified On: 12/30/2019