The drooping tip

What repeats

Five findings that hold across the literature.

A muscle pulls the tip down when the patient smiles

The depressor septi nasi runs from the upper lip to the base of the columella. When it is overactive, smiling drops the tip, shortens the upper lip and shows more gum. In a series of 100 primary rhinoplasty patients examined for this, 36 had tip ptosis on animation from an overactive muscle. The examination is done on the smile, not at rest. The anatomy was mapped on 55 fresh cadavers and sorted into three types: the muscle inserting fully into the orbicularis oris in 62%, inserting into periosteum and incompletely into the orbicularis oris in 22%, and absent or rudimentary in 16%. Dissection and transposition of the paired muscle in 62 patients with a descending tip and a shortened lip on animation improved or corrected the tip and lip relationship in 88%.

Rests on: Rohrich et al., the depressor septi nasi muscle · Tellioglu et al., hyperdynamic tip ptosis · Benlier et al., depressor septi review.

Cutting the muscle and moving it give the same result

Two ways of handling that muscle were compared head to head, resection through a transfixion incision against transposition through an upper labial sulcus incision, in one hundred patients split into two equal groups. Smiling moved the nose and lip significantly less after surgery in both arms, and the techniques did not differ on nasal length, tip projection or upper lip height. A third route reaches the same muscle from inside the mouth, through a zetaplasty at the labial frenum, releasing the medial bundles from the nasal spine and plicating the intermediate ones.

Rests on: Kalantar-Hormozi and Beiraghi-Toosi, randomised smile analysis · de Souza Pinto, the intraoral approach.

Adding a strut to the muscle release reduces the droop on smiling further

Photographs taken a mean of 14 months after endonasal rhinoplasty measured how far the nasolabial angle changed from rest to smiling. With muscle release alone, in 29 patients, the mean change was 3.66 degrees. With muscle release and a columellar strut, in 11 patients, it was 2.27 degrees.

Rests on: Brady et al., strut against muscle release · and tip support.

Fixing the medial crura to the septum lifts the resting position and holds it

Tongue-in-groove sets the tip on the caudal septum without a graft. In forty-two patients followed for a mean of 17.3 months, the mean nasolabial angle went from 85.7 to 99.3 degrees and the projection ratio from 0.60 to 0.64. Across 237 open cases the same family of techniques held the nasolabial angle better than a columellar strut. Measured on 94 lateral views from 20 patients, the nasolabial angle rose at every time point after tongue-in-groove and the exposed lateral nostril area fell.

Rests on: Kocak and Gokler, modified tongue-in-groove · Erdal et al., 237 cases · Shah et al., morphometric change after tongue-in-groove · and tip rotation and projection.

The nose lengthens and the tip falls with age, and the skin comes into it

A review of rhinoplasty over the age of 55 lists tip ptosis, valve collapse, soft tissue atrophy and a worsening hump as the age-related findings. In the authors' own twenty-seven patients, tip work used tip grafts in 70%, caudal septal extension grafts in 67% and columellar struts in 26%. Where the skin is redundant, some surgeons remove skin as well: lenticular excision in 12 patients over the age of 50, up to 1.6 cm wide. Tip ptosis after rhinoplasty was described as an avoidable outcome in 1973, and the aging nose has been described the same way since: tip ptosis, growing bulbosity, a longer looking nose and altered airflow, with the droop following loss of tip support and the answer being to restore that support rather than cut more away.

Rests on: Tardy, tip ptosis, etiology and prevention · Rohrich and Hollier, rhinoplasty with advancing age · Romo et al., the aging nose · Khetpal et al., rhinoplasty in the older adult · Caterson et al., skin excision.

By what is holding the tip down

Four causes, four different operations.

The caudal septum is long

A long caudal septum carries the tip forward and down. Shortening it, or setting the medial crura higher on it, raises the tip. The tongue-in-groove series report the change as a rise in the nasolabial angle.

Rests on: Kocak and Gokler · Erdal et al..

The depressor septi nasi is overactive

The muscle is divided, transposed or resected. It changes the movement on smiling rather than the resting position, and the effect on the upper lip is small and unpredictable: across 36 patients, mean upper lip length fell 1.74%, with 24 patients shorter by a mean of 5.89% and 12 longer by a mean of 6.55%. The smile changes too. Across 100 charts reviewed, with 61 women and 15 men included at a mean follow-up of 16 months, maxillary incisor show fell after a columellar strut, an extended spreader graft or depressor septi release, and did not change after a tip rotation or tip suspension suture.

Rests on: Ho et al., upper lip length · Pi et al., upper lip position and incisor show · Benlier et al..

The tip supports are weak

A tip with no support falls back to where the tissue takes it. A columellar strut added to muscle release cut the smiling droop nearly in half, and the graft techniques carry most of the tip work in older patients. The graft used for that job was described in 1997 for this nose in particular, weak lower lateral cartilages with a plunging tip and drawn up alae. In 20 patients at risk of losing projection, a strut alone failed in all but one, and in a further 20 given a graft fixed to the septum, projection was maintained or increased in all but one.

Rests on: Byrd et al., septal extension grafts · Brady et al. · Khetpal et al. · and tip support.

The skin is heavy and the nose has aged

In thick-skinned ptotic noses the excess skin can be removed through the dorsum. In a small series the mean nasolabial angle went from 72.9 degrees before surgery to 92 at three months and 91 at twelve, with less than 2 degrees of derotation in the patients followed for two years, and the NOSE score fell from 79.5 to 11.5.

Rests on: Ozturan et al., wide-open dorsal approach · Caterson et al. · and recovery.

What to ask about a drooping tip

Questions the evidence supports asking.

Did you look at my nose while I was smiling

The dynamic droop is invisible in a resting photograph. Ask whether the surgeon photographs the smile, and what they found.

Rests on: Tellioglu et al. · Kalantar-Hormozi and Beiraghi-Toosi.

Will you touch the muscle, and what does that do to my lip

Resection and transposition performed the same in the randomised comparison. The effect on upper lip length in repose was small and went in both directions, so ask what the surgeon tells patients to expect.

Rests on: Kalantar-Hormozi and Beiraghi-Toosi · Ho et al..

What holds the new tip position

Ask whether the plan fixes the medial crura to the septum, adds a graft, or relies on sutures alone. Tongue-in-groove also changes the slope of the upper lip on the profile, measured across 367 patients.

Rests on: Kocak and Gokler · Sazgar et al., upper lip slope.

Does my skin need to come out too

In an older nose with inelastic skin, reducing the frame can leave the skin redundant. Ask whether skin excision is part of the plan and where the scar sits.

Rests on: Caterson et al. · Ozturan et al..

The terms, defined

The words used about a tip that points down.

• Tip ptosis: the tip sitting lower than the plane the surgeon is aiming for. [22527586]
• Hyperdynamic tip ptosis: the tip dropping further on smiling. [22527586]
• Depressor septi nasi: the muscle running from the upper lip to the base of the columella. [25076456]
• Nasolabial angle: the angle between the columella and the upper lip, the number used for tip rotation. [33649928]
• Tongue-in-groove: suturing the medial crura onto the caudal septum to set tip position. [34644278]
• Columellar strut: cartilage set between the medial crura to support the tip. [33868871]
• Caudal septal extension graft: cartilage fixed to the caudal septum that the tip is set on. [33739380]
• NOSE score: the patient-completed questionnaire for nasal obstruction. [25480746]
• Maxillary incisor show: how much of the upper front teeth is visible when the patient smiles. [28032172]
• Transposition: moving the depressor septi nasi and reattaching it, rather than cutting it out. [10627007]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline on nasal form and function after rhinoplasty sets what should be assessed and recorded before the tip is repositioned. Its plain language summary is written for patients.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on setting tip position on the septum and on tip contour and support.

• Tongue in groove technique for nasal tip positioning
• Nasal Tip Contour and Support Management

The reference summary

Rhinoplasty Tip-Shaping Surgery and Anatomy, Head and Neck, Nose in StatPearls, on the National Library of Medicine's Bookshelf, cover the muscles and the tip manoeuvres in full text.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.

The trials in progress

• Unilateral Septal Extension Graft and Bilateral Septal Extension Graft in Droopy Tip, not yet recruiting, 34 participants.

What is not settled

• The strut against muscle release comparison is small and uneven, 29 patients against 11, and retrospective. [33868871]
• The randomised muscle study found no difference between resection and transposition, which leaves the choice to surgeon preference rather than evidence. [24469161]
• The effect of depressor septi resection on upper lip length was unpredictable, and no factor identified in the series predicted which direction it would go. [24830366]
• The drooping thick-skinned nose is reported in a series small enough that four patients carried the two-year follow-up. [25480746]
• Rhinoplasty in older patients rests on a literature the reviewers found to be nine articles, plus one institutional series of twenty-seven patients. [33739380]
• The muscle types were counted on 55 cadavers, and the clinical arm of the same paper was a single surgeon's 62 patients. Whether the type predicts the result has not been tested. [10627007]
• The septal extension graft was described in two groups of 20 patients in 1997 and is now the default. No trial has compared it with muscle release for the tip that droops on smiling. [9290671] [33868871]
• Tip position after tongue-in-groove was measured in 20 patients over weeks, not years. [25673570]
• Tip ptosis in the older nose is described consistently and measured rarely. The aging series are narrative rather than longitudinal. [4576001] [14737699] [8726428]
• Rhinoplasty changes how much tooth shows on smiling, and no series predicts by how much for a given patient. [28032172]