Multifactorial approaches for correction of the drooping tip of a long nose in East asians

Abstract

A long nose with a drooping tip is a major aesthetic problem. It creates a negative and aged appearance and looks worse when smiling. In order to rectify this problem, the underlying anatomical causes should be understood and corrected simultaneously to optimize surgical outcomes. The causes of a drooping tip of a long nose are generally classified into two mechanisms. Static causes usually result from malposition and incorrect innate shape of the nasal structure: the nasal septum, upper and lower lateral cartilages, and the ligaments in between. The dynamic causes result from the facial expression muscles, the depressor septi nasi muscle, and the levator labii superioris alaeque nasi muscle. The depressor septi nasi depresses the nasal tip and the levator labii superioris alaeque nasi pulls the alar base upwards. Many surgical methods have been introduced, but partial approaches to correct such deformities generally do not satisfy East Asians, making the problem more challenging to surgeons. Typically, East Asians have thick nasal tip soft tissue and skin, and a depressed columella and alar bases. The authors suggest that multifactorial approaches to static and dynamic factors along with ancillary causes should be considered for correcting the drooping tip of the long noses of East Asians.

Keywords: Esthetics; Nose; Rhinoplasty.

Fig. 1

Static and dynamic causes of drooping tip in long noses (A) Static causes usually result from large and long alar cartilages with the distal septum placed downward. (B) Dynamic forces of the depressor septi nasi muscle and levator labii superioris alaeque nasi muscle worsen the drooping tip when smiling.

Fig. 2

Algorithm for surgical correction of drooping tip To correct the drooping tip, first, five basic procedures for building and maintaining adequate tip projection are performed, and then additional procedures can be considered. SMAS, superficial musculoaponeurotic system; ANS, anterior nasal spine.

Fig. 3

Lateral crus stealing technique A proximal portion of the lateral crus (red line) is advanced medially by a horizontal mattress suture, resulting in tip projection and upward rotation by tip gathering on the columellar strut.

Fig. 4

Correction of a hanging columella In the long septum, the distal part can be excised to create a space for the medial crus to be moved upwards. Further, the batten graft or columellar strut is used for ensuring the stability of the medial crus and for tip projection with upward rotation, and two or three layers of cartilage grafts including onlay tip graft, shield graft, and/or cap graft are performed for tip definition.

Fig. 5

Turn-up cartilage flap (A) This picture shows how the cartilage flap is created with the pedicle base located on the domal portion of the alar cartilage. (B) The flap is then attached to the anterior septal angle to secure the nasal tip in its upwardly rotated position.

Fig. 6

Excision of the depressor septi nasi muscle The depressor septi nasi muscle between the foot plates of the medial crus and the dermocartilagenous ligament (Pitanguy's ligament) connecting the supratip area should be removed. The excised soft tissue can be rolled and inserted in front of the anterior nasal spine to eliminate the dynamic tip drooping forces and augment the acute columella-labial angle.

Fig. 7

Columellar base augmentation using V-shaped implant The anterior nasal spine is exposed by an intraoral approach, and a V-shaped silicone implant is inserted.

Fig. 8

Perialar augmentation using silicone implant After the intraoral incision, the levator labii superioris alaeque nasi muscle is dissected in the alar base, and a breakwater stone-shaped silicone implant is inserted under the periosteal dissection to elevate the alar base.

Fig. 9

Debulking of bulbous drooping tip To correct the drooping and bulbous tip and remove the bulky tissues, the redundant fat and the nasal superficial musculoaponeurotic system layer after the subcutaneous dissection should be removed at the supraperichondrial level.

Fig. 10

Photographs of case 1 patient (A) Preoperative frontal view when smiling. (B) Twenty-month postoperative frontal view when smiling.

Fig. 11

Photographs of case 2 patient (A) Preoperative lateral view when smiling. (B) Two-month postoperative lateral view when smiling.