Tip Droop Prevention in Rhinoplasty: Dynamic Effect of Strut Graft on Smiling versus Depressor Muscle Release

Abstract

Background: Aesthetic rhinoplasty is one of the most challenging procedures performed by aesthetic surgeons. Tip droop, especially on smiling, may not be noted by the surgeon postoperatively but can be concerning to patients. Our aim was to determine if the division of the depressor septi nasi or its combination with a columellar strut graft during rhinoplasty produce a measurable reduction in nasal tip droop on smiling.

Methods: A retrospective casenote and photograph review was conducted on patients who had undergone aesthetic endonasal rhinoplasty, performed by a single surgeon between 2015 and 2019. In total, 29 patients had release of the depressor septi nasi muscle, whilst 11 had release of the muscle along with a strut graft. Lateral smiling photographs were taken postoperatively. Tip droop was measured as a variation of the nasolabial angle from rest to smiling using the Frankfurt line.

Results: Photographs were taken at a mean of 14 months postoperatively. In the group who had muscle release only, a mean increase in nasolabial angle of 3.66 degrees was seen when smiling when compared with rest. In the group who had muscle release combined with strut graft, a mean increase of 2.27 degrees was seen. When using a columellar strut along with muscle release, tip droop on smiling was reduced.

Conclusions: This study demonstrates that columellar strut grafting in combination with muscle release can alleviate drooping of the tip better than muscle division alone after rhinoplasty. The columellar strut graft provides tip stability and can therefore be used to enhance dynamic outcomes after rhinoplasty.

Fig. 1.

Nasal dissection during rhinoplasty demonstrating insertion of depressor septi nasi muscle at the nasal spine.

Fig. 2.

Example photographs taken for all patients pre and postoperatively. In addition to the standard set of 6 views, we always take a “maximum smile” view. A gentle smile is insufficient to asses dynamic tip movement. Patients are asked to smile and grit their teeth to achieve maximum smile impact of all muscles acting on the tip. The top image shows a droop of 3.1 degrees on maximum smiling, and the bottom image shows a droop of 3.8 degrees. A, Gentle smile view. B, Maximum smile view. C, Gentle smile view. D, Maximum smile view.

Fig. 3.

Measurement of nasolabial angle. The nasolabial angle was measured by the same observer in both smiling and neutral positions. The nasolabial angle was defined as the angle between the line drawn through the midpoint of the nasal aperture and a line drawn perpendicular to the Frankfurt horizontal whilst intersecting the subnasale.

Fig. 4.

Protractor measurements of nasolabial angle showing angle at rest and during smiling. As the tip drooped on smiling, the angle was reduced. The smaller the angle, the more the tip droop became apparent. The smaller the angle, the more the patient sensed that they did not like their tip when they smiled in photographs. As a result, some patients avoided smiling in photographs. The images demonstrate a change of +3 degrees of droop on smiling. A, nasolabial angle measured with gentle smile; B, nasolabial angle measured with maximum smile.

Fig. 5.

Marking of hemi-transfixion incision. This endonasal approach preserves Pitanguy ligament and allows access for a pocket to be created in the midline between the medical crura for the strut. It also allows access for division of the depressor nasi muscle.

Fig. 6.

Dissection before columellar strut insertion. The medial and lateral crura are fully exposed to allow intra-domal sutures to be placed. The pocket for strut placement can also be measured accurately in realtime as the skin envelope is intact. During open rhinoplasty, the skin tension can distort the final tip position after skin closure.

Fig. 7.

Columellar strut. This image shows the typical size and shape of the strut. The precise length and shape is adjusted for each patient. It is placed between the medial crura and sutured in place with 5/0 PDS. The strut should ideally sit on the maxilla for stability, although the sutures provide the greatest contribution to long-term stability. The septum is the ideal graft harvest site because the cartilage is stiff enough to provide support and the harvest site is easy to access. Rib cartilage is also of excellent quality, but many patients and surgeons prefer to avoid the donor site issues. Conchal cartilage from the ear is generally too soft to provide support unless re-enforced with sutures.

Fig. 8.

Dynamic smile outcome of a 41-year-old patient 15 months after division of depressor nasi muscle and columellar strut for support. The patient had required tip support on smile and therefore the strut was used. The combination of the strut and muscle division has helped prevent drooping of the tip related to activity of the SMAS and depressor muscles. The nasolabial angle droop has been reduced by 2.3 degrees. A preoperative assessment of dynamic smile changes is required to provide appropriate support during rhinoplasty. A, Preoperative gentle smile view. B, Preoperative maximum smile view. C, Postoperative gentle smile view. D, Postoperative maximum smile view.

Fig. 9.

Dynamic smile assessment for 38-year-old patient 19 months after rhinoplasty with the division of depressor nasi muscle alone. Although drooping of the end of the nose is improved by dividing the muscle alone, the effect is less than if a strut is used in addition for tip support. In this case, the reduction in nasolabial angle was only 2.9 degrees. Muscle division alone without strut support is 18% less effective in preventive dynamic tip droop when smiling. A, Preoperative gentle smile view. B, preoperative maximum smile view. C, Postoperative gentle smile view. D, Postoperative maximum smile view.

Fig. 10.

Three-dimensional planning using surface laser rendering helps analyze the details of the tip with the greatest accuracy (Crisalix Software, Switzerland). The patients in this series found the images valuable in planning their operation and assessing the dynamic movements before and after surgery. However, the lack of accuracy is a drawback, as the 3D image does not always reflect the emotions of the patient nor the skin tone in different lighting. A, Preoperative appearance. B, Proposed results from rhinoplasty.