THE PTOTIC TIP (“DROOPY TIP”)
A common patient complaint is a ptotic nasal tip, otherwise known as a droopy tip or hooked nose. The tip of the nose typically points downward, and the appearance is commonly worsened with smiling. Patients seeking ptotic tip rhinoplasty desire a more upturned or rotated position for their nasal tip. Females typically desire a more upturned or upwardly rotated nose compared to males.
WHAT CAUSES A “DROOPY” PTOTIC TIP?
Aging is a common cause of the droopy nasal tip. As we age the support structures of the nose weaken, leading to downward descent of the type. Trauma can also result in a ptotic nasal tip if the support structures of the nose are injured. Some patients' noses may point downward naturally, without a definitive cause. Patients that complain of a plunging tip when smiling may suffer from muscle tightness. The depressor septi muscle runs between the base of the nose and upper lip. In cases of facial animation when smiling, overactivity of the muscle can lead to abnormal sagging of the tip.
PTOTIC TIP RHINOPLASTY
Many techniques are used to improve a ptotic nasal tip. In all cases, the goal is to rotate the tip upwards into a more aesthetically pleasing position. In cases of depressor septi muscle overactivity, the muscle fibers can be divided, resulting in less downward traction on the nasal tip especially when smiling. In cases of caudal septal excess, the caudal septum can be shaved which helps to shorten the septum, resulting in upward tip rotation. In cases of poor nasal tip support, cartilage grafts can be placed to provide more tip strength. The most common graft for this need is called the columellar strut graft. Cartilage is typically harvested from the septum, ear, or rib to create the graft. It is placed in a precise pocket created between the medial crura and secured in place to provide strength and support for the nasal tip.
A Columellar Strut Graft (Yellow) positioned between the medial crura to provide improved tip support.
Tip suture techniques can also be utilized to achieve improved tip rotation and projection. The “Tongue in Groove” technique is very useful for this purpose. In this technique, the medial crura are advanced onto the caudal septum and is positioned to create a more upturned tip. Lastly, a septal extension graft can also be used to achieve upward nasal tip rotation.
Both patients underwent rhinoplasty to correct a long nose with ptotic tip. Note the resulting upward rotation of the nose and shortening of the length of the nose to a more aesthetically pleasing proportion.