Official News of the International Society of Aesthetic Plastic Surgery – Dec 2020

Features of a droopy tip include inferior rotation of the tip and an acute nasolabial angle. Droopy tips can result from intrinsic or extrinsic factors or a combination thereof. The intrinsic factors are a long, lateral crus, a cephalic orientation of the lateral crus, or a weak, medial crus. The extrinsic factors responsible for droopy tips are tension nose (oversized septal cartilage), long upper lateral cartilage, or a weak tip or thick tip skin being pulled down by gravity.

The choice of surgical technique for the correction of a droopy tip depends on its etiology.

Lateral crural steal, lateral crural overlay¹ and tongue-in-groove² techniques are useful when a droopy tip is due to an intrinsic factor. Similarly, resection of oversized septum, long upper lateral cartilage and strengthening of the medial crura by columellar strut may be chosen depending on the extrinsic factor that is responsible for the droopy tip. Certain ancillary measures are also taken to aid the superior rotation of tip. Keeping in mind the tripod analogy, the medial crus fixation suture is used along with an interdomal stitch to allow the paired lower lateral cartilage to rotate in unison. Cephalic trim of lateral crus and/or excision of the scroll area may be required to create the space for superior rotation of tip. Lateral crural steal pulls the medial part of lateral crus into the middle crus by means of horizontal mattress suture. This, in addition to rotating the tip, also increases its projection. Lateral crural steal is indicated in droopy tips due to weak medial crura, evident by its buckled appearance (Figures 1a, 1b).

Lateral crural overlay entails transaction of its central part, followed by double breasting of the lateral and medial half, which is secured with a 5-0 nylon suture. This, in addition to rotating the tip, also decreases its projection. Lateral crural overlay is useful in droopy tips due to long lateral crura (Figures 2a, 2b).

Tongue-in-groove technique involves pushing the paired medial crura (the space between the medial crura being the groove) superiorly and securing it to the caudal part of the septum with a 5-0 nylon mattress suture. This technique is indicated when the superior rotation of the droopy tip is required without change in tip projection.

The open rhinoplasty approach is preferred as it allows excellent delineation of the cartilaginous framework. If present, the extraneous factors are first dealt with. For instance, in tension noses the septal cartilage is oversized in comparison to the bony component. This will result in the dorsal hump and the caudal septum pushing the nose down and into the lip. After the septal cartilage is released from its attachment, the dorsal and caudal strut are trimmed which allows the tip to rotate superiorly (Figures 3a, 3b).

In another patient, the caudal septum was elongated and deviated to the right causing a droopy tip (Figures 4a, 4b)

Sometimes a combination of factors may be responsible for droopy tip (Figures 5a, 5b).

n droopy tips, accurate delineation of anatomical causes helps plan a tailored surgical approach. This along with understanding the nuances of interplay of forces affecting the nasal tip appearance ensures a successful outcome.

REFERENCES

1. Foda HM, Kridel RW. Lateral crural steal and lateral crural overlay: an objective evaluation. Archives of Otolaryngology–Head & Neck Surgery. 1999 Dec 1;125(12):1365-70.
2. Kridel RW, Scott BA, Foda HM. The tongue-in-groove technique in eptorhinoplasty: a 10-year experience. Archives of facial plastic surgery. 1999 Oct 1;1(4):246-56.