Nasal tip rotation — Drooping tip and over-rotated tip
Why a tip droops, which manoeuvres rotate it, and how the shape of the resected caudal septal fragment determines the exact result.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- The tip droops from a tripod imbalance: long lateral legs, or a short or weak middle leg from insufficient medial crura or a hypotrophic anterior nasal spine.
- Drooping is not always structural: hyperactivity of the depressor septi and the alar levators produces it dynamically.
- The shape of the resected caudal septal fragment determines the result. Triangle, trapezoid and rectangle do three different things.
- When resecting the cephalic alar border, leave at least 5 mm intact, and know that the scroll ligaments are being divided.
- The over-rotated tip is almost never primary: it is the sequela of an over-shortened nose, and correcting it is among the hardest tasks in rhinoplasty.
What rotation is and what accompanies it
The tip may be drooping or elevated, primarily or as a sequela. The drooping tip is always accompanied by three things: a closed nasolabial angle, increased nasal length and, to a greater or lesser degree, breathing difficulty. Recognising the whole picture matters, because treating the tip without accounting for nasal length leaves the profile unbalanced.
The tripod explains why it droops
The tip is supported like Anderson’s tripod. Drooping results from imbalance between its legs, and there are only two ways to unbalance it. Either the upper legs are too long — excessive length of the lower lateral cartilages — or the middle leg is short or weak: short or weak medial crura, or a hypotrophic anterior nasal spine. The caudal septum also plays a part: it is what prevents the base retracting and the columellolabial angle closing.
The muscular cause, easily overlooked
Not every drooping tip is structural. There is a muscular constriction of the tip from hyperactivity of the depressor septi and Pitanguy’s ligament, acting synergistically with the alar levators. The mechanism is twofold: the former lower the tip directly on contraction, and the latter elevate the alae, which also lowers the tip. It is identified by asking the patient to smile — the tip visibly drops — and its treatment differs: muscle division or resection, not grafts. If unrecognised, surgically obtained rotation is lost.
Other causes of a drooping tip
- Senile nose: age-related loss of ligament strength and elasticity, compounded by gravity.
- In operated noses, the commonest cause: excessive shortening of the posterior caudal septum at the anterior nasal spine, or over-resection of the spine itself. It also increases upper lip height.
- Angulation of the lower lateral cartilages after previous surgery.
- Cicatricial columellar retraction or persistence of untreated muscular constriction.
Two mandatory steps before rotating
Whatever the cause, treatment always requires two things. First, degloving and redraping of the dorsal skin: if the envelope does not follow, it pulls the tip back. And second, complete release of the ligaments that fix the alar cartilages laterally at their lower portion, without which the cartilage cannot rotate however much is resected. This is why technically correct rotations recur: the manoeuvre was performed but the structure preventing it was not released.
What upward rotation means
Upward rotation consists of elevating the columellar plane through a cephalic movement of the tip, and it entails shortening the nose. One geometric point is worth being clear about: if the arc described by the rotation keeps the same radius from the facial plane, projection does not change. That is, rotating and projecting are independent as long as the radius is respected; when it is not, projection is gained or lost without intending it.
The shape of the caudal septal fragment decides the result
| Shape resected | Effect |
|---|---|
| Triangle with anterior base | Rotates the tip upward without changing upper lip height, and increases the columellolabial angle. Shortens the nose |
| Trapezoid with anterior or superior base | Rotates the tip — the larger the superior base, the greater the rotation — and also elevates the nasal base in proportion to the shorter base |
| Rectangle | Elevates the nasal base as a block. Shortens the nose without changing the nasolabial angle, but increases upper lip height |
Manoeuvres that rotate the tip upward
- Resection of a wide strip of the cephalic alar border, with the rotation point at the junction of the alar and sesamoid cartilages.
- Resection of the caudal septal border, shaped according to the desired effect.
- Lateral crural overlay: division and overlapping of the alar crura. Especially useful with simultaneous over-projection and ptosis, because it rotates and repositions with excellent control.
- Shortening the caudal border of the lower or upper lateral cartilages, and resecting the cephalic portion of the medial crura.
- With an inadequate anterior nasal spine or ineffective medial crura: a columellar strut or an inferiorly based caudal extension graft.
- Fixing the medial crura to the caudal septum, or the alar cartilages to the anterior septum or upper laterals, to maintain the rotation achieved.
The limit of cephalic resection: 5 mm
The rotation achieved by resecting the cephalic alar border is limited by cartilage strength and by the width left intact, which should not fall below 5 mm. And one must be aware of what is being done: resecting that strip divides the ligaments between upper lateral and alar cartilages, and retraction of that scar can produce tip deformities and bossae. If more rotation is needed, it is preferable to create a second rotation point by resecting a triangle of cartilage in the mid-portion of the alar cartilages — apex inferior, base superior — preserving the vestibular skin.
The three complications of rotating
- Recurrence: the tip droops again, almost always from insufficient release or untreated muscular constriction.
- Overcorrection: excessive tip shortening or reduction of nostril size.
- Tip distortion. Particular care in thin skin: any edge of divided cartilage may become visible.
Over-rotated tip: the short nose
The nose with an elevated tip and open nasolabial angle — short nose or pig-snout deformity — is rare as a primary alteration. It is almost always the sequela of excessive shortening during rhinoplasty, from inexperience or from following an aesthetic now abandoned: the so-called Parisian nose, which sought rejuvenation by reproducing a childlike format — short, flat, upturned, with visible nostrils. In many such cases the short nose is compounded by a saddle nose.
The nuance: resecting caudal septum is not an error
Do not draw the wrong conclusion. Caudal septal resection is a routine and correct procedure in very long noses with a drooping tip, because it is what allows the skin to retract, the tip to rise and the nose to shorten. The problem is not the manoeuvre but the amount: excessive rotation comes from over-resecting — or from excessive treatment of the lateral cartilages, which then lose the capacity to resist cicatricial retraction.
Correcting a short nose: why it is so hard
The principle is the inverse of what caused the problem: if the nose was shortened by resecting caudal septum, it is lengthened by placing a caudal extension graft that compensates the defect and lowers the tip. But in severe cases there are two problems at once, and the second complicates everything: cartilage deficiency is compounded by fibrous retraction preventing expansion. Lengthening the cartilaginous framework is the easy part; overcoming the fibrosis is the hard one.
Short nose: the two fronts
- Lengthening the cartilageCartilage graft in the membranous septum or caudal extension graft fixed to the caudal septum. If cartilage is short, the perpendicular plate of the ethmoid
- Overcoming the fibrosisReleasing incisions in the scarred areas, cautious removal of fibrosis, or intraoperative tissue expansion
- If lining is missingAuricular chondrocutaneous graft or septal chondromucosal flaps, to compensate for inadequate mucosa
References
- 1.Arquero P. Alteraciones nasales: rotación. rinoplastia.eu.
- 2.Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol. 1984;110(6):349-358.
- 3.Constantian MB. The two essential elements for planning tip surgery in primary and secondary rhinoplasty: observations based on review of 100 consecutive patients. Plast Reconstr Surg. 2004;114(6):1571-1581.
- 4.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
Related specialty: Rhinoplasty