Tip Ptosis Research Articles

Correcting Different Degrees of Droopy Nose, an Overview of Techniques and Strategies at Tertiary Facial Plastic Center. A Retrospective Analysis.

The variety of noses in the mixed Saudi population keeps rhinoplasty surgeons on their toes. The main treatment goal for drooping nose tips is the first rotation of the nasal tip superiorly. Although droopy nose is a common disease in Saudi Arabia, none of the previous studies recognized the general features of droopy nose. A retrospective analysis of 352 patients with nasal drooping nose from 2016 to 2022. The main outcome measurements were general characteristics of nasal tip ptosis, and the most common surgical techniques used to treat nasal tip ptosis in a tertiary hospital. Analysis of 352 patients with droopy nose showed that 29.0% were between 25 and 29 years old, and 56.3% were female patients. The most common characteristic seen with droopy nasal tip was a significant dorsal hump in 64.8% of patients, followed by amorphous, boxy, and bulbous nasal tip in 33.5%. Significant dorsal hump and bifid tip were more common between 18 and 24. Meanwhile, amorphous, boxy, and bulbous nasal tip were more common in female individuals. The surgical techniques mostly addressed the underlying cause, which was tip grafting (83.0%), lateral osteotomy (77.3%), hump removal (66.5%), lateral crura method (61.9%), and septal extension graft (40.9%). The research concluded that the surgeon should be familiar with the patient's underlying cause of nasal tip ptosis and use surgical techniques accordingly. To get a pleased long-term outcome, it is often essential to repair the inferiorly rotated tip using more than one surgical approach.

Medial Crural Auto-rim Flap in Primary Open Rhinoplasty

Background: Aging significantly affects the nasal tip and columella; thus, weakening of fibroelastic attachments in the scroll area and intercrural suspensory ligaments results in tip ptosis, separation of the medial crural footplates, and expansion of the membranous septum.Aim: Thus, we focused on a new technique to maintain tip support without grafting and treat columellar-hanging deformity by folding in the caudal edge of the medial crura as a flap instead of trimming it in patients undergoing open aesthetic rhinoplasty.Patients and Methods: In this prospective-observational study, 37 patients were enrolled between July 2020 to January 2022 at Sulaimani Plastic, Burn and Reconstructive Surgery Hospital and Royal Private Hospital in Sulaimani, Republic of Iraq. After asking the age of the patients, all participants were appropriately prepared for the surgery and underwent primary open rhinoplasty for columellar hanging deformity correction.Results: We found that all enrolled patients were satisfied with their nasal shape except one patient who complained about the columellar region's appearance but without the need for revision. Also, the objective assessment of the nasal tip support showed good maintenance upon the follow-up time for patients despite the lack of cartilage graft in the tip area.Conclusion: In the medial crural auto-rim flap technique, the excess caudal medial crural cartilage could be used as a flap instead of trimming it despite concomitant tip support intercrural augmentation and correction of the columellar hanging deformity.

The Rhino-Lip-Lifting: A Novel Proposal for Midface Profileplasty Performed as a Single Surgical Procedure.

As facial aging occurs, aesthetic changes of the nasal tip and the senile upper lip include tip ptosis, increase in skin length, loss of vermillion height and Cupid's bow, and vertical wrinkles.Regardless of the rejuvenation procedure, the lips are not to be considered as a single anatomical entity, instead they should be placed in a strong correlation with the nose. The aim of this study is therefore to demonstrate the effectiveness of the association of primary closed rhinoplasty together with indirect subnasal lip-lifting technique.A total of 45 patients were enrolled in this study and underwent primary closed rhinoplasty with indirect subnasal lip-lifting. The result showed an overall average nasolabial angle width reduction of 10.9% and lip length shortening of 23.5%, as assessed 1 year after the surgical procedure. When comparing before and after photographs and using the Subjective Global Aesthetic Improvement Scale (sGAIS), the overall satisfaction was rated 4.4 on 5, as "much improved."The authors show that lips should not be considered as a single anatomical entity but that they indeed must be placed in a strong correlation with the nose since a droopy nasal tip is likely to be considered unattractive and is often associated with the appearance of a long nose with covered philtrum and upper lip.Tip rotation to a normal nasolabial angle width could grant a beneficial impact on overall nose aesthetics; however, it may not fully balance the midface profile as it is the "lip position-to-incisal show" ratio that defines beauty, whereas the balance among forehead, nasal tip, upper lip, and chin is what defines the contour of harmonious profiles.This is the first patient series to show that the combination of closed rhinoplasty and indirect lip-lifting is a highly effective, safe, and reliable procedure to address profile rejuvenation.

Rhinoplasty in the Older Adult.

Rhinoplasty in older adults requires unique consideration of the aging nose. The purpose of this study was to systematically review the literature pertaining to rhinoplasty in the aging population, review the senior author's experience, and describe techniques aimed at addressing age-related features. It was hypothesized that consistent age-related nasal dysmorphology is described in the literature and standard rhinoplasty techniques may effectively address these changes. Furthermore, it was hypothesized that rhinoplasty is more commonly performed for posttraumatic and functional indications than for aesthetic reasons. A literature review including publications describing rhinoplasty in patients over 55 years old was conducted. Additionally, a retrospective review of the senior author's cases was performed. Pre- and postoperative photographs were used to compare anthropometric changes. Demographic factors, surgical indications, and operative details were collected. Nine articles met the study criteria. Manifestations of the aging nose included soft tissue atrophy, bony fragility and resorption, tip ptosis, internal and external valve collapse, and worsening dorsal hump. Twenty-seven patients were included in this institutional review. Primary indication for rhinoplasty was posttraumatic deformity in 17 (63%) patients and nasal obstructive symptoms in 10 (37%) patients. Tip refinement and ptosis were addressed through tip grafts (70%), columellar struts (26%), and caudal septal extension grafts (67%). Nasal obstruction was relieved through septoplasty (96%), turbinate ablation (85%), and spreader grafts (70%). This study presents a systematic review of rhinoplasty in the older adult as well as a retrospective review of the senior author's patients. Unique considerations specific to this population should be integrated into treatment planning.

Restoring Balance and Symmetry to the Aging Nose

Accurate assessment of facial symmetry is a key component of successful rhinoplasty surgery but is often overlooked by both surgeon and patient. Up to three-quarters of patients with a significantly crooked nose have been found to have concurrent marked facial asymmetry. Whilst not a contraindication to rhinoplasty, provided that facial asymmetry is identified in advance and expectations realistic, the correction of nasal deformities can improve perceived facial asymmetry. In the aging face, aside from soft tissue and bony resorption that can amplify facial asymmetry, there are specific surgical challenges to the aging nose; the normal tip support mechanisms deteriorate with age giving rise to distinctive changes to the aging nose-typically tip ptosis and a hanging columella; bone quality becomes more brittle and skin overlying this area becomes thinner. There is also weakening of the external nasal valve thus causing functional impairment too. As a result, rhinoplasty techniques used in younger patients may not be suitable in the aging nose. In this article, the authors describe their experience and outline the evidence on the management of the aging patient with facial and nasal asymmetry.

COMPLICATIONS AND MANAGEMENT OF ENDOSCOPIC SEPTOPLASTY AT A TERTIARY CARE CENTER IN INDIA

Introduction: Septoplasty for nasal septal deviation is one of the most commonly performed surgeries by the otolaryngologist. Though various surgical techniques have evolved for correction of a deviated septum, complications are still common. Method: A prospective study of 90 patients of symptomatic nasal septal deviation was done to investigate for development of complications after endoscopic septoplasty. Complications were catagorised into early, occurring within 7 days and late, usually detected within three months after surgery. Results; Most common early complication was haemorrhage seen in overall 16.66% of patients. 6.66% had primary hemorrhage during surgery and 8.88% had reactionary hemorrhage within 24 hours of surgery. Secondary hemorrhage and septal hematoma was rare(1.1%) . Most common late complication was persistence of subjective symptom of nasal blockage(15.55%) followed by nasal synache(5.55%). Septal perforation and vestibular stenosis are less common(1.1%). CSF leak, saddle nose, nasal tip ptosis or any ocular complications were not seen in any patient. Conclusion:. Meticulous preoperative planning with precise surgical techniques during endoscopic septoplasty can reduce the risk of complications that may have a profound effect on the functional and aesthetic aspects of a person’s life.

Sublabial Approach to Tip Rhinoplasty: A Cadaver Model

Objectives The main objective of this study was to investigate the utility of the sublabial approach in gaining proper exposure for tip rhinoplasty maneuvers in a cadaver model. Additional objectives included identifying types of grafts that can be placed sublabially and whether these methods can be translated successfully to human subjects. Methods Ten (N = 10) fresh-preserved cadavers were dissected at our academic institution from August 18, 2019 through February 5, 2020. Photographs of the cadavers were taken with permission from the anatomy laboratory manager using an iPhone 10 (Apple Inc., Cupertino, CA). Standard rhinoplasty views were taken of all ten cadavers. Results Grafts were harvested and designed from septal (80%), auricular (50%) and rib cartilage (40%). The division of depressor septi muscle was accomplished in all ten (100%) cadavers to address tip ptosis. Placement of the columellar strut and shield grafts resulted primarily in the improvement of nasal projection as well as rotation in all (100%) cadavers. Premaxillary augmentation was not always indicated but helped to improve an acute, retrodisplaced nasolabial angle in three (30%) cadavers. Lateral osteotomies via this approach addressed the nasal bony pyramid in all ten (100%) cadavers. The swinging door technique enabled correction of the caudal septum in six (60%) cadavers. Conclusions Several rhinoplasty techniques can be successfully performed on cadavers via the sublabial approach and we hope this work can be translated to human subjects.

Rhinoplasty in the aging patient

Aging can slowly affect the appearance and function of the nose. Rhinoplasty is becoming a more common procedure for older patients seeking reversal of these effects on their nasal form and function. A number of anatomical changes contribute to the classic changes in the aging nose: tip ptosis and a dorsal hump or pseudohump. The preoperative evaluation is critical in this patient population in which comorbidities are almost guaranteed and the risks of general anesthesia may frequently outweigh the benefits of the procedure, especially when solely cosmetic. Furthermore, the patient's chief complaint—aesthetic, functional, or both—must be explored and considered in choosing operative techniques. In older patients, multilevel surgery and more aggressive techniques are often needed to provide a substantial improvement than in younger patients. We advocate for a graduated approach that may include tip work, septoplasty, nasal valve correction, augmentation of the maxilla, and skin and rhinophyma excision.

Modified Rhinolift: A Minimally Invasive Technique for Age-Related Tip Ptosis

As one ages, the structure of the nose undergoes a number of changes, leading to alterations in form and function. Patients with no previous history of nasal issues may present with age-related nasal obstruction later in life. Tip ptosis is a well-recognized etiology of nasal obstruction in the aging patient.

Triangular excision and submucosal rejoining to correct horizontally folded caudal nasal septum.

Surgical correction of severe caudal deviation of nasal septum using an endonasal approach is challenging for surgeons. Among cases of severe caudal septal deflection, fracture lines along the horizontal direction are occasionally encountered during the surgery. We devised a simple and efficient technique called "triangular excision and submucosal rejoining" to address this kind of deformity. A total of 9 patients with severe caudal septal deflection underwent "triangular excision and submucosal rejoining." After the removal of the deformed posteroinferior portion of the quadrangular cartilage, 2 incision lines were made on the remaining caudal septum, starting from a point at the most anterior portion of the fracture line and diverging posteriorly above and below the fracture line. After removing a triangular cartilaginous piece, the upper and lower remaining cartilage segments were approximated using a single or 2 simple interrupted sutures. Sutures exiting the mucosa were re-entered from the exit point so that all the sutures were buried underneath the mucosa while the mucosal flap was elevated only unilaterally. This technique was effective in all cases. Septal batten grafts were applied in 3 patients, in whom the remaining quadrangular cartilage was weak and thin. One patient showed a mildly recurred septal deviation, but the nasal cavities remained patent with no symptoms. Serious complications such as dorsal saddling or tip ptosis did not occur in any cases. "Triangular excision and submucosal rejoining" may be a safe and efficient septoplasty technique to correct a horizontally folded caudal septum.

A novel and cost-effective technique for securing the nasal septum to the anterior nasal spine in septoplasty and/or rhinoplasty surgery

SummarySeptoplasties and septorhinoplasties are common procedures in otolaryngology, aimed at addressing septal and/or bony pyramidal deflections to improve functional and cosmetic outcomes. The nasal septum as well as regulating air flow provides structural support to the nasal tip. The attachment of the nasal septum to the anterior nasal spine must be structurally resilient to prevent saddling or tip ptosis. This can be achieved by direct attachment with absorbable suture material to the periosteum of the anterior nasal spine or a drill fitted with 0.6 mm diamond tip burr (Ultrabur, Invotec International), to create channel through which the nasal spine can be secured to the anterior nasal spine. We describe a novel, and cost-effective alternative utilising a blunt fill needle and simple absorbable suture. A blunt fill needle (Sol-Millenium®, cost £0.03 per unit) is passed through to form a securing channel. The neoseptum is then secured using a figure-of-eight suture. Our novel technique enables the nasal septum to be secured to the anterior nasal spine in a cost effective and efficient manner.

Association of Dorsal Reduction and Tip Rotation With Social Perception.

Social perception by laypersons of people who have undergone rhinoplasty primarily for cosmetic purposes has not been fully described. To evaluate the social perception of patients who have undergone cosmetic rhinoplasty. Preoperative images of 4 patients with dorsal hump and tip ptosis were selected using the Delphi method. Computer simulations of dorsal hump reduction and tip rotation, alone or in combination, were performed. Using the Qualtrics internet-based survey platform, laypersons blinded to the purpose of the study viewed randomized original and simulated images and estimated the age, approachability, perceived success, overall health, intelligence, and rated their attractiveness on a visual analog scale from 0 to 100. Comparison of responses (mean [SD] score) for each of the 3 types of simulated image against the original image employing a pairwise comparison of means (Dunnett test). After excluding 27 (4%) invalid responses, a total of 813 respondents (593 women and 220 men) were included in the study. The mean (SD) age was 44.6 (16.2) years. A total of 628 (77%) respondents were white and the observed highest level of education was a bachelor's degree (193 [24%]) or having attended college but without a diploma (194 [24%]). A significant age reduction (31 [10] years; 95% CI, -2.5 to 0; P = .04) and an increase in approachability (64 [22]; 95% CI, 0.7-5.8; P = .009), attractiveness (60 [22]; 95% CI, 4.0-9.4; P < .001), and health (70 [19]; 95% CI, 0.7-5.2; P = .006) for the simulation involving hump reduction was observed. When combined simulation of dorsum and tip rotation were tested, only significant increases in attractiveness (60 [23]; 95% CI, 3.6-9.0; P < .001) and health (69 [19]; 95% CI, 0.1-4.6; P = .03) were seen. No significant association was found for any of the responses when the tip alone was rotated. The Wilks λ varied slightly below 1.0 showing significant P values (P < .05) for all variance and covariance (respondent particulars). Though rhinoplasty procedures for nasal cosmesis involving both the nasal dorsum and tip were perceived to make a person more attractive and healthier, these results suggest that manipulation of the dorsum is more strongly associated with perception of the nose. NA.

Transcutaneous Columellar Strut for Correcting Caudal Nasal Septal Deviation

Correction of caudal septal deviation is a challenging issue because of its significant role in tip support mechanisms. Some interventions especially aggressive resection of caudal septum to correct deviation, may compromise external nasal valve, tip ptosis and persistence of nasal obstruction. Many surgical techniques have been suggested to correct this type of nasal septal deviation. This study presents a technique to correct caudal septal deviation without weakening of tip support mechanisms. To evaluate the efficacy of insertion of a transcutaneous columellar strut during correction of caudal septal deviation. The study was performed in patients complaining from nasal obstruction with caudal septal deviation. After intranasal incision and elevation of mucoperichondrial flap, Caudal septum released from anterior nasal spine (ANS) and a band of cartilage removed from inferior and caudal part of septum and septum again fixed to ANS. Through a vertical transcutaneous incision, a cartilaginous strut is placed in columella, between medial crurae. Preoperative and postoperative NOSE score determined and photographs were taken. In 14 patients we performed this technique, the postoperative NOSE score showed significant improvement, (p = 0.001). Nasal breathing improved in all patients without any complication or tip ptosis or worsening of nasal appearance. This septoplasty technique along with placement of transcolumellar strut, is an easy, efficient and complication free method for simultaneously correction of caudal deviation of nasal septum, reinforcing external nasal valve and prevents tip ptosis.

Nasal tip ptosis and some of its causes in patients who referred for rhinoplasty

Introduction:Nasal tip ptosis or droopy nose tip is a fairly common nasal deformity. Given the importance of correcting nose tip in rhinoplasty and the need to diagnose the causes of tip ptosis.Aims:The current study was performed aimed to investigate the frequency of the causes of this deformity in rhinoplasty candidates.Methods:In this cross-sectional study, 257 patients (205 women and 52 men; mean age: 26.6 ± 1.7 years old) who came to Amiralmomenin Teaching Hospital of Rasht for rhinoplasty in 2011- 2012 were selected by simple sampling method. The contributing factors that led to tip ptosis were diagnosed and recorded based on the results of preoperative and the intraoperative clinical observations.Results:In this study, 44% (113 patients) of the patients had tip ptosis. Statistically, no significant difference was observed between the incidence of tip ptosis in men and women (p=0.504). The prevalence of tip ptosis among patients older than 40 years old was significantly greater (p=0.039). Based on the results of preoperative and intraoperative observations, long caudal septum was the most important cause of tip ptosis. The most common coordination between the causes of tip ptosis in preoperative and intraoperative observations was the thick skin of nose lobules.Conclusion:It seems that nasal tip ptosis is common in our rhinoplasty subjects, and there is only a partial correlation between the mentioned causes of tip ptosis in preoperative and intraoperative assessments, hence more consideration is required for a precise diagnosis of tip ptosis.

A novel technique for the quantitative examination of nasal tip support.

We proposed a novel technique for the quantitative examination of tip recoil. The technique measures nasal tip strain as an objective measure of tip recoil. We used the term tip recoilometry to refer to this measurement technique. We performed case studies in two phases. Phase 1 included 30 candidates with normal tip recoil and 30 candidates with weak tip recoil. Phase 2 included 40 patients who had undergone open rhinoplasty surgery by either columella strut or caudal extension graft methods. We evaluated tip support of patients 1 year after the surgery. The nasal tip strain of normal target group before any surgery was 0.158 and that of the patients with nasal tip ptosis was 35% more than that of the normal target group. The methods columella strut and caudal extension graft achieved 43% and 74% nasal tip strain reduction, respectively. The proposed technique can help a surgeon to select a proper plan and to evaluate the success of the surgery.

The Causes of Persistent and Recurrent Nasal Obstruction After Primary Septoplasty.

Septoplasty is the most frequently performed surgical procedure in patients with nasal obstruction. However, nasal obstruction may persist or recur after septoplasty in some patients. In this study, the authors aimed to determine the causes of nasal obstruction after septoplasty. Fifty consecutive patients who admitted to our clinic with the complaints of persistent or recurrent nasal obstruction after primary septoplasty and had revision surgery between 2011 and 2015 were included in this study. Demographic data and physical examination findings of the patients were recorded. There were 33 men (66%) and 17 women (34%) with a mean age of 37.3 ± 10.5 (range, 21-57) years. Deviation of perpendicular plate of ethmoid bone (44%), inferior turbinate hypertrophy (36%), concha bullosa (26%), caudal septal deviation-nostril asymmetry (20%), and alar collapse (6%) were the pathologies that were unaddressed during primary surgery. The iatrogenic causes of nasal obstruction after septoplasty were collumellar retraction-nasal tip ptosis (46%), nasal synechiae (20%), nasal septal perforation (10%), and saddle-nose/flat nose deformity (10%). Iatrogenic deformities due to surgery and pathologies ignored during primary surgery may cause persistent/recurrent nasal obstruction after primary septoplasty. A detailed physical examination and objective tests showing the site of nasal obstruction, an extensive surgical plan that covers all diagnosed pathologies, and a careful postoperative care must be undertaken to prevent undesired postoperative results.

Rejuvenation of the ageing upper lip and nose with suspension lifting.

There are growing number of patients attending aesthetic consultations and requesting the rejuvenation of ageing upper lips. Often these patients also have nasal tip ptosis. There are a number of direct and indirect upper lip lifting procedures. We describe a novel technique, which combines upper lip and nasal tip rejuvenation through hidden incisions and the use of suspension micro-screws.

Skin Excision as an Adjunctive Technique to Rhinoplasty in Middle-Aged and Elderly Patients.

Rhinoplasty in middle-aged and elderly patients comes with its own set of challenges. There is relative lengthening of the nose with drooping of the nasal tip. With aging, the skin loses its elasticity, and the combination of nasal skeletal reduction along with overlying inelastic skin provides a setup for skin redundancy and poor postoperative outcome. We describe a surgical technique involving lenticular skin excision as a part of rhinoplasty in 12 patients older than 50 years to improve the aesthetic outcome. Skin width up to 1.6 cm was excised. Included is a literature review of skin excision in rhinoplasty. In elderly patients with thin, inelastic skin and long nose with a drooping tip, a reduction rhinoplasty technique might result in skin redundancy. Lenticular skin excision along the radix of the nose in these 12 patients improved the aesthetic outcome by decreasing the redundancy and preventing nasal tip ptosis. The wound from the skin resection healed in all the patients with minimal scar, and no complication was noted after at least 1 year of follow-up for each patient.

Caudal extension graft versus columellar strut with plumping graft for acute nasolabial angle correction in rhinoplasty surgery.

Nasal tip support is an important factor to be considered in rhinoplasty surgery. There are several techniques for improving tip support. Caudal extension graft (CEG) and columellar strut with plumping graft (CSPG) are two methods in rhinoplasty surgery. The final goal of this experimental study is to find the most effective method for tip correction among patients with tip ptosis. In this study, we compare two different methods which are used for the tip correction among patients who suffer from acute nasolabial angle (NLA) and columellar retraction. We performed a randomized clinical trial to compare correction ratio of NLA and columellar show obtained via CEG and CSPG methods. Standardized photographs were taken before the surgery and 12 months after the surgery to compare results between two groups. The mean post-operation NLA was 112.55° in CEG and 104.17° in CSPG (p value < 0.001). Correction ratio of NLA was 22.26° in CEG and 13.77° in CSPG (p value < 0.001). The difference in the mean and the correction ratio of NLA were statistically significant in two groups. The mean post-operation columellar show was 3.75 mm in CEG and 3.44 mm in CSPG (p value < 0.083). The correction ratio of columellar show was 1.76 mm in CEG and 1.20 mm in CSPG (p value < 0.007). The difference in the correction ratio of the two groups was statistically significant. Our study reveals that both techniques properly improve NLA and columellar show, however, CEG is a more stable method in patients with tip ptosis.

Intraoral Approach for Nasal Tip Upturning

The nose is an important landmark in facial beauty, and slight modifications lead to dramatic changes. The authors describe their surgical technique to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi. There were 14 patients (5 male and 9 female patients) in this study. All patients complained of nasal tip ptosis. The surgical procedure was explained to the patients, and the informed consent was obtained; preoperative frontal and lateral photographs were taken. The same surgical procedure was performed in all patients. No complications were observed. Tip upturning, with satisfaction of the patients, was observed in all cases and was confirmed comparing preoperative and 6-month postoperative photographs. From the outcomes of this short case series, the surgical technique described to upturn the tip of the nose with an intraoral approach sectioning the fibers of muscle depressor septi and with the skeletization of the premaxilla is an easy, safe, and inexpensive technique that can be easily performed at the office.