Pronounced nasal tip ptosis is generally regarded as an unattractive facial feature. Besides its aesthetic ramifications, marked inferior displacement of the nasal tip adversely affects nasal function by restricting airflow through the nares. We present a new technique that is a modification of a lateral crural flap procedure that was described in 1975. This technique, which is performed using an open rhinoplasty approach, predictably rotates the nasal tip upward by restructuring the alar cartilages via controlled overlay of the lateral crura. When overprojection accompanies tip ptosis, the controlled lateral crural overlay technique permits graduated retrodisplacement of the tip, in addition to rotation, giving the surgeon full control for reliably and accurately repositioning the nasal tip superiorly and posteriorly.
Nasal plastic surgery should be thought of not only in terms of cosmesis, but also in terms of function. Nasal tip ptosis is a condition that affects both the appearance and the function of the nose. A nasolabial angle of 95° to 100° in males, and 100° to 115° degrees in females, is usually regarded as aesthetically pleasing. Contraction of the nasolabial angle beyond these accepted standards is generally considered an unattractive facial feature. Additionally, marked tip ptosis can significantly increase upper airway resistance by impeding airflow through the nares.
A variety of factors may contribute to a drooping nasal tip. The most common include:
Long, vertically oriented lateral crura that force the
tip inferiorly.
Weakened tip support mechanisms. This may follow a poorly performed rhinoplasty during which overaggressive incising and/or excising maneuvers were performed. It can also occur naturally as aging leads to progressive stretching of the nasal tip's fibrous suspensory system.
Thick, heavy skin over the nasal tip that is pulled downward by the force of gravity.
Atrophy of bone or premaxillary subcutaneous fat at the nasolabial angle. A loss of tissue mass here, as can occur with aging or nasofacial trauma, allows the medial crura to drift backward. This change can culminate in drooping of the nasal tip.
Rhinoplasty is often thought of as the most challenging of all aesthetic procedures. The most sought nasal tip changes are those of rotation, refinement, and projection. A variety of techniques have been described for accomplishing these goals, these being broadly classified into those that maintain and those that interrupt the continuity of the alar cartilages. Transection of the lobular cartilages near the dome can result in pinching, notching, and tip asymmetries, especially in poorly selected patients or from faulty surgical technique. To avoid such complications, intact rim cartilage techniques are advocated whenever possible.1
Correction of the ptotic tip varies according to the specific cause of the problem. The ultimate goal, however, is to raise the nasal tip. Because severe tip ptosis commonly has several contributing factors, a combination of surgical maneuvers may be required for optimal correction. In general, two types of surgical maneuvers are used for correcting tip ptosis. The first are those that vertically shorten the nose by removing various tissue components between the nasal tip and the radix. The cephalic margin of the lateral crura, the caudal margin of the upper lateral cartilages, the caudal septum, the septal angle, and the skin between the nasal tip and the radix can be excised in varying proportions to create tissue voids that allow the tip to be displaced superiorly with healing and soft-tissue contracture. The second variety of maneuvers are those that directly alter the length of the alar cartilages. The principles behind this type of correction are best appreciated by referral to the tripod theory of nasal tip position.2 According to the tripod theory, maneuvers that augment the medial crura or that shorten the lateral crura result in superior tip rotation.
This article describes a surgical technique—controlled lateral crural overlay—that is performed through an open rhinoplasty approach. This technique predictably and accurately rotates the severely ptotic nasal tip by shortening the lateral crura, while preserving an intact rim in the region of the domes to minimize the risk of postoperative nasal tip deformity.
