Whereas an overrotated nasal tip gives a feminizing look to the male nose, an underrotated or droopy nasal tip gives an aging or unattractive appearance. There is no question that the nose is subject to gravity and that over time the tip drops (Fig. 13).

Fig. 13. This drawing by Leonardo DaVinci illustrates the effects of aging on the nose, including elongation and loss of nasal tip support with the formation of a pseudohump.

All we need to do is to look at photographs of our grandparents when they were young and compare their noses to where they are now. It always appears as if a dorsal hump has grown with time, but rather the tip supporting mechanisms have weakened, and the tip descends, creating an acute nasolabial angle and making the dorsum appear more prominent in contrast to the tip. Because men generally start with larger noses and because, over time, male nasal tip skin thickens secondary to glandular hypertrophy, the loss of tip support may become more evident sooner. Alternatively, there are those whose particular tripod cartilage anatomy is such that their lower lateral cartilages are overly long and push the tip downward or their medial crura are too short and fail to support the tip (see Fig. 7). To some, these latter individuals look older because we associate droopy noses with the aging process, or they look less than desirable because those with droopy nasal tips have always been used in caricatures by artists from Leonardo to modern-day cartoonists as unattractive or leering men (Fig. 14).

	Fig. 7. A, This 30-year-old man appears older than his stated age in his preoperative view. He had tip ptosis that prematurely aged him. B, The postoperative results of revision rhinoplasty surgery with a lateral crura overlay technique as well as a columellar strut and double- dome suturing.

	Fig. 14. In this drawing by Leonardo DaVinci the major facial feature that makes these unusual caricatures seem grotesque is their large and often drooping noses.

Because of heavy and large nasal tips in the man, routine nasal tip rotation and support techniques must be more robust, and often more than one technique may be necessary. Generally, three methods are available, the first of which vertically shortens the nose by removing cartilage between the nasal tip and the bony radix. The cephalic margin of the lower lateral crura, the caudal margin of the upper lateral cartilages, and the septal angle may be excised in varying proportions so as to create a tissue void with the goal of producing rotation secondary to taping, the healing process, and scar contracture. In most very ptotic tips, this scar contracture obtained is insufficient. A second method that consists of shield-type tip grafting is truly just a camouflage technique that creates the illusion of rotation but makes no structural adjustment to the cartilages and does not prevent further ptosis, which most assuredly occurs secondary to gravity. (Such tip grafts, however, are helpful in creating definition in the thicktipped male nose.) What seems best for these heavy tips is a third method that involves actual structural change in the cartilages making up the tripod, rather than just camouflage. Such structural change, if sutured, can withstand the forces of time and gravity effectively. Therefore, based on the tripod theory of nasal tip position,1 to rotate the tip either the lower lateral cartilages need to be shortened or the medial crura need to be lengthened.

The lateral crural overlay16 technique is a controlled method to shorten the lower lateral cartilages precisely while preserving and simultaneously strengthening the support of the tip by maintaining an intact rim. First, a conservative trim of the cephalic margin of the lower lateral cartilage is accomplished to promote tip refinement and to remove the scroll attachments to the upper lateral cartilages (Fig. 15). After elevating the vestibular skin from the underside (Fig. 16) an incision is made across the midportion of the lower lateral cartilage about 1 cm from the dome. The cut edges of the cartilages are overlapped until the desired rotation is achieved and then suture fixated with permanent suture. The process of overlapping the cartilages with fixation actually strengthens the connection, whereas direct excision and end-to-end reapproximation are inherently weak and unstable and can distort during the healing process. This lateral alar shortening process relies on a firmly bound flap and therefore the fibrous posterolateral attachments must be preserved. Because of the lateral posterosuperior pull created by this maneuver, the dome cartilages may tend to lateralize. Dome or double-dome sutures hold the tip together and provide added narrowing and definition.

	Fig. 15. The lateral crural overlay procedure. A, Preoperatively, the lateral crura in a nose with severe tip ptosis are typically long and tend to push the nasal tip downward. A, Tip refinement begins by performing a conservative cephalic trim. The midportion of the lateral crus is cut in a straight line between the cephalic crural margin and the caudal crural margin. B, After mobilizing the anterior portion of the lobular cartilages, the nasal tip is rotated superiorly. This maneuver shortens the lateral crus (posterior arrow), resulting in overlay of the free transected crural segments. C, The mobile lateral crural segments are stabilized with two 5-0 permanent transcartilaginous horizontal mattress sutures. These sutures are placed side by side to secure the tip into position. A triangular cartilage irregularity forms along the inferior crural margin (curved arrow) as a consequence of rotating the anterior lateral crural segment superiorly. D, The caudal margin of the lateral curs is tailored with a scalpel to create a smooth inferior border. Postoperatively, the lateral crural overlay technique rotates the nasal tip superiorly by shortening the lateral crura. (Copyright Russell W.H. Kridel, MD; with permission.)

	Fig. 16. The vestibular skin is elevated from the under-surface of the lateral crura. This maneuver permits safe and precise placement of the transcartilaginous stabilization sutures and it releases tethering forces along the lateral crus that could restrict mobility of the alar cartilages during nasal tip repositioning. (Copyright Russell W.H. Kridel, MD; with permission.)

In men, in addition to the overlay technique, a cartilaginous strut is often placed between the medial crura to solidify the newly acquired tip position and improved support. The strut may also assist in lengthening the medial crural component of the tripod and thereby further aid in rotation. Struts are particularly helpful in those with thick nasal tip skin that weighs down the tip. Using fine tenotomy scissors, a pocket is developed between the medial crura toward the premaxilla. The strut extends from the premaxilla to just under the dome cartilages and is sewn into place with buried, nonabsorbable sutures.

Some droopy tips, especially those in which there is also columellar show, may benefit from the tongue-ingroove18 technique, which can improve tip position by moving the medial crura back onto the caudal septum (Fig. 17).

	Fig. 17. A and B, This 39-year-old man was concerned about the droopiness of his nose tip. A tongue-in-groove maneuver combined with a medial crural overlay was performed to improve this unattractive angle and to lessen the patient's columella show.