Tip Ptosis (the Droopy Tip)
Stephen S. Park
INTRODUCTION
Tip ptosis (droopy tip) is a common finding, and correcting it is a fundamental step in rhinoplasty. This maneuver is unique in that it may be applied to patients in both the young and older age group, seeking aesthetic as well as functional improvements. There are a number of different causes of tip ptosis, and it is important to distinguish between them since the precise anatomic etiology influences the choice of surgical technique, and each maneuver can be unique.
The tip may droop as a function of advanced age as the numerous support mechanisms weaken over time. The scroll between the upper and lower lateral cartilages begins to loosen and simultaneously, other structural parts loosen, such as ligaments between the medial crura and the septum and the interdomal ligament. In addition, the overlying skin and soft tissue lose its elasticity, allowing the tip to droop further. The weight of the skin of the nasal tip can pull the tip down and lengthen the nose. This is especially true for patients who have very thick and sebaceous skin, including patients with rhinophyma.
The preoperative analysis will determine if tip projection or deprojection is needed along with the cephalic tip rotation. The surgical plan then employs a series of steps designed to reposition the lower lateral cartilages and then fixate them firmly to hold against postoperative wound contracture. There are different surgical techniques that can accomplish similar changes.
HISTORY
Obtaining a history from a patient interested in a rhinoplasty who has tip ptosis is no different than with any elective procedure. The standard tenants of preoperative evaluation are undertaken and include a general review of systems. A detailed history of previous nasal trauma or nasal surgery is essential. A detailed history of past and present cardiac and pulmonary issues is recorded. A complete review of medications and allergies is performed. Attention is dedicated to any form of anticoagulant that the patient may be taking. If elective, they will be discontinued for a minimum of 2 weeks before surgery. Anticoagulation is for an underlying condition; therefore, consultation with the prescribing physician will be made to coordinate a window for a medication holiday. One must also assess such concerns as motivation, expectations, and ability to cooperate during the postoperative period. It is worthwhile to differentiate between cosmetic concerns and functional, such as nasal obstruction. Tip rotation can impart a more youthful appearance, but the magnitude of this change must be realistic.
PHYSICAL EXAMINATION
There a few key elements to the physical examination of a patient with tip ptosis. The critical step is making a careful diagnosis of the exact anatomic etiology of the deformity. This then leads to the most direct method
of repair. The first step in the examination is distinguishing between the tip that needs cephalic rotation with increased projection versus the tip that requires rotation with deprojection (Fig. 19.1A and B).
of repair. The first step in the examination is distinguishing between the tip that needs cephalic rotation with increased projection versus the tip that requires rotation with deprojection (Fig. 19.1A and B).
 FIGURE 19.1 Tip ptosis needing cephalic rotation and projection (A) and deprojection (B). |
Palpation of the nose is an underemphasized aspect of the preoperative evaluation, and yet it is critical in tip ptosis. Identifying the anterior septal angle as a key anatomic landmark for tip support is accomplished best through palpation. Thickness of the skin is also an important part of the preoperative analysis also best accomplished by palpation. When extremely heavy skin is the problem, it may require a direct excision of dorsal skin since cartilage repositioning may not suffice.
INDICATIONS
Indications for repairing tip ptosis are twofold. Aesthetically, the ptotic tip may put the nose and face out of balance. Such a tip is often lacking in definition and tends to appear broad and wide. Moreover, tip ptosis creates several illusions to the other areas of the nose; the plunging tip and acute nasolabial angle often appear to lengthen the nose and create a “pseudohump” at the dorsum, especially the anterior septal angle. The supratip will appear relatively overprojected with respect to the tip. Simultaneous tip rotation and tip projection can be synergistic and reduce the amount of dorsal resection needed in order to achieve balance. Patients are rarely cognizant of a plunging tip and may request a hump or dorsal reduction rather than increased tip support; their perception is often that the nose is too large. The importance of an early diagnosis and distinction of this anatomic variant cannot be overstated (Fig. 19.2A-D).
A patients’ chief complaint may be abnormal nasal function where the anatomic etiology for this obstruction, especially in the elderly population, is tip ptosis. Septal deviation, turbinate hypertrophy, and lateral wall collapse can all coexist within the group, but tip ptosis from lack of support can be a major contributor that should not be overlooked. Not infrequently, the patient will demonstrate a simple maneuver that alleviates the nasal obstruction—manually pushing the tip up. Once recognized, surgical correction of tip ptosis through any of the techniques discussed below will have a profound positive effect.
 FIGURE 19.2 A and B: Combination of subtle dorsal hump, tip underprojection, and ptosis C and D: Correction with tip rotation, projection, and hump reduction. Balance is achieved by the combination of effects. |
CONTRAINDICATIONS
Any surgical risk factor is amplified when considering elective procedures. In addition to this, psychological factors can be a contraindication. Fixation on one’s nose is not uncommon and the surgeon must proceed with caution.
PREOPERATIVE PLANNING
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