Tip Rotation

Rotation of a droopy nasal tip is a common request of patients who present to a facial plastic surgery office. A ptotic tip can cause an aged appearance, because the nasal tip tends to counterrotate with time. In addition, feminine noses may appear more masculine if the tip is ptotic. The ideal tip angle for feminine noses is 95 to 105, whereas this same angle should be 90 to 95 for male noses.

The Tripod Theory is a well-established principle in rhinoplasty. Each lateral crus represents 1 leg of the tripod, whereas the paired medial crura represent the third. Nonsurgically, the medial crural leg of the tripod can be effectively lengthened with placement of filler under the base of the medial crura, in the area of the footplates. Typically 0.15 to 0.2 mL is required for this maneuver. The filler advances the medial crural footplates anteriorly as well, reducing the degree of overlap of these footplates with the septum. This placement lengthens the base of the columella slightly, which can be advantageous in patients with a mildly retracted base. The filler is introduced from an anterior approach directly at the base of the columella. The filler is placed deep, near the posterior septal angle, to avoid injection near or into the columellar arteries, which are superficial. Aspiration is also important. The injector should place his or her fingers on each side of the medial crural footplates, to avoid splaying them. The amount of filler should generally not exceed 0.2 mL, because a large bolus may compromise the external valves and widen the columellar base.