Author Affiliations: Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan (Dr Zuliani); and Department of Otolaryngology–Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia (Dr Silver).
To evaluate the durability of lower lateral to upper lateral cartilage suspension (LUCS) in the correction of nasal tip ptosis.
Patients with extreme nasal tip ptosis who subsequently underwent cosmetic rhinoplasty were eligible for this retrospective case study. Severe tip ptosis was defined as a nasolabial angle less than or equal to 80° in men and 90° in women. Of 34 patients identified who underwent LUCS in the past 18 years, 24 were found to have at least 1-year follow-up images and documented clinic visits. Thirteen of these patients were observed for at least 3 years and comprise the long-term cohort. Preoperative morphed or hand-drawn illustrations were obtained, and the nasolabial angles were measured and compared with those of the standard preoperative, 1-year postoperative, and long-term postoperative groups.
The mean preoperative nasolabial angle for the entire group was 83.4°. The mean preoperative morphed or illustrated angles measured 104.7°. The mean 1-year and long-term follow-up angles measured 102.5° and 101.5°, respectively. The differences among the preoperative, 1-year postoperative, and long-term groups were significant at P < .001. The similarities between the morphed, 1-year postoperative, and long-term angles were also statistically significant.
The LUCS is a durable technique in the correction of nasal tip ptosis. It has consistently proved to provide accurate and reproducible results.
Nasal tip ptosis is a relatively common deformity observed by facial plastic surgeons. In fact, some series report its incidence to be as high as 72%.1 It is a deformity with a multifactorial etiology that is characterized by an excessively long nose with an acute nasolabial angle. This cosmetically unappealing tip may also have functional disturbances owing to limited airflow through constricted nares.1
Correction of such a deformity relies on an understanding of the pathogenesis of the droopy tip, nasal tip dynamics, and the postoperative forces of wound and scar contracture. The rhinoplasty surgeon must be able to identify the intrinsic and extrinsic forces causing the ptosis. Many of these factors can, thus, be conceptualized through the tripod theory of tip dynamics.2 Intrinsic forces include the lateral crura of the lower lateral cartilages (LLCs) being too long or vertically oriented or the medial crura being too short. Examples of possible extrinsic factors are long upper lateral cartilages (ULCs), an overdeveloped caudal septum, a high anterior septal angle, thick nasal skin, an overactive depressor septi muscle, and loss of tip support from previous surgery or as a part of the normal aging process.1
To diagnose the anatomical derangements, the surgeon must aesthetically judge the needed alterations based on a variety of precise measurements and proportions. Nasal tip rotation, defined as movement of the nasal tip along an arc with constant distance from the facial plane, is measured via the nasolabial angle.3 This is the most useful angle in critically analyzing preoperative ptosis and postoperative results.
Many surgical techniques have been used to correct tip ptosis. To rotate the tip, procedures such as caudal septal shortening and cephalic trimming are normally used. However, when an excessive degree of ptosis is present, more complex procedures are often necessary. Previously described maneuvers include a variety of sculpting and suture modifications. These include, but are not limited to, the tongue-in-groove, lateral crural steal, and lateral crural overlay techniques.4- 6 All these different techniques have the same goal of cephalically rotating the LLCs.
It is the goal of this article to critically examine the ability to correct extreme tip ptosis using the lower lateral to upper lateral cartilage suspension (LUCS) technique. We also set out to scrutinize how close the 12-month and long-term results are to the proposed preoperative modifications. The LUCS involves transposing the LLCs over the ULCs the exact amount that the tip is to be rotated superiorly. This maneuver also serves to add a moderate degree of stabilization to the external nasal valve, thus aiding in the prevention of postoperative nasal airway obstruction.
We analyzed the medical records of all patients undergoing the LUCS for extreme tip ptosis operated on by 1 of us (W.E.S.) during the past 18 years. Primary and revision surgical procedures were included in this study. Only patients who had preoperative morphed images and at least a 12-month follow-up with photographs were eligible. In this article, extreme tip ptosis is defined as a nasolabial angle greater than 10° less than the ideals for men and women. These preferred nasolabial angles have a range of 90° to 115°. We found, as other researchers7 have pointed out, that in actuality the desired nasolabial angles are 95° to 100° in men and 103° to 108° in women. Thus, for this study, male patients were included if their preoperative nasolabial angles measured 80° or less, and females were included if their preoperative angles measured 90°or less. All patients included in this study provided written consent for their photographs to be used for research purposes in the scientific literature.
The nasolabial angles in the preoperative (hand illustrated [before 1996] or digitally morphed [Uniplast Software; United Imaging Inc, Winston-Salem, North Carolina]) and postoperative photographs were analyzed. All photographs were obtained at exactly half-scale with the patient in the Frankfort horizontal plane. The nasal tip angle was measured by drawing a line from the tip-defining points to the alar crease and calculating this angle in relation to the vertical facial plane.7 These measurements were performed by 1 of us (G.F.Z.) to ensure consistency. Nasal rotation was evaluated in the 12-month and long-term cohorts compared with the preoperative angle and the proposed angle as demonstrated through morphing. The paired t test was used to detect any significance between the groups, and Pearson parametric correlation coefficients were used to detect the similarity of the morphed angles to the 1-year follow-up and long-term angles.
The right lateral photographs were analyzed, and the desired amount of rotation was carefully measured. These numbers were then multiplied by 2 to give the surgeon the correct amount of necessary surgical reduction because the photographs were obtained at half-scale. The measured amount of cephalic rotation desired is the measurement used to suspend the cephalic border of the lateral crura of the LLC over the caudal border of the ULC.
Through an open approach, the LLCs are exposed and separated in the midline. Dorsal and septal modifications are then performed as needed. Suspension of the LLCs first requires the sharp dissection of vestibular skin from the cephalic borders of both LLCs. Dissection is carried anteriorly just until the area of the intermediate crura, thus allowing for any additional tip work to be performed without the concern of redundant mucosa. The LLCs are then transposed over the ULCs the exact amount that the tip is to be rotated superiorly. It is sutured in place using 2 to 3 laterally placed 4-0 polydioxanone mattress sutures (Figure 1 and Figure 2). This maneuver also serves to reinforce the lateral nasal valves, which reduces or eliminates postoperative lateral nasal valve collapse. After repeating the procedure on the opposite side, the caudal septum is shortened to allow the tip to cephalically rotate. The amount of LLC that lies above the lateral and dorsal profile is then resected as it would be if this was the original position of the LLCs. Lateral osteotomies are also performed if needed. The incisions are closed, and a routine dressing is applied.8
Suture suspension of the lower lateral cartilage to the upper lateral cartilage. Note the completely freed right lower lateral cartilage while the left is being sutured in a more cephalic position using 4-0 polydioxanone mattress sutures, thus reconstituting a major tip support element.
Artist's rendition of the lower lateral to upper lateral cartilage suspension procedure showing the area to be undermined (A) and how transposing this cartilage over the upper lateral cartilage will change the nasal rotation angle (B). Reprinted with permission from Silver and Zuliani.8
Thirty-four patients were identified who underwent the LUCS for tip ptosis during the past 18 years. Of these 34 patients, 24 (5 men and 19 women) had complete medical records and postoperative photographs, making them eligible for the study. The mean age of the patients was 44.5 years (men, 36.4 years; women, 46.7 years; age range, 17-69 years). Two of the procedures were revisions of previous operations performed elsewhere. Of the 24 patients, 13 (1 man and 12 women) were observed for an extended period and were included in the study as the long-term cohort. The mean age of this population was 43.2 years (men, 24.0 years; women, 44.8 years). The mean follow-up for this group was 10.2 years (range, 3-18 years).
Almost all the patients underwent caudal septal shortening and cephalic trimming of the LLCs as adjunctive methods to cephalically rotate the nose. Other procedures noted included medial crural struts, plumping grafts, and spreader grafts. Spreader grafts were required in 1 patient who had a large dorsal hump and in another who had undergone a previous rhinoplasty.
The mean preoperative nasolabial angle for the entire group was 83.4° (men, 76.6°; women, 85.2°) (Table 1). The mean preoperative morphed or illustrated angles measured 104.7° (men, 99.0°; women, 106.5°). The mean 1-year follow-up angles measured 102.5° (men, 96.8°; women, 104.1°). The differences between the preoperative and 1-year postoperative groups were significant at P < .001 (paired t test). The Pearson parametric correlation coefficient was then used to determine the similarity between the morphed and 1-year postoperative groups. These groups were similar at P < .001.
When stratifying the 13 patients who had long-term follow-up, the mean preoperative nasal rotation angle was 85.5° (men, 79.0°; women, 86.0°) (Table 2). Their mean preoperative morphed or illustrated angles measured 106.3° (men, 100.0°; women, 106.8°). The mean 1-year follow-up angle in these patients measured 103.8 (men, 100°; women, 104.1°), and the mean nasolabial angle in long-term follow-up was 101.5° (men, 95.0°; women, 102.1°). The t test was again used to determine that the difference between the preoperative and long-term groups was significant at P < .001. The similarity between the preoperative and long-term follow-up nasolabial angle measurements was significant at P < .001. The Pearson parametric correlation was also used to evaluate the stability of tip rotation between the 1-year follow-up group and the long-term cohort. These results were similar at P < .001.
Four patients noted nasal airway obstruction in the postoperative period, 2 of which were successfully managed with nasal corticosteroids secondary to a diagnosis of allergic rhinitis and turbinate hypertrophy. One patient required a revision septoplasty, and 1 required reconstruction of an external nasal valve with titanium mesh. Note that this patient also experienced valve collapse in the preoperative setting. Figure 3 and Figure 4 demonstrate the changes in nasal tip rotation at 12-month and long-term follow-up compared with the preoperative and morphed images.
Patient 3. A, Preoperative view of a 37-year-old man with extreme tip ptosis. B, Morphed image of proposed modifications. C, Twelve months later, one can see the similarity between the morphed image and the actual result.
Patient 22. A, Right lateral preoperative view of a 67-year-old woman with an excessively ptotic tip. B, Computer-generated postoperative image. Her 1-year (C) and 5-year (D) postoperative photographs demonstrate the overall durability of this technique.
Surgery of the lower third of the nose is often the most complex part of any rhinoplasty operation. The correction of one deformity may adversely affect the structure and function of critical tip support elements. This, along with the varying forces of wound and scar contracture, can cause bossae, knuckling, warping, and loss of tip projection and rotation. Thus, producing predictable and durable results is extremely challenging.
Many different techniques exist for correction of the ptotic nose. Open and endonasal approaches exist, with proponents on either side of the fence. Even nonsurgical methods, such as botulinum toxin injections, have been reported for correction of dynamic nasal tip ptosis.9 Deterrents of the open approach often criticize the potential loss of tip projection and the need for routine use of multiple cartilaginous grafts, such as columellar struts.10 As demonstrated in this article, the use of columellar struts was not a routine practice (4 of 24 patients [17%]) in performing the LUCS. Using the open approach gives us the ability to precisely transpose the cephalic border of the LLC up over the caudal border of the ULC. In dissecting the LLC from its vestibular attachments, we necessarily disrupt its attachment to the ULC at the scroll area. This major tip support is reconstructed, however, via the suture technique. The durability of the technique is reinforced by examining the continued maintenance of tip rotation in the long-term cohort.
Suture techniques to produce tip rotation and projection in rhinoplasty have become increasingly popular and accepted options for the rhinoplasty surgeon. These procedures have been shown to be predictable and controllable while also adhering to modern rhinoplasty paradigms by being nondestructive. Cárdenas et al11 describe a method of suture suspension for controlled tip rotation through an endonasal approach and report good results in 30 patients during a 24-month follow-up period. Margulis and Harel10 also report consistent 12-month results with their horizontal columellar strut, which is similar to the tongue-in-groove technique.
The results of Kridel and Foda,1,4- 6 with their large numbers of patients, are excellent. In their studies, they do not comment, however, on the degree of preoperative tip ptosis present in their subsets. Long-term results similar to those reported herein have been reported by these researchers. They describe observing a group of 30 patients for 4 to 7 years and report no considerable changes from the 1-year follow-up evaluation.1 Variations of their procedures have been used with success in our practice in patients with lesser degrees of nasal tip ptosis. For severe tip ptosis, however, the LUCS is our procedure of choice.
We believe that there are a few advantages to the LUCS procedure over suture and other alar cartilage–modifying techniques to correct for severe tip ptosis. In precisely transposing and suturing the cephalic margin of the LLC over the caudal LLC, we reconstitute a major tip support while also proving a moderate degree of bulk and strength over the area of the external nasal valve. One patient experienced postoperative valve collapse in the present series, and he subsequently required surgical revision. In addition, because relatively small amounts of lateral crural cartilage are incised or excised, we found excellent results in thin-skinned patients. Note that none of the present surgical revisions (n = 2) were necessary from a cosmetic standpoint.
Because of the criteria used for the procedure, we have fewer patients than in most reported series, which necessarily affects the power of this study. Perhaps the numbers would have been greater if the medical records of 10 patients had not been incomplete. Despite the lower numbers, however, we believe that the results in the long-term cohort are worth repeating because there are few accounts in the literature that report such long-term follow-up.
In conclusion, correcting nasal tip ptosis can be a frustrating endeavor even for experienced rhinoplasty surgeons. We found the LUCS technique to be valuable in correcting this deformity even in the droopiest of noses. In addition, the LUCS keeps all major tip support elements in place and adds stability to the external nasal valve, thus preserving function. This procedure is durable and has yielded consistent, reproducible results during the past 18 years.
Correspondence: Giancarlo F. Zuliani, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, 4201 St Antoine University Health Center-5E, Detroit, MI 48201 (firstname.lastname@example.org).
Accepted for Publication: July 14, 2010.
Author Contributions: Dr Zuliani had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Zuliani and Silver. Analysis and interpretation of data: Zuliani. Drafting of the manuscript: Zuliani. Critical revision of the manuscript for important intellectual content: Silver. Statistical analysis: Zuliani. Study supervision: Silver.
Financial Disclosure: None reported.
Previous Presentation: This study was presented at the 10th International Symposium of Facial Plastic Surgery; April 28, 2010; Hollywood, Florida.
Thank you for submitting a comment on this article. It will be reviewed by JAMA Facial Plastic Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 3
Customize your page view by dragging & repositioning the boxes below.
The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Population for Whom Myasthenia Gravis Could Be Considered
The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.