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The standard or traditional closed rhinoplasty may produce a nose with an unstable, rounded and featureless tip. The tip can droop and there appears to be swelling above the tip, so called supra tip swelling. Photo of patient with supratip swelling after rhinoplasty
Investigators have described skin and subcutaneous tissue thickening in the supra tip area which is probably secondary to skin bunching. The skin bunches up because the skeleton is reduced, usually by resection of the upper portion of the alar cartilages and resection of the anterior (dorsal) margin of the septal cartilage, but no skin is removed. Diagram of cartilage resection from edge of tip skeleton

A second, less well recognised, cause of the rounded and drooping tip is loss of nose tip projection due to retrusion of the columella  1  . This change is best appreciated at the lip-columella angle which changes from more obtuse to more acute. This change is very likely to occur if the nose is shortened by resection of the caudal margin of the septal cartilage.

Supra tip swelling can be improved by widely undermining the skin over the nose and redraping it towards the cheeks. Some surgeons may be reluctant to try this technique because they fear the extra dissection will lead to more tissue swelling. However, extra skin is required for draping over the infractured nasal bones at the lateral osteotomies so the excess from the supra tip area can be taken up there if the undermining is wide enough.

Retrusion of the columella secondary to nasal shortening is very difficult to control. Strong permanent sutures can be placed between the columella cartilages and the septal cartilage to force the columella forward but this will immobilise the nose tip. Another recommended technique is placement of a cartilage strut in the columella base. To be reliable the strut has to be very large. These findings suggest the presence of some sort of tether between the columella cartilages and the lip. The tether resists elongation by pulling the columella back.

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