Dynamic Nose Tip Position

The superficial depressor septi muscle acts like a tether preventing elongation of the distance between the upper anterior surface of the orbicularis muscle and the footplates of the columella cartilages. The distance can stay the same or shorten.

Protrusion of the tip depends on the balance between the tone of the superficial depressor septi muscle pulling the columella backwards and the elastic tissue in the membranous septum pulling the columella forwards. Thus, it is important to restore the elastic tissue attachments when forward projection is to be maintained. This is facilitated by pre-marking the tissue attachment with a small cross incision or ink.

Tip tilt depends on the relative lengths of the columella plus tip  9  and the alar cartilage plus lateral alar ligament  10 .

The lateral alar ligament should be shortened to maintain tip tilt when the columella plus tip is set back. Shortening the alar ligament more than the columella plus tip set back tilts the tip upwards. Setting the columella plus tip back while maintaining alar ligament length tilts the nose tip downwards.

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