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Secrets of a Beverly Hills Cosmetic Surgeon

with Robert Kotler, MD, FACS

Dr. Kotler's blog has now been retired. We appreciate all the wisdom and support he has brought to the WebMD community throughout the years.

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Tuesday, July 20, 2010

Dropped Tip After a Nose Job

Sometimes patients are disappointed after rhinoplasty, or nose surgery, because various changes can evolve negatively in the postoperative period. One of the more common effects is the so-called “dropped tip.”

Here’s what that means. Initially, when seen from the side, the profile view, the tip sits at a desirable level in relation to the rest of the nose’s profile. But with time, the tip actually settles down, drops and gives a round or convex appearance to the front half of the profile. It may look like a new bump has formed.

There are several reasons why this happens. In most cases, such a drop is predictable — and preventable. The first reason is that the surgeon fails to allow for an anticipated drop and, therefore, incorrectly sets the tip position in reference to the rest of the nasal profile including the bridge. It is well-known among experienced nasal surgeons that there will always be some downward contraction of the tip owing to the fact that their incisions tend to contract. The natural downward pull of gravity and contractile forces from those incisions will tend to make the tip drop. The surgeon must anticipate that during the planning of your operation and during its execution.

The second common reason for the tip dropping is that there is not enough strength in the remaining tip cartilage to maintain its position. If the surgeon fails to recognize that the tip cartilage is weak and will not hold its posture after part of it has been removed to narrow the lower half of the nose, then such a dropped tip will occur and the profile will be imperfect. An assessment of the prospects of that happening should take place at the consultation as the surgeon feels the strength of the nasal cartilages and makes an estimate as to what percentage of the strength can be maintained after a portion of the cartilage is removed.

Here is the analogy in architecture and construction: If you weaken a load-bearing support wall too much, the roof will sag or come tumbling down.

Reason number three for the “dropped tip” is that, in fact, the tip does not drop but the tissue of the nose above the tip rises up and makes it look like the tip has dropped. This is generally due to the surgeon’s failure to anticipate the contraction and tightening that will certainly take place during healing. As swelling diminishes and the tissues begin to weld together,  an upward elevation of the cartilages in the midportion of the nose can occur.  These “upper lateral” cartilages automatically and naturally migrate towards the middle and if they had not been trimmed enough in anticipation of this migration, then they tend to rise above the anticipated profile level. Thus, a profile convexity occurs that makes the tip look as though it has dropped. An illusion has been created.

Rhinoplasty is a complex operation which requires imagination on the part of the surgeon, a working game plan based on anticipated changes and, most importantly, a knowledge of the consequences of each and every surgical maneuver that takes place during the operation.

No wonder rhinoplasty holds its reputation as the most difficult operation in the world of cosmetic plastic surgery. And, remember, not all plastic surgeons are equipped by training, experience or talent to perform it.

Always look for a master of cosmetic nasal surgery, a super-specialist. They will be more likely to create a outcome that meets your expectations.

- Robert Kotler, MD, FACS

Have you heard of a “dropped tip” following a nose job? Have you had a positive or negative experience with rhinoplasty? Share your comments with the Skin and Beauty Community.

Posted by: Robert Kotler, MD, FACS at 6:59 am

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