Management of the droopy tip: a comparison of three alar cartilage-modifying techniques

The droopy tip is a common nasal deformity in which the tip is inferiorly rotated. Five hundred consecutive rhinoplasty cases were studied to assess the incidence and causes of the droopy tip deformity and to evaluate the role of three alar cartilage-modifying techniques--lateral crural steal, lateral crural overlay, and tongue in groove--in correcting such a deformity. The external rhinoplasty approach was used in all cases. Only one of the three alar cartilage-modifying techniques was used in each case, and the degree of tip rotation and projection was measured both preoperatively and postoperatively. The incidence of droopy tip was 72 percent, and the use of an alar cartilage-modifying technique was required in 85 percent of these cases to achieve the desired degree of rotation. The main causes of droopy tip included inferiorly oriented alar cartilages (85 percent), overdeveloped scrolls of upper lateral cartilages (73 percent), high anterior septal angle (65 percent), and thick skin of the nasal lobule (56 percent). The lateral crural steal technique increased nasal tip rotation and projection, the lateral crural overlay technique increased tip rotation and decreased tip projection, and the tongue-in-groove technique increased tip rotation without significantly changing the amount of projection. The lateral crural overlay technique resulted in the highest degrees of rotation, followed by the lateral crural steal and finally the tongue-in-groove technique. According to these results, the lateral crural steal technique is best indicated in cases with droopy underprojected nasal tip, the lateral crural overlay technique in cases of droopy overprojected nasal tip, and the tongue-in-groove technique in cases where the droopy nasal tip is associated with an adequate amount of projection.