The Plunging Tip: Illusion and Reality

Transcription

1 Rhinoplasty The Plunging Tip: Illusion and Reality Aaron M. Kosins, MD, MBA; Val Lambros, MD; and Rollin K. Daniel, MD A large body of literature exists regarding the plunging tip, including discussions of etiology, treatment, and changes associated with age. 1-3 However, the term itself is confusing and has been applied to a variety of deformities, both static and dynamic. The plunging or drooping tip has been associated with downward tip rotation, inadequate tip projection, long lower lateral cartilages (LLC), and both long and short caudal septums. 4 Similarly, the term has been applied to dynamic deformities that occur during smiling (Figure 1; animations of patients with dynamic deformities are also available as supplemental files for this manuscript at However, none of these deformities have been objectively measured during smiling. The purpose of this study was to objectively and prospectively analyze a series of patients whose main complaint was a plunging tip on smiling, with a specific focus on the anatomic changes of the nose that occur during smiling. Methods Aesthetic Surgery Journal 2014, Vol 34(1) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Abstract Background: The plunging tip is defined as a nasal deformity where the nasal tip descends or plunges during smiling. Objective: The authors prospectively measure a series of 25 patients with a focus on the anatomic changes of the nose before and after the patient smiles. Methods: Twenty-five women who presented for cosmetic primary rhinoplasty and complained of a plunging tip were included in the study. Three angles were measured on lateral view (tip angle, nasolabial angle, and columella inclination angle), along with changes in tip, subnasale, and alar crease. The Simon tip rotation angle (STRA) measured tip position in relation to the static tragus. The alar rim angle measured the angle of the alar rim at the nostril. Changes in static and smiling positions were compared. Results: Tip, nasolabial, and the columella inclination angles decreased between static and smiling positions by 10.9, 11.8, and 11.9 degrees, respectively. Tip position dropped by 0.9 mm, while the subnasale and alar crease junction elevated by 1.3 and 3.7 mm, respectively. The STRA, an angle independent of alar base movement, decreased by less than 1 degree. The alar rim angle increased by 9.9 degrees. Conclusions: Our data demonstrate that the nasal tip changes its position less than 1 mm with a full smile. The concept of a plunging tip is an optical illusion. In reality, the alar crease and subnasale elevate and the alar rim straightens, while the tip position changes minimally. Objectively, the tip moves less than 1 mm and less than 1 degree using the STRA. Level of Evidence: 3 Keywords rhinoplasty, plunging tip, projection, depressor septi nasi, tip angle Accepted for publication July 8, At the rhinoplasty consultation, patients were asked to describe 3 characteristics of their nose that they did not like Dr Kosins is a Volunteer Clinical Assistant Professor WOS and Dr Daniel is a Clinical Professor, University of California, Irvine Medical Center, Irvine, California. Dr Kosins and Dr Daniel are in private practice in Newport Beach, California. Dr Lambros is a plastic surgeon in private practice in Newport Beach, California. This paper was presented in part at the 15th Annual Rhinoplasty Symposium, April 18, 2013 in New York City, New York. Corresponding Author: Dr Rollin K. Daniel, University of California, Irvine Medical Center, 1441 Avocado Dr, Suite 308, Newport Beach, CA 92660, USA. rkdanielmd2@gmail.com

2 46 Aesthetic Surgery Journal 34(1) Figure 1. Patients who illustrate the dynamic plunging tip deformity. (A, B) This 29-year-old woman is shown in repose and with a full smile. (C, D) This 55-year-old woman is shown in repose and with a full smile. Notice that neither patient s nasal tip plunges in repose, but they do appear to have a plunging tip during smiling. and wanted to change. If the patient complained of a plunging tip, they were included in the study. Informed consent was obtained. Three surgeons were involved in the study, each with a separate responsibility (RKD, VL, AMK). Surgeon 1 (RKD) selected 25 consecutive female cosmetic rhinoplasty patients who complained of a nasal tip that plunged on smiling. At their preoperative visit, each patient was photographed in static and smiling sequences on standard rhinoplasty views with a ruler included in each photograph. Marks were made

3 Kosins et al 47 Figure 2. Standard preoperative photographic analysis. (A, B) This 22-year-old woman is shown resting her hand on her upper sternum with her index finger below her chin. This was done to minimize changes in head position during photographs in repose and smiling. Photographs were taken sequentially. (C, D) On this 30-year-old woman, we demonstrate the markings made on all 25 patients. These include the 3 points of the tip diamond, subnasale, and alar crease cheek junction. We also included a ruler for accurate and reproducible measurements. Finally, the tragus was included, as it represents a static point on the face that does not move appreciably during smiling. to standardize the position of the alar crease, subnasale, and 3 positions of the nasal tip diamond. The tragus was included in the lateral photographs of each patient because this facial subunit does not change position during a smile. The patient s index finger was placed at the posterior portion of the symphysis of the mandible, with the hand resting comfortably on the upper sternum to prevent changes in head position (Figure 2).

4 48 Aesthetic Surgery Journal 34(1) Surgeon 2 (VL) overlaid the static and dynamic images to achieve as perfect an alignment as possible using Adobe Photoshop CS4 (Adobe Systems, San Jose, California). Photographs were adjusted for color and exposure and finally overlaid using various static landmarks (tragus, nasal dorsum, and anterior portion of the cornea) to achieve alignment. Animations for this portion of the study are also available as supplemental files for this manuscript at Surgeon 3 (AMK) measured 3 angles to assess tip rotation (tip angle [TA], nasolabial angle [NLA], columella inclination angle [CIA]), as well as change in tip, subnasale, and alar crease position for both static and smiling views (Figure 3). The TA, as described by Byrd and Hobar, 5 was measured by dropping a perpendicular line from the Frankfurt horizontal line through the alar crease junction. The angle was formed by intersecting another line from the alar crease junction to the most projecting part of the nasal tip. The NLA, as described by Armijo et al, 6 was measured by dropping a perpendicular line from the Frankfurt horizontal line through the subnasale. The angle was formed by intersecting another line through the most anterior and posterior portions of the nostril. The CIA was measured by dropping a perpendicular line from the Frankfurt horizontal line through the alar crease cheek junction. 4 The angle was formed by intersecting another line that paralleled the columella. The Simon tip rotation angle (STRA) was used to measure the change in tip position in relation to the most posterior portion of the static tragus. Finally, the alar rim angle (ARA) was measured by calculating the angle between the anterior and posterior limbs of the alar rim at the nostril. 4 Angles were measured with the ruler tool in Adobe Photoshop in both static and dynamic views and then compared. To measure changes in subunit position (in mm), overlays were made transparent so that static and dynamic views could be seen simultaneously. For purposes of discussion, we will define the following terms. The tip point was defined as the most projecting point on the tip lobule in lateral position. Tip position referred to the location of the tip point independent of the nose (ie, a vertical line dropped from the Frankfurt horizontal line to the tip point). Tip rotation was measured using the tip angle. Results Average patient age was 31 years (range, years). The TA, NLA, and CIA decreased by an average of 10.9, 11.8, and 11.9 degrees, respectively (Table 1). The subnasale and alar crease junction were elevated by 1.3 and 3.7 mm, respectively. The STRA, an aesthetic angle independent of alar base movement, decreased by less than 1 degree. Finally, the ARA increased by an average of 9.9 degrees. Figure 4 shows an example of static and dynamic measurements. Tip position (marked at the point of maximal projection of the tip) dropped by an average of 0.9 mm. GIF animations, available as supplemental files at show clinical examples (Figures 7-10). Discussion The word plunging may be used as an adjective and, as such, should be viewed as a static characteristic of the nasal tip. This term may describe a nasal tip with downward rotation, a long caudal septum forcing the nasal tip downward, long LLC, and/or a tension nose with a short caudal septum as well as a tip that falls off the end of the caudal septum. Sajjadian and Guyuron 7 have classified the different reasons for what they call tip ptosis and developed a treatment algorithm. On the other hand, the word plunge is a verb and describes a dynamic action. Historically, this term has been applied to tips that are perceived to change position with smiling. As our data suggest, there is a group of patients (and surgeons) who believe that the nasal tip plunges when smiling. However, our data conclusively demonstrated that it does not. In our 25 patients, prospective and objective data measurements clearly demonstrated that the nasal tip did not move more than 1 mm, even with a full smile. There was also less than 1 degree of angular movement from the static tragus to the most projecting part of the nasal tip. If we can conclude that the plunge is an optical illusion, what causes the illusion of a plunge? The Plunging Tip Illusion A unifying characteristic and 3 nasal movements were present in all our patients who complained of a plunging tip (Table 2). The defining characteristic was a static tip angle that was less than ideal and measured, on average, 91 degrees (range, degrees). Thus, the alar crease junction was in the same approximate horizontal plane as the most projecting portion of the nasal tip. Three movements of the nose that occur during a smile contribute to the complete plunging tip illusion: (1) the rise of the alar crease, (2) the posterosuperior movement of the subnasale, and (3) the straightening of the alar rim. With a full smile, the nasal tip moves down, on average, less than 1 mm. The disproportionate movement of the alar base upward and the nasal tip downward occurs in patients during a smile, and this creates the illusion of a plunge. The best way to conceptualize the illusion of a plunge is a teeter-totter. In a teeter-totter, the fulcrum lies in the middle. However, in the nasal tip, the fulcrum lies much closer to the tip and is dependent on tip support (Figure 5; Figures at During a smile, the alar crease moved up 0.4 mm for every 0.1-mm depression of the nasal tip on average in our patient population. Clinical Application: Who Is Susceptible to the Illusion of a Plunge? What differentiates a plunging tip patient from a normal, non plunging tip patient? Regardless of the characteristics

5 Kosins et al 49 Figure 3. This 27-year-old woman demonstrates our measurements of different angles on our 25 prospective patients. (A) Tip angle, as described by Byrd and Hobar, 5 was measured by dropping a perpendicular line from the Frankfurt horizontal line through the alar crease junction. The angle was formed by intersecting another line from the alar crease junction to the most projecting part of the nasal tip. (B) Nasolabial angle, as described by Armijo et al, 6 was measured by dropping a perpendicular line from the Frankfurt horizontal line through the subnasale. The angle was formed by intersecting another line through the most anterior and posterior portions of the nostril. (C) Columella inclination angle was measured by dropping a perpendicular line from the Frankfurt horizontal line through the alar crease cheek junction. The angle was formed by intersecting another line that paralleled the columella. (D) Simon tip rotation angle was used to measure the change in tip position in relation to the static tragus. (E) The alar rim angle was measured by calculating the angle between the anterior and posterior limbs of the alar rim at the nostril.

6 50 Aesthetic Surgery Journal 34(1) Table 1. Average Angle Measurements of the Nasal Tip That Are Dependent (TA, NLA, CIA) and Independent (STRA) a of the Nasal Base Static, deg Smile, deg Change, deg Tip angle (TA) Nasolabial angle (NLA) Columella inclination angle (CIA) Simon tip rotation angle (STRA) a The STRA is an angle independent of the nasal base because it is measured at the static tragus. The TA depends on movement of the alar crease cheek junction, the NLA depends on movement of the nostril, and the CIA depends on movement of the columella. of the nose, all people have similar facial muscles. During a smile, the alar crease rises, the subnasale moves posterosuperiorly, and the alar rim straightens. In a normal patient (a patient without a plunging tip illusion), the tip angle is ideal or close to ideal with regard to tip rotation. As the tip angle (rotation) increases, the tip point lies further and further above the alar crease junction in repose. When a normal patient smiles, the alar crease will rise but will fail to rise above the tip point. It is only when the alar crease begins to rise above the nasal tip that the illusion of a plunge becomes apparent. Rotation of the nasal tip is a continuum from very acute (underrotated) to very obtuse (overrotated). Tip rotation in repose is the key characteristic of the plunging tip illusion. Downward Tip Rotation The more acute (underrotated), the more the nose will look like it is plunging all the time, and the word plunging can be used as an adjective to describe a characteristic of the nose. In patients with downward rotation of the nasal tip (Figure 6A,B), the alar crease cheek junction in repose is clearly above the tip defining point, and the patient appears to have a tip that is plunging. When the patient smiles, the nose continues to look like it is plunging, as the alar crease rises and subnasale moves posterosuperiorly. While the plunge may worsen upon smiling, the downward rotation is apparent to the patient at all times. This downward rotation is often caused by a long caudal septum or weak LLC that appear to literally be falling off the end of the nose. Tip support is minimal at best. Figure 4. This 22-year-old woman demonstrates a typical plunging tip patient from our cohort in repose and during smiling. (A) Patient in repose. Tip angle (TA) measures 81.5 degrees, nasolabial angle (NLA) measures 79.7 degrees, columellar inclination angle (CIA) measures 93.2 degrees, Simon tip rotation angle (STRA) measures 84.8 degrees, and alar rim angle (ARA) measures degrees. (B) Patient smiling. The TA measures 70.8 degrees, NLA measures 65.9 degrees, CIA measures 70.5 degrees, STRA measures 84.4 degrees, and the ARA measures degrees. The decrease in TA, NLA, CIA, and STRA was 10.7, 13.8, 22.7, and 0.4 degrees, respectively. The increase in ARA was 19.4 degrees as the alar rim straightened. The alar crease cheek junction rose by 3.5 mm, the subnasale rose by 1.7 mm, and the tip moved down 0.3 mm. Note that the tip itself moved less than half a millimeter and less than half a degree during smiling.

7 Kosins et al 51 Table 2. Characteristics of Patients Who Have Plunging Tip Deformity Unifying Characteristic Movements of the Nasal Base During Smile 1. Tip angle less than ideal 1. Rise of alar crease cheek junction 2. Posterosuperior movement of subnasale 3. Straightening of the alar rim Nonideal Tip Rotation: The Plunging Tip Illusion As the tip rotation increases and comes close to a right angle, the nose will no longer appear to plunge in repose, even though tip rotation is not ideal. However, when the patient smiles, the movements of the alar crease, subnasale, and rim will give the illusion of a plunge (used as a verb because of the illusion of a tip that moves/plunges on smiling; Figure 6C,D and Figures at This is because in repose, the alar crease cheek junction lies at approximately the same level as the tip defining point. When the patient smiles, the alar crease cheek junction moves above the tip defining point, giving the illusion of a plunge even though the tip barely moves at all. Ideal Rotation and Overrotation As tip rotation increases toward ideal (105 ± 5 degrees), the alar crease does not rise above the level of the tip during a smile. The alar crease cheek junction lies below the nasal tip in repose. During smile, the alar crease cheek junction rises to the same level as or below the tip defining point. Therefore, a plunging tip will not be perceived by the patient or an observer, as the alar crease cheek junction does not rise above the nasal tip defining point (Figure 6E,F and Figures at Summary of Plunging Tip Illusion In summary, the plunging tip is an illusion based on a patient s static tip rotation in combination with the movement of the rest of the nose during a smile. Tip rotation is a spectrum. However, a patient with downward rotation will look like he or she has a tip that is plunging in repose or during smile because the alar crease cheek junction is always above the tip defining point. A patient with ideal rotation or overrotation will not demonstrate a plunging tip illusion because the alar crease cheek junction does not rise above the tip defining point during a smile. The susceptible group of patients who demonstrate a plunging tip deformity have tip rotation close to 90 to 95 degrees (average TA, NLA, and CIA in repose are 91, 91.2 and 95.7 degrees, respectively). Therefore, the alar crease cheek junction lies in the same plane or slightly below the tip defining point. During smile, the rise of the alar crease (along with the other components of the illusion of a plunge) above the tip defining point gives the illusion of a plunge. Last, there is a group of patients who do not demonstrate a plunge on smile but in whom the tip does plunge Figure 5. This 27-year-old woman demonstrates a typical patient with the plunging tip illusion. On average, for every 0.1-mm drop in the nasal tip, the alar crease cheek junction will rise by 0.4 mm. This is because the fulcrum of the teeter-totter is not in the middle of the nasal base. The fulcrum lies much closer to the tip because this is where the intrinsic components of tip support are located. Therefore, as the patient smiles, her tip will barely descend while the alar crease cheek junction rises. The nasal base will then be in plane with the teeter-totter (the white line) and the nose will appear to plunge. during speech. This was not objectively measured, but the nasal tip certainly moves downward independent of the rest of the nasal base during the kissing test in some patients (Figure 17 at When these patients pucker their lips or lengthen their upper lip downward, the tip independently moves significantly down in some patients. These patients can be differentiated because when they speak, their nasal tip dips often several times during each sentence and sometimes several times while saying a single word. These patients can have excellent tip rotation, which means their tip does not appear to plunge on smile but can dip several millimeters during speech. The Muscles of the Nasal Base and Their Effect on Smile Several muscles that exert their forces on the lips affect a smile. The human smile is dynamic and affected by multiple facial muscles. 8 In addition, many of these muscles affect the nose and specifically the lower nasal base. 9 It is implausible that this perceived plunge could be attributed to a single muscle. Specifically, the actions of the depressor septi nasi (DSN) and, less commonly, the levator labii superioris alaeque nasi (LLSAN) have been attributed to the tip that plunges on smiling. 10 The LLSAN has been shown to insert into the lateral portion of the LLC and alar crease and thus raises the alar crease on smile. 6,11 On the other hand, many authors have postulated that the DSN

8 52 Aesthetic Surgery Journal 34(1) Figure 6. Spectrum of rotation. (A) A rendition of Cyrano de Bergerac with true downward rotation and a nasal tip that plunges in repose. (B) This 31-year-old woman has true downward rotation and appears to have a tip that plunges both in repose and upon smiling, as the alar crease cheek junction lies far above the tip defining point at all times. (C, D) This 18-year-old woman has a typical plunging tip deformity. Tip angle (TA), nasolabial angle (NLA), and columellar inclination angle (CIA) measure 88.5, 85.5, and 95 degrees, respectively. Less than ideal tip rotation, close to 90 degrees, is the unifying characteristic of the plunging tip. During smile, the alar crease rises, the subnasale moves posterosuperiorly, and the alar rim straightens. This, combined with the alar crease cheek junction rising above the nasal tip defining point, gives the plunging tip illusion. Note that the tip descends only 1 mm during smiling. (E, F) This 14-year-old girl has ideal tip rotation with a TA, NLA, and CIA of 100.6, 106.2, and degrees, respectively. During full smile, the alar crease cheek junction never rises above the nasal tip defining point. With enough tip support and rotation, the middle crura sit high above the anterior caudal septum, and there is not enough movement of the nasal base (alar crease and subnasale) to demonstrate a plunging tip deformity.

9 Kosins et al 53 Figure 6. (continued) Spectrum of rotation. (A) A rendition of Cyrano de Bergerac with true downward rotation and a nasal tip that plunges in repose. (B) This 31-year-old woman has true downward rotation and appears to have a tip that plunges both in repose and upon smiling, as the alar crease cheek junction lies far above the tip defining point at all times. (C, D) This 18-year-old woman has a typical plunging tip deformity. Tip angle (TA), nasolabial angle (NLA), and columellar inclination angle (CIA) measure 88.5, 85.5, and 95 degrees, respectively. Less than ideal tip rotation, close to 90 degrees, is the unifying characteristic of the plunging tip. During smile, the alar crease rises, the subnasale moves posterosuperiorly, and the alar rim straightens. This, combined with the alar crease cheek junction rising above the nasal tip defining point, gives the plunging tip illusion. Note that the tip descends only 1 mm during smiling. (E, F) This 14-year-old girl has ideal tip rotation with a TA, NLA, and CIA of 100.6, 106.2, and degrees, respectively. During full smile, the alar crease cheek junction never rises above the nasal tip defining point. With enough tip support and rotation, the middle crura sit high above the anterior caudal septum, and there is not enough movement of the nasal base (alar crease and subnasale) to demonstrate a plunging tip deformity. causes a droopy or hypermobile nasal tip when smiling. Recently, Rohrich et al 12 published that the DSN inserts into the orbicularis oris in the majority of patients, and this causes downward rotation of the tip and shortens the upper lip during smiling because of the interdigitation. As a result, authors have studied each of these muscles anatomically and suggested both surgical and nonsurgical treatments for each. Treatment strategies as well as modification of the muscles and their insertions into the nasal cartilage using botulinum toxin have also been described. 13 Contribution of DSN to the Movement of the Nasal Tip A great deal of attention has been given to the DSN as the main contributor to a plunging nasal tip. However, no author has objectively studied the isolated action of the DSN. Conclusions have been made by looking at pre- and postoperative photographs that do not take into account head position, differences in camera angle, and the strength of the patient s smile. Without objective data, these conclusions are essentially anecdotal. Clinically, no real conclusions can be drawn regarding isolated modification of the DSN muscle, as multiple other maneuvers are performed that affect the tip during rhinoplasty. In addition, our recent dissections have demonstrated that the unique origin of the DSN comes from the maxilla in 100% of cases and the insertion occurs in the anterior nasal septum, medial crural footplates, and membranous septum. 5 Even if the DSN did interdigitate with the orbicularis oris as advocated by Rohrich et al, 12 why would this cause the tip to droop on smile? The orbicularis oris is a circular muscle. When circles contract, they get smaller. A smile is

10 54 Aesthetic Surgery Journal 34(1) not a circle and is greatly affected by other muscles of the lip (levator labii superioris, zygomaticus major, LLSAN, etc). In fact, it is pursing of the lips that causes the circle to get smaller, and this would theoretically be the best way to evaluate the DSN if it interdigitated in a perpendicular fashion with the orbicularis oris. The connection between the DSN and Pitanguy s ligament was noted by Pitanguy and confirmed by De Souza Pinto. 10,14 Additionally, Saban et al 15 have demonstrated that the nasal superficial musculoaponeurotic system (SMAS) divides into a superficial and deep layer at the internal nasal valve. The superficial layer runs anterior to the interdomal ligament into the columella and is continuous with the superficial orbicularis oris nasale (SOON). 5 The deep layer runs posterior to the interdomal ligament in the membranous septum and is continuous with the DSN. This insertion of the DSN with the deep SMAS beneath the interdomal ligament certainly creates a tether. However, its bony origin fails to explain its contraction on smiling. Because it is an independent muscle with minimal interdigitation, its contribution during smiling cannot be directly measured. Although its muscular action can be independent of other muscles, results from injection of neurotoxin also have little value as it lies in close proximity to many other muscles that affect the dynamic position of the nasal tip. Contribution of LLSAN to the Movement of the Lower Third of the Nose With the realization that the lower third of the nose moves as a unit on smiling, the LLSAN has been addressed as a way to blunt the movement of the nostril alae. 16 This has also been addressed surgically for treatment of facial paralysis. 17 Although it has not been objectively measured either, several authors claim that transection of the LLSAN will decrease the movement of the alar base and can modify the medial portion of the nasolabial angle. 11 The LLSAN has a labial and alar portion the insertion of which is into the upper lip as well as the nasal alae and accessory cartilages at the level of the pyriform aperture, respectively. 9 It is an obvious target when trying to correct the smiling deformity. Our recent cadaver studies demonstrate that the labial portion of the LLSAN wraps around the alar lobule, interdigitates with the SOON, and inserts into the base of the columella (subnasale). 9 The alar portion uniquely inserts into the alar crease and LLC. The 2 insertions of the LLSAN act to not only lift the alar crease in an almost vertical direction but also create a vector of pull in a superoposterior direction at the subnasale. When a patient presents with the complaint of a plunging tip, the surgeon must (1) ask when this plunge occurs and (2) watch when the patient speaks and smiles. Is the plunge static? Does it occur on smile? Or does it occur during speech? By watching and documenting with photography the movement of the tip on smile, during speech, and with the kissing test, the surgeon can logically classify the deformity and choose an appropriate treatment. The unifying characteristic of the plunging tip deformity is tip rotation that is not ideal and slightly underrotated. Therefore, any surgical maneuvers aimed at increasing tip support and rotation will help to ameliorate a plunging tip deformity. Arbitrary cutting of muscles has never been measured independently and certainly is not the answer. Now that we have prospectively and objectively measured 25 plunging tip patients and we understand the illusion of a plunge, our future work will detail our treatment planning and algorithms for this cohort. Conclusions Our objective data clearly demonstrate that the nasal tip barely plunges, even with a full smile. Therefore, we believe that surgeons who describe a plunging tip on smile have been making the wrong diagnosis. The concept of a plunging tip is an optical illusion perceived by the observer. In reality, the alar crease and subnasale elevate disproportionately to the descent of the nasal tip in a susceptible group of patients. 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