Rhinoplasty
The Plunging Tip: Illusion and Reality
Aaron M. Kosins, MD, MBA; Val Lambros, MD; and
Rollin K. Daniel, MD
Aesthetic Surgery Journal
2014, Vol 34(1) 45­–55
© 2013 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
http://www​.sagepub.com/
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DOI: 10.1177/1090820X13515482
www.aestheticsurgeryjournal.com
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, 2013.
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 www.aestheticsurgeryjournal.com).
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
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.
E-mail: [email protected]
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
Kosins et al47
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).
48
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 www.aestheticsurgeryjournal.com.
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, 19-55 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 www.aestheticsurgeryjournal.com,
show clinical examples (Figures 7-10).
Aesthetic Surgery Journal 34(1)
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 Guyuron7 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, 86.2-100.9 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 11-14 at www.aestheticsurgeryjournal.com).
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
Kosins et al49
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.
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)
91.0
80.1
10.9
Nasolabial angle (NLA)
91.2
79.3
11.8
Columella inclination angle (CIA)
95.7
83.8
11.9
Simon tip rotation angle (STRA)
84.8
83.7
0.7
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 118.9 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 138.3 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.
Kosins et al51
Table 2. Characteristics of Patients Who Have Plunging Tip Deformity
Unifying Characteristic
1. Tip angle less than ideal
Movements of the Nasal Base During Smile
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 12-14 at www.aestheticsurgeryjournal.com). 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 15-16 at www.aestheticsurgeryjournal.com).
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 www.aestheticsurgeryjournal.com).
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
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 103.8 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.
Kosins et al53
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 103.8 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 al12 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
54
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 al15 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
Aesthetic Surgery Journal 34(1)
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.
Disclosures
Dr Daniel receives royalties from Springer Publishing. The
other authors have nothing to disclose.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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