Rhinoplasty For Tip and Nostril Changes

Q: Dr. Eppley, I am interested in rhinoplasty and have several specific concerns/goals I want to achieve.The only other thing about my nose that I am most uncomfortable with is the lower part of my nose. It appears that my columella is hanging or sagging. I really don’t like the way that part of my nose looks. The nostrils also appear higher than the bottom part of my nose and you can see the inside. I am not sure if this is because of natural Alar retraction or because the columella is hanging down? Both? Neither? The nostrils themselves are kind of “pinched”. They are very narrow and a lot of times I feel like they are the biggest cause of my breathing problems as they seem to collapse some even during normal breathing. Also, Is it possible to change the angle of the tip more upwards? It may just be the bottom part of my nose that makes it looks like its not angled up but I am really not sure? I know that you have said that anytime you make the nose smaller you risk making breathing problems worse. Is it possible to make the nose wider? Like the nostrils or the base itself? If so, would this help with breathing? 

A: I would not call your columella a true hanging columella. This is controlled/treated by the reduction of the caudal end of the septum (which is necessary to tip rotation) and removal of any redundant columellar mucosa.

One of the hardest things to improve in any nose is nostril show. This will be potentially magnified with any degree of tip shortening/rotation that is done. Alar rim grafts are placed to combat it but there is no guarantee that it will not be a persistent issue. Pinched nostrils are treated through the use of batten grafts to provide improved lower alar cartilage support.

The best strategy to manage breasting difficulties in a rhinoplasty are middle vault spreader grafts to help open up the internal nasal valve.

The combination of extensive cartilage grafting (columellar strut, alar rims, batten and spreader grafts) is the most one can do to improve nasal tip support and open the anterior nasal airway as much as possible.

Dr. Barry Eppley

Indianapolis, Indiana