Plastic surgery is a science. In addition, aesthetic surgery has an undeniable artistic side. That's okay, but when it comes to performing surgery, we plastic surgeons are craftsmen. Craft means a profession that is based on qualified labor rather than capital and requires manual dexterity, professional competence and mastery as well as training. As in all craftsmen, we can talk about a "practical skill" in plastic surgeons. The practical skill is actually a skill that accelerates the surgeon and enables them to do their work in a cleaner, sharper and more targeted manner. In order to gain such practical skill in any subject, it is necessary to practice it repeatedly for ultimate excellence.

When it comes to rhinoplasty (nose job), things get a little more complicated. Because each patient's nose is different from another, the needs of each patient are different from one another, and the procedures to be performed in each surgery have to be tailored. Surgeons, on the other hand, have their own list of habits. Some surgical techniques and maneuvers are performed so frequently and become so habitual over time that they are performed via practical skill in cases where that surgical technique does not work or is useless. About 20-25 years ago, rhinoplasty was a procedure in which the same maneuvers were repeated in almost every operation, the nose was shaped in a closed procedure, individual anatomical differences were not considered and took a total of 30 minutes in the hands of an experienced surgeon. Although the situation in rhinoplasty today is very different, we can still talk about some maneuvers that are routinely performed by practical skill.

First of all, you should know that after all nose surgeries, the tip of the nose droops a little. We know this, and thus we usually lift the tip of the nose a little more than the final position we want in surgeries. If it's been less than 6 weeks since your surgery and your nose seems too upturned, don't worry. It will probably correct by itself in the coming weeks.

The “drooping nose” I refer to in this article is when the nose tip is not in the aesthetically ideal position desired by the patient and the doctor although it’s been a long time after the surgery.

 

 

Let's start by focusing on a beam in our eyes. A drooping nose may be due to errors caused by the surgical technique. To that end, the most common errors are as follows:

1.  Excessive lowering of the anterior segment of the middle cartilaginous wall (septum), which provides the height of the nose tip
2. Inaccurate shaping of the cartilages of the nasal tip
3. Failing to repair the connective tissue support mechanisms that hold the nose tip in place.
    

The factors that play a role in nose surgery are very diverse, and the patient-related factors are at least as important as the surgeon-related ones. The nasal tip cartilages of the patient are sometimes very weak, weaken further during surgery and cannot resist the pressure caused by the skin cover and the total force of gravity. Particularly in cases where the patient's skin is thick and the cartilage is weak, the nasal tip is especially prone to drooping, and it may be necessary to strengthen the skeleton by transplanting cartilage from other parts of the body during the first surgery.

Since the nose tip is in close contact with the lip, the nose tip may droop in cases where the lip muscles are hyperactive and constantly pull the nasal cartilages down. In that case, no matter how much you suspend the nose tip with stitches, no suture can defeat the lip muscles in the long run. Therefore, in my patients with hyperactive lip muscles, we prefer to make a "new nose tip" in a non-load-bearing position instead of moving the nose tip somewhere else.

Sometimes the tip of the nose does not actually droop but looks as if it does so. This situation, where the position, angle and height of the nose tip is normal, but the nose tip appears "relatively" drooping since the nasal ridge remains too high, is called false nasal tip droop (pseudoptosis). One of the most common causes of pseudoptosis is the excessive swelling of the “supratip” area, an area just behind the nose tip where the nasal ridge and the nose tip meet. When this area is swollen, the nose looks like a polly beak when viewed from the side. We call this deformity “soft tissue supratip deformity”. It is particularly seen in patients with thick skin and may persist for 1.5-2 years after surgery.

In some cases, it is “technically” impossible for the nose tip to be as high/raised as the patient wants. Examples include situations where the bridge (columella) connecting the nose and the lip is structurally underdeveloped and short, or the nose loses its flexibility due to multiple surgeries. Although they are very rare, if you have one of these conditions, your surgeon will inform you about the limitations before the operation.

When a non-doctor reads this article, they will be confused and not have much of a clue about what they read. Although I only touch on major issues here, this seemingly simple matter is a very deep subject, and thousands of plastic surgeons around the world are still pondering on how to achieve better results.

If you have had surgery and your nose tip is not in the position you want, it is not the end of the world. In the next article “My nose drooped after surgery. What should I do?”, I will talk about how you can cope with this unfortunate situation.