Tip Droop Prevention in Rhinoplasty: Dynamic Effect of Strut Graft on Smiling versus Depressor Muscle Release

Brady C, Berwick D, Uppal R.

PubMed 33868871 Publisher (DOI)Free full text (PMC)

What this paper says

Comparing 29 patients who had the depressor muscle released against 11 who also received a columellar strut, tip droop on smiling averaged 3.66 degrees with muscle release alone and 2.27 degrees with the added strut.

Overview

The tip of the nose can drop when a patient smiles, which surgeons may not notice after surgery but patients do. The study asked whether dividing the depressor septi nasi muscle, or combining that with a columellar strut graft, produces a measurable reduction in that movement. It reviewed notes and photographs from patients who had endonasal aesthetic rhinoplasty by a single surgeon between 2015 and 2019.

Sections of note

Retrospective case note and photograph review; single surgeon, 2015 to 2019.
Twenty nine patients had release of the depressor septi nasi muscle alone.
Eleven patients had muscle release plus a columellar strut graft.
Lateral photographs while smiling were taken after surgery, at a mean of 14 months.
Tip droop was measured as the change in nasolabial angle from rest to smiling, referenced to the Frankfurt line.
The muscle release group showed a mean increase in nasolabial angle of 3.66 degrees when smiling.
The muscle release plus strut group showed a mean increase of 2.27 degrees.
The authors conclude the strut plus release reduces droop on smiling more than division alone.

What it means for a patient

Tip movement on smiling is a dynamic result that static photographs do not capture.
Adding a cartilage post between the nostrils reduced that movement by about 1.4 degrees on average.
Only 11 patients received the combined treatment, and groups were not randomized.
No statistical test result is reported in the abstract for the difference between groups.

Why this paper matters

Rhinoplasty results are almost always judged at rest, while patients see their nose in motion. This study measures a dynamic outcome and links it to a specific graft. The clinical significance of a 1.4 degree difference is not established.

Terms

Tip droop: the nasal tip dropping downward, here specifically when smiling.
Depressor septi nasi: a small muscle that pulls the nasal tip down.
Columellar strut graft: a cartilage post placed between the nostrils to support the tip.
Nasolabial angle: the angle between the base of the nose and the upper lip.
Frankfurt line: a standard horizontal reference line across the head used in facial measurement.

Summary written by rhinoplasty.cc from the abstract, 2026-09-09; not medical advice. The authors' own abstract follows.

Abstract

Background: Aesthetic rhinoplasty is one of the most challenging procedures performed by aesthetic surgeons. Tip droop, especially on smiling, may not be noted by the surgeon postoperatively but can be concerning to patients. Our aim was to determine if the division of the depressor septi nasi or its combination with a columellar strut graft during rhinoplasty produce a measurable reduction in nasal tip droop on smiling.

Methods: A retrospective casenote and photograph review was conducted on patients who had undergone aesthetic endonasal rhinoplasty, performed by a single surgeon between 2015 and 2019. In total, 29 patients had release of the depressor septi nasi muscle, whilst 11 had release of the muscle along with a strut graft. Lateral smiling photographs were taken postoperatively. Tip droop was measured as a variation of the nasolabial angle from rest to smiling using the Frankfurt line.

Results: Photographs were taken at a mean of 14 months postoperatively. In the group who had muscle release only, a mean increase in nasolabial angle of 3.66 degrees was seen when smiling when compared with rest. In the group who had muscle release combined with strut graft, a mean increase of 2.27 degrees was seen. When using a columellar strut along with muscle release, tip droop on smiling was reduced.

Conclusions: This study demonstrates that columellar strut grafting in combination with muscle release can alleviate drooping of the tip better than muscle division alone after rhinoplasty. The columellar strut graft provides tip stability and can therefore be used to enhance dynamic outcomes after rhinoplasty.

Abstract as indexed by PubMed; the article is open access (PubMed Central).