Management of the Long Nose: Review of Techniques for Nasal Tip Supporting Structures

The long nose with a “plunging” tip is a deformity that involves an inferiorly rotated nasal tip, leading to an increase in the length of the nose. The anatomic basis of the long nose with a plunging tip may be divided into two types. Type 1 presents a normal alar–cartilage complex inferiorly displaced by a long nasal septum and long upper lateral cartilages. Type 2 is caused by a dislocation of the alar cartilages downward from the aponeurotic attachments to the septal angle. During the study period, the authors identified 60 patients with long noses and plunging tips. For 22 patients with type 1 long noses, the high septal incision technique was used in 12 cases and the step technique in 10 cases. The invagination procedure alone was used for 22 of 38 patients with type 2 plunging noses. Also, an extension graft with the invagination procedure was used for 6 patients, and a columellar strut graft was used for 10 patients. A high septal incision increased tip rotation without significantly changing the amount of tip projection. However, the step procedure, the invagination technique alone, septal extension graft with the invagination technique, and columellar strut grafts increased nasal tip rotation and projection. During the study period, 38 patients were identified as having a smiling deformity, which was improved using the authors’ modification procedure. On the basis of the results, the authors recommend that the appropriate treatment for each patient with a long nose and a plunging tip must be determined by preoperative and intraoperative examination findings with the patient at rest and while smiling.