A. To put it simply: tip ptosis (drooping) is correctable through revision surgery, using techniques like septal extension grafting, cartilage reinforcement, and tip support framework redesign.

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Here's why.

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1. Root causes of tip ptosis. The primary culprit is weakening of the tip support mechanism — specifically the lower lateral cartilages (alar cartilages) and the caudal septum. This can result from over-resection during a prior surgery, implant weight compressing the cartilage framework over time, or inadequate initial tip support.

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2. The role of septal extension grafting. A septal extension graft (SEG) extends the caudal septum toward the tip, providing a rigid strut onto which the alar cartilages are secured with sutures. This is currently the most reliable method for achieving controlled, long-lasting tip projection and rotation.

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3. Holistic balance is essential. Simply "lifting the tip" without considering dorsal-tip proportion, alar-columellar relationship, and airway patency will yield an unnatural result. A successful tip correction integrates the entire nasal framework.

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Why the Closed Approach Makes a Difference

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Tip ptosis correction is readily performed via the closed approach. Endonasal incisions provide direct access to the lower lateral cartilages for repositioning and graft placement. Critically, the closed technique preserves columellar skin blood supply, which directly impacts graft survival rate and maintains natural tip skin texture. Septal extension grafting is performed with equal precision endonasally.

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When to Be Cautious

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- If prior surgery excessively resected the alar cartilages, tip elevation has inherent limitations. In such cases, alar cartilage reconstruction using conchal or costal cartilage must be performed before or concurrent with tip lifting.

- Patients with very thick skin may not see dramatic tip refinement from cartilage reshaping alone; septal extension grafting is essential in these cases.

- Aggressive tip rotation risks creating a "Miss Piggy" deformity — excessive nostril show and potential nasal valve compromise with airway obstruction.

- If tip skin has become fibrotic and rigid from prior surgery, a staged approach may be necessary.

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What I've Observed in Clinical Practice

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In my experience, the vast majority of tip ptosis revision patients achieve stable, long-term correction through septal extension grafting (SEG). This technique allows precise control of both tip projection and rotation angle. When costal cartilage is used as the extension graft material, long-term dimensional change is minimal — rib cartilage is the most structurally stable option for permanent tip support.

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Surgeon's Note

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If your tip is progressively drooping over time, weakened internal support is the most likely cause. As a surgeon who has performed all revision and reconstructive rhinoplasty exclusively through the closed technique, I place great importance on addressing both function and structural integrity in every procedure. Early evaluation allows for timely intervention before further support loss occurs.

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Summary

- Tip ptosis results from weakened alar cartilage and caudal septal support; revision correction is effective

- Septal extension grafting (SEG) provides the most reliable, long-lasting tip repositioning

- Over-aggressive tip lifting risks unnatural appearance and airway compromise