Rhinoplasty

Aesthetic Surgery Journal

2015, Vol 35(4) 367–377
The Plunging Tip: Analysis and Surgical © 2015 The American Society for
Aesthetic Plastic Surgery, Inc.
Treatment Reprints and permission:
journals.permissions@oup.com
DOI: 10.1093/asj/sju110
www.aestheticsurgeryjournal.com

Aaron M. Kosins, MD, MBA; Val Lambros, MD;

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and Rollin K. Daniel, MD

Abstract
Background: The plunging tip refers to a deformity in which the nasal tip plunges on smiling.
Objectives: To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a
focus on the anatomic changes of the nose on smiling.
Methods: Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static
and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose.
Results: Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one
year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively.
Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip.
Conclusions: This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate
that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose.
No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles
is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.

Level of Evidence: 2

Accepted for publication October 8, 2014. Therapeutic

The plunging tip deformity has been described in different
ways using both static and dynamic criteria.1-3 Many
authors prefer the term “droopy tip” for the static deformity
and “plunging tip” for the dynamic deformity. We prefer to
define the plunging tip as a dynamic entity in which the
nasal tip visually appears to descend on smiling. The causa-
tive factors for a plunging tip have been attributed to both
extrinisic factors (long lower lateral cartilages, long and
short caudal septum, overactive columellar base muscles)
as well as intrinsic tip factors (downward tip rotation, tip
deficiency leading to inadequeate projection).4 Treatment
of the dynamic deformity on smiling has largely focused
on transection, weakening, and repositioning of specific
muscles.5-7
We now have completed a two-part study to objec-
tively and prospectively analyze a series of female
primary rhinoplasty patients who complained of a
plunging tip on smiling. As detailed in Part 1 of our
study, the data indicated that the tip of the nose during
a smile plunges less than 1 mm and changes position
less than 1 degree when measured from the static tragus
(Simon tip rotation angle).6 Since the tip of the nose
barely moves on smiling, we identified the four
Dr Kosins is a Volunteer Clinical Assistant Professor and Dr Daniel is a
Volunteer Clinical Professor, University of California, Irvine Medical
Center, Irvine, CA. Dr Lambros is a plastic surgeon in private practice
in Newport Beach, CA.
Corresponding Author:
Rollin K. Daniel, MD, 1441 Avocado Drive, Suite 308, Newport Beach,
CA 92660.
E-mail: rkdanielmd2@gmail.com
368 Aesthetic Surgery Journal 35(4)

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Figure 1. Demonstrates a preoperative 24-year-old female patient who complained of a plunging tip on smiling. (A) Static photo-
graph and (B) on smiling. The four characteristics that make up the plunging tip illusion include: (1) the initial relationship of the
tip and alar crease junction; (2) the rise of the alar crease; (3) the posterosuperior movement of the subnasale; and (4) the straight-
ening of the alar rim.

Figure 2. To control head position and for accurate measurements of nasal angles, each patient’s index finger was placed at the
posterior portion of the symphysis of the mandible with the hand resting comfortably on the upper sternum to prevent changes in
head position. A 22-year-old female patient is shown for demonstration.

characteristics that make up the plunging tip illusion: posterosuperior movement of the subnasale; and (4) the
(1) the initial relationship of the tip and alar crease straightening of the alar rim (see Figure 1 and
junction; (2) the rise of the alar crease; (3) the Supplementary GIF S1).
Kosins et al 369

Part 2 of our study is designed to answer the following
four questions: (1) Was our treatment of the plunging tip
illusion effective; (2) was muscle excision or manipulation
necessary; (3) since the diagnosis is not a change in tip
position, what changes occurred after rhinoplasty that elim-
inated the plunging tip illusion; and (4) what are the surgi-
cal options for treatment of the plunging tip?
METHODS
At the rhinoplasty consultation, patients were asked to
describe three characteristics of their nose that they did not
Informed consent was acquired from all patients. Exclusion
criteria included prior nasal surgery or trauma, as well as
male patients. The study period was from June 2012 to
March 2014, with inclusion in the study from June 2012 to
February 2013. Twenty-two of 172 patients (12.8%) com-
plained of a plunging tip and met the inclusion criteria.
Three surgeons were involved in the study, each with a
separate responsibility. Surgeon #1 picked 22 female cos-
metic rhinoplasty patients who complained of a nasal tip
that plunged on smiling to include in the study. It should
be noted that Surgeon #1 included 3 patients who did not
complain of a plunging tip as controls, unbeknownst to the

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like and wanted changed. If the patient complained of a other two surgeons. At their preoperative and oneyear post-
plunging tip on smiling, they were included in the study. operative visits, each patient was photographed in static and

Figure 3. This 27-year-old woman demonstrates our measurements of different angles on our 25 prospective patients. (A) Tip angle, as
described by Byrd and Hobar,7 was measured by dropping a perpendicular line from the Frankfurt horizontal line through the alar
crease junction. The angle was formed by intersecting another line from the alar crease junction to the most projecting part of the nasal
tip. (B) The nasolabial angle, as described by Armijo et al,8 was measured by dropping a perpendicular line from the Frankfurt horizon-
tal line through the subnasale. The angle was formed by intersecting another line through the most anterior and posterior portions of
the nostril. (C) The columella inclination angle was measured by dropping a perpendicular line from the Frankfurt horizontal line
through the alar-cheek junction. The angle was formed by intersecting another line that paralleled the columella. (D) The Simon tip rota-
tion angle was used to measure the change in tip position in relation to the static tragus. (E) The alar rim angle was measured by calculat-
ing the angle between the anterior and posterior limbs of the alar rim at the nostril. Reprinted with permission from Sage Publications.
370 Aesthetic Surgery Journal 35(4)

Table 1. Demonstrates the Change in Tip Rotation Angles on Smiling Table 2. Demonstrates the Change in Tip Rotation Angles on Smiling
Preoperatively Postoperatively
Preoperative Static Smile Change Postoperative Static Smile Change
Measurements Measurements

Tip Angle ↓ 91.0° 80.1° 10.9° Tip Angle ↓ 94.7° 86.2° 8.5°

Nasolabial Angle ↓ 91.2° 79.3° 11.8° Nasolabial Angle ↓ 95.3° 84.2° 11.1°

Columella-Inclination 95.7° 83.8° 11.9° Columella-Inclination 100.3° 92.6° 7.7°

Angle ↓ Angle ↓

Simon Tip Rotation 84.4° 83.7° 0.7° Simon Tip Rotation 83.7° 83.5° 0.2°
Angle ↓ Angle ↓

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Tip angle, nasolabial angle, columella inclination angle, and Simon tip rotation angle were Tip angle, nasolabial angle, columella inclination angle, and Simon tip rotation angle were
measured preoperatively in static and smiling views. The average values as well as the average measured one year after each patient’s operation in static and smiling views. The average
change on smiling are shown. values as well as the average change on smiling are shown.

Table 3. Demonstrates the Average Change in the Cardinal Points Table 4. Demonstrates the Average Change in Tip Rotation on Smiling
of the Nose on Smiling, Both Preoperatively and One Year Postoperatively Both Preoperatively and One Year Postoperatively
Change on Smiling Preoperative Postoperative Change on Smiling Preoperative Postoperative

Tip Position ↓0.9 mm ↓0.9 mm Tip Angle 10.9° 8.5°

Nasolabial Angle 11.8° 11.1°

Subnasale ↑1.3 mm ↑1.6 mm
Columella Inclination Angle 11.9° 7.7°

Alar-Cheek Junction ↑3.7 mm ↑4.2 mm Simon Tip Rotation Angle 0.7° 0.2°

There is no statistically significant difference with the preoperative and postoperative Even though the data shows that the nose moves slightly less after surgery, there is no
values. statistically significant difference with the preoperative and postoperative values. The nose
moves just as much after surgery as it did before. The tip dynamics remain the same.

smiling sequences using standard rhinoplasty views with a
ruler included in each photograph. Marks were made to
standardize the position of the alar crease, subnasale, and
three positions of the nasal tip diamond. The tragus was in-
cluded in the lateral photographs of each patient because
this facial subunit does not usually change position during a
smile. The patient’s index finger was placed at the posterior
portion of the symphysis of the mandible with the hand
resting comfortably on the upper sternum to prevent
changes in head position (see Figure 2). All patients were
standardized as to the measurements, markings, finger on
chest/chin, and ruler. However, we also took pictures with-
out markings and without the finger on the chin in some in-
stances, in addition to the standard photographs.
Surgeon #2 overlaid the static and dynamic images to
achieve as perfect an alignment as possible using Adobe
Photoshop CS4. Photographs were adjusted for color and
exposure, and finally overlaid using various static land-
marks (tragus, nasal dorsum, and anterior portion of the
cornea) to achieve alignment. GIF animations were created
and are included in the Supplementary Materials.
Surgeon #3 measured five angles preoperatively and one
year postoperatively to assess tip rotation: the tip angle
(TA), nasolabial angle (NLA), columella-inclination angle
(CIA), Simon tip rotation angle (STRA), and alar rim
angle (ARA).6 The change in the position of the tip, subna-
sale, and alar crease for both static and smiling views was
also measured (Figure 3).
The TA, as described by Byrd, was measured by dropping
a perpendicular line from the Frankfurt horizontal line
through the alar crease junction.7 The angle was formed by
intersecting another line from the alar crease junction to the
most projecting part of the nasal tip. The NLA, as described
by Guyuron, was measured by dropping a perpendicular line
from the Frankfurt horizontal line through the subnasale.8
The angle was formed by intersecting another line through
the most anterior and posterior portions of the nostril. The
CIA, as described by Daniel, was measured by dropping a
perpendicular line from the Frankfurt horizontal line through
the alar-cheek junction.4 The angle was formed by intersect-
ing another line that paralleled the columella. The STRA was
used to measure the change in tip position in relation to
the most posterior portion of the static tragus. Finally, the
ARA was measured by calculating the angle between the an-
terior and posterior limbs of the alar rim at the nostril.4
Statistics were performed to compare anatomical changes in
static and smiling positions both pre- and postoperatively.
Measurement of angles was done using the ruler tool in
Kosins et al 371

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Figure 4. Treatment of the plunging tip illusion was effective in this 35-year-old female patient. (A) Preoperative static, (B) preop-
erative on smiling, (C) postoperative static at 14 months, and (D) postoperative smiling at 14 months. The illusion has disappeared.

Figure 5. Treatment of the plunging tip illusion was effective in this 24-year-old female patient. (A) Preoperative static, (B) preop-
erative on smiling, (C) postoperative static at 12 months, and (D) postoperative smiling at 12 months. The illusion has disappeared.
372
Figure 6. Treatment of the plunging tip illusion is not effective if the patient (as with this 35-year-old female patient) does not
desire a change in tip rotation. (A) Preoperative static, (B) preoperative on smiling, (C) postoperative static at 12 months, and
(D) postoperative smiling at 12 months. The illusion has not disappeared. Figures A and B from Kosins et al.6 Reprinted with
permission from Oxford University Press.
Adobe Photoshop in both static and dynamic views, both
preoperatively and postoperatively, and then compared.
To measure changes in subunit position (in millimeters),
overlays were made transparent so that static and dynamic
views could be seen simultaneously. Where the ruler is
placed in the photograph and to what magnification the
photograph was taken does not impact the measurements.
In Adobe Photoshop, the ruler tool was used to measure 1
mm on the ruler. This was then translated to distances mea-
sured on the nose. For purposes of discussion, we will
define two terms: (1) the tip point is defined as the most
projecting point on the tip lobule in lateral position; and (2)
the tip rotation is measured using the TA as described by
Byrd.7
RESULTS
Twenty-five female rhinoplasty patients aged 16 to 51
(average 23.4) were included in the study, 22 of whom
were patients who complained of a plunging tip during
smiling and 3 of whom were controls. No males were in-
cluded. Average follow-up s 12.8 months with a range of 10
to 15 months.
Aesthetic Surgery Journal 35(4)
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Operative Technique
The operative technique performed by the senior author
that affects tip rotation and projection will be reviewed.
The open technique was used in 24 of 25 patients. A colu-
mellar strut was inserted when using an open rhinoplasty
technique in the 24 patients. Domal creation sutures were
used in 24 of25 patients. Twenty-three fo the25 patients
had caudal septal excisions ranging from 3-6 mm with an
average of 4.4 mm. A tip position suture (suture from the
distal portion of Pitanguy’s ligament to the caudal septum)
was performed in 14 patients. A tip graft was used in 5
patients.9 A tongue-in-groove maneuver was performed in
1patient. Excision of columellar base muscles was per-
formed in 2patients: 1 for treatment of external nostril valve
obstruction and the other for treatment of a “gummy
smile.” It should be noted that 2 patients, both of Israeli
background, were adamant that they did not want their tips
rotated significantly above 90 degrees.
Preoperative Measurements
For the 22 plunging tip patients, the TA, NLA, and CIA all
decreased on smiling preoperatively by an average of 10.9,
Kosins et al 373

11.8, and 11.9 degrees, respectively (see Table 1). The sub-
nasale and alar-cheek junction elevated on smiling by 1.3
and 3.7 mm, respectively. The STRA, an aesthetic angle in-
dependent of alar base movement, decreased by less than 1
degree. Finally, the ARA increased by an average of 9.9
degrees. Tip position (marked at the point of maximal pro-
jection of the tip) dropped by an average of 0.9 mm on
smiling, thus nullifying the concept of a plunging tip. See
GIF animations online for more clinical examples (see
Supplementary GIFs S2 and S3).
Postoperative Measurements
The TA, NLA, and CIA all decreased on smiling post-
operatively by an average of 8.9, 11.2, and 7.8 degrees,
respectively (see Table 2). The subnasale and alar-cheek
junction elevated on smiling by 1.6 and 4.2 mm, respec-
tively. The STRA, an aesthetic angle independent of alar
base movement, decreased by less than 1 degree.
Finally, the ARA increased by an average of 9.4 degrees.
Tip position (marked at the point of maximal projection
of the tip) dropped by an average of 0.9 mm. See GIF an-
imations for more clinical examples (see Supplementary
GIFs S4 and S5).

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Table 5. Patients can be Classified as Type 1, 2, or 3 Depending on the
Table 3 compares the change in angles of the nose both
Relationship of the Nasal Tip-Defining Point to the Alar-Cheek Junction in
Repose preoperatively and postoperatively. Table 4 compares the
change in position of the subunits of the nose before and
Type 1 Type 2 Type 3 after surgery.
Relationship of tip T > ACJ T = ACJ T < ACJ A comparison of the preoperative and postoperative
(T) to measurements illustrates that the cardinal points and nasal
alar-cheek angles of the nose move just as much after surgery as
junction (ACJ)
before. There is no statistically significant difference before
This is the key characteristic that makes a patient susceptible to the plunging tip illusion. and after surgery.

Figure 7. This figure demonstrates a type 1, 32-year-old patient preoperatively. The tip-defining point lies well above the
alar-cheek junction. This patient does not demonstrate the plunging tip illusion. (A) Static view with a tip angle of 99.3 degrees.
(B) On smiling, the tip stays above the alar-cheek junction and there is no appearance of a plunge. Tip angle measures 92.5
degrees. From Kosins, Lambros, and Daniel.6 Reprinted with permission from Sage Publications.
374
DISCUSSION
Historically, treatment of the plunging tip dynamic deformity
has focused mainly on manipulation of the muscles of facial
expression on smiling.10 Since most surgeons feel that the tip
of the nose is plunging on smiling, their treatment focuses on
changing the dynamics of the movement of the nasal tip.
Wright described an overactive depressor septi nasi (DSN) as
being responsible for the plunging tip phenomenon and stated
that it could be diagnosed with the smile test.11 Multiple
authors then recommended transection, excision, and en bloc
removal of tissue.12,13 Rohrich identified the anatomy of the
DSN using a top-down approach and recommended manipu-
lation of these muscles and a columellar strut in patients
whose DSN attached into the orbicularis oris or periosteum.14
In performing our literature review, we did not find
any publications or presentations that objectively mea-
sured the movements of the nose on smiling. The discus-
sions of many articles focus on subjective, visual
observations made before and after rhinoplasty without
objective measurements. Importantly, these investiga-
tions failed to stabilize the chin on smiling.15 The slight-
est degree of head movement can dramatically alter
rhinoplasty results, especially regarding tip angle.
Was Treatment of the Plunging Tip Effective?
Our treatment of the plunging tip was effective. All patients
treated for the plunging tip deformity no longer plunged
clinically when observed by both the surgeon and the pa-
tients (see Figures 4 and 5). Only 2 patients had their colu-
mellar base muscles cut, which included the DSN. This
excision was done to treat an external valve obstruction
exacerbated by a wide columellar base in 1 patient and
a gummy smile in the other. Neither of these 2 visually
plunged after surgery. Interestingly, 2 patients were adamant
about not having more tip rotation postoperatively, and
these patients still continued to visually plunge after surgery
(see Figure 6).
Perhaps the most surprising finding was that the nasal
base moves just as much after surgery as it did preopera-
tively. The subnasale and alar crease rise and the nasal
angles decrease, but the illusion of the plunge disappears.
Importantly, the tip still only moves less than 1 mm and
less than 1 degree when measured from the tragus both
pre- and postoperatively. Since only 2 patients had their col-
umellar base muscles cut, and the dynamics of the nose
are the same preoperatively and postoperatively in the
22 patients, cutting muscles appears to be unnecessary. Why
does the plunging tip illusion go away with surgery even
though the muscles contract the same as preoperatively?
To answer this question, the authors have classified pa-
tients into three different types depending on their profile
in repose and during smiling (see Table 5). Regardless of
Aesthetic Surgery Journal 35(4)
the characteristics of the nose, during a smile, the alar
crease rises, the subnasale moves posterosuperiorly, and
the alar rim straightens. What differentiates a plunging tip
patient versus a “normal” patient is the initial position of
the tip relative to the alar crease in repose.
Type 1: Ideal Tip Angle With the Tip-Defining
Point Above the Alar-Cheek Junction
In a Type 1 patient, the tip lies above the alar-cheek junc-
tion (ACJ) in repose (Figure 7 and Supplementary GIF S6).
Their tip angle is ideal or close to ideal as regards tip
rotation (approximately 95 to 105 degrees). As tip angle
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(rotation) increases, the tip lies further and further above
ACJ in repose. When the smile occurs in a type 1 patient,
the ACJ will rise, but will fail to rise above the tip.
Therefore, they do not have a plunging tip illusion. It is
only when the alar crease begins to rise above the nasal
tip on smile that the illusion of a plunge becomes appar-
ent. Tip angle in repose is the key characteristic of the
plunging tip illusion.
Type 2: Nonideal Tip Angle With the Tip
at Approximately the Same Level as the
Alar-Cheek Junction
The type 2 patient suffers from the plunging tip illusion. As
the tip rotation decreases from the ideal and approaches 90
degrees, the nose does not appear to plunge in repose, but
is susceptible to the illusion on smiling. The deformity
occurs because both the tip and ACJ are at approximately
the same level. During a smile, all the normal movements
of the alar crease, subnasale, and rim will give the illusion
of a plunge (used as a verb here because of the illusion of a
tip that moves/plunges on smiling). This plunge occurs
because the ACJ moves above the tip, giving the illusion of
a plunge even though the tip barely moves at all (see
Figures 8 and 9 and Supplementary GIF S7).
Type 3: Downward Tip Angle With Tip
Below ACJ
Downward rotation causes the nose to look like it is plunging
all the time and the word plunging can also be used as an ad-
jective to describe a characteristic of the nose. When the tip
is below the ACJ in repose, the patient appears to have a tip
that is plunging; and this is the group that has been labeled
as having a “droopy tip” on static view. On smiling, all the
normal movements of the alar crease, subnasale, and rim
will make the plunge appear worse (see Figure 1).
In summary, the plunging tip illusion occurs in a subset
of patients where the tip appears to plunge as the ACJ rises
above the tip on smiling. Tip angles reside on a spectrum.
The susceptible group of patients that demonstrate a
Kosins et al 375

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Figure 8. (A) The plunging tip illusion is demonstrated in a 37-year-old type 2 female patient. On static view, the tip-defining
point lies at approximately the same level as the alar crease junction, with a tip angle of 91.7 degrees. (B) On smiling, the appear-
ance of a plunge occurs as the alar crease rises and the tip now lies below the alar-cheek junction even though the tip has moved
less than 1 mm. Tip angle now measures 85 degrees.

average tip angle of 95 degrees in repose. This small change

in tip rotation is what eliminates (treats) the illusion.

Figure 9. This figure demonstrates the difference between a
32-year-old type 1 female patient (A) and a 37-year-old type 2
patient (B). Tip angle in repose is the key characteristic of the
plunging tip illusion. The type 1 patient has a tip angle in
repose of 99.3 degrees while the type 2 patient has a tip angle
in repose of 91.7 degrees.
plunging tip illusion have tip angles close to 90 degrees.
Before surgery, the patients had an average tip angle of
91 degrees in repose. After surgery, the patients had an
Appropriate Treatment
All patients treated for a plunging tip illusion no longer ap-
peared to plunge on smiling, except the 2 patients who re-
quested no change in tip rotation (angle). Since the only
difference before and after surgery was a change in tip
angle, the appropriate treatment for the plunging tip is to
convert type 2 and 3 patients to type 1 (see Figure 10 and
Supplementary GIFs S5, S7–S9).
Converting a type 2 or 3 patient to a type 1 requires an
increase in tip angle. We prefer to increase rotation with
cephalic trim, caudal septal resection, tip position sutures,
and tip grafts. However, the method by which the rhino-
plasty surgeon increases the tip angle is less important
than making the correct diagnosis and treatment plan. It is
important to understand that the diagnosis of a plunging
tip deformity is dynamic. The nose moves on smiling and
the tip appears to plunge. However, the treatment is static,
meaning that the nose will continue to move after sur-
gery just as it did before. The notion of cutting muscles
376 Aesthetic Surgery Journal 35(4)

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Figure 10. The appropriate treatment of the plunging tip illusion is to convert a type 2 or type 3 patient to a type 1 by changing the
tip angle. This 37-year-old female patient has been converted from a type 2 to a type 1 patient in repose. (A) Preoperatively she had
a tip angle of 91.7 degrees and (B) her 12-month postoperative lateral photograph in repose shows a tip angle of 100 degrees. (C)
At 12 months preoperatively on smiling the patient has the plunging tip illusion, as the tip is below the alar-cheek junction with a
tip angle of 85 degrees. (D) Postoperatively on smiling the illusion has disappeared, as the tip is no longer below the alar-cheek
junction with a tip angle of 92.9 degrees. This 24-year-old female patient has been converted from a type 3 to a type 1 patient in
repose. (E) Preoperatively she had a tip angle of 82.8 degrees and the patient appears to plunge already. This has been described as
a “droopy tip.” (F) Her 12-month postoperative photograph in repose shows a tip angle of 95 degrees. (G) Preoperatively on
smiling the patient has a “droopy tip” that gets worse on smiling as the tip moves well below the alar-cheek junction, with a tip
angle of 72.4 degrees. (H) Postoperatively on smiling, the “droopy tip” has been corrected, as the tip is no longer below the
alar-cheek junction with a tip angle of 89 degrees. The nose no longer appears droopy in repose or on smiling.

becomes irrelevant since (1) the nasal tip does not change
position on smiling; and (2) the lower third of the nose
moves the same amount before and after surgery. In fact,
if one looks at previous articles on treating the plunging
tip with manipulation/resection of the DSN, the authors’
treatments appear effective, but in reality all patient have
had an increase in tip angle and have been converted from
type 2 or 3 to 1. Cutting the DSN may have some effect
on the plunging tip, as it is a muscle of facial expression
and its strength and direction of pull varies from patient
to patient. We do not believe that the DSN should be
completely disregarded, but cutting this muscle does not
treat the plunging tip. The treatment causes a static change
in tip position.
Study Limitations
Although this is a Level 2 study, and photographs and mea-
surements were standardized, we were unable to control
the effort of smile. The patients’ smiles preoperatively and
postoperatively could not always be perfectly reproduced
and this may have slightly affected our measurements.
Patients were asked for a “full smile” for standardization.
Tip angle depends on the alar-cheek junction as well as the
Kosins et al
position of the nasal tip, so changes in cheek position could
also affect our results. It should be noted that no lateral
wall grafts were placed and nostril sill excision was only
done in 2 patients. Although the cheek may move position,
the alar-cheek junction was visible in all photographs,
as it had been marked by the operating surgeon before
photography.
CONCLUSION
This is the first prospective, evidence-based study on the
plunging tip. Measurements taken of the lower third of the
nose before and after surgery demonstrate that the nasal tip
moves less than 1 mm and 1 degree on smiling. In addition,
treatment of the plunging tip illusion was effective in all pa-
tients by increasing the tip angle so that the nasal tip lies
above the alar crease junction in repose. No columellar
base muscles were cut to treat the plunging tip, and the
nose moved just as much after surgery as it did before.
Therefore, cutting or manipulating muscles is not necessary
to treat the plunging tip. Muscle excision is not the answer.
Type 2 and 3 patients must be converted to a type 1 to effec-
tively treat the illusion by whatever means (technique) the
surgeon prefers.
Supplementary Material
This article contains supplementary material located online at
www.aestheticsurgeryjournal.com.
Disclosures
Dr Daniel receives royalties from Springer Publishing, Dr
Kosins is a consultant for ZO Skin Health, and Dr Lambros has
nothing to disclose.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
377
REFERENCES
1. Rees TD, LaTrenta GS. Aesthetic Plastic Surgery. 2nd ed.
Philadelphia, PA: Saunders; 1994:272-281.
2. McCarthy JG. Plastic Surgery. Philadelphia, PA: Saunders;
1990:1853-1856.
3. Rohrich RJ, Hollier LH, Janis JE, et al. Rhinoplasty with
Advancing Age. Plast Reconstr Surg. 2004;114:936–944.
4. Daniel RK. Rhinoplasty: An Atlas of Surgical Techniques.
New York: Springer, 2002.
5. Arregui JS, Elejalde MV, Rehalado J, et al. Dynamic
rhinoplasty for the plunging nasal tip: Functional unity of
the inferior third of the nose. Plast Reconstr Surg.
2000;106:1624–1629.
Downloaded from https://academic.oup.com/asj/article/35/4/367/233966 by guest on 10 January 2022
6. Kosins AM, Lambros V, Daniel RK. The Plunging Tip:
Illusion and Reality. Aesthet Surg J. 2014;34:45–55.
7. Byrd HS, Hobar PC. Rhinoplasty: A practical guide
for surgical planning. Plast Reconstr Surg. 1993:91:
642–654.
8. Armijo BS, Brown M, Guyuron B. Defining the ideal naso-
labial angle. Plast Reconstr Surg. 2012;129:759–764.
9. Daniel RK. Mastering Rhinoplasty. New York: Springer;
2010.
10. Rees TD, La Trenta GS. Aesthetic Plastic Surgery. 2nd ed.
Philadelphia, PA: Saunders; 1994.
11. Wright WK. Symposium: the supra-tip in rhinoplasty: a
dilemma. II: Influence of surrounding structure and pre-
vention. Laryngoscope. 1976;86:50-52.
12. Ham KS, Chung SC, Lee SH. Complications of Oriental
augmentation rhinoplasty. Ann Acad Med Singapore.
1983;12:460-462.
13. Cachay-Velasquez H. Surgical lengthening of the short
columella: divison of the depressor septi muscles. Eur
Arch Otorhinolaryngol. 1992;249:336-339.
14. Rohrich RJ, Adams WP, Ahmad J. Enhancing the
nasal tip–upper lip relationship: The importance of the
depressor septi nasi muscle in rhinoplasty. Dallas
Rhinoplasty, 3rd ed. St Louis: Quality Medical
Publishing, 2014.
15. Kalantar HA, Beiraghi TA. Smile analysis in rhinoplasty: a
randomized study for comparing resection and transposi-
tion of the depressor septi nasi muscle. Plast Reconstr
Surg. 2014;133:261-268.