How can I fix my turned up nose?

Today there are several new techniques that can push the nose tip down, whether it is naturally turned up or the result of a previous surgery. In either situation, structural cartilage and grafting techniques are now performed to push the tip down in the event it has scarred or is naturally upturned.

Your complaint is a common one in patients seeking revision rhinoplasty. But even if you have never had a rhinoplasty before, some patients are born with upturned noses.

The solution is known as derotation of the tip. Adding length to the top of the nose is usually the only means by which the tip cartilages can be rotated down. Multiple techniques such as dorsal onlay grafting (with rib cartilage), extended spreader grafts, and suture techniques are often combined with extensive skin release and undermining to set the tip down and keep it there. The surgeon has to combat internal forces in the nose and changes that internal scarring can create to keep the position of the tip stable. This is typically a difficult maneuver. Make sure your surgeon is comfortable with revision rhinoplasty techniques.

The angle that the nasal tip makes with the upper lip when viewed from the side is medically referred to as "rotation." Your problem appears to be one of "over-rotation" which results in increased nostril visibility. In the context of nasal problems, this is a relatively uncommon one.

Defining the "best" nasal tip position is a very subjective idea. Many things play into the determination of whether your nasal tip is in the best possible place for you. The height of the bridge (where a bump usually is) often determines the best tip placement: a higher bridge usually goes best with a lower tip and vice-versa. The age of the patient is considered, as older patients typically want a longer, more elegant nose. The ethnicity of a patient is considered, as there are certain traits more typical to different groups of people. The height of a patient is usually considered, as shorter people can tolerate a more upturned tip (most people are going to be looking down at them, rather than up). A patient's facial shape helps to determine the optimal length for their nose, which is also related to the degree of rotation. Also, some people have jobs, such as waiters and airline workers who spend a lot of time interacting with people that are sitting while they stand. Considering a person as a whole in this manner typically results in the best decision for both the patient and the surgeon.

You describe a situation that is more common after previous surgery. However, certain ethnic groups - asian, african american, latino, and some caucasians - have characteristically shorter and more up-turned noses.

Since the biomechanical structure of the nasal tip exists in order to hold it up, de-rotating the nose is harder than lifting it. There are several surgical options that can be used, depending on your specific anatomy. They often give subtle, not extreme, correction of your problem. Sometimes the nose appears over-rotated due to a long nasal septum, which pushes out the columella (the skin that separates the nostrils). Shortening the septum can allow the nose to assume a more natural position.

I am not aware of any non-surgical options, other than filler injections to the nasal bridge. This may provide the illusion of dropping the tip, but it will not correct your nostril visibility. Botox might be used to derotate the tip, but it will likely create nasal obstruction as a side affect.

Turned up nose or over-rotated nose is commonly seen after an aggressive reduction rhinoplasty followed by tissue contracture, but can also exist for patients who never had any nasal surgery in the past. There are several options both non-surgical and surgical, depending on one's anatomy.

Non-surgical (limited): If the dorsum (bridge of the nose) is concave (sloped), adding fillers such as Radiesse can give an allusion of a longer nose (nasal lengthening). This however, will do very little for the nostrils that are visible.

Surgical: Correction of an over-rotated nose is one of the most difficult procedures for any facial plastic surgeon. Several things need to happen for a succesful outcome. First, there must be enough skin to drap the lengthening of the nose. To accomodate this, patients will be asked to exercise stretching of the skin by pulling on the nasal skin for several weeks. Second, an augmentation is often necessary by using an implant (rib, gore-tex etc) to address the sloping of the dorsum. Lastly, a de-rotating (less turning -up) tip grafts or tip extension grafts are necessary not only to lengthen the nose but also to show less of the nostrils.

This type of surgery should be reserved for the most experienced rhinoplasty surgeons.

I assume that you never had a rhinoplasty before, because these are often the complaints of some patients that I see for secondary rhinoplasty procedures (operations performed after a patient's original rhinoplasty by another surgeon).

If the bridge is low, it can be augmented. If the nose is turned up, sometimes the nose can be de-rotated using several different techniques to bring it back down. Nostril visibility is often a complaint of patients undergoing secondary procedures, and there are a few ways to correct this as well.