Reattaching lip muscles to alar sill during revision rhinoplasty? (Photos)

Question

(2+ yr post op). Long upper lip and v-shaped crease below my nose when smiling as a result of open rhinoplasty. Nose angle and hump is higher now with a ptotic tip that is shorter and less defined. One surgeon suggests a septal extension as well as “reattaching lip muscles to alar sill” during revision to correct lip length and loss of function from possible depressor resection. If these orbiculares muscles are easy to see during open rhinoplasty has anyone else actually tried this? Thanks!

Matthew Bridges, MD, FACS · Answer

What you describe is a relative common issue usually associated with open rhinoplasty techniques. Is your tip really stiff?  In my estimation this is usually the problem, in that the tip is so unnaturally stiff after rhinoplasty that normal smile muscle activation creases the lip because the nose does not "give" like it's supposed to.  I have not heard of "reattaching" any muscle to solve this.  They only muscle that is ever really modified with rhinoplasty is the depressor septi.  The aesthetic problem with your nose that was not corrected in the surgery but is shown in the morphed view is lack of intrinsic tip projection.  Increasing the distance from the front part of the  nostril to the tip defining point it the key.  I do this closed without causing the nose to be so stiff.  Noses done open are frequently made to be too stiff by large columellar struts, or worse, columellar extension grafts.  I would love to take a look at your nose in person and your operative report from previous surgery to see if I'm right.  Sorry you've had do much trouble...

Oakley Smith, MD, FRCSC · Answer

Based on your before picture, you had a gummy smile, and your after picture you do not-- however, you subsequently have  creases when smiling. Without your operative report I cannot be sure, but likely the depressor septi muscle was cut/released in your primary surgery (hence the decreased amount of gum show while smiling). Additionally, a columellar strut graft, or other such grafts in the columella area (that usually increase the support of your tip) can cause these unnatural creases when smiling.I have not personally heard of re-attaching the muscles; the orbicularis is a circular sphincter-like muscle that encircles the mouth, but does not insert on the nasal septum or alar cartilages. Should a graft be responsible for the distorted smile (which in my opinion based on these photos, it is), it can be removed, re-shaped, and repositioned for a more natural result. I find the creasing with smiling more noticeable than the actual length of the lip.  I do like the morph that shows a more refined tip, decreased infratip fullness/hanging columella and an elegant bridge. The only way I can think of shortening the upper lip is to have a upper lip lift, which can decrease the length a few mm but carries the risk of visible scars. I personally do not perform this procedure (lip lift).Best of luck!

Reattaching lip muscles to alar sill during revision rhinoplasty? (Photos)

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Reattaching lip muscles to alar sill during revision rhinoplasty? (Photos)

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Everything you need to know about Revision Rhinoplasty

Our mission is to create a world where every investment in modern beauty is Worth It.