title: Treatment of hyperdynamic nasal tip ptosis in open rhinoplasty: using the anatomic relationship between the depressor septi nasi muscle and the dermocartilaginous ligament.
abstract: BACKGROUND
  Smiling causes a deformity in some rhinoplasty patients that includes drooping of the nasal tip, elevation and shortening of the upper lip, and increased maxillary gingival show. The depressor septi muscle leads this deformity. The dermocartilaginous ligament originates from the fascia of the upper third of the nose and extends down to the medial crus, merging into the depressor septi muscle.
  
  
  METHODS
  In this study, 100 primary rhinoplasty patients were studied for hyperdynamic nasal tip ptosis. Of these patients, 36 had hyperdynamic nasal tip ptosis due to hyperactive depressor septi nasi muscle. The dermocartilaginous ligament was used as a guide to reach the depressor septi muscle in open rhinoplasty. Muscle excision was performed just below the footplates of the medial crura. A strong columellar strut graft was placed between the medial crura to avoid narrowing of the columellar width resulting from tissue excision and to withstand activation of depressor septi muscle remnants.
  
  
  RESULTS
  No complications such as infection or hematoma occurred in the early postoperative period. The technique corrected the hyperdynamic nasal tip ptosis, increased upper lip length, and decreased gingival show when patients smiled. There was no narrowing of the columellar width. No depression in the columellar-labial junction due to distal resection of the depressor septi muscle was observed.
  
  
  CONCLUSIONS
  The dermocartilaginous ligament can be used as a reliable guide to reach the depressor septi muscle in open rhinoplasty. Therefore, the hyperactive depressor septi muscle can be definitively identified and treated without an intraoral approach.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266.
authors.affiliation: Department of Plastic, Reconstructive, and Aesthetic Surgery, Yildirim Beyazit University and Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.
authors.forename: Ali Teoman
authors.initials: AT
authors.lastname: Tellioglu
authors.forename: Emre
authors.initials: E
authors.lastname: Inozu
authors.forename: Rifat
authors.initials: R
authors.lastname: Ozakpinar
authors.forename: Tolga
authors.initials: T
authors.lastname: Eryilmaz
authors.forename: Ali Firat
authors.initials: AF
authors.lastname: Esmer
authors.forename: Tulin
authors.initials: T
authors.lastname: Sen
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Tekdemir
mesh_terms: D000328:Adult; D005152:Facial Muscles / Q000033:anatomy & histology / Q000601:surgery; D005260:Female; D006801:Humans; D051457:Hyaline Cartilage / Q000033:anatomy & histology / Q000601:surgery*; D008022:Ligaments / Q000033:anatomy & histology / Q000601:surgery*; D008297:Male; D009300:Nasal Septum / Q000033:anatomy & histology / Q000601:surgery*; D009666:Nose / Q000601:surgery; D012225:Rhinoplasty / Q000379:methods*; D055815:Young Adult