An upturned nose, and what limits how far a tip rotates

What rotation actually moves

Rotation is a change in the tip rather than in the bridge above it. The structures involved are the lower lateral cartilages that form the tip, and the caudal septum, the front edge of the wall between the nostrils.

The droopy tip page reads the same measurement the other way. It carries the angle rotation is taken with, the published ranges and the grafts that rotate a tip upwards. This page takes the limit at the top of that range.

The shape has trend names too, ski slope among them. A name is easy to carry into a consultation and says nothing about how much rotation a particular nose will hold.

The limit is set by what is already there

An article on unfavourable results in aesthetic rhinoplasty, organised round each operative step, concludes that most of them are the result of over-resection of tissues, either bone, cartilage, or both, and that they are avoidable.

Its own illustration of a shortened nose is captioned as excessive and inappropriate resection of the caudal septum. That is a caption on one case rather than a rate, and it names the trade: shortening buys rotation, and the caudal septum pays.

The skin over the tip sets a limit of its own. The page on a bulbous tip sets out why thick skin decides how much definition is possible.

What over-rotation shows from the outside

The visible costs of taking too much are named in the same article. The endo-nasal approaches resect the cephalic portion of the lower lateral cartilage, and it says that if the mucosa is resected with the cartilage, retraction of the ala will result.

A retracted rim lifts, so more of the nostril shows. Where the rim of the ala has to be disrupted, the article says it should be reconstituted, and that failure to do so results in a pinched nose.

The tip plasty page sets out how much lateral crural width is preserved to avoid that.

Where over-rotation is paid for

Tip surgery works next to both nasal valves. The article says violation of the internal valve, particularly through an inter-cartilaginous incision, can result in nasal airway obstruction through cicatrisation of that valve, and calls protecting its integrity extremely important.

At the rim it reports that extreme resection of lower lateral cartilage will result in alar collapse, which its abstract describes as causing external valve obstruction.

The American Academy of Otolaryngology states that nasal valve dysfunction is a common clinical cause of symptomatic nasal airway obstruction. The NHS says nose reshaping surgery can occasionally result in permanent breathing difficulty.

Its list also carries damage to the cartilage wall between your nostrils, an altered sense of smell and heavy nosebleeds.

What it takes to put length back

Lengthening a shortened nose needs material. The article prefers autografts, cartilage from the septum, the ear or a rib among them, and calls them the grafts with the least complications for the most part.

The septum is the obvious donor, and a shortening is what took it. The article also states that alloplasts should not be used in secondary rhinoplasties, because of the scars and the decreased vascularity.

Where an implant becomes infected and extrudes, it says, the resulting deformity compounds the problem it was used for. The complications it lists for grafts are displacement, warping, resorption and visible or palpable irregularities. A second operation is covered elsewhere here.

What only an examination can settle

Three things decide how much rotation a nose will hold, and a photograph shows none of them. Whether the cartilage is strong enough to keep a rotated position is a finding on handling it.

How thick the skin over the tip is comes next, and that is not read off a photograph either. Whether the caudal septum can spare length is the third, and that is partly settled in theatre.

The breathing guide sets out the scale obstruction is scored on, and what this nose scores before anything is done is a measurement nobody has taken yet.