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To achieve permanent results for the correction of a drooping nasal tip, it is important to understand the mechanism responsible for the caudal rotation of the tip when a person speaks or smiles. This mechanism can be considered to depend on a "functional unity" formed by three components: (1) the cartilaginous framework (alar cartilages and accessories acting as a single structure); (2) muscular motors (m. levator labii superioris alaeque nasi and depressor septi nasi); and (3) gliding areas (apertura piriformis, the valvular mechanism between the upper lateral cartilages and alar cartilages, the lax tissue of the nasal dorsum, and the membranous septum). We describe a new anatomical and functional concept responsible for the plunging of the nasal tip. When a person smiles, the functional unit is activated by a combination of two forces acting simultaneously in opposite directions that rotate the tip caudally and elevate the nasal base. The levator moves the alar base upward and the depressor pulls the tip caudally. To correct the drooping tip, the transcartilaginous incision is extended laterally, and the lateral portion of the alar arch is dissected free from the skin and the mucosa, thus exposing the accessory cartilages. The arch is then severed at the level of the accessories to allow the cephalad rotation of the domes. The muscle insertions are dissected free from the accessories and a section of the muscle and, if necessary, the accessory cartilages, is removed. From January of 1991 onward, 312 patients have had this ancillary procedure performed in addition to the basic rhinoplasty technique.

The authors present a multidisciplinary approach to the gingival smile in which its three components are evaluated. These components are the dynamic component of the lip (repose versus smiling) and the two static elements of the gum and maxilla. Once an appropriate diagnosis has been made, the authors act on the gingiva for delayed passive eruption, on the maxilla for long face syndrome, and on the lip with lip-elongation techniques. When delayed passive eruption is associated with hyperfunction of the lip elevators, an intraoral approach with an incision at the level of the upper labial frenulum and dissection from the anterior nasal spine to the anterior maxillary fossae, in addition to gingival remodeling, is recommended to reduce gingival exposure.

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