A mountain is only a mountain because the area around it is lower than the mountain itself. If there are valleys around the mountain, the mountain seems bigger, and if there are hills around the mountain, the mountain appears smaller.
This is a relative perspective, and it applies to all things, including the shape of the nose.
The Importance of the Columella and Bridge in Nose Tip Perception
When considering the tip of the nose we generally define the tip of the nose as that area that transitions from the columella—the fleshy area between the nostrils—and the bridge of the nose. Like in the mountain analogy with surrounding valleys or surrounding hills, the tip of the nose also is perceived relative to the columella and bridge. If the columella and bridge are big, the nose tip may seem small, and if the columella and bridge are small, the nose tip may seem big. This is important because a patient may think and feel that their nose tip is too big (most common), but in fact, it may only be slightly too big or, in fact, not too big at all in part because the areas near the nose tip—the columella and bridge—are too small. It is important for both the patient and the surgeon to identify and address this properly since reducing the tip a lot or at all in these cases may make the nose seem too small for the face or give the nose a “washed out” appearance that lacks definition.
When considering the nose tip, we need to also consider the general direction of the nose tip. Sometimes, a nose tip may seem too big when, in fact, it may be poorly supported and, therefore, pointing too much toward the upper lip. This usually happens from a columella that is both small and weak. When this occurs, the tip of the nose droops down toward the upper lip, making the nose tip look too big from a position standpoint but also relative to the columella. Ironically, this also tends to make the bridge look too big as well. If not properly diagnosed, the rhinoplasty procedure may mistakenly reduce the nose tip and the nose bridge when, in fact, strengthening the columella would have been the most important to address in part or fully the concerns of nose tip and nose direction concerns.
Adjusting the Tip, Columella, and Bridge for a Balanced Appearance
The reality is that in the majority of rhinoplasty cases, all three areas—the bridge, the nose tip, and the columella—are adjusted accordingly. This usually allows the proper adjustment of each, making smaller adjustments in each area as opposed to very large adjustments to the nose tip. The benefit of doing so has many advantages. The nose remains stronger overall, so the healing process changes it less. It also allows the function of the nose—breathing—to be better.
Like many other plastic surgery procedures, rhinoplasty has and continues to evolve. One of the main changes over the last few years has been a shift from large resections (removal of tissue) to a more balanced and nuanced change that allows the aesthetic concern to be addressed without making a small “pixie” nose that lacks aesthetic strength.
Because sometimes we need to add structure in addition to removing tissue especially in cases where the columella is too small, cartilage is usually removed from the septum. The septum is the large square-like cartilage in the middle of your nose that separates one nostril from the other. The development of the septum, especially during puberty, tends to impact the shape of the bridge, nose tip, and columella. If a septum is too big, these structures tend to be too big, and if the septum is too small or too short, the columella tends to be too small and retracted, thereby making the nose tip seem too big or too droopy, pointing too much toward the upper lip.
As you sit down with your plastic surgeon and discuss your nose shape and, in particular, nose tip aesthetic concerns, these are the things that your plastic surgeon will be thinking about, and these are the things that you should be discussing with them.