If the Arrow Nose Remains After Arrow/Bulbous Nose Surgery — Distinguish the Columella and Smiling Expression First

2024. 8. 2.

An answer to the question of why the arrow nose still stands out after arrow/bulbous nose surgery — distinguishing cases where the alae lift when smiling from cases where the columella stays lowered even at rest, and situations where blocking the depressor septi helps.

Key points

If the alae lift a lot upward when smiling while only the columella stays in place, the nose can look like an arrow nose even after surgery.
If it looks like an arrow nose even at rest without smiling, a method that slightly raises the tip can be considered; if the columella droops downward when smiling, a method that blocks the depressor septi muscle's action can be considered.
However, sideways spreading when smiling may be hard to improve even with correction — so the method must be decided after directly checking which case applies.

"I had surgery for an arrow nose and bulbous nose — the bulbous part seems a bit better, but the arrow nose seems to stand out even more."

This story starts from a real consultation question. This person was considering revision and told the surgery clinic what they were unsatisfied with — and heard from the director that "the alae lift more than others' when smiling, a trait that emphasizes the arrow nose, and raising the columella further could make it look upturned." Even by their own observation the columella sat lowered at rest, and after surgery the alae still spread and rose unusually when smiling — so they asked whether alar reduction alone could improve it.

This article organizes the answer to that question for the homepage.

Why can the arrow nose stand out more even after surgery?

If the alae rise upward when smiling while only the columella area stays in place, the columella can relatively look drooped downward — making it look like an arrow nose. In other words, rather than the tip itself being the problem, it is a case where the difference between how much the surroundings move during expression and the columella's position creates the arrow-nose impression.

In such cases, what comes first is not how much the tip was raised, but checking the resting and smiling appearances separately. Even more so when considering revision. What is checked in revision can be seen in the revision rhinoplasty guide.

Which case it is	Direction that can be considered
Looks like an arrow nose even at rest without smiling	A method that slightly raises the tip area
The columella droops downward when smiling	A method that blocks the depressor septi muscle's action
The nose spreads sideways when smiling	Improvement may be difficult even with correction — direct confirmation needed

How is the drooping-when-smiling case approached?

When the columella area droops downward when smiling, a method of blocking the action of the depressor septi muscle can be considered to reduce the nose's sideways spreading — because this is a case where the movement of the muscle that pulls the tip downward during expression is involved in the arrow-nose impression.

On the other hand, the sideways spreading of the nose itself when smiling may be difficult to improve even with correction. Even within the same "nose that changes when smiling," drooping and spreading take different approaches — so which applies must be distinguished first. What is checked in tip-side correction is organized in the nasal tip surgery guide.

Then how is the right surgery decided?

The exact improvement method can only be known by directly checking the current nose shape and its appearance when smiling. As in the question, judging in advance whether alar reduction alone would work is difficult — because with only a state described in photos or words, the columella's position and the degree of change by expression are hard to gauge.

Appearance at rest — how lowered the columella is, and the tip's direction are checked.
Appearance when smiling or talking — how much the alae lift, and whether the columella droops or spreads is checked.
The difference between the two — depending on where the difference comes from, the direction changes between raising the tip and blocking muscle action.

Summary — viewing the two appearances separately comes first

If the arrow nose still looks present after surgery, rather than deciding "what to raise more" first, how the resting and smiling appearances differ must be distinguished first. Whether the columella sits lowered, expression muscles pull it, or it spreads sideways — the methods and limits to consider each differ.

If you are curious which case your nose falls under, the resting and smiling appearances can be checked directly in a 1:1 video consultation.

Frequently asked questions

Answers to common questions patients ask before a consultation.

Can the arrow nose stand out more even after arrow/bulbous nose surgery?

If the alae rise a lot upward when smiling, it can relatively look like an arrow nose when the columella stays in place. The approach differs depending on whether it looks like an arrow nose even at rest or only stands out when smiling.

Wouldn't raising the columella more solve it?

The point that raising the columella further could make it look upturned must also be considered together. So rather than only measuring how much to raise, the range is decided after first distinguishing where the arrow-nose impression comes from.

Can alar reduction alone also improve the spreading when smiling?

Sideways spreading of the nose when smiling may be difficult to improve even with correction. However, if the columella droops downward when smiling, a method of blocking the depressor septi muscle's action to reduce the spreading can be considered — judgment is needed after direct confirmation.

Responses to treatment and recovery progress vary by individual. Outcomes and side effects vary from person to person. Bleeding, infection, swelling and asymmetry may occur. Please consult our medical team before making a decision.

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