Rhinoplasty for Various Nose Shape
Our noses are the first organ of our upper respiratory system. It provides passage of air into our lungs for normal breathing as well as acts as a humidifier. Beyond this primary function, noses are also a prominent feature of our facial structure.
If someone is unsatisfied with their nose shape, might be causing the breathing issues and dramatically affects self-confidence, and overall quality of life, Rhinoplasty surgery is a life-changing experience for them
Typical Nose Size and Shape
The nose is a central part of the face; it should be in proportions with other facial features to look like an attractive face.
A. Size to Facial Proportion
It is important to look for the underlying facial skeleton as the face is divided into third using horizontal lines adjacent to the hairline, brow (at the level of the supraorbital notch), nasal base, and menton.
The upper third is the most variable and the lower third of the face is then subdivided into thirds by visualizing a horizontal line between the oral commissure (stomion). The upper third of this subdivision lies between the nasal base and the oral commissure, and the lower two thirds between the commissure (stomion) and the menton.
The nasal length (radix-to-tip distance, or RT) should be equivalent to the stomionto-menton distance (SM), as described by Byrd and Hobar dropping a vertical line from a point one half of the ideal nasal length tangential to the vermilion of the upper lip. The lower lip should be within 2mm of this line. The ideal chin position varies with sex, with the chin lying slightly posterior to the lower lip in women, but equal to the lower lip in men.
B. Subunits of Nose
For the descriptive purpose, nose is divided into various units.
1. Frontal View
Aline is drawn from the midglabellar area to the
menton, bisecting the nasal ridge, upper lip, and Cupid’s bow. Any deviation in the nose from this line typically indicates an underlying septal deviation that will need to be addressed during surgery to correct the deformity.
In the frontal view, the curvilinear dorsal aesthetic lines are traced from supraorbital ridges to the tip-defining points, slightly diverging caudally. Ideally, the width of the dorsal aesthetic lines should match the width of either the tip-defining points or the interphiltral distance.
The Alar base width is equal to the intercanthal distance. If alar base is wider, it must be determined,either this is the result of a narrow intercanthal distance, a true increased intercanthal width, or Alarflaring.
The tip is assessed by determine by the supratip break, the tip-defining points, and the columellar-lobular angle. These points serve as landmarks to draw two equilateral triangles with their bases opposed.
The outline of the alar rims and the columella should resemble a seagull in gentle flight, with the columella lying just inferior to the alar rims. If the curve is too steep, the patient likely has an increased infratip lobular height. On the other hand, if the curve is flattened,it is likely the patient has decreased columellar show, which may require columellar augmentation or alar rim modification. Facets of the soft tissue triangles shouldbe noted, because these may require alar contour grafts to prevent alar notching.
2. Basal View
The outline of the nasal base is an equilateral triangle with a lobule-to-nostril ratio of 1:2. The nostril is of a teardrop-SHAPE, with the long axis from the base to the apexoriented in a slight medial direction. In indian patient it is less prominent compared to Caucasian nose
3. Lateral View
Perceived nasal length and the tip projection can be altered by the position of the nasofrontal angle.
Two Preferred Method
In a patient with normal upper lip projection, the tip projection is considered normal if 50% to 60% of the tip lies anterior to a vertical line adjacent to the most projecting part of the upper lip. The tip is considered to be over projecting if more than 60% of the tip lies anterior to this reference line and may, therefore, require de-projection.
Conversely, if less than 50% of the tip lies anterior to the line, the projection may need to be augmented (in any number of ways).
Nasal length: nasal tip ratio is 1:0.67
Nasal dorsum should lie approximately 2 mm behind and parallel to a line from the radix to the tip-defining points in women, but in men, it should be slightly higher. A slight supratip break is preferred in women but not in men.
The nasolabial angle is used to determine the degree of tip rotation. This angle is obtained by measuring the angle between a line coursing through the most anterior and posterior edges of the nostril and a plumb line dropped perpendicular to the natural horizontal facial plane. This angle should be 95 to 100 degrees in women and 90 to 95 degrees in men, but more rotation leads to piggy nose.
Alar Collumellar Relationship:
The distance from the alarrim (point A) to the long-axis line (point B) should equal the distance between the long-axis line and the columellar rim (point C) if the alar-columellar relationship(ACR) is normal (AB _ BC _ 2 mm).
D. Variations According To following Aspects:
1. Gender Variation
The Female has a delicate nose. It is narrower and less project. It is overall small in size.
The dorsum is a little concave in female while it is straight or little convex in male
The term ethnic can be applied to a group of people, who share a common racial, cultural, national, religious, or linguistic heritage. It is commonly used in the United States (US) to describe non-white minority groups. Their facial features are different than the Caucasian people. One must ask the patient about their desired nose shape. They want Caucasian like nose or refinement and maintain their own ethnicity. Image software is useful in such patients for the planning of the surgery
- Hispanic Heritage
- African Heritage
- Asian Heritage
- Middle Eastern Heritage
Rhinoplasty Surgery Types:
(I) According to the Time of Rhinoplasty Surgery:
- Primary Rhinoplasty: When surgery is done first time,
- Secondary Rhinoplasty: When surgery is done following trauma, birth defect or after tumor excision
- Revision Rhinoplasty: When one have not got the expected result after first surgery.
(Ii) According to the Technique of Rhinoplasty Surgery:
The open approach continues to gain in popularity over the end nasal approach for both primary and secondary rhinoplasty. There are advantages and disadvantages of both the techniques, but the correct approach determined by the patient’s anatomic deformity and the surgeon’s experience. Clearly, what is performed to alter the underlying anatomy is far more important than the type of incision used.
A) Open Rhinoplasty
Distinct Advantages are as follows:
- Binocular visualization
- Evaluation of complete deformity without distortion
- Precise diagnosis and correction of deformities
- Allows use of both hands
- More options with original tissues and cartilage grafts
- Direct control of bleeding with electrocautery
- Suture stabilization of grafts (invisible and visible).
Potential Disadvantages are as follows:
- External nasal incision (transcolumellar scar)
- Prolonged operative time
- Protracted nasal tip edema
- Columellar incision separation
- Delayed wound healing.
B) Closed Rhinoplasty
The Advantages of Endonasal Approach Are as Follows:
- Leaves no external scar
- Limits the dissection process to the areas, where it is needed modification
- Permits the creation of precise pocket so graft material fits exactly without need for fixation
- Allows percutaneous fixation when large pockets are made
- Promotes healing by maintaining the vascular bridge
- Encourages accurate preoperative diagnosis and planning
- Produces minimal post-surgical edema
- Reduces operating time
- Results in faster recovery
- Creates intact tip graft pocket.
Disadvantages Are Jotted Down Below:
- Requires experience and great reliance on accurate preoperative diagnosis
- Prohibits simultaneous visualization of the surgical field by a teaching surgeon and students
- Does not allow direct visualization of nasal anatomy
- Makes dissection of Alar cartilages difficult, particularly in cases of malposition.
(Iii) According to Nose Shape Concern
C) Septum Correction:
The most common cause of functional nasal airway obstruction is inferior turbinate hypertrophy; however, septal deviation or internal or external nasal valve abnormalities must also be considered.
Some important concern that is considered in the septum correction as follows:
- It exposes all deviated structures and release of all mucoperichondrial attachments to the septum, especially the deviated part.
- Straightening of the entire septum while maintaining a 10 mm caudal and dorsal L-strut is done.
- Restoration of long-term support with cartilage graft is made.
- Airway opened with inferior turbinate surgery.
- The bone is straightened with osteotomy.
I. Septoplasty/deviated Septum Surgery: It is concerned to correct the breathing issue
Ii. Septorhinoplsty/twisted Nose Rhinoplsty: It corrects the asymmetric nose typically characterized by the deviation of bony upper third and /or the cartilaginous lower two-thirds of the nose.
Iii. Crooked Nose Rhinoplasty: A crooked nose that doesn’t follow a straight, vertical line down the centre of your face. It is corrected by crooked nose rhinoplasty. Whole bony and cartilaginous structure is re-oriented.
D) Tip Correction
1. Bulbous Tip/Boxy Tip:
TIP DEFINING POINTS ARE IMPORTANT LAND MARKS, a classification system based on the angle of divergence of the middle crura and the width of the domes can aid in the diagnosis and treatment of nasal tip deformities like bulbous tip or boxy tip where divergence angle is more. In the cases when the tip is boxy or bulbous and requires better refinement and definition newer suture technique is applied or rarely cephalic trimming of the tip cartilage is done.
Pinch Tip/Pinch Nose
When tip cartilage is weak or conclave it results in pinch nose, cartilage graft strengthens the tip cartilage to correct the pinched nose.
2. Over Projected Tip
Nasal tip projection depends on the fibroelastic and ligamentous attachments, length and strength of the lower lateral cartilages. Therefore, in the open approach, if the skin envelope has been undermined and these fibroelastic tissues have been severed, the primary means of decreasing tip projection lies in altering these lower lateral cartilages.
It is important to recognize that if the tip projection is decreased significantly, alar flaring or columellar bowing may result, which would necessitate concomitant correction.
3. Under Projected Tip
Commonly use four suture techniques to alter projection and shape the nasal tip:
- Medial crural
- Medial crural septal
- The only tip graft
When tip cartilge is weak or support sytem is weak, cartilage grat strenthen the tip support and improve tip projection
4. Rotation of Tip
Up Turned Tip
When tip is upturned, the extrinsic forces holding the tip at its current angle must be released. This is generally done by severing the connection between the cartilages as well as adding the length between cartilages.
Down Turned Tip
Furthermore, the fibrous attachments of the medial crura and the caudal septum can be transected to release the tension on the nasal tip and allow for more cephalad rotation. This is generally achieved by resecting a variable amount of the caudal septum.
This maneuver can also affect tip projection.
5. Droopy Tip
Routine preoperative examination of rhinoplasty patients should easily identify those who demonstrate a drooping nasal tip and shortened upper lip on animation, particularly when smiling. In such patient’s dissection and transposition of the distal depressor septi muscles and suturing together of the cut ends reliably and effectively correct this dynamic facial deformity AND provide fullness to the central upper lip. Follow-up of up to 2 years shows well-maintained aesthetic results without signs of relapse. Specifically, the technique achieves the following goals:
- Enhancement of the tip-lip relationship
- Relative upper lip lengthening
- Relative fullness to the upper lip
- Maintenance of tip rotation/projection on animation
E) Length of the Nose
1. Short Nose/Piggy Nose:
Nose length is short, the tip is rotated more upward and the nasolabial angle is more than 100 degrees. Nares (nostrils) are visible more than normal from the front. It is either congenital or after over resection during the previous surgery. It requires extensive release and bone graft to correct the deformity. Kin and mucous elasticity are the limiting factors to get the intended results.
2. Long Nose:
When the nose is long and in the facial proportion one has to rule out smaller chin first. On the second condition, when the nasofrontal angle is shallow or at the high, the nose looks long as well.
When it is long due to septal cartilage then trimming of the septal cartilage corrects the concerns.
F) Dorsum of the Nose
1. Saddle Nose/Flat Nose:
When the nose is flat and under projected and the tip is also broad and under projected. The augmentation of dorsum requires a large volume of materials. So rib cartilage graft or silicone implant is the choice. Tip projection also requires good graft in such cases.
Skin elasticity and mucosa stretch ability limit the amount of augmentation height.
Small deficit in dorsum projection can be corrected with septal graft or ear cartilage graft.
Small irregularity can be corrected with fillers; it is also called as non-surgical rhinoplasty.
2. Nasal Hump:
The first surgeon has to see it is a real hump or it is due to depressed cartilaginous dorsum and or tip.
After elevating the skin envelope, the hump is reduced incrementally. Component resection is preferred to unblock resection or it well develops inverted ‘V’ deformity. Bony hump less than 5mm, rasping is done. Large hump osteotomy is done. One has to be careful not to over resect the hump.
G) Correcting The Alar-columellar Relationship
In profile view, nares (nostrils) should be visible about 4 mm.
Columella and Alar rim relation create any type of concerns in which the following are so common:
1. Hanging Collumella:
When the long axis–columellar rim distance more than 2 mm is called hanging columella. This can be corrected by resection, either the caudal septum, the caudal portion of the medial crura or a combination of these, according to the cause of the deformity.
2. Retracted Ala:
Alar contour grafts help to correct and prevent alar notching or retraction, and facets of the soft tissue triangles. A subcutaneous pocket parallel to the alar rim is created an alar contour graft depends on the size of the deformity.
H) Width of the Nose
1. Midnose Reduction
Mainly bony vault is wide
Osteotomy is the answer to narrow the mid-nose
One has to take care of nasal function and airway patency should be assured while narrowing the nose.
Deviated septum should be treated and if inferior turbinate hypertrophy is there should be taken care of.
2. Alar Reduction
Wide nostril sills/alar flaring, is a common concern. A small crescent resection of the alar base is excised; a wide alar base is corrected by wedge-type excision and may include a small portion of the nostril sill. The alar rims should also be assessed for symmetry and should flare slightly outward in infer lateral direction.
I) Broad Nose
The nose looks whole broad. Tip, alam, and mid-nose everything is broad. It is the doctor’s expertise to tackle everything in one go.
Figure description: Frontal view of a “large nose” in a Teenager
(a). The analysis of nasal width should consider eight different basic parameters.
(b) Whole nasal width, radix width atthe level of the base, radix width at the level of the profile, dorsal width at the level of the base, dorsal width at the level of theprofile, alar base width, nasal tipwidth, columellar base width.
(Iv) According to Ethinicity
It is vitally important to understand an ethnic patient’s aesthetic goals. Some request cosmetic enhancements that preserve their unique ethnic characteristics; others will seek a more Western or white/European standard. Fastidious patients may voice their concerns using accurate terminology, whereas others will have difficulty identifying features they like and dislike. For the latter, photographs of desirable noses will help to get desired planning
J) Hispanic Heritage
Hispanic groups exhibit varied features combination of their individual Spanish and American Indian descent.
One spectrum, Castilian nose, with long nasal bones, a high dorsum, and normal tip projection is essentially a white nose. Another spectrum is the mestizo’s nose, and overall a short and a broad nose, with thick skin, wide alae, a retracted columella, under the projected tip. Any anatomic combination along this continuum may be seen.
K) African Heritage
It is characterized by a wide, low dorsum and broad, under-projected tip, and broad middle vault. Thick skin, fat layer leads to the bulbous tip. Anacute nasolabial angle is caused by both an under-rotated tip and bi-maxillary protrusion.
The nasal base is often wider than the inter-alar distance, and the under-projected tip contributes to excessive alar flaring.
The goal of rhinoplasty in a patient of African descent include achieving, straight dorsum, improved tip projection and definition, decreasing alar flaring andalar base width and narrower. Tip definition is improved by suture techniques and cartilage grafting. Improvement of low nasal dorsum require cartilage graft or silicone implant.
L) Asian Heritage
Typically it is a low radix, low dorsum, and broad, under-projected, round, blunt tip. Thick, sebaceous skin contributes to poor definition. The columella and soft triangle are retracted. They have an acute nasolabial angle and protrusive premaxilla. The radix of Asian patients typically lies at the midpupillary level.
Cartilage is overall weak and soft. Dorsal graft placement thus depends on the degree of ethnic characteristics the patient wishes to maintain.
M) Middle Eastern Heritage
Skin is thick and sebaceous and is most prominent at the supra-tip. The radix may over-project, the bony and middle vaults are wide, and the large dorsal hump is common. Tip is poorly defined; under-projected droopy tip .there may be an acute columellar labial angle. The tip deformities may be exacerbated by hyper dynamic action. Nasal deviation and nostril asymmetry are also common.
The goal of rhinoplasty in a Middle Eastern patient is moderate dorsal hump reduction, narrowing of the wide nasal bones, debunking of soft tissue, correction of the nasal tip potion, improvement of tip definition and correction of nostril asymmetries.