The short nose deformity is a complex entity with diverse causes and variable characteristics. This article divides shortening into anterior and pan-nose shortening as well as mild, moderate, or severe. Mild anterior shortening can be corrected with shield grafting, whereas moderate to severe shortening can be corrected using septal extension grafts, composite grafts, or the tongue-and-groove technique. Ancillary technical considerations are reviewed. General principles of patient assessment and rhinoplasty execution are discussed. Surgical cases are presented, and pertinent aspects of preoperative planning, surgical technique, and perioperative care are discussed.
Key points
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The correct lengthening procedure is one that elongates deficient/deformed structures and respects overall nasal and facial aesthetic proportions.
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More significant length deficiency requires elongation of the dorsal frame with septal extension grafts, composite grafts, or the tongue-and-groove technique.
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A tongue-and-groove construct consists of paired septal extension spreader grafts that interdigitate with a columellar strut.
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Lateral crural repositioning, alar rim grafting, lateral crural strut grafting, composite grafting, or V-Y mucosal advancements may be necessary if lateral tissues do not advance with central components.
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It may be prudent to sacrifice some central lengthening if there are soft tissue limitations preventing concurrent advancement of lateral tissues.
Introduction or overview
The short nose represents one of the most challenging problems in rhinoplasty. The shorter the nose, the greater the challenge. A mastery of nasofacial analysis and rhinoplasty dynamics as well as a thorough understanding of the cause of the shortening are prerequisites to designing effective nasal lengthening procedures.
Nasal length is typically measured from radix to pronasale, and, in an otherwise idealized face, nasal length should equal two-thirds the height of the midface (supraorbitale to subnasale) or the distance from stomion to menton. As an alternative, the Goode ratio defines the ideal nasal length as a ratio with respect to nasal projection (5:3). Although nasal length can be strictly defined in this manner, the short nose deformity often presents as a constellation of features. Hallmark features of the short nose include decreased nasal bridge length, increased nostril show, retracted alae, cephalic tip over-rotation, a low or deep radix, and a long upper lip. Given the variety of characteristics that comprise this deformity, certain investigators have advocated algorithmic classification systems to help guide operative approaches.
The short nose can be further understood in terms of cause. Deformities are classified as either acquired or congenital, with most cases being acquired. In the past, the most common cause was iatrogenic, characterized by cephalic over-rotation. Additional causes of acquired deformities include trauma, cocaine insufflation, autoimmune disorders, local or systemic infections, or a history of oncologic nasal surgery. In acquired cases, scarred or contracted tissues, fractured skeletal structures, or loss of graft sites can be encountered. Among congenital causes, short noses can arise from uniform hypoplasia of nasal anatomic structures, such as the nasal spine.
As expected for a deformity with diverse features and causes, many different lengthening techniques have been described, including craniofacial osteotomies, locoregional flaps, cartilage grafts, and incisional/dissection techniques. Regardless of the choice of technique or approach, effective nasal lengthening procedures are typically accomplished using well-accepted principles. Principles of nasal lengthening include (1) precise assessment of length deficiency; (2) accurate identification of deficient tissues; (3) adequate release of the soft tissue envelope; and (4) pertinent modification of deficient skin, mucosa, and/or skeletal deformities to restore length.
In the experience of the senior author (BG), the tongue-and-groove technique is a versatile means of achieving consistent, precise, and stable nasal lengthening in most patients with moderate to severe shortening. This technique uses a custom construct consisting of paired septal extension spreader grafts that interdigitate with a columellar strut. Ancillary techniques, such as alar or lateral crural modifications, soft tissue undermining, mucosal advancement flaps, or interpositional composite grafting may be indicated in specific circumstances. In cases of mild anterior shortening, tip grafting in the form of shield grafts may be preferred.
Introduction or overview
The short nose represents one of the most challenging problems in rhinoplasty. The shorter the nose, the greater the challenge. A mastery of nasofacial analysis and rhinoplasty dynamics as well as a thorough understanding of the cause of the shortening are prerequisites to designing effective nasal lengthening procedures.
Nasal length is typically measured from radix to pronasale, and, in an otherwise idealized face, nasal length should equal two-thirds the height of the midface (supraorbitale to subnasale) or the distance from stomion to menton. As an alternative, the Goode ratio defines the ideal nasal length as a ratio with respect to nasal projection (5:3). Although nasal length can be strictly defined in this manner, the short nose deformity often presents as a constellation of features. Hallmark features of the short nose include decreased nasal bridge length, increased nostril show, retracted alae, cephalic tip over-rotation, a low or deep radix, and a long upper lip. Given the variety of characteristics that comprise this deformity, certain investigators have advocated algorithmic classification systems to help guide operative approaches.
The short nose can be further understood in terms of cause. Deformities are classified as either acquired or congenital, with most cases being acquired. In the past, the most common cause was iatrogenic, characterized by cephalic over-rotation. Additional causes of acquired deformities include trauma, cocaine insufflation, autoimmune disorders, local or systemic infections, or a history of oncologic nasal surgery. In acquired cases, scarred or contracted tissues, fractured skeletal structures, or loss of graft sites can be encountered. Among congenital causes, short noses can arise from uniform hypoplasia of nasal anatomic structures, such as the nasal spine.
As expected for a deformity with diverse features and causes, many different lengthening techniques have been described, including craniofacial osteotomies, locoregional flaps, cartilage grafts, and incisional/dissection techniques. Regardless of the choice of technique or approach, effective nasal lengthening procedures are typically accomplished using well-accepted principles. Principles of nasal lengthening include (1) precise assessment of length deficiency; (2) accurate identification of deficient tissues; (3) adequate release of the soft tissue envelope; and (4) pertinent modification of deficient skin, mucosa, and/or skeletal deformities to restore length.
In the experience of the senior author (BG), the tongue-and-groove technique is a versatile means of achieving consistent, precise, and stable nasal lengthening in most patients with moderate to severe shortening. This technique uses a custom construct consisting of paired septal extension spreader grafts that interdigitate with a columellar strut. Ancillary techniques, such as alar or lateral crural modifications, soft tissue undermining, mucosal advancement flaps, or interpositional composite grafting may be indicated in specific circumstances. In cases of mild anterior shortening, tip grafting in the form of shield grafts may be preferred.
Treatment goals and planned outcomes
The ultimate goal is to appropriately lengthen deficient tissues, restoring facial harmony and preserves nasal function. In order to accomplish this goal, the surgeon must understand the cause of nasal shortening, identify specific anatomic structures that are deficient, and execute a sound operative plan in a safe and practical manner. Many of the lengthening techniques, especially in cases of severe shortening, are associated with either unstable alignment or significant rigidity. The ideal lengthening technique is one that offers versatility in elongation and optimizes the suppleness of the nasal base and stability of the nasal construct.
Preoperative planning and preparation
Standard aspects of the preoperative rhinoplasty evaluation apply in cases of short noses. Inquiry about previous nasal surgery, trauma, or substance abuse is particularly important. If prior radiographic imaging was obtained, these studies should be reviewed. If the patient had previous surgery, assessment of donor sites is essential. An understanding of patient expectations is also important, because it is crucial for the surgeon to consider the patient’s exact wishes. A review of factors contributing to excessive bleeding can also be performed, including a history of procedural bleeding, known or suspected coagulopathy, and a review of pharmaceutical agents commonly associated with increased bleeding. A comprehensive questionnaire can be helpful in the assessment of nasal dysfunction, including an assessment of breathing dynamics, rhinitis, or sinusitis. Questions related to a history of headache or migraines can guide specific rewarding ancillary procedural interventions. For instance, rhinogenic migraine headaches start from behind the eyes, with headaches arising at night or with atmospheric pressure changes. In patients with severe headache symptoms that do not respond to conventional medical therapies, septorhinoplasty or endoscopic nasal surgery may be indicated to address disorders such as septal spurs or contact points, septum bullosa, and concha bullosa.
After a thorough history is obtained, standardized nasofacial analysis is performed to identify nasal flaws and sources of facial disharmony. Observation of patient skin thickness allows an understanding of the way that osseocartilaginous modifications manifest after skin redraping. The ideal radix is 4 mm deep in men and 6 mm deep in women. Women should have a well-defined supratip break. The nasolabial angle for men is 94° to 97° and 97° to 100° for women. The columella protrudes 3 to 4 mm caudal to the alar rim in optimally positioned alae. The septum is observed internally for deviation. A drafting film is placed over profile and anteroposterior (AP) views of life-sized photographs and marked systematically to define flaws in the nasofrontal groove, dorsum, tip, alar bases, and chin position, using the cephalometric analysis described by the senior author (Guyuron ). A prefabricated template is also used to create an ideal nasal outline in a segmental fashion.
With the general patient assessment complete, a refined understanding of the details of nasal shortening should be sought. With regard to nasal length assessment, it is crucial to distinguish between isolated anterior and pan-nose shortening and to consider the anatomic implications of these observations. Anterior shortening is suggested by isolated tip over-rotation or lobule deficiency, whereas pan-nose shortening represents total length deficiency. Anterior shortening can arise from over-resection of the anterocaudal septum, collapse of the septum from a caudal blow to the nose, or chemical septal destruction as with cocaine. In these cases, the columella and nasal spine may be adequately positioned. In contrast, pan-nose shortening is a combination of anterior and posterior shortening, as seen in some congenital cases.
An assessment of the alae and the quality of the soft tissues is also essential, because they can thwart efforts to achieve a uniform nasal lengthening. Actual or potential alar retraction, if not accounted for preoperatively, can compromise the aesthetic result or limit the amount of central tissue advancement. Likewise, soft tissue contracture along mucosal or external tissues can resist lengthening. In cases of severe contracture, structures such as the columella may not be supple enough to be displaced caudally if soft tissues are not widely released.
Determinations of cartilage availability and priority are especially important in cases of previous nasal trauma or in cases of secondary rhinoplasty. Septal cartilage may not be available, and conchal or costal cartilage may have been used previously. Understanding this point allows the surgeon to prioritize grafts based on limited donor cartilage availability. Depending on the specific lengthening procedure, the availability of strong, straight pieces of cartilage for the dorsum and columellar strut are a top priority; followed by spreader grafts, tip grafts, alar rim grafts, radix grafts, and nasal spine grafts, in order of decreasing priority.
Patient positioning/preparation
Patients are typically placed in the supine position. The head is placed on a horseshoe head support and as close to the edge of the operating room table as possible. Both arms are tucked. The face and the anterior chest wall are prepped. Life-sized photographs can be taped on an intravenous pole and placed nearby for intraoperative review. Once general anesthesia is induced, the patient is intubated using an oral ray endotracheal tube.
Injection of local anesthesia is performed in the following manner. To minimize the systemic effects of epinephrine, such as tachyarrhythmia and hypertension, staged injections with increasing concentrations of epinephrine are performed. Xylocaine containing 1:200,000 epinephrine is used first. In cases of planned turbinectomy, turbinates are injected. Gauze packing soaked in oxymetazoline hydrochloride or phenylephrine is then placed as far posteriorly and cephalically as possible. The radix is then injected, followed by soft tissues along the lateral and medial surfaces of the nasal bones. The dorsal septum on either side of the nasal roof is then injected, followed by the lining of the vomer and the floor of the nose as far posteriorly and caudally as possible. After waiting several minutes for the epinephrine to work, the same steps are followed with 0.5% ropivacaine containing 1:100,000 epinephrine. This double-injection method ensures maximal vasoconstriction, limits postoperative narcotic use, and provides an opportunity for intraoperative visibility.
Procedural approach
Choice of operative approach and technique ultimately depends on the type and severity of length deficiency. If there is mild anterior deficiency in the infratip lobule or columella, a shield-tip graft can be used. In contrast, if there is moderate to severe shortening, then the dorsal nasal framework must be elongated. Elongation of the dorsum can be accomplished using septal extension grafts, composite grafts in case of severe lining deficiency, or the tongue-and-groove technique. In addition, ancillary maneuvers can be performed to ensure adequate lengthening and balanced proportions, including soft tissue undermining, upper lateral cartilage derotation, lateral crural grafting or alar grafting, and tip suturing.
Shield-tip graft
Mild shortening attributed to the infratip lobule or anterior columella can be corrected using a shield-type tip graft. Fig. 1 shows an example of a patient who would benefit from this technique. If the only modification required is a shield-type tip graft, this can be placed endonasally through a marginal incision extending laterally from the anterior portion of the columella. However, in most cases of shortening, other flaws are present, such as alar retraction, which requires additional modifications.
In all cases except for minor tip graft modifications, an external rhinoplasty approach is preferred. A transcolumellar incision is marked in the narrowest portion of the columella using double-hook retraction to pull the domes anteriorly. The stair-step transcolumellar incision is connected to bilateral marginal incisions along the caudal edge of the medial and lateral crura. This incision provides the least visible scar and the best alignment of the wound margins. Modifications of operative approach may be required in cases of traumatic lacerations.
After exposure of the lower lateral cartilages, the medial crura are approximated. A shield graft is carved using a tip punch device. Septal cartilage is preferred but conchal cartilage can be used when there is a paucity of donor septum. The punch creates an anatomic graft with 2 round cephalic segments and an infratip portion, which emulate the shape of the natural domes and infratip ( Fig. 2 ). A second layer can be applied depending on the amount of elongation needed and the thickness of the first graft. Only a single graft is usually required.
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Lateral Crural Tensioning for Refinement of the Wide and Underprojected Nasal Tip
Rhinoplasty: Contemporary Innovations
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Nasal Tip Deprojection with Crural Cartilage Overlap
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