Depending on how cephalad the deepening of the radix is, a different outcome can be expected (Figure 3.1; Animation 3.1). More cephalad deepening will result in elongation of the nose, while deepening at the medial canthus or caudal to it will produce a shorter appearance in the nose. This is very intriguing in that both augmentation and reduction can potentially make the nose look long, depending on the site of deepening (Figure 3.2; Animation 3.2). Deepening of the radix will induce the appearance of an increased intercanthal distance.

Figure 3.1 As the radix is deepened, if the deepening is cephalad, it will result in elongation of the nose.

Figure 3.2 As the radix is augmented, it will result in elongation of the nose.

Animation 3.1 •

Animation 3.2 •

The Dorsum

The presence of a dorsal hump provides the appearance of a narrower bridge. As the hump is removed, the dorsum will appear wider even after an osteotomy and narrowing of the distance between the nasal bones (Figures 3.2, 3.3). Additionally, removal of the dorsal hump provides an appearance of increased intercanthal distance. Augmentation of the dorsum will have a reverse effect: the dorsum will look narrower and the intercanthal distance will appear shorter as long as the graft utilized is not too wide (Figure 3.4). Osteotomy of the nasal bones will result in the appearance of a narrower nose and a decrease in the intercanthal distance (Figure 3.5).

Figure 3.3 A wider appearance of the nose following removal of the dorsal hump and osteotomy.

Figure 3.4 A narrow appearance of the nose after application of a dorsal graft.

Figure 3.5 Osteotomy and medial positioning of the nasal bones will cause the appearance of a reduction in the intercanthal distance and the nose will seem narrower.

Furthermore, osteotomy and medial transposition of the nasal bone and the upper lateral cartilage (ULC) may also reduce the nasal airway. However, this change will be more drastic when the nasal bones are longer, which will have more influence on the ULC (Figure 3.6; Animation 3.3) if the nasal bones are transposed medially to a significant degree (Figure 3.7) or if the inferior turbinate extends anterior to the plane of osteotomy (Figure 3.8). To avoid medialization of the inferior turbinates, one may start the osteotomy more anteriorly or do a high to low osteotomy (Figure 3.9). Alternatively, one may perform a conservative inferior turbinectomy.³ Avoiding an osteotomy is an option, but in most instances this is not an acceptable aesthetic compromise. Furthermore, in order to reduce the ill effects of the medialization of the ULC on the nasal valve and dorsal aesthetic lines, insertion of spreader grafts may become necessary. If the removed dorsal hump is small enough to avoid an open nasal roof, spreader grafts may not be necessary unless there is a primary internal valve dysfunction. When removal of a small dorsal hump results in minimal opening of the roof, preservation of the mucoperichondrium may make it unnecessary to use spreader grafts to prevent medialization of the ULC. However, whenever a large dorsal hump is removed, it invariably results in medial transposition of the ULC, which may not be initially discernible. It may take between 6 months and a year for the inverted ‘V’ deformity to become visible. It is thus prudent to use bilateral spreader grafts or flaps whenever a large dorsal hump is removed. While in most instances spreader grafts will be sufficient, in rare cases when the ULCs are extremely short or attenuated a splay graft may provide a better functional outcome.⁴

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