Lengthening the short nose is a challenging area of rhinoplasty. The short nose can be a naturally occurring aesthetic disproportion, or the result of a congenital abnormality or traumatic deformity. The surgical approach depends mostly on the quality of the lining, skeleton, overlying skin, and the amount of correction desired.
The short nose is a challenging problem in rhinoplasty. The short nose is characterized by 1 or more of the following:
- 1.
Disproportion with the midface and other areas of the face
- 2.
An excessively obtuse nasolabial angle
- 3.
Excessive nostril show.
The short nose can be a naturally occurring aesthetic disproportion, the result of a congenital abnormality, or traumatic deformity. The surgical approach depends mostly on the quality of the lining, skeleton, overlying skin, and the amount of correction desired.
Analysis
Although the diagnosis is usually obvious, precise soft-tissue analysis is beneficial for surgical planning. The method the authors use is a simple soft-tissue cephalometric analysis that can be performed in less than a minute. Six measurements are taken:
- 1.
Midfacial height: the distance from the glabella to the bottom of the ala.
- 2.
Lower facial height: the distance from the subnasale to the menton.
- 3.
Nasal length: the distance from the root of the nose at the level of the supratarsal fold to the tip projecting point.
- 4.
Chin vertical: the distance from the stomion to the menton.
- 5.
Tip projection: the distance from the junction of the cheek and the ala to the tip of the nose.
- 6.
Chin projection: the distance from the anterior projecting point of the chin to a line drawn from the half-way point of nasal length and extending through and beyond the anterior projecting point of the upper lip.
This analysis allows for determination of ideal nasal length with respect to the midface and chin vertical portion of the lower face. In the face with ideal proportions, nasal length should be two-thirds of the midfacial height and approximately equal to chin vertical. In a face where either the midface or chin vertical is abnormal, the most aesthetically ideal subunit should be used as the reference. The goal is not to blindly match a set of numbers, but to quickly and precisely obtain a useful and practical guide for surgical planning.
Surgical approach
There have been several techniques described to lengthen the nose. The techniques that we have found most useful and effective are described here.
Technique 1: Septal Extension Graft
In the patient with no lining restriction, good overlying skin quality, and abundant septal cartilage of adequate strength, this is a powerful and straightforward way of lengthening the nose and controlling tip projection at the same time. The technique and its applications have been well described by Byrd and colleagues, and the reader is referred to these references for an excellent description of the technique.
Case 1: Primary rhinoplasty
A 27-year-old man sought surgical correction of a shortened over-rotated nose and improvement of what he perceived as a weak chin. Midfacial height was used as the reference unit for desired nasal length and chin vertical. An open approach was used. Adequate septal cartilage was harvested for graft material. The lower lateral cartilages were freed from the upper lateral cartilages. A septal extension graft was placed along the dorsal septum to allow 5 mm of nasal lengthening and control of tip projection. A sliding genioplasty was performed to gain 5 mm of increase in chin vertical and 8 mm of increase in anterioposterior projection ( Fig. 1 ).
Case 2: Secondary rhinoplasty
A 28-year-old woman underwent a rhinoplasty as a teenager and had been living with a shortened, severely over-rotated nose since that time. She had good skin quality and a large amount of good quality septum. Facial analysis showed her nose to be approximately 6 mm short in relation to her midface height and chin vertical. An open approach was used. The lower lateral cartilages were mobilized and using a septal extension graft; 6 mm of lengthening was achieved ( Fig. 2 ).
