Technique for Treating the Short Nose
Nicholas Lahar
Jason Roostaeian
DEFINITION
The short nose is defined as a perceived excess upward tilt of the nasal tip that results in a foreshortened appearance. Common defining features include a decreased distance from nasofrontal angle to tip defining point, an over-rotated tip, and an increased nasolabial angle. Other commonly associated features can include decreased dorsal nasal length, increased nostril show, cephalic over-rotation of tip, low/deep radix, and long upper lip.1 The perceived deficits of the nose must be evaluated with respect to the other facial features, but there are generally accepted measurements of facial harmony (see below).
ANATOMY
The structural nose is composed of the paired nasal bones, upper lateral cartilages, and lower lateral cartilages. The midline septum also offers significant support for dorsal height and projection.
PATHOGENESIS
Tip projection is highly dependent on support of the lower lateral cartilages. In cases of poor lower lateral cartilage support, tip support becomes more dependent on septal cartilage. Other supporting structures include intercartilaginous ligament between the upper and lower lateral cartilages, lateral crural complex extending from the piriform rim, interdomal ligaments, and medial crural attachments to the septum.
Deformities are typically acquired or congenital.
Acquired causes: iatrogenic, trauma, chemical (eg, cocaine), autoimmune disorders, and infections
Scar contracture from tumor resection or trauma involving the lower portion of the nose may distort and retract the nasal tip.
PATIENT HISTORY AND PHYSICAL FINDINGS
A detailed nasal history should be obtained, in particular to include a history of symptoms related to nasal obstruction, nasal allergies, prior nasal trauma, and nasal surgeries. Any patient aesthetic concerns and goals should be elicited and clearly defined.2
A complete external and internal nasal examination should be conducted in all patients.
Facial harmony is evaluated with particular attention to the relationships of the facial thirds on the profile view, nasofrontal angle, tip defining point, nasal length, nasolabial angle, and nostril show.
Via palpation and examination, identify typical findings such as lack of nasal cartilage, weakened or fractured osseous/cartilaginous support, scar tissue, and contracture of soft tissue.
Evaluate the nose with respect to the other facial features to assess facial harmony.
There are generally accepted measurements for nasal length and nasolabial angle that can be used to assess the appearance.
Nasal length is typically about two-thirds the height of the midface (supraorbitale to subnasale).1
Ideal nasal length: nasal length/nasal projection ratio of 5:3.1
Ideal nasolabial angle:
Caucasian women: 95 to 105 degrees
Caucasian men: 90 to 95 degrees1
The columella protrudes 3 to 4 mm below the alar rim. The ideal ala-columella relationship creates a symmetrical oval outline on profile view bisected by a line connecting the most anterior to most posterior portion of the nostril.
Assess the nasal alae and soft tissues aesthetically and for skin quality.
A nasal speculum is used to evaluate the septum and the inferior turbinates for abnormalities.
Standardized photographs including frontal, lateral oblique, and basal views should be obtained in all patients.
Assess septal cartilage and other potential donor sites (ear and/or rib), particularly if the patient has had nasal surgery previously.
Priority should be given to strong, straight pieces of cartilage for dorsal and columellar strut grafts.
IMAGING
No specific imaging is required if attention is being paid specifically to a shortened nose.
A nasal x-ray can be helpful in cases of prior trauma or asymmetric nasal bones.
Computed tomography (CT) imaging can help evaluate nasal bones, septal deviation, turbinate pathology, and the sinuses when the history warrants further investigation.
SURGICAL MANAGEMENT
The primary objective in correction of the short nose is to increase overall radix to tip length. This often requires a concomitant increase in tip projection while reducing tip rotation and the nasolabial angle.2
Adjunctive procedures, eg, functional modifications, should also be determined and made part of the operative plan accordingly.
Preoperative Planning
Risks, benefits, and expectations must be discussed with the patient prior to surgery.
Consideration of the soft tissue envelope and its overall compliance, previous operations, extent of previous nasal trauma, and involved structures and available septal and other potential cartilage grafts (ear, rib) should be taken into account. The patient should be informed of the possible need to harvest cartilage from these other donor sites such as the ear or rib. In cases of severe soft tissue contracture, preoperative discussion to set expectations accordingly and/or attempts to increase compliance via mechanical means such as frequent downward massaging should be considered.
Principles of nasal lengthening
Precise assessment of length deficiency
Accurate identification of deficient tissues
Adequate release of soft tissue envelope
Pertinent modification of skin, mucosa, and/or skeletal deformities to restore length
Maintaining patency of the nasal airway
Positioning
The patient is positioned supine with arms tucked. The head is placed at the very end of the bed.
An oral right angle endotracheal tube is used for intubation, and should extend inferiorly in the midline away from the nose, and secured without distorting the upper lip and nose.
Nasal hairs may be trimmed, if desired.
Oxymetazoline or 4% cocaine-soaked pledgets are placed in each nostril.
Local anesthetic consisting of 1% lidocaine with 1:100 000 epinephrine is infiltrated into the nasal sidewalls, into the columella, and inside the nostril along the lower lateral cartilages.
A throat pack is placed to prevent gastric accumulation of blood.
The face is prepped with dilute Betadine.
A sterile head wrap is placed followed by surgical drapes.
Approach
An endonasal approach is indicated for simple refinements of the nasal tip. Otherwise, an open approach is preferred particularly when there is poor support for the nasal tip or when more complex nasal tip adjustments are necessary.
TECHNIQUES
▪ Shield-Tip Graft
Indication: Mild shortening attributed to a deficient infratip lobule or columella
Concept: Cartilage graft is placed at the tip of the lower lateral cartilages to increase the length or manipulate contour.
TECH FIG 1 • A. A transcolumellar incision is made with care to avoid injuring the medial crus. B. An infracartilaginous incision is made at the lower margin of the lower lateral cartilages. C,D. The transcolumellar incision is completed.Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Get Clinical Tree app for offline access
