Common rhinoplasty problems such as width, asymmetry, droopy nose, and upturned nose



 
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Rhinoplasty are by far one of the most complex and artistic procedures in facial plastic surgery. Dr. Naficy's practice has been 100% devoted to rhinoplasty and facial plastic surgery for the past 15 years. Trust your nose to an expert!


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Rhinoplasty Aesthetics

VISUAL PERCEPTION & THE ART OF RHINOPLASTY

When we look at an object, our eyes are rapidly scanning (at extremely high speeds) over a number of "points of interest" over the contour of that object. This visual scanning process (known as saccades) typically occurs at very high speeds such that it is not noticed.

Scientists in the 1960's studied this visual scanning process with rather interesting results. When we look at the human face, these "points of interest" are highly focused on the shadows and highlights of the eyes, lips, and yes, the nose! You can see from the images below that when we look at a face, the vast majority of out time is spent looking at a triangle defined by the eyes and the mouth.






The nose, being situated at the center of this so-called "aesthetic triangle", has the potential to sort of "get in the way" of the other features, mainly the eyes, being fully appreciated. It is easy then to understand why it is that an unattractive nose can steal away from the beauty of the face.











After a successful rhinoplasty, patients often receive compliments about their improved appearance from unsuspecting friends, and co-workers. What is truly fascinating is that the facial feature that are perceived to be more attractive after a successful rhinoplasty is not always just the nose itself, but often times the eyes! Before rhinoplasty, the beauty of the eyes (and often that of the entire face) was being masked by a nose that was out of proportion to the face.

The art of rhinoplasty is therefore in creating a nose of desirable aesthetic proportions that appears natural in shape and in harmony with the rest of the face, softly blending with and accentuating the beauty of the eyes and the mouth.

SCIENCE OF RHINOPLASTY

There are a number of descriptive parameters, both absolute and relative, that are used by rhinoplasty surgeons to describe the appearance of a nose. The most important descriptive parameters used to describe a nose in preparation for rhinoplasty are the following:

  • Projection
  • Rotation
  • Alar-Columellar relationship
  • Width
  • Symmetry

Projection

In rhinoplasty, projection refers to how much the nose sticks out from the face. This can be measured in both absolute terms (i.e. distance in millimeters) or in relative terms. In relative terms, the projection of the nose in profile view should be roughly equal to the length of the upper lip.

Noses that seem to stick out too much from the face are called over-projected. This over-projection may involve the entire nose (upper, middle, and lower thirds) or it may be limited to just a portion of the nose (typically the lower third or the middle third).





Normal nose (left) and over-projected nose (right)

Noses that don't stick out enough from the face are called under-projected. This under-projection may also involve the entire nose (upper, middle, and lower thirds) but typically it is limited to just the lower third or tip of the nose. African-American noses and certain Asian noses may also be under-projected at the top (bridge) of the nose.





Normal nose (left) and under-projected nose (right)

Rotation

Rotation is a term used by rhinoplasty surgeons to define the angle between the upper lip and the nose (the nasolabial angle). This angle is ideally between 90-95 degrees in men and between 90-105 degrees in woman.

For example, a droopy nose is called under-rotated. This means that it has a narrow (or sharp) nasolabial angle and requires additional upward rotation (upward tilt) to be more aesthetically pleasing. People of the Middle East, Latin America, and parts of Europe tend to have long and droopy noses.





Normal nose (left) and under-rotated nose (right)

Conversely, an overly upturned nose is called an over-rotated nose. This means that it has a wide nasolabial angle and requires de-rotation (downward tilt) to be more aesthetically pleasing. This type of anatomy is more common in people from a Nordic (Scandinavian) background.





Normal nose (left) and over-rotated nose (right)

Alar-columellar relationship

The relationship between the alar margin and the columella is probably the single most important aspect of an attractive nose. When viewed from the side, an attractive nose typically has no more than about 3 to 5 millimeters (1/6 of an inch) of the nostril showing (called the columellar show). However, as we will see, this ideal alar-columellar relationship can be upset by changes in either the ala or the columella or by a combination of both.





Ideal alar-columellar relationship in rhinoplasty

The Alae

The position of the alar margin can disturb this ideal alar-columellar relationship. A hanging ala is typically seen in noses with heavy skin. The hanging nostril reduces the amount of columellar show and can give a bottom-heavy appearance to the nose. Hanging nostrils are typically more common in Latin American, African American, and Southeast Asian noses.

If the alar margin is positioned too high, it can result in an unnaturally large amount of columellar show. This condition is called alar retraction or alar notching and can be he result of prior rhinoplasty surgery, typically in situations where too much of the alar cartilages are removed and there is not enough cartilage support left for the alar margin.





Alar malposition can result in an undesirable alar-columellar relationship such as a hanging ala (left) or alar retraction (right)

The Columella

The amount of columellar show can be more excessive than desirable, as in the case of a hanging columella. A hanging or droopy columella typically occurs as an undesirable side effect of previous rhinoplasty surgery. The appearance of the hanging columella is typically due to the central portion of the tip cartilages of the nose (medial crura of the alar cartilages) that when not adequately supported can droop.

On the other hand, there can be not enough columellar show, a feature known as columellar retraction. A retracted columella may also be the result of previous surgery, either rhinoplasty, septoplasty (surgery to correct a deviated septum), or from a previous injury to the nose. This feature is typically caused by loss of the cartilage of the septum, which then leaves the columella unsupported and causes it to retract back into the nose.





Columellar malposition can result in an undesirable alar-columellar relationship such as a hanging columella (left) or columellar retraction (right)

Combination problems

There are a number of other possible combinations with the alar-columellar relationship that involve abnormal position of both the ala and the columella. These combinations could be either in the same direction (convergent) or in opposite directions (divergent) such that they would either make the alar-columellar relationship even worse or they would improve it. Here are the examples:





Alar and columellar divergent malposition can result in a more exaggerated degree of alar-columellar disharmony such as a hanging columella + a retracted ala (left) or columellar retraction + a hanging ala (right)





Alar and columellar convergent malposition can result in a less exaggerated degree of alar-columellar disharmony such as a hanging columella + a hanging ala (left) or columellar retraction + ala retraction (right)

NASAL WIDTH

Rhinoplasty can alter nasal width in either direction, meaning it can make a nose narrower or wider. The usual scenario is that of a wide nose that requires narrowing. There are a number of possible causes for a wide nose and in many instances more than one factor may be present:

  • Wide nasal bones
  • Wide nasal cartilages
  • Thick skin
  • Lack of structural support
  • Flaring nostrils




Normal nasal width (left) compared to wide or bulbous tip due to large cartilages (right)





Excessive nasal width due to bone and cartilage (left) compared to excessive width due to flaring nostrils (right)

SYMMETRY

Rhinoplasty can also improve nasal asymmetry. Asymmetry is typically caused by a combination of factors that include:

  • Deviation of the septum
  • Crooked nasal bones, possibly from injury
  • Asymmetric cartilages, possibly from injury




Normal nasal symmetry (left) compared to asymmetry due to crooked nasal bones and deviated septum (right)


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