Functional and Cosmetic Rhinoplasty

1

What is rhinoplasty?

Rhinoplasty is a challenging surgical operation used to change the functional performance or aesthetic appearance of the nose through manipulation of bone, cartilage, and soft tissue.

2

Who undergoes rhinoplasty?

An estimated 80% of rhinoplasty surgeries are performed on women, and it is the most common procedure performed in facial plastic surgery. Rhinoplasty is most common in the 22- to 34-year-old age group (44% of all), followed by the 35- to 60-year-old age group (31% of all).

3

Why is rhinoplasty a challenging operation?

There are few surgical procedures in which the perception of success rests so substantially on the abilities of the surgeon. In cosmetic rhinoplasty, millimeter changes mean the difference between a satisfactory and a disappointing outcome. Rhinoplasty therefore requires a collaborative discussion of what the patient desires and how his or her expectations match surgical realities. The surgeon must have experience with numerous rhinoplasty techniques and have a thorough grasp of nasal anatomy ( Figs. 61.1 and 61.2 ). The success or failure of rhinoplasty depends on the interplay of the patient’s unique nasal anatomy and comorbidities, the surgeon’s experience and ability, and the patient’s preparation regarding realistic outcomes.

4

How does one analyze the nose preoperatively for rhinoplasty?

While a comprehensive discussion of preoperative nasal analysis is beyond the scope of this chapter, there are several general points worth mentioning. Every initial rhinoplasty consultation includes six standard preoperative rhinoplasty photos, which provide a framework to analyze the nose. These views are the frontal, right/left oblique, right/left lateral, and basal views.

• Frontal View: on frontal view, the nose is divided horizontally into thirds. The upper third comprises the nasal bones, which should be symmetric and 75% of the intercanthal distance. The middle third, also called the “midvault,” is formed by the upper lateral cartilages and the dorsal septal cartilage. A line connecting the glabella to the ipsilateral tip-defining point is called the brow-tip aesthetic line. It should be curvilinear, symmetric, and smooth. Deformities from trauma or prior surgery disrupt the brow-tip aesthetic line. A narrow middle third suggests the presence of nasal valve dysfunction (see Question 8). Nasal tip shape may be characterized as bulbous, narrow, bifid, boxy, or amorphous. The elegant tip forms a diamond shape with two tip-defining points, which are identified by the light reflex they produce. The tip-defining points are ideally separated by less than 1 centimeter. Finally, the nostril rims should form a “gull-in-flight” relationship with the columella.

• Lateral View: the lateral view provides assessment of the profile of the nose and also the ala-tip complex. On lateral view, the length of the ala and tip should be roughly equal and there should be 2 to 4 millimeters of columella showing below the level of the nostril rim. The elegant nasal tip profile has a “double break” produced by (1) the tip-defining point and (2) a subtle angulation at the junction of the tip lobule with the columella. Additionally, a supratip break should be present between the nasal tip and the nasal dorsum.

• Basal View: the basal view is used to assess nasal base width and nasal tip symmetry. On basal view, the nose should form an equilateral triangle. The width of the columella compared to the width of the lobule should be 2:1. The tip should comprise one third of the total height, while the nostrils make up the remaining two-thirds on basal view.

5

What is nasal tip rotation and nasal tip projection?

• Tip Rotation: rotational movement of the position of the tip along an arc formed from a fixed point at the superior tragus

• Tip Projection: the anterior or posterior positioning of the nasal tip relative to the midface

6

Define the nasofrontal, nasolabial, and nasofacial aesthetic angles ( Fig. 61.3 ).

• Nasofrontal Angle: intersection of a line connecting the glabella and sellion and a line tangent to the nasal dorsum (ideally 115 to 130 degrees)

• Nasolabial Angle: intersection of a line tangent to the columella and a line tangent to the upper lip, which forms a vertex at the subnasale (ideally 90 to 95 degrees in males and 95 to 110 degrees in females)

• Nasofacial Angle: intersection of a line tangent to the nasal dorsum with a line from the glabella to the soft tissue pogonion (ideally 36 to 40 degrees)

7

What is the internal nasal valve and why is it important?

The internal nasal valve is approximately 1 centimeter posterior to the nostril aperture and comprises the septum, caudal edge of the upper lateral cartilage, and nasal floor. The angle between the upper lateral cartilage and the septum is acute at this location and is susceptible to collapse. The anterior head of the inferior turbinate may crowd the internal nasal valve, though it is not strictly part of the nasal valve. This internal nasal valve behaves like a Starling resistor in that it shuts once a threshold flow rate is reached. If the triggering flow rate is relatively low, the patient perceives difficulty breathing through the nose.

8

What is external nasal valve collapse?

The lower lateral cartilages form an incomplete ring around the nostril called the external nasal valve. They are designed to prevent the collapse of the soft tissue of the nose during nasal inspiration. External nasal valve collapse occurs when these cartilages are insufficient to support the soft tissue during inspiration.