The Clinical Problem
A prominent nose is regarded as abnormal if it is larger than average, but even within different cultures this is very subjective. Larger prevalence of the prominent nose in a total population is seen in the Mediterranean basin and in the Middle East.
Patients look at their noses through a prism of internal reflection, which may also be the outlet for a psychological load they carry inside. When patients are photographed in profile and asked to draw the desired change in the nasal profile, they will frequently draw the nose unreasonably small. The surgeon must balance the patient’s dreams and desires and the existent anatomic predispositions with his knowledge of predictable surgical techniques and healing processes to obtain favorable yet well-camouflaged results.
Although beauty can be interpreted variably, certain geometric criteria and accuracy of proportions must be met. Goode introduced a simple formula that delineates the approximate relationship between tip projection and nasal length ( Fig. 15.1 ). The Goode ratio is an expression of proportion in measurement between a line drawn from the alar crease to the nasal tip and from the nasal tip to the nasion. In the aesthetically-pleasing Caucasian nose BC should equal 0.55 to 0.60 of AB. If it is more than that, the nose is overprojected; if it is less, the nose is underprojected. Adherence to this ratio prevents underprojection or overprojection with rhinoplasty. If there is a preoperatively unrecognized deviation from this ratio that persists after the surgery, the final result will be substandard.
Surgical Principles
In the patient with the prominent nose, particular attention is directed to the following features:
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Age, gender, skin quality, and ethnicity
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Overall nasal length
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Height (Goode’s ratio)
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Width (lateral facial proportions)
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Nasofrontal angle (NF)—midface proportionate development)
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Nasolabial angle (NL)—female greater than male
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Nose—upper lip distance (dental show)
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Nose-chin proportions—mandible versus maxillary development)
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Shape and position of the chin—mandibular hypoplasia
Basic rhinoplasty technique relies on three cardinal steps: (1) reduction of the alar cartilages; (2) removal of the dorsal hump; and (3) narrowing of the nasal pyramid by lateral osteotomies and infracture.
A prominent nose requires a broader theoretical and practical understanding of advanced rhinoplasty techniques and considerable skill. Aesthetic rhinoplasty has evolved considerably over the decades, and we can now make a selection from a palette of additional procedures on the radix–NF, modulation of the NL, reduction of the nasal spine, lengthening or shortening of the upper lip, chin reduction, chin augmentation, and advanced tip procedures. To lower an overprojecting tip, the height of the cartilaginous framework has to be reduced. Such tip setback can be achieved by alar cartilage remodeling, as it was described by Peck ( Fig. 15.2 ). The lateral part of the alar cartilage is excised and the intermediate crus area is scored to permit a lateral slide of the alar cartilage. Gubisch and Eichhorn-Sens have refined the medial and/or lateral sliding technique, in which the alar cartilages are cut and pushed down above the lateral and/or inside the lower fragment and fixated in the overlapping position by the permanent sutures ( Fig. 15.3 ).
The NF can be deep, well-balanced, or shallow; this plays an important role in our perception of the size and length of the nose and facial harmony ( Fig. 15.4 ). The NF also determines the angle of inclination between the outlines of the nasal pyramid and the vertical vector of the face, or how much the nose sticks out.
Inadequate Deepening of the Nasofrontal Angle ( Figs. 15.5 and 15.6 )
Fig. 15.5 illustrates the importance of deepening of the NF angle and its impact on optical impression of the length of the nose. Fig. 15.6 shows the profile 2 years postrhinoplasty. The radix was left untouched, and the optimal improvement was not achieved. Despite the fact that the NL angle is 100° her nose is perceived as long.
