Rhinoplasty (Nose Job) – Important Information

The nose is the central feature of the face. Its aesthetics affect the rest of the facial features in several ways.
Many techniques have been described which help improve the appearance of the nose. None of these are as versatile as a proper open rhinoplasty.
To fully appreciate rhinoplasty, it is essential to have a good understanding of the anatomy of the nose and the recommended aesthetic proportions.

Anatomy of the Nose
Aesthetic Proportions of the Nose
Cosmetic and Functional Rhinoplasty
How Rhinoplasty Changes the Whole Face
Closed vs Open Rhinoplasty
Minimally Invasive Technique vs Closed vs Open Rhinoplasty

ANATOMY OF THE NOSE

Anatomy of Nasal bone and Cartilages

The nose can be divided into thirds :
- Upper third of the nose is made up of the nasal bones
  - Low bony radix is a common complaint
- Middle third is occupied by the upper lateral cartilages which join the nasal septum. This septum separates the left and right nostrils
- Lower third is occupied by the lower lateral cartilages
  - A low dorsum and broad nasal tip is due to a small and short nasal septum with weak and broadened lower lateral cartilages.

AESTHETIC PROPORTIONS OF THE NOSE

The important aesthetic proportions of the nose originally described for Caucasian still applies to the Oriental nose.
The followings are selected features which are applicable in Oriental rhinoplasty

FRONT VIEW

Facial proportion – Rhinoplasty

Facial proportion – Side – Rhinoplasty

Face is divided into upper, middle and lower thirds at (i) hairline, (ii) brow at the level of the supraorbital notch, (iii) subnasale, and (iv) mentum.
Lower third is further divide into (1) upper third and (2) lower two thirds by line between oral commissures.

Face Proportion – Nose Width – Rhinoplasty

The width for the nose is equal to one eye width (intercanthal distance).

LATERAL VIEW

Facial proportion – Length of Nose – Rhinoplasty

Tip projection :
- The ratio of nasal length to tip projection should be 1.0:0.67 or 3:2 (Bryd).

Facial proportion – Columellar labial angle – Rhinoplasty

Columellar-labial angle is at the junction of the columella with the upper lip.
- The aesthetic columellar-labial angle is 90-95^o for male and 95-105^o for female.

AESTHETIC PROPORTIONS OF THE CHIN

Facial Proportion – Chin – Rhinoplasty

It is very important to have chin length and projection proportional to that of the nose.
The Riedel’s plane is a simple way to assess the aesthetics of the chin. It is a line connecting the most prominent portion of the upper and lower lip which, on a balanced face, should touch the most prominent anterior portion of the chin (pogonion).

COSMETIC AND FUNCTIONAL RHINOPLASTY

Rhinoplasty can be done for cosmetic and reconstructive purposes.

Cosmetic rhinoplasty addresses the followings :
- Low nasal dorsum and radix
- Wide nasal vault
- Poor tip projection
- Broad nasal tip
- Broad alar
- Poor columellar projection
- Short nose
- Crooked nose

Functional rhinoplasty treats the followings :
- Functional and structural deformities
  - Cleft lip and palate nasal deformity
  - Septal perforation
  - Nasal passage obstruction due to nasal valve dysfunction
  - Inferior turbinate hypertrophy
  - Deviated septal bones
  - Nasal tumor
- Traumatic incidence such as sports injury, fall, road traffic accident etc
  - Post traumatic event resulting in deviated septum and/or dorsum; facial fracture
- Deformities caused by previous rhinoplasty

HOW RHINOPLASTY CHANGES THE WHOLE FACE

A well augmented nose can improve the other facial features in many ways :
Gives the face a more three-dimensional and slimmer appearance.
Reduce the distance of the inner corner of the eye (medial epicanthoplasty effect), making the eye appear longer
- Improve the columellar-labial angle :
  - This can make a patient look younger especially when if the upper lip is receded (giving an illusion of aged appearance).
- Improve the nasolabial fold

METHODS OF NOSE AUGMENTATION

There are various methods to augment the nose:-

Minimally Invasive Techniques :
- Hyaluronic acid filler injection
- Fat injection to nose
- Thread insertion

Closed Rhinoplasty :
- This is a smaller procedure with no external scar. It has limited capabilities and its effects are not as dramatic as open rhinoplasty.

Open Rhinoplasty :
- This has been the de-facto standard for performing Oriental rhinoplasty in many countries especially in South Korea.
- It allows full visualisation of all internal structures of the nose and enables a full range of corrective procedures to be done with accuracy.

TABLE OF COMPARISON OF CLOSED VS OPEN RHINOPLASTY

	Closed Rhinoplasty	Open Rhinoplasty
Diagram	Closed Rhinoplasty – Incision	Open Rhinoplasty – Incision
External Scar	Incision within the nose with no external scar.	Small imperceptible scar across the columella. The rest of the scar is within the nose.
Visualisation of Internal Structures of Nose	Limited visualisation through a small opening.	Complete visualisation of all structures of the nose – allows accurate diagnosis and surgical correction. Accurate placement of implant or cartilage graft.
Corrective Capability	Limited range of corrective procedures. Difficult to suture and secure implants or cartilage grafts in position.	Full range of corrective surgery can be done. Position of implant or cartilage graft is visually confirmed and secured in place with suturing
Duration of Surgery	Shorter	Longer
Post-op Recovery	Usually shorter. Most swelling and bruising subside in 1-2 weeks. Most patients return to work in 1-2 weeks.	Slightly longer recovery. Significant decrease in swelling and bruising in 2 weeks. Most patients return to work in 1-2 weeks.

TABLE OF COMPARISON CAPABILITIES OF MINIMALLY INVASIVE TECHNIQUE VS CLOSED VS OPEN RHINOPLASTY

This table outlines the common problems in the Oriental nose and their corrective measures.

	Minimally Invasive e.g Filler	Closed Rhinoplasty	Open Rhinoplasty
Low dorsum Low radix	Slight improvement to dorsum and radix height. (excessive filler material can result in a broad radix)	Insertion silicone implant (usually L-shaped)	Insertion of silicone implant or rib cartilage. (Less tendency for implant displacement because of more accurate placement and ability to suture the implant in place)
Wide nasal vault	Unable to correct.	Unable to correct.	Nasal bone narrowed by : Cutting the sidewall (nasal bone lateral osteotomy) Rasping (filing) of the nasal bone.
Poor tip projection	Can improve tip projection slightly but cannot refine the tip.	Insertion of L-shape implant to improve tip projection. (High risk of implant perforation to the skin)	Caudal extension graft (derived from nasal septum or rib cartilage) to improve tip projection. Tiplasty (suturing of the nasal cartilage to produce a more refined tip) Shield graft and cap graft from conchal (ear) cartilage
Broad nasal tip	Unable to correct.	Unable to correct a broad nasal tip well.	Tiplasty (suturing of the nasal cartilage to produce a more refined tip)
Broad alar	Unable to correct.	Alarplasty can be combined with closed rhinoplasty	Rhinoplasty – Alarplasty Open rhinoplasty can produced better tip projection thereby reducing the need for alarplasty.
Poor columellar projection	Difficult to achieve	Insertion of L-shape implant to improve columellar projection. (usually limited results)	Caudal extension graft to improve columellar projection.
Short nose	Unable to correct.	Insertion of L-shape implant to increase nasal line. (usually limited results)	Caudal extension graft to improve length of nose.
Crooked nose	Illusion of improvement but not actually correcting the nasal anatomy.	Unable to correct.	Osteotomy is cutting of the nasal bone (osteotomy) and rasping (filing of the nasal bone)
Septal deviation and nasal obstruction	Unable to correct.	Limited septoplasty.	Septoplasty under direct vision. Scoring of nasal septum.

TYPE OF CARTILAGE GRAFT USED IN RHINOPLASTY

Origin	Ear	Nose(Septum)	Chest(Rib)
Autogenous cartilage graft	Conchal cartilage	Septal cartilage	Costal cartilage
Diagram	Rhinoplasty – Conchal (Ear) Cartilage Harvest	Rhinoplasty – Septal cartilage graft	Rhinoplasty – Rib Cartilage Graft
Characteristic	Curved, flexible cartilage, shaped like a bowl.	Usually straight flat fairly stiff cartilage. May be deficient after previous septoplasty May not be usable if there is significant septal deviation	Larger quantity Able to shape into straight flat strong piece Special cutting technique to prevent warping of cartilage (balanced cross sectioning) May not be usable in older age group because cartilage has turned into bone (ossified).
Function	Cap or shield graft to improve shape of nasal tip. Usually not strong or straight enough to be used as caudal extension or spreader grafts	Caudal extension graft to improve nasal length and tip projection. Spreader graft to prevent nasal obstruction.	Caudal extension graft to improve nasal length and tip projection. Spreader graft to prevent nasal obstruction. Can be carved for nasal dorsum augmentation (to replace silicone implant)