Page 56 - Read Online

Page 2 of 14 Patel et al. Plast Aesthet Res 2024;11:20 https://dx.doi.org/10.20517/2347-9264.2024.17

cartilaginous structure can result in a number of aesthetic and functional sequelae seen in the short nose.
On profile view, these are observed as a decreased nasal bridge distance from the nasofrontal angle to the tip
[2]
defining points with an increase in the nasolabial angle, as shown in Figure 1 . Associated retraction of the
nasal ala with over-rotation of the nasal tip are common, with patients commonly distressed by increased
nostril show [Figure 1]. The dorsum may be concave with a low or deep radix. Nasal tip projection can be
variable, although commonly, there is increased height of the nasal tip in relation to the dorsum and the
upper lip appears long . It is important to note that some of these features can give the perception of a
[3]
[4]
shortened nose despite an appropriate nasal length .
IDEAL NASAL LENGTH
The classic description of the ideal nasal length suggests that it should be one-third the distance from the
hairline to the menton. Another perspective defines the ideal nasal length as 0.67 of the midfacial height,
[3]
which is measured from the soft tissue glabella to the alar base . Additionally, the ideal nose length can be
evaluated in relation to nasal tip projection [Figure 2]. Goode described this correlation by establishing a
ratio between the ala-facial groove to the tip defining point (projection) and from the nasion to the tip
defining point (length). In an aesthetically pleasing face, this ratio should be 0.55-0.60. Importantly, these
measurements may vary based on a patient’s aesthetic preference and other facial morphology. As such,
considering the nose in the context of the entire face is essential and neoclassical canons should only be
regarded as guides. Facial photography and cephalometric analysis can allow for planning a balanced nasal
profile. Notably, the definition of an “excessively “short nose is subjective and unique to each patient. As
such, a universal definition does not exist. One may consider an excessively short nose < 75% of the ideal
length (or > 25% loss of distance from the nasion to the tip defining point). All short noses can be treated
fundamentally with similar techniques, although greater deformities may require longer or larger grafts or a
number of techniques implemented simultaneously.

ETIOLOGY OF A SHORT NOSE
Acquired short nose deformities may arise from trauma, infection, underlying inflammatory disease, or
prior surgery that violates the nasal soft tissue and/or underlying cartilaginous framework. Short noses of
various etiologies are shown in Figure 1. Congenital short noses can occur in isolation or in the setting of
[3]
other facial malformations, including craniofacial dysmorphisms such as cleft lips . Ethnic variations in
nasal morphology may also present as shortened noses with a need for careful counseling and preservation
of racial features as appropriate . Consideration of the etiologic and chronicity of factors contributing to
[5]
the observed deformity are paramount for successful correction of a short nose deformity. Interventions
made during active disease or pathology (e.g., autoimmune conditions or drug use) can result in deleterious
effects and poor surgical outcomes [Table 1].

EXAM AND IMAGING
Preoperative rhinoplasty evaluation should include a comprehensive functional and aesthetic evaluation,
which includes a thorough assessment of the external and internal nose as well as the use of patient-
reported outcome measures that address satisfaction with the internal and external elements of the nose
[6,7]
(e.g., SCHNOS) . Palpation of the nose is paramount to elucidate the integrity of the osseocartilaginous
framework. Focal areas of scar or contracture can also be identified. The internal exam may reveal synechiae
or perforations of the septum that correspond to the patient’s external or functional complaints. A critical
component of the physical exam that is not typical of most rhinoplasty consultations is the manual
elongation of the nasal skin in order to delineate the limitations in soft tissue or mucosa. As the
cartilaginous framework can be augmented in most patients using autologous or homologous grafting
sources, inadequate soft tissue and/or mucosal pliability are more commonly the limitations to lengthening