Nasal Aesthetics Research Articles

Nasal Aesthetics

Nasal Aesthetics

Reshaping the Medial Nostril and Columellar Base

Achieving ideal shape and position of the medial nostril and columellar base is a crucial component of successful rhinoplasty. The lateral border of the basal columella should exhibit slight concavity and a relatively smooth contour. Both nasal aesthetics and functionality may be compromised if such a result is not obtained. Herein, a reproducible technique is described which allows for treatment of this region.

The impact of Metzembaum septoplasty on nasal and facial growth in children

Several studies have investigated the effects of septoplasty on facial growth in children, with conflicting results. However, just handful of those employed objective measures or evaluated patients after facial growth completion. ObjectiveThis study assesses the effects of the Metzenbaum septoplasty, which preserves the perichondrium and growth-related areas on nasal and facial growth in children. MethodWe included those children submitted to surgery before the age of 14 and who had 16 years or years of follow up. Sixteen patients were selected. We evaluated the following parameters: clinical satisfaction (nasal patency and aesthetics), anthropometric measurements and cephalometry. Scientific design: cross-sectional historical cohort. ResultsThe mean age at surgery was 13 years, children were assessed on average 4.3 years after surgery. Only one patient had anthropometric and cephalometric values below normal, but no aesthetics or patency complaints. Four other patients complained about their nasal aesthetics and three had patency complaints. ConclusionThe Metzenbaum septoplasty appears to be a safe technique to correct caudal septum deviations. This technique had no significant impact on facial growth of the patients assessed.

Commentary on: Rhinoplasty: Surface Aesthetics and Surgical Techniques

Contour of the nose is determined by a series of shadows and highlights that emphasize the shape of the nose.1 The desired contours are curvilinear with smooth transitions from dorsum to mid-vault to nasal tip. Control of nasal contour requires precise management of the underlying nasal structures. The structure approach to rhinoplasty employs conservative reduction of the cartilage structures and reshaping using cartilage grafting.2 Cartilage grafts such as spreader grafts and lateral crural strut grafts help to control the shape of the middle nasal vault and lower third of the nose, respectively.3,4 Such grafts have helped surgeons improve their long-term outcomes as well as link nasal aesthetics and surgical technique. In the article entitled, “Rhinoplasty: Surface Aesthetics and Surgical Technique,” Dr Cakir and his coauthors have described how the nasal contour is composed of a series of polygons as aesthetic units and linked these concepts to their own techniques. The ideal contour on frontal view is typically described as having bilateral divergent concave lines that create symmetric “brow tip aesthetic lines.”5–7 In contrast, the authors describe the frontal view as a series of polygons, with a superior polygon that is narrow at the radix and widens toward the middle nasal vault and an inferior polygon that narrows at the supratip. This series of shapes more closely represents the shape of the underlying nasal structures (nasion, nasal bones, and upper lateral cartilages) rather than the superficial nasal contour. Transitions in skin thickness—from thick in the radix region, to …

Nasal Aesthetics

Plastic surgeons often approach nasal aesthetic evaluation with the aid of seemingly objective measurements. However, ideal measurements of an attractive nose, as suggested in the literature, might not apply on a cross-cultural basis. Given these controversies, this study aimed to investigate the cultural and ethnic impact on nasal shape preferences. Computerized images of a model's nose were generated in which the nasal width, root, tip, dorsum, and projection of the lips and chin could be altered. A survey containing these images was sent to over 13,000 plastic surgeons and lay people in 50 different countries, with a total response rate of 9.6 percent. Demographic information about the interviewees was obtained. Preferred dimensions of the nose were broken down according to geographic, ethnic, occupational, and sex variables. Interregional comparison revealed that plastic surgeons from Latin America and the Caribbean overall prefer smaller and narrower noses, with more projecting tips, lips, and chins. Similar trends hold true when analyzing results from the general public. Significant differences were found comparing preferences between plastic surgeons and the general public. Plastic surgeons preferred wider nasal roots and tips and, in combination, more projected nasal dorsi, tips, lips, and chins. No universal parameter can define ideal aesthetics of the nose across cultures and ethnic backgrounds. As demonstrated, geographic, ethnic, and cultural factors influence aesthetic perceptions of patients and surgeons.

Presurgical Orthopaedic Nasoalveolar Molding in Cleft Lip and Palate Infants: A Comparative Evaluation of Cases Done With and Without Nasal Stents

Addressing the craniofacial anomaly of cleft lip and palate presurgically has been done since more than 50years now, with a constant improvisation of the treatment protocols from time to time. The present study deals with a modification of the technique devised 16years ago. The effect of nasal stents attached to a pre-surgical naso-alveolar molding (PNAM) appliance on the nasal morphology achieved prior to primary surgical correction of the cleft lip was to be evaluated. Twenty subjects, infants with cleft lip and palate, less than 2months of age were selected for presurgical nasoalveolar molding treatment. Impressions were recorded, casts made and PNAM appliance fabricated. Ten infants were given the appliance without nasal stents and to the other ten appliances nasal stents were added. The patients were recalled every 2-3weeks and a series of 9 measurements were recorded every visit along with adjustments made to the appliance for desirable effects on the lip, alveolus and nose. This was carried out till the patient was taken up for lip repair. The final measurements obtained at the end of the presurgical treatment were recorded. Mann-Whitney test, between study and control group showed that the increase in the columella length was statistically significant (p=0.0001 and p=0.033) in the study group as compared to the control group. Also the increase of the nasal tip projection (mean=1.30mm) in the study group was found to be statistically significant (p=0.006) as compared to the control group. We concluded that nasal stents attached to the alveolar molding appliance, yield significant improvement of the nasal morphology and better nasal aesthetics presurgically.

A Multivariate Analysis of Nasal Tip Deprojection

Projection of the nasal tip is a complex problem that often mandates attention during rhinoplasty. Occasionally, the goal is to decrease tip projection. Most published solutions to this problem involve division or manipulation of the lower lateral cartilages, although objective data on the efficacy of these techniques are limited. This study reviews a series of rhinoplasties and determines which maneuvers had the greatest effect on tip projection. One hundred twenty-five consecutive rhinoplasties performed by a single surgeon in a university setting were reviewed. Charts were analyzed for surgical indications and technical steps performed in the operating room. Preoperative and postoperative photographs underwent multivariate analysis to determine changes in nasal projection and which factors contribute to affecting tip projection. Overall revision rate was 3.8 percent. Cartilage-splitting techniques were used in only 2.4 percent of cases. Multivariate dummy variable analysis revealed that only dorsal component reduction and caudal trim were associated with significant decreases in tip projection. Alar base resection did not change absolute tip position but did have a marked effect on the position of the alar-cheek junction and thus the overall balance of the nose with regard to length-to-projection ratios and projection proportions. Cartilage-dividing techniques are rarely necessary to reduce projection. Release of the soft-tissue attachments of the lower lateral cartilages and modification of the anterior septum are frequently sufficient to achieve a satisfactory aesthetic endpoint. Alar base resection has a complex interaction with nasal aesthetics with regard to tip projection. Therapeutic, IV.

Minimally invasive procedures for nasal aesthetics

Nose has an important role in the aesthetics of face. It is easy to understand the reason of the major interest that has revolved around the correction of its imperfections for several centuries, or even from the ancient times. In the last decade, all the surgical or medical minimal-invasive techniques evolved exponentially. The techniques of rejuvenation and corrections of nasal imperfections did not escape this development that is much widespread in the medicine of the third millennium. In many cases, the techniques of surgical correction involve invasive procedure that necessitates, for the majority of cases, hospitalisation. The author, using a different approach, has developed mini-invasive techniques using botulinum toxin A (BTxA) and absorbable fillers for the correction of nasal imperfections. BTxA allows to reduce the imperfections due to hypertension of muscles, while the absorbable fillers allow to correct all the imperfections of the nasal profile from the root to the tip in total safety. The correction is based on the precise rules that allow avoiding the majority of side effects. Results are long lasting and well appreciated by patients.

Parent and child ratings of satisfaction with speech and facial appearance in Flemish pre-pubescent boys and girls with unilateral cleft lip and palate

The purpose of this controlled study is to determine satisfaction with speech and facial appearance in Flemish pre-pubescent children with unilateral cleft lip and palate. Forty-three subjects with unilateral cleft lip and palate and 43 age and gender matched controls participated in this study. The Cleft Evaluation Profile was used to assess the perceived satisfaction for individual features related to cleft care. Both the cleft palate subjects and their parents were satisfied with the speech and facial appearance. The Pearson χ2 test revealed significant difference between the cleft palate and the control group regarding hearing, nasal aesthetics and function, and the appearance of the lip. An in depth analysis of well specified speech characteristics revealed that children with clefts and their parents significantly more often reported the presence of an articulation, voice and resonance disorder and experienced /s/ /r/ /t/ and /d/ as the most difficult consonants. To what extent the incorporation of specific motor oriented oral speech techniques regarding the realisation of specific consonants, attention to vocal and ear care, and the recommendation of secondary velopharyngeal surgery, with the incorporation of primary correction of the cleft nose deformity simultaneously with primary lip closure, will aid these patients are future research subjects.

Twisted nose: a new simple classification and surgical algorithm in Asians

The purpose of this study was to present our experiences with correction of twisted nose in Asian patients using a new and simple classification and a surgical algorithm. A classification and standard surgical algorithm was followed to determine treatment strategies for 384 patients with twisted nose between June 2001 and July 2009. A retrospective chart review from the Tri-Service General Hospital archives was performed to collect patients' data and surgical details. A follow-up self-evaluation survey regarding satisfaction with nasal function and esthetics was distributed to all participants. Preoperative and postoperative standardized photography of the face were evaluated to judge objectively the esthetic outcomes of the surgery. There were 147, 131, and 106 patients in Type I, Type II, and Type III patients, respectively. The percentages of functionally satisfied and very satisfied patients were 95.2, 93.9, and 93.4% in Type I, Type II, and Type III groups, respectively. The percentages of esthetically satisfied or very satisfied patients were 89.1, 88.5, and 87.7% in Type I, Type II, and Type III groups, respectively. There were only 2 patients with type III deviation with residual deviation of dorsum objectively who were satisfied with the results after undergoing a revision rhinoplasty. Aside from residual deviation, the postoperative periods were uneventful and without major complications. We propose a new and simple classification and surgical algorithm to optimally correct twisted nose deformities for Asian patients. The classification and surgical algorithm, which is simple and reproducible especially for beginner, guides surgical decisions that yield consistently satisfactory functional and esthetic results.

Treatment Protocol for “Mestizo Nose” with Open Rhinoplasty

The aim of this study was to develop an operative sequence to guide plastic surgeons on how to handle the challenges of "Mestizo nose" during rhinoplasty. This type of nose has characteristics quite different from the Caucasian nose. Rhinoplasties on Mestizo nose represent a surgical challenge because of the anatomical characteristics of a weak frame and thick skin. The Hispanic population has grown, and nowadays a large number of patients requesting rhinoplasty within the US belong to this ethnic group. We have developed an operative sequence for the treatment of Mestizo nose. This operative sequence has been tested in 879 rhinoplasties (92.37% females and 7.62% males, aged 15-63years, mean age=39years). All were primary cases. An algorithm on how to approach the different types of Mestizo nose is presented. We had overall good results using our algorithm, with an improvement in the nasal aesthetics of about 54.75%. Complications were postoperative bleeding (1.37%), pain (0.57%), septal hematoma (0.23%), unaesthetic scars (0.34%), and cartilage extrusion (0.11%). Our revision rate was 5%. We present ten complete cases to show our surgical results. This operative sequence has allowed us to get predictable and reliable surgical outcomes when used in Mestizo rhinoplasty operations. We think it can be very useful for every plastic surgeon who performs Mestizo nose rhinoplasty, although not all steps need to be performed in every case.

High patient satisfaction after secondary rhinoplasty in cleft lip patients

We surveyed the subjective outcome of secondary rhinoplasty in cleft lip patients. Questionnaires were sent to 38 patients who had undergone a secondary rhinoplasty. A total of 30 questionnaires were returned and analyzed. Patients were asked to score their preoperative and postoperative nasal function and form. The validated Rhinoplasty Outcome Evaluation (ROE) questionnaire was supplemented with questions on the subjective burden of the procedure and general satisfaction. In parallel, the objective aesthetic outcome was judged by 2 surgeons using preoperative and postoperative photographs. There was a significant subjective improvement in ROE scores (from 39.3 ± 3.1 to 73.1 ± 2.0, p < 0.001), and in specific scores for nasal aesthetical appearance (from 3.6 ± 0.3 to 7.9 ± 0.2, p < 0.0001) and breathing capacity (from 4.9 ± 0.4 to 6.8 ± 0.3, p < 0.01). Subjective improvement in nasal aesthetics was generally evaluated to be better than improvement in nasal breathing. In retrospect, all patients would undergo the procedure again. Patient satisfaction did not correlate with the surgeon's appreciation of the aesthetic outcome of the rhinoplasty. Patient satisfaction after secondary rhinoplasty in cleft lip patients is high and comparable to that of non-cleft lip rhinoplasty patients.

Structure Rhinoplasty of the Long Nose

Rhinoplasty modifies the aesthetic appearance and functional properties of the nose with operative manipulation of the skin, underlying cartilage, bone, and linings. A long nose is an aesthetically undesired feature disturbing the harmony of the face. The underlying pathology of the long nose may be due to either a long septum that invades the lip or dislocation of the alar cartilages downward from the aponeurotic attachments to the septal angle. The increase in the nasal height due to a dorsal nasal hump may give an illusion of a long nose. An absent or shallow frontonasal angle also gives the illusion of a long nose. With the introduction of the dynamics of the nasal structures and dynamics in rhinoplasty, recreation of a straight nasal dorsum and a normal frontonasal angle dynamically shortens the long nose. This study presents a multicenter experience (three centers) in rhinoplasty of long noses. The study included 138 patients who complained of having a long nose. The study employed the concept of structure rhinoplasty to address the three-dimensional nasal structures contributing directly or indirectly to the appearance of the long nose rather than the traditional excisional techniques. Based on objective and subjective evaluation, shortening of the nose was achieved in 122 patients (88.4%) with better overall nasal aesthetics. The study concluded that structure rhinoplasty, which addresses the three-dimensional nasal anatomy, maximizes the aesthetic and functional outcomes when treating the long-nose deformity.

Three-Dimensional Morphologic Nasal Surface Characteristics that Predict the Extremes of Esthetics in Patients with Repaired Cleft Lip and Palate

The purposes of this study were (1) to develop imaging methods and objective numeric parameters to describe nose morphology, and (2) to correlate those parameters with nasal esthetics for patients with clefts. A total of 28 patients with repaired complete unilateral cleft lip and palate (CUCLP) and 20 age- and gender-matched individuals without clefts were identified. A panel of orthodontists rated and ranked nasal esthetics from nose casts for the cleft group. Best and worst esthetic cleft groups were established from the cast assessments. Three-dimensional surface coordinates of the casts were digitally mapped with an electromagnetic tracking device. Digitized nasal images were oriented, voxelated, sliced, and mathematically curve-fitted. Maximum difference, percent area difference, and maximum and minimum derivative differences between cleft and noncleft and between right and left nose sides were calculated. Differences in parameters between groups were assessed with the use of analysis of variance (ANOVA) and t tests, and correlations with esthetics were assessed with the Spearman rank correlation test. Differences were seen between cleft and noncleft and best and worst esthetic groups for all four parameters (p < .05). The best esthetic cleft group had (1) lower percent area difference (p < .0001), (2) lower maximum difference (p < .001), and (3) smaller differences in slope of the nose in the coronal plane (p < .0001) than the worst esthetic cleft group. Maximum difference and maximum derivative difference and, to a lesser degree, percent area difference can be used to identify differences between cleft and noncleft nasal morphology and to assess levels of nasal esthetics for patients with CUCLP.

Rinoplastia endonasal: um estudo do grau de satisfação dos pacientes em cinco anos

INTRODUCAO: Muito tem sido discutido a respeito das varias tecnicas e vias de acesso em rinoplastia. Todas as tecnicas buscam um resultado previsivel e reprodutivel, associado a melhora estetica e funcional do nariz. Nesse trabalho, foi avaliado o nivel de satisfacao dos pacientes submetidos a rinoplastia nos ultimos cinco anos: rinoplastia reducional por via endonasal associada ou nao a rinodinâmica. METODO: Por meio de um estudo retrospectivo foram identificados 201 pacientes submetidos a rinoplastia endonasal entre 2005 e 2010. Todos os procedimentos foram realizados com a mesma rotina cirurgica, conforme indicacao. Os pacientes foram avaliados de maneira objetiva quanto a cirurgia realizada e, de maneira subjetiva, a respeito de sua funcao respiratoria anterior e posterior a intervencao cirurgica e o grau de satisfacao quanto a estetica nasal por meio de um questionario. RESULTADOS: A idade dos pacientes variou de 14 a 68 anos; com predominância da raca branca (96,75%). Referiram melhora no padrao respiratorio apos a cirurgia, 83,87% dos pacientes estudados. Em relacao a estetica nasal, 30 (32,26%) pacientes tiveram suas expectativas superadas, 42 (45,16%) consideraram muito boa, 18 (19,36%), como boa e tres (3,22%), como abaixo do esperado. CONCLUSAO: O procedimento resultou em melhora da funcao respiratoria em quase 90% dos pacientes, alem disso, o alto grau de satisfacao com a estetica exposto pelos pacientes permite concluir que rinoplastia endonasal tem apresentado otimos resultados ate o momento.

Lambeau total du dos du nez basé sur l’artère alaire supérieure

The complete dorsal nasal aesthetic unit can be raised in a vascular island flap based on the superior alar artery, at the level of the nasalis muscle. This flap uses the vertical glabellar cutaneous laxity. It hides scars between the nasal aesthetics units and its distal rotation point allows a pure translation of the nasal skin without distortions encountered when using medial canthal rotation flaps. This local flap is reliable and had been successfully used for four patients without complications or secondary procedures. It allows large reconstructions for up to 25 mm defects leaving minimal scars. It represents an interesting alternative for the reconstruction of defects of the nasal tip or supra tip of the nose, and has also been used for alar reconstructions.

Panel and patient perceptions of nasal aesthetics after secondary cleft rhinoplasty with versus without columellar grafting

Background Cleft-lip nasal deformity alters patient’s self-image, as well as posing unique challenges for the rhinoplastic surgeon. Objectives The main purpose of this study was to compare the panel perceptions of nasal aesthetics following secondary cleft rhinoplasty with versus without caudal septal extension grafting (columella grafting). We also investigated whether patient’s self-assessment and satisfaction correlated with 4 other variables: (1) rhinoplasty techniques; (2) patients’ age; (3) patients’ gender; and (4) panel perceptions. Methods Using a cross-sectional study design, we enrolled a sample of adult laypersons and medical experts. The predictor variable was the rhinoplasty techniques (with/without columellar grafting). The outcome variable was the panel rankings of nasal aesthetics based on the photographs of 50 nonsyndromic cleft patients before and after the rhinoplasty. Other variables included the patient’s subjective assessment and satisfaction, demographic and anatomic variables. Appropriate descriptive, uni- and bivariate statistics were calculated. The significance level was set at P ≤ 0.05 and <0.05 for single- and two-tailed tests of hypothesis, respectively. Results The sample consisted of 507 laypersons and 51 professionals who gave comparative ratings ( P > 0.05). Columellar grafting was associated with higher rankings of postoperative nasal aesthetics ( P = 0.04). Most of the patients (90%) rated positive outcomes. Surgical techniques, patients’ age and gender, and panel perceptions were not individually significantly associated with subjective measures and satisfaction. Conclusions Our results suggest that caudal septal extension grafting improves the nasal aesthetics of the cleft patients, as judged by the panel. Patient’s self-assessment seems unreliable to be used as an outcome measure.

Functional and Aesthetic Concerns of Patients Seeking Revision Rhinoplasty

To assess the subjective aesthetic and functional concerns of patients seeking revision rhinoplasty and to compare them with objective deformities found on evaluation by the surgeon. This prospective study used a questionnaire to systematically target the aesthetic and functional concerns of 104 consecutive patients seeking revision rhinoplasty. Analysis of the subjective data revealed the frequency of each concern, which was then compared with objective deformities found on evaluation by the surgeon. The most common patient and surgeon aesthetic concerns were (1) tip asymmetry, (2) crooked middle third of the nose, and (3) upper third irregularity. A mean of 79% of patient concerns were also reported by the surgeon. Of the 64 patients describing subjective nasal obstruction, 60 (94%) had objective physical findings related to obstruction. The 3 most troublesome patient concerns were (1) tip asymmetry, (2) difficulty breathing or nasal blockage, and (3) crooked middle third of the nose. Tip asymmetry was the most common deformity noted. Symptomatic nasal obstruction was the second most frequent reason for seeking revision rhinoplasty. Differences in patient and surgeon findings were largely due to differences in assessment skills and should be addressed by thorough explanation of nasal aesthetics.

Does Rhinoplasty Improve Nasal Breathing?

Rhinoplasty is a surgical procedure that aims to improve nasal aesthetics and nasal breathing. The aesthetic improvement of the nose is usually judged subjectively by the patient and the surgeon, but the degree of improvement of nasal obstruction is difficult to assess by clinical examination only. The measurement of peak nasal inspiratory flow (PNIF) is a reliable tool that has been shown to correlate with other objective methods of assessing nasal breathing and with patients' symptoms of nasal obstruction. Twenty-three consecutive patients undergoing rhinoplasty have been evaluated by measurement of PNIF before and after surgery. All but three patients had an increase in PNIF after surgery. The mean preoperative PNIF was 86.5 L/min and the mean postoperative PNIF was 123.0 L/min ( P < 0.001). Not surprisingly, the greatest improvement in PNIF was achieved when bilateral spreader grafts were used. This study suggests that rhinoplasty does improve nasal breathing.

4 Nasal cosmesis following alveolar bone grafting in unilateral cleft patients

4 Nasal cosmesis following alveolar bone grafting in unilateral cleft patients K. Shekar, N. Jones, T.R. Flood. Salisbury NHS Foundation Trust, UK Objective: To assess the affects of secondary alveolar bone grafting to the unilateral cleft defect on nasal aesthetics. Methods: Secondary alveolar bone grafting was carried out with a formal reconstruction of the bony nasal floor. This retrospective study used pre and postoperative photographs to assess six components of nasal aesthetics. A panel of 12 used a five point scale to grade each component. Results: All assessors noted a statistically significant improvement in columella deviation (P = 0.008) and alar base symmetry (P = 0.001). The consultant surgeon group also noted an improvement in nasal symmetry (P = 0.014). Conclusion: Secondary alveolar bone grafting using a technique with formal reconstruction of the bony nasal floor using a cortical plate graft from the iliac crest appears to significantly improve the columella deviation and symmetry of the alar base.