22 Functional Tension Nose and the Overprojected Nose
22.1 Functional Tension Nose
“Tension nose” is commonly associated with an overprojected nose or nasal tip. Due to the presence of excess cartilage, a functional tension nose is often disharmonious in relation to the face.
22.1.1 Measurement of Overprojection
Jacques Joseph used the profile angle as a measure of overprojection. 1 He defined it as the angle formed by the intersection of two straight lines: one drawn tangent to the glabella and chin, and one drawn tangent to the nasal dorsum. Joseph reported a normal range of 23 to 37 degrees. Richard Goode recommended the ratio of nasal length, measured as the distance between the nasion and pronasale, and projection, measured between the alar crease and the pronasale, for evaluating underprojection or overprojection of the nose and nasal tip. He defined the normal range as a ratio of 0.55–0.60. 2
Charles Baud described a method of profile analysis in which he drew a circle around the face, using the distance from the external auditory canal to the pronasale (tip defining point) as the radius. He then assessed the relationship of three key profile points: the pronasale, the pogonium, and the frontal hairline ( Fig. 22.1 ). 3 Ideally, these three key points are located on the path of the circle. In applying this method, we have developed our own modification of the “facial circle.” In our experience the circle should be centered on the porion at the upper part of the tragus, or at the edge of the external auditory canal. We have had good results with this simplified and modified method in practice, as it permits a rapid assessment of nasal projection in relation to the chin and forehead. The following determinations can be made:
Is the nose or tip overprojected?
Does the patient have prognathism or a receding chin?
How does the forehead affect the facial profile (high or sloped forehead)?
Aided by digital imaging and modern graphics software for aesthetic surgery, we can predict whether decreasing the projection of the nasal tip, and thus advancing the pogonion toward the reference circle, will provide adequate profile correction or whether it would also be advisable to perform a chin augmentation.
The revision of an overprojected functional tension nose always has both functional and aesthetic indications. 4 , 5
22.1.2 Functional Indications
Typically the nostrils are narrow and elongated, presenting a slit-like rather than oval shape, and they open into a high “gothic arch” nasal vestibule. The crura of the upper and lower lateral cartilages are medialized, causing stenosis of the external and internal nasal valves. The internal nasal valve angle is less than 15 degrees. Alar collapse occurs on deep inspiration. Even a mild degree of high septal deviation in this situation will produce significant aerodynamic effects ( Fig. 22.2 ).
22.1.3 Aesthetic Indications
Hyperplasia of the septal cartilage in its dorsobasal dimension tends to raise the cartilaginous nasal dorsum. As a result, the dorsum may appear convex or may form a cartilaginous hump that is continuous with a bony hump at the rhinion. The supratip point moves to the level of the tip defining points, and the tip loses definition. When the elastic fibers in the skin yield to the tension of the upper and lower lateral cartilages, the supratip point rises above the tip defining point. The nasal tip droops and becomes ptotic.
Case 23
This case illustrates the management of a persistent overprojected tip (operation by Holger Gassner).
Introduction
A 23-year-old woman presented 4 years after undergoing an open-structure rhinoplasty. She sought correction of her persistent overprojected nasal tip and improvement of her predominantly right-sided nasal obstruction, which had been unresponsive to medical therapy.
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