The etiologies of a short nose include iatrogenic factors, trauma, Wegener’s granulomatosis and congenital deformities.
When discussing the short nose, it is crucial to be clear whether the deficiency is in the anterior length, the posterior length, or both.
A patient with short nose and retracted alae with rigid, fixed soft tissues of the nose poses a significant challenge in correction of the deformity.
Minimal anterior length deficiency can be corrected with a shield graft.
A significant nasal length deficit will require elongation of the dorsal frame using a tongue-and-groove technique.
The two key components of the tongue-and-groove technique for nasal elongation include bilateral extended columella struts that protrude beyond the anterocaudal septum proportional to the elongation necessary and a columella strut that accommodates both the spreader grafts as well as medial crura creating continuity.
To be able to advance the alae effectively, it is crucial to dissect the lower lateral cartilages from the upper lateral cartilages and, if necessary, mobilize them completely and transpose them in a separate pocket caudally.
If the intentions are to elongate the nose and gain more projection during the tongue-and-groove technique, 5–0 clear nylon is utilized to suture the spreader grafts to the columella strut in a more anterior relationship. Otherwise, these two structures are not fixed to each other to minimize nose rigidity.
In case of inability to achieve enough length due to soft tissue limitations laterally, the compromise should be in the length of the nose rather than trying to protrude the columella, in which case, the alae will not be able to follow the central portion of the nose.
One of the features that makes rhinoplasty more complex is a length deficiency, especially if this is significant. In this chapter, we will discuss the etiology and management of the short nose, surgical techniques of nose elongation, and their variations.
Etiology and Pathology
Cephalic over-rotation of the nose is a hallmark of rhinoplasties performed from the 1960s to the mid-1980s. During this period in particular, iatrogenic short noses were commonly seen. Today, trauma is one of the common causes of a short nose. Although rare, there are patients who have had ablative surgery, have lost the septum to cocaine abuse or Wegener’s granulomatosis, or were born with a short nose.
When discussing the short nose, it is crucial to be clear whether the reference is to the anterior length, the posterior length, or both. In other words, the nose can merely be over-rotated, or the entire nose can be short. These two types of short nose will require somewhat different management. The over-rotated nose is usually the consequence of surgical removal of a segment of the anterocaudal septum, collapse of the septum as a result of a caudal blow to the nose, or destruction of the septum by cocaine abuse. Generally, the nasal spine and the base of the columella are in the proper position and only anterior elongation is desired. Most congenitally short noses have deficiency evenly distributed through the caudal septum and the nasal spine is deficient or completely missing, as in a patient with Binder’s syndrome.
The key to a successful correction of this type of deformity is an understanding of the nature of the deficiency and the involved structures. The goal of the correction of this deformity should be optimal elongation of all of the deficient structures. It is, therefore, paramount to recognize the extent of the deficiency in the caudal septum, medial crura, lateral crura and the soft tissues. A patient with a short nose and retracted alae poses a far greater enigma than a patient who has hanging alae and a retracted columella. Additionally, the suppleness of the columella and the soft tissues is very important. The rigidly scarred nose that one cannot elongate by pulling the columella caudally is going to present more challenge in achieving sufficient length than the one that is supple enough to allow for manual elongation of the nose with ease.
The management of the short nose is dependent on the magnitude of the deficiency. Additionally, the position of the alar rims makes a significant difference in the choice of corrective approach.
For a short nose with deficiency mainly in the infratip lobule and columella, where the alae are minimally retracted, the choice would be a shield-type tip graft applied through an open or closed technique, depending on the other necessary maneuvers, along with alar rim grafts. If placement of a shield graft is the sole maneuver, it can be placed through a marginal incision that is placed along the anterior portion of the columella and extends laterally. Commonly, however, this type of minor nose length deficiency is corrected in conjunction with many other abnormalities, often requiring exposure of the medial and lateral crura. In this scenario, the medial crura are approximated first. A shield graft is then carved using a tip punch ( Figure 8.1 ). While a septal cartilage graft is preferred, a conchal graft can also be used. The punch carves an anatomically shaped graft with two round attached segments cephalically, emulating the natural domes and an infratip portion. The graft is designed in such a way that it can either drape over the existing domes where a tip projection deficiency coexists, in which case it will not have a clearly visible outline, or it can be added caudal to the current domes to achieve simple elongation of the nose without adding tip projection. The margins are beveled, particularly on patients with thin skin, to diminish graft visibility. The graft is sewn in position precisely while it is observed three-dimensionally ( Figure 8.2 ). For fixation, 6-0 polyglactin is used because it ties more easily and the residual ends are not firm enough to create palpable or visible irregularities. A second layer can be applied if necessary. Depending on the magnitude of the deficiency and the thickness of the selected cartilage, one layer is usually sufficient. Three stitches are applied: one on each dome area and one on the columella. As an example, Figure 8.3 shows a patient who would benefit from this type of tip elongation. This technique can be combined with an alar rim graft or V–Y advancement to advance the ala caudally and restore congruity between the alae and the lobule.