37 Rhinoplasty and Nasal Cosmesis

37.1 Cosmetic Assessment of the Nose (Fig. 37.1)

• Divide into 1/5s

• Brow–tip aesthetic line

• Length of nasal bones

• Asymmetry

• Width/height ratio of nose (6:8)—nasion to tip

• Infratip lobule

• Overall facial contour

Glabella

Radix—depth and projection

Dorsal profile and supratip

Tip projection

Columella show

Nasiolabal angle 90 to 120°

37.2 Radix Deformities

• Radix = 4 to 6 mm posterior to glabella

• Temporalis fascia can be used to augment radix

• Spreader grafts used to widen lower portion of nose and correct cartilaginous deformity

37.3 Indications for Open Rhinoplasty

• Highly asymmetric tip

• Markedly overprojected tip

• Severely underprojected tip

• Secondary revision cases

37.4 Indications for Good Prognosis

• Obvious disfigurement

• Occupational reason to improve appearance

• Realistic wish to appear younger

• Long-standing desire to have surgery performed

37.5 Causes for Caution in Rhinoplasty Patient Selection (Schulman)

• Unrealistic motive

• Sudden whim to have surgery

• Expectation of surgery being solution for all problems (e.g., save marriage)

• History of hospitalization or recurrent psychiatric illness

• Relentless “surgeon shopping”

• Repeated surgery with consistent dissatisfaction

• Unable or unwilling to follow important instructions provided by surgeon or staff

• OCD tendencies

• Poor interaction with medical staff

37.6 Classic Rhinoplasty Steps

• Septoplasty

• Tip remodelling, projection, and cephalic rotation

• Hump removal (profile line)

• Narrowing of nose (osteotomies)

• Final correction of subtle deformities

37.7 Tip Support Mechanisms

• Major:

Medial and lateral crura (size/shape/resilience)

Medial crural footplate attachment to caudal border of quad. cartilage

Attachment of ULCs to lower lateral cartilages (LLCs) (scroll area)

• Minor:

Ligamentous sling spanning paired domes of LLCs

Cartilaginous septal dorsum

Sesamoid complex extending support of lateral crura to piriform aperture

Attachment of LLCs to overlying skin and musculature

Nasal spine

Membranous septum

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