Lengthening the short nose is one of the most difficult challenges in rhinoplasty. Etiologies for the development of a short nose include congenital, traumatic, iatrogenic (previous surgery), infectious, and granulomatous factors. Regardless of the cause, short nose correction requires the surgeon to precisely identify anatomical abnormalities and deficiencies and to perform an array of technically precise and difficult operative techniques.
The Short Nose Defined
There is no strict definition of what makes a nose “short,” but multiple surrogate measurements exist. These proportions and measurements enable the surgeon to ascertain an “ideal” nasal length and shape that are harmonious with the rest of the face. The face in its vertical dimension may be divided into thirds, with the nose—measured from the glabella to the subnasale—comprising the middle third of the face. In a similar fashion, ideal nasal length measured from the radix to the subnasale should approximate 47% of the distance measured from the radix to the menton.
Ideal nasal length can also be extrapolated through the use of various formulas devised to determine ideal nasal tip projection. Goode determined that the ideal ratio between nasal tip projection and length ranged from 0.55 to 0.6 : 1. The pitfall of using this ratio to extrapolate ideal nasal length is that one must assume ideal tip projection, a condition that is not universally met. In fact, many short noses feature poorly supported, underprojected tips.
Tip rotation is another determining factor in producing a short or short-appearing nose. Rotation is determined by the nasolabial angle or the angle between a line drawn from the subnasale along the columella and a line drawn from the subnasale down to the upper lip vermillion. Nasolabial angles are gender-specific in that an ideal male nasolabial angle ranges from 90 to 105 degrees, while the ideal female angle ranges from 95 to 115 degrees. Nasolabial angles greater than these ideal ranges are considered overrotated and can produce a “snub-nose” or “pig snout” appearance.
Additional factors that contribute to a short-appearing nose are a dorsal concavity, a long upper lip, an overprojected tip, and a low and deep nasion or nasal starting point. In Caucasian patients, the nasal starting point should be at the level of the superior palpebral fissure, while in other ethnic populations, such as Asians, a lower starting point at a mid-pupillary level may be more appropriate.
A thorough understanding of ideal nasal proportions enables the surgeon to identify patient-specific anatomic deficiencies. As such, various operative maneuvers and techniques have been devised to lengthen a short nose into a more ideal shape.
A Short History of Short Nose Correction Techniques
Jackson and Reid and Millard used full-thickness external incisions in the supratip area referred to as a “guillotine chop.” The tip was then released inferiorly, creating a defect of the skin–soft tissue envelope (SSTE). This cutaneous defect was then replaced with tissue provided by a paramedian forehead flap. The placement of cartilage grafts was staged and done only when extra support was deemed necessary.
Dingman and Walter emphasized the augmentation of inner lining through the use of composite grafts. Bilateral, curved conchal cartilage composite grafts were placed within bilateral intercartilaginous incisions. The septal portions of the flaps were sewn together such that the two grafts were “gull wing”–like in appearance. The juxtaposition of the septal portion of the grafts essentially created a four-layer composite graft. If the SSTE was deficient, cutaneous releasing incisions in conjunction with forehead flap reconstruction were used.
Kamer’s technique also featured the use of composite grafts in short nose correction. He described the inferior release of the bilateral mucoperichondrial flaps through the use of staggered septal incisions. The mucoperichondrial void created within the inferiormost incision was filled with a composite cartilage graft, while the superiormost void was left to heal by secondary intention. As with Dingman’s technique, the grafts were not fixated to the underlying cartilaginous substructure.
In 1987, Giammanco described the use of a pedicled chondromucosal flap in short nose correction. This flap emanated from the dorsal septal cartilage and was rotated to reside along the caudal edge of the septal cartilage. This maneuver, in conjunction with bilateral composite grafts placed between the upper and lower lateral cartilages, served to lengthen the nose by creating additional septal extension.
Gruber’s preferred technique featured the release of the lower lateral cartilages from the upper lateral cartilages. Depending on the amount of release and correction necessary, intervening auricular composite grafts (with the skin side replacing a vestibular defect) may be used as an interposition graft. Subsequent placement of a batten graft secured to the caudal septal cartilage served to brace the tip into its new, lower position.
Through an endonasal delivery approach, Gunter and Rohrich performed a similar tip release maneuver between the upper and lower cartilages. In addition, they resected a small wedge-shaped portion of the posterior septal angle. Therefore, the nose gained absolute length via the tip release maneuver while apparent length was afforded by the posterior septal angle excision. Both maneuvers serve to counter rotate—and consequently lengthen—the nose. Additional apparent lengthening through modest deprojection is afforded by the transfixion portion of the incision. They described this technique as a “less aggressive” approach to lengthening that would obviate the need for flaps, grafts, and implants, while acknowledging that that this operation was mostly suitable for minor to moderately short noses.
Modern Lengthening Techniques
Many different nasal lengthening techniques have been described. As is the case with many surgical challenges, the fact that many operative techniques exist illustrates that there is not one single ideal technique. However, despite their differences, most modern and successful short nose operations often exhibit the following: (1) extensive undermining of the SSTE, (2) release, mobilization, or replacement of the inner lining, and, most importantly, (3) the construction of a stable cartilaginous or bony framework that can resist the relentless forces of contraction exhibited by the healing nose.
Recent descriptions of nasal lengthening techniques build upon the work of the aforementioned pioneers. Currently, many of these surgical descriptions emphasize open structure techniques and increasingly stable reconstructions of the cartilage framework designed to resist the contractile forces associated with healing.
Increased nasal length can be achieved by anchoring grafts to the existing septal cartilage. An example is the caudal septal extension graft. These extension grafts can be fashioned into a wedge shape such that the wider end is placed anteriorly. This placement serves to counter rotate the nasal tip and add absolute length to the nose. Due to this graft’s unilateral nature, it is preferably sutured to the nondeviated side to achieve balance ( Figure 28-1 ).
Alternatively, extended spreader grafts—which extend past the anterior septal angle—may be used for increased length in conjunction with an extended columellar strut. Fixation of these two structures can create a longer and more stable cartilaginous L-strut. The dorsal portion of the strut, which is composed of the paired extended spreader grafts, is suture-fixated to the existing dorsal septum and the paired upper lateral cartilages. The caudal portion of the L-strut is then either placed to reside within a columellar pocket or anchored to the nasal spine. Once the L-strut is in place, then the medial crura of the lower lateral cartilages are sutured to the columellar strut in a tongue-and-groove manner. Placement of the lower lateral cartilages can be tailored to reside in a less rotated position.
Multiple versions of this L-strut have been described with relatively minor differences. However, one special case deserves mention. In cases where saddle deformity is concomitantly present, a canoe-shaped cartilage graft crafted from autologous costal cartilage can be used for both dorsal augmentation and lengthening. Fixation of this graft can be achieved by cutting a notch in the caudal end of the graft and interdigitating a columellar strut graft. The result is an L-strut with the benefit of having the additional dorsal bulk required to augment the saddle-nose deformity.
Despite the interest in open structure techniques, many simple, less aggressive maneuvers are available to lengthen the short nose. Because nasal length is measured from the tip-defining points to the nasal starting point, it would follow that placing the nasal starting point in a more cephalic position and the tip-defining points in a more caudal position would provide additional length. The former can be achieved by placing radix grafts in patients who have a low and deep radix. This is done while keeping in mind that the ideal nasal starting point in Caucasians is approximately at the level of the superior palpebral fissure, while certain ethnic populations, such as Asians, feature ideal nasal starting points at the mid-pupillary level.
At the tip of the nose, grafts can be placed to move the tip-defining points to a more inferior position while simultaneously providing apparent counter rotation. On occasion, stacking multiple layers of tip grafts may be necessary to achieve the desired amount of correction. Additional derotation can be achieved by a conservative wedge-shaped resection of the membranous septum with the wider portion of wedge resection positioned anteriorly. The clear benefit of these less aggressive techniques is that tip support structures are maintained and thus do not need replacement or reconstitution.
With the techniques described here, abundant grafting material is often required. Autologous sources of cartilage include auricular, septal, and costal cartilage. Advantages of using auricular cartilage include minimal donor site morbidity, minimal resorption, the possibility of simultaneous harvest, and the possibility of composite grafting. However, auricular cartilage often lacks the rigidity to provide meaningful strength and support for structural purposes, but can be useful in fashioning tip grafts. Septal cartilage may have adequate strength and stability, but it is often absent or insufficient secondary to harvest from a prior operation. If present, septal cartilage can be used to fashion tip grafts, columellar struts, and/or spreader grafts. Autologous costal cartilage has the advantage of potentially providing abundant amounts of rigid grafting material. Some potential disadvantages include donor site pain, scarring, and the possibility of pneumothorax and graft warping. However, with technical refinements, many of the potential complications related to rib cartilage harvest have been minimized. The use of homologous, irradiated cadaveric costal cartilage in lengthening is less ideal in light of its relatively higher resorption rates.
Alloplastic materials such as expanded polytetrafluoroethylene (Gore-Tex; Implantech Associates, Ventura, CA) and porous polyethylene (Medpor; Porex Surgical, Newnan, GA) can also be used in the short nose. Layered Gore-Tex sheets or blocks can augment dorsal and radix deficiencies, while the structural rigidity of Medpor allows for its use as a stable columellar strut or caudal septal extension grafts. Although alloplastic materials are easy to work with and obviate the need for a separate donor site, their increased rates of infection and extrusion relative to autologous materials have limited their popularity within the United States.
The importance of the preoperative history and physical cannot be overemphasized. Notably, the patient’s past medical and surgical history may impact the surgeon’s ability to achieve optimal results. Previous rhinoplasty or nasal procedures can make surgical correction extremely challenging as many of the problems associated with the postrhinoplasty short nose stem from the overzealous resection of cartilage and support structures. For instance, the removal or overresection of lateral crura can cause overrotation of the nasal tip as predicted by the “tripod” concept described by Anderson. Similarly, overresection of a prominent nasal dorsum may cause iatrogenic saddling, another feature contributing to a short nose. These factors, in addition to changes to the SSTE after nasal surgery, can make revision short nose surgery technically demanding.
A thorough examination of the nose facilitates the identification of patient-specific anatomic deficiencies. Assessment of the degree of tip support should be performed as these elements may require replacement or strengthening during the upcoming surgery. An intranasal examination should ascertain the presence or absence of internal lining as a paucity of septal mucosa (e.g., septal perforation) and vestibular skin may require replacement or at least wide elevation and release. Last, the mobility and quality of the SSTE deserve close evaluation. Toriumi et al. caution others with regard to the presence of a significantly immobile and scarred envelope as this may limit the amount of nasal lengthening possible. In those patients, they advocate a preoperative program of vigorous massage to aid in stretching and loosening the SSTE.
Standard, seven-view preoperative studio-quality photographs should be taken to compare the patient’s nasal shape to previously mentioned ideals. Some practitioners perform computer imaging to predict or estimate nasal changes following surgical correction. Discussion of these images with the patient may be helpful to explain the surgery and set expectations so long as conservative computer modifications are made. If one is to use computer-altered imaging, it is important to show realistic modifications because changes are infinitely easier to perform at the computer table than in the operating room.
The patient’s anatomy will guide the surgeon with regard to what techniques or combination of techniques will be required. However, an algorithm devised by Naficy and Baker attempts to simplify this process. The crucial decision-point in their short nose algorithm concerns the status of tip rotation. If the nasal tip is overrotated, maneuvers such as the “flying buttress graft” or L-strut, interposition grafts between the upper and lower lateral cartilages, wedge-shaped caudal septal extension grafts, and layered tip grafts may be appropriate. On the other hand, if the tip is underrotated or has normal rotation, techniques such as radix grafting, full-length tip grafts, and rectangular caudal septal extension grafts may be used when appropriate. Regardless of the system used by the surgeon, treatment must be individualized based on correcting each patient’s specific deficiencies.