Nose

Published on 16/03/2015 by admin

Filed under Dermatology

Last modified 16/03/2015

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17 Nose

Introduction

The nose represents the central feature of the face with an aesthetically profound effect on the overall balance of the other facial features. Accordingly, enhancing a flat, poorly defined nose can give definition to the face and refine its overall appearance. For this reason, augmentation rhinoplasty has long been practiced as a well-established procedure among Asians, who have relatively smaller noses than Caucasians. Significantly, the ability to conveniently reshape the nose without undergoing surgery is a key benefit of filler rhinoplasty, which has made it one of the most popular filler procedures among Asian patients.

While some drawbacks of filler rhinoplasty versus conventional surgery are the need for repeat treatments when using temporary fillers and the unsuitability for reduction rhinoplasty (e.g. sharpening a bulbous nose, reducing the size of a large hump, or narrowing a wide nasal base), the countervailing advantages are numerous and compelling: it ensures minimum social downtime since there is no significant bruising or swelling even immediately after the procedure compared with surgery; in terms of its safety profile, filler rhinoplasty does not entail any of the potential risks arising from surgery, such as unnatural contractural pull and distortion; furthermore, filler rhinoplasty is capable of making the shape appear more natural by allowing the creation of arches extending from the medial brows to the dorsum of nose.

This chapter aims to provide an overview of the concept, techniques, useful tips, and precautions involved in performing filler rhinoplasty.

The attractively proportioned nose and face

There is no set standard for an ideal nose that works for every face, since aesthetic standards tend to vary among different ethnicities, between the sexes, as well as evolving over time. Just as importantly, facial beauty is a function of the balance among various facial features, including the nose, which together produce an aesthetically pleasing result. Thus, efforts have been directed at identifying the ideal facial and nasal proportions, and effecting changes that afford better proportionality and harmony to the overall face. This notion of facial proportion also assists the field of filler rhinoplasty in the planning of the treatment strategy for a given patient.

The nose is divided into several subportions including the dorsum, sidewall, nasal tip, ala nasi, and columella. Such regional subdivision helps with surgical planning and descriptions of the cosmetic procedures. In addition, there are certain topographic landmarks of the nose used for describing the cosmetic and reconstructive procedures. Recognized topographical facial landmarks are shown in Figure 17.1. Of such landmarks, the nasion, sellion (radix), rhinion, and pronasale are worthy of mention with respect to filler rhinoplasty. Although the term ‘nasion’ is sometimes confusingly used to refer to the deepest point of the nasal root, it in fact represents the median anterior tip of the nasofrontal suture. Rather, the sellion represents the deepest point of the nasal bone or the nasofrontal angle. Since the sellion is also the bony landmark, corresponding to surface anatomy, the term ‘radix’ is used for the deepest point of the nasal root or the nasofrontal angle. Rhinion refers to the osteocartilaginous junction, while pronasale is the most prominent point of the nasal tip and the subnasale represents the junction between the columella and philtrum.

On the frontal view, a balanced face should divide into equal vertical thirds and equal horizontal fifths, as shown in Figure 17.1. The ideal length of the nose in proportion to the face is three-quarters the length of the lower one-third of the face, from the subnasale to mentum. Meanwhile, the ideal nasal width at the alar base is believed to correspond to the intercanthal distance, which equals one-fifth of the facial width. The width of the body of the nose should be 80% of the width of the nose at the alar bases. The narrowest point of the nasal dorsum is at the radix, where the width at the radix approximates the height of the palpebral fissure. A gentle curve emanating from the medial brow courses along the lateral border of the nasal dorsum to end at the ipsilateral tip-defining point. Any irregularities of this line will be easily noticeable as deviations from the contralateral line, thereby contributing to asymmetry and unsightly appearance.

On the lateral view, there are certain facial angles related to the nose that deserve special mention in evaluating filler rhinoplasty patients (Fig. 17.2). The glabella-to-radix line intersecting with the radix-to-tip line forms the nasofrontal angle. Ideally, this angle should be within 115–130°. Meanwhile, the nasofacial angle is the angle formed by the line tangent to the nasal dorsum intersecting with the vertical facial plane, which is a two-dimensional coronal section connecting the glabella-to-pogonion line. The aesthetic ideal for the nasofacial angle is 35–40°. The nasolabial angle is defined by the line from the subnasale to the superior vermilion border of the upper lip intersecting with the line tangent to the columella from the subnasale. The ideal aesthetic range should be between 90° and 110° depending on the ethnicity and sex.