Primary Rhinoplasty

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Chapter 11 Primary Rhinoplasty

Historically, rhinoplasty remains one of the most complex and challenging operations in plastic surgery.


Historically, rhinoplasty remains one of the most complex and challenging operations in plastic surgery.

Cosmetic rhinoplasty has its roots in nasal reconstruction with the first techniques recorded by Sushruta in India around 500 BC. Centuries later these techniques gained more widespread access to the European medical community as they were reported and refined by individuals such as von Graefe and Dieffenbach who published their results in the 1800s. Later in that century, the first intranasal approach to rhinoplasty was described by an American otolaryngologist, John Roe. Jacques Joseph studied nasal deformities, developed numerous techniques and published his work in a classic two-volume set between 1928 and 1931. Safian and Aufricht, considered among the forefathers of modern rhinoplasty, built upon this early foundation. When first described by Rethi in 1934, the open transcolumellar approach was deemed radical. However, Sercer and his student Padovan provided further modifications for a skin only incision, thus providing foundation for the open approach as it is described today.

When reviewing the literature, it is readily apparent that the history of rhinoplasty is rooted in the surgeon’s thorough understanding of the three-dimensional nasal anatomy of the nasal region, proficiency in nasal and facial analysis, and firm grasp of the core concepts in manipulating nasal soft tissues, cartilage, and bone.1 Having satisfied these requirements, the surgeon relies on his or her aesthetic sense to craft a result that will produce a balanced, harmonious nose in relationship to the rest of the face.2 The initial operation is critical to the long-term result in primary rhinoplasty, because the tissues are virginal and undistorted by prior operative procedures.


The indications for rhinoplasty fall along a spectrum from purely functional to purely cosmetic. There can be great advantages to the patient when rhinoplasty is performed for functional reasons. An example is airway obstruction which can be significantly improved if not totally eradicated. Whether the etiology is congenital or traumatic, patient satisfaction can be substantial after corrective surgery.

The patient who undergoes rhinoplasty for cosmesis stands to benefit with respect to self-image and self-esteem after a successful rhinoplasty. However, patients who perceive a significant deformity in themselves when physically the deformity appears slight to the surgeon should arouse suspicion. Such patients may not be satisfied with an outcome, regardless of how well the rhinoplasty is executed. To avoid this situation, additional preoperative visits may be necessary to completely understand not only what the patient desires, but also to confirm realistic patient expectations and emotional stability.

Patient Selection

Proper patient selection is vital to a successful outcome. Some patients will likely be dissatisfied regardless of the surgery result. This emotional dissatisfaction often supersedes technical failure as the most common cause of poorly perceived results.

Gunter and Gorney35 have both commented on ‘danger signs’ that may be exhibited (Box 11.1). Individuals who meet these criteria should be approached with caution because surgical intervention may not be in the best interests of either the patient or the surgeon.

Similarly, Gorney employs two systems to identify potential problem patients:

the second plots the patient’s concern on one axis and the degree of deformity on the other (Fig. 11.1) – patients who have an appropriate level of concern relative to their degree of deformity are excellent candidates for treatment, but those who have minimal deformity and a disproportionate level of concern should be avoided because their expectations may exceed the amount of aesthetic improvement possible.

If the level of skill and expertise required to perform the rhinoplasty exceeds the surgeon’s ability, the patient should be referred to another more proficient surgeon.

The surgeon must rely on both subjective and objective findings when considering the relative indications and contraindications for performing a rhinoplasty; the skills required to accomplish this develop with time and experience.

Preoperative History and Considerations

Patient Factors

When initially assessing a patient for potential rhinoplasty, the surgeon should concentrate on evaluating the patient’s desires and expectations prior to performing the comprehensive facial analysis. Although there are different methods for integrating the patient into the surgical process, we find that computer imaging provides an excellent way for patients to gain a realistic understanding of the anticipated outcome. Although the images are not a guarantee of surgical results, they do provide a visual representation and a means for patient education. These images, combined with standardized anterior, lateral, oblique, and basal photographs, provide the basis for the preoperative surgical plan.

To identify potential ‘problem patients’ preoperatively, we ask the patient to first describe what issues they have. We encourage them to be as specific as possible, listing their concerns in order of importance in their own words. A handheld mirror is useful in this situation. The patient’s desires are then documented in the chart verbatim. Frequently, the patient will state in general terms, ‘I just want a better nose. What would you do?’ This has been a red flag in our practice because it is usually a reflection of general dissatisfaction, poorly thought-out desires, or a poor self-image. We politely redirect these patients in an attempt to ascertain their specific concerns about their nose. Again, a disproportionate amount of concern in the presence of a minimal deformity is a cause for concern.

Other red flags in rhinoplasty include:

This second criterion is vague, but we place tremendous importance on the development of our interpersonal relationship with our patients, and if this cannot be forged, for whatever reason, we decline to perform the operation. In other words, ‘do not operate on a patient you don’t like’.

It should be noted that men tend to have a poorer understanding of their deformity than women and have a more difficult time elucidating the changes they want.68

A second follow-up consultation is recommended to reiterate the patient’s desires, develop a realistic operative plan, and reaffirm the patient’s understanding of the anticipated procedure.

Anatomic Features

Having determined that the patient is an appropriate candidate for surgery, the next element to proper preoperative surgical planning is critical facial analysis.9,10

Each individual nose has different proportions, morphology, and relative relationships with the surrounding face. To preserve nasofacial harmony, it is crucial to perform a systematic and meticulous analysis of the nose and face. The evaluation is performed in a systematic manner cultivated by the surgeon to assure consistency.1113

Accurate diagnosis of the deformity(s) determines the optimal surgical plan for correction. The surgeon should point out natural facial asymmetries preoperatively so that the patient gains a better understanding of what is present before any operative intervention.

Systematic analysis of the nose and face

Next, a systematic analysis of the nose and face is undertaken.

Look for potential anomalies of the underlying facial skeleton

Initially we evaluate potential anomalies of the underlying facial skeleton, including the maxillomandibular relationship.

We divide the face into thirds using horizontal lines adjacent to the:

The upper one-third is the least important because it is the most variable.

The lower one-third of the face is then subdivided into thirds by visualizing a horizontal line between the oral commissures (stomion):

If there are disproportions, the patient may have underlying craniofacial anomalies (e.g. vertical maxillary excess) that necessitate correction.

The nasal length (radix to tip [RT]) should be equivalent to the stomion-to-menton distance (SM), as described by Byrd and Hobar.

A natural horizontal facial plane is determined by drawing a line perpendicular to a plumb line superimposed over the head in repose and the eyes in straightforward gaze. This will serve as a future point of reference (Fig. 11.2).

The lip-chin relationship is assessed by dropping a vertical line from a point one-half the ideal nasal length tangential to the vermillion of the upper lip. The lower lip should lie no more than 2 mm behind this line (Fig. 11.3). The ideal chin position is gender dependent. The female chin should be slightly posterior to the lower lip, but equal to the lower lip in men. Discrepancies in these relationships may warrant orthodontics, orthognathic surgery, or a chin implant.

Nasal features

Frontal view

Nasal deviation is evaluated by drawing a line from the mid-glabellar area to the menton, bisecting the nasal ridge, upper lip, and Cupid’s bow. This line will also pass between the central incisors when occlusion is normal. Any deviation of the nose from this line will likely require septal surgery.

The nasal dorsum is then assessed. The curvilinear dorsal aesthetic lines are traced from the origin at the supraorbital ridges to the tipdefining points, slightly diverging from each other along the dorsum during their course. Ideally, the width of the dorsal aesthetic lines should match the width of either the tip defining points or the interphiltral distance.

A relationship between the bony base width and the alar base is then assessed. The bony base width should be 80% of the normal alar base width, and a normal alar base width 2 mm wider than the inter-canthal distance, or the width of one eye (Fig. 11.4A&B). If the bony base is greater than 80% of the alar base width (assuming the alar base width is normal), osteotomies will be required to narrow the dorsum. Males tend to have a wider bony base than females and it is important not to over-narrow the male dorsum creating a feminized result.

Next the alar base and alar rim are analyzed. If the alar base width is over 2 mm and greater than the intercanthal distance, it must be determined whether the cause is a narrow intercanthal distance, a true increased interalar width, or alar flaring:

The alar rims should also be assessed for symmetry, and should flare slightly outward in the inferolateral direction.

The tip is assessed to determine:

These points serve as landmarks to draw two equilateral triangles with their bases opposed. If these triangles are asymmetric, the underlying reason should be investigated, and the patient will likely require tip modification.

The final assessment on frontal view is of the outline of the alar rims and the columella, which should resemble a seagull in gentle flight, with the columella lying just inferior to the alar rims. If the curve is too steep, the patient likely has an increased infratip lobular height, which will need correction. If, on the other hand, the curve is flattened, it is likely the patient has decreased columellar show which may require columellar augmentation or alar rim modification.

Lateral view

The lateral view is then analyzed, beginning with the position and depth of the nasal root at the nasofrontal angle (radix). This angle connects the brow and the dorsum through a soft concave curve. The apex of this angle should lie between the upper lid eyelashes and the supratarsal fold, with the eyes in natural horizontal gaze. Although this angle can vary from 128 to 140 °, it is ideally 134 ° in females and 130 ° in males. Other important reference measurements from this view include:

While still concentrating on the lateral view, it is important to remember that the perceived nasal length and tip projection can be altered by the position of the nasofrontal angle. For instance, if the nasofrontal angle is positioned more anteriorly and superiorly than normal:

On the other hand, if the nasofrontal angle is too posteriorly and/or inferiorly positioned, the nose will appear shorter, and the tip more projecting. Ideally, the nasofacial angle (as defined by the junction of the nasal dorsum with the vertical facial plane) should measure 32–37 °.

Tip Projection

Tip projection is addressed on the lateral view. We describe two methods to accomplish this.

Tip Rotation

The nasolabial angle is used to determine the degree of tip rotation. This angle is obtained by measuring the angle between a line coursing through the most anterior and posterior edges of the nostril and a plumb line dropped perpendicular to the natural horizontal facial plane. This angle should be between 103–105 in women and 95–100 in men (Fig. 11.11).

Do not confuse the nasolabial angle with the columellar-labial angle, which is formed at the junction of the columella with the infratip lobule. This angle is normally 30–45 ° (Fig. 11.12). Increased fullness in this area is usually caused by a prominent caudal septum giving the illusion of increased rotation, even though the nasolabial angle is normal.

Patient Counseling

After the initial history and physical examination, the procedure is fully discussed with the patient. The risks and benefits of the procedure are detailed, and all questions answered. The patient is provided with a written, detailed estimate of surgical charges with complete explanations. It is recommended that patients sign a form accepting financial responsibility. A second clinic visit is encouraged to review the previous discussions. The deformities are reiterated, questions answered, and the consent reviewed and signed. A preoperative instruction sheet and a list of medications to be avoided are also provided (Box 11.3).

Box 11.3 Preoperative instruction sheet

Prior to surgery we convert our operative plan into a graphic re presentation (using Gunter Graphics5) to assist us in the operating room. Modifications to the plan are documented intraoperatively, transposed to the graphic depictions postoperatively, and placed in the patient’s chart for future reference.

Operative Approach

Relevant Anatomy

A complete knowledge of anatomy is paramount to obtaining the superior result. The nose is divided into:

The rhinoplasty surgeon must be familiar with each structure’s native morphology and its variants and have an appreciation for the dynamic interplay between these components.

Blood supply

The vascular supply to the nose is derived from branches of the ophthalmic and facial arteries (Fig. 11.16).

It is important to note the vascularity to the nasal tip because an open rhinoplasty approach using a transcolumellar incision will transect the columellar vessels (when present), leaving the lateral nasal and dorsal nasal arteries as the remaining blood supply.

In our 1995 study,21 we found the lateral nasal arteries to be present (either singularly or bilaterally) in 100% of cases, with the columellar branches present 68.2% of the time.

The lateral nasal vessels are found approximately 2–3 mm above the alar groove, so extended alar resections to this level are prohibited because injury to these vessels after the transcolumellar approach would severely compromise blood flow to the nasal tip. Furthermore, be cautious when debulking the nasal tip after an open approach because the subdermal vascular plexus connecting the dorsal nasal and lateral nasal blood supplies may be damaged, leading to a similarly disastrous result.

Toriumi et al.22 studied the vascular and lymphatic anatomy of the nose and determined that the transcolumellar incision itself did not compromise major venous or lymphatic outflow. Furthermore, they recommend dissection just above the perichondrium in the deep areolar plane, leaving the musculoaponeurotic layer intact, which preserves the major arterial vascular supply and avoids damage to the venous and lymphatic vasculature that lies in a more superficial (subcutaneous) plane. In this way, bleeding and postoperative edema are minimized.

Nasal vaults

The osteocartilaginous nasal framework can be subdivided into three separate vaults: bony, upper cartilaginous and lower cartilaginous.

Bony vault

The bony vault (Fig. 11.17) constitutes the upper one-third to one-half of the nose and is made up of the paired nasal bones and the ascending frontal process of the maxilla. It is important to note that the nasal bones are narrowest and thickest above the canthal level. As a result, osteotomies are rarely indicated above this level.