Pre-operative Planning for Rhinoplasty (Nose Reshaping) Fayetteville

The modern rhinoplasty requires detailed pre-operative planning. Many Plastic surgeons have a detailed written and diagrammatic rhinoplasty plan so the patient understands exactly what will be done during the procedure, and what each maneuver will accomplish. While there may be small alterations in the surgical plan, the specifics of the plan are understood, set, and approved by the patient before the operation begins. The pre-operative planning is completed with a combination of pre-operative images and a physical exam, which are used in conjunction with the patient’s stated goals.

The planning of the rhinoplasty can be divided into two separate parts. The first is to consider the nose as an isolated anatomic entity. During this part of the planning, the anatomy of the nose is considered in isolation. General aspects of the nose are considered including shape, size, and angles. The general size of the nose is assessed using three different dimensions. First is the nasal width. This is the largest width of the nose at its base. This dimension is measured as the physician faces the patient and is the distance from the base of the outside of one nostril to the outside of the other nostril (see image below). The second and third dimensions are measured from the lateral side (side view) of the patient. The nasal length is measured from the glabellar area (depression between the eyes) to the nasal tip (see image below). The nasal projection is measured from the base of the nose to the nasal tip (see image below). Any of these dimensions that are outside the normal range are corrected with the rhinoplasty.

Nasal width

Nasal length

Nasal projection

The shape of the nose is then assessed. The nasal tip may be too narrow, too broad, have too little projection, or have too much projection. The nasal tip may have too much droop or too much elevation. The nasal dorsum may be too wide, too narrow, have a prominent hump, or a concavity. The nose may also be asymmetrical in the dorsum (top, deviated septum) or may have misshapen alar cartilages (the lower part of the nose). All of these non-ideal anatomical situations can be seen in isolation, or in combination. Note that a non-ideal anatomical situation may be seen in both the size and shape evaluations of the nose. For example, if a patient has a drooping nasal tip seen in the shape evaluation, the nasal length will likely be outside the normal range seen in the nasal length evaluation.

The nose is also assessed in relation to the face. Facial shape as it relates to the nose is a very important aspect of the assessment. There are many variations of nasal shape that still appear to be in perfect proportion because the nose “matches” the face. A “thin” nose may appear normal and in proportion if “matched” with a thin face. A more rounded bulbous nose may appear perfectly normal and in proportion if “matched” with a round or full face. While there is the concept of an “ideal nose”, this does not mean that anything outside that ideal is not attractive. Proportion in part defines beauty, and there are many different shapes that can be considered “ideal” if they are in proportion with the face. A good example of this concept is the comparison of two very attractive women with very different noses. Meryl Streep has a thin, less full face and also has a thin nose which is a perfect match. Dyan Cannon has a more rounded full face and also has a more rounded nose, which is also a perfect match. The fact that these two women have very different nasal shapes but are both very attractive emphasizes the concept of proportion. Conversely, if the noses of these two actresses were photographically transposed, there would not be a good “match”.

Meryl Streep

Dyan Cannon

There are many variations of facial shapes that should be considered when planning the rhinoplasty. As noted above, the nose should “match” the facial shape as much as possible after the rhinoplasty procedure. There are as many as nine defined facial shapes termed Kite, Heart, Rectangle, Oval, Round, Square, Teardrop, Heptagon, and Oblong, with the first four being the most common. The “ideal facial shape” has been defined by a number of objective parameters including the “Golden ratio”, which is length to width ration of the face (ideal being defined as 1.6 times longer than it is wide). Because there are so many different facial shapes, it follows that there will be many different nasal shapes that will “match”.

There are many other factors to consider when planning a rhinoplasty. Ethnicity also plays a role in the pre-operative planning. When considering ethnicity, many surgeons feel that it is inappropriate to erase ethnic characteristics completely. As noted above, proportion and “match” are also very important when considering facial shape, and the same holds for ethnicity. This means that when the so called “ethnic rhinoplasty” is performed, a good measure of common sense should be applied to help ensure a good overall “match”.

A patient’s gender is also very important when planning a rhinoplasty. There are characteristics that are more frequently identified as masculine, and others that are more frequently identified as feminine. Years ago there were limited maneuvers used in the rhinoplasty procedure, so every patient got the same rhinoplasty. This meant that the 250 pound football player got the same nose as the 90 pound ballerina. With a multitude of rhinoplasty techniques currently available, and a focus on individuality, a bias towards femininity or masculinity can be achieved.

The rhinoplasty plan typically involves two general corrections in addition to some minor corrections. The two general corrections that are commonly altered are the nasal tip and the nasal dorsum. These are the two most common concerns patients voice when seeking a rhinoplasty procedure. The nasal tip correction consists of alterations of the cartilages at the bottom of the nose. The cartilages involved with this part of the correction are the alar (lower lateral) cartilages and the cartilaginous septum (cartilage plate in the bottom of the midline of the nose). The alar and septal cartilages together determine how the skin is shaped at the tip of the nose. Any abnormal shapes or sizes of the alar cartilages are directly reflected in the shape of the nasal tip. One method of assessing the shape of the alar cartilage is to press upward on the nasal tip, which will reveal the general outline of the cartilage in the skin. In extremely thin skinned patients, the borders of the alar cartilage can be easily seen without this maneuver. When those cartilages are altered, the nasal tip skin re-drapes over the new cartilage shape. The shape of the alar and septal cartilages is the cause of the drooping tip (tip is too low), the over-projecting tip (tip is too long), and the broad nasal tip (tip is too wide). Many different maneuvers are used to change the shape and size of these cartilages. The cartilages are changes in shape, size and position to achieve the desired aesthetic result. Many surgeons believe that some of the more complex maneuvers are more easily and accurately performed with the “open rhinoplasty technique” (see section on “open” versus “closed” rhinoplasty techniques).

Another very common concern that patients voice is the “prominent nasal dorsum”, and it is sometimes called the nasal “hump”. In addition to concerns about the nasal tip, the nasal dorsum is the other most commonly voiced concern patients voice seeking a rhinoplasty. This can be treated under direct vision with the “open rhinoplasty technique” or can be treated without direct vision with the “closed rhinoplasty technique”. In some circumstances a graft is needed on the nasal dorsum to correct the contour deformity on the nasal dorsum. The support for the nasal dorsum consists of cartilage and bone. The length of the bone in the nasal dorsum can be determined by wiggling the tip of the nose laterally from side to side. The cartilage is flexible, and the bone is not, so the intersection of those structures is simple to determine.

After the initial assessment is made and the patient’s goals are understood, a definitive plan is made and approved by the patient. Dr. Jack Gunter, a skilled and innovative rhinoplasty surgeon designed a rhinoplasty diagram (below) to plan, record, and explain the plan to the patient. This diagram is very helpful and is routinely used for all rhinoplasty patients (copyright and courtesy Dr. Jack Gunter).

There two general types of rhinoplasty, physiologic (functional) and aesthetic. When planning an aesthetic rhinoplasty, the physiologic (functional) aspects of the nose are also considered. If the nasal airway is blocked, the etiology is assessed. When the nasal airway is blocked, it is usually the result of a deviated septum or overgrowth of the turbinate bones (scroll shaped bones inside the nose). In many circumstances, the nasal obstruction is corrected at the same time as the aesthetic rhinoplasty.