Lengthening Short Noses in Rhinoplasty

Abstract

Objective: Rhinoplasty aims to create a nose in harmony with an ideal face, help patients with specific aesthetic concerns, and improve the nose’s function. So, learning all types of deformities and rhinoplasty procedures is essential to solving that particular problem. So, we aimed to point at a neglected nasal deformity to serve as a guide in short nose rhinoplasty. Methods: Hereditary factors usually determine the length of a nose, such as cephalo-caudal patterning. Nowadays, individuals who want a change on their nose neglect whether it suits their face. Therefore, a considerable change may cause a paradox and lead to losing the operated nose and face harmony. As a general rule, it should be remembered that short nose elongation sounds more complicated than reduction rhinoplasty. Indeed, multiple soft tissues, mucosa, and structures exist, and short noses may get fibrotic, thickened, and inflamed skin for various reasons. Results: Dorsal augmentation through autologous cartilage grafts or implants is often used in patients with short noses. This demands a primary focus on lengthening the short nasal base. The simplest method of lengthening the short nose is dorsal onlay or radix implants. Silicone implants with a reported non-negligible tendency of infection are no longer used. Autologous cartilage grafts can be harvested from the septum, auricular cartilage, or rib. In the case of short noses, the surgeon can remove the septum as a graft and increase the nasal dorsum or undertake dorsal augmentation through septal cartilage grafts. Conclusion: Dorsal augmentation through autologous cartilage grafts or implants remains valuable for patients with short noses. Surgeons can achieve the desired length and proportional rotation by employing various methods, such as dorsal onlay or radix implants, septal cartilage grafts, and careful tip rotation. Through skillful execution and a patient-centered approach, surgeons can help patients with short noses achieve improved facial harmony and self-confidence.

Introduction to Short Nose Rhinoplasty

Over 220,000 rhinoplasty surgeries are performed yearly as aesthetic or medical interventions. Rhinoplasty aims to create a nose in harmony with an ideal face, help patients with specific aesthetic concerns, and improve the nose’s function. The upper third of the nose is an integral part of rhinoplasty surgery. The aesthetic evaluation includes the forehead, brows, eyes, and nose. The upper nasal third is critical; the nose should harmonize with other facial areas. Deficiencies of the upper nasal third can be due to structural problems or developmental problems over time. The most common problem is the excessive resection of the anterior nasal spine and septal cartilage during septorhinoplasty. The central third part is a part of the middle third and deserves special attention. The dorsal hump can mask the upper third of the nose, but it cannot change its character. In cases without a dorsal hump, the short nose becomes more noticeable. The third part of rhinoplasty includes the nasal tip. The horizontal relationship between the radix and the tip is 1:1. A proportion of 1:1.25 can be desired. The proportion areas must also be precisely planned to prolong the short nose. Proposed interventions may be operative or nonoperative.^1,2

Anatomy of the Nose

The nose is a complex structure with various aesthetic and functional functions. From an aesthetic viewpoint, the nose is the central focus of the face. The structural framework of the nose consists of bony and cartilaginous components. The bony framework of the nose is formed of paired nasal bones at the interfacing interpupillary width and a large quadrangular plate of frontal bone centrally. The vault is divided by the nasal midline. The lateral vault is wide and broad and comprises the paired nasal processes of the maxilla and greater and lesser alar cartilages. The cartilaginous part consists of the septum, upper lateral cartilage, and lower lateral cartilage. Various skin segments, such as nasal tip skin, nasal skin of the mid part, nasal skin of the upper part, and the junction of nasal skin with fronto-facial skin, cover the nasal framework.

The septal angle and nasolabial angle tend to be slightly acuter in males. The septum, upper lateral cartilage, and lower lateral cartilage all interact. These interactions are complex and need to be adequately described. Surgery that impacts 1 element of the nasal pyramid impacts the aesthetic and functional aspects of the overall nose. The attachment of each pair of alar cartilages to the upper lateral cartilages creates the internal nasal valve, which is a medium in the midportion of the airway and contributes significantly to nasal airflow resistance. Evaluation of the subjective symptoms of the nose reveals that airway reconstruction increases airway resistance. Changes in external nasal valve tests show slight improvements. On the other hand, the internal nasal valve repairs have yielded reliable outcomes, showing a remarkable change in nasal breathing.^2-4

Critical Considerations for Lengthening Short Noses

The length of a nose determines the genetic codes as cephalo-caudal patterning. Therefore, a considerable change may cause a paradox and lead to the loss of the operated nose body’s harmony. As a general rule, it should be remembered that short nose elongation sounds more complicated than reduction rhinoplasty. Indeed, multiple soft tissues, mucosa, and structures exist, and short noses may get fibrotic, thickened, and inflamed skin for various reasons. ⁵

Evaluation of Short Noses

Short Nose Evaluation

Evaluating a short nose usually starts by listening to the patient who is bothered by some aspects of the aesthetics and function of the nose. However, a careful patient assessment is necessary since the patient’s perception may or may not always be the ideal evaluation. Often, a short nose is perceived when the profile is compared to another individual, where the height of the nose is a racial characteristic. Although a patient desires to have a longer profile, they must be made aware of the fact that the lengthening of the nose may result in minor mental depression or spilling. These are the most common remarks by patients who received implants or lengthening and enhancing their profile. The patient and the physician should make the final decision before surgery. Communication about the aesthetic profile without affecting the vestibule or the function of the nose is an art that the surgeon should perform effectively. Preoperative analysis may allow a deeper study of what structures have been resected, possibly restoring the aesthetic lines and maintaining a structural shield.^6,7

Imaging

Preoperative imaging will be an essential aspect of the operation. Frontal X-rays and oblique basal views should be obtained. The standardized measurement of the nasal base will give the surgeon an idea of the necessary lengthening. With the X-rays obtained, emphasis has to be placed on the possibility of re-establishing the degree of the descending process and the caudal septum. A straight and long nasal dorsum must have a corresponding dorsal view of the nasal bone and cartilage.^8,9

Patient Assessment and Communication

Facial analysis is one of the most crucial parts of evaluation in short noses. The diagnosis should be specified by measuring the nose, midface, and upper face in basal and profile views. In addition, the face should be classified according to phenotype and ethnic background. The upper face and midface should be regarded as an entity for short noses because the fund greatly influences the silhouette of the nose. The proportions between these regions should be analyzed above all. A short nose is generally defined as a nasal length equal to or less than 52% of the vertical size of the face. Rigidity or lobulation should be noted when evaluating these patients, especially those with short midfaces and long skin.^1,6

The patient’s aesthetic goal should be clarified orally and through three-dimensional (3D) computer-simulated images during the examination. Any functional complaint related to the short nose should be noted. Planning and line crossing help in this examination. All preoperative planning steps should be shared, and planning should be done symmetrically with the patient. Angles between the forehead and nose should be determined correctly. Effective planning is often correlation-related. Patients should be told to share their surgical goals with their family members.

Surgical Techniques for Lengthening Short Noses

Dorsal augmentation through implants or autologous cartilage grafts is often used in patients with short noses. This demands a primary focus on lengthening the short nasal base. The simplest method of lengthening the short nose is dorsal onlay or radix implants. Tip rotation can be controlled by shortening the medial and intermediate crura and the lower end of the septum. Caudal extension of the septal cartilage can be achieved through division at the caudal tip and adding grafts. Additional methods of lengthening the nasal base are employed for adequate tip rotation due to septal cartilage division. Silicone implants with a reported non-negligible tendency of infection are no longer used. Autologous cartilage grafts can be harvested from the septum, auricular cartilage, or rib. In the case of short noses, the surgeon can remove the septum as a graft and increase the nasal dorsum or undertake dorsal augmentation through septal cartilage grafts. Grafts are added over the existing septum or replanted to increase nasal length. Long-standing rhinoplasty experience is essential to preventing complications stemming from prolonged hospitalization and the possibility of reoperation by identifying the different degrees of skin thinness that allow for the adhesiveness and revascularization of the grafts. Rotation of the nasal tip is, in the same manner, vital because it aids in lengthening the short nose. Techniques in longer noses are needed for short noses to have an angular and proportional rotation.^10-12 Expanding upon the techniques mentioned above, it is crucial to note that careful consideration must be given to the overall facial harmony and the desired aesthetic outcome. In cases where the nose is significantly undersized, additional measures beyond dorsal augmentation may be required to achieve optimal results.^13,14 These measures can include alar base reduction or nasal implants specifically designed for projection and lengthening. Various factors are considered when assessing the suitability of autologous cartilage grafts. The choice of donor need is paramount, as it can significantly affect the procedure’s success. The septum, auricular cartilage, and ribs offer viable options for cartilage harvest; however, each has advantages and potential drawbacks. The surgeon must carefully evaluate the patient’s anatomy and medical history to determine the most appropriate graft source. Sometimes, the septum may be a suitable graft, mainly when dealing with short noses. Removing the septum as a graft allows for nasal dorsum enhancement and can effectively address the length issue. Alternatively, dorsal augmentation through septal cartilage grafts can also be performed, wherein the grafts are added over the existing septum or replanted to increase nasal length further. ¹⁰ This technique gives the surgeon greater flexibility and allows for a more personalized approach to nasal lengthening. In addition to addressing the size of the nose, it is essential to consider other aspects that contribute to overall facial aesthetics, such as the rotation of the nasal tip. A balanced and proportional rotation creates a harmonious and natural-looking result. Techniques used for longer noses may need to be adapted for short noses to achieve the desired angular and proportional rotation. The surgeon must deeply understand rhinoplasty techniques and experience dealing with various nasal shapes and sizes to ensure optimal outcomes for patients with short noses. Preventing complications is a critical aspect of the surgical process. Prolonged hospitalization can increase the risk of infection and other postoperative issues. Therefore, it is essential to monitor patients closely and follow strict protocols for wound care to minimize the potential for complications. Experienced surgeons will also be vigilant in identifying potential signs of graft failure or inadequate vascularization, as these issues can significantly impact the long-term success of the procedure.^13-16

Dorsal Augmentation with Implants or Grafts

Despite the wide range of available techniques for dorsal augmentation, nearly all the procedures performed are rooted in a single principle: altering the ratio between the length of the lower and upper sections of the nose. The most frequently mentioned technique is utilizing alloplastic materials, autogenous up dislocation, and various materials. To elongate a short nose, surgeons commonly employ autologous L-strut cartilage grafts, irradiated homografts, polytetrafluoroethylene, silicone implants, and cantilever bone grafts. Throughout the years, various materials for dorsal augmentation have been suggested or discouraged, with ongoing debates regarding the most effective options for dorsal implants among different surgeons. Augmenting the nasal framework, such as using the septum, auricular cartilage, rib grafts, and implants, is often helpful in lengthening short noses.^17,18

Emerging Trends and Innovations in Rhinoplasty

One of the innovations that might be introduced is using tissue patch materials enriched with adipose-derived stem cells/progenitors in short nose lengthening. In addition, tissue patch materials enhanced with platelet-rich plasma (PRP) increased the proliferation of human septal chondrocytes. However, PRP did not improve the production of the chondrocytes’ extracellular matrix. Moreover, tissue patch materials enriched with recombinant growth factor could prevent the apoptotic cell death of chondrocytes cultured with serum starvation. Similarly, in an in vivo experimental rabbit study, the recombinant growth factor added to the tissue patch materials was observed to increase the chondrocyte proliferation on the skin. However, it did not increase the hyaline cartilage in the tissues. If progress can be achieved in obtaining high-quality grafts with increased hyaline cartilage, various fillers could be used for nasofacial angle changes post-surgery.

Future collaborations between stem cell researchers and commercial companies might lead to the development of a new augmentation material for short nose lengthening. Some potential applications involve high-potential cells, platelet-rich fibrin, types I and III collagen, and fibroblasts as the cells if it is possible to culture the fibroblasts on a custom-made biodegradable internal structure for tissue engineering. Three-dimensional bioprinting creates functional tissue constructs that mimic the native sites throughout the body, which makes it possible to replace or regenerate tissues. It allows control over the biomaterial composition and design so that the produced constructs can fit the patient’s shape and needs. Therefore, innovation in lengthening short noses using 3D bioprinting might be achievable.

In conclusion, dorsal augmentation through autologous cartilage grafts or implants remains a valuable technique for patients with short noses. Surgeons can achieve the desired length and proportional rotation by employing various methods, such as dorsal onlay or radix implants, septal cartilage grafts, and careful tip rotation. Attention to detail and a comprehensive understanding of rhinoplasty techniques are essential in ensuring optimal outcomes while minimizing the risk of complications. Through skillful execution and a patient-centered approach, surgeons can help patients with short noses achieve improved facial harmony and self-confidence.