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Short Nose Virginia

The definition of a “short nose” is one that is proportionately short for the patient’s face and stature. A nose that is 3cm in length may look cute on a 5 foot tall 17 year old female’s face, but it will almost certainly not look right on a 6 foot tall 50 year old male’s face.

Although a “short nose” does not always occur concurrently with an excessively “upturned nose”, it often does. Moreover, while many short noses are hereditary, often they are sign of an over-aggressive previous Rhinoplasty, by a Plastic Surgeon with poor judgment.

Whether the short nose is due to genetics or a poorly performed previous Rhinoplasty, the correction involves the same stepwise algorithm:

  1. Diagnose the problem
    1. Is it a Primary or Revision Rhinoplasty
    2. How short is the nose?
    3. Is the nose also too upturned (over rotated)?
    4. Does the nose look short from front and profile views?
      1. If the patient likes her nasal length from the profile view but wants a longer nose from the front view, this unrealistic expectation must be addressed and demonstrated, using computer imaging during the consultation, by the Rhinoplasty Surgeon.
    5. Are the alar margins retracted as well?
    6. Is there too much “nostril show?”
    7. What is the condition of the nasal septum?
      1. Has the septum been operated on before
      2. Is there a septal perforation?
        1. If so, what part of the septum has a hole?
        2. How large is the hole?
    8. Assess availability of adequate nasal skin envelope
      1. It is useless if the Rhinoplasty Surgeon builds up the cartilage and bone properly, but is unable to drape the skin over the newly built-up framework – without tension.
    9. Assess the Rhinoplasty patient’s aesthetic taste and see what she/he likes
      1. The Rhinoplasty Specialist Surgeon must use computer imaging to discuss his recommendations and abilities, while prioritizing the patient’s desires and goals.
        1. The patient may want a longer nose than is surgically possible and this discussion needs to be taken before any surgery. Computer imaging is a crucial part of this discussion so the patient can see what is realistic surgically.
        2. The surgeon’s aesthetic taste or recommendations may not be the same as the patient’s and these issues must be addressed before any surgery so that compromises and changes can be made or so that another unsatisfactory surgery can be avoided
    10. The Rhinoplasty Surgeon must assess the availability of sources of cartilage and discuss these with the patient
      1. Cartilage from Septum
      2. Cartilage from ears
      3. Cartilage from patient’s own ribs (Costal Cartilage)
      4. Cartilage from Cadaver (Frozen or Irradiated Rib Cartilage)
  2. Plan the surgery
    1. Plan the timing of Rhinoplasty (applies to Revision Rhinoplasty)
      1. Sometimes it is better to wait longer for Revision Rhinoplasty so the skin relaxes and scar tissue softens up
      2. Sometimes it is not good to wait too long as the skin will “shrink-wrap” further, and will be more difficult to stretch out over a more built up nasal framework.
    2. Open Rhinoplasty or Closed Rhinoplasty?
    3. Rhinoplasty technique for achieving length?
      1. Release of scar tissue &/or previous permanent sutures to allow the tip position to drop down 1-2mm
      2. Single, double or triple layer tip grafts to lengthen nose during Rhinoplasty
      3. D.A.R.T. to lengthen nose (use of two large and long spreader grafts attached to a strong columellar strut graft, to create a cantilever and lengthen nose by pushing the tip downwards)
      4. Caudal Septum extension graft to build up the “foundation” of the nose.
        1. Often combined with total tip reconstruction
          1. Tip grafts
          2. Alar strut grafts
          3. Lateral Crus (LLC) repositioning technique
          4. Composite auricular (ear) cartilage grafts
      5. Para-median Forehead Flap nasal reconstruction
        1. Used in Revision Rhinoplasty cases where the nasal tip skin is severely inadequate due to multiple previous Rhinoplasties and skin “shrink-wrapping.”
          1. This aggressive Revision Rhinoplasty technique may have been necessary in a case such as Michael Jackson to build up his nose and create a stronger, more natural and masculine nose.

Figure 1: Normal septum anatomy

Figure 2: Short nose due to caudal septum resection

Figure 3: Caudal septum extension graft