Wide Nose Virginia
Proper nasal width should be assessed in relationship to nasal length and the rest of the face. Over and over again we come back to the notion that “the nose must fit” the face. Whether Caucasian (white), African American, Asian, Hispanic, or Middle Eastern – after a good Rhinoplasty, the nose has to fit the face. Classically the face can be holistically analyzed by assessing the “facial fifths” and “facial thirds” as seen below in figure 1. Essentially the “ideal face” can be divided into five equal vertical columns and three equal horizontal rows. However, there are significant variations in facial proportions amongst different races and ethnicities. Furthermore, most people do not have an ideal face. In fact about 85% of the general population has significant facial asymmetry. With the exception of the chin, the various facial features are not easily or safely modifiable. The height and slope of the forehead cannot be changed easily. Changing the position of the maxilla or mid-face requires major maxillofacial surgery, etc. So while the face cannot be easily modified to fit the nose, the nose can be shaped to “fit” the rest of the face in order to give it balance and harmony.
The width of the nose is assessed on the frontal view as well as the base view. On the front view, classically the ideal nose should have two “brow-tip aesthetic lines.” Some Rhinoplasty surgeons call these the “brow-dome aesthetic lines.” In white as well as ethnic patients, these lines start from each eyebrow head and extend along the side of the nose down towards each “tip defining point.” Ideally these lines start narrow and progressively and smoothly diverge from each other as they reach the tip. In figure 2 below, you can see that a wide nasal tip (before Rhinoplasty on left side) created an unfavorable set of brow-tip aesthetic lines. A painless closed Rhinoplasty through a non-delivery approach, which took about 15 minutes to perform and 3 days to recover from, resulted in a much improved set of brow-tip aesthetic lines. The post Rhinoplasty results, on right side, demonstrate much smoother aesthic contour from the eyebrows to the nasal tip, and less distraction from the beauty of the eyes.
A wide nose can be due to any of the following:
- Wide nasal bones
- Wide middle vault cartilages
- Wide Upper Lateral Cartilages
- Wide dorsal septum
- Wide nasal tip
- Wide Lower Lateral Cartilages
- Thick skin
- Wide nostrils (ala)
- “Relative illusion of width” due to inadequate length of the nose
Occasionally the nose may have a near perfect shape but be wide from top to bottom requiring a stepwise approach during Rhinoplasty. The goal in such situations is to proportionately refine the nose from top to bottom while maintaining is essential balance and shape.
However, most commonly, the wide nose has certain wide areas that are not in harmony with the rest of the nose. It is extremely important for the skillful Rhinoplasty Surgeon to first diagnose the issue and determine if the wide appearing part of the nose is truly due to excess width or due to an adjacent, proportionately, extra-narrow area. This is often seen in patients who think, or have been told by other Plastic Surgeons, that they have a wide nasal tip and need tip narrowing, while all along their tip was perfectly fine, but the middle vault was too narrow. The disproportionately narrow middle vault (pinched Upper Lateral Cartilages) makes the tip appear to be wider than it actually is. Clearly, in such cases, spreader grafts or onlay cartilage grafts to the middle vault is the proper approach rather than nasal tip narrowing maneuvers, which will make the nose even more unbalanced and pinched or fake in appearance. These are plans and decisions that should be made by the experienced Rhinoplasty Surgeon during the initial consultation. Proper diagnosis and skillful execution separate the Rhinoplasty Specialist from the average Plastic Surgeon.