UPTURNED NOSE RHINOPLASTY (Washington DC, Virginia & Chevy Chase Maryland)
Position of the nasal tip and the shape of the nasal bridge are intimately related aesthetically.
For example: a hump or bump on a nose can look completely different depending on changes to the nose tip:
- Moving the tip back towards the face (de-projecting the tip), to make it less protruding, will make a hump look larger.
- Moving the tip forward (adding projection to the nose tip), to make the tip protrude more from the face, will make a hump look smaller or even disappear.
- Moving the tip up (rotating the nose tip) to make the tip more up-turned, may make a hump look smaller often times.
- Moving the tip downward (de-rotating the nasal tip) to make the tip less up-turned, may make a hump look larger.
There are two approaches to performing a Rhinoplasty during the surgery. I am not referring to Closed or Open approaches, which are techniques used to make the changes. By approach here I am referring to an aesthetic eye and a stepwise approach to creation of the changes to the nose during Rhinoplasty.
- The tip position can be set or changed to the ideal shape and position first. Then the bridge and the rest of the nose can be changed to match the tip.
- The bridge height and shape can be set or changed to the ideal height and position and shape first. Then the tip can be changed to match the bridge.
So what should the ideal tip position be?
- Two factors determine the ideal tip position:
- Although there are many methods of calculating the ideal projection of the nose tip, classically one of 3 methods below are used by most Rhinoplasty Specialists:
- Goode method sets the tip projection as 55-60% of the nasal bridge
- Crumley method equates the nose to a 3:4:5 triangle using the relationship between projection to vertical length to dorsal length.
- Simons method relates the projection of the nasal tip to the length of the upper lip with an ideal 1:1 relationship.
But in reality none of these methods should be used alone. The nose has to fit the entire face, and even the body, and “look” of the patient. The fact is that other factors affect the projection of the nose:
- Chin position:
- Stronger, more protruding chins warrant maintaining or creating a somewhat over projected nasal tip, in order not to throw off the harmony and balance of the face. An “ideal tip projection” based on the 3 above methods, will draw too much attention to the chin of a patient with a strong chin.
- Weak or retro-positioned chins will make the tip appear over projected even if it is not. It is important to recognize this fact before surgery to either plan for a chin implant at the time of surgery or to avoid de-projecting the tip position too much. The tip position should not be compromised in order to match a smaller chin.
- Forehead slope, Radix depth, & Glabellar prominence:
- Foreheads that are sloped back will make the nose appear to be over projected
- Prominent Glabellar prominence (brow ridge) as well as the depth of the radix also affect appearance of the nasal projection. A strong brow ridge or a deep radix can make the tip appear under projected.
- Mid-face position:
- A midface or maxilla that is positioned too far forward in relation to the upper face (forehead) and lower face (jaw), will make the nose appear over projected.
- Height, sex, age and “look” of the patient:
- Taller patients, male patients, older patients and more “exotic” patients often times look better with slightly over projected noses.
So what should the ideal tip rotation be?
- Rotation or how up-turned a nose is (also called the naso-labial angle) has to be measured and then adjusted if necessary. The calculation is as follows:
- The angle is the junction of a line drawn along the slope of the upper lip, and a line drawn through the nostril. Many Plastic Surgeons use the columella erroneously instead of the line through the nostril.
- In men the naso-labial angle should be about 90-95 degrees
- In women the naso-labial angle should be about 95-120 degrees
- The taller the patient, the less rotated the nose should be
- The shorter the patient, the more rotated the nose can be
- A 120-degree naso-labial angle does not necessarily equal an “up turned” or “miss piggy” nose. Poor positioning and relationship between the tip, infra-tip lobule, columella, septum, and nostrils is what creates a “miss piggy nose.”
The upturned looking nose (referred to as a “miss piggy nose”) can be a result of a “short nose” or an “over rotated nose.” Often times though, this visually unappealing look of an upturned nose is the result of a short and an over rotated tip as well as other factors.
There are lots of patients who are born with upturned noses. Many Asians, some African Americans, some Latinos, and some Caucasians have naturally upturned or over rotated noses. These patients can undergo correction of this aesthetic issue with a properly planned primary Rhinoplasty.
However, the vast majority of patients with an upturned nose, are ones seeking a Revision Rhinoplasty after over aggressive, over reductive prior Rhinoplasty. The creation of an upturned nose is often times a simple task. In young patients and ones with thin skin, the rotation of the nose can be accomplished in a matter of seconds by any Plastic Surgeon. But the correction of this “error in judgment” of the previous Plastic Surgeon, involves much more skill, and effort by the Rhinoplasty Surgeon, and much higher emotional and financial burden on the patient.
The correction of an upturned or over-rotated nose depends on the degree of correction necessary. Single or double or even triple layer tip grafts can accomplish lesser corrections. Greater correction may be accomplished by the D.A.R.T. method. This method described by Dr. Dyer, uses structural spreader grafts, attached to a structural columellar strut graft, to create a cantilever, to “push” the tip down. More significant corrections often times require addition of length and support to the Caudal Septum. This may be necessary in order to lengthen the foundation of the nose first using a Caudal Septal Extension Graft. Then the tip, dorsum and rest of the nose can be “built around” this stronger, longer foundation. Sometimes, the limiting factor in de-rotation or lengthening of the nose, by the Rhinoplasty Surgeon, during a Revision (but even in some primary Rhinoplasties such as in Asian patients) is the stretch-ability of the skin envelope. The Rhinoplasty Surgeon can create a great cartilage and bony framework, but if there is not enough skin to drape over the structure, in a tension-free manner, significant problems can arise – such as horrific tip necrosis.
- In summary, the skilled Rhinoplasty Specialist Surgeon can determine the proper nasal tip position in Primary Rhinoplasty or in Revision Rhinoplasty cases. The execution of various techniques requires the utmost skill as well as a good source of cartilage (be it septum, ear or rib).