PANEL DISCUSSION
Nasal Length and Projection
Editor's note: I'd like to offer a special thanks to the ments. I determine the actual length of the nose by mea-
moderator, Bahman Guyuron, MD (board-certified plas- suring ro ughly from the level of the supratarsa l fold or 6
tic surgeon, Lyndhurst, OH), and to the panelists, Henry mm above the inner canthus down to the dome-project-
Steve Byrd, MD (board-certified plastic surgeon, Dallas, ing points. Basically I would like the nasal length to be
T X); Ronald P. Gruber, MD (board-certified plastic sur- equal to the chin vertical measured from where the lips
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geon, Oakland, CAY; and Dean T oriumi, MD (board- come together (stomion) down to the undersurface of the
certified otolaryngologist, Chicago, IL) for sharing their chin (menton), or two thirds of the midfacial height.
views and expertise for this discussion. These are the ideal aesthetic relationships in the white
female's nose. From my perspective, a nose is long if it
Dr. Guyuron: The main focus exceeds these relationships
of this panel is the manage- and short if it does not equal
ment of nasal length and pro- them. Thus my assessment of
jection. Dr. Gruber, how do nasal length and projection
you analyze a patient's nose in are not based on a rigid
terms of length and projec- number but rather on mea-
tion? surements that are propor-
tionate to the face.
Dr. Gruber: In general, I take
measurements with a video I have found that the proj ec-
imager, which provides a one- tion of the nose from the
to-one size. It is really by trial Bahman Guyuron, MD Henry Steve Byrd, MD facial plane should be two
and error manipulation of the thirds of the nasal length.
image using the video imaging These parameters are based
system and then asking the on studies that my colleagues
patient what he or she thinks and I have done in which we
of my assessment that I deter- analyzed Ricket's "golden"
mine a patient's ideal nose proportion and tried to sim-
length and projection. I no plify it into a useful, surgery-
longer use specific numbers friend ly formula. They are
because the distances and sort of a "poor man's" way
angles on the nose are differ- of taking a short cut to that
Ronald P. Gruber, MD Dean Toriumi, MD
ent for each patient. I have golden proportion described
found that it is best to use my by Ricket.
aesthetic judgment with regard to how the particular
Dr. Guyuron: That proportion is based on existing facial
length and projection of the nose relates to the rest of the
structures. How do you assess the length of the nose
face .
when the patient has a short, lower face?
Dr. Guyuron: Dr. Byrd, how do you determine the proper
Dr. Byrd: One should look at nasal length on the basis of
nasal projection and length for your patients?
measurements derived from both the midface and the
Dr. Byrd: First, I measure the patient directly. Then I lower face because in a patient who has a maldevelop-
measure life-size photographs of the patient. I correlate ment of either the maxilla or the mandible, this approach
the measurements on the photograph with the ones that allows you to use either cephalometrics or other methods
I' ve taken of the patient to avoid measurement errors to bring the face into proportion before pressing for nasal
that can occur as a result of the way in which the pictures length. If the disproportion is localized to the maxilla,
were developed. This is a way of confirming my measure- then the chin vertical parameter can be used. If the dis-
A EST H E T IC 5 U R G E R Y J 0 URN A L - 5 E PTE M B E RI O C T 0 B E R 1 9 9 7 323
PANEL DISCUSSION
proportion is in the This deformity is pushing
mandible, then the midface the cephalic margin of the
vertical parameter can be left lateral crura to the left,
used. In some instances, if creating a fullness in the
the patient has a dental left supra alar region. The
facial deformity, I will use patient also has blunting of
casts to determine where the nasolabial angle, which
the maxilla and the facial needs to be corrected. This
structures should be and patient has the appearance
base the nose length and of someone with a "tension
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projection on that. If the nose deformity."
patient has just microgenia
To manage her problem, I
or something fairly simple,
would try to achieve sym-
then I will base the nose
Figure 1. Twenty-three-year-old woman who desires improvement of metry of the nasal base and
parameters on the maxil- her overprojected nose.
decrease the tip projection.
lary aspect rather than on
Assessing the skin thick-
mandibular measurements.
ness would be of utmost
My staff and I try to use an
overprojected. To assess her overall importance. I believe that
approach that will ultimately pro-
nasal length, I would measure the this patient has medium thick skin,
vide the greatest facial balance.
distance from the nasal starting which is favorable for rhinoplasty. I
Dr. Guyuron: The first patient point-the radix-down to the base would begin by performing a trans-
(Figure 1) is a 23-year-old woman of the nose in relation to the length fixion incision to access the septum
who desires improvement in the of the forehead and the lower third and correct the septal deformity.
appearance of her nose. Dr. of the face. Through the transfixion incision I
Toriumi, what is your would trim the posterior
assessment of her defor- septal angle to deproject
mity, and how would you the nose and create a
more acute nasolabial
correct it? Thr ugh th tran 1 IOn
angle. I would approach
Dr. toriumi: Initially, I I would trim th . po trior .ptal the nose through an
would look at all four external rhinoplasty
views-that is, the anglf> to deproj ct th , no ' approach, freeing the
frontal, lateral, three upper lateral cartilages
quarter, and basal. On and r at a m r a ut from the septum before
the frontal view, I would
na olahial angl ." performing a conserva-
divide the patient's face tive dorsal hump reduc-
into an upper third, mid- tion. Patients with short
dle third, and lower third. nasal bones frequently
Ideally, the length of the Several other anatomic points need spreader grafts to reposition
nose on frontal view should lie with- should be noted. One can see from the upper lateral cartilages. From
in the middle third. When you look the frontal view that her nasal base these photographs it looks as though
at the frontal view of this patient, it is slightly deviated. Intranasal exam- this patient has short nasal bone,
is apparent that she has a relatively ination would probably reveal a C- which puts her at risk for middle
long forehead and her nose is short. shaped deformity, with the caudal vault collapse. Thus I would insert
When we look at her face from the septum protruding into the right air- bilateral spreader grafts to reposi-
lateral view-specifically her nasal way, tilting the columella back to tion the upper lateral cartilages,
projection in relation to her fore- the other side. In addition, this straighten the dorsal septum in the
head and chin-it is evident that she patient has a concavity of the middle middle vault region, and create sym-
has a flat forehead and her nose is vault on the right side of the nose. metry.
324 A EST H E TIC 5 U R G E R Y J 0 URN A L - 5 E PTE M B E RIO C T 0 B E R 1 9 9 7 Volume 17, Number 5
PANEL DISCUSSION
Examination of the nasal tip to prevent any notching or
indicates that this patient possible visibility of the
may have cephalic position- cartilage edges.
ing of the lateral crura; the
Dr. Guyuron: Dr. Gruber,
degree of that deformity
what are your thoughts
would have to be deter-
about managing this
mined once the nose was
patient's problem?
opened. I would perform a
conservative cephalic trim Dr. Gruber: This patient
of the lateral crura and
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has a severely overproject-
insert a transdomal suture ed tip that is at risk of
and columellar strut to being undercorrected. It's
achieve symmetry of the not a matter of simply
lower third of the nose. trimming the septum, as it
Figure 2. Forty-three-year-old man with excessive nasal width and no
Then I would assess the tip support. might seem in this case.
nasal projection and the Moreover, correcting that
relationship of the tip- obtuse columellar labial
defining point to the angle by resecting a por-
supra tip region, as well as her over- dividing the dome and excising a tion of the anterior nasal spine area,
all profile alignment. If the projec- small triangular segment of cartilage which one needs to do to improve
tion and length were acceptable, to drop the tip back further. How- the lip, will aggravate the overpro-
then I would suture the upper lateral ever, I don't believe that would be jection of the nose. Thus I would
cartilages back to the septum. It necessary for this patient, because approach this patient'S problem by
might be necessary to trim the cau- bringing down her posterior and transecting the lower lateral carti-
dal margin of the medial lage very low near the
and intermediate crura to
base-that is, near the
reduce the lobule fullness
piriform aperture-
or to correct a hanging Thi pati ,nt n d. a lran. fi ion undermine, and, if neces-
columella deformity.
int rcartila~ou. m('ISlon and th sary, just remove a
Dr. Guyuron: What would segment of cartilage. I
be an acceptable distance ntire tip ompl n t'd to b would be inclined to
from the tip-defining transect and overlap the
point to the supratip area r tat d and h Id ... to th elements of either the
or septal angle for this middle or medial crus-
artilaginou ptumn a1' th
particular patient? depending on which is
Dr. Toriumi: After replac-
ptal angllO ' longer. I am very hesitant
to actually amputate a
ing the skin over the tip
dome. I believe that
cartilages, I would like to
would create a problem, particularly
see a slight supratip break. In most anterior septal angles would cause a
with this patient's skin thickness. I
cases this would be about 6 mm significant drop in tip projection.
believe that sutures would help keep
between the dome and anterior sep- Very precise tip projection and rota-
the overprojected tip down and
tal angle. tion can be achieved by performing
avoid overcorrection.
direct cartilage excision in the dome
Dr. Guyuron: What would be your
region. Rather than suture the two Dr. Guyuron: The second patient
next step if you redraped the skin
ends together, I would probably (Figure 2) is a 43-year-old man who
and excessive tip projection still
overlap the edges of the cartilage is dissatisfied with the position of his
existed?
slightly and try to regain a curvilin- nasal tip and the excess nasal width.
Dr. Toriumi: I would then consider ear soft contour to the dome region Dr. Gruber, what is your analysis of
Nasal Length and Projection AESTHETIC SURGERY JOURNAL - SEPTEMBER/OCTOBER 1997 325
PANEL DISCUSSION
his problem in terms of projection option in terms of getting the final Dr. Toriumi: I believe that preopera-
and how would you correct it? desired result. The key step would tive imaging would be important to
be to get the tip back up and then assess the degree of change that this
Dr. Gruber: Several pertinent factors
use heavy sutures and an intercrural patient desires. This would help me
will affect the ultimate treatment of
graft beginning at the anterior nasal to determine the type of technique
this patient. First, his tip has no sup-
spme. that I would use. I agree that this
port; it has dropped and is falling off
patient has a defiency in the radix
the end of his septum. He also has Dr. Guyuron: Dr. Byrd, do you have
and inadequate tip projection, which
an acute columellar labial angle. In any comments with regard to this
is due primarily to the lack of sup-
addition, his skin is very thick. This patient's problem and treatment?
port in the lower third of the nose.
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is a very big and thick nose, and the
Dr. Byrd: I have a few comments Depending on the degree of change
tip support is gone, which creates
regarding things that one should not this patient desires, I would consider
the perception of increased length.
do in a patient like this. The surgeon using a columellar strut sutured
However, I suspect that the length of
should not sculpt the lower lateral between the medial crura with very
this nose will be quite normal once
cartilages thinking that he or she is little cartilage resection. Then a tip
the tip is placed back in its proper
going to achieve refinement. I also graft could be used to increase tip
position. This patient also has a
wouldn't perform any of the respec- projection.
minimal radix deficiency and not
much of a dorsal hump. Although tive procedures that we've become
Dr. Guyuron: The third patient
we're not focusing on this aspect, he comfortable with to improve the
(Figure 3) is a 16-year-old girl who
also has a very broad nose of the thin-skinned, white
would like the appear-
nasal base. Because of ance of her nose
this heavy tip and thick improved. Dr. Toriumi,
skin, nothing that we do h ti PI'dur C what is your assessment
is going to yield a perfect of this patient's problems
result. This patient's skin to im 1'0 th no. ofth and how would you
is so thick that I would be address them?
inclined to use a closed lhin- kinn d whit woman . .. will
approach to surgery for Dr. Toriumi: On frontal
ha lilll to no ft ct in a pati fit view, this patient's nose
fear that the fibrosis
would offset any fine nch a thi . is slightly widened in the
sculpturing from the open bony vault. She has a lit-
approach. tle narrowing in the mid-
dle vault and bulbosity of
I believe this patient needs a trans- woman; these techniques will have the nasal tip. She also has a slight
fixion, intercartilaginous incision, little to no effect in a patient such as prominence of the infratip lobule.
and the entire tip complex needs to this. My main goal for this patient Examination of the lateral view
be rotated and held with some very would be to achieve structure. I have shows relatively good tip projection,
strong sutures to the cartilaginous
found that the ear and the septum with some deficiency in the chin pro-
septum near the septal angle. He frequently are structurally inade- jection. The patient has a modest
also needs a little support for the tip
quate in heavy-skinned individuals dorsal hump and a slightly long
in the form of an intercrural graft. and that the septum tends to be very nose. Much of what I would do for
Rather than use the usual approach, thin and delicate. Thus it is not her would depend on her stature. If
in which one drives the intercrural uncommon for me to use a rib graft she is short, then I would shorten
post between the medial crura, for in a patient such as this to get the her nose and rotate the nasal tip. If
this particular case I would create a structure that I need. she is tall, then I would leave her
"prop" between the anterior nasal
nose a little more projected.
spine and the medial foot plates. I Dr. Guyuron: Dr. Toriumi, what are
don't believe this patient would need your thoughts regarding this patient's Dr. Guyuron: Let's assume that this
a tip graft, but that would be an problem? patient is 5 feet 4 inches tall. What
326 A EST H E T reS U R G E R Y J 0 URN A L - 5 E PTE M B E RIO c T 0 B E R 1 9 9 7 Volume 17, Number 5
PANEL DISCUSSION
would be your manage- lower the radix breakpoint
ment approach? and create the illusion of
shortening. I would do pre-
Dr. Toriumi: If she were 5 cisely what Dr. Gruber
feet 4 inches tall, then I described, which is bring
would make conservative the nasion down to about
changes to her nose. I the pupil rather than to the
would consider doing this supratarsal fold. This
through an endonasal patient's deficient upper lip
approach--again, depend- bothers me almost as much
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ing on the extent of as her long nose. The
changes she desires. One upper lip is rolled up and
could deliver the cartilages, short, which accentuates
perform a conservative dor- her problem. I believe that
Figure 3. Sixteen-year-old girl with a modest dorsal hump and slightly
sal hump reduction, and long nose. she would be very pleased
use a transdomal suture to if one could augment her
approximate her domes vermilion and lengthen her
more closely and narrow upper lip.
the nasal tip area. In addition, one Dr. Gruber: My treatment protocol
could shorten this patient's nose by for this patient would be relatively Dr. Guyuron: This patient appears to
reducing the caudal septum primari- straightforward; her nose needs to have a long nose in addition to a
ly in the anterior septal angle region. be shortened and that would length- short upper lip and short lower face.
This would not only help shorten en her upper lip. In her particular Will removing the caudal septum
case, however, I would keep in mind solve the problem, or will it actually
her nose but also increase tip rota-
the location of the root of the nose pull the columella cephalically and
tion. It would also give her upper lip
and place the nasion right at the reduce the columella show without
a slightly longer appearance and
the alar base responding to this
decrease the fullness of the
change, creating a dispro-
lobule.
portion between the alar
Dr. Guyuron: What would base, alar rim, and col-
be the shape of your exci-
I would k p in mind umella?
sion segment from the car- th I ati n f th r t f th Dr. Toriumi: Such distor-
tilaginous and membran-
ous septums? n an pIa th na i n riO'ht tion would be unlikely as
long as any prominence of
Dr. Toriumi: It would be a at th pupil. the medial crura and inter-
superiorly based triangle, mediate crura was correct-
so there would be a larger ed. If we performed an
amount of cartilage external rhinoplasty on
pupil. Placing it lower than usual
excised near the anterior septal angle this patient and raised the skin flap,
would help to shorten her nose.
and a smaller amount excised near we probably would see a prominent
the posterior septal angle or nasal Dr. Byrd: I would suggest a protocol intermediate or middle crural seg-
spine. With this approach I could similar to that described by Dr. ment, which is creating fullness in
increase the tip rotation and Gruber. Examination of her the lobule. That fullness could be
decrease some of the lobule fullness nasolabial angle shows that the nose corrected by trimming the caudal
that we see on the frontal view. needs some shortening. However, if margin of the medial crura, middle
you try to shorten it through the crura, and caudal septum. We
Dr. Guyuron: Dr. Gruber, how usual maneuvers, it might introduce wouldn't be removing a tremendous
would you improve this patient's a distortion such as an overrotation amount of caudal septum but rather
nose? or other problems. One could also a small amount just to facilitate
Nasal Length and Projection AESTHETIC SURGERY JOURNAL - SEPTEMBER/OCTOBER 1997 327
PANEL DISCUSSION
rotation and correction of the exces- to the nasolabial angle region. To cant disparity between the alar and
sive columellar show. I believe that account for this loss of tip projec- the rest of the nose as a result of
if one moves the columella up, it tion, I would insert a transdomal shortening it-at least not with a
may cause a slight flaring of the nos- suture to increase projection of the nose of this length. The degree of lip
trils but little, if any, distortion. domes and rotate the nasal tip. lengthening that can be achieved is
limited, however, because no real lip
If you trim the caudal septum, the Dr. Gruber: I don't know of any bet-
exists there, and we're expecting
medial and middle crura are going ter way to shorten the nose, move some of the columella to become
to set back closer to this patient's the ala up, and lengthen the lip other lip .•
face. This maneuver will, in essence, than to mobilize the soft tissue,
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decrease tip projection, which will shorten the septum, and do all of the Reprint orders: Mosby-Year Book, Inc., 11830
Westline Industrial Drive, St. Louis, MO 63146-
produce some increased length to other things that we've described. I 3318; phone (314) 453-4350; reprint no.
the upper lip and a little better shape don't recall encountering any signifi- 70/1/86182
328 A EST H E TIC 5 U R G E R Y J OUR N A L - 5 E PTE M B E RIO eTa B E R 1 9 9 7 Volume 17, Number 5
