Faces are like impressionist paintings. It can be difficult to tell what each individual element is contributing, but all of the elements together have a strong holistic effect.
Artists ensure that all of the visual elements of a painting work together cohesively, and plastic surgeons can do the same with the features of the face. And for surgeons, one of the most critical facial elements to consider is the nose.
In their 2017 paper, Implications of Facial Asymmetry in Rhinoplasty, Rohrich et. al. wrote, “The shape and anatomical position of the nose are major determinants of overall facial harmony and aesthetics.” The nose is one of the first facial features that humans register when observing another human face, and also lies between other prominent features, like our eyes and lips.
For this reason, many patients are particularly interested in correcting the shape of their nose and adjusting the role it plays in the overall effect of their facial features. Last year in 2018, over 214,000 cosmetic rhinoplasty surgeries were performed, and in the last several years, rhinoplasties have remained one of the top cosmetic surgery procedures.
This means that it’s increasingly important for plastic surgeons to understand the nuances of nasal deformities that patients may have. Understanding them is essential to evaluating nasal shapes and creating the best overall effect for each individual face.
Let’s take a closer look at how nasal deformities affect the appearance of the face and what plastic surgeons should know about the most common nasal deformities that they can correct.
In understanding deformities, it’s important to recognize that there isn’t one single perfect nasal shape for everyone. Because the nose is part of a holistic impression that all facial features create together, the ideal nasal shape is as unique as the face itself and should enhance the rest of the facial features.
It’s more useful for surgeons to evaluate based on proportions, rather than reproducing a standard nasal shape for different patients. As plastic surgeon Dr. Rawnsley points out, these ideal proportions are affected by many factors including face shape, age, and ethnicity.
The many factors that can contribute to the ideal nasal shape also include subjective opinions and societal beauty standards. In fact, Dr. Rawnsley argues that the ideal nasal shape has varied throughout history and across cultures and that different versions even contradict one another.
One common factor, however, is symmetry. Facial symmetry is a widely accepted standard of beauty, and Dr. Rawnsley maintains that many individuals who are considered conventionally attractive have very symmetrical faces.
The nose plays an important part in facial symmetry because it lies along the vertical axis. Symmetry in the nose is also important because it prevents the nose from drawing attention away from the rest of the face. The more cohesive and balanced a nose is with the rest of the facial components, the more it can enhance the face and allow more expressive facial features like eyes and lips to be the focus of attention.
When the nose is not balanced among the rest of the facial proportions, it draws unwanted attention and detracts from other features. This is what makes cosmetic rhinoplasty so appealing to some patients.
At MirrorMe3D, we wanted to better understand the most common nasal deformities that patients present with and the most important corrections for surgeons to consider when evaluating nasal shape and fit. We asked plastic surgeons to describe their most common rhinoplasty corrections, and they listed these five:
These corrections are nuanced, but critical to achieving the symmetry and optimized proportions that each unique patient is seeking in a rhinoplasty procedure. Let’s take a look at each deformity, the typical correction procedures, and why each is important to the cosmetic appearance of the nose in relation to the rest of the face.
A dorsal hump deformity is an unwanted bump on the bridge of the nose, or the dorsum.
Because the dorsal hump is on the top of the nose, it’s not as visible from the front view. Instead, it’s most noticeable in lateral view of the face and also from below.
A dorsal hump deformity can detract from the rest of the face because it breaks the lines of an individual’s profile. The hump increases the size of the nose, which draws visual attention and can unbalance the aesthetics of the face.
A dorsal hump reduction involves removal of some cartilage or bone, depending on the makeup of the individual’s nose. According to plastic surgeon Dr. John Hilinski, the final slope of the nose after the reduction depends on the individual's ethnicity and their desired outcome. Some patients simply prefer a reduction of the hump without complete removal, while others look for a straight bridge. Dr. Hilinski reports the the most requested result is a “supra-tip break,” which is a slight upward angulation as the bridge of the nose meets the tip of the nose.
As the experiences of Dr. Hilinski—and many other plastic surgeons—show, even nasal deformities that can be classified as a dorsal hump can still vary a lot from patient to patient and treatment must be highly individualized.
In some cases, a surgeon will choose to make adjustments to a patient’s dorsal aesthetic lines, which are the contours of the nose that are visible from a front view.
Patients may present with dorsal aesthetic lines that are too far apart or too close together, or with lines that don’t curve in a way that is flattering to the rest of the face. This may be an existing condition, or it may be a result of a dorsal hump removal where the hump is removed but the widened base remains.
The dorsal aesthetic lines affect how the width of the face is perceived and how the other facial elements relate to one another. For example, the width and curve of the dorsal aesthetic lines can make the eyes appear closer together or further apart and can change the apparent width of the cheeks.
Like the dorsal hump removal, adjusting dorsal aesthetic lines is also a reductive surgery in which the surgeon removes cartilage and bone. The resulting width of the nose will also vary depending on the patient’s gender, ethnicity, and other facial proportions.
Many cosmetic rhinoplasty procedures involve osteotomy, or bone removal. One of the most common reasons for osteotomy is to remove bone from the lateral nasal areas, or the sides of the nose.
This can create a steeper and more defined slope on the sides of the nose from the bridge down to the cheek, and can shorten the medial canthal distance, or the distance between the nasal bones.
By removing bone on the sides of the nose that is seen as excess, the distance between the eyes becomes less crowded and the nose has a smooth slope from between the eyes down to the end of the nose. Overall, the nose will look narrower and more symmetrical.
The process of performing a nasal osteotomy involves breaking or fracturing the nasal bones so that they can be moved, reset, or occasionally taken out. This particular type of lateral osteotomy—where bone is removed from the sides of the nose—is called an infracture.
Surgeons performing osteotomies to narrow the nose have to be especially conscious of nasal function. Making the nose too narrow can make it difficult for the patient to breathe, so the surgeon needs to find the perfect balance between aesthetic correction and function preservation.
Some patients look for cosmetic rhinoplasties to correct the shape of the tip of their nose. These patients typically have a bulbous, round tip that flares out wider than the nasal bridge.
Because the tip is so round, it doesn’t have much definition along any planes that correspond with the rest of the nose.
The undefined tip is a result of the shape of the cartilage at the end of the nose. This cartilage supports the nasal rim on both sides. In some patients, this cartilage is wider and more rounded.
An undefined tip immediately calls visual attention to the end of the nose because it looks like it is protruding more than it is. Because the bulbous end is so much wider than the nasal bridge, it breaks the fluid lines of the nose.
There are a few different techniques that surgeons can use to give more definition to a bulbous tip. For one, they can trim the cartilage at the tip to reshape the end of the nose from being rounded to a more triangular shape.
In some cases, patients might also need cartilage grafts, where excess cartilage is taken from somewhere else on the patient’s body, like their ear or septum, and then added to the tip. The excess cartilage adds support and can make the planes of the tip straighter, which also results in a more triangular shape at the end of the nose.
In some patients, the tip of the nose is not only round or bulbous, but it's also too wide. Surgeons can adjust the nose in this case by narrowing the tip of the nose.
This can look very similar to an undefined nasal tip at the very end of the nose in that it's rounded and sometimes bulbous. In some cases, if the tip is excessively wide, the entire lower half of the nose begins to flare out as it approaches the tip. This creates a large, wide triangle shape in the front view of the bridge of the nose and sometimes may look like the tip of the nose is dripping downward. Overall, this creates the appearance of a very wide and very long nose.
Rhinoplasties that deal with nasal tip narrowing usually rely on sutures. A surgeon can place permanent sutures at the tip of the nose to bring the cartilage on both sides closer together and narrow the tip of the nose. A wide nasal tip can also be narrowed with cartilage trimming, just like the tip definition procedure, depending on what will work best for a particular patient's nose.
When surgeons evaluate what kind of procedures to perform to create the best nasal proportions for a unique face, they're juggling many cosmetic and functional factors. The plan that the surgeon eventually makes is incredibly nuanced. It can be difficult to then try to explain to the patient exactly what you're going to do in the surgery because patients have a hard time visualizing their own anatomy and an even more difficult time understanding what exactly the surgery will change.
Clear communication is key because it helps patients understand the surgery they're about to undergo and makes them feel more comfortable. It can also help them to feel happier and more satisfied after the surgery.
3D visualizations and models help you explain your plan of action to your patients and give them a better understanding of how the overall impression of their face will change after their surgery.
With better educational tools and clearer communication, surgeons don't just give patients confidence in the procedure; they can also show their patients how much they mean to them and how committed they are to the patient's unique treatment and results.