The overly shortened nose can often be the result of previous rhinoplasty. The causes can include weakening or missing cartilage for nasal tip support as well as contraction and scarring of the skin. The purpose of this article was to provide the authors’ approach to this deformity.
The overly shortened nose is often caused by previous surgery.
Causes for an overly shortened nose include contraction of the skin as well as scarring after initial or previous rhinoplasties.
Correction of the overly shortened nose often includes costal cartilage grafting.
Preoperative discussion of goals for the surgery allows for management of patients’ expectations.
The overly shortened nose can often be a complication from prior rhinoplasty surgery or from congenital and traumatic causes. Nasal length is usually described as the distance from the glabella to the subnasale, and its ideal length is when it is one-third the length of a person’s face. An overly shortened nose is often paired with an upturned and overrotated nasal tip. For men, the ideal aesthetic for the nasolabial angle should be anywhere from 90 to 105°, whereas for women, it is 95 to 115°.
In this article, we discuss the correction of the short nose deformity after previous rhinoplasty and the techniques used by both authors. Historically, rhinoplasties were often reductive in nature to achieve the desired aesthetic goals. We have since found that reductive rhinoplasties can lead to many issues of nasal valve collapse as well as issues of tip deviation, overrotation, and overshortening of the nose.
The preoperative evaluation is critically important. Standardized preoperative photographs are taken the clinic during both the consultation as well as the preoperative appointment. At the time of the consultation, the patient is examined in the clinic room and the septum is palpated as well as the nose and nasal skin and soft tissue envelope. This is to evaluate the amount of remaining septal cartilage from previous rhinoplasty as well as gauge the ability of the skin to stretch as the nose is lengthened in surgery.
One of the major limitations during the correction of the overly shortened nose is the quality of the skin and its ability to cover over the area of grafting once the nose is lengthened and be able to close at the transcolumellar incision without tension. The limitations can be the scar tissue of the skin, lack of skin due to previous resection, or very thick skin that is already tight over the nasal dorsum and tip. Skin that is excessively scarred down to the underlying framework needs to also be noted, as that skin will have a higher chance for issues with vascularity and perfusion postoperatively.
Should skin appear to be too tight to be able to allow for adequate lengthening, the patient can help to stretch out the skin by pulling down caudally and exercising the skin to loosen it. It is also important to evaluate other procedures that will be done simultaneously that will help to provide some skin laxity, which can include deprojection of the tip or decreasing the height of the dorsal profile. Surgery should be performed only once the skin and soft tissue envelope is ready.
Subsequently, the patient is brought into the consultation office where the surgeon and the patient evaluate the photos and discuss what can be achieved with surgery based on the patient’s examination. In certain patients, the desire for a certain length and counterrotation cannot be achieved due to skin limitations. This discussion ensures that both the surgeon and the patient have similar goals for surgery and that expectations of the patient are managed.
It is important to note that even though lengthening of the nose is desired, it is important to maintain an aesthetic infratip break as well as supratip break.
Costal Cartilage Harvest
Cartilage grafting in rhinoplasty can come from several sources, including septal, auricular, and costal. Oftentimes in revision rhinoplasty, there is some septal cartilage remaining inside the nose in order for septal cartilage to be used for cartilage grafting. However, in the overly shortened nose, there is generally the need for stronger and larger amounts of cartilage, which would render the septal cartilage insufficient. Because of the soft nature of auricular cartilage, it is not ideal for structural grafting of the nose. Our preferred source of grafting for revision rhinoplasties is using costal cartilage. Cartilage taken from the rib is both abundant and strong. In the overly shortened nose, there is a deficit of nasal cartilage for tip support, and thus, using costal cartilage is preferred.
For costal cartilage harvest, the incision is marked in either the right-sided inframammary crease in female patients or infrapectoral crease in male patients. This generally translates to either the fifth, sixth, or seventh rib depending on each patient’s anatomy, musculature, breast size, or breast implant size. A 1.0-cm to 1.5-cm incision is made, which allows for a very small and hidden incision. In addition, during rib cartilage harvest, a small piece of overlying rib perichondrium is harvested at the same time, as it can be used later and placed over areas where the skin is thinner to help improve the vascularity of the nasal tip skin and decrease the visibility of cartilage grafts. In general, a 4-cm to 5-cm piece of rib cartilage can be harvested ( Fig. 1 ).