The first step is the assessment of the general symmetry of the face and nose utilizing one reliable horizontal reference line. The most commonly utilized horizontal references are the lines connecting the medial canthus, the upper palpebral folds, or the apex of the eyebrow, which are easy to detect and draw; the next step is the creation of a unique vertical midline that should bisect the glabella, the nasal bridge, the nasal tip, and the Cupid’s bow (Fig. 7.2a–d). In a complex case, instead of a unique vertical midline, it is necessary to trace several small midline segments for every facial subunit to evaluate better the role of nasal asymmetry in the context of an asymmetric face (Fig. 7.2e–h).

The skeletal boundaries of the nose must be evaluated in order to recognize the surrounding structures from which the nasal pyramid emerges. Figure 7.3 shows these boundaries in a subject with an adequate supporting base, whereas Fig. 7.4 depicts three cases of depressed paranasal region due to maxillary hypoplasia and a case of a too protruding anterior nasal spine that greatly influences how the observer sees the shape and the projection of the nose. The reader can find the clinical and instrumental assessment of skeletal midface deformities in Chap. 9.

Utilizing the oblique views, the entire nasal outline must be evaluated, searching for the presence of a bilateral symmetric “unbroken” line [11]. In the attractive nose, this line descends gracefully from the supraorbital ridge onto the nasal dorsum and the nasal tip (Fig. 7.5). In the case of a deviated nose, dorsal irregularities, a dorsal hump, or a dorsal saddle, this line is “broken,” creating one or two steps or a strong curve as depicted in Fig. 7.6. Utilizing the nasal outline obtained from the oblique view helps in the assessment of the type, grade, and location of the deformity.

The nasal profile slope should be assessed clinically and utilizing the fullface profile view for a better comparison with the whole facial profile. In many cases, identifying and drawing the dorsal line is an easy task, and the difficulties that can remain lie only in the construction of a correct facial plane (Fig. 7.7).

In some nasal and dentofacial deformities, the assessment of nasal slope can be difficult. In a posttraumatic nose with dorsal irregularities, as in a combination of bone hump and cartilage saddle, more than one dorsal line can be considered (Fig. 7.8). Furthermore, none of these lines can be utilized as guidance for the visualization of the treatment goals as they reflect the actual situation measured at different levels (bony nasal dorsum, cartilaginous nasal dorsum, and nasal lobule outline) and not the ideal slope for this subject.¹

The difficulty in assessing the nasal slope increases in the case of obvious nasal deformity combined with an equally obvious dentofacial deformity. Tracing some reference points and lines helps the observer to distinguish and grade the severity of each deformity (Fig. 7.9). In the sections dedicated to specific nasal regions, such as radix and lobule, more of the factors affecting the real and perceived nasal slope are explored.

The next step consists of the appreciation of nasal widths. It should be done considering eight different basic parameters:

Figure 7.10 shows a case of a large nose in which all eight widths are depicted.

The general nose assessment is not finished without examining the overlaying skin and without the information obtainable by palpation. The skin assessment is a very important step; from radix to tip, along the midline, the thickness of the soft tissue envelope is thick over the glabella and radix breakpoint, thinner over the rhinion, and thick again at the supratip area (Fig. 7.11a). Moving from the midline to the nasal base line, at the level of the radix and osteocartilaginous dorsum, the skin thickness increases (Fig. 7.11b). The skin thickness at the level of the lobule and the base of columella is highly variable and must be assessed precisely in each case (Fig. 7.11c–f).

Utilizing the thumb and the index finger of the dominant hand (Fig. 7.12), the nose is palpated in order to establish:

Identifying the spatial location of the radix breakpoint and the definition of the nasofrontal angle is a fundamental part of nasal analysis.

The radix breakpoint is the most posterior point of the outline between the nasal dorsum and the frontal bone. Any change in the radix breakpoint influences how the observer judges the length as well as the slope of the entire nose. It is best assessed utilizing the corneal plane, the glabella, and the superior palpebral fold² as references (Fig. 7.13).

The nasofrontal angle is not necessarily measured and can be assessed simply by drawing (or imaging) two lines on the profile. The upper line is based on the mean inclination of the outline from glabella to the radix breakpoint, whereas the lower one is based on the mean inclination of the outline from the radix breakpoint to the supratip area. Figure 7.14 shows the nasofrontal angle of the three clinical cases presented in Fig. 7.13.

The profile of the bony portion is usually one third of the entire nasal dorsum and should be palpated to identify the real length of the nasal bones. Any convexity–concavity, symmetry–asymmetry, unilateral–bilateral lateral hump must be assessed visually.