Key points

Introduction

When a patient presents with a short nose, the diagnosis is fairly obvious. The challenge becomes correctly identifying the cause(s) of the deformity, ascertaining the anatomic components involved in the deformity, and then tailoring the surgery so that these each of these components is addressed. To this point, it cannot be overstressed that the short nasal deformity can involve asymmetries and/or deficiencies of all of the components of the nose, including skin, cartilage support, skeletal support, and mucosal lining. Moreover, the etiology can include a full spectrum from congenital malformations to acquired deformities.

Despite this great variability in etiology and in applied anatomy, the short nose is characterized by certain key findings: decreased nasal length, overrotation of the nasal tip, and associated increased nostril show. This article is designed to elucidate involved anatomic asymmetries and deficiencies and then to tailor reliable techniques that address these asymmetries and deficiencies. Although the short nose presents elevated challenges, its correction offers elevated satisfaction to the patient and surgeon.

Introduction

When a patient presents with a short nose, the diagnosis is fairly obvious. The challenge becomes correctly identifying the cause(s) of the deformity, ascertaining the anatomic components involved in the deformity, and then tailoring the surgery so that these each of these components is addressed. To this point, it cannot be overstressed that the short nasal deformity can involve asymmetries and/or deficiencies of all of the components of the nose, including skin, cartilage support, skeletal support, and mucosal lining. Moreover, the etiology can include a full spectrum from congenital malformations to acquired deformities.

Despite this great variability in etiology and in applied anatomy, the short nose is characterized by certain key findings: decreased nasal length, overrotation of the nasal tip, and associated increased nostril show. This article is designed to elucidate involved anatomic asymmetries and deficiencies and then to tailor reliable techniques that address these asymmetries and deficiencies. Although the short nose presents elevated challenges, its correction offers elevated satisfaction to the patient and surgeon.

Preoperative planning and preparation

The first step in evaluation is determining the etiology of a patient’s short nose and the involved anatomy. Congenital short noses can be associated with craniofacial malformations or syndromes, such as cleft lip or Binder syndrome, and they can be familial.

Acquired short noses have an even more diverse background, and can include acute trauma or posttraumatic scarring and secondary rhinoplasty deformity (from overrotation of the nasal tip or overresection of the septum or dorsum). Rare causes include substance abuse (cocaine), syphilis, leprosy, or Wegener granulomatosis.

With such a diverse spectrum of etiologies, preoperative planning is focused on the following:

• 1.

  A thorough history, especially past trauma, surgeries, syndromes, and insults; and

• 2.

  A physical examination, including intranasal examination, manual manipulation of the nose, and facial analysis.

Although the diagnosis is usually obvious, facial analysis is greatly beneficial for surgical planning and for framing a patient’s expectations. The method we use is a simple soft tissue cephalometric analysis that can be performed in less than a minute. Six measurements are taken:

• 1.

  Midfacial height (MFH); the distance from the glabella to the bottom of the ala.

• 2.

  Lower facial height: the distance from the subnasale to the menton.

• 3.

  Nasal length: The distance from the root of the nose at the level of the supratarsal fold to the tip projecting point.

• 4.

  Chin vertical: The distance from the stomion to the menton.

• 5.

  Tip projection: The distance from the junction of the cheek and the ala to the tip projecting point.

• 6.

  Chin projection: The distance from the anterior projecting point of the chin to a line drawn from the halfway point of the ideal nasal length and extending through and beyond the anterior projecting point of the upper lip.

Facial analysis is especially helpful in case of short nose because surgical correction of the short nose generates a significant change to the entire balance of the face. Thus, the optimal lengthening procedures take into account the proportions of the face. These measurements are meant to be a guide rather than a blueprint, and often “uncover” facial imbalances related to the short nose. When compared with ideal proportions, a short nose demonstrates a nasal length that is less than the chin vertical length (and <0.67 MFH). The nasolabial angle is increased from the normal values of 90° to 95° in men and women 95° to 105° in women, which generates an increased nostril show. Additional findings can include a deep radix, retracted alae, lack of cartilaginous or osseous support, and contraction of the soft tissue envelope.

Manual manipulation of the nose gives insight into skin quality, the strength of the cartilaginous and bony framework, and the anatomy (skin, cartilage, bone, and/or lining) that resists lengthening the nose. Another key aspect of the physical examination is an assessment of whether sufficient septal cartilage exists to elongate the nose or whether an additional cartilage donor site is required. If additional cartilage is required, our preference is to harvest rib, and specifically, the straight segment of the 10th rib. Although the 11th rib is often straight as well, it does not provide the length of the 10th rib. As known from cleft rhinoplasty, the 10th rib provides roughly 33 mm for use as a columellar strut and 40 mm for a dorsal graft. The information gained from a thorough physical examination and history allows a well-formulated plan that accounts for each patient’s unique anatomy and challenges.

Patient positioning

We perform an open approach for all cases involving a short nose. The patient is placed in a supine position with shoulder roll to create neck extension. If rib grafting is anticipated, this surgical site is prepped as an additional sterile field.