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Overview, The Aesthetic Ideal, History. Preoperative images of the nose are essential to rhinoplasty surgery.

The 6 standard rhinoplasty views are frontal, right/left oblique, right/left lateral, and basal. The frontal, oblique, and lateral views are taken with the patient in the Frankfort horizontal position, wherein the head is positioned so that a line from the superior aspect of the external ear canal (the porion) to the inferior orbital rim is parallel with the horizon (see image below).

Lighting should provide for a somewhat harsh view of the nose and should not wash out fine details or shadows. To assess symmetry, divide the face into vertical fifths and horizontal thirds (see image). The width of each sagittal fifth of the face is approximately the intercanthal distance. The width of the nasal base should also approximate the intercanthal distance. Dividing the facial height into thirds is also useful to assess facial symmetry. The anterior- most portion of the glabella forms the division between the upper and middle thirds. The subnasale (junction of the columella with the upper lip) forms the division between the middle and lower thirds.

The nose should occupy the middle facial third. See the image below. The nose itself is also described in terms of horizontal thirds. How To Fix A Broken Micro Sd Card Slot. The nasal bones form the upper third, the upper lateral cartilages and dorsal septum form the middle third, and the nasal tip forms the lower third (see image below). Upper third (nasal bones)The nasal bones (upper third) should be symmetric and approximately 7. Deviations of the bony third are typically treated with osteotomies, whereas bony asymmetries may be treated with rasping or augmentation. Middle third (midvault)A line connecting the club head of the eyebrow to the ipsilateral tip- defining point is known as the brow- tip aesthetic line.

The brow- tip aesthetic line is best seen on frontal and oblique views. Deformities from trauma, masses, or prior surgery (eg, an inverted- V deformity) disrupt the brow- tip aesthetic line. A narrow middle third suggests the potential for nasal valve dysfunction. Lower third (nasal tip)The symmetry and size of the nasal tip should be recorded in the medical record. A slight supratip break is ideally present at the junction of the middle third and nasal tip. The tip shape may be characterized as normal, bulbous, narrow, bifid, boxy, or amorphous.

The concept of an aesthetic diamond is useful when visualizing the tip and was first described by Sheen. The domes of the medial crura should diverge from each other at 5.

Narrow divergence causes the tip- defining points to be too close together and gives a pinched or “unitip” appearance. The position and fullness of the lateral crura of the lower lateral cartilages is noted as it contributes to bulbosity. Finally, the nasal rims on frontal view should form a “gull- in- flight” relationship with the columella. Lateral view. The dominant characteristics of the nasal profile are the projection and rotation of the nasal tip and the dorsal nasal contour. While there are several ways to measure it, projection generally refers to the distance of the nasal tip from the anterior facial plane. The facial plane is defined by an imaginary vertical line connecting the nasion (posterior- most bony point at the root of the nose) with the point where the alar groove intersects the nasolabial fold.

Projection is often examined in relation to the overall nasal length, which is the distance from the sellion (defined below) to the tip- defining point. The normal projection–to–length ratio is 0. Alternatively, the distance from the base of the columella (the subnasale) to the nasal tip should equal the length of the upper lip, if the lip height is normal. Although some surgeons make extensive measurements on preoperative photos, as a practical matter making such calculations at the initial patient encounter is difficult.

Integral to altering nasal length is an understanding of the soft- tissue starting point of the nasal dorsum, termed the sellion (as opposed to the nasion, which is the bony starting point of the dorsum). The sellion represents the soft- tissue vertex of the nasofrontal angle, which is the angle formed between the dorsum of the nose and the beginning of the forehead/glabella. The ideal nasofrontal angle is approximately 1. Sheen suggested that the sellion be placed at the supra tarsal fold, based on his personal observations over many years of clinical practice. However, the most commonly cited position of the sellion by rhinoplastic surgeons is the supratarsal crease. The position of the sellion on lateral view can help to determine whether augmentation of a deficient radix or resection of a dorsal hump is needed.

A straight, high dorsal profile is the currently accepted standard. A slightly scooped appearance of the dorsum in females or a slight dorsal hump in males may be acceptable. Nasal tip rotation occurs along an arc from the tip- defining point around the porion. An indirect measure of tip rotation is the nasolabial angle, which is the angle formed between the columella and the upper lip. Angles of 9. 0- 1. However, these angles are approximations and narrower angles are appropriate in taller patients. If the entire sill cannot be viewed, the nose can tolerate rotation.

Specific patient or surgeon preferences may modify these guidelines. The well- defined nasal tip will have a . The nasal tip should lead the nasal dorsum by 1- 2 mm, creating a slight supratip break (see the image below).

Some surgeons routinely perform a smiling lateral view to document the plunging tip deformity, a condition wherein the tip of the nose plunges with smiling due to contraction of the depressor septi nasi and the levator labii superioris alaeque nasi. The relationship of the alar rims to the columella should be carefully assessed. The alar rim should arch 2- 3 mm above the columella on this view. Deviations indicate alar or columellar retraction that may need to be addressed. The chin and nose must harmonize to achieve balance of the facial profile. The nose appears more overprojected if the chin is retrusive and vice versa. The zero- meridian is a vertical line that aids in determining if the chin position is adequate.

In women, the pogonion should fall just behind this line. The relationship of the chin to the lower face is assessed with a vertical line from the lower vermilion border of the lip.

In men, the pogonion is tangent to this line, with the mentolabial sulcus lying 4 mm posteriorly. In women, this line should lie 2- 3 mm anterior to the pogonion. Prognathia or retrognathia is defined by deviation of the pogonion from these positions. If retrognathia or microgenia is present, the patient may be offered chin augmentation. Oblique view. The right and left oblique images are appropriately oriented when the tip of the nose is tangent to the contralateral malar eminence. These views are ideal for demonstrating the ipsilateral brow tip aesthetic lines (see image below).

Further assessments can therefore be made regarding the asymmetries or prominences of the nasal dorsum. Basal view. To assess the nasal base, the patient's head is tilted back until the nasal tip projects on the midline point between the eyebrows along the axis of the surgeon's view (see image below). The shape of the nasal base is ideally an equilateral triangle. This triangle can again be divided into thirds, with the nostrils comprising the lower two thirds. The remaining third is compose of the infratip lobule. The nostrils should be symmetric and ovoid in shape.

The flare of the medial crural footplates variably and normally causes an indentation in the silhouette of the nostrils. Asymmetry of the nostrils demands a search for an explanation. Possible causes include alar retraction from scar, prior nasal surgery, dislocation of the caudal septum off the maxillary spine, and congenital nostril asymmetry.

The width of the alar base is best assessed on the basal view.