Rhinoplasty

55.1 Introduction

The nose is the most distinctive part of one’s face, and its shape and size as well as possible deformities influence its aesthetics and distinction.

The idea of a beautiful nose has changed throughout history, and it is still relative nowadays for beauty is in the eye of the beholder. Unlike the idea of what makes one’s nose beautiful, the idea of what makes one’s nose symmetrical is easier to define thanks to existence of certain measures and index representing relations between certain anatomic facial structures. Symmetrical nose does not have to indicate a beautiful one, because nasal beauty is defined according to the whole face of an individual; so there are cases when a less symmetrical nose of one person can be more beautiful in relation to a symmetrical nose of another person.

The external nose is most often compared to threefold pyramid which is, by its surface, linked to the other parts of the face and is called the base of the nose. The root of the nose represents its link with the front. Nasal dorsum is the most prominent part of the pyramid. The length of the nose represents the distance from the root to the lower hem of nasal septum. The width of the nose represents the distance between two most distant symmetrical points of nasal wings. The relation between length and width is called nasal index.

In relation to nasal index, there are differences among races; so, white people most often have leptorrhine

V. Kljajic ( ) and S. Savovic

ENT Clinic, Clinical Center of Vojvodina, Hajduk Veljkova 1, Novi Sad, Serbia

e-mail: kljaja@eunet.rs; savovics@yahoo.com

nose, black people have platyrrhine one, while yellow people have a mesorrhine one [1].

Aesthetically speaking, the nasal profile line is very important and it differs in the nasolabial and profile angles of the nose. The nasolabial angle shows the relation between outer bottom of the nose and frontal part of upper lip. The size of this angle, according to some authors, should be between 80° and 100° in men and 90° and 100° in women. This size influences the position of nasal entrance. Surgical correction of the angle size is often necessary, not only for aesthetic reasons, but also for functional reasons. Profile angle of the nose is formed by facial line and nasal dorsum line. On symmetrical noses this angle is 30°. Noses which have much smaller or much bigger angle than 30° are aesthetically impaired.

Besides these angles, the way nasal profile is linked to facial profile is very important in terms of aesthetics. In symmetrical noses, the size of the nasofrontal angle should be between 127° and 150°. We talk about the Greek nose when nasal profile goes almost directly into frontal profile. When there is greater or lesser recess between nasal root and the front, we can talk about the Roman nose, while the Nordic nose is characterized by a certain convexity degree of the dorsum.

55.2 Types of Nasal Deformity

Nasal deformities can be inborn or gotten throughout a lifetime. Besides thumb sucking, the most common nasal deformities are consequences of nasal injuries or personal massive injury. These injuries can occur during delivery time, in early childhood, or in adulthood. There are more and more injuries that are results of the traffic, industry, and sport development in modern society.

Nasal deformities can be isolated or associated with the deformities of surrounding structures (eye, lips, and ear) [2]. Nasal deformities can be limited to bone deformities or deformities of cartilage structures, but they are most often deformities of both cartilage and bone structures.

There are numerous kinds of nasal deformities; although some are really scarce, some others are quite frequent in general population. One of the most frequent deformities is rhinokyphosis (nasal hump), where nasal dorsum is distorted to a greater or a lesser degree. Nasal hump is quite often without septal deviation. It is relatively easy to correct surgically [3].

Rhinoscoliosis is a kind of deformity with greater or lesser medium nasal lines curvatures. The bony pyramid leans to one side. It is asymmetric, with a short, steep slope on the side of the deviation and a long, shallow slope on the opposite side. The cartilaginous pyramid is deformed in a similar way. The triangular cartilages are asymmetric, especially when the trauma occurred in childhood years.

We deal with rhinolordosis in case of dorsum recess. If one’s nose is too large (considering length and width) according to a certain face, we deal with macrorhinia, if only the length is too big, we have nasus longus, or if it is too wide, we can talk about the wide nose or pachyrhinia. Platyrrine means that the nose is flat and wide in wings. If the nose is too small in relation to the rest of the face, we have microrhinia. If the nose is too narrow, we deal with stenorhynia.

Isolated deformities of nasal tip are quite common, so we have: nasal tip protrusion (apex nasi prominens), lifted nasal tip (apex nasi excelsus), pointed nose (nasus acutus), obtuse nose (nasus obtusus), lowered nasal tip (ptosis apices nasi), and others.

Nasal wing deformities are quite frequent, the wings being too wide (ala nasi prominens) or too narrow due to weakly developed alar cartilage, so that inhaling can cause nasal wing aspiration (aspiration alarum nasi). Skin part of nasal septum can be lowered (protrusio septi) or widened (hypertonia phyltri). Luxation of lower nasal septum is quite frequent (luxation septi nasi). In case when nasolabial angle is significantly bigger than usual, we deal with nostril declination (declination orificii nasi), and when it is significantly smaller we deal with nostril inclination (inclinatio orificii nasi).

Nasal deformities that can be accurately classified into one of the above deformities are quite scarce. We usually have one leading deformity, while some others follow it and are associated with it.

A special group of deformities are deformities that are the consequences of upper lip fissure, upper jaw, and palate. Some typical disorders can also be manifested by deformities that occur during one’s lifetime such as rhinophyma, nose elephantiasis, acromegaly, and others.

Rhinoplasty is a surgical procedure where nasal pyramid is formed according to other facial parts. This is acquired by greater or lesser bone or cartilage structure reduction, by autotransplant implantations or bone or cartilage heterotransplants. Besides these, other materials can also be used. Aesthetic nose surgery is usually combined with functional nose surgery, so nose surgeries for pure aesthetic reasons are quite scarce. Attempting to achieve the best postsurgical result, one cannot forget the main nose function, i.e., breathing. The postsurgical result is not acceptable if the nose is aesthetically beautiful but not functional. If we have a functional postsurgical nose, but not aesthetically beautiful, the result may not be satisfactory either way. It is not always easy to acquire both beautiful and functional noses, but it is a challenge for every surgeon to be knowledgeable, skillful, and experienced and this has to show in each individual case. Every patient and his/ her nose represent an isolated case and a new challenge for the surgeon. It is highly important to keep blood circulation of the surgical area. Otherwise, tissue withering can occur or skin malnutrition, which can be manifested by cyanosis, especially in cold weather. In order to have a successful nose surgery both aesthetically and functionally, it is necessary to have a thorough preoperative preparation for every sort of superficiality and negligence can take an enormous toll in reconstructive surgery. Being unsatisfied with the shape of their noses, patients require an aesthetic surgery. Their wish has to be carefully studied and their surgeons should have long and cautious conversations with them prior to the surgery. Sometimes it is necessary to involve a psychologist or a psychiatrist before the surgery in order to make sure that patients’ problems won’t stay the same after the procedure, because their main problem is not deformity itself but it is their being insecure, scared, and with low self-esteem. Intelligent and well-educated patients are better prepared and better candidates for