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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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6
Nasofacial Proportions
and Systematic Nasal Analysis
Rod J. Rohrich Jamil Ahmad Jack P. Gunter
Attractive faces have certain proportions and relationships in common.
make an accurate diagnosis and establish the best treatment plan for a rhinoplasty
patient, these proportions and relationships must be thoroughly analyzed. When
disproportions and poor relationships are present, correction may only be possible with major orthognathic or even craniofacial procedures. However, these
discrepancies should be discussed with the patient and taken into consideration
when determining the surgical procedure best suited for that particular patient.
In addition, the shape, proportions, and relationship of the dierent parts of the
nose itself should be thoroughly studied. Closer scrutiny of these areas has taught
us that instead of performing a routine reduction rhinoplasty, better results may
be obtained in some cases if we augment certain areas of the nose. For example,
enhanced nasofacial balance may be achieved by increasing tip projection, dorsal
augmentation, lowering retracted alar rims, or lengthening a short nose.
In this chapter we will illustrate the nasofacial proportions and relationships
found to be helpful in evaluating a patient for rhinoplasty. is is not meant to
be a complete compilation of facial measurements and proportions but instead
should provide a framework for the rhinoplasty surgeon to use as reference. e
relationships and proportions detailed here can serve as a foundation for analyzing a face and help in understanding what gives a face its individual appearance. Rhinoplasty surgeons should keep in mind that these relationships are not
absolute; many attractive faces have harmonious nasofacial relationships despite
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having less than ideal proportions. Sex- and ethnic-specic aesthetic ideals and
proportions as well as considerations in the aging population are discussed in the
respective chapters. In addition, we present our approach to nasal assessment,
which allows systematic and comprehensive nasal analysis to identify nasofacial
disproportions and imbalances and helps to identify the goals for rhinoplasty
surgery.
NASOFACIAL PROPORTIONS
Proportions of the Face
Facial symmetry should always be assessed. Most patients’ faces are not symmetrical. It is very common for patients to be unaware of their facial asymmetries
and nasal deviation. Because most patients are highly critical of their appearance
aer surgery, any asymmetries or other preexisting aws should be pointed out
preoperatively to prevent patients from attributing them to the surgery.
is is a frontal view of a face drawn with aesthetic proportions. e face is divided into vertical hs by lines drawn adjacent to the most lateral projection of
the head, the lateral canthi, and the medial canthi.
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e width of the mouth approximates the distance between the medial limbi of
the corneas. e lower third is equally divided by a horizontal line adjacent to
the lowest point of the lower lip vermilion.
A horizontal line through the labial-mental groove divides the distance from the
stomion to the menton (lowest point of the chin) into a : ratio. e width of the
mouth and the distance from the stomion to the menton are equal.
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e distance from the brows to the menton (B) is equal to the width of the face
at the malar level. e distance from the infraorbital rim to the base of the nose
is equal to the width of the nasal base and one half the distance of the middle
third of the face.
e facial skeleton should be evaluated for deformities such as maxillary or mandibular hyperplasia and hypoplasia, periapical hypoplasia, and malar prominence or recession. Adjunctive procedures such as orthognathic surgery, piriform
aperture augmentation, or malar augmentation may be considered.
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e relationships between the mandible and maxilla are of utmost importance
and are determined next. e face is divided into thirds by horizontal lines drawn
adjacent to the menton, the nasal base, the brows (supraorbital notch level), and
the hairline (the upper line varies with hairstyle, so this landmark is least important). e lower third is divided into an upper third and lower two thirds by
a line drawn through the oral commissures.
When these relationships are outside the normal ranges, optimal improvement
of the patient’s appearance may require orthodontics or orthognathic surgery
as well as rhinoplasty for the best aesthetic results. In addition, the prominence
of the dierent areas of the maxilla should be observed. In some patients with
periapical hypoplasia, the upper lip may appear prominent. Augmentation of the
piriform aperture may be indicated as an adjunct to rhinoplasty. Malar prominence should also be assessed. Weak malar eminences detract from the facial
appearance, and augmentation may need to be considered.
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is lateral view is drawn with aesthetic proportions showing the face divided
into horizontal thirds on prole. e distance from the mandibular angle to the
menton is one half the distance from the menton to the natural hairline.
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Natural horizontal
facial plane
Given the importance of lip position and contour in assessing nasal tip projection
and rotation, the lip-chin complex should be evaluated before proceeding with
the nasal analysis. e desired relationship of the lip-chin complex is an upper lip
that projects approximately mm more than the lower lip. In women, the chin
lies slightly posterior to the lower lip. In men, it is slightly stronger. If the upper
lip is not in good position or does not have good contour, it may be corrected at
the time of rhinoplasty. Some patients have a “tension lip,” which is characterized
by fullness at the columellar-labial angle and a thin lip and vermilion surface that
appears slightly retracted. is is most oen seen in patients with overprojecting
noses and can oen be relieved by setting the nasal tip back closer to the face.
Tension lip is occasionally seen in patients with decient tip projection. When
this is the case, it is usually best to relieve the tension by releasing the base of the
nose, allowing it to settle posteriorly, and augmenting the tip with a gra to gain
as much projection as possible.
e upper lip should be evaluated for position and contour; specically, a tension
lip can be associated with an overprojecting nose as well as an underprojecting
nose. e rhinoplasty procedure can be designed to help decrease the tension lip
appearance.
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Another cause of an abnormal looking upper lip is a prominent posterior caudal
septum. is creates fullness at the columellar-labial junction and gives the appearance of pseudorotation of the nose. is is corrected by resecting a portion
of the posterior caudal septum. e anterior nasal spine is usually not involved
in this deformity, and it is seldom necessary to resect any portion of the anterior
nasal spine.
Pseudorotation is observed when there is a prominence of the posterior caudal
septum, which provides fullness in the columellar-labial junction.
Increased projection of the upper lip may be caused by prominent or improperly
inclined central incisors. Reducing the projection will require orthodontics or
orthognathic surgery. Such a deformity should be discussed to see if the patient is
interested in having it corrected before rhinoplasty. If not, at least the patient will
be aware that the overall result of the surgery will be somewhat compromised.
Proportions of the Nose
Clinical analysis and diagnosis of external nasal deformities are performed using the measurements and proportions described herein as standard references.
e skin type and texture should be evaluated rst. If the skin is thick and sebaceous, it does not drape as well as thin skin and takes longer for the edema to
subside before the nal result is seen. On the other hand, thin skin sometimes
drapes too well and aer the edema subsides it shows small deformities underneath the skin. ick skin will also have less capability to retract aer signicant
reductions in the osteocartilaginous framework. Although most sebaceous skin
is thick, occasionally a patient will have sebaceous, oily skin that is thin. e
thickness of the skin is more important than its sebaceous character in predicting the way it will drape.
e thickness of the skin should be evaluated because thick skin will not drape
over the reconstructed osteocartilaginous framework as well as thinner skin and
will be edematous for a longer period. When thin skin redrapes over the osteocartilaginous framework, it is more likely to show deformities than thick skin.
Aer the skin is analyzed, the nose is evaluated for possible
deviation. A line from the midglabellar area to the menton
should bisect the nasal bridge, the nasal tip, and Cupid’s
bow. If deviation is present, the cause must be determined.
Some deviations will require septal surgery for correction,
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sessed. If the distance between the nasal-cheek junction is
more than % of the normal alar base width, the bony base
should be narrowed at the time of osteotomy. If the bony
base width is within the normal range but the bony dorsum
is wide, mobilization of the nasal bones will be required to
narrow the dorsal portion of the bones while keeping the
bony base width the same. Maintaining the bony base width
may require packing between the lateral osteotomy sites and
the septum. In a nose that has never been operated on, it is
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whereas others may be corrected with osteotomies or cam
ouage.
Next, the width of the body and the tip of the nose are as
seldom necessary to try to widen the bony base.
e width of the bony vault of the nose should be 80% of the width of the nose at
the alar bases, assuming the width at the alar bases is normal.
e width of the alar base should be approximately the same
as the intercanthal distance, which should be the same as
the width of an eye. If the intercanthal distance is smaller
than the width of the eye, it is better to keep the nose slightly
wider than the intercanthal distance. If the nose is wider
than the width of the eye, alar base resection for narrowing
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should be considered.
e alar base width should approximate that of the intercanthal distance and
palpebral ssure width.
e alar rims should have a slight outward are in an inferior direction. e nasal dorsum should be outlined by two slightly curved divergent lines extending
from the medial supraciliary ridges to the tip-dening points.
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