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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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Chapter Nasofacial Proportions and Systematic Nasal Analysis 95
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On the frontal view the tip should have four dening landmarks: A tip-dening
point on each side, the supratip break, and the columellar-lobular angle. Lines
connecting the tip-dening points with the supratip break and columellar-lobular
angle should form two equilateral triangles. If any of these four landmarks are
not in the correct position, it must be determined which is out of position and
why. Tip modication will be required to correct this problem.
e tip is evaluated by locating the tip-dening points on each side, the point of
the supratip break above, and the columellar-lobular angle below. Any discrepancy in the two equilateral triangles formed by these points should be evaluated
to determine the cause.
e degree of bulbosity of the tip should also be noted. If the tip is bulbous or
boxy, the lower lateral cartilages will probably need to be attenuated. If thick skin
is contributing to the problem, debulking of the musculoaponeurotic layer may
help. If an increased distance between the domes is the cause, they will have to
be moved closer together.
e columella is inspected on the frontal view. It should
hang just inferior to the alar rims so that a line outlining
the rims and the lowest portion of the columella will give
a gentle gull wing appearance. Too much curve of this line
indicates an increased infratip lobular height, which will
mellar show, which will require columellar augmentation
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require reduction. A straight line signies decreased colu
and/or superior movement of the alar rims.
1/3
2/3
On inspection of the basal view, an equilateral triangle should be visualized. e
ratio of the columella to the lobular portion of the nose should be :, and the
nostrils should be teardrop shaped with the long axis from the base to the apex
oriented in a slightly medial direction. From the junction of the columella with
the lobule, the sides of the columella should be fairly straight down to the point
where the medial crura start to are. If the medial crura are too soon, the columella may appear short and diminish the teardrop shape of the nostril. When
this happens, removal of some of the so tissue between the feet of the medial
crura, reduction of their are by incising the cartilage where they start to are,
and suturing the feet together may be indicated.
All prole views should be with the head in the natural
horizontal head position. In this position the neck and
chin area should be relaxed with the eyes focused on a
distant point at eye level. With the head in this position,
any line through the face on a horizontal plane will be
-
-
pendicular to a plumb line superimposed over the head
at rest with the eyes in forward gaze. is plane may be
on the same plane as the Frankfort line, but it may dier
because of the varying position of the external auditory
canal in individual patients. All facial angles should be
measured from the natural horizontal facial plane when
Chapter Nasofacial Proportions and Systematic Nasal Analysis 97
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On the basal view the nose should form an equilateral triangle. e ratio of the
columellar to the lobular portion of the nose should be 2:1, and the nostrils should
be teardrop shaped.
Natural horizontal
facial plane
in the natural horizontal facial plane. e natural hori
zontal facial plane is determined by drawing a line per
they dier from Frankfort’s line.
Nasofrontal
angle
Supratip
break
On the lateral view, these nasal landmarks should be evaluated: nasofrontal an
gle, supratip break, tip-dening points, and columellar-labial angle. e angle
between the tip-dening points and the columellar-labial angle is the columellarlobular angle.
Tip-defining
points
Columellar-lobular
angle
Columellar-labial
angle
-
e position of the nasofrontal angle is evaluated rst on the
prole view. e angle should start at the infrabrow area and
be a gentle, concave curve that connects the brow with the
dorsum. e deepest part of the nasofrontal angle should
lie between the upper eyelash line and supratarsal fold with
the eyes in forward gaze. ere are no standard parameters
for determining the correct depth of the angle; therefore the
surgeon must use aesthetic judgment to determine whether
Nasal tip projection is determined next. Several dierent
methods of evaluating tip projection have been described.
Tip projection can be evaluated by drawing a line from the
alar-cheek junction to the tip of the nose. If the upper lip
projection is normal, a vertical line is drawn adjacent to the
most projecting part of the upper lip. To achieve adequate
tip projection, at least % of the horizontal line should lie
anterior to the vertical line. If more than % of the line lies
anterior to it, the tip is considered to be overprojecting and
should be reduced. If less than % of the tip is anterior to
the vertical line, this indicates a short nose with inadequate
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it is too shallow or too deep.
On the prole view, the deepest portion of the nasofrontal angle should lie between the upper eyelash line and the supratarsal fold with the eyes in forward
gaze. An abnormal position may give the appearance of a long or shortened nose.
A
B
A 5 50%-60%
of AB
projection that should be augmented.
Chapter Nasofacial Proportions and Systematic Nasal Analysis 99
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For evaluating tip projection, a vertical line should be drawn adjacent to the
most projecting part of the upper lip, and at least 50% to 60% of the tip should
lie anterior to this line. is assumes that the upper lip has normal projection.
e length/projection ratio should be 1:0.67.
A B
A 5 B
Another method to evaluate tip projection is to determine whether tip projection equals alar base width.
1. 0
If the nasal length is correct, the ratio of nasal length to tip projection should be ap-
0.67
proximately :..
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R
A
T
S
M
Tip projection can also be determined in relation to ideal nasal length; ideal tip
projection (AT) 5 . 3 ideal nasal length (RT).
R
T
S
M
e length of the nose should also be considered when determining tip projection and rotation. e ideal nasal length (RT) should equal the distance from the
stomion to the menton (SM), which equals . 3 TS.
Chapter Nasofacial Proportions and Systematic Nasal Analysis 101
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With the desired tip projection determined, the nasal dorsum is then evaluated. In women it should lie approximately mm posterior and parallel to a line
connecting the nasofrontal angle with the desired tip projection and should be
slightly more anterior in men. If it is too far posterior to this line, augmentation
will be required. If it is on the line or anterior to it, reduction is indicated. A slight
supratip break of the dorsum is preferred, especially in women. is gives the
nose more denition and helps demarcate the body from the tip.
Aer the desired tip projection has been determined, the nasal dorsum is evalu
ated to see if reduction or augmentation is indicated.
Overprojection of the nasal tip may manifest as a “tension tip” deformity. is tip
deformity is usually septal dependent with the appearance of the anterior septum
pushing the tip away from the face and in some cases rotating the tip complex
inferiorly. ere is typically supratip fullness, blunting of the columellar-labial
angle, and shortening of the upper lip creating the “tension lip” deformity.
Overprojection of the nasal tip may manifest as a “tension tip” deformity.
-
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Natural horizontal
facial plane
95°-110°
Next, the degree of tip rotation is determined. Rotation is determined by the
degree of the nasolabial angle (angle of rotation), which is not the same as the
columellar-labial angle. e nasolabial angle is measured by drawing a straight
line through the most anterior and posterior points of the nostrils as seen on the
lateral view. e angle this line forms with a perpendicular line to the natural
horizontal facial plane is the nasolabial angle.
We prefer a to degree nasolabial angle in women and approximately to
degrees in men. e surgeon should be aware that a nose with a high dorsum
without a supratip break will appear less rotated than one with a low dorsum and
a supratip break, even though the degree of rotation is the same. For this reason
the amount of desired rotation should not be decided until the proposed dorsal
prole line is determined. In a short person the nose may be slightly more rotated than in a tall person.
Chapter Nasofacial Proportions and Systematic Nasal Analysis 103
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30°-45°
e columellar-lobular angle is formed by the junction of the columella with the
infratip lobule and is approximately to degrees. Increased fullness in this
area, usually caused by a prominent caudal septum, will give the appearance of
increased rotation even though the nasolabial angle (the angle of rotation) is
within normal limits.
e degree of tip rotation is evaluated based on the degree of the nasolabial angle. A decreased nasolabial angle indicates the need for increased tip rotation.
SYSTEMATIC NASAL ANALYSIS
Systematic nasal analysis plays a key role in achieving nasofacial harmony aer
rhinoplasty. is system allows for systematic and comprehensive nasal analysis
to identify nasofacial disproportions and imbalances and will help to establish
the goals for rhinoplasty surgery.
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Systematic Nasal Analysis
Frontal View
Facial proportions
Skin type/quality—Fitzpatrick type, thin or thick, sebaceous
Symmetry and nasal deviation—midline, C-, reverse-C-, S- or S-shaped deviation
Bony vault—narrow or wide, asymmetrical, short or long nasal bones
Midvault—narrow or wide, collapse, inverted-V deformity
Dorsal aesthetic lines—straight, symmetrical or asymmetrical, well or ill dened,
narrow or wide
Nasal tip—ideal/bulbous/boxy/pinched, supratip, tip-dening points, infratip lobule
Alar rims—gull shaped, facets, notching, retraction
Alar base—width
Upper lip—long or short, dynamic depressor septi nasi muscles, upper lip crease
Lateral View
Nasofrontal angle—acute or obtuse, high or low radix
Nasal length—long or short
Dorsum—smooth, hump, scooped out
Supratip—break, fullness, pollybeak
Tip projection—over- or underprojected
Tip rotation—over- or underrotated
Alar-columellar relationship—hanging or retracted alae, hanging or retracted colu-
mella
Periapical hypoplasia—maxillary or so tissue deciency
Lip-chin relationship—normal, decient
Basal View
Nasal projection—over- or underprojected, columellar-lobular ratio
Caudal septal deviation
Nostril—symmetrical or asymmetrical, long or short
Columella—septal tilt, aring of medial crura
Alar base—width
Alar aring
Systematic nasal analysis allows for comprehensive nasal analysis to identify
nasofacial disproportions and imbalances and will help to establish the goals
for rhinoplasty surgery.
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