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Chapter Nasofacial Proportions and Systematic Nasal Analysis 105
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Anterior Right lateral Left lateral
Right oblique Left oblique
High basal Low basal Overhead
Standardized photography including frontal, lateral, oblique and basal views,
should be obtained for every patient. ese photos are a critical component for
preoperative planning and evaluation of postoperative results. In addition, these
photos are an essential element of the medical record. Standardized photography
is discussed in detail in Chapter .
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Systematic nasal analysis begins by examining facial proportions and skin characteristics. Next, nasal analysis is performed sequentially evaluating frontal, lateral and basal views. Finally, examination during smiling may reveal decent of
the nasal tip, shortening of the upper lip, or a transverse crease in the midphiltral
area which may benet from depressor septi nasi muscle release or dissection
and transposition.
CASE ANALYSES
On the frontal view, this patient has ideal facial proportions and Fitzpatrick type
II, thin, acne prone skin. She has S-shaped deviation of her nasal dorsum with
asymmetric dorsal aesthetic lines and le midvault collapse. She has a large, illdened nasal tip with wide tip-dening points.
On the lateral view, this patient has a low radix, moderate dorsal hump, and supratip fullness. She appears to have adequate tip projection but her tip is underrotated. Her columellar-labial angle is decreased while her columellar-lobular
angle is increased.
On the basal view, she has a boxy tip, faceting of her so triangle, nostril asymmetry, and aring of the medial crural footplates.
Chapter Nasofacial Proportions and Systematic Nasal Analysis 107
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On the frontal view, this patient has ideal facial proportions and Fitzpatrick type
II, thin skin. She has a reverse-C shaped deformity of her nasal dorsum with
asymmetric dorsal aesthetic lines, and midvault collapse. She has an inverted-V
deformity of the nasal dorsum. Her nasal tip is ill-dened and deviated to the
le. She has asymmetry of her nostrils with her caudal septum or medial crural
footplate visible in her le nostril.
On the lateral view, this patient has a large dorsal hump with supratip fullness.
She has an overprojected, tension tip with decreased columellar-lobular angle,
blunting of the columellar-labial angle, and shortening of her upper lip. Her chin
is slightly decient.
On the basal view, she has an overprojected tip with a : columellar to lobular
ratio. She has severe caudal septal deviation. She has faceting of her so triangles, and long, asymmetric nostrils due to her caudal septal deviation and medial
crural footplates. She has a narrow alar base secondary to her overprojected tip.
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On the frontal view, this patient has ideal facial proportions and Fitzpatrick type
III, thick, oily skin. He has a reverse-C-shaped deformity of the nasal dorsum
with deviation of his tip to the right. e bony vault is wide. His nasal tip is large
and ill-dened with an excess infratip lobule. is exaggerates the plunging nature of the tip and gives his nose an elongated appearance.
On the l
ateral view, this patient has a moderate dorsal hump with supratip full-
ness. He has an underrotated tip with an acute columellar-labial angle. His chin
htly decient.
is slig
On the basal view, he has adequate tip projection but the tip is mildly bulbous.
He has aring of the medial crural footplates and a wide columellar base.
KEY POINTS
■
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.
■
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.
■
Pseudorotation is observed when there is a prominence of the posterior caudal
septum, which provides fullness in the columellar-labial junction.
■
e thickness of the skin should be evaluated because thick skin will not drape
over the reconstructed osteocartilaginous framework as well as thinner skin
Chapter Nasofacial Proportions and Systematic Nasal Analysis 109
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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.
■
e width of the bony vault of the nose should be % of the width of the nose
at the alar bases, assuming the width at the alar bases is normal.
■
e alar base width should approximate that of the intercanthal distance and
palpebral ssure width.
■
e tip is evaluated by locating the tip-dening points on each side, the point
of the supratip break, and the columellar-lobular angle. Any discrepancy in
the two equilateral triangles formed by these points should be evaluated to
determine the cause.
■
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 :, and the nostrils
should be teardrop shaped.
■
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.
■
For evaluating tip projection, a vertical line should be drawn adjacent to the
most projecting part of the upper lip, and at least % to % of the tip should
lie anterior to this line. is assumes that the upper lip has normal projection.
e length/projection ratio should be :..
■
Aer the desired tip projection has been determined, the nasal dorsum is evaluated to see if reduction or augmentation is indicated.
■
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 allows for comprehensive nasal analysis to identify
nasofacial disproportions and imbalances and will help to establish the goals
for rhinoplasty surgery.
REFERENCES
1. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg :e-e, .
2. Bernstein L. Esthetics in rhinoplasty. Otolaryngol Clin North Am :-, .
3. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg :
-; discussion -, .
4. Daniel RK, Farkas LG. Rhinoplasty: image and reality. Clin Plast Surg :-, .
5. Farkas LG, Katic MJ, Munro IR. Inclinations of the facial prole: art versus reality. Plast Reconstr
Surg :-, .
6. Farkas LG, Kolar JC, Munro IR. Geography of the nose: a morphometric study. Aesthetic Plast Surg
:-, .
7. Leong SC,White PS. A comparison of aesthetic proportions between the healthy Caucasian nose
and the aesthetic ideal. J Plast Reconstr Aesthet Surg :-, .
Part One Basic Perioperative Concepts110
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8. Guyuron B. Precision rhinoplasty. Part I: e role of life-size photographs and so-tissue cephalometric analysis. Plast Reconstr Surg :-, .
9. Greer SE, Matarasso A, Wallach SG, Simon G, Longaker MT. Importance of the nasal-to-cervical
relationship to the prole in rhinoplasty surgery. Plast Reconstr Surg :-; discussion , .
10. Peck GA. Techniques in Aesthetic Rhinoplasty, ed . Philadelphia: JB Lippincott, .
11. Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg :-, .
12. Sheen JH. Aesthetic Rhinoplasty, ed . St Louis: Quality Medical Publishing, .
13. Rohrich RJ, Liu JH. Dening the infratip lobule in rhinoplasty: anatomy, pathogenesis of abnormalities, and correction using an algorithmic approach. Plast Reconstr Surg :-, .
14. Ghavami A, Janis JE, Acikel C, Rohrich RJ. Tip shaping in primary rhinoplasty: an algorithmic approach. Plast Reconstr Surg :-, .
■ ■ ■ ■ ■ ■
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7
Digital Imaging and Standardized
Photography in Rhinoplasty
Paul N. Afrooz Bardia Amirlak
H
igh-quality, standardized imaging is an integral part of rhinoplasty planning, communication, execution, and mastery. Standardized imaging serves to
identify the anatomy while providing the opportunity to encourage open patientsurgeon communication. Furthermore, rhinoplasty is a technically challenging
procedure, the results of which are oen measured by millimeters. As such, highquality, standardized imaging facilitates critical analysis of postoperative results,
thus fostering further mastery of this challenging operation.
Surgeons began to incorporate techniques of digitized photography into their
practice as early as . Since that time, digital imaging has rapidly evolved
and today has signicant impact in plastic surgery. One of the many benets of
digital photography is that it allows surgeons to obtain immediate feedback from
a rapidly generated image. is immediacy facilitates education of and consultation with patients as well as education of residents. Images can be inspected to
identify those that are less than ideal and the process repeated until the desired
image is obtained. is promotes standardization and eliminates the costs and
time associated with lm development. e user-friendly ability to store, organize, copy, share, edit, and import images into programs reduces the considerable
storage and care costs associated with physical photographs. In addition to many
educational, research, and marketing applications, photographic documentation
also serves a medicolegal function.
-
111
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PHOTOGRAPHY BASICS
Cameras and Lenses
To capture an image, an appropriate amount of light strikes the medium onto
which the image is being recorded. is medium can be a digital sensor chip or
the more traditional silver-based lm. In digital photography, the most widely
used sensor is the charge-coupled device (CCD). e CCD is composed of indi-
vidual light-sensitive electrodes that represent a pixel in the nal image. Light
travels through the lens and strikes the electrodes to generate an electric signal.
is signal strength is proportional to the amount of light that strikes each electrode. A digital converter converts the signal into digital form, which is then processed by the camera’s microprocessor and displayed as a color image. e CCD
itself is not sensitive to color; therefore only a black-and-white image is created.
e individual color lters over each electrode allow the processor to produce a
color image.
When light enters through the lens of the camera, it passes through a diaphragm.
In a digital camera, the diaphragm functions as both a shutter and an aperture
regulator. e shutter speed controls the amount of time that light strikes the recording medium. Aperture diameter (D) refers to the diameter of the adjustable
diaphragm of the lens, which determines the amount of light that falls onto the
medium, much like the iris of the eye. Together, the aperture diameter and shutter speed control the amount of light that strikes the recording medium, thus
determining the exposure.
-
Shutter speed is generally measured in fractions of a second (/ sec, / sec,
or / sec). e focal length (f) is the distance in millimeters from the optical
center of a lens to the focal point located on the lm or digital sensor. Focal ratio,
f-number, or f-stop (N) is the ratio of the lens’s focal length to the aperture (N 5
f/D). Because f-numbers are fractions of the focal length, larger f-numbers represent smaller aperture diameters. e depth of eld refers to the distance between
the closest and farthest objects that appear in focus in the photograph. at is,
objects within a certain range of distance behind or in front of the focal plane of
the lens appear sharp according to the depth of eld. Depth of eld is aected
by the aperture, subject distance, and focal length of the lens. e aperture can
be adjusted to increase or decrease the depth of eld; the smaller the aperture,
the greater the depth of eld. In contrast, a large aperture has a shallow depth of
eld, making objects behind or in front of the focal plane blurry.
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Camera lenses are categorized as normal/standard, telephoto, and wide-angle. A
standard lens does not magnify or diminish the size of an image and has a focal length approximately equal to the length of the diagonal measurement of the
recording medium. For example, mm is the length of the diagonal for mm
lm ( by mm), and the closest focal length equivalent is a mm lens, which
is considered the accepted standard lens. Currently, discrepancies exist between
mm lm and the size of digital sensor chips, but digital sensors are being developed that will allow the use of interchangeable lenses more freely without
concern for converting focal length.
,
Lenses with a focal length that is shorter
than the sensor’s diagonal are considered wide-angle, whereas lenses with a focal
length that is longer than the sensor’s diagonal are considered telephoto. In con-
trast to prime lenses, which have a xed focal length, zoom lenses are designed
to have an adjustable focal length. However, zoom lenses create variability when
standardization of clinical photographs is attempted.
Barrel distortion is a lens eect that causes images to be spherized or inated.
e image on the le was taken with a mm lens. e image on the right was
taken with an mm lens, and the face has a centrally full appearance. Barrel
distortion is associated with wide-angle lenses and typically occurs at the wide
end of a zoom lens. In a clinical scenario, this distortion can create a rounded
and centrally bulging appearance.
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e opposite eect is pincushion distortion, which is a lens eect that causes
images to be narrowed at their center. e image on the le was taken with a
mm lens. e one on the right was taken with a mm lens, and the face
has a centrally pinched appearance. Pincushion distortion is associated with long
or telephoto lenses, or the telephoto end of zoom lenses.
For rhinoplasty patients, it is important to use a lens that provides the least
amount of distortion with the greatest depth of eld to ensure that the whole
face is in focus. Lenses recommended for rhinoplasty are known as portrait
lenses. ey are in the range of to mm in focal length and prevent barrel
distortion that oen occurs with shorter focal lenses. is photo was taken with
a mm portrait lens.
Portrait lenses are recommended for rhinoplasty. ey have a focal length range
of 90 to 105mm and prevent barrel distortion that oen occurs with shorter focal lenses.
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