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Profile correction in the overprojected nose
In rhinoplasty, profile reduction is one of the most frequently performed procedures. The nasal profile can be defined as a line connecting the anterior border of glabella, radix, dorsum and tip seen in side view. Among the most common ideals for the nasal profile are a straight line in males and a slightly sloping line in females. However, the desired profile in an individual patient can differ substantially from these guidelines.
Common measures for determination of nasal profile are the nasofacial angle (ideally 30 to 40 %) and the method of Goode (length alar crease to tip = 55 to 60 % of length alar base to nasion). In judging the nasal profile it is important two distinguish between 1.) shape of the profile line (straight, uneven, hump, saddle, etc.) and 2.) projection of the profile, as determined by e.g. nasofacial angle and tip projection.
When performing a major dorsal reduction, the upper lateral cartilages are detached from the septum, and the cartilaginous middle vault of the nose is compromised according to its long term stability, natural width, and natural round shape. This eventually leads to long term problems both functionally (too narrow inner nasal valve) and aesthetically (deviations of dorsum, inverted-V-deformity). The use of spreader grafts can help to prevent such sequelae. These grafts are mostly harvested from excess septal cartilage. They are positioned between the septum and the upper lateral cartilages on both sides, thus restoring the initial width of the middle vault in a stable manner, and straightening out the cartilagenous dorsum. The author of this newsletter uses them in almost all moderate and major dorsum reduction, i.e. about two thirds of his cases.
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Case example 1: Profile analysis: major hump, minor overall overprojection, major de-rotation of crura lateralia, nostril show. Applied techniques: open approach, major hump reduction, spreader grafts (effect not visible in side view), major up rotation of tip by non-resorbable sutures and columellar strut, tip refinement by sutures, alar rim grafts. The achieved profile line in this case is slightly sloping, according to the patient´s wishes.
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Case example 2: Profile analysis: moderate hump, major overall overprojection. Applied techniques: open approach, major overall dorsal reduction, spreader grafts (effect not visible in side view), tip de-projection by dome excision and re-suturing. The achieved profile line in this case is straight, according to the patient´s wishes. Note how also the position of the upper lip has changed
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Fig. 3: Positioning of spreader grafts. Top right and left: Dorsum and hump reduction. Bottom left: Situation after reduction. Upper lateral cartilages detached from septum, floating freely, prone to wandering around over time. Bottom right: Spreader grafts sutured in place: Upper lateral cartilages fixated, thus middle vault restored and straightened in a stable manner.