Short Nose Rhinoplasty

The short nose has represented one of the greatest challenges in rhinoplasty. This type of deformity typically involves all 3 layers of nasal tissue (ie, skin, internal lining, skeletal support). Short noses present both aesthetic problems and functional deficits. When skillfully executed, the short nose rhinoplasty can produce dramatic improvement.[1]

The classic short nose is upturned and depressed (see the image below). More specifically, it is defined as a nose lacking dimension from the nasofrontal angle to the tip. A lack of tip projection often is implied in the diagnosis. To determine if a short nose is present, a surgeon first must be aware of the dimensions of the normal nose. When identifying a short nose, analysis of the full face, particularly of the profile, is undertaken along with analysis of the nose in particular.

Vertically, the face is divided into thirds (see the image below). The upper third extends from the hairline to the glabella, the middle third from the glabella to the subnasale (ie, the point where the columella strikes the lip), and the lower third from the subnasale to the menton (ie, the lowest point of the chin).

The root, or radix, of the nose is located where the nasal bones project from the frontal bone. In whites, this nasofrontal angle usually lies at the level of the superior tarsal crease (see the image below) with the eyes looking forward. At the radix, the nose projects beyond the supratarsal fold on lateral view. From this perspective, the distance from the canthal ligament to the nasion (ie, radix projection) should be about one fourth to one third of the nasal length. The dorsum of the nose usually extends in a straight line in a caudal direction from the nasofrontal angle to the tip. The supratip is the area just superior to the domes. Ideally, the supratip should have a slight depression (see the image below).

A saddle nose has a concave nasal dorsum. Saddle noses frequently are seen in conjunction with the short nose. At the supratip, the lateral crura diverge, which is seen on the frontal view. In this area, ligaments attach from the domes to the septal angle (ie, the intersection of the caudal and dorsal borders of the quadrilateral cartilage).

Nasal length is defined as the distance between the nasofrontal angle and the nasal tip. Nasal length should be two thirds to three fourths of the midfacial height and should approximate the height of the chin (see the image below). Nasal height is defined as the distance between the nasion and the subnasale. This distance is also approximately two thirds to three fourths of the midface height. Paradoxically, in the short nose with an upwardly rotated tip, nasal height may be perfectly normal.

On anterior view, the border of the nasal dorsum should be evident as a smooth, gentle curve from the eyebrow through the glabella into the shadow line of the nasal dorsum and into the alar facial crease. Breakup of this line distorts the contour of the mid face. In the short nose, this line may be indistinct because of flattening of the dorsum.

Although the nasal tip has several ideal qualities, the 2 most important qualities of the short nose, for purposes of discussion, are critical—tip projection and tip rotation. Projection refers to the distance the tip protrudes from the face. Several methods exist for evaluating this relationship, some of which may give an inaccurate reading if the nasal root is depressed or inferiorly displaced, if the maxillary teeth protrude, if the upper lip is too long or too short, or if the chin protrudes or recedes abnormally. Three methods are recommended: the nasofacial angle, the Crumley and Lanser method, and the Goode method (see the image below).

The nasofacial angle measures the intercept of a line joining the glabella to the pogonion (ie, the most anterior point on the chin) with a line joining the nasion to the tip. The ideal angle varies according to practitioner, but it should be 30-40°. The Crumley and Lanser method analyzes the distance from the mandibular profile line (menton) to the nasion and measures projection to this line. The ratio of the length of the mandibular profile line to the projection distance should be between 4:1 and 4.5:1. The Goode method uses a vertical line from the nasion to the alar facial groove. A horizontal line is drawn through the tip perpendicular to this vertical line. The ratio of the horizontal line to the vertical line should be 0.55:0.60.

Rotation is measured as the angle of intersection between the facial plane (glabella to pogonion) and a line along the long axis of the nostril on lateral view (see the image below). The nasolabial angle differs from the columella-labial angle. The columella-labial angle is more obtuse when the caudal septum or nasal spine is prominent and more acute when the maxillary teeth protrude. Therefore, the nasolabial angle is more indicative of the true tilt of the nasal base. Determining rotation by passing a line perpendicular to the Frankfort horizontal, which passes through the alar facial groove, also is possible. This line is compared to a line that passes through the long axis of the nostrils. In females, the angle between the 2 lines should be approximately 95-105°. In males, this angle should be 90-95°. No more than a third of the vertical height of the nostril should be visible when the nose is viewed from the front.

Typically, the short nose displays various degrees of overrotation. On anterior view, one should have a foreshortened perspective of the nostrils. Too much nostril visibility indicates an upturned tip, a common finding in the short nose. When the tip is overrotated and the dorsum is flat, what is known as a porcine deformity results. A severe saddle nose may have lack of tip projection, a retracted columella, a bulbous lobule, a widened base, and apparent flattening and widening of the nasal bones.

The short nose may be encountered as a variant of normal. Otherwise healthy people who have a depressed nasal root, an upturned nasal tip or a combination are not unusual. Such patients may seek correction for purely cosmetic reasons.

Trauma

The most common cause of the short nose is trauma. Severe frontal blows to the dorsum and tip cause the nasal bones to fracture and splay. The upper lateral and septal cartilages also fracture, buckle, and disrupt. Hematomas between the cartilage and perichondrium can cause cartilage death as the cells are robbed of their nutrient supply. Because the lower lateral cartilages have lost their cephalic support, nothing prevents upward rotation and deprojection of the tip. As the contractile forces of scarring proceed over the ensuing weeks after initial injury, the short nose deformity worsens. Problems with the lower lateral cartilage include loss of projection, flaring of the alae, widening of domes, rounding of the anterior nares and asymmetry.

Prior nasal surgery

Prior nasal surgery is another common cause of the short nose. The dorsum and root may be overreduced. An open roof deformity, in which the nasal bones are splayed, may be present. Overreduction of the nasal septum leaves a flimsy dorsal strut and causes the bridge to collapse and the tip to rotate superiorly. This rotation is facilitated if the upper lateral cartilage is inadvertently disrupted off the nasal bones and/or septum. Aggressive resection of the lateral crura weakens the cartilaginous integrity of the tip and deprives the tip of important fibrous connections between the lateral crura and upper lateral cartilages.[2]

Drug abuse

Cocaine and methamphetamine use also can cause short nose deformity. Septal perforations have been found in 4.8% of regular cocaine users. As a vasoconstrictive agent, cocaine promotes a localized rhinitis that leads to dryness, crusting, and bleeding. Focal necrosis of the perichondrium ensues and leads to exposure and death of chondrocytes. Eventually, the bulk of the septal cartilage is destroyed, causing collapse of the dorsum and upward rotation of the tip.

Infectious and inflammatory conditions

Other infectious and inflammatory conditions may cause similar destruction. An undiagnosed septal hematoma may become infected, leading to destruction of the cartilaginous nasal skeleton. Rhinoscleroma, syphilis, and leprosy are less frequent infectious causes. Wegener's granulomatosis is an autoimmune disorder that is characterized by vasculitis, glomerulonephritis, and pneumonitis. The vasculitis may cause erosion and collapse of the nasal septum.

Neoplasms

Neoplasms (eg, esthesioneuroblastoma, inverting papilloma, squamous cell carcinoma) may result in the short nose deformity. Angiocentric immunoproliferative lesions represent another class of neoplasm that frequently destroys nasal tissue. These lesions are caused by a spectrum of entities known by various names, including polymorphic reticulosis, lymphomatoid granulomatosis, pseudolymphoma, lethal midline granuloma syndrome, nonhealing midline granuloma, and midline destructive granuloma. All of these entities may produce tissue destruction resulting in the short nose deformity.

Binder syndrome

Binder syndrome is a congenital abnormality associated with a short anteroposterior maxillary length, an absent nasal spine, and occlusion that is usually normal or near normal. The condition may be found in families, and a probable predilection exists for Binder syndrome in certain ethnic groups. The underprojecting skeletal structures combine to produce a nose that is functionally and cosmetically deficient. The tip and dorsum are depressed, resulting in poor airflow through the nasal cavities. Maxillary osteotomies are occasionally required to treat problems with occlusion.[3]

The nose warms and humidifies air by forcing approximately 2000 gallons of air per day in a narrow stream over a large surface area. The most efficient way for this airflow to occur is in a parabolic arc (see the image below). If the structure of the nose is altered through trauma or disease affecting the nasal septum or nasal valves, this normal airflow may be disrupted. The internal nasal valve is the main regulator of nasal airflow in whites.

The internal nasal valve consists of the caudal edge of the upper lateral cartilage, the cephalic margin of the lateral crus laterally, and the nasal septum medially. The angle between the septum and the upper lateral cartilage should be at least 10°. If the angle is smaller, airway obstruction and a loss of sensation of airflow are likely to result. The patient with a short nose may have obstruction, scarring, and displacement of the internal nasal valves. With nasal blockage, turbulence increases, and eddy currents form. This results in localized drying of the nasal membranes, causing crusting and epistaxis.

Obtain a careful history to exclude untreated ongoing causes of the short nose deformity. Carefully question the patient for past medical history of neoplastic, infectious, or autoimmune disorders, medication and illicit drug use, and prior surgery and trauma. A family history may be helpful in diagnosing conditions such as Binder syndrome. On physical examination, take note of the quality of the skin, the integrity of the underlying cartilages and bone, and the condition of the septum. Although sometimes difficult, the surgeon should try to assess the amount of septal cartilage available for grafting material and anticipate the need for auricular grafts, rib grafts, or alloplastic materials.

Short nose rhinoplasty is indicated for cosmetic or functional reasons for patients who are considered good surgical candidates. Functional indications for short nose rhinoplasty include difficulty breathing through one or both nostrils, nasal bleeding, crusting, dryness, infection, or pain. Cosmetic indications include a tip that is retracted or upturned, with or without collapse of the nasal dorsum.

The bony skeleton of the radix and dorsum consists of the paired maxillary and nasal bones. From the anterior view, the bony nasal opening has the appearance of a pear, hence the name pyriform aperture. The cartilaginous framework provides support for the lower dorsum and nasal tip. The septal (ie, quadrilateral) cartilage adjoins the perpendicular plate of the ethmoid, the vomer, and the maxillary crest. At the most anterior portion of the nasal floor, the paired maxillary bones give rise to the nasal spine, upon which the caudal septum rests.

The septal angle is the point where the dorsal and caudal borders of the septum intersect, and it is a critical landmark for determining the position of the nasal tip. The keystone, or K area, is where the nasal bones overlap the septal cartilage near the superior borders of the upper lateral cartilage. The septal cartilage, perpendicular plate of the ethmoid, paired nasal bones, and paired upper lateral cartilages meet at this critical area. Disruption of the septum during trauma most often occurs in the keystone area, possibly resulting in saddle-type deformities.

The upper lateral cartilages slightly underlie the caudal edge of the nasal bones superiorly, and they turn upward at their caudal end to form a scroll that approximates the cephalic end of the lower lateral cartilages. Laterally, little soft tissue support is present between the pyriform aperture and the upper lateral cartilage.

The lower lateral cartilage consists of a medial crus and a lateral crus. The medial crus joins the lateral crus at the dome. In the clinical setting, the size, shape, position, and strength of the lower lateral cartilages define tip projection and rotation. Other major tip support mechanisms include the attachment of the medial crural footplates to the caudal septum and the attachment of lateral crura to the upper lateral cartilages. Minor tip support mechanisms include the strength of the dorsal septum, the interdomal ligaments, the membranous septum, the nasal spine, the skin–soft tissue envelope, and the lateral crural attachments to the pyriform aperture.

The skin of the nose varies greatly among individuals. However, in general, the skin is thickest over the glabella and nasal tip and thinnest over the dorsum. Skin thickness plays an instrumental role in the ability of the soft tissues to drape properly over the altered nasal skeleton. In many patients with a short nose, the skin is thick, scarred, taut, and deficient.

Short nose rhinoplasty is contraindicated in patients who have surgical risks from a physiologic standpoint. Psychological or emotional instability also should exclude prospective candidates. This type of operation is not recommended for patients who have undergone high-dose radiation therapy to the face or have facial burns involving nasal skin. Lack of available donor tissue argues against surgery. Treat active infectious, neoplastic, or autoimmune diseases before considering surgery. A history of multiple previous rhinoplasties is a relative contraindication.

See the list below:

• Obtain benzoylecgonine levels for patients in whom cocaine abuse is suspected to exclude recent cocaine use. Such patients should have abstained from cocaine use for more than a year.

• A complete blood count, serologic tests for syphilis, a tuberculin skin test, rheumatoid factor, and an erythrocyte sedimentation rate are helpful in determining infectious or autoimmune etiologies.

• Aerobic, anaerobic, and acid-fast cultures of nasal secretions may be indicated.

• An antineutrophil cytoplasmic antibody test, if positive, is highly specific for Wegener granulomatosis.

See the list below:

• Preoperative photographs should be taken from at least 4 different views. Most surgeons prefer 6 standard views, including frontal, right and left laterals, right and left obliques, and basal views.

• Although not mandatory, preoperative radiography or CT scanning may indicate the extent of bone or cartilage loss.

• Chest radiography is helpful in determining infectious or autoimmune etiologies.

• Although plain radiographic studies and CT scanning often are performed around the time of trauma to the nose and mid face, these studies are not essential for reconstruction of the short nose. Using a careful physical examination to determine the amount of bony and cartilaginous deficiency is more reliable.

See the list below:

• Acoustic rhinometry is often used to verify subjective descriptions of nasal obstruction.

See the list below:

• A tissue biopsy may be necessary to confirm the presence of neoplastic or autoimmune disease. Biopsies for this indication are notoriously unreliable, however. Biopsy is probably best performed when cancer is strongly suspected.

When the short nose is caused by an active underlying etiology, whether infectious, autoimmune, or neoplastic, treat the underlying cause before initiating surgical therapy. Therapy for the disorders that cause short nose deformity is beyond the scope of this article.

If there is no history of underlying disease or trauma, one may consider a cosmetic rhinoplasty for the short nose. Probably the most common type performed worldwide is one in which an L-shaped silicone strut is introduced over the dorsum, tip, and columella via a closed approach. It is best tolerated in patients with a thick skin-soft tissue envelope and relatively strong cartilages. Extrusion of the implant is possible, but unlikely.[4, 5]

Many short noses are the result of trauma, and sometimes the surgeon may be able to address the trauma acutely. Existing lacerations may be used for access. Re-establishing normal anatomic relationships and stabilizing support structures within the nose are important. This is generally easier to accomplish during the first 14 days after injury because scar contraction has not yet occurred. Conversely, the bony support of the nose may be unstable, and using rigid or semirigid fixation with plating systems often is necessary. Acute saddle nose fractures can be fixed with a Kershner wire through the perpendicular plate and the frontal processes of the maxilla.

When bone is absent or severely comminuted, bone grafts may be required. Calvarial bone grafts are good options when support in the upper bony and lower cartilaginous dorsum is lost. Drain hematomas and splint appropriately. In patients with acute trauma, when the skin–soft tissue envelope has no underlying support, this envelope contracts during the healing phase, and the short nose must be treated secondarily.

When treating the short nose or saddle nose of long duration, 3 key principles are observed: extensive undermining of skin, restoration of structural support, and if indicated, release of internal lining. Wide dissection of the nasal skin is necessary because it is needed for redraping. Carry out undermining beyond the pyriform aperture and up to the radix. Take care not to perforate thin scarred skin. Antibiotics are recommended for major nasal reconstructions, especially with the use of alloplasts or when internal lining is torn.

Open approach

The open approach is useful for the short nose, both in the acute phase and later. This approach involves making marginal incisions that are joined at the midcolumellar level by a skin incision. This allows the surgeon to raise the skin and soft tissue of the lower third of the nose and visualize the cartilages in situ. The open approach is particularly useful in the patient with the short nose because grafting, visualization of existing cartilage deficits, and use of both hands is important. In contrast to the closed approaches, the open technique allows direct visualization, binocular vision, and bimanual manipulation of structures. Tip grafts, onlay grafts, and struts can be carved to exact specifications and stabilized in precise positions without risk of moving or shifting. It allows the operator greater precision while addressing the cartilaginous dorsum and upper lateral cartilages.

Closed approaches

Closed approaches also can be used to treat the short nose. With these methods, mucoperichondrial flaps are raised on each side of the septum, back cuts are made, and the flaps are advanced anteriorly and inferiorly. Transfixion incisions are performed to release the lower lateral from the upper lateral cartilages. Batten grafts may be inserted through hemitransfixion incisions in the membranous septum to push the nasal tip in a caudal direction. When the mucosa between the upper and lower lateral cartilages needs to be cut, and as the lower lateral cartilages are moved caudally, a gap may appear. This gap can be filled with a conchal cartilage composite graft. Using composite or full-thickness skin grafts in the membranous septum to advance the columella is possible.

Graft and implant materials

Release of the upper lateral cartilage from the septal remnant may be important when the septum has collapsed. Separating the upper lateral cartilage from the nasal bones also is possible, but a filler graft must be used to hide the potential depression. Staggered incisions also may be required in septal mucoperichondrium to allow anterior displacement of the tip. Further nasal lining release is accomplished by dissecting mucoperichondrial sleeves from the septum and from beneath the nasal bones back to the nasopharynx. In the presence of congenital absence of bone, osteotomies may be made around the nasal bony pyramid and the nasal tissues advanced forward. Interpositional grafts may be placed through sublabial and/or coronal approaches.

Because the nasal septum is critical in providing integrity to the cartilaginous dorsum and the tip, begin restoration of the nasal framework with reconstruction of the septum. The position of the septal angle is a key determinant of nasal tip rotation and projection. In addition, the septum provides cartilage graft material needed for many short noses. Performing a septoplasty prior to setting the nasal tip and reconstructing the dorsum is wise. If necessary, the upper lateral cartilages can be dissected sharply from the dorsal septum, but care should be taken not to injure the mucosa on each side. Spreader (batten) grafts formed from small strips of septal cartilage may be sutured between the medial borders of the upper lateral cartilages and the septum to alleviate twisting or narrowing of the nasal valve area.[6]

These grafts also may be used to improve nasal function in the area of the valve. The angle of attachment of the upper lateral cartilage to the septum must be greater than 10°. If the angle is too acute, as is common in the short nose, spreader grafts are indicated.[7] Secure the spreader grafts in mattress fashion, with semipermanent sutures, to the upper lateral cartilages and septum. Do not place spreader grafts until the osteotomies are completed.

Septal cartilage is the preferred graft material for the short nose because it is readily available, resilient, and resists rejection and resorption. However, in the short nose, septal cartilage is usually limited, particularly when it is necessary to leave behind adequate dorsal and caudal septal cartilage support for the tip.[8]

Cartilage grafts harvested from the conchal bowl differ from their septal counterparts. Auricular cartilage is softer, more brittle, and more convoluted than septal cartilage. The curvature of auricular cartilage makes it an attractive option for battens replacing the lateral crura, but its shape and limited availability make it unsuitable for larger dorsal defects. A slightly increased (< 5%) infection rate is associated with auricular cartilage grafts. Nevertheless, cartilage from the concha cymba, concha cavum, or both may be used to act as dorsal onlays or dorsal or caudal struts. Rarely is enough cartilage available to reconstruct all 3 areas. Curvature of the grafts may be negated by folding the graft and suturing the halves together.

For large saddle defects involving bony and cartilaginous dorsum, rib cartilage makes excellent graft material. Follow-up study demonstrates that rib cartilage maintains its bulk as long as 48 years after surgery. Rib cartilage should be carved so that equal amounts of perichondrium are removed from both sides to discourage warping. Warping is particularly noted in children's cartilage, but in older patients the cartilage is partly calcified; therefore, the warping tendency is not noted as much in older patients. Rib cartilage grafts with large cross-sectional areas tend to become warped less frequently. The cartilage may be carved into 3 pieces. One piece is placed as a dorsal strut, the second acts as a columellar strut, and the third as the dorsal onlay. The columellar strut is grooved to fit into the dorsal strut. This configuration resists posterior displacement of the tip and dorsum.

Rib grafts containing both cartilage and bone also may be used. These grafts typically are obtained from the 9th, 10th, or 11th rib. The bony portion may be fixated with screws or k-wires. Mutaf has described a technique for saddle nose correction known as anatomic replication (ART).[9] A larger graft, from the fifth rib, is harvested and carved in such a way to replace missing bony dorsum, dorsal strut, caudal strut and upper lateral cartilages. Since all the components remain attached, there is less likelihood of postoperative displacement. Drilling the nasal bones down and drilling the bony undersurface of the onlay graft may add long-term stability.[10] Osteotomies, if needed, are performed in such a way to minimize disruption of the overlying periosteum.

In a retrospective study of 36 Asian patients with short nose deformity (either congenital or secondary to previous rhinoplasty), Park et al found that the key lengthening procedures performed consisted of the use of septal extension grafts (reinforced with extended spreader grafts), dorsal onlays, and tip grafts. The investigators reported that all of the study’s patients were satisfied with the cosmetic results of the surgery and that no serious complications arose. They also reported that a better increase in the distance from the nasion to the tip-defining point was achieved with rib cartilage than with septal or conchal cartilage.[11, 12]

In another study of Asian patients with short nose deformity, Kim and Kim also reported the successful use of rib cartilage grafts to obtain septal extension. In the study, which included 38 patients, external nose lengths increased by an average of 8 mm from the nasal root to the tip.[13]

When autologous cartilage is in limited supply, surgeons have made use of other biologic materials in short nose rhinoplasty. Banked demineralized bone has an unacceptably high absorption rate. Concern also exists about transmission of human immunodeficiency virus (HIV) and of slow viruses with homografts.

Although HIV transmission has been reported with banked homograft bone, no cases have been reported with banked irradiated cartilage. Irradiated homograft cartilage has demonstrated satisfactory results when used in the nose, as opposed to other areas of the face.[14] Large series (in which irradiated homograft cartilage has been used in the short nose) have documented low rates of warping, infection, and resorption over many years.[15] Columellar struts and dorsal onlay grafts have been found to fare better than tip grafts.[16] Freeze-dried bone has also shown good success in maintaining projection at 5 and 10 years.[17]

Dermal allografts (eg, AlloDerm) are inert biologically. Because the normal human dermal architecture is preserved, native vascular ingrowth is rapid. However, with dermal material, structural rigidity is a problem, and dermal allografts are probably best considered to camouflage dorsal irregularities. Studies are indicating that the retention rate of homograft dermis is about 50% at 1 year. A better option in patients with thick skin–soft tissue envelopes may be to excise the nasal superficial musculoaponeurotic system (SMAS) en bloc from the tip and supratip areas and use it to augment the dorsum.

Bone grafts are useful in the short nose because they replace structurally important elements and adequately resist the forces of postoperative scar contraction. Rib and iliac crest grafts, such as endochondral bone, undergo a higher rate of resorption than the membranous bone of the calvarium. Iliac bone grafts are associated with a painful donor area for 2-3 weeks. Rigid fixation may help retard the rate of bone resorption. Donor site pain in the chest and hip is somewhat higher than that in the skull. Therefore, consideration of outer table calvaria as the primary source of bone graft for augmentation of the short nose is recommended.

Calvarial bone is strong and thin. Grafts can be thinned to 1 mm. These grafts can be used as battens for nasal valve collapse, as dorsal grafts for saddle nose deformities, and as columellar struts. Calvarial bone is especially useful in noses with severe loss of tip support due to absence of the dorsal and caudal septal strut. Grafts may be secured with wire or with microplates and screws. Calvarial bone grafts may have a rigid appearance and feel. Theoretically, rigid bone grafts in the lower third of the nose may erode through the soft tissues and may be subject to fracture.

In the past, synthetic substances have been widely used for dorsal augmentation. Infection and extrusion rates have varied.

Extruded polytetrafluoroethylene (ePTFE) is an excellent material for dorsal augmentation because of its high tissue compatibility. Although it is porous, significant tissue ingrowth does not occur. The material may be stacked in multiple layers and sutured into position with the open approach. An infection rate of 3.2% has been reported.[18] . It is not recommended for use when a septal perforation is present. When placing ePTFE, the area of dissection must be large enough to avoid rolling or bunching. Let the graft run the entire length of dorsum to avoid a postoperative step-off. The material should be soaked in antibiotics prior to placement. Fresh gloves and instruments should be used to manipulate the implant. Because ePTFE is soft, it is better used as a filler than as a strut. Infection or capsular distortion also can be a problem.

Calcium hydroxylapatite in a carrier-based gel (Radiesse) has been used as an injectable material successfully for small dorsal depressions.

In summary, alloplasts are best used in the at-risk nose only when autologous material is not an option. Broad-spectrum antibiotics should be used perioperatively. Multiple intranasal incisions increase the risk of infection. In soft tissues under tension, especially in the nasal columella and tip, alloplastic implants should be avoided.

Procedure

The nasal tip may be thought of as a tripod. The 2 lateral crura form the cephalic limbs of this tripod, and the paired medial crura form the inferior limb of the tripod. Reducing the length of the lateral crura and/or increasing the length of the medial crura cause the tip to rotate superiorly (see the image below). Conversely, reducing the length of the medial crura and/or increasing the length of the lateral crura cause the tip to rotate inferiorly. If all 3 legs are shortened symmetrically, the tip does not rotate, but projection decreases. If all 3 legs are augmented to the same degree, tip projection increases.

Other techniques attempt to alter tip rotation by moving the position of the dome. For instance, creating a new dome several millimeters lateral to the old one effectively shortens the lateral crus, and it lengthens the medial crus by the same amount. With this technique, the cartilage is softened and a new surgical dome is created by placing mattress sutures through the cartilage at the desired point. If the nasal tip is underprojected, as is often the case with the short nose, leaving lateral crural length intact when achieving upward rotation is preferable. In these cases, the middle leg of the tripod must be lengthened. This most commonly is performed with a cartilage strut. Struts usually are fashioned from septal or auricular cartilage and are secured between the medial crura with dissolvable sutures that traverse the vestibular skin (see the image below).

Further lengthening of the middle leg of the tripod may be achieved by using a columellar-septal suture. This technique secures the medial crural strut complex to the septum in a more projected fashion. Use of a tip graft also may affect rotation and projection. Septal and auricular cartilage grafts are the most common grafts used for this purpose. To decrease rotation, the graft should be sutured into position slightly caudal to the tip-defining cartilage (the caudal border of the domal cartilage). Four 5-0 or 6-0 polydioxanone or clear nylon sutures are used to secure the graft. Tip grafts may be stacked upon one another to increase the effect. Septal cartilage tip grafts have been demonstrated to have long-term survival in 95% of patients. Tip grafting is not recommended in patients with thin skin unless the graft is made of auricular cartilage, is beveled meticulously, or is covered with a thin fascia graft. In patients with thick skin, thicker and more angulated grafts may be used.

Because of the forces of scarring in the healing nose, downward rotation of the tip is more difficult to achieve than upward rotation. The technique used depends on the strength and availability of the cartilages, the thickness of the skin, and the amount of projection present. For instance, the lateral crus may be lengthened by cartilage or composite grafting (see the image below). In addition, the dome may be moved to a more medial position by cartilage-stealing techniques. Alternatively, the medial crura may be shortened by transverse excision, a procedure that is rarely necessary in the short nose.

The septal angle may be moved in a caudal direction with a caudal extension graft. This is a triangular piece of cartilage, the base of which lies along the dorsal plane. In cases in which derotation (ie, downward rotation) is desired, freeing the lateral crura from their attachment to the pyriform apertures and upper lateral cartilages may help. If a rent occurs between the upper and lower lateral cartilages during downward positioning of the tip, a composite graft taken from the concha may be necessary.

Resection of the posterior caudal septum, rotation and stabilization of the lower lateral cartilages in an inferior direction, and internal and external postoperative nasal splinting may effect sufficient lengthening in many short noses. A long dorsal graft may move the nasion superiorly and push tips caudally. A flying buttress graft is a single or paired extended spreader graft secured to a columellar strut. A further development of this concept is the dynamic adjustable rotation tip tensioning technique. This technique involves 2 battens secured on either side of the septum and the columellar strut. Suturing the battens to the septum once proper tip positioning is accomplished makes adjustment of tip rotation and projection possible.

A similar method, using 2 slips of bone, takes advantage of the strength of calvarial bone. One piece is perforated and secured between the medial crura as a columellar strut. A second piece is used as a dorsal strut. If dorsal augmentation is needed, the dorsal strut extends from the nasion to tip and is secured to the underlying bone with lag screws.

If no bony dorsal augmentation is needed, the dorsal bone is fixated to the nasal bones in an end-to-end fashion using a miniplate. A slot is drilled in the caudal end of the dorsal bone strut so that the 2 calvarial bone grafts interdigitate in a tongue-in-groove fashion (see the image below).

A small titanium screw on the columellar piece acts as a stop to prevent retrodisplacement of the bones as scar contraction occurs. A cartilage tip graft is usually necessary to camouflage the corners of the bone grafts. The length of the columellar piece may be reduced and the slot lengthened to adjust rotation and projection of the tip.

Nasal tip projection depends not only on the 3 legs of the nasal tripod but also on the position and integrity of the septal angle and the fibrous attachments between the lower lateral cartilages and the septum–upper lateral cartilage complex. The position and integrity of the septal angle, in turn, depends on the presence of strong dorsal and caudal cartilaginous struts and an intact nasal spine. These conditions are typically absent to one degree or another in the short nose.

As discussed, tip projection may be increased by lengthening the medial crural support using a cartilaginous strut or by advancing the columella along the septum with a septocolumellar suture. Theoretically, cartilage grafting to the 3 legs of the tripod can be performed to increase projection, but in practice this does not produce a tripod strong enough to withstand the forces of scarring. Tip grafts also may be effective in increasing projection, especially when placed directly over the caudal border of the dome cartilage. When the skin is particularly thick, more than a single layer of cartilage may be necessary.

Once the nasal tip has been modified, the surgeon is able to address the dorsum more accurately. In the short nose, dorsal augmentation of both the cartilaginous and bony dorsum often is indicated. Need for dorsal reduction rarely is encountered in this situation and is addressed in other Medscape Reference articles. Following repositioning of the nasal bones, the upper lateral cartilages may be freed from both the septum and nasal bones, and sutures may be secured into more appropriate positions. If the septum remains deviated at the rhinion, cartilage-scoring methods or dorsal spreader grafts can be used.

For significant dorsal deficiencies, graft material must be shaped, inlaid, and secured. For mild-to-moderate deficiencies in the cartilaginous or bony dorsum, flat, beveled pieces of septal or auricular cartilage are placed deep to the skin–soft tissue envelope. Small dorsal irregularities are treated by carving oval pieces of cartilage and morcellating them. Securing these grafts either to the periosteum of the nasal bones or to the upper lateral or septal cartilages with permanent sutures is helpful.

Craniofacial techniques for nasal lengthening take advantage of sublabial and coronal approaches. Osteotomies are performed around the pyriform aperture so that the bony nasal pyramid may be advanced forward. The nasal lining is divided, and interpositional bone grafts are secured. Flaps from the buccal sulcus may be used to fill defects caused by mobilizing the lower lateral cartilage anteriorly. Some patients, particularly those with congenital short noses, may be candidates for LeFort advancements. In such cases, advancement of the maxilla should be carried out prior to the short nose rhinoplasty.

Lengthening the short nose may be accomplished by moving the nasal frontal angle in a cephalad or anterior direction. This can be achieved with grafts made of the same materials used for dorsal modification. Often, the radix is augmented simply by extending the dorsal graft in a cephalad direction. When radix grafts are placed independently, the best approach is to dissect as small a soft tissue pocket as possible and fixate the grafts with internal or external sutures or with screws.

Marianetti et al described the caudal septum pivot (CSP) technique for short nose rhinoplasty, which, in a retrospective study, they suggested could be an effective alternative to the classic septal extension graft in selected patients. CSP surgery involves insertion of a graft into “the dorsal septum after its division using as pivot the caudal portion, without detaching it from its natural anchorage to the anterior nasal spine.” Comparing patients treated with the CSP technique with those who underwent classic septal extension grafting, the investigators found that at 1-year follow-up, patients in both groups demonstrated a statistically significant decrease in the nasolabial angle, with increases in tip projection and nasal length.[19]

After appropriate modification of the internal lining and skeletal framework, the skin and soft tissues are replaced in their anatomic positions and the incisions are closed. Proper taping and splinting help reduce the amount of postoperative swelling. A dorsal splint is placed over a tape dressing to protect the nose and to ensure proper reduction of the nasal bones. The splint also helps prevent swelling in the supratip. Several different types of dorsal splints are available, including plaster, plastic, and metal. Septal splints have been demonstrated to reduce the necessity for revision septal surgery. Packing the nose is rarely necessary. Sutures and internal and external splints are removed approximately 5-8 days later.

Bruising, swelling, and numbness typically are more marked for short nose rhinoplasty than for other rhinoplasties because undermining is usually more extensive. If an open approach is used, tip edema and paresthesias may not resolve completely for 6-12 months.

When robbed of its underlying support, the natural tendency of the nose is to heal in a collapsed, upwardly rotated position. This tendency makes rhinoplasty of the short nose a particular challenge, and it demands that the surgeon extensively undermine both skin and nasal lining and take pains to reconstitute a stable nasal superstructure. If short nose rhinoplasty is successful, dramatic improvement in function and appearance results.

The primary complications of the short nose rhinoplasty include bleeding, infection, extrusion of implant materials, scarring, and unacceptable cosmetic results. Further surgery is occasionally necessary. Intracranial complications have been reported at the calvarial bone harvest site, and pneumothorax is possible with the harvest of rib cartilage.

The first 6 months following the procedure are critical. During this time, the forces of scarring act against the reconstructed underlying skeletal support. This is also the critical period for healing of the internal lining. Nerves and lymphatics continue to heal for up to a year. Further scar remodeling is observed for 12 months. If a patient is satisfied with function and cosmesis 1 year after surgery, the chances for long-term success are excellent.

In the future, new alloplastic implant materials likely will be developed for use in the treatment of the short nose deformity. No doubt the future also will bring controversy as to which, if any, of these materials will act as suitable substitutes for autologous tissue. Growth factors currently are being developed to promote angiogenesis, promote bone development, and improve wound healing.