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European Journal of Plastic Surgery

, Volume 41, Issue 5, pp 543–556 | Cite as

Prominent nose, its modalities and their treatment

  • Igor Niechajev
Original Paper

Abstract

Background

Size of the nose varies in the different parts of the world, and perception of what is the aesthetically acceptable nose shows large differences depending on the ethnic background, type of the society, gender and age. Nose which is generally larger than the average nose in a given society, particularly regarding the height of its nasal bridge, could be defined as a prominent nose.

Methods

Photographs of the 414 consecutive patients who underwent rhinoplasty by the author during the years 2014 and 2015 were reviewed. Attention was directed to the following outer features: overall length, height and width of the nose, nasofrontal angle, nasolabial angle, nose-lip and nose-chin relations, shape and position of the chin and the evaluation of the respiratory function. Among determinants was formula of Goode, which delineates the approximate relationship between tip projection and nasal length.

Results

A total of 144 patients, 112 females and 31 males, who fulfilled criteria of prominent nose were selected for the further analysis. A total of 70% of the patients were of Middle-Eastern origin. The following four types of prominent nose were recognised: (1) short prominent nose, or tension nose was present in 38 patients. It has overprojecting dorsum, which usually forms a hump. Nasolabial angle is obtuse, and nasal spina is frequently overgrown. The rate of functional problems is quite high due to the overdevelopment and subsequent deviation of the septal cartilage. (2) Long prominent nose, present in 96 patients, usually has an arched dorsum, sharp NL angle and drooping tip. (3) Long nose depending on the height of the dorsum in the lateral projection can be the low long nose and it was seen in four patients, or when the nose is both long and the tip is overprojecting, it is called Pinocchio nose and it was present in eight patients. (4) Rhinomegaly is the term describing nose which is very large in all dimensions, the height, length and width and was also seen in eight patients.

Conclusions

Prominent nose has several modalities and each of them requires different techniques applied during the surgical intervention. Both aesthetic and functional topics are frequently present, and multiple nasal structures, both external and internal, are commonly involved. In the aesthetically pleasing Caucasian nose, Goode’s ratio should equal 0.55 to 0.60. If there is before operation unrecognised deviation from this norm, which is also persistent after the rhinoplasty, the final result will be substandard.

Level of Evidence IV, risk / prognostic study.

Keywords

Prominent nose Large nose Rhinomegaly Rhinoplasty Middle-eastern rhinoplasty 

We are in the process of perfecting our craftsmanship but we have yet to be artists. (Mario Gonzales-Ulloa 1962)

Introduction

The size of the nose varies in the different parts of the world, and perception of what is the aesthetically acceptable nose shows large differences depending on the ethnic background, type of the society, gender and age. Nose which is generally larger than the average nose in a given society, particularly regarding the height of its nasal bridge, could be defined as a prominent nose. Larger prevalence of the prominent noses in a total population is seen in the Mediterranean basin and in the Middle East [1, 2, 3].

Several modalities of the nasal pyramid such as deviated nose [4], twisted nose, crooked nose [5] and the saddle nose deformity [6, 7, 8] are well described in the literature. PubMed search did not reveal any papers concerning the opposite condition to the latter, the prominent nose. The prominent nose is a large nose per definition, but it has several varieties. The goals of this study were to analyse and classify varieties of the prominent nose and describe the guidelines for special rhinoplasty techniques applied in each subgroup.

Material and method

The current study was based on the analysis of compiled data from medical charts and photographs of the 414 consecutive patients operated by the author during the years 2014 and 2015. The group consisted of 339 females and 105 males ranging in age from 17 to 70 years (mean 28 years).

A total of 144 patients, 35% of the whole cohort, were judged by the surgeon as having some type of the prominent nose and were sorted out for the further analysis. Among them were 112 females and 31 males, and they underwent either the primary rhinoplasty (132) or were originally operated elsewhere and came for the secondary correction (12). Endonasal approach was prevailing, but 16 patients, among them the secondary cases or patients with the rhinomegaly, were operated by the open technique. In four patients with the broad tip, the semi-open method was chosen. Seventy percent of the patients had middle-eastern ancestry.

Measurements for the preoperative evaluation

In the patient with the prominent nose, particular attention is directed to the following outer features: overall length, height and width of the nose, nasofrontal angle (NF), nasolabial angle (NL), nose-lip and nose-chin relations, shape and position of the chin and the evaluation of the respiratory function. Among the determinants is also the formula of Goode, which delineates the approximate relationship between tip projection and the nasal length (Fig. 1 right) [9]. In the aesthetically pleasing Caucasian nose, BC should equal 0.55 to 0.60 of AB. For example, if the length of the nose is 50 mm, then the optimal tip projection should be 30 mm, or just below.
Fig. 1

Right-inclination of the nasal bridge (NB) is the angle between the line tangential to the nasal dorsum and the vertical vector of the face. Goode’s ratio delineates relationship between the tip projection and the nasal length. The nasal length is measured from the nasal radix to the nasal tip (a, b). The projection is measured from the nasolabial junction to the tip (b, c). Left-nasofrontal angle and nasolabial angle. C-corneal line, G-glabella, N-nasion, F-Frankfort horizontal, SN-subnasale, T-tip (left part: modified from I.Niechajev, Noses of the Middle East: Variety of Phenotypes and Surgical Approaches. J Craniofac Surg 27(7):1701. Right part: displayed with the permission of Elsevier publishers. From E.M. Tardy Rhinoplasty the Art and the Science, Saunders Co, 1977, Vol. II, p. 526)

For the routine daily work, we may use calliper, for example, the Martin (KLS Martin, Tuttlingen, Germany), but for the scientific purposes, more precise measurements are required. One of the tools available is the GIMP Unix-like Image Manipulating Program, which is similar to Adobe Photoshop, but it is a free ware program. Using measure tool for distance and angle allows the program to calculate angles by drawing lines connecting two points superimposed on the patient’s photograph (Fig. 2) [10].
Fig. 2

An example of angle measurement for scientific purposes, performed using the measure tool in the GIMP program for distance and angle is shown on the profile view of 32-year-old male with rhinomegaly

Nasofrontal angle is measured between the nasal bridge contour and the anterior surface of the forehead below the glabella (Fig. 1 left). NF angle can be deep, regular well-balanced or shallow and plays an important role in our perception of the size and length of the nose and the facial harmony [3]. In Caucasians, normal values are 115–130°. Inclination of the nasal pyramid, or how much the nose sticks out, is determined by the angle between the line tangential to the nasal dorsum and the vertical vector of the face (normal in Caucasians is 30–40°.

Nasolabial angle measurement aids to assess the position of the nasal tip in relation to the nasal base. The coherent method is to measure the angle between the line connecting the subnasale and the nasal tip and the line perpendicular to the Frankfort horizontal, which is the line drawn from the upper border of the external auditory canal to the most inferior point of infraorbital rim (Fig. 1 left). Therefore, it is important to include tragus on the lateral photographs. The normal value is 90–120°.

Nasal length is obtained either by superimposing the straight line from the nasion to the tip on the life-size image, or by taking such measurement with the calliper on the patient.

Also, the rational approach to the osteotomies is important. Several various osteotomes from fine to heavy are available and held sterile in the transparent package. Depending on the patient’s variations in bony anatomy, optimal osteotomes are chosen for each patient (Fig. 3).
Fig. 3

System of osteotomes with the variating form and strength

Another important aspects to be evaluated at planning of the procedure are skin thickness, amount of the subcutaneous fat and the shape of the medial crura, including footplates, which affects the aesthetic appearance of the columella.

Results

The following four types of prominent nose were recognised:
  1. 1.
    Short prominent nose, or tension nose was present in 38 patients (Figs. 4 and 5). It has overprojecting dorsum, which typically forms a hump. NL angle is obtuse, and nasal spina is frequently overgrown. Alae could be high-arched and inserted high on the alar-facial junction, exposing excessive area of membranous septum. The rate of functional problems is quite high due to the overdevelopment and subsequent deviation of the septal cartilage. Such noses are frequently seen in the people with the Latin origin, both in Europe and in the South America, and in the Middle East [2, 3].
    Fig. 4

    Short prominent nose in a 28-year-old woman of Chilean origin before and 1.5 year after the rhinoplasty

    Fig. 5

    Short prominent nose in 19-year-old woman with of Assyrian ancestry, born in Syria (left) before the procedure, (center) good aesthetic appearance after 3 years and excellent appearance (right) after 8 years

    Correction includes an aggressive lowering of the nasal bridge and, if needed, the septoplasty. Transfixion incision is extended downwards to the level of nasal spine. Reduction of anterior nasal spine with rongeur, and non-resorbable suture between the orbicularis oris muscle and the base of the septum cause desired change in N-L angle from obtuse to more aesthetically pleasing. If upper lip is short and teeth are exposed in the relaxed state, frenulum plasty (elongation) is indicated. Unfolding procedure might be necessary to lower retracted alar rim, and it involves composite chondro-cutaneous graft from the ear’s concha. Cranial rotation of the tip is contraindicated.

     
  2. 2.
    Long prominent nose, present in 96 patients, usually has an arched dorsum, sharp NL angle and drooping tip, which rotates downwards during the animation (Figs. 6 and 7). Such noses are rather unusual in the population of the Northern and Central Europe, but we see them in the Mediterranean region and throughout the Middle East [2, 3].
    Fig. 6

    Long prominent nose in a 19-year-old girl born in the Kurd region of the Northern Irak. (Left) before and (right) 1 year after the septo-rhinoplasty

    Fig. 7

    Long prominent nose in 35-year-old women born in Iraq. N-L angle before operation was 80°

    Correction includes cranial rotation of the tip and humpectomy. Cartilaginous dorsum can be lowered by the supramucosal technique described and popularised by Jost [11]. Instead of cutting off the dorsal part of the lateral cartilages and septum in one piece, the lateral cartilages are separated from septum and pushed down and laterally, preserving continuity of the nasal mucosa. In the next step, the dorsal septum is judiciously lowered under the direct vision control.

    To lower overprojecting tip, the height of the cartilaginous framework has to be reduced. It could be achieved by several ways and is usually the combined effect of lowering of the nasal dorsum, cephalad reduction of alar cartilages, shortening of the remaining alar cartilaginous arch [12] and reduction of the nasal spine [13, 14, 15]. Deprojection of the tip inevitably results in alar sidewall flaring, which sometimes requires alar reduction.

     
  3. 3.
    Long nose has an abnormal length of the dorsum, measured from radix to the tip and can be graded depending on the height of the dorsum and the degree of tip projection. There are two variants. Long nose which is prominent forwards is called “Pinocchio nose”. Long nose prominent downwards can be called long low nose. It has its tip below the level of subnasale (Figs. 8 and 9) and was seen in four patients. Former German chancellor Konrad Adenauer was a known proprietor of the long low nose.
    Fig. 8

    Long low nose in 32-year-old woman of Turkish ancestry. Before and 1.5 year after the septo-rhinoplasty and the reduction of the lower turbinates

    Fig. 9

    Long low nose in 29-year-old women born in the Kurd region of Turkey, before and 1 year after the rhinoplasty

    Besides standard rhinoplasty manoeuvres, special techniques are undertaken to decrease length of the nose. Redundant skin envelope can be reduced by the horizontal ellipsoid excision at the level of nasion. Subperiosteal and subcutaneous dissection follows in the retrograde manner. The whole skin envelope of the nose is lifted cephalad and anchored to the subcutis and periost of the glabella at the upper edge of the excision.

    Lowering of the nasal bridge is judicious and conservative. In some patients, the nasal bridge, in profile view, is a direct prolongation of the frontal contour. Such nose, sometimes wrongly called “Greek nose”, can be made optically shorter by chiselling out the cortical part of the nasal bones below the nasofrontal junction. This will break the continuous nosofrontal line and place the nasion point more caudally [13]. En bloc triangular excision of the septum membranosum, connective tissue, parts of medial crus and caudal septum lifts the tip of the nose. The base of this triangle is upward and parallel to the nasal dorsum. This manoeuvre was originally described in 1931 by Joseph in his monumental book [16].

    Pinocchio type of nose is both long and has the tip with exuberated forward projection and it was present in eight patients (Figs. 10 and 11). Persons with the Pinocchio type of nose are frequently subject of jokes and ridiculing remarks, which is emotionally severely disturbing. French novelist Cyrano de Bergerac (1619–1655) is the most famous person with such nose, and whose long nose is a documented fact. He is best known as the inspiration for Edmond Rostand’s drama Cyrano de Bergerac.
    Fig. 10

    Pinocchio nose in a 30-year-old woman born in Colombia

    Fig. 11

    Pinocchio nose in a 25-year-old male of Assyrian ancestry with overprojected tip in a wide and deviated nose. (Left) before and (right) 1 year after the septo-rhinoplasty, which included general setback, straightening and narrowing of the nose

    Correction of the Pinocchio nose involves bold reduction of the soft tissues by the wedge resection of the alae and 4–7-mm horizontal excision of portion of columella including medial crura. Lateral crura must also be shortened, followed by angled resection of the caudal and dorsal parts of the septum. Once the tip is moved to the new desirable position, the anticipated hump appears on the nasal dorsum. The hump is removed and the lateral and medial osteotomies will narrow the nasal bridge. At the end, the excess of the vestibular skin is trimmed [17, 18].

     
  4. 4.
    Rhinomegaly is the term describing nose which is very large in all dimensions, the height, length and width (Figs. 12 and 13) and was seen in eight patients. The term derives from the Greek, rhino (ρινο), means nose and megalo (μεγαλο) great. Noses in advanced rhinophyma can achieve rhinomegalic proportions. An overlarge nose can overwhelm the remaining facial features and draw unwanted attention from the surrounding persons. Through the history, many prominent people had prominent, rhinomegalic noses, one of the most famous was that of Charles de Gaulle. Several rhinomegalic noses can, e.g., also be seen on the portraits of XV-th century Italian noblesse in the Uffizi Gallery in Florence.
    Fig. 12

    Rhinomegaly in a 39-year-old Syrian woman. (Left) before reduction septo-rhinoplasty and (right) 7 years postop, when she accompanied her 18-year-old daughter for the rhinoplasty

    Fig. 13

    Ageing rhinomegalic nose in 63-year-old Kurdish man from Irak, with thick skin and loss of tip projection. Preoperative nasolabial angle was 70°. He underwent open septo-rhinoplasty. The tip was elevated and stabilised by the 35-mm-long columellar strut. The bulk of the alar lobuli and the width of the nasal base were reduced

    In rhinomegaly, the goal for both patient and surgeon is to diminish the nose as much as possible, without compromising its respiratory function. Majority of patients are males. From the palette of the techniques and approaches, some particularly suitable for the correction of the rhinomegalic nose are chosen. Open rhinoplasty is mandatory, because of the need for a major rearrangement of the cartilaginous framework, requiring the internal sutures. Thickness of the skin envelope and the bulging shape of the tip can be reduced by plucking of fatty- and connective tissue from the subcutis under the direct vision control (Fig. 14). After reduction of large alar cartilages, various deprojection manoeuvres on its medial, intermedial and/or lateral crus are undertaken.
    Fig. 14

    Plucking of fatty- and connective tissue from the subcutis of the tip under the direct vision control

    Alar resection cutaneous and vestibular (Sheen type II) [19] is frequently indicated. Nostrils can be thick and with alar hooding, resulting from a large alar lobule segment inserting lower on the face then normal and hiding columella on the side view. Correction of such poor columellar–alar relationship will require thinning of the alar tissues, tangential vestibular resection and infolding of the lateral alar rim (Fig. 6 left). Nasal bones are usually thick and will require strong Silver osteotomes for lateral osteotomies. External and internal medial osteotomies aid to bring wide positioned bones of the nasal dorsum together and create narrower nasal bridge. In most of the patients with large noses and NL angle ≤ 900, animation sharpens the NL angle by about 10–15 °, and the tip appears to curl down in what patients perceive as very unattractive. This undesirable phenomenon ceases or strongly diminishes after rhinoplasty due to the stabilizing effect of the intranasal and paranasal scar formation (Fig. 12).

     

Discussion

Prominent nose can in some patients be caused for the offensive comments and nicknames, but in the majority, it just disturbs their own perception of their appearance in the mirror. As a group or category, patients with a large nose are usually grateful task for the plastic surgeon, because their desires are clear and their “deformity” is real.

Prominent nose has several modalities, and therefore, no single operating technique is advocated. Surgeon neophyte can master one single technique in breast reduction or blepharoplasty and this, properly executed, can carry him or her long. Having patient with the prominent nose requires, besides the skills in several rhinoplastic techniques and approaches, broader theoretic and practical knowledge of the ancillary procedures. Among them are manoeuvres on the radix and NF angle, modulation of N-L angle, reduction of the nasal spine, lengthening or shortening of the upper lip, chin reduction and chin augmentation.

In the most of cases with prominent nose, the short prominent nose is an exception, the tip setback and cephalad rotation are necessary. Regulation of the tip projection and rotation can be comprehensively explained by the tripoid principle [12, 20]. Paired medial crura of alar cartilages are the forward and central leg and each of the lateral crura are two lateral legs of the tripoid. This tripoid is supported by the caudal septum, which acts as its pedestal. By changing the length of its legs, the projection, rotation and the shape of the tip can be changed (Fig. 15). Height reduction of the central, anterior leg reduces the projection and tilts the tip downwards. Contrary, lowering of the two posterior elements will decrease the projection and increase or support the cranial rotation of the tip [12, 20].
Fig. 15

Tripoid principle (displayed with the permission of Elsevier publishers and by the courtesy of Prof. Fazil Apaydin, Clin Plast Surg 43(1):152, January 2016)

This can be achieved by alar cartilage remodelling popularised by George Peck [21]. The lateral part of the alar cartilage is excised and the scoring on the intermedial crus area permits the lateral slide of the alar cartilage. Gubisch and Eichhorn-Sens [12] refined the medial and/or lateral sliding technique, in which the alar cartilages are cut and pushed down above the lateral, and/or inside the lower fragment and fixated in the overlapping position by the permanent sutures (Fig. 16).
Fig. 16

Tip setback can be performed by sliding and overlapping on the lateral or medial crura and sometimes on both, depending on the clinical situation

Surgeons who do rhinoplasty less frequently usually have one rhinoplasty instrument set, with one or two osteotomes, which they use for all cases. An easier operation conduct and thus better results could be achieved, if the optimal osteotome is chosen for each particular modality of the nasal bones.

The nose type termed “Greek nose” was indeed created by the chisels of idealising artists in the antique Greece and is appearing as a long nose with the well-balanced dorsal height, straight and narrow bridge, pointing tip and narrow nostrils. Such noses can be seen in the antique sculptures or are depicted on vases from the antique Greece. They are also present in this patient series, but only as result of manipulation by rhinoplasty (Fig. 17).
Fig. 17

The “Greek nose” (right) was created in this 23-year-old male, born in the Kurd region of the Northern Iraq. (Left) the preoperative appearance

The “Greek nose” does not correlate to the noses of the population of Greece today. Actually, many Greeks are not fully satisfied with the prevailingly Mediterranean type of nose they have. Nose surgery is the third most common aesthetic operation in Greece, with the annual number of 6900 in an 11 million population (ISAPS 2016 year international survey) [22].

Conclusions

Prominent nose has several modalities and each of them requires different techniques applied during the surgical intervention. Both aesthetic and functional topics are frequently present and multiple nasal structures, both external and internal, are commonly involved. The surgeon must balance patient’s dreams and desires and the existent anatomic predispositions with his knowledge of predictable surgical techniques and healing processes to obtain favourable, yet well-camouflaged results. In the aesthetically pleasing Caucasian nose, Goode’s ratio should equal 0.55 to 0.60. If there is before operation unrecognised deviation from this norm, which is also persistent after the rhinoplasty, the final result will be substandard.

Notes

Compliance with ethical standards

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of retrospective study, formal consent is not required.

Patient consent

Informed consent was obtained from all individual participants included in this study.

Conflict of interest

Igor Niechajev declares that he has no conflict of interest.

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Lidingö-clinicLidingöSweden

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