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Rhinoplasty, the balancing act

Posted: 28th February 2011
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Rhinoplasty (Greek rhinos=nose, plastikos=to mould) is the technical term for a “nose job”. While in most cases it is the nose that is “moulded” and remodelled, there are occasions when under or overdevelopment of other parts of the face give the illusion of a disproportionate nose.

The aesthetic objective of most patients is to create balance within the nose and to balance the nose with the rest of the face. Facial proportions vary considerably between men and women and across different racial groups, and part of the skill, and art, of rhinoplasty is the ability to identify what has tipped the nose out of balance. Often, as in cases of a clear nasal hump or a bulbous tip, the disproportion will be obvious to the patient, on other occasions, the imbalance may be more subtle, and then the patient's complaint may be less focused,  and may simply be “my nose is too big”.

A combination of a lengthy discussion with the patient, careful measurements of the face and analysis of photographs will help the surgeon determine how the nose could be improved. Photographic manipulation or morphing then allows the surgeon to rebalance the proportions and provides a picture to help the patient when considering their objectives 

What is a balanced nose?

A well-balanced nose will complement the rest of the face, it will not dominate the face, it will not make a female face look masculine or feminise a male face, and ideally it will not clash with other facial features. The nose does not need to be completely symmetrical but marked asymmetry distracts the eye.  While assessing the nose, the surgeon will take at least 30 measurements, the following are a few examples based on classical da Vinci proportions.

A balanced nose will occupy about a third of the facial length, and its width at the nostril base will be equal to the width of one eye, the space between the eyes, or two thirds of the width of the mouth.  The angle between the nose and the lip is about 90 degrees in men and a little more in women (95-100 degrees), this angle will mean that the nostrils will not be too obvious, on account of an over upturned tip or be completely hidden by a drooping tip.

The ideal tip is well defined and should be the highest point of the dorsal nasal line. The volume, rotation and shape of the tip are also critical to a well-proportioned nose.

In the interest of individuality, the classical rules of facial proportion are there to be broken, it would certainly be a shame if we all had similar faces. But while a large nose can compliment a “strong” face, just look at Sophia Loren or Adrien Brody, there are certainly cases where disproportion distracts and spoils an otherwise very attractive appearance. 

Loss of balance of the nose

Features within the nose that create imbalance include prominent nasal bones and cartilage that project the nose excessively. An under supported tip will accentuate the humped appearance of the nose and spoil the proportions of the nasal tip. Large, bulky, tip cartilages will produce a bulbous and featureless tip.

The nose may in itself be well proportioned but will look more “obvious” if the tissues around it are under-developed. The two classic areas that may be responsible for this illusion are the chin and the root of the nose. If the root of the nose is recessive, the remainder of the dorsum will appear humped, and the tip will dominate. A recessive or underdeveloped chin is another feature that will make the nose appear more prominent.   

How can the nose and face be rebalanced

Traditionally, rhinoplasty surgery involved either the removal or reshaping of tissues from the nose, the so-called reduction rhinoplasty.  Over the last fifteen years one of the more important advances in rhinoplasty has been the development of what has become known as augmentation rhinoplasty. In these cases, tissue from other areas of the body, or occasionally artificial material, is used to build up areas that are under-developed. It is now acknowledged that a combination of both augmentation and reduction should be considered when planning rhinoplasty surgery.

Sometimes very little needs to be done to correct an imbalance.  For instance, the loss of definition of the nasal tip may blur the distinction between the tip and the remainder of the nose, the result can give the impression of an excessively long and bulky tip. The simple act of creating a distinct ”break” between the two can rebalance the nose beautifully, and is achieved either by the removal of a small segment of tip cartilage or by supporting and elevating the tip.  A combination of cartilage from within the nose, or from the ear, and a thin layer of tissue from the hairline can be used to elevate a low root or dorsum and draw the eye away from the tip. The tip can be re-projected and supported to correct the imbalance seen in the long gentle curve of some hooked noses.

In patients with a recessive chin, a normal sized nose may appear to dominate the face. In many cases, the situation can be redressed without touching the nose, but by providing augmentation to the chin. This procedure can involve sliding the bone forward or introducing an implant at the level of the bone.  Other surgical manoeuvres that can balance the nose include changing the width of the upper two thirds of the nose, refining a bulky tip or camouflaging a pinched tip and reducing flare of wide nostrils or by splinting excessively narrow, nostrils.  It has been correctly stated that much of the skill in rhinoplasty is in the planning.

An understanding of proportion and an aesthetic eye are critical. When there is a true hump, it is fine to remove it,  but to remove “the bump” in situations where a low set root, unsupported tip or recessive chin are actually responsible for the disproportion simply shifts the imbalance. The message is, don’t look at the nose in isolation; remember the rest of the face.

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