The complexity of the nose comes from the association of a tension nose scenario, a short septum, an upturned, short and poorly supported tip and a certain grade of Jewish ethnicity or at least a trait visible as a polly beak deformity due to supratip prominence due to an excessively divergent dorsum.
It is a matter of highly experienced aesthetic judgment determining what is the right level of a dorsum; such a decision has to take into consideration the tip level, the frontal bone level, the overall facial profile balance and the final nasal size wished or planned.
The same perfect and straight profile can be set at different levels or heights, as long as the radix, the bony dorsum, the cartilaginous middle vault, the supratip and the tip are in the right alignment; deciding what is the adequate alignment line is important in many cases but in those like the one shown here it is extremely difficult to assess and much more to execute technically.
After a thorough reflection about facial proportions and the facial balance it was deemed, evident by the final outcome, necessary applying the principle of the two elevators, one ascending and the other descending in order to meet at the right level.
On one side there is an excessive and high humpless dorsum with a peak at the lower dorsum, made up by oversized caudal septum and upper lateral cartilages; on the other side there is a short and underprojected tip which is aggravated by the short septum and the tension nose due to shortfall of skin at the lower third of the nose.
With that said, the right neo level for the dorsal profile is somewhere between the current humpless and divergent dorsum and the sunken or short tip; setting the right level at the supratip prominence would lead to a straight profile by means of massively lengthening the tip ending in Pinoccio's deformity and a piggy nose, also this would entail an oversized nose; setting the right dorsum at short and underprojected tip would force to perform an aggressive reduction scooping of the dorsum and the supratip, ending in a disproportionately small, sunken and flat nose, like some ethnicities; this patient's nose needed both, lowering the lower part of the dorsum and raising or reprojecting the tip, with an associated change in the angle between dorsum and maxilla so that it is a less divergent dorsum.
The course of action began harvesting a deep septum graft to proceed an one on one septal lengthening, which was used as pillar or support to perform full nose lengthening, tongue in groove fixation of the medial cruras and tip reprojection to the desired level.
Then the dorsum was shaved down still preserving its preoperative straight line but carefully planned so that its angle from the maxilla was decreased to the right degrees, thus correcting the caudal excess of the septum and upper lateral cartilages which underlied the polly beak prominence of the supratip; the broad dorsum required paramedial resection of nasal bones and subsequent osteotomies to close the roof.
Finally a customized tip grafting was tailored out of an ear concha cartilage harvest, so that the new tip is defined and relocated, creating a smooth and subtle supratip break effect.
Regarding the chin it was deemed a good one in height and width, so that only anterior projection was intended by means of a basic sliding genioplasty to forward the central chin.
The final result shows a brand new face with an awesome improvement in facial balance and a total correction of the issues preoperatively targeted.
READ LESS