Dr. Alejandro Nogueira's Case #XCQEHCBX

This nose is tricky because at first or lay glance one might say there is a long hump needing removal so that the tip of the nose and the radix would form a straight profile line; that would be a dramatic error of judgment, since doing so the nasal pyramid would barely exist and the nose would end flat and fully Asian; furthermore such a tiny nose would not fit at all with the broad craniofacial skeleton of this patient's face, the large cheekbones, forehead, etc.

The real hump excess was minimal, but was virtually aggravated due to the Asian features of the patient visible in her tiny tip; the nasal tip was short, sharp, underprojected and as happens in most Hispanic and Andine noses was also poorly supported due to partial absence of a very short caudal septum.

Such short caudal septum made also the nasolabial angle too wide and the tip upturned, plus a short nose syndrome.

We are not talking about a slightly or moderately short tip, it is a matter of a large amount of millimeters the tip had to be lengthened and quite ones the nose lengthened which equals to derotate and lower the tip; the former connects with another peculiar issue, the patient suffered from short columella syndrome, this means the skin at the columella was in massive shortfall and did not allow the grade of tip lengthening that was required to restore normal facial proportions; this is the reason why a columella lengthening flap had to be done instead the traditional open approach incision, so that a supply of cutaneous length would make viable the skeletal lengthening which was accordingly planned; note the atypical columellar incision for the advancement skin flap, which recruited skin from the nostrils towards the midline.

To summarize, we have a short nose syndrome, a short tip syndrome, a short columella syndrome and an apparently large and long hump which actually is a very short and thin one; but there were more issues.

A typically Arabic feature is the noticeable inversion or concavity of the lateral cruras of the lower lateral cartilages, which was bilateral, total, symmetrical and very deep; note how the nostril rims were collapsed and the tip was excessively sharp due to this fact.

Due to the short tip and the short caudal septum there was a sunken supratip which required a raise with grafting; actually this case could be flagged also as tension nose deformity, due to having a relative excess of pyramidal structures and a shortfall of tip and soft parts, which for real was a massive shortfall of the lower part of the nose and a lesser but still severe shortfall of the pyramidal parts, with only a subtle dorsal real excess.

As minor features it is to mention the slight and atypical concavity of the upper lateral or triangular cartilages and the supratip pinching.

Last but not least, the dorsal hump and the humpless dorsum had a rhomboid configuration, requiring paramedial resection of the lower synchondrosis and the upper synostosis between the nasal wall and the, respectively, soft and hard nasal septum.

All the former issues are not atypical or weird themselves, actually all of them are very typical from different ethnicities; what is a real oddity and a technical ordeal is facing them all together in the same nose.

Deeming the nose disproportionately small in massive grade if considered within this particular patient's face, the surgical plan was a full augmentative rhinoplasty at all areas except two; the only reduced parts were the real hump arising after the nasal augmentation and the broad dorsal rhombus which required narrowing as mentioned before.

The comprehensive augmentative rhinoplasty began harvesting the maximum availability from the donor ears' concha bowls, which fortunately had cartilages large and thick enough for the purpose, therefore preventing the use of rib cartilage.

Once the dorsal work and the mandatory osteotomies were performed the grafting phase began, applying onlay grafts on top of the naturally existing skeleton which was used as underlying platform; a pair of onlay grafts were applied riding the original lateral cruras and in practical terms replacing their aesthetic effect, enlarging the alae, correcting the lateral crura concavity and treating the alar rim collapse.

A supratip graft was applied to correct the sunken middle vault; then a highly customized and augmentative tip graft was applied on top of the original tip domes, very finely tailored and scored as grid on its outer surface to achieve a rounded effect; a columellar onlay graft made the caudal extension effect in a indirect manner and provided the nasolabial angle reduction.

The thin dorsal skin allowed multiple transparencies of the heterogeneous dorsal work, since each dorsal part had received a different technique due to be featured by different issues, so it was decided to apply a superficial temporalis fascia all over the dorsum and nasal walls, from radix down to the supratip, in order to provide the right camouflage; this was a successful solution as can be noted in the postoperative smooth dorsal contour; this temporal fascia graft also allowed correction and hiding to the concavity of the upper lateral cartilages and the pinched middle vault.

Augmentative rhinoplasties are way more difficult, challenging and complex than reduction ones; should the patient have mixed and atypical features this escalates to a superior level; this patient enjoys now of a larger, proportionate and suitable nose within her now balanced facial features.