Short Nose 

Overview

A short nose with a low seated nasal bridge is seen in many persons. This might result in a nose that is excessively short for the proportions of the face, giving the face a shorter and rounder appearance. The nasal region is frequently lacking in projection and definition when viewed from the side. Functionally, glasses may not sit well and may slip off the face.

A button nose is defined as having a rounded nasal tip and a tiny nose that may tilt up or down slightly, giving your nose a rounded appearance.

One of the most difficult issues in rhinoplasty has been the short nose. This sort of malformation usually affects all three layers of nasal tissue (ie, skin, internal lining, skeletal support). Short noses cause both cosmetic and practical issues. When done correctly, short nose rhinoplasty may yield dramatic results.

What Causes a Short Nose?

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:

Trauma is the most prevalent cause of a short nose. Frontal impacts to the dorsum and tip of the nose cause the nasal bones to shatter and splay. Upper lateral and septal cartilages crack, buckle, and disturb as well. Hematomas between the cartilage and perichondrium can induce cartilage destruction by depriving the cells of nutrients. Nothing stops upward rotation and deprojection of the tip since the lower lateral cartilages have lost their cephalic support. The short nose deformity increases as the contractile forces of scarring progress over the weeks following the original injury. Loss of projection, flaring of the alae, enlargement of domes, rounding of the anterior nares, and asymmetry are all symptoms of problems with the lower lateral cartilage.

• Prior nasal surgery:

Another typical reason of a small nose is previous nasal surgery. The dorsum and root may be underutilized. An open roof malformation with splayed nasal bones may be present. Over-reduction of the nasal septum results in a fragile dorsal strut, which collapses the bridge and causes the tip to spin superiorly. This rotation is aided if the upper lateral cartilage is accidentally torn away from the nasal bones and/or septum. Aggressive lateral crura excision compromises the tip's cartilaginous integrity and deprives the tip of essential fibrous connections between the lateral crura and upper lateral cartilages.

• Drug abuse:

Cocaine and methamphetamine addiction can also result in a short nose deformity. In 4.8% of habitual cocaine users, septal perforations were discovered. Cocaine, as a vasoconstrictor, causes localized rhinitis, which causes dryness, crusting, and bleeding. Focal necrosis of the perichondrium occurs, exposing and killing chondrocytes. Eventually, the majority of the septal cartilage is lost, resulting in dorsum collapse and tip upward rotation.

• 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:

Short nose deformities can be caused by neoplasms such as esthesioneuroblastoma, inverting papilloma, and squamous cell carcinoma. Another type of tumor that regularly damages nasal tissue is angiocentric immunoproliferative lesions. Polymorphic reticulosis, lymphomatoid granulomatosis, pseudolymphoma, deadly midline granuloma syndrome, nonhealing midline granuloma, and midline destructive granuloma are some of the conditions that produce these lesions. All of these organisms have the potential to cause tissue damage, resulting in the short nose deformity.

When Short Nose Rhinoplasty is Indicated?

Short nose rhinoplasty is recommended for people who are deemed suitable surgical candidates for aesthetic or functional reasons. Breathing difficulties via one or both nostrils, nasal bleeding, crusting, dryness, infection, or discomfort are all functional grounds for short nose rhinoplasty. Cosmetic indications include a retracted or upturned tip, with or without nasal dorsum collapse.

Contraindications For Short Nose Rhinoplasty

Patients with an unstable mental state at the time of consultation or surgery, patients with BDD or unrealistic expectations, obstructive sleep apnea, active cocaine users, and patients with comorbidities that contraindicate surgical treatments are all common contraindications for rhinoplasty.

• Body Dysmorphic Disorder (BDD): 

This mental condition is characterized by excessive anxiety about a perceived or barely detectable fault in one's appearance. As a result of these variables, patients have more difficulties socializing, have a worse quality of life, are more prone to depression, and have a higher risk of suicidal thoughts.

Because symptoms may develop postoperatively if not noticed, and the patient will be unsatisfied with the outcomes, surgeons must identify this type of patient early. Currently, there is no validated questionnaire available to appropriately diagnose these people. If clinical suspicion arises, a referral for mental health evaluation is necessary.

• Obstructive Sleep Apnea: 

This common condition is defined by repeated episodes of airway obstruction while sleeping. Patients with this condition are more prone to experience perioperative complications. The symptoms of the patient may lead to a diagnosis, although it may also be asymptomatic. While screening questionnaires can be used, their accuracy is limited.

The gold standard for diagnosis is polysomnography. Patients with this illness should be made aware of the risks, and preoperative therapies such as the use of a continuous positive airway pressure (CPAP) device may be utilized to reduce complication rates.

• Cocaine Abuse:

Patients who abuse cocaine fall into a separate group. Inhaled cocaine induces significant vasoconstriction and prolonged mucosal irritation due to the many contaminating components.

During a rhinoscopy, everything from mild inflammation to major septal perforations might be detected. These people are also more likely to have postoperative complications including septal collapse or delayed septal mucosa healing, thus they should avoid nose surgery.

• Tobacco Smoking: 

Although it appears that cigarette smoking has no influence on the success of septoplasty, patients should be advised to quit smoking before the surgery because of the numerous negative consequences.

• Bleeding Disorders:

Following surgery, blood clotting issues may emerge. Patients should be questioned if they have a history of severe bruising or bleeding, whether they use anticoagulant medications, supplements, or vitamins, and if they have had previous thrombotic episodes. Any medication, vitamin, or supplement that affects coagulation may need to be stopped before surgery.

In general, individuals who have had a previous rhinoplasty and are dissatisfied with the results should wait at least one year before undergoing any examination on the definite outcome or subsequent treatment.

How to Prepare Before the Procedure?

In preparing for rhinoplasty surgery, you may be asked to:

• Get a lab test (e.g. CBC).
• Take certain medications or adjust your current medications.
• Stop smoking.
• Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding.

Your plastic surgeon will also go over the site of your surgery with you. Rhinoplasty can be done at a hospital, a licensed ambulatory surgery center, or a permitted office-based surgical facility. Make plans for someone to drive you to and from surgery and to remain with you for at least the first night following surgery.

Short Nose Rhinoplasty Procedure

When treating a long-standing short nose or saddle nose, three main concepts are observed: thorough skin undermining, restoration of structural support, and, if required, release of internal lining. A thorough dissection of the nasal skin is required for redraping. Undermine past the pyriform opening and all the way to the radix. Take care not to puncture delicate damaged skin. Antibiotics are advised for extensive nose reconstructions, particularly when alloplasts are used when the internal lining is damaged.

• Open approach:

The open approach is beneficial for the short nose in both the acute and post-acute phases. This method entails producing marginal incisions that are linked by a skin incision at the midcolumellar region. This enables the surgeon to lift the skin and soft tissue of the bottom part of the nose and see the cartilages in situ. The open method is especially beneficial in patients with short noses because it allows for grafting, visibility of existing cartilage deficiencies, and the use of both hands.

 In contrast to closed techniques, the open methodology allows for direct visibility, binocular vision, and bimanual structural manipulation. Tip grafts, onlay grafts, and struts may be precisely carved and anchored at precise places without moving or changing. It gives the operator more accuracy while working on the cartilaginous dorsum and upper lateral cartilages.

• Closed approaches:

Closed techniques can also be employed to address short noses. Mucoperichondrial flaps are raised on either side of the septum, back incisions are performed, and the flaps are advanced anteriorly and inferiorly using these techniques. Transfixion incisions are used to separate the lower lateral and upper lateral cartilages. To push the nasal tip caudally, batten grafts can be placed through hemitransfixion incisions in the membranous septum. When the mucosa between the upper and lower lateral cartilages must be removed, a gap may emerge when the lower lateral cartilages travel caudally. A conchal cartilage composite transplant can be used to close this gap. It is feasible to advance the columella using composite or full-thickness skin grafts in the membranous septum.

• Graft and implant materials:

When the septum has collapsed, releasing the upper lateral cartilage from the septal remnant may be necessary. It is also feasible to separate the upper lateral cartilage from the nasal bones; however, a filler graft must be utilized to conceal any potential depression. Staggered incisions in the septal mucoperichondrium may also be necessary to facilitate anterior tip displacement. Dissecting mucoperichondrial sleeves from the septum and behind the nasal bones back to the nasopharynx allows for further nasal lining release. 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 crucial in supplying integrity to the cartilaginous dorsum and tip, commence nasal framework repair with septum rebuilding. The location of the septal angle influences nasal tip rotation and projection. Furthermore, the septum produces cartilage graft material, which is required for many small noses. It is prudent to do a septoplasty before fixing the nasal tip and rebuilding the dorsum. The top lateral cartilages can be dissected abruptly from the dorsal septum if necessary, although care must be given not to harm 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.

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. 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.

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.

How Recovery Looks Like?

The recovery length varies by patient; however, it is usually approximately 8 days. Rhinoplasty is a simple procedure that may cause discomfort for a few days thereafter. You may suffer slight bruising or swelling around the eyes after surgery, which should go away by day 8. Herbal medicines and cold Swiss therapy gel masks can help alleviate this after nose surgery.

Your cast and stitches will be removed on the sixth postoperative day, and your nose will be retaped. On day 8, he removes all of the sutures and the tape. You've gotten friends at this point! Most, if not all, of your bruises should be gone by then. At this time, the nose will be enlarged but not visible to others. After 2 weeks, you may resume your normal workout program.

Your swelling will subside as the months pass. At three weeks, 20-30% of the edema has subsided. At 6 weeks, 50-60% of the edema has subsided. It will take a year for all of the swelling to go down.

While recovering over the next 2 weeks, avoid:

• Blowing your nose.
• Excessive chewing.
• Facial expressions that require excessive movement (laughing).
• Painkillers containing ibuprofen or aspirin.
• Physical contact with your nose.
• Smoking.
• Strenuous physical activities.
• Swimming.

Short Nose Rhinoplasty Risks

Just like any major surgery, rhinoplasty has risks, including: 

As previously said, rhinoplasty is one of the most difficult surgical operations, and one of the primary reasons for this is its lack of predictability. An immediate positive surgical outcome may not be such one year later.

This is mostly due to the numerous factors involved in the healing process. Individual nasal tissue responses are not always predictable, and as a result, undesirable outcomes might occur.

Although the risk for major complications is low, functional and, mainly, aesthetic complications can cause social and psychological issues and may result in legal problems for the surgeon.

Surgical complications can be defined as hemorrhagic, infectious, traumatic, functional, and aesthetic

• Bleeding

Bleeding after rhinoplasty is a common complication. They are typically minor and can be treated with head elevation, nasal decongestants, and compression. If the bleeding persists, an anterior tampon should be performed, and the patient should be evaluated. If the bleeding continues despite the anterior tampon, posterior hemorrhage should be considered, and a posterior tampon should be used. Although significant bleeds are uncommon, an endoscopic approach or angiographic embolization may be required in some cases.

• Infection

Infections during rhinoplasty can vary from minor cellulitis to serious systemic infectious diseases. As an early complication of rhinoplasty, cellulitis may occur. It typically responds well to cephalosporins, although constant monitoring is required to prevent progression. 

Septal abscesses are a consequence of an untreated hematoma, and the treatment of choice is surgical draining followed by antibiotics. They might occur in the septum, tip, or dorsum of the body. Severe infectious processes are quite uncommon. They occur in fewer than 1% of the cases.

• Adverse reaction to anesthesia.
• Breathing difficulties.
• Permanent numbness in or around the nose due to nerve congestion or injury.
• The possibility of an uneven look of the nose.
• Scarring.
• Pain.
• Discoloration.
• Swelling that might persist.
• The need for additional surgery.
• Septal perforation.
• Intracranial injury 

Intracranial injury is an uncommon condition that can result in a cerebrospinal fluid leak, causing rhinorrhea and migraines. This issue necessitates hospitalization and a neurosurgery assessment.

• Rhinitis: 

This is frequently a transient problem, especially once a blocked airway has been cleared. It might cause nasal discharge, dryness, and breathing problems. Topical treatments are often used to treat it. A CSF fluid leak might be considered if rhinorrhea persists after a few weeks.

• Injury to the Lacrimal Ducts: 

This can result in epiphora, which can be accompanied by bleeding. It is sometimes induced by lateral osteotomies and requires duct intubation to be treated. It is crucial to understand that epiphora may occur in the first few weeks following the surgery as a result of edema compressing the lacrimal ducts, which usually resolves spontaneously.

Conclusion

The distance between the nasal tip and the angle between the eyes is used to determine the length of the nose. While there is no such thing as the "ideal" nose, it should be around one-third the height of the face. This implies that the distances between the hairline and the brows, the brows and the bottom of the nose, and the bottom of the nose and the chin should all be the same. However, for certain people, the nose is shorter than a third of the way down, making it out of proportion with the rest of the face.

Because of big nostrils or an upturned nasal tip, a nose might appear small. A short nose can also be congenital; this is most frequent among African Americans and Asians. Men and women of these ethnicities have a depressed, non-prominent nasal bridge. A short nose can also be the result of trauma or prior rhinoplasty surgery. The initial surgeon may have removed too much cartilage, or a collapsed bridge may have resulted in a saddle nose deformity and, as a result, nasal tip retraction. Nose lengthening rhinoplasty for a short nose is performed for cosmetic purposes, but it can have functional benefit as well.