Rethinking Rhinoplasty and Facial Surgery by Howard D. Stupak

Author:Howard D. Stupak
Language: eng
Format: epub
ISBN: 9783030446741
Publisher: Springer International Publishing

Fig. 5.26Clinical photographs of patient with antero-posterior excess (AP+). Left profile view

From a symmetry perspective, if the antero-posterior extrusion is severe enough, over-coming the stretching point of the canopy layer (skin and alar cartilages) in an anterior direction, the septum will tilt as seen on the base view, tilting the whole axis of the nose to one side, sometimes creating an illusion of, or exacerbating pre-existing facial asymmetry. In AP+ (anterior excess), the deviation is most pronounced from the base view, but of course this base deviation will cause the entire A-P axis of the nose to deviate on front view as well, but typically as a complete unit, including nasal bones (see figure). I make this point only in contrast to the SI+ (superior-inferior excess), which tends to form more irregular frontal asymmetries like c- or s-shaped noses as we will discuss shortly. Internally, the septum may actually be straight in the AP+ configuration, with narrowed nostrils, or the internal quadrangular cartilage (posterior portion) can bend in the direction opposite the external septum, taking the septal bones with it, and creating a large “spur” appearing region (see the figure of external effect on internal). Because the septum is protruding anteriorly, it tends to keep the lip under some tension, even if it does not encroach into the lip. These patients can have a shortened, tense lip due to the overly large nose taking up too much skin real-estate for the upper lip to properly close without a lot of effort.

As you are hopefully starting to imagine, treatment strategies will revolve around re-sizing the septum and returning all components back to their midline position independently. (This will be discussed in detail in the next chapters.)

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