Prominent nose, its modalities and their treatment
Size of the nose varies in the different parts of the world, and perception of what is the aesthetically acceptable nose shows large differences depending on the ethnic background, type of the society, gender and age. Nose which is generally larger than the average nose in a given society, particularly regarding the height of its nasal bridge, could be defined as a prominent nose.
Photographs of the 414 consecutive patients who underwent rhinoplasty by the author during the years 2014 and 2015 were reviewed. Attention was directed to the following outer features: overall length, height and width of the nose, nasofrontal angle, nasolabial angle, nose-lip and nose-chin relations, shape and position of the chin and the evaluation of the respiratory function. Among determinants was formula of Goode, which delineates the approximate relationship between tip projection and nasal length.
A total of 144 patients, 112 females and 31 males, who fulfilled criteria of prominent nose were selected for the further analysis. A total of 70% of the patients were of Middle-Eastern origin. The following four types of prominent nose were recognised: (1) short prominent nose, or tension nose was present in 38 patients. It has overprojecting dorsum, which usually forms a hump. Nasolabial angle is obtuse, and nasal spina is frequently overgrown. The rate of functional problems is quite high due to the overdevelopment and subsequent deviation of the septal cartilage. (2) Long prominent nose, present in 96 patients, usually has an arched dorsum, sharp NL angle and drooping tip. (3) Long nose depending on the height of the dorsum in the lateral projection can be the low long nose and it was seen in four patients, or when the nose is both long and the tip is overprojecting, it is called Pinocchio nose and it was present in eight patients. (4) Rhinomegaly is the term describing nose which is very large in all dimensions, the height, length and width and was also seen in eight patients.
Prominent nose has several modalities and each of them requires different techniques applied during the surgical intervention. Both aesthetic and functional topics are frequently present, and multiple nasal structures, both external and internal, are commonly involved. In the aesthetically pleasing Caucasian nose, Goode’s ratio should equal 0.55 to 0.60. If there is before operation unrecognised deviation from this norm, which is also persistent after the rhinoplasty, the final result will be substandard.
Level of Evidence IV, risk / prognostic study.
KeywordsProminent nose Large nose Rhinomegaly Rhinoplasty Middle-eastern rhinoplasty
We are in the process of perfecting our craftsmanship but we have yet to be artists. (Mario Gonzales-Ulloa 1962)
The size of the nose varies in the different parts of the world, and perception of what is the aesthetically acceptable nose shows large differences depending on the ethnic background, type of the society, gender and age. Nose which is generally larger than the average nose in a given society, particularly regarding the height of its nasal bridge, could be defined as a prominent nose. Larger prevalence of the prominent noses in a total population is seen in the Mediterranean basin and in the Middle East [1, 2, 3].
Several modalities of the nasal pyramid such as deviated nose , twisted nose, crooked nose  and the saddle nose deformity [6, 7, 8] are well described in the literature. PubMed search did not reveal any papers concerning the opposite condition to the latter, the prominent nose. The prominent nose is a large nose per definition, but it has several varieties. The goals of this study were to analyse and classify varieties of the prominent nose and describe the guidelines for special rhinoplasty techniques applied in each subgroup.
Material and method
The current study was based on the analysis of compiled data from medical charts and photographs of the 414 consecutive patients operated by the author during the years 2014 and 2015. The group consisted of 339 females and 105 males ranging in age from 17 to 70 years (mean 28 years).
A total of 144 patients, 35% of the whole cohort, were judged by the surgeon as having some type of the prominent nose and were sorted out for the further analysis. Among them were 112 females and 31 males, and they underwent either the primary rhinoplasty (132) or were originally operated elsewhere and came for the secondary correction (12). Endonasal approach was prevailing, but 16 patients, among them the secondary cases or patients with the rhinomegaly, were operated by the open technique. In four patients with the broad tip, the semi-open method was chosen. Seventy percent of the patients had middle-eastern ancestry.
Measurements for the preoperative evaluation
Nasofrontal angle is measured between the nasal bridge contour and the anterior surface of the forehead below the glabella (Fig. 1 left). NF angle can be deep, regular well-balanced or shallow and plays an important role in our perception of the size and length of the nose and the facial harmony . In Caucasians, normal values are 115–130°. Inclination of the nasal pyramid, or how much the nose sticks out, is determined by the angle between the line tangential to the nasal dorsum and the vertical vector of the face (normal in Caucasians is 30–40°.
Nasolabial angle measurement aids to assess the position of the nasal tip in relation to the nasal base. The coherent method is to measure the angle between the line connecting the subnasale and the nasal tip and the line perpendicular to the Frankfort horizontal, which is the line drawn from the upper border of the external auditory canal to the most inferior point of infraorbital rim (Fig. 1 left). Therefore, it is important to include tragus on the lateral photographs. The normal value is 90–120°.
Nasal length is obtained either by superimposing the straight line from the nasion to the tip on the life-size image, or by taking such measurement with the calliper on the patient.
Another important aspects to be evaluated at planning of the procedure are skin thickness, amount of the subcutaneous fat and the shape of the medial crura, including footplates, which affects the aesthetic appearance of the columella.
- 1.Short prominent nose, or tension nose was present in 38 patients (Figs. 4 and 5). It has overprojecting dorsum, which typically forms a hump. NL angle is obtuse, and nasal spina is frequently overgrown. Alae could be high-arched and inserted high on the alar-facial junction, exposing excessive area of membranous septum. The rate of functional problems is quite high due to the overdevelopment and subsequent deviation of the septal cartilage. Such noses are frequently seen in the people with the Latin origin, both in Europe and in the South America, and in the Middle East [2, 3].
Correction includes an aggressive lowering of the nasal bridge and, if needed, the septoplasty. Transfixion incision is extended downwards to the level of nasal spine. Reduction of anterior nasal spine with rongeur, and non-resorbable suture between the orbicularis oris muscle and the base of the septum cause desired change in N-L angle from obtuse to more aesthetically pleasing. If upper lip is short and teeth are exposed in the relaxed state, frenulum plasty (elongation) is indicated. Unfolding procedure might be necessary to lower retracted alar rim, and it involves composite chondro-cutaneous graft from the ear’s concha. Cranial rotation of the tip is contraindicated.
- 2.Long prominent nose, present in 96 patients, usually has an arched dorsum, sharp NL angle and drooping tip, which rotates downwards during the animation (Figs. 6 and 7). Such noses are rather unusual in the population of the Northern and Central Europe, but we see them in the Mediterranean region and throughout the Middle East [2, 3].
Correction includes cranial rotation of the tip and humpectomy. Cartilaginous dorsum can be lowered by the supramucosal technique described and popularised by Jost . Instead of cutting off the dorsal part of the lateral cartilages and septum in one piece, the lateral cartilages are separated from septum and pushed down and laterally, preserving continuity of the nasal mucosa. In the next step, the dorsal septum is judiciously lowered under the direct vision control.
To lower overprojecting tip, the height of the cartilaginous framework has to be reduced. It could be achieved by several ways and is usually the combined effect of lowering of the nasal dorsum, cephalad reduction of alar cartilages, shortening of the remaining alar cartilaginous arch  and reduction of the nasal spine [13, 14, 15]. Deprojection of the tip inevitably results in alar sidewall flaring, which sometimes requires alar reduction.
- 3.Long nose has an abnormal length of the dorsum, measured from radix to the tip and can be graded depending on the height of the dorsum and the degree of tip projection. There are two variants. Long nose which is prominent forwards is called “Pinocchio nose”. Long nose prominent downwards can be called long low nose. It has its tip below the level of subnasale (Figs. 8 and 9) and was seen in four patients. Former German chancellor Konrad Adenauer was a known proprietor of the long low nose.
Besides standard rhinoplasty manoeuvres, special techniques are undertaken to decrease length of the nose. Redundant skin envelope can be reduced by the horizontal ellipsoid excision at the level of nasion. Subperiosteal and subcutaneous dissection follows in the retrograde manner. The whole skin envelope of the nose is lifted cephalad and anchored to the subcutis and periost of the glabella at the upper edge of the excision.
Lowering of the nasal bridge is judicious and conservative. In some patients, the nasal bridge, in profile view, is a direct prolongation of the frontal contour. Such nose, sometimes wrongly called “Greek nose”, can be made optically shorter by chiselling out the cortical part of the nasal bones below the nasofrontal junction. This will break the continuous nosofrontal line and place the nasion point more caudally . En bloc triangular excision of the septum membranosum, connective tissue, parts of medial crus and caudal septum lifts the tip of the nose. The base of this triangle is upward and parallel to the nasal dorsum. This manoeuvre was originally described in 1931 by Joseph in his monumental book .Pinocchio type of nose is both long and has the tip with exuberated forward projection and it was present in eight patients (Figs. 10 and 11). Persons with the Pinocchio type of nose are frequently subject of jokes and ridiculing remarks, which is emotionally severely disturbing. French novelist Cyrano de Bergerac (1619–1655) is the most famous person with such nose, and whose long nose is a documented fact. He is best known as the inspiration for Edmond Rostand’s drama Cyrano de Bergerac.
Correction of the Pinocchio nose involves bold reduction of the soft tissues by the wedge resection of the alae and 4–7-mm horizontal excision of portion of columella including medial crura. Lateral crura must also be shortened, followed by angled resection of the caudal and dorsal parts of the septum. Once the tip is moved to the new desirable position, the anticipated hump appears on the nasal dorsum. The hump is removed and the lateral and medial osteotomies will narrow the nasal bridge. At the end, the excess of the vestibular skin is trimmed [17, 18].
- 4.Rhinomegaly is the term describing nose which is very large in all dimensions, the height, length and width (Figs. 12 and 13) and was seen in eight patients. The term derives from the Greek, rhino (ρινο), means nose and megalo (μεγαλο) great. Noses in advanced rhinophyma can achieve rhinomegalic proportions. An overlarge nose can overwhelm the remaining facial features and draw unwanted attention from the surrounding persons. Through the history, many prominent people had prominent, rhinomegalic noses, one of the most famous was that of Charles de Gaulle. Several rhinomegalic noses can, e.g., also be seen on the portraits of XV-th century Italian noblesse in the Uffizi Gallery in Florence.In rhinomegaly, the goal for both patient and surgeon is to diminish the nose as much as possible, without compromising its respiratory function. Majority of patients are males. From the palette of the techniques and approaches, some particularly suitable for the correction of the rhinomegalic nose are chosen. Open rhinoplasty is mandatory, because of the need for a major rearrangement of the cartilaginous framework, requiring the internal sutures. Thickness of the skin envelope and the bulging shape of the tip can be reduced by plucking of fatty- and connective tissue from the subcutis under the direct vision control (Fig. 14). After reduction of large alar cartilages, various deprojection manoeuvres on its medial, intermedial and/or lateral crus are undertaken.
Alar resection cutaneous and vestibular (Sheen type II)  is frequently indicated. Nostrils can be thick and with alar hooding, resulting from a large alar lobule segment inserting lower on the face then normal and hiding columella on the side view. Correction of such poor columellar–alar relationship will require thinning of the alar tissues, tangential vestibular resection and infolding of the lateral alar rim (Fig. 6 left). Nasal bones are usually thick and will require strong Silver osteotomes for lateral osteotomies. External and internal medial osteotomies aid to bring wide positioned bones of the nasal dorsum together and create narrower nasal bridge. In most of the patients with large noses and NL angle ≤ 900, animation sharpens the NL angle by about 10–15 °, and the tip appears to curl down in what patients perceive as very unattractive. This undesirable phenomenon ceases or strongly diminishes after rhinoplasty due to the stabilizing effect of the intranasal and paranasal scar formation (Fig. 12).
Prominent nose can in some patients be caused for the offensive comments and nicknames, but in the majority, it just disturbs their own perception of their appearance in the mirror. As a group or category, patients with a large nose are usually grateful task for the plastic surgeon, because their desires are clear and their “deformity” is real.
Prominent nose has several modalities, and therefore, no single operating technique is advocated. Surgeon neophyte can master one single technique in breast reduction or blepharoplasty and this, properly executed, can carry him or her long. Having patient with the prominent nose requires, besides the skills in several rhinoplastic techniques and approaches, broader theoretic and practical knowledge of the ancillary procedures. Among them are manoeuvres on the radix and NF angle, modulation of N-L angle, reduction of the nasal spine, lengthening or shortening of the upper lip, chin reduction and chin augmentation.
Surgeons who do rhinoplasty less frequently usually have one rhinoplasty instrument set, with one or two osteotomes, which they use for all cases. An easier operation conduct and thus better results could be achieved, if the optimal osteotome is chosen for each particular modality of the nasal bones.
The “Greek nose” does not correlate to the noses of the population of Greece today. Actually, many Greeks are not fully satisfied with the prevailingly Mediterranean type of nose they have. Nose surgery is the third most common aesthetic operation in Greece, with the annual number of 6900 in an 11 million population (ISAPS 2016 year international survey) .
Prominent nose has several modalities and each of them requires different techniques applied during the surgical intervention. Both aesthetic and functional topics are frequently present and multiple nasal structures, both external and internal, are commonly involved. The surgeon must balance patient’s dreams and desires and the existent anatomic predispositions with his knowledge of predictable surgical techniques and healing processes to obtain favourable, yet well-camouflaged results. In the aesthetically pleasing Caucasian nose, Goode’s ratio should equal 0.55 to 0.60. If there is before operation unrecognised deviation from this norm, which is also persistent after the rhinoplasty, the final result will be substandard.
Compliance with ethical standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of retrospective study, formal consent is not required.
Informed consent was obtained from all individual participants included in this study.
Conflict of interest
Igor Niechajev declares that he has no conflict of interest.
- 1.Niechajev I (2017) Prominent nose. In: Frame JD, Bagheri SC et al (eds) Aesthetic surgery techniques, Elsevier Publ, UK, chapter 15, pp, pp 111–119Google Scholar
- 2.Niechajev I, Haraldsson PO (1997) Ethnic profile of patients undergoing aesthetic rhinoplasty in Stockholm. Aesthetic Plast Surg 21:139–145Google Scholar
- 5.Parker Porter J, Toriumi D (2002) Surgical techniques for management of the crooked nose. Aesthetic Plast Surg 26:18–32Google Scholar
- 6.Türegun M, Sengezer M, Güler M (1998) Reconstruction of the saddle nose deformities using porous polyethylene implant. Aesthetic Plast Surg 22(1):38–41Google Scholar
- 7.Niechajev (1999) Porous polyethylene implants for nasal reconstruction: clinical and histologic aspects. Aesthetic Plast Surg 23(6):395–402Google Scholar
- 8.Niechajev I (2012) Facial reconstruction using porous high-density polyethylene (medpor): long-term results. Aesthetic Plast Surg 36:917–927Google Scholar
- 9.Tardy EM (1997) Anatomy of changes of ageing and sculpting of nasal tip. In: Tardy EM (ed) Rhinoplasty the art and science, Saunders, Philadelphia, Vol 2, p 526Google Scholar
- 10.Niechajev I (2012) Effect of the depresor septi nasi muscle on the nasal lengthening over the time. (editors invited commentary). Aesthetic Plast Surg 37:987–992Google Scholar
- 11.Jost G (1988) Supramucosal technique. In: Jost G (ed) Atlas of Aesthetic Plastic Surgery, 2nd edn . Masson, Paris Pp. 44–55 Google Scholar
- 12.Gubisch W, Eichhorn-Sens J (2008) The sliding technique: a method to treat the overprojected nasal tip. Aesthetic Plast Surg 32:772–778Google Scholar
- 16.Joseph J (1931) Die Zurücksetzung der abnorm prominenten Nasenspitze. In: Nasenplastik und sonstige Gesichtsplastik nebst Mammaplastik. Verlag Curt Kabitzsch, Leipzig, pp 131–148Google Scholar
- 18.Papanastasiou S, Logan A (2000) Management of the overprojected nasal tip: a review. Aesthetic Plast Surg 24:353–356Google Scholar
- 19.Sheen JH, Sheen AP (1987) Nostrils aesthetics and Types of alar resection. In: Sheen JH (ed) Aesthetic Rhinoplasty 2nd edn. St. Louis Miss. Mosby , Vol 1, pp 106–111 and pp 254–266Google Scholar
- 21.Peck GC (1990) Broad nasal tip. In: Peck GC (ed) Techniques in aesthetic rhinoplasty, 2nd edn. Lippincott, Philadelphia, pp 137–141Google Scholar
- 22.ISAPS (2016) International study on aesthetic/cosmetic procedures performed 2016, Grece. https://www.isaps.org/wp-content/uploads/2017/10/2016-ISAPS, Accessed 25 July 2016