Frontal view

On frontal view, the observant surgeon first notes nasal width, any deviation from the midline, and characteristics of the nasal tip. Nasal width can be assessed in the upper, middle, and lower third of the nose. A saddle deformity of the bony or cartilaginous dorsum contributes to the appearance of an overwide dorsum on frontal view, whereas a hump gives the impression of a narrow dorsum. Similarly, a low bony dorsum creates an illusion of a relatively wide upper third of the nose and wide intercanthal distance or pseudohypertelorism [12]. This appearance can be improved significantly by augmenting the nasal dorsum. The width of the nasal base on frontal view should approximate the intercanthal distance.

The contour of the curved esthetic lines that follow the eyebrows, traverse the radix, and continue down along the lateral nasal dorsum to end at the tip-defining points (brow-tip esthetic lines) should be followed. Any asymmetries, twists, or deviations should be noted. These brow-tip esthetic lines should be smooth, unbroken, gently curved, and symmetric [9,11].

The nasal tip should be characterized on frontal view with regard to symmetry and definition. Concavity or other anatomic findings of the alar sidewall are noted. Vertical and horizontal aspects of bulbosity should be recognized when present. Bifidity of the nasal tip may be visible on this view (but is typically best appreciated on base view). The gentle "gull-in-flight" relationship of the nasal alae to the infratip lobule should be followed, and any asymmetry should be noted. Exaggeration of this curve suggests alar retraction or a dependent infratip lobule. If the columella is not visible ("hidden columella") on frontal view, this also may indicate a retracted columella. The vertical position and symmetry of the alar insertions should be described on the frontal view.

Base view

On base view, special attention should be given to triangularity, symmetry, columella-to-lobule ratio, and width and insertion of the alar base. The nasal base should be configured as an isosceles triangle with a gently rounded apex at the nasal tip and subtle flaring of the alar sidewalls [13-15]. Poor triangularity or trapezoidal configuration with broad domal angles may suggest abnormal divergence of the intermediate crura. The presence of asymmetry of the tip may be appreciated best on this view. Often, one can visualize the outline of the lower lateral cartilages beneath the thin skin of the columella and alar rim, and asymmetries or buckling can be noted. Overlong or short medial crura may be apparent; a wide columella and flaring of the medial crural footplate should be noted when present. One should look into the nasal vestibule to identify possible recurvature of the lateral aspect of the lower lateral cartilage (lateral crura), which occasionally contributes to nasal obstruction or correlates with an alar concavity seen on frontal view. This recurvature of the lateral crura can be accentuated with application of dome-binding sutures (eg, transdomal sutures) resulting in nasal airway obstruction. The caudal septum may be seen protruding into a nostril. Asymmetric nostrils or protruding medial crural footplates may be a clue of subtle caudal septal deviation or asymmetry. Asymmetric orientation of the nostril apices may indicate underlying abnormalities of the domal region of the lower lateral cartilages.

The width of the alar base should be noted, with normal width generally being within a vertical line dropped from the medial canthi. Variations in the appearance of width on the base view may be due to the variation in horizontal position of the alar insertions on the face or in the flare of the alar sidewalls. The alar sidewalls themselves are characterized with regard to thickness and flare. Alar base insertions are described by degree of recurvature, with straight insertions going directly into the face (ie, no nostril sill), and extremely recurved alae inserting directly into the columella [13-15].

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Ask Dr. Becker a question about revision rhinoplasty or make an appointment for a consultation, by calling 856-589-NOSE (6673) or emailing us at info@revisionrhinoplasty.com.