The short nose - techniques

Techniques for absolute lengthening by closed approach (endonasal approach) -
A nose where absolute measurements indicate a short nose syndrome
There will be some patients who have a short nose who may be amenable to undergo lengthening the nose by the endonasal or closed approach, according to Dr. Sam Rizk, a New York nose job or rhinoplasty surgeon. This technique does not give as much length as the open approach but it does give a significant amount of noticeable length. Dr. Sam Rizk feels this technique should be available in the surgeon's armamentariium to lengthen the nose also. It incorporates the basic principles of batten graft, but does so without full exposure and without extensive undermining of all tissues. The technique begins a transfixion incision which is just at the caudal edge of the septum on one or both sides, all the way back to the bony septum. The mucoperiosteum and mucoperichondrium is then elevated and some central septum is resected to use as a batten graft. It is important to preserve an L-shaped caudal strut to attach the batten graft. This graft will push the tip cartilage graft forward. If too much lengthening is attempted, the transfixion incision cannot be closed. But according to Dr. Sam Rizk, a NYC rhinoplasty surgeon (New York City nose job surgeon), if the membranous septum is large and somewhat floppy, it may allow further lengthening of the tip and nose. The direction of the batten graft is important because in some noses it may not be desirable to push the actual tip forward, whereas in some noses, it may be more desirable to push the posterior aspect of the tip cartilages forward. If after elongating the columella there appears to be alar retraction, an intracartilaginous incision is made. One side of the intracartilaginous incision will connect with the hemitransfixion incision. Soft tissues in the upper lateral cartilage and lower lateral cartilage area are spread, the action of which also allows the lateral crura to advance.

Techniques for the apparently short nose correction - A nose where absolute measurments do not show a short nose but the shape and angles of the nose make it look short
The obtuse columellar angle and over projected tip is corrected by making a complete transfixion incision and connecting it with an intercartilaginous incision. This maneuver permits derotation of the tip and in effect, the tip is allowed to drop, correcting both the obtuse columellar-labial angle, and lengthening the nose slightly. The nasion, should it be inferiorly located and causing an apparently short nose, is also raised by augmenting the nasion-radix region of the nose with cartilage. Usually the nasion (the top part of the nose between the eyes) is not raised to a level higher than the level of the supratarsal fold in an attempt to attain apparent lengthening of the nose. If that were to be done, the nose would have the appearance of arising from the forehead-a slightly unnatural appearance. A dorsal graft itself can of course lengthen the nose by pushing the tip cartilages forward slightly and by also changing the tip-defining point of the nose inferiorly. As the nasiofacial angle is often abnormal in the apparently short nose, it has to be corrected as well. That is accomplished by simply augmenting the dorsum if necessary. Dr. Sam Rizk, a NYC rhinoplasty or New York City nose job expert, has pioneered the use of 3d endoscopic high definition technology in order to more accurately define the deficits in the nose and either augment or reduce them more accurately using this high-tech method of visualizing and changing the nasal dorsum.

Potential problems and undesirable results
Donor site - The concha or ear potentially may be a problem in terms of collapse and posterior displacement of the ear.If the conchal graft is not taken out as an ellipse but is wedged at the ends, the ear may lose its prominence. If however, the ends of the resection are rounded off as in a true ellipse, the ear tends not to collapse. One other important consideration when taking conchal graft or ear graft, according to Dr. Sam Rizk, a New York rhinoplasty specialist, is anticipation of the need for a composite graft. One ear always should be reserved for that possibility because the removal of the composite graft cannot be achieved once cartilage is taken from the concha.

Inadequate lengthening-Failure to achieve the desired length usually is due to the following- inadequate release of upper and lower lateral cartilage, severe scarring, fibrosis, and inelasticity of the mucoperichondrium resulting in no lengthening other than that achieved by the releasing incision itself, not using a composite graft on the upper and lower lateral cartilage region when the through-and-through gap is significant (greater than 0.5cm).

Summary
Lengthening the short nose is arguably the most difficult operation in aesthetic rhinoplasty. Open and closed operative techniques are used by Dr. Sam Rizk to achieve lengthening, depending on the case. In open technique, maximum lengthening is achieved by releasing the mucoperichondrium, which has to be elevated bilaterally from the septum; releasing the soft tissue between the upper and lower lateral cartilages; and attaching a batten graft to the septum to project the tip cartilages caudally. The closed technique uses a complete or hemitransfixion incision and elevation of the mucoperichondrium bilaterally, followed by attachment of a batten graft. The apparently short nose also can by treated by derotatiing the tip, correcting the columellar labial angle, and altering the location of the nasion as well as the nasofacial angle.