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Changes in nasal tip projection and rotation after septorhinoplasty: A cephalometric analysis
733
M. EUGENE TARDY, JR J Oral
Maxillofac 1998
Surg
56733,
Discussion Changes in Nasal Tip Projection Rotation After Septorhinoplasty: A Cephalometric Analysis
and
M. Eugene Tardy, Jr, MD Professor of Clinical Otolaryngology-Head and Neck and Director, Division of Facial Plastic and Reconstruclive University of Illinois Medical Center, Chicago, Illinois
Surgery Surgery,
Accurate preoperative and postoperative analysis and evaluation of the anatomy and appearance of the nose is paramount to assess the efficacy of surgical techniques, as well as to modify surgical procedures based on their long-term outcomes. Drs Werther and Freeman present an interesting modality for documenting changes in nasal tip projection (NTP) and nasal tip rotation (NTR) based on cephalometric analysis. I applaud any attempt to more accurately assess changes wrought by nasal surgeons by using stable bony landmarks. However, several of their findings and conclusions require discussion. The assumption that the nasion-articulare-pogonion angle cannot be altered may be inaccurate. Significant dorsal nasal reduction or augmentation, with or without an intended change in the nasal prolile starting point, may affect the position of the nasion significantly, and therefore alter their equation. Also, the ultimate impact of the skin-soft tissue envelope on the final healed appearance cannot be discounted. Aesthetic excellence more often than not results from creating an illusion of balance and proportion, rather than from an adherence to a set of rigid quantitative rules. Our studies of patients over 25 years after rhinoplasty surgery show unequivocably that the nose continues to heal and change over time, as aging and scar tissue continue to
exert their influence on aesthetic appearance. The nature of the skin-soft tissue envelope change over time is vitally important, because this dynamic overlying canopy “shrinkwraps” around the altered bony-cartilaginous framework. A factor to consider also may be the cost of serial cephalometric studies over time versus time-honored photographic comparative methods (the photographs in this article, parenthetically, suffer from inaccurate lightingbackground shadows result from improper positioning of the electronic flash). In addition, at least four standard and uniform photographic views must be used to accurately assess projection as well as rotation. The lateral view alone is insufficient to assess the overall impact of surgical changes. Of interest is that projection was lost over time in most of the cases presented. In any rhinoplasty, only three outcomes of tip projection can be affected by the surgeon: it may be reduced (intentionally or inadvertantly), it may be increased, or it may be preserved intentionally, with no surgical change. Preserving nasal tip projection, the goal in most caucasion rhinoplasties, is currently a matter of respecting and preserving the major and minor tip support mechanisms, which may differ in individual patients, depending on the unique varying anatomy found in each. Concerning rotation, again only three outcomes occur after rhinoplasty: increased cephalic rotation, caudal tip rotation (elongation of the nose), or avoidance of tip rotation. Caudal rotation is not addressed in this study. In summary, the authors should be lauded for their efforts to improve the quality of analysis in rhinoplasty by quantitive means. In the end, the only opinion that counts in aesthetic rhinoplasty is that of the satisfied patient-an elusive but vital goal.
M. EUGENE TARDY, JR J Oral
Maxillofac 1998
Surg
56733,
Discussion Changes in Nasal Tip Projection Rotation After Septorhinoplasty: A Cephalometric Analysis
and
M. Eugene Tardy, Jr, MD Professor of Clinical Otolaryngology-Head and Neck and Director, Division of Facial Plastic and Reconstruclive University of Illinois Medical Center, Chicago, Illinois
Surgery Surgery,
Accurate preoperative and postoperative analysis and evaluation of the anatomy and appearance of the nose is paramount to assess the efficacy of surgical techniques, as well as to modify surgical procedures based on their long-term outcomes. Drs Werther and Freeman present an interesting modality for documenting changes in nasal tip projection (NTP) and nasal tip rotation (NTR) based on cephalometric analysis. I applaud any attempt to more accurately assess changes wrought by nasal surgeons by using stable bony landmarks. However, several of their findings and conclusions require discussion. The assumption that the nasion-articulare-pogonion angle cannot be altered may be inaccurate. Significant dorsal nasal reduction or augmentation, with or without an intended change in the nasal prolile starting point, may affect the position of the nasion significantly, and therefore alter their equation. Also, the ultimate impact of the skin-soft tissue envelope on the final healed appearance cannot be discounted. Aesthetic excellence more often than not results from creating an illusion of balance and proportion, rather than from an adherence to a set of rigid quantitative rules. Our studies of patients over 25 years after rhinoplasty surgery show unequivocably that the nose continues to heal and change over time, as aging and scar tissue continue to
exert their influence on aesthetic appearance. The nature of the skin-soft tissue envelope change over time is vitally important, because this dynamic overlying canopy “shrinkwraps” around the altered bony-cartilaginous framework. A factor to consider also may be the cost of serial cephalometric studies over time versus time-honored photographic comparative methods (the photographs in this article, parenthetically, suffer from inaccurate lightingbackground shadows result from improper positioning of the electronic flash). In addition, at least four standard and uniform photographic views must be used to accurately assess projection as well as rotation. The lateral view alone is insufficient to assess the overall impact of surgical changes. Of interest is that projection was lost over time in most of the cases presented. In any rhinoplasty, only three outcomes of tip projection can be affected by the surgeon: it may be reduced (intentionally or inadvertantly), it may be increased, or it may be preserved intentionally, with no surgical change. Preserving nasal tip projection, the goal in most caucasion rhinoplasties, is currently a matter of respecting and preserving the major and minor tip support mechanisms, which may differ in individual patients, depending on the unique varying anatomy found in each. Concerning rotation, again only three outcomes occur after rhinoplasty: increased cephalic rotation, caudal tip rotation (elongation of the nose), or avoidance of tip rotation. Caudal rotation is not addressed in this study. In summary, the authors should be lauded for their efforts to improve the quality of analysis in rhinoplasty by quantitive means. In the end, the only opinion that counts in aesthetic rhinoplasty is that of the satisfied patient-an elusive but vital goal.