Cosmetic

Components of the Short NostrilBahman Guyuron, M.D., Ashkan Ghavami, M.D., and Sarah M. Wishnek, B.A.Cleveland, Ohio

Background: The short nostril, best visual-ized on the basilar view, is a multifaceteddysmorphology that requires evaluation be-yond that of alar/columellar deformities.While the soft triangle is the key compo-nent in short nostril disharmony, the alarrim and cartilaginous structures that bor-der the nostrils play a salient role as well.Methods: A retrospective review of 200consecutive rhinoplasties (primary and sec-ondary) examined the specific role of softtriangle excision and other components inthe short nostril deformity. Twenty-sevenpatients underwent soft triangle excisionwith or without alteration of the otherstructures influential on nostril length. Ofthese 27 patients, only three patients re-quired soft triangle excision alone.Results: The distance from the nostrilapex to the caudal border of the alar domewas found to be the crucial element in de-fining the treatment approach for creatingnostril length. When this distance was long,excision of the soft triangle lining and ap-proximation of the alar rim to the liningunder the dome elevated the nostril apexand elongated the nostril. When the dis-tance between the nostril apex and overly-ing dome was ideal or short, soft trianglelining removal was not required, and anoptimal nostril length was established byrepositioning the other components. Rais-ing the dome using transdomal sutures re-directed the wide domal arch vertically,narrowing and lengthening the nostril,provided there was no redundancy in the

soft triangle. In a similar fashion, inter-domal sutures improved both nostrillength and inclination. Placement of a col-umellar strut also elongated the nostril. Analar rim graft, used primarily to correct alarrim retraction and concavity, also elon-gated the short nostril.Conclusions: The most important factor inanalysis and treatment of the short nostrilis the extent of the soft triangle tissuepresent. Soft triangle lining removal is in-dicated when the distance from the nostrilapex to the caudal dome is excessive. Thisallows the nostril apex to be pulled anteri-orly, thus elongating the nostril. The shortnostril often coexists with multiple otherabnormalities of the nasal base and tip,mandating a comprehensive approach toaddress all the deformities encountered. Cor-rection of alar retraction also effectively in-creases nostril length. Further improvementof asymmetric tips and nostrils can beachieved through unilateral soft triangle lin-ing excision with dome equalization throughtip suturing and a subdomal graft. (Plast.Reconstr. Surg. 116: 1517, 2005.)

Detailed anatomical analysis and treatmentof nostril/lobule imbalance are crucial to asuccessful rhinoplasty. Correction of the shortnostril can pose a unique challenge and war-rants evaluation of the soft triangle in conjunc-tion with that of alar-columellar deformities, asobserved on the lateral view.1 On the otherhand, all the components of the nasal base

From the Division of Plastic and Reconstructive Surgery, Case Western Reserve University, and Cleveland State University. Received forpublication July 8, 2004; revised November 8, 2004.

This article was presented during the Annual Ohio Valley Society of Plastic Surgeons Meeting, May 14, 2004, Cleveland, Ohio, and receivedthe first place prize for Outside Clinical Papers.

DOI: 10.1097/01.prs.0000182590.01431.3d

1517

including the soft triangle, nostril shape, alarrim, and columella length and width are bestassessed on the basilar view.2

The short nostril represents an imbalancebetween the nostril aperture and the nasal lob-ule, in which the nostril length is dispropor-tionately undersized in relation to the lobulelength. In studying the opposite abnormality,large nostril/small lobule disproportion,Daniel found the ideal nostril/tip ratio to be55:45 on lateral view.3 Other studies define theaesthetic balance to include a lobule that isapproximately 33 percent of the columellarlength.4,5,6 Our observations of the basilar viewhave been similar to those of Daniel,3 and con-sist of a pleasing nostril/infratip lobule ratio ofapproximately 60:40 to 55:45. In addition, anaesthetically pleasing nasal base should fallwithin an equilateral triangle, while containingovoid-shaped and symmetrical nostrils. Basedon a study by Farkas et al., the aestheticallybalanced nostril possesses an angle of inclina-tion of approximately 50 to 60 degrees relativeto a vertical line drawn through the nasalspine, columella, and tip7 (Fig. 1).

The short nostril abnormality often includesadditional features that are epitomized by thecleft lip nasal deformity: short, round,malshaped nostrils with a narrow angle of in-clination and concomitant excess soft triangletissue with flattened domes, an ill-defined nasaltip, and inadequate tip projection. The pri-mary abnormality is seldom the result of a dis-proportionately large lobule. However, a largelobule with a normal size or short nostril canbe seen in secondary rhinoplasty patients onwhom the lobule and nasal tip have been aug-mented utilizing an onlay graft by the primarysurgeon.

This article describes the specific role of al-teration of the soft triangle, alar rim, and car-tilaginous framework in correcting the shortnostril and achieving a balanced nostril/lobuleratio. Proper management of the short nostrilrequires careful preoperative evaluation of allthe components, in addition to continual in-traoperative surveillance of the effect of manip-ulation of each of these components on nostrillength, shape, and nostril/lobule relation-ships.

MATERIALS AND METHODS

Two hundred consecutive rhinoplasty proce-dures were reviewed to investigate the effects ofsoft triangle excision, along with alteration ofthe other nasal base components including thealar rim and cartilaginous structures, on theshort nostril deformity. A comprehensive com-puter database of all procedures performedduring each rhinoplasty case was examined.Patients who had soft triangle lining removalwere selected, and their preoperative and post-operative photographs were analyzed. Thisgroup of patients was further divided intothose who had soft triangle excision alone, andthose who underwent excision of the soft tri-angle lining and additional procedures on theother structures surrounding the nostril havingpotential effects on nostril length. Preoperativeand postoperative photographs were com-pared to assess the effects of excision of the softtriangle lining on nostril length and the nos-tril/lobule harmony. The role of the soft trian-gle, alar rim, and the cartilaginous structuresbordering the nostril was delineated throughextensive intraoperative observation and post-operative evaluation. A comprehensive treat-ment approach was outlined, beginning withthe evaluation and treatment of the soft trian-gle, and incorporating each of the above com-ponents.

The Soft Triangle and Short Nostril

Procedures involving the soft triangle havetraditionally been a source of controversy, pro-hibited by some9 and advocated byothers.10,11,12,13 However, based on findingsfrom this study, alteration of the soft trianglelining is of paramount significance in success-ful treatment of the short nostril deformity.The soft triangle extends from the skin marginof the nostril apex to the overlying alar dome.Converse defines the soft triangle as compris-ing two adjacent layers of skin, separated by

FIG. 1. Aesthetically pleasing proportions of the nasalbase elements.

1518 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

loose areolar tissue.14 Natvig et al. describe theregion of inferior alar rim skin as “the onlyplace in humans” where skin abuts skin di-rectly, without any intervening soft tissue.15

A recent anatomical study by Ali-Salaam etal. further elucidates the complexity of the softtriangle region.16 Through histologic analysisof the soft triangle, the authors describe threedistinct zones. Zone 1, underlying the apex ofthe dome of the lower lateral cartilage, con-tains fibers of the dilator naris muscle. Morecaudally, Zone 2 is composed of dermis. Zone3 at the nostril rim contains interdigitatingmuscles that are extensions of the nasalis mus-cle or depressor nasi septi muscle within the der-mal layers.

The distance from the nostril apex to thecaudal border of the corresponding alar dome,as measured by the distance of the posterocau-dal border of the dome to the alar rim, is thekey determinant in planning the operativestrategy. On patients with thin skin, the caudalborder of the cartilage is readily visualized.Otherwise, this anatomical point can be iden-tified internally. When this distance is longerthan 3 mm and the nostril is short, it is imper-ative to remove the soft triangle lining to allowelevation of the nostril apex through othermodalities, such as tip suturing techniques(Fig. 2). This is a common finding, as the shortnostril is often accompanied by excess soft tri-angle lining and coexists with other abnormal-ities, such as flattened, poorly-defined domes.An extreme manifestation of this constellationof abnormalities can be seen in the cleft lip

nasal deformity, in which an anterior soft-tissueweb that includes the soft triangle and othersoft tissues dictates sufficient soft triangle lin-ing resection,10,11,17,18 while malpositioned, se-verely flattened domes require repositioningand reshaping through cartilage suturingtechniques19–21 and cartilage grafts.11

Removal of the soft triangle lining can beaccomplished through open or closed tech-niques with equal success. Although the softtriangle is evaluated at the onset of the opera-tion, excision is undertaken as one of the finalsteps in the operative sequence. A crescent-shaped piece of redundant soft triangle liningis removed with a pair of Iris scissors (RobbinsInstruments, ) and the nostril rim is approxi-mated to the lining under the domes with 6-0plain catgut or chromic sutures (Figs. 3 and 4).Any error in judgment should be on the con-servative side, since additional lining can bereadily re-excised while overresection may re-sult in notching of the nostril.

When the distance from the nostril apex tocaudal boarder of the dome is optimal or short,the elongation of the nostril is accomplishedby other means.

The Cartilage Frame

Modifications of the cartilaginous frame-work of the nasal base can effectively alter theshape and length of the nostril as long as thesoft triangle lining is not superfluous. Underthis condition, the short nostril often coexistswith flat, divergent domes and an ill-defined,under-projected nasal tip. With the evolution

FIG. 2. Rendering of a short nostril with excessive soft-tissue lining (left) andelongation of the nostril after elimination of the redundant soft triangle lining(right).

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of a multitude of suturing techniques, the car-tilaginous components can be reshaped22,23

and the nostrils will lengthen simultaneously.The transdomal sutures redistribute the wide

domal arches vertically and elongate the nos-tril, provided that the distance from nostrilapex to caudal dome is optimal (Fig. 5). In thepresence of excess soft triangle lining, thechange in the nostril length may not be dis-cernible until the redundancy is eliminated.

Correction of a wide angle between the me-dial genu with interdomal or middle crural

sutures25 can improve the inclination of thenostrils and increase nostril length minimally.These suturing techniques can also slightly in-crease tip projection and augment lobule vol-ume if the soft triangle lining is excessive.Placement of interdomal and middle crura su-tures may have to be followed by excision ofthe soft triangle lining to change the nostrillength sufficiently.

In addition to increasing tip projection,placement of a columellar strut between themedial crura elongates the columella as long as

FIG. 3. Intraoperative illustration (from the surgeon’s perspective) of excessive softtriangle lining before incision (above, left), while the lateral portion of the soft tissue isbeing incised (above, right), while the medial portion is being incised (below, left), andfollowing removal of redundant soft triangle lining (below, right).

1520 PLASTIC AND RECONSTRUCTIVE SURGERY, October 2005

the strut abuts the anterior nasal spine.26 Thiswill also increase the nostril length (Fig. 6).Other columellar changes that affect nostrilproportions involve the medial crura and foot-plates. Approximation of footplates (with re-section of the lateral portion of the footplates,if indicated) controls the nostril angle andwidth, and establishes nostril symmetry whileslightly increasing its length. Placement of amedial crura-septal suture at the antero-caudalseptum further enhances the tip projectionand elevates the nostril apex, thus elongatingthe nostril.25,27,28

The Alar Rim

Alar concavity seen on the basilar view isfrequently the result of alar retraction ornotching.2 Techniques that correct alar retrac-tion also lengthen the nostril, as the concaveala assume a more straight shape. Differentmethods are indicated depending on the sever-ity of alar retraction present. Alar rim grafts, aspopularized by Rohrich et al. are useful whenthe alar retraction is mild to moderate,2,8 whilean internal V-Y advancement is required toeffectively repair severe alar retraction.2 Alarrim grafts should also be inserted when numer-ous tip suturing methods are employed, sinceexternal valves become weak and the ala ap-pear concave and retracted.2,8,29

Further refinement of the nostrils can beaccomplished by debulking excess alar soft tis-sue, which can elongate the nostril slightly.The approach can be either through an alarbase incision30 or a rim incision.2 Comprehen-sive management of the short nostril and asso-ciated alar rim deformities complement thetreatment of alar-columellar disharmonies aswell.

RESULTS

Of 200 rhinoplasty cases reviewed, 27 pa-tients required soft triangle excision. Of thesepatients, isolated excision of the soft trianglelining was performed in only 3 patients (11percent). The remaining 24 patients (89 per-cent) underwent excision of the soft trianglelining combined with manipulation of theother nostril components, such as elongationof columella with a strut, alar rim grafts, medialcrura approximation, and placement of trans-domal sutures. Seventeen of 27 patients (63percent) were secondary or tertiary rhinoplastypatients. The distance from the nostril apex tothe overlying caudal border of the domes wasfound to be the key determinant in both eval-uating and planning the surgical approach. Nocases of notching in the region of the softtriangle were observed postoperatively. Threeof 27 patients (11 percent) required a revision

FIG. 4. Basilar view of a patient’s nose, revealing the short nostril due to excess softtriangle lining before (left) and elongation of the nostrils after excision of lining only(right).

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rhinoplasty unrelated to the alteration of thenostril length.

DISCUSSION

The most important factor in analysis andtreatment of the short nostril is the extent ofthe soft triangle tissue present. Soft trianglelining removal is indicated when the distancefrom the nostril apex to the caudal dome is

excessive. This allows the nostril apex to bepulled anteriorly, thus elongating the nostril.The short nostril often coexists with multipleother abnormalities of the nasal base and tip,mandating a comprehensive approach to ad-dress all the deformities encountered. Correc-tion of alar retraction also effectively increasesnostril length. Further improvement of asym-metric tips and nostrils can be achieved

FIG. 5. Elongation of the short nostril (left) after placement of medial crura andtransdomal sutures with a conservative excision of the soft triangle lining (right).

FIG. 6. Basilar view of the nostrils before (left) and after (right) insertion of acolumella strut, approximation of the medial crura, and transdomal sutures, resultingin elongation of the nostril.

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through unilateral soft triangle lining excisionwith dome equalization through tip suturing24

and a subdomal graft.31

There is a dearth of information germane tothe short nostril and nostril/lobule dishar-mony. As described by Fomon and Bell,32 andlater reemphasized by Sheen,33 the lobule is“the portion of the nose ventral to an imagi-nary horizontal line across the apices of thenares” on the basilar view. The nostril mayappear short as a result of the presence of alarge lobule, although the absolute size of thenostril is indeed optimal. Farkas et al. de-scribed vast differences in nostril shape andinclinations among racial groups, with a moreobtuse nostril inclination and a more obliqueor horizontal orientation in the African-American and Asian nose.7 This informationwas used to formulate a nostril classification.Based on this classification, “nasal tip protru-sion” was observed to decrease as nostril incli-nation decreased (from Type I through TypeVI).7 The cleft lip nose and African-Americannostril/lobule characteristics exemplify themost severe variants of the short nostril defor-mity, requiring robust and comprehensivemeasures to improve nostril length and incli-nation, as well as to improve overall nasalaesthetics.34

A large lobule is more often observed insecondary and tertiary cases, where the previ-ous rhinoplasty resulted in an increase in lob-ule volume without proper identification andelimination of the excess soft triangle lining. Anostril may not appear short when associatedwith flattened, divergent domes and a lack oftip projection. However, as the improvementsin tip projection and other abnormalities areachieved during the operative phase, the defi-ciency in nostril size becomes apparent. It iscrucial to identify the potential for nostril dis-harmony and anticipate the nasal tip changesthat may engender nostril/lobule dispropor-tion.

Several authors have elaborated on manage-ment of the misshapen nostril in both aestheticrhinoplasty and cleft lip nasal deformity recon-struction. Although a few authors have dis-cussed the role of excision of the soft trianglelining in lengthening the nostril,10 –12,17 thecomplex interplays between the soft trianglelining and the other nasal base componentsand their role in nostril lengthening have notbeen explored. Excision of the soft trianglelining alone was utilized in reshaping the nos-

tril in only 11 percent of our patients. Theremaining 89 percent required a combinationof maneuvers. Our study emphasizes that opti-mal treatment of the short nostril requires athorough understanding of the role of all com-ponents: the soft triangle, alar rim, and carti-laginous framework buttressing the nostrils.

Some consider the nasal base morphology lesscrucial, arguing that patients seldom view thispart of the nose. In our experience, most fastid-ious patients note the flaws and are disturbed byany minor imperfections present in this part ofthe nose. In addition, perfection, and finesse arevital parts of plastic surgery and aiming for asuboptimal result is imprudent. Furthermore, anoptimally shaped nasal base inevitably providessuperior external nasal valve function and morerobust tip support, the cardinal features of anysuccessful rhinoplasty outcome.

Bahman Guyuron, M.D.29017 Cedar RoadCleveland, Ohio 44124bguyuron@aol.com

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