Upturned Nose
The techniques used to down rotate the nasal tip includes use of the extended spreader grafts or a septal extension graft onto which the lower lateral cartilages can be sutured onto in their new position. One limiting factor is the amount of skin laxity which will allow the additional length of the nose to be created without placing any undue tension in the skin. In the male patient the angle made by the nose against the upper lip (nasolabial angle) should be around 90 degrees whereas in a female this can be 95 – 105 degrees.
Bulbous Tip
Improvement can be made by reshaping the lower lateral cartilages but care has to be taken to ensure excessive cartilage is not removed as this can result in weakness of the side walls (giving rise to secondary problems of nasal blockage) and scar tissue formation causing knuckles to occur (bossa formation).
A number of methods are used to improve the shape of the nasal tip. Such techniques include reducing size of the lower lateral cartilages and use of suture techniques to change the shape of these cartilages. Newer techniques include utilising thin strips of cartilage (lateral crural strut graft) which are placed underneath the curved lower lateral cartilages and by suturing the two together the excessive curvature of the bulbous tip can be refined. Please see before and after sections for examples.
Nasal Hump
Today, a straight or in men a very slightly convexed nose is preferred. Reduction of a dorsal hump will usually require fracturing in of the nasal bone so that the pyramidal shape of the nose can be regained usually resulting in a narrow appearance from frontal view. Large dorsal hump reduction involves associated reduction of the upper lateral cartilages and this necessitates the use of spreader grafts in order to avoid mid-vault collapse which is a recognised complication of rhinoplasty surgery (see Revision Rhinoplasty).

Wide Nose
Fracture of the nasal bones (osteotomies) is carried out using special sharp chisel like instruments called osteotomes. A common technique involves making 1 mm stab incisions on either side of the nose. Then a 2 mm osteotome is used to make a series of breaks along the sides of the nose rather like holes around a postage stamp. This allows a controlled break of the nasal bones. A new technique is the use of powered osteotomies. This utilises small saws and allows precise linear cuts to be made in the nasal bones.
In patient’s with weak nasal bones or those who have had previous trauma, the exact position of the fracture line is unpredictable and can result in floating pieces of nasal bones (comminutated fracture). Although the nasal cast applied over the nose at the end of the procedure helps to keep the pieces stable, subsequent healing can result in migration of the bone fragments giving an unsatisfactory result.
Narrow Nose
Some patients have a prominent dorsal hump due to a large nasal septum and this result in a tension nose. Here, the nose often has a narrow appearance from the frontal view. Reduction of the dorsal hump and use of spreader grafts can result in a more balanced view.
Many patients have a narrow nose on frontal view but with a prominent dorsal hump. This is often described as a tension nose. In these instances reduction of the dorsal hump does not require fracturing of the nose as the newly widened appearance is desired. Ideally the width of then nose should equate to one fifth of the width of the whole face or equal to the width of the eye. A patient who has had too much tissue removed in the form of an alar wedge resection may require a revision procedure to widen this. This can be achieved by using a composite graft of a piece of cartilage and skin from the ear and inserted into the nostril to give it a wider appearance. Please see before and after examples.
Twisted Nose
The twisted nose is usually due to bony and/or cartilaginous deformities or indeed involving both structures. In some patients, twisting of the nose occurs after a previous operation due to asymmetric scar tissue formation and contraction, particularly affecting the nasal tip. Correction of a twisted nose is one of the most challenging aspects of rhinoplasty surgery. Rather like rebuilding a house, the foundations have to be corrected and only then can any subtle improvements be reliably assured. In some severely traumatised noses, surgical correction may need to be staged to get the optimum result over an 18 to 24 month period.
There is often inadequate good cartilage from the patient’s own nose available for the reconstructive process.
Broken Nose
In certain circumstances a broken nose can be pushed back into its original shape at the time of injury before facial swelling occurs. This would obviously depend on the nature of the injury and the presence of a suitably qualified and experienced person in attendance. A common example is an injury during a rugby or football match where a broken nose can be clicked back into place by the Team Doctor. Following an injury the patient should be seen by a Doctor to exclude the possibility of a septal haematoma. The latter is a collection of blood within the layers of the septum and if left untreated can result in the loss of septal cartilage, abscess formation and subsequent saddle deformity of the nose. A septal haematoma requires immediate drainage under a short general anaesthetic.
If the nose is deviated after the swelling has reduced, the nose needs to be manipulated under anaesthetic. This requires admission to hospital as a day case, and the nose is pushed back into its original shape. The results are good but occasionally unsatisfactory and a formal Septorhinoplasty needs to be done 4-6 months later.
Occasionally the septum can be traumatised and fractured following an injury and during the manipulation procedure attempts can be made to manipulate the septum back into the middle. The results, however, are variable.