What Is the Ideal Nose? Individual Perspectives and Virtual Simulation Results from Rhinoplasty Surgeons Around the World
Much of the existing literature on rhinoplasty focuses on new surgical techniques, with little emphasis placed on the variability and evolution of ideal nasal aesthetics in our field. Our group sought to use virtual 3D computer simulation to identify potential similarities and differences in ideal nasal aesthetics between various rhinoplasty surgeons worldwide.
Methods/Technique:
A cohort of surgeons were invited to participate in this simulation study. Participating surgeons then took part in a simulation session, in person or via Zoom, using an identical set of 3D images (Vectra H1) for 3 patients (P1,2,3), with varying degrees of nasal deformities and facial proportions. Using the Canfield Vectra software system, surgeons were asked to create an ideal rhinoplasty result. At the conclusion of the simulation session, additional data about their practice was also obtained, including location, years experience, percent cosmetic and open rhinoplasty performed, number of rhinoplasties performed each year, and private vs academic practice.
All simulated 3D images were then analyzed by placing standardized landmarks and measuring the distance (mm) of radix height (RH), dorsal height (DH), alar width (AW), nasal tip projection (NTP), and nasal tip rotation (NTR). A blended view of each surgeon’s simulations (i.e. surgeon-specific ideal) was then created by combined simulations with generalized Procrustes algorithm via tpsSuper. Statistical analysis was performed using SPSS Version 26 to perform unpaired t-tests, one-way ANOVA, and multivariate linear regressions.
Results/Complications:
A total of 81 surgeons from 24 countries completed the study to date (response rate 6.4%). Rhinoplasty surgeon demographics were as follows: 90% male, 66% plastic surgeons (33 facial plastics, 1% OMFS), 71% private practice, and 64% fellowship trained. The surgical practices included in the study demonstrated the following averages: 18+/-11 years experience, 124+/-101 rhinoplasties performed per year, with 76% and 74% of rhinoplasty procedures being cosmetic and via an open approach, respectively.
Radix & Dorsum:
The combined ideal result among all surgeons was noted to have an RH of 14mm and DH of 20mm. Interestingly, increasing number of years of experience was associated with an ideal nose that demonstrated an increase in both RH and DH. (RH, P1,2,3; p=0.042, 0.0175, 0.013) (DH, P2,3; p=0.001, 0.0012). Similar findings of an increased RH and DH were noted in rhinoplasty practices that were primarily cosmetic (P2; p=0.012) and using an open technique (P2; p=0.030) Conversely, the ideal DH was noted to be lower for surgeons who were fellowship trained (P2; p=0.041) and performed numerous rhinoplasties each year (P2; p=0.020).
Nasal tip complex:
The ideal nose among the entire surgical cohort was defined by the following nasal tip features: AW 32 mm and NTP 20mm.
Ideal noses demonstrated a significant increase in NTR for surgeons who were ENT trained (P3; p=0.039), performed increased numbers of rhinoplasties each year (P3; p=0.046), and those who primarily performed open rhinoplasty (P2; p=0.0305). NTP was significantly increased in ideal noses by surgeons who had increased years of experience (P2,3; p=0.002, 0.048) and increased numbers of cosmetic rhinoplasties (P2; p=0.007). Fellowship trained rhinoplasty surgeons, on the other hand, simulated noses with significantly less NTP. (P2,3; p=0.012, 0.042). The ideal AW was found to be significantly decreased in ideal noses created by facial plastic surgeons (P2,3; p=0.033, 0.031), those with increasing percentage of cosmetic cases (P3; p=0.038), and overall case number (P3; p=0.024). When stratifying surgeons by location, distinct visual differences were noted in simulated ideals (Figure 1). For instance, Eastern European countries, such as Turkey, increased NTP, NTR and decreased DH when compared to the Northeast US, such as New York. However, these comparisons did not reach statistical significance.
Conclusion:
3D analysis demonstrated variations in ideal nasal aesthetics between surgeons. Our data suggests that surgeons with increased years of experience produce a more conservative nasal profile with radix augmentation and less aggressive DH reduction. Surgeons who performed higher volumes of rhinoplasty per year demonstrated a more aggressive rhinoplasty result with a decreased DH, increased NTR, and decreased AW. Analysis of geographic location and ideal nasal aesthetics did not produce a statistically significant result however, visual representation of geographical ideal results proves to highlight differences in the ideal nose. While aesthetic standards in rhinoplasty exist, 3D technology reveals and quantifies differences in perceived ideal aesthetics between surgeons.