Rhinoseptoplasty II — Analysis, lines and angles: how a nose is planned
The lines, angles and proportions measured before surgery, and a closed diagnostic classification by subunit that turns examination into a surgical plan.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Analysis is not a ritual: it is what turns “I don’t like my nose” into a closed list of diagnoses, and each diagnosis into a specific surgical manoeuvre.
- Every measurement is taken with the face aligned in the Frankfort plane. Without that reference, the angles mean nothing.
- The radix defines the hump and the hump defines the radix. A prominent dorsum with a deep radix reads as a hump; the same dorsum with a high radix does not.
- Tip projection is judged in the context of the face: a retruded chin makes it look greater. Before reducing the nose, look at the whole profile.
- The normative values described correspond to the leptorrhine nose. In mesorrhine and platyrrhine noses the figures differ: applying them unadjusted is an error of judgement.
Photography: without it there is no analysis
Analysis begins with a standardised photographic series, and the word that matters is standardised. The face is aligned in the Frankfort plane and six views are taken: frontal, both profiles, both three-quarter, basal and dorsal. Two positioning errors invalidate any subsequent measurement and are seen constantly: a raised chin, which falsifies the nasolabial angle and hides the dorsum, and pupils at different heights, which makes a straight nose look deviated. The series serves three distinct purposes: planning, since many decisions are made on the photograph rather than in front of the patient; showing the patient what was already there, the best defence against late complaints about pre-existing asymmetry; and documentation with medicolegal value. Three-quarter views best reveal rhinion irregularities, and the basal view shows the true shape of the base and nostril symmetry.
Frontal view: thirds, fifths and the two lines
The face divides into horizontal thirds — trichion to glabella, glabella to subnasale, subnasale to menton — and vertical fifths, each one eye wide. The nose occupies the middle third and central fifth, and that is the first check: if the nose looks large but the thirds are proportionate, the problem may lie elsewhere in the face. On the nose itself, two references are drawn. First, the dorsal aesthetic lines, two smooth symmetric curves running from the medial supraciliary ridge to the tip-defining points; their interruption, asymmetry or divergence is what the eye reads as a crooked or wide nose, even with a straight dorsum. Second, the alar base width, which in a leptorrhine nose should equal the intercanthal distance; anything beyond that measurement is alar flare, not a wide base, and is corrected differently.
Profile angles and proportions
| Measurement | How it is drawn | Reference value |
|---|---|---|
| Nasofrontal angle | Between the glabellar tangent and the dorsal tangent, apex at the nasion | 115-130° in Caucasians; less in Asian, Latin and African biotypes. More obtuse favours women |
| Nasolabial angle | Between columella and upper lip, apex at the subnasale | 95-110° in women and 90-95° in men. Above 120° the tip reads as upturned |
| Nasofacial angle | Between the facial plane (glabella-pogonion) and the dorsal line | Around 30°, with an acceptable range of 27 to 36° |
| Goode ratio | Ratio of tip projection to nasal length | 0.55-0.60. Below, under-projected tip; above, over-projected |
| Crumley triangle | Projection, nasal height and length as a Pythagorean triangle | 3 : 4 : 5 ratio, corresponding to a 36° nasofacial angle |
| Simons rule | Compares tip projection with the height of the cutaneous upper lip | They should be equal (1 : 1). The quickest check in clinic |
| Columellar show | Height of columella visible below the alar margin, in profile | 2-4 mm. Less indicates caudal septal retraction; more, a hanging columella or retracted ala |
The radix defines the hump: the Roman and the Greek nose
This is probably the concept that most changes planning and the one most often overlooked. Radix depth depends on the position of the nasofrontal suture relative to the prominence of the glabella and the rhinion, and determines how dorsal projection is perceived. A nose with a deep radix and prominent dorsum reads as humped — the classic Roman nose. The same nose, with the same dorsum but a high radix in which the nose seems to continue directly from the forehead, is not perceived as humped: the Greek nose. The practical consequence is immediate: in some patients the solution is not to lower the dorsum but to augment the radix, and doing the opposite leaves a short, scooped nose that must later be rebuilt. Hence the figure worth remembering: in roughly 80 % of cases the nasofrontal angle needs no change, in 15 % it needs augmenting and in 5 % reducing.
Is it a true hump or is it the radix?
With the face in Frankfort, does the dorsum project beyond the nasion-tip line, or is the nasion too deep?
Under-projected tip: is it the nose or the chin?
With the face in Frankfort, where does the pogonion sit relative to the nasion?
Goode below 0.55 and projection less than cutaneous lip height?
Basal view: the most information in the least time
From below, the nasal base should describe a triangle, not a trapezoid: a trapezoidal outline indicates a wide base or an under-projected tip. Within that triangle, the infratip lobule length should be half the columellar length, and the nostrils should be symmetric and teardrop-shaped, their long axis running medial-posterior to lateral-anterior. In profile there is another quick check that gets forgotten: the tip lobule length should equal the alar width. And gently palpating the tip gives what no photograph can: how much cartilaginous support there is. Broad lateral crura produce supratip fullness; crura excessively narrowed at previous surgery produce alar retraction and excessive rotation. Lateral crural recurvature and bossae are identified here, before surgery, not in theatre.
From impression to diagnosis: why a closed list
Writing “wide nose with a bulbous tip” is an impression, not a diagnosis. The practical difference is that an impression does not translate into manoeuvres and a diagnosis does. Hence the value of working with a closed list of diagnoses organised by subunit, ticking every one that applies: the result is a complete inventory that converts, line by line, into the surgical plan. It has three benefits that show immediately. It forces you to look at everything, including what the patient did not mention — chin, lip, skin thickness. It allows comparison of the preoperative state with the result using the same vocabulary. And it makes the plan reproducible: another surgeon reading the sheet understands exactly what was seen and why each step was chosen. The tables below set out that classification, grouped as it is used in practice.
Diagnostic classification — Dorsum
| Category | Diagnoses |
|---|---|
| Profile | Hump · kyphosis · mild kyphosis · concave dorsum · saddle nose · polly beak |
| Radix | Low radix · high radix · very wide radix · short nasal bones |
| Supratip | Excess anterior septal cartilage · excess upper lateral cartilage · fibrosis |
| Width | Wide at the base · wide at the ridge · wide bony dorsum · very wide and flat · narrow · thin base · thin ridge · widening at the osseocartilaginous transition · lateral ridges |
| Sequelae and surface | Inverted-V deformity · dorsal irregularities · bony dehiscence · axe-cut sign · upper valve collapse |
Diagnostic classification — Tip
| Category | Diagnoses |
|---|---|
| Rotation | Elevated tip · drooping tip · open nasolabial angle · closed · correct |
| Projection | Over-projected · under-projected · slightly projected · correct projection · tension nose |
| Width and shape | Fine · wide · very wide · bulbous · boxy · amorphous · undefined · wide lobule |
| Symmetry | Asymmetric tip · nostril asymmetry · deviated columella |
| Support | Unsupported tip · unsupported columella · unsupported alar rim · tip suspended on the anterior septum · alar rim weakness · alar collapse |
| Alar cartilages | Malposition · concave · undulating · lateral convexity · alar pinching · long intermediate crus · high lateral crus |
| Lobule | Bifid · bilobed · cleft · absent lobule · pinched infratip lobule · lobule-ala imbalance |
| Alar-columellar balance | Hanging columella · retracted columella · anterior alar retraction · posterior · thick, drooping alae · visible alar rims · soft triangle collapse |
Diagnostic classification — Skin, lip, base and facial context
| Category | Diagnoses |
|---|---|
| Skin | Thin · moderately thick · thick · oily · rhinophyma |
| Nasal base | Excess nostril show · visible mucosa · depressor septi hypertrophy · alar levator hypertrophy |
| Lip | Short lip · very short · high · tense · lip incompetence · lip imbalance |
| Facial skeleton | Chin hypotrophy · vertical hypertrophy · anterior hypertrophy · chin-mandible hypotrophy · maxillary hypotrophy · flat face · concave face |
| Global diagnosis | Rhinomegaly · nasal deviation · short nose · wide (dorsum and tip) · traumatic · boxer’s nose · senile · cleft · tubular · triangular · hourglass · funnel · harpoon-tip · Pinocchio · mixed-ancestry nose · secondary rhinoplasty |
From diagnosis to plan
Once the list is ticked, the plan is written in the order it will be performed, not the order it was thought out. It is a small difference that saves real time in theatre, because the sheet is read top to bottom as you go. A typical plan reads: transcolumellar and prerimal incision; tip and dorsal degloving specifying the plane for each segment — subperichondrial at tip and cartilaginous dorsum, subperiosteal at bony dorsum; septoplasty with its fixation point to the anterior nasal spine; anterior septal border resection; rasping and shaping of the bony dorsum; lateral and transverse fracture; spreader flaps from upper lateral cartilage; caudal extension graft fixed to the spreaders; cephalic alar resection; intradomal, interdomal and intra-alar sutures; prerimal grafts; and alar base resection if indicated. Every line of the plan answers a line of the diagnosis, and that correspondence is what allows later review of what worked and what did not.
Two cautions about the numbers
First: normative figures describe the leptorrhine nose, the narrow, projected Caucasian biotype. In mesorrhine and platyrrhine noses projection is lower, the base wider and the nasofrontal angle more acute, and forcing “ideal” values produces noses that do not fit the patient’s face. Second: the numbers guide, they do not command. The goal is not a nose that measures what the table says, but a nose that does not draw attention on that particular face. When measurement and impression disagree, the impression is usually right; angles serve to understand why something looks wrong and to be able to explain it, not to replace judgement.
References
- 1.Piedra Buena IT, Kahn D. Rhinoplasty. In: StatPearls. Treasure Island: StatPearls Publishing; 2024.
- 2.Crumley RL, Lanser M. Quantitative analysis of nasal tip projection. Laryngoscope. 1988;98(2):202-208.
- 3.Naini FB, Cobourne MT, Garagiola U, McDonald F, Wertheim D. Nasofrontal Angle and Nasal Dorsal Aesthetics: A Quantitative Investigation of Idealized and Normative Values. Facial Plast Surg. 2016;32(4):444-451.
- 4.Powell N, Humphreys B. Proportions of the Aesthetic Face. New York: Thieme-Stratton; 1984.
- 5.Daniel RK, Palhazi P. Rhinoplasty: An Anatomical and Clinical Atlas. Cham: Springer; 2018.
Related specialty: Rhinoplasty