Flat Nose

“Flat” is a description of the bridge, not a diagnosis. Several features usually come as a set:

• A low dorsum and a low, set-back radix. The radix is the deepest point where the nose meets the forehead. When it sits low and posterior, the whole bridge reads as flat even when the tip itself is fine.
• Short, wide nasal bones. Less bony support along the upper third, and a broader base to work from.
• Softer, more pliable cartilage. The upper and lower lateral cartilages are frequently less springy than in a thin-skinned European nose, which matters more for breathing than for looks.
• Thicker, more sebaceous skin over the tip. The skin and soft tissue envelope can be several millimetres thick at the tip, which blurs whatever framework sits underneath it.
• A wider alar base with more horizontally set nostrils.

None of that is pathology. It is a different set of building materials. Farkas and colleagues measured facial proportions across 25 population groups and found nasal width and dorsal height varying enormously between them, which is a polite way of saying that the “ideal” numbers printed in older rhinoplasty textbooks were drawn from one narrow population and were never meant to be applied to everyone else.¹

The practical figure worth knowing: the difference between a bridge that reads as flat and one that reads as defined is, in my hands, usually 3 to 5 mm of dorsal height. That is a smaller change than almost anyone expects, and it is why photographs of dramatic transformations should make you suspicious.

There was a period when augmentation rhinoplasty meant moving every nose towards a single template: high narrow bridge, sharp tip, pinched base. It produced noses that did not belong on the faces they were attached to.

What I plan instead is deliberately conservative. Raise the dorsum by the few millimetres that give the bridge a line. Set the radix at a height that suits the brow and the chin rather than a textbook angle. Build tip definition by supporting the framework underneath the skin. Leave the alar base alone unless narrowing the nostrils is something the patient has asked for specifically and for their own reasons, in which case alar base reduction is a small, separate procedure from £4,500.

The goal is a nose that still looks like it grew on your face. Ask any surgeon you see to show you results in patients whose starting anatomy resembles yours. I use digital imaging at consultation so we can agree what we are aiming at before anything is booked, but imaging is a planning tool and a way of testing whether we want the same thing. It is not a prediction and it is certainly not a promise. More on how heritage shapes the surgical plan on my ethnic rhinoplasty page.

A low bridge has to be built up with something. The options split into your own tissue and manufactured material, and they do not carry the same risk.

Septal cartilage is my first choice: it is already in the surgical field, it is straight, and it costs nothing extra in recovery. The catch is quantity. A septum that has never been operated on yields a usable piece of a few square centimetres once the L-strut that holds the nose up has been left intact, and that is often not enough for a dorsum that needs real height.

Conchal cartilage from behind the ear is soft and naturally curved. It is excellent for the tip and the sidewall, and poor for a straight bridge. The scar sits in the crease behind the ear and the ear shape is unchanged.

Costal cartilage from the rib is the workhorse for significant dorsal augmentation. It gives as much material as anyone could need. The costs are real: a chest scar of around 3 to 4 cm, a week or two of sore ribs that most patients find more uncomfortable than the nose itself, and a tendency for carved rib to warp over years. Dicing the cartilage and wrapping it in the patient's own fascia largely removes the warping problem and gives a softer, more natural dorsal line than a solid carved block.

Silicone and porous polyethylene implants are quick, need no donor site, and come in fixed sizes. They are widely used in parts of East Asia. I do not use them. My reason is the published complication data. A meta-analysis of alloplastic materials in rhinoplasty found removal rates of 3.1 per cent for expanded PTFE and porous polyethylene, and 6.5 per cent for silicone.²

What those numbers describe, in the clinic, is a foreign body sitting under thin skin at the most exposed point of the face for the next forty years. Infection and extrusion can present a decade or more after an uneventful operation, and a nose that has extruded an implant is a harder problem than the one you started with. Cartilage takes longer to harvest and heals into you.

Thin skin drapes over the cartilage framework and shows every edge of it, for better and for worse. Thick, sebaceous skin does not. It sits over the framework like a duvet and hides the detail, which is why tip work that produces a lovely result in one nose produces a soft, undefined blob in another.

So definition in a thick-skinned tip comes from pushing the framework out against the skin, not from cutting cartilage away. In practice that means a septal extension graft or a columellar strut to set projection and rotation, and a cap or shield graft to give the tip a point for the skin to tent over. Suture techniques that reshape cartilage beautifully in a thin-skinned nose barely register through a thick envelope.

The mistake that generates revision work is the opposite approach: trimming the lower lateral cartilages hard in the hope the skin will shrink down onto a smaller framework. It does not shrink. The tip loses its support, scar tissue fills the space, and the result is amorphous and difficult to correct. Revision rhinoplasty for a collapsed thick-skinned tip starts from £12,000 and almost always needs rib.

Timing, because it catches people out. Splint off at a week. Most of the obvious swelling gone by three weeks. Then thick skin carries on refining for 18 months, sometimes 24. Month four is when patients email me convinced nothing has changed, and month four is exactly when nothing much has. Tip surgery on its own, where the bridge needs no work, is from £8,000.

This is the part that gets missed, and as an ENT surgeon it is the part I look at first. The nasal valve is the narrowest part of the nasal airway, and it is where a soft, wide nose tends to fail.

The internal valve is the angle between the septum and the upper lateral cartilage. The external valve is the nostril rim, held open by the lower lateral cartilage. Where those cartilages are thin, soft and set horizontally, they behave like a floppy straw: fine at rest, collapsing inwards the moment you breathe in hard. Patients rarely describe it as a nose problem. They say their nostrils suck shut when they run, or that nasal strips help, or that they sleep with their mouth open.

A clinical consensus statement from the American Academy of Otolaryngology concluded that nasal valve compromise is under-recognised, that it can be diagnosed on history and examination without special investigations, and that surgical repair is the mainstay of treatment where the problem is structural.³ In clinic that examination takes seconds: a modified Cottle manoeuvre, supporting the sidewall or the rim with a probe, and watching whether the airway opens.

The repairs are grafts, and they overlap almost entirely with the grafts used for shape: spreader grafts to widen the internal valve angle, alar batten and lateral crural strut grafts to stiffen a collapsing sidewall, rim grafts to hold the nostril open. Raising a low dorsum with a graft often improves the internal valve as a side effect. A deviated septum frequently sits underneath all of it, and septorhinoplasty addresses the airway and the shape in one anaesthetic. Where the problem is purely functional, septal surgery from £6,000 is BUPA fee-assured work and may be covered by your policy.

A nose that looks flat and breathes badly is one operation, not two. Augmenting the bridge while ignoring a collapsing sidewall is a good way to leave someone looking better and breathing worse.