Original Research

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Middle Eastern Rhinoplasty: Relationship Ó The Authors 2017

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of the Nasal Spine and Caudal Septum to DOI: 10.1177/2473974X17742857
http://opnjournal.org
Tip Projection and Columellar-Labial
Angle

Richard L. Arden, MD1, Brett J. Baldwin, DO2, and

Mary P. Coffey, PhD3

No sponsorships or competing interests have been disclosed for this article. Received August 31, 2017; revised October 10, 2017; accepted
October 27, 2017.

Abstract
Objective. To measure the anterior nasal spine length (ANSL)

M
iddle Eastern rhinoplasty is becoming increasingly
and septal caudal extension (SCE), as well as assess the more common in the United States with distinct
strength of association between these variables and tip pro- demographic distributions. According to the Arab
jection in the Middle Eastern nose. Our secondary aim was American Institute Foundation (AAIF), nearly 3.6 million
to assess if columellar-labial angle (CLA) or columellar-spinal Americans trace their roots to an Arab country, with the
angle (CSA) vary as a function of ANSL and/or SCE. majority having ancestral ties to Lebanon, Syria, Palestine,
Study Design/Setting. Prospective single institutional study. Egypt, and Iraq.1 Two-thirds of Arab Americans are concen-
trated in 10 states, with one-third of the total residing in
Subjects. Middle Eastern primary rhinoplasty patients with- California, New York, and Michigan. Broadly speaking, the
out nasal trauma or prior endonasal surgical history. term Middle Eastern has referenced individuals of Persian,
Methods. Photographic and intraoperative caliper measure- Arabic, Turkish, and Northern African descent but can also
ments were used to determine Goode ratio (GR), CLA, be further subdivided into specific countries.2
CSA, ANSL, and SCE. Associations between numeric vari- Common anatomic features ascribed to the Middle Eastern
ables were examined with scatterplots, including use of nose include normal to thick sebaceous skin type (Fitzpatrick
LOWESS curves and Pearson correlation coefficients. Linear III-V), normal to high radix, wide bony and middle nasal vault,
regression models were used for predicting quantitative prominent dorsal hump, excessive nasal length, tip ptosis with
variables (GR, CLA, CSA). Logistic regression models were acute columellar-labial angle, and occasional hyperdynamic
used for predicting overprojection status based on GR. depressor nasi septi muscle activity.2-6 Conspicuously absent is
any detailed characterization of the anterior nasal spine/posterior
Results. In total, 102 patients met inclusion criteria (82 septal angle complex in this ethnic group and its possible associ-
females, 20 males). Mean ANSL and SCE were 8.6 mm and ation with the ‘‘tension nose,’’ which shares similar structural
14.9 mm, respectively; ANSL and SCE had a strong positive features in the lower one-third of the nose. Originally coined by
association with each other. SCE and ANSL were found to Cottle, this deformity typically describes overgrowth of the
have low predictability for GR, CLA, or CSA.
1
Conclusion. Determinations of projection status using the GR Division of Otolaryngology, Beaumont Hospital Troy, Troy, Michigan, USA
2
method do not appear to be related to ANSL or SCE values Department of Otolaryngology–Facial Plastic Surgery, Henry Ford
Macomb Hospital, Clinton Township, Michigan, USA
in our Middle Eastern study group. Relationships of absolute 3
Department of Biostatistics, Beaumont Health Research Institute,
columellar-labial or columellar-spinal angles are likely more Beaumont Hospital Royal Oak, Royal Oak, Michigan, USA
complex than isolated value implications of SCE or ANSL.
This article was presented at the 2017 AAO-HNSF Annual Meeting and
OTO Experience; September 10-13, 2017; Chicago, Illinois.
Keywords Corresponding Author:
Middle Eastern nose, nasal spine, Goode ratio, septal length, Richard L. Arden, MD, Department of Surgery, Division of Otolaryngology,
columellar-labial angle Beaumont Hospital Troy, 44201 Dequindre Rd, Troy, MI 48085, USA.
Email: [email protected]

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further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-
access-at-sage).
2 OTO Open

anterior nasal spine (ANS) and dorsal and quadrangular carti-

lage, leading to tip overprojection, blunting of the columellar-
labial angle (CLA), and apparent foreshortening of the upper
lip.7 Although the ANS can contribute to the disproportionate
relationships of the nasal base in the tension nose, it is felt that
the prominence of the posterior septal angle is invariably the
main cause of these problems. In a series of 57 consecutive
female patients of Northern European descent, Rowe-Jones and
van Wyk8 identified tip overprojection in 54%, tension nose in
30%, and a prominent ANS/posterior septal angle in 26%.
Similar to Johnson and Godin,7 they also felt extrinsic nasal Figure 1. Profile view demonstrating columellar-labial angle (red
dorsal and tip overprojection related more to overdevelopment arc and arrow) and columellar-spinal angle (blue arc and arrow).
of the septal quadrangular cartilage than ANS. Note the blunting of the ‘‘nasolabial angle’’ by the soft tissue over-
Given the paucity of objective data relating to this area lying the anterior nasal spine (black triangle), foreshortening of the
of the Middle Eastern nose, the goal of this study was to upper lip, and nasal tip overprojection.
assess the strength of association of the values of anterior
nasal spine length (ANSL) and septal caudal extension
(SCE) with nasal tip projection. Our secondary aim was to soft tissue over the spine is present, the CSA is always more
determine if CLA and columellar-spinal angle (CSA) vary obtuse than the CLA. This is demonstrated in Figure 1.
as a function of these values. SCE and ANSL were measured intraoperatively in milli-
meters using a caliper following an open approach exposure
of the anterior-most and caudal aspect of the septum and
Materials and Methods premaxilla. The SCE was measured between the anterior-
A prospective study used 102 consecutive Middle Eastern most point of the pyriform aperture (PA) and the anterior-
patients who underwent primary external rhinoplasty (6 most point of the caudal septum in a ventral-dorsal plane.
septoplasty) by the primary author between January 2015 The ANSL was measured between the PA and the leading
and November 2016. The Beaumont Health Institutional point of the bony spinous prominence in the ventral-dorsal
Review Board approved the study (2016-241), and verbal plane following soft tissue removal. Data were compiled by
informed patient consents were obtained. To meet inclusion the primary author and stored in an Excel (Microsoft,
criteria, individuals had to be dentate, without prior septona- Redmond, Washington) file following institutional review
sal fracture injury or history of previous endonasal surgery, board security guidelines.
and without moustaches that would obscure topographic
landmarks. Baseline data pertaining to age, sex, and country Statistical Analysis
of origin were recorded. Categorical variables were summarized with counts and fre-
Preoperatively, standard 4-view rhinoplasty photographs quencies. Numeric variables were summarized by mean and
were acquired with a Canon EOS 30D camera (Canon, Oita, standard deviation for normally distributed variables and by
Japan) on full auto mode using a 28- to 135-mm zoom median and range otherwise. The associations between
macro lens. All photographs were taken at a fixed distance numeric variables were examined with scatterplots with
to a target of 30 inches (0.85m) at an f-stop of 1:5.6 and LOWESS (LOcally WEighted Scatterplot Smoothing) lines.
shutter speed of 1/60 s. Images were stored on a 32-GB Pearson’s correlation coefficients summarized the strength of
SanDisk Compact Flash (CF, Milpitas, California) and sub- association between numeric variables. Linear regression
sequently developed onto 6 3 4-inch photo paper using an models were used for the prediction of quantitative variables;
Epson Picture Mate PM240 printer (Epson, Manila, logistic regression models were used for the prediction of over-
Philippines) with a resolution of 5760 3 1440 dpi. Using a projection status. Both univariate and bivariate regression
lateral view, the Goode ratio was determined with direct models were considered; Receiver operating characteristic
ruler measurement following defined points of reference, as (ROC) curves were obtained for logistic regression models.
summarized by Robinson and Thornton.9 Overprojection We used the SAS System for Windows version 9.3 (SAS
was defined as a Goode ratio 0.61 and underprojection as Institute, Cary, North Carolina) for statistical analysis and
a Goode ratio 0.54. CLA and CSA were derived by pro- Minitab Release 14 (Minitab, State College, Pennsylvania) for
tractor measurement and recorded in degrees (Figure 1). In graphs.
cases where a CSA did not exist, we defined CSA = CLA.
These angles become identical as there is absence of an Results
anterior soft tissue prominence overlying the spine on lateral
view, which otherwise creates a blunting of the CLA if Demographics
measured at the point anterior to this prominence (CSA) or Table 1 shows the demographic and clinical characteristics
at the base of the columella where it meets a line drawn of the 102 Middle Eastern study patients. The group was
adjacent to the upper lip line (CLA). When this prominent 80% female with a median age of 23 years (range, 16-46).
Arden et al 3

Table 1. Demographic and Clinical Characteristics of the Middle Eastern Rhinoplasty Patients, Overall and by Sex (N = 102).
Characteristic Overall Summary Female (n = 82) Male (n = 20)

Sex, No. (%)

Female 82 (80)
Male 20 (20) NA NA
Age, median (range), y 23 (16-46) 23 (16-46) 23 (16-43)
Ethnicity, No. (%)
Iraqi 97 (95)
Other 5 (5)
Projection, No. (%)
Over 46 (45) 34 (41) 12 (60)
Ideal 49 (48) 41 (50) 8 (40)
Under 7 (7) 7 (9) 0(0)
ANSL, mean (SD), mm 8.6 (2.5) 8.3 (2.3) 10.0 (2.8)
SCE, mean (SD), mm 14.9 (2.9) 14.3 (2.5) 17.1 (3.3)
Goode ratio, mean (SD) 0.61 (0.05) 0.60 (0.05) 0.63 (0.05)
CSA, median (range), deg 130 (72-152)
CLA, median (range), deg 94 (55-112)

Abbreviations: ANSL, anterior nasal spine length (millimeters); CLA, columellar-labial angle (degrees); CSA, columellar-spinal angle (degrees); NA, nonapplic-
able; SCE, septal caudal extension (millimeters).

Using Goode ratios, 45% of subjects had overprojection, models for predicting overprojection from some combina-
48% had ratios in the ideal range, and 7% had underprojec- tion of ANSL and SCE. In univariate logistic regression, the
tion. Most (95%) identified their country of origin as Iraq, odds of overprojection increase by 16% per 1-unit increase
with very small counts from other countries: Jordan (1), in SCE (odds ratio, 1.157; 95% confidence interval [CI],
Lebanon (1), Yemen (2), and Palestine (1). The average 1.01-1.34); the area under the ROC curve for the univariate
nasal spine length was 8.6 mm with a wide range (3-15 logistic regression with SCE is 0.606 (1 indicates a perfect
mm). The anterior-most septal cartilage ledge extended, on prediction and 0.50 corresponds to chance, and therefore
average, over 6 mm from the nasal spine point. 0.606 represents a low accuracy despite a statistical signifi-
cance of P = .04). In the other univariate logistic regression
Relationship of SCE and ANSL to Goode Ratio model, the odds of overprojection increase by 23% per 1-
Scatterplots depicting the relationships of the Goode ratio to unit increase in ANSL (odds ratio, 1.234; 95% CI, 1.05-
SCE and ANSL are shown in Figure 2A, B. While there is 1.48); the area under the ROC curve is 0.638 (representing
a strong positive association between the values of SCE and low accuracy despite statistical significance of P = .02). In a
ANSL, there does not appear to be a strong relationship of bivariate logistic regression model with both SCE and
either SCE or ANSL with the Goode ratio. Pearson’s corre- ANSL, neither variable is statistically significant, and there
lation coefficients are as follows: ANSL and SCE, 0.74; is little change in the c-statistic (0.644).
SCE and Goode ratio, 0.19; and ANSL and Goode ratio,
0.27. The scatterplots with LOWESS smoothers suggest that Relationship of SCE and ANSL to CSA and CLA
the relationship between the Goode ratios and these 2 vari- Using a scatterplot matrix (not shown), neither SCE nor
ables is no more complicated than linear; linear regression ANSL appears related to CSA. Pearson’s correlation coeffi-
models predicting the Goode ratio from ANSL and/or SCE cients are 20.04 between SCE and CSA and 0.07 between
explain no more than 7% of the variation in the Goode ANSL and CSA. Scatterplots with LOWESS smoothers pro-
ratio. vided little evidence that the relationship between CSA and
We used logistic regression models to examine whether these 2 variables was more complicated than linear. When
SCE and/or ANSL help predict whether the Goode ratio is linear regression models were fit relating one or both of
at least 0.61 (overprojected). While SCE (P = .04) and SCE and ANSL to CSA, less than 3% of the CSA variabil-
ANSL (P = .02) each had a statistically significant effect in ity was explained by the model, and no effect was statisti-
univariate logistic regression models, neither variable was cally significant. Using a scatterplot matrix (not shown),
statistically significant in a bivariate logistic regression neither SCE nor ANSL appears related to CLA. Pearson’s
model with both ANSL and SCE. However, none of the 3 correlation coefficients are 0.19 between SCE and CLA,
models provided a good prediction of overprojection as and 0.14 between ANSL and CLA. Scatterplots with
measured by the area under the ROC curve (c-statistics). LOWESS smoothers provided little evidence that the rela-
Figure 3 displays the ROC curves and c-statistics of 3 tionship between CLA and these 2 variables was more
4 OTO Open

Figure 2. Scatterplot of the Goode ratio vs (A) septal caudal extension (SCE) and (B) anterior nasal spine length (ANSL) with LOWESS
and regression lines.

complicated than linear. When linear regression models given level of SCE or ANSL, men tend to have larger
were fit relating one or both of SCE and ANSL to CLA, values for the Goode ratio than do women; however, these
less than 3% of the variability in CLA was explained by the differences do not achieve statistical significance at the .05
model, and no effect was statistically significant. level, although they do at the .15 level. On average, the
Goode ratio for a man is 0.022 larger than for a woman
Exploration of the Effect of Sex with the same value of SCE, 0.020 larger than for a woman
Boxplots (not shown) were obtained comparing the values with the same value of ANSL, and about 0.022 larger than
of SCE, ANSL, and the Goode ratio for women and men. for a woman with the same values for both CSE and ANSL
The boxplots indicate a tendency for men to have larger using the 2 univariate and bivariate linear regression models,
values for all 3 of these characteristics than women. In addi- respectively.
tion, scatterplots were obtained with separate LOWESS
smoothers by sex to examine whether the relationship Discussion
between the Goode ratio and SCE or ANSL was similar for The ANS is formed from the fusion of the maxillary alveo-
women and men (Figure 4). These plots suggest that for a lar processes and is subjected to anterior tractive forces at
Arden et al 5

reduction in approximately 20% of patients with elongated

septums. By contrast, others have found the posterior septal
angle to often be overdeveloped in the presence of a normal
ANS.8 Among our study participants, we found a strong posi-
tive association between the values of SCE and ANSL
(Pearson’s correlation coefficient = 0.74), which frequently
required some form of septal shortening at the time of ANS
resection.
The nasal spine is considered a minor tip support
mechanism, and its overdevelopment imparts an upward
thrust of the tip components.17 Despite claims that hyperpla-
sia of the ANS can be partially or totally responsible for
overprojection of the tip,18 others have observed that its
removal alone has little or no effect on nasal tip projec-
tion.19 More often, it is a combination of factors that contri-
butes to overprojection and may include overdevelopment
of the alar cartilages, quadrangular cartilage, ANS, or any
combination of these.
The Middle Eastern nose shares many features of the
caudal excess nasal deformity and the tension nose, including
a long nose, ptotic tip, acute columellar-labial angle, and pro-
Figure 3. Receiver operating characteristic (ROC) curves for pre-
minent hump.4,20 In addition, frequent features of a heavy
dicting overprojection from anterior nasal spine length (ANSL),
septal caudal extension (SCE), or a linear combination of the two.
thick skin envelope, bulbous tip, and wide bony middle vault
often impart the impression of an overall large nose, which
on cursory inspection may seem overprojected. We tested
this premise using the Goode ratio, which is the most widely
the site of insertion of the septo-premaxillary ligament.10 quoted and used objective method to assess nasal tip projec-
ANS formation, which is unique in humans among mam- tion.17,21,22 Despite observations of significant variation in
mals and primates,11 may be the result of bony resorption ranges of projection among different cultures and ethnicities,
on the labial side of the premaxilla and depository fields on little normative data exist. Rohrich and Ghavami2 cited 0.67
the lingual side, resulting in downward growth direction.12 as an ideal tip height to length ratio in the Middle Eastern
Anatomically, it is defined by the linear measurement from nose and 90 to 95 degrees as the desired CLA. By compari-
the maxillary-palatine suture to its tip and is variable in son, traditionally accepted parameters for CLA are 95 to 105
shape and length. Lang13 believed the ANS correlated with degrees for a Caucasian female and 90 to 95 degrees for a
the shape of the soft tissues of the nose and alveolar posi- male.23 We found that using the standard Goode ratio calcu-
tion and reported variations in length of 0 to 9 mm in adults lation, only 45% of our subjects were overprojected. Of the
and up to 15 mm in cadavers (sex/ethnicity unspecified). 71 patients described by Rohrich and Ghavami2 (sex unspeci-
Racial differences in ANS morphology and prominence fied), 79% were underprojected, likely reflective of how the
were reported in a study consisting of 190 dried African Goode ratio was defined. In addition, we did not find a
American and Caucasian skulls, showing a more prominent strong relationship between either ANSL or SCE with the
ANS among Caucasians that was determined by 24 weeks Goode ratio. A potential explanation for this may be the fact
prenatally.14 In our own study, predominantly consisting of that the ANSL represents a relatively small contribution to
patients of Iraqi descent, ANS values trended toward promi- septal elevation (projection), while tip projection may be
nent (mean, 8.6 mm; range, 3-15 mm). To our knowledge, more related to the product of rostral-caudal and dorsal-
there are no other specific normative data pertaining to ventral measurements (ie, total septal area) and not the
ANS length other than cited herein. restrictive measurement used in this study (ie, SCE). In lieu
The anteroinferior edge of the caudal septum is attached of our findings, and consequent to the illusionary impact of
to the ANS (chondro-spinal junction) and is defined as the overprojection attributable to a prominent ANS and obtuse
posterior septal angle. Although quantitative studies corre- CLA, it has been our practice to correct these features prior
lating septal and ANS length have not yet been reported to to any adjustments in tip position. This approach would be
our knowledge, observations of the ‘‘caudal excess nasal independent of ethnic derivation.
deformity’’ have been described.15 This rare profile defor- The morphology of the caudal septum, ANS, maxilla,
mity is attributed to elongation of the caudal septum, over- upper incisor inclination, and medial crural footplate diver-
growth of the ANS, premaxillary protrusion, or combinations gence influences profile relationships of the upper lip and
thereof. Considered by some to be a variation of the ‘‘tension columella. A prominent ANS makes identification of the
nose,’’ it is distinguished in that it may occur independent of subnasale (used in Goode ratio calculation) difficult and
dorsal overgrowth. Friedman et al16 reported a need for ANS biases the slope of the vertical limb of the upper lip, leading
6 OTO Open

Figure 4. Scatterplot of the Goode ratio vs (A) septal caudal extension (SCE) and (B) anterior nasal spine length (ANSL) with separate
plotting characters for men and women, as well as separate LOWESS and regression lines for men and women.

to a more obtuse angle. The dimension and orientation of the measurement in a relatively large and ethnically comparable
septum can also influence the CLA. While some believe ANS patient population. Weaknesses of the study include the lim-
prominence is more associated with an obtuse angle than an itations of using Goode ratio parameters that have not been
increase in septal length,24 others relate it more to the effects established for the Middle Eastern population and that possi-
of dorsal nasal length. In addition, it is believed the caudal end ble sex differences could not be explored thoroughly given
of the septal cartilage more likely influences columellar shape the number of men in the study, thereby introducing potential
rather than the ANS.25 In this study, we attempted to evaluate selection bias. All the study patients sought surgery and may
the influence of the ANSL and SCE upon either the CLA or not be representative of all individuals of Middle Eastern des-
CSA. In all methods of statistical analysis that we employed, cent. Methodologic criticism may include that ANS measure-
neither SCE nor ANSL had a statistically significant effect on ments were taken from the anterior-most pyriform ledge
CSA or CLA; the explained variation in angles with these 2 rather than the maxillary palatine suture and that the CSA
measures was very small. This finding was surprising to us may correlate with changes at the posterior septal angle
and would seem to suggest that other factors not measured in rather than the SCE where we measured.
this study influence the CLA, and described herein,23 may be
affecting these associations. Conclusion
The strengths of this study include a single surgeon’s The current study shows that among predominantly Iraqi
experience with a uniform approach and consistent method of female participants, there is a strong positive association
Arden et al 7

between the values of SCE and ANSL. Neither SCE nor 9. Robinson S, Thornton M. Nasal tip projection: nuances in
ANSL was very useful in predicting the Goode ratio (either understanding, assessment, and modification. Facial Plast
its numeric variable or its dichotomization into overprojec- Surg 2012;28:158-165.
tion or not). In addition, neither SCE nor ANSL was useful 10. Latham RA. Maxillary development and growth: the septo-
in predicting CLA or CSA. Future studies that consider pos- premaxillary ligament. J Anat. 1970;107:471-478.
sible sex differences and the complex morphology of other 11. Walter C. The importance of the nasal spine for the operation
bony or soft tissue structures, such as the lower lateral carti- of the nasal septum. Laryngol Rhinol Otol. 1960;39:774-780.
lages, will lend better insight into Middle Eastern nasal 12. Enlow DH. Handbook of Facial Growth. Philadelphia, PA:
dynamics. WB Saunders; 1982.
13. Lang J. Clinical Anatomy of the Nose, Nasal Cavity and
Author Contributions Paranasal Sinuses. New York, NY: Thieme Medical Publishers;
Richard L. Arden, study conception and design, surgical measure- 1989.
ments, drafting of manuscript, revision, final approval; Brett J. 14. Mooney MP, Siegel MI. Developmental relationship between
Baldwin, study conception, data acquisition, drafting of manu- premaxillary-maxillary suture patency and anterior spine mor-
script, revision, final approval; Mary P. Coffey, data analysis, sta- phology. Cleft Palate J. 1986;23:101-107.
tistical analysis, drafting of manuscript, revision, final approval. 15. Davis RE. Diagnosis and surgical management of the caudal
Disclosures excess nasal deformity. Arch Facial Plast Surg. 2005;7:124-
134.
Competing interests: None.
16. Friedman WH, Pearlman SJ, Rich JS. A systematic approach
Sponsorships: None. to the columellar-labial angle in rhinoplasty. Am J Cosmet
Funding source: None. Surg. 1990;7:253-259.
17. Tardy EM, Walter MA, Patt BS. The overprojecting nose: ana-
References tomic component analysis and repair. Facial Plast Surg. 1993;
9:306-316.
1. Arab American Institute. Demographics. http://www.aaiusa.org/ 18. Marianetti TM, Boccieri A, Pascali M. Reshaping of the ante-
demographics. Accessed September 24, 2016. rior nasal spine: an important step in rhinoplasty. Plast
2. Rohrich RJ, Ghavami A. Rhinoplasty for Middle Eastern Reconstr Surg Glob Open. 2016;4:e1026.
noses. Plast Reconstr Surg. 2007;123:1343-1354. 19. Pearlman SJ. Surgical treatment of the nasolabial angle in
3. Bizrah MB. Rhinoplasty for Middle Eastern patients. Facial balanced rhinoplasty. Facial Plast Surg. 2006;22:28-35.
Plast Surg Clin North Am. 2002;10:381-396. 20. Daniel RK. Middle Eastern rhinoplasty: anatomy, aesthetics,
4. Daniel RK. Middle Eastern rhinoplasty in the United States: and surgical planning. Facial Plast Surg. 2010;26:110-118.
Part I. Primary rhinoplasty. Plast Reconstr Surg. 2009;124: 21. Powell N, Humphreys B. Proportions of the Aesthetic Face.
1630-1639. New York, NY: Thieme-Stratton; 1984.
5. Azizzadeh B. Middle Eastern rhinoplasty. Facial Plast Surg 22. Crumley RJ, Lanser M. Quantitative analysis of nasal tip pro-
Clin North Am. 2010;18:201-206. jection. Laryngoscope. 1988;98:202-208.
6. Sajjadian A. Rhinoplasty in Middle Eastern patients. Clin 23. Kim DW, Egan KK. Metrics of nasal tip rotation: a compara-
Plastic Surg. 2016;43:281-294. tive analysis. Laryngoscope. 2006;116:872-877.
7. Johnson CM, Godin MS. The tension nose: open structure rhi- 24. Aston SJ, Guy CL. The nasal spine. Clin Plast Surg. 1977;4:
noplasty approach. Plast Reconstr Surg. 1995;95:43-51. 153-162.
8. Rowe-Jones J, van Wyk FC. Special considerations in 25. Anderson KJ, Henneberg M, Norris RM. Anatomy of the nasal
Northern European primary aesthetic rhinoplasty. Facial Plast profile. J Anat. 2008;213:210-216.
Surg. 2010;26:75-85.