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Original Investigation
October 24, 2019

The Tripod Concept of the Upper Nasal Third

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Louisiana State University, New Orleans
  • 2Department of Facial Plastic & Reconstructive Surgery, University of California, Davis, Sacramento
JAMA Facial Plast Surg. Published online October 24, 2019. doi:https://doi.org/10.1001/jamafacial.2019.0884
Key Points

Question  Can we describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty?

Findings  In this study of 10 lay individuals and 10 rhinoplasty-trained individuals who evaluated manipulated photographs of 3 women who had not had surgery, lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture, while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (statistically significant). Projection was recognized as being altered by both rhinoplasty-trained and lay individuals (although not statistically significant), whereas subjective changes in rotation were significantly more elusive to the lay individual (statistically significant).

Meaning  Simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Abstract

Importance  The tripod theory of the upper nasal third parallels the concept of the well-known nasal tip tripod. We are evaluating the idea that one can simply alter the upper nasal angles reliably without the complex physics associated with the nasal tip to achieve a pleasing cosmetic result.

Objective  To describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty.

Design, Setting, and Participants  This is a prospective study in which lateral photographs of 3 women who had not undergone surgery (age range, 20-50 years) were selected for digital manipulation of the nasal radix with subsequent alteration of the nasofrontal and nasofacial angles via imaging software. The altered images were analyzed by 20 blinded individuals between July 2009 and June 2017 to assess how changes in the height of the nasal dorsum and radix alone affect nasal appearance and the perception of ideal nasal angles. The study took place at a tertiary center, and the patients chosen for evaluation had nasal architecture that only required subtle changes rather than structure that demonstrated glaringly obvious overprojection or underprojection and rotation or a large dorsal bony hump. Analysis began June 2018.

Main Outcomes and Measures  Overall trend in recognition of objective and subjective alterations in projection and rotation for the rhinoplasty- and non–rhinoplasty-trained evaluators.

Results  Ten medically trained and 10 lay individuals (13 women [65%]; mean [SD] age, 38 [8.6] years) analyzed digitally manipulated photographs of 3 women (age range, 20-50 years) who had not undergone surgery. Lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture (28 of 30 [93%]), while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (18 of 30 [60%]) (P < .001). Projection was consistently and accurately recognized as being altered by both rhinoplasty-trained and lay individuals (95% CI, −0.18 to 0.38; P = .60 and 95% CI, −0.26 to 0.33; P > .99 for most and least projected), whereas subjective changes in rotation were significantly more elusive to the lay individual (95% CI, −0.04 to 0.52; P = .12 and 95% CI, 0.11 to 0.65; P = .01 for most and least rotated).

Conclusions and Relevance  Predictable and consistent aesthetic results are the primary aim in rhinoplasty. Alterations in the upper nasal tripod are more reliable with extrapolated healing than with the tripod of the nasal tip. Ultimately, simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Level of Evidence  NA.

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