What is the Ideal Nose? Individual Perspectives and Virtual Simulation Results from Rhinoplasty Surgeons Around the World

BACKGROUND: Existing literature on rhinoplasty places little to no emphasis on variability and evolution of ideal nasal aesthetics. Our group sought to use virtual 3D computer simulation to identify potential differences in ideal nasal aesthetics between rhinoplasty surgeons with varied experience, training, and geography. METHODS: 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, and were asked questions regarding their practice, including location, years experience, percent cosmetic and open rhinoplasty performed, number of rhinoplasties performed each year, and private vs academic. An identical set of 3D images (Vectra H1) for 3 patients (P1,2,3), with varying degrees of nasal deformities and facial proportions were used and surgeons were asked to create an ideal rhinoplasty result using the Canfield Vectra software system. 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). RESULTS: A total of 111 surgeons from 28 countries completed the study to date (response rate 6.4%). Rhinoplasty surgeon demographics were as follows: 92% male, 70% plastic surgeons (29% facial plastics, 1% OMFS), 75% private practice, and 64% fellowship trained. The surgical practices included in the study demonstrated the following averages: 17+/-11 years experience, 123+/-101 rhinoplasties performed per year, with 75% and 77% of rhinoplasty procedures being cosmetic and via an open approach, respectively. Radix & Dorsum: Interestingly, increasing number of years of experience was associated with an increase in both RH and DH(RH, P1,2,3;p=<0.05,<0.01,<0.01)(DH, P2,3; p=<0.01,<0.01). Similar findings of an increased RH were noted in surgeons that identified as private practice(P3;p=<0.05). Conversely, the ideal RH was noted to be lower for surgeons using an open technique(P2;p=<0.05). The ideal DH was noted to be lower for surgeons who were fellowship trained(P2;p=<0.05) and performed primarily cosmetic rhinoplasty(P2;p=<0.05). Nasal tip complex: Ideal noses demonstrated a significant increase in NTR for surgeons who had increased years of experience(P1;p=<0.05) and those who primarily performed open rhinoplasty(P3;p=<0.05). NTP was significantly increased in ideal noses by surgeons who had increased years of experience (P2,3;p=<0.05,<0.05) and performed an increased number of cosmetic rhinoplasties(P2;p=<0.05). On the other hand, ideal noses demonstrated a significant decrease in NTP in fellowship trained rhinoplasty surgeons(P2,3;p=<0.05,<0.05), facial plastic surgeons(P2;p=<0.05), and female surgeons(P2;p=<0.05). When stratifying surgeons by location, distinct visual differences were noted in simulated ideals. 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: Our data suggests surgeons increased years of experience produce a more conservative nasal profile characterized by radix augmentation and less aggressive DH reduction. Analysis of geographic location showed no significance, however, visual representation of geographical ideals proves to highlight differences in the ideal nose. While aesthetic standards in rhinoplasty exist, 3D technology quantifies differences in perceived ideal aesthetics.