Prevalence of Occult Nostril Asymmetry in the Oversized Nasal Tip: A Quantitative Photographic Analysis

Objective To objectively determine the prevalence of occult nasal base asymmetry in adults with wide nasal tips using a standard photographic editing program. Methods We performed a retrospective observational study in a private practice, ambulatory care setting. The photographs of 100 randomly selected patients undergoing rhinoplasty who presented with excessive nasal tip width and no apparent nasal base asymmetry were evaluated for occult nostril asymmetry. Patients varied by ethnicity and sex and ranged in age from 16 to 40 years. We excluded patients with discrete nasal base asymmetry, crooked or twisted noses, caudal septal deviation, columellar tilt, a history of craniofacial trauma, or a history of nasal surgery. Measurements were obtained using a standard photographic analysis program. Results On the basal view, the median percentage of asymmetry (95% confidence interval) was 4.91% (4.17%-5.66%); on the frontal view, 4.66% (3.68%-5.62%). On the basal view, 73% of noses were at least 2.5% asymmetric; on the frontal view, 67% (McNemar P = .53). On the basal view, 48% of noses were at least 5% asymmetric; on the frontal view, 50% (McNemar P = .74). On the basal view, 11% of noses were at least 10% asymmetric; on the frontal view, 20% (McNemar P = .11). Conclusions A large percentage of individuals presenting with excessive nasal tip width and no obvious alar size discrepancies have nasal base asymmetry. Moreover, nostril asymmetry is demonstrated from the frontal and basal views with reasonable consistency. In a small subset of study patients, occult nostril asymmetry exceeded 10% of the total nasal base width. We postulate that clinically significant nostril size discrepancies are hidden by excessive tip width, and we speculate that these nostril size discrepancies become more apparent after surgical refinement of the oversized nasal tip, thereby potentially leading to unexpected postoperative cosmetic imperfections and patient dissatisfaction. The apparent frequency of (occult) nostril asymmetry in patients with excessive nasal tip width underscores the importance of nostril size assessment in the preoperative aesthetic analysis. We offer a reliable and convenient method for objective analysis of nasal base symmetry.