A hump or bump on the bridge of the nose is probably the most common feature altered with rhinoplasty. The hump may be a familial trait or caused by trauma. Even as we age, it seems like we ‘grow’ a hump due to loss of nasal tip support. This is such a common phenomenon that we often associate a hump with an aged appearance. As a result, removing a hump will often make one appear younger. 

A hump may involve all or part of the bridge. The skill in hump removal is making sure the bone and cartilage blend into one another so that the bridge looks smooth from top to bottom. After the hump is removed, the sides of the nose are pushed inward to narrow the new bridge. It is often assumed that the process of removing or moving the nasal bone is forceful; however, we actually perform this in a finessed and controlled manner. Finally, the width of the nasal valve area is checked. A narrow nasal valve not only makes breathing more difficult, it may create a visible indentation that looks like an upside-down ‘V’. If narrow, the nasal valve area is widened with cartilage grafts from the nasal septum, creating a smooth flow from the top to bottom of the nose.

A saddle nose has a bridge that appears low or indented on profile and wide and undefined from the front. It may be congenital, an ethnic variation, or occur as a result of trauma or previous surgery in which the bridge was reduced too much. Commonly, we see a saddle nose in the presence of a large nasal septal perforation inside the nose. 

With a saddle nose, insufficient cartilage and bone give the nasal bridge a flattened or indented appearance. When the nasal valve area is affected, there is often trouble breathing. Cartilage grafts are placed to widen the nasal valve area and create a larger airway. In cases of nasal septal collapse, the nasal tip falls up and into the nose creating a flattened and upturned appearance. Cartilage grafts are used to extend and rotate it to a more natural position.

The cartilage grafts that are used must be strong. For this reason, we prefer rib cartilage. Not only is it firm, but it may also be sculpted to resemble normal structure (e.g. the nasal bridge). We prefer to use your rib cartilage, but another option is to use donor rib cartilage from the deceased who have donated their bodies for medical use. The donor's rib has been treated to remove all microbes and cells. Once the treated rib cartilage is put into your nose, your own cells occupy it and it becomes a part of you. 

A crooked nose may be quite noticeable and impede breathing. It may prevent you from wearing eyeglasses or sunglasses correctly. A crooked septum inside the nose may cause breathing problems on one or both sides. Trauma is often the cause of a crooked nose, though it is possible to have one since birth. 

Deviations in the nasal septum or nasal bones often cause the entire nose to bend to one side. These bends can affect breathing by blocking airflow, especially at the nasal valve region. They may also block sinus drainage. The nose may bend to one side only or in multiple directions creating a C- or S-shaped nose. 

During rhinoplasty, the structures of the nose are "released" from one another to reduce tension. Cartilage that is bent or deviated has “memory” and resists straightening. Methods of scoring, shaving, flattening, splinting, or removing cartilage is necessary to cause bends to unbend. The key is to strengthen, not weaken, structural supports for the nose – otherwise, the nose may collapse over time. The nasal bones often need to be re-positioned into a straighter, more symmetric position. It is often assumed this process is forceful; however, we perform it in a finessed and controlled manner. Cartilage grafts from the nasal septum are often used to splint and straighten the bridge of the nose. The released structures are put back together in a more symmetric fashion. Strength may be added to the nasal tip with additional cartilage grafts.

The pinched nose appears too narrow and may compromise breathing. Unfortunately, this may be a by-product of previous aggressive rhinoplasty. A nose that is narrow may make the face appear wider or make the eyes appear widely set. Narrowness solely in the tip and nostrils may make the bridge look too wide, and vice versa. The goal is to make the nose more balanced top to bottom and better proportioned to the size of the face. 

The pinched portion may be at the nasal valve region, located just below the bony bridge, and may appear as an upside-down ‘V’. Another site of pinching may be at the nostrils and/or nasal tip. This may appear as a deepening of the crease above the nostril and lead to airway collapse with forceful inspiration. A weak nostril rim may also contribute to airway collapse. 

The goal of correction is to strengthen the nose and re-create structure. In the case of a narrow nasal valve, cartilage grafts are placed to widen this region. When the nostrils and nasal tip are pinched, cartilage grafts are used to fill-in the contour from the nasal tip to the nostril crease. For a weak nostril rim, a cartilage graft is precisely placed directly into the rim to add strength and support.

With an upturned nasal tip, the nostril openings are much too visible from the front, and the nose may appear under-projected from the side. The nose may look too short overall. One may have been born with an upturned nose or acquired it from trauma or a large septal perforation. 

During this rhinoplasty, the nasal tip may be pushed downward by using cartilage grafts the extend the septum and tip complex to a lower position. A cartilage graft secured on the nasal tip may also lower the apparent position of the tip and add more projection. 

A downturned, or droopy, nasal tip may make a face look prematurely aged or emotionally upset. The nose may look too long overall. This may be congenital or due to aging. We believe that with aging, the ligaments supporting these cartilages weaken and the tip cartilages begin to sag and point downward. 

During rhinoplasty, the nasal tip may be tilted upward with a variety of methods. One we commonly use is to shorten the upper legs of the tip cartilages to tip them upward. If the columella also hangs downward, we may tuck it up into the nose (see section on Too Much Nostril Show).

A bulbous nasal tip makes the tip of the nose look balloon-like. It often distracts from the rest of the nose and is a source of unwanted attention. In most cases, individuals are born with a bulbous tip.

With a bulbous tip, the cartilages are often too wide and convex, creating a ballooning effect which pushes out on the nasal skin. During rhinoplasty, the width of the nasal tip cartilage is trimmed. This reduces the tip size and convexity. Next, the arch of each tip cartilage is tightened into a sharper bend, and the two arches are bound together. This also lessens tip width and convexity. If the ballooning effect persists, cartilage grafts are placed liked splints to straighten the tip cartilages.

A bumpy nasal tip may appear irregular, asymmetric, and draw attention away from the eyes. This bumpiness often results from asymmetries and irregularities in the underlying cartilage and bone and may be congenital or acquired through injury or previous surgery. 

With a smooth nose, the bony and cartilaginous structures tend to feel smooth, seamless, and symmetric. A step-off or asymmetric shift from side to side bumpy appearance in the overlying skin. Sometimes, if the tip cartilages are spaced too far apart an indentation forms at the tip of the nose. 

During rhinoplasty, the nasal cartilage is shaped to make them more symmetric and smooth. Sometimes cartilage grafts from the nasal septum are used to splint cartilage that is curved or bumpy. Suture techniques are also used to make the cartilages more symmetric.

A nose that sticks out too far may draw unwanted attention. Often one is either born with this type of nose or acquires it from previous surgery. The over-projected nasal tip may have stretched-thin skin with too visible underlying cartilages. Also, the nostrils may appear long and thin from the bottom view and may collapse with forceful inspiration. Over-projection may result from previous surgery due to improper placement of a nasal tip cartilage graft. An overly reduced nasal bridge may also make the nasal tip appear over-projected. In this case, the problem is not with the tip cartilage, but with the height of the bridge. 

During rhinoplasty, the nasal tip may be pushed closer to the face with a variety of methods. One we commonly use is to shorten the upper and lower legs of the tip cartilages to bring them back. An improperly placed nasal tip graft may be re-positioned or removed, and any over-reduction of the bridge may be corrected with a rib cartilage graft. This graft may come from the patient or a donor (see section on The Low Bridge). Nostril flaring is usually increased if the tip of the nose is de-projected, and this must be accounted for (see section on Wide Nostrils).

When the nasal tip does not project adequately from the face, it may appear flat on profile and broad or bulbous from the front. Often one is either born with this type of nose or may acquire it from previous surgery, trauma, or aging that has led to the loss of ligamentous tip support.

During rhinoplasty, the nasal tip may be projected farther from the face in a variety of ways. One common method we use is to place a cartilage nasal tip graft that projects farther than the tip cartilages.

The nostrils may appear wide, especially when compared to a narrow nasal bridge or tip. This creates a perceptual imbalance. One is typically born with wide nostrils, and average nostril width varies between races. Wider nostrils may also result from previous nose surgery due to loss of nasal tip projection. 

Nostril flare is outward bending of the nostril beyond its attachment point to the cheek. Nostril flaring increases when the nasal tip is pushed closer to the face and must be accounted for when correcting an over-projected nose. Nostril-reducing procedures address both nostril flaring and nasal sill width. It is important to maintain enough nostril size to maintain proper breathing. 

For nostril flaring, the position of the nasal tip is assessed and corrected first. Adding projection to an under-projected nasal tip will, in itself, reduce nostril flaring. In cases where the nasal tip is adequately- or over-projected, nostril tissue is removed at the nostril crease. In those with wide nasal sills, the tissue is removed from the sill region. These maneuvers create a more triangular appearance to the base, and the incisions are concealed in natural creases.

Overly visible nostril openings as seen from the front or profile is generally not desired and may be a source of insecurity. This may be congenital or from previous rhinoplasty or trauma. The nostril openings become more visible if the tip is upturned, the columella hangs downward, or the nostrils are arched upward. 

For a hanging columella, we trim and tighten the hanging components, thereby tucking the columella upward into the nose. For an overly arched nostril, the nasal tip cartilages may be manipulated, or cartilage grafts may be used to further drive the nostril margins downward. Cartilage grafts may also be placed into the rims of the nostrils to help straighten them from an overly arched configuration. In cases where scarred skin prevents downward movement of the nostril, ear cartilage grafts are used to extend the tight skin and cartilage that are pulling up on the nostril. Regarding an upturned nasal tip, please see section on the Upturned Nose. 

Though not evident at first glance, not being able to see much of the nostril openings as seen from the front or profile may make the nostrils appear low-hanging (or hooded) or the nasal tip droopy. This may be congenital or from previous surgery or trauma. 

The nostril openings become less visible if the tip is downturned, the columella retracts upward, or the nostrils are hooded. Hooded nostrils may be a normal ethnic variation and are often just due to increased nostril tissue. For a retracted columella, through incisions inside the nose, we can place a cartilage graft that will push the columella downward. Removal of excess nostril tissue treats nostril hooding. Regarding a downturned nasal tip, please see section on the Droopy Nasal Tip.