There is general agreement that when discussing surgery with the prospective rhinoplasty patient, one may also include discussion of the chin because of the important interrelationship between these two regions. It is apparent that on the profile-lateral view, the four prominences-the forehead, nose, chin, and neck-balance and complement one another. The cervical region, the fourth dimension, was examined to estimate the aesthetic significance of the nasal-to-cervical relationship and to determine the implications to rhinoplasty surgery. Part I of the study was a survey to test the hypothesis that the cervical region affects the perceived impression of the nose. Four standard facial-profile black-and-white photographs were chosen to represent varying degrees of nasal dorsum hump and cervical ptosis problems. Using computer-altering software, only the cervical regions were altered to create a pair of photographs for each of the four profiles: one with a youthful-looking non-ptotic cervical region, the other with a ptotic aged-looking cervical region. Raters were asked to give their first-impression opinions of which nose subjectively appeared "better." Raters consistently (84 percent of the time) chose the nose on the faces with the less ptotic neck as being better. Therefore, a less ptotic neck improved the perceived appearance of the nose. Part II was a retrospective chart review of the rhinoplasty patients of a single surgeon by independent raters. To estimate the aesthetic significance of the nasal-to-cervical relationship, the proportion of patients undergoing rhinoplasty surgery who could have potentially benefited from a youth-restoring neck procedure was determined. Criteria originally described by Ellenbogen and Karlin for judging the results of youth-restoring neck procedures were used as relative indications for neck surgery. An average of 27.2 percent of the patients did not have visible criteria and therefore by definition had relative indications for neck-rejuvenating procedures when undergoing rhinoplasty surgery. As demonstrated in part I of the study, improving the neck could improve the perceived results of the rhinoplasty. Part III of the study validated the Ellenbogen and Karlin criteria. The present authors found that the original criteria were probably based on female patients, that male and older patients had more indications for surgery, and that there was significant interrater agreement with the youthful criteria. In summary, the authors established that a strong nasal-to-cervical relationship exists whereby the perceived appearance of the nose is affected by the neck. The significance of this relationship to rhinoplasty surgery was determined, and it was found that more than 27 percent of rhinoplasty patients could obtain better perceived nasal results with a concomitant neck-rejuvenating procedure. Consequently, discussing neck-rejuvenating procedures with the rhinoplasty patient is valuable.

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