Skin

(fig. 45-1)

• 
  

  Skin thickness and sebaceousness are often underestimated components in predicting final nasal shape. ²

  
  
• 
  

  Skin is thickest in the lower third (tip, alae).

  
  
• 
  

  Skin is thinner in the upper and middle thirds, with more gliding.

  
  
• 
  

  Understanding the contractile properties of each patient’s nasal skin is critical to the outcome.

  
  
  
  
  • 
    

    Modifications of the underlying bony and cartilaginous frame (particularly at the paradomal and tip regions) may be obscured by thick, poorly contractile skin.

    
    
  • 
    

    Debulking of skin and soft tissue can be an important maneuver.

Nasal Muscles

(fig. 45-2)

• 
  

  Nasal superficial musculoaponeurotic system (SMAS)

  
  
  
  
  • 
    

    Includes dilator nasi, transverse muscle fibers

    
    
  • 
    

    Flares nostrils

  
  
• 
  

  Levator labii superioris alaeque nasi

  
  
  
  
  • 
    

    Helps external valve to stay open

    
    
  • 
    

    Elevates nostrils

  
  
• 
  

  Depressor septi nasi muscle ^{3 , 4}

  
  
  
  
  • 
    

    An important muscle in dynamic tip ptosis

    
    
  • 
    

    Raises upper lip and pulls nasal tip down

    
    
  • 
    

    Can be transpositioned or transected as part of rhinoplasty ⁵

    
    
  • 
    

    Can be chemodenervated for diagnostic or treatment purposes

Blood Supply

⁵

(fig. 45-3)

• 
  

  Most blood supply is located within subcutaneous plane.

• 
  

  Angular artery

  
  
  
  
  • 
    

    Lateral nasal branch arises from this artery 2-3 mm above alar groove.

    
    
    
    
    • 
      

      Supplies the subdermal plexus at nasal tip either unilaterally or bilaterally in 100% of cadaver specimens

    
    
  • 
    

    Excessive defatting of skin that violates subdermal plexus can compromise vascularity of tip/columellar skin.

• 
  

  Facial artery

  
  
  
  
  • 
    

    Branches: Superior labial artery and angular artery

    
    
    
    
    • 
      

      Supply nasal tip via columella

    
    
  • 
    

    Dedicated columellar branch from superior labial artery

  
  
• 
  

  Ophthalmic artery

  
  
  
  
  • 
    

    Gives off the following branches: Anterior ethmoidal, dorsal nasal, and external nasal arteries to sidewalls and upper third of nose

Internal Nasal Valve

• 
  

  Narrowest segment of nasal airway

  
  
• 
  

  Two thirds of airway resistance

  
  
• 
  

  Angle between caudal upper lateral cartilage (ULC) and septum should be >10-15 degrees.

  
  
• 
  

  Length, stability, and strength of ULC are important.

External Nasal Valve

• 
  

  Dynamic structure: Mobile alar sidewalls and caudal septum

  
  
• 
  

  Alar arch, along with musculature, allows stenting effect with inspiration.

  
  
• 
  

  Internal nasal valve narrows while external valve opens during the negative pressure effect of inspiration.

  
  
• 
  

  Size, shape, strength, and orientation of lower lateral cartilage (LLC) help to determine external valve sufficiency.

  
  
• 
  

  External nasal valve insufficiency ^{1 , 6}

  
  
  
  
  • 
    

    Flaccid or weak LLC

    
    
  • 
    

    Slitlike nostril rims (vertical/narrow: iatrogenic or inherent)

    
    
  • 
    

    Thin alar sidewalls

    
    
  • 
    

    Malposition of LLC (cephalically oriented)

    
    
    
    
    • 
      

      Caudal edge of LLC is an excessive distance from nostril rim, so alar rim support is not provided during inspiration.

Nasal Vaults

(fig. 45-4)

• 
  

  Three nasal vaults: Bony, upper cartilaginous, and lower cartilaginous

Upper Cartilaginous Vault

• 
  

  Known also as nasal midvault

  
  
• 
  

  Paired ULCs

  
  
  
  
  • 
    

    Underlap nasal bones 6-8 mm (keystone area)

    
    
    
    
    • 
      

      Widest portion of nasal dorsum

    
    
  • 
    

    Scroll area: Junction where ULCs underlap LLCs

    
    
  • 
    

    Internal nasal valve: At junction of caudal ULC and septum

    
    
  • 
    

    ULCs join the nasal septum at dorsum to form a T.

    
    
    
    
    • 
      

      Affects dorsal aesthetic lines

      
      
    • 
      

      Spreader grafts are placed at this junction.

Tip:

The “component dorsum reduction” technique helps to preserve the ULC-septal relationship through separation of the ULC from the adjacent mucoperichondrium and septum and incremental dorsal reduction. ⁷

Nasal Tip

• 
  

  Shape and position are critical in rhinoplasty.

  
  
• 
  

  Tripod concept: LLC and medial crura act like legs of a tripod ^{8 , 9} (Fig. 45-5).

  
  
  
  
  • 
    

    Variations in length and strength of each structure influence tip position and shape.

  
  
• 
  

  Nasal tip supported by several ligamentous attachments ^{9 – 11} (Fig. 45-6):

  
  
  
  
  • 
    

    Piriform ligament: LLC abutment with piriform aperture

    
    
  • 
    

    Domal suspensory ligament

    
    
  • 
    

    Fibrous attachments between ULC and LLC

    
    
  • 
    

    Medial crural ligaments

    
    
  • 
    

    Anterior septal angle

Septum

(fig. 45-7)

• 
  

  Septal cartilage, perpendicular plate of ethmoid, and vomer

  
  
• 
  

  Perpendicular plate of ethmoid is continuous with the cribriform plate.

  
  
  
  
  • 
    

    Surgical or traumatic fractures of the perpendicular plate can result in CSF rhinorrhea.

    
    
  • 
    

    Rhinoplasty fracture technique must be meticulous, gentle, and in a lateral direction to prevent cribriform injury.

Internal Nasal Valve

(fig. 45-8)

• 
  

  Formed by junction of caudal ULC and nasal septum

  
  
• 
  

  Normal valve angle is 10-15 degrees.

  
  
• 
  

  Angles <10 degrees can lead to nasal airway obstruction.

  
  
• 
  

  Internal nasal valve provides 50% of total airway resistance.

  
  
• 
  

  True spreader grafts and autospreader flaps function through increasing the internal nasal valve angle.

External Nasal Valve

• 
  

  Formed by caudal edge of LLC, alar soft tissue, membranous septum, and nostril sill

  
  
• 
  

  Dynamic structure

  
  
• 
  

  Nasal muscles help to keep open during inspiration

  
  
• 
  

  Alar contour grafts and lateral crural (alar) strut grafts can strengthen and reinforce external nasal valve.

Turbinates

• 
  

  Superior, middle, and inferior turbinates

  
  
• 
  

  Extensions of lateral nasal cavity wall

  
  
• 
  

  Anterior portion of middle and lateral turbinates project into airway and can affect airway resistance.

  
  
• 
  

  Inferior turbinate is capable of up to two thirds of airway resistance at internal nasal valve region.

Types of Nasal Airway Obstruction

• 
  

  Allergic rhinitis: Seasonal or obstruction related to dust, pollen, or other antigens

  
  
• 
  

  Bilateral obstruction: Possible severe mucosal disease

  
  
• 
  

  Constant-fixed obstruction: May be associated with a fixed abnormality such as septal deviation

Nasal Obstruction Complaints

• 
  

  Nasal crusting

  
  
• 
  

  Dry mouth (from mouth breathing, especially during sleep)

  
  
• 
  

  Frequent sore throats

  
  
• 
  

  Sinus problems

Nasal Obstruction History

• 
  

  Time of onset

  
  
• 
  

  Duration of obstruction

  
  
• 
  

  Precipitating events

  
  
• 
  

  Rhinorrhea (amount, duration)

  
  
• 
  

  Epistaxis

  
  
• 
  

  History of trauma or surgery

  
  
• 
  

  Use of medications, nasal sprays

  
  
• 
  

  Use of alcohol, tobacco, and drugs (especially cocaine)

  
  
• 
  

  History of headaches, visual disturbances, and middle ear symptoms

Physical Examination

• 
  

  Visual clues

  
  
  
  
  • 
    

    Allergic shiners: Dark circles under eyes suggesting allergic rhinitis

    
    
  • 
    

    Supraalar pinching or an excessively narrow midvault (inverted-V deformity) may have internal nasal valve insufficiency.

    
    
  • 
    

    Watch midvault motion during nasal respiration.

    
    
    
    
    • 
      

      If dynamic collapse occurs, midvault support will be needed.

• 
  

  Cottle test

  
  
  
  
  • 
    

    Not specific because many will be positive, but is useful

    
    
  • 
    

    Cottle maneuver: Hold unilateral cheek laterally to stabilize the nasal sidewall on one side while occluding the contralateral airway.

    
    
    
    
    • 
      

      If significant improvement in the ipsilateral airway is noted on deep inhalation, then internal nasal valve narrowing may be present.

  
  
• 
  

  Alar rims

  
  
  
  
  • 
    

    Evaluate for notching or potential thereof, especially at soft triangle.

    
    
  • 
    

    Dynamic notching may be a reflex of patient against external valve collapse.

    
    
  • 
    

    Evaluate position of LLC (“parenthesis tip”).

  
  
• 
  

  Intranasal examination

  
  
  
  
  • 
    

    Can use thumb to push up nostril rims to observe internal nasal valve angle without artificially stenting the valve open, which can occur with a nasal speculum

    
    
  • 
    

    Use speculum and visualize septum, valve, turbinates with and without a vasoconstrictive agent.

    
    
  • 
    

    Evaluate for polyps, crusting, mucosal color (excessive erythema suggests allergies).

    
    
  • 
    

    In the septum look for spurs, deviation, perforations (postsurgical or from cocaine use).

Medical Therapies

• 
  

  Mucosal disease from common cold (viral rhinitis) most common cause

  
  
  
  
  • 
    

    Bacterial rhinitis may complicate viral rhinitis.

    
    
  • 
    

    Acute and chronic bacterial infection can be treated with a combination of:

    
    
    
    
    • 
      

      Saline solution nasal irrigation

      
      
    • 
      

      Short course of decongestant (spray and/or oral)

      
      
    • 
      

      Nasal steroid spray

      
      
    • 
      

      Mucolytic therapy

    
    
  • 
    

    Check for concomitant sinus disease, because rhinosinusitis is common, with one aggravating the other.

  
  
• 
  

  Allergic rhinitis

  
  
  
  
  • 
    

    Allergen (environmental exposure) avoidance

    
    
  • 
    

    Antihistamines

    
    
  • 
    

    Intranasal steroid regimen

    
    
  • 
    

    Allergy test

    
    
    
    
    • 
      

      Rhinitis medicamentosa: Rebound vasodilation and nasal mucosa hypertrophy-hypersecretion

      
      
      
      
      • 
        

        Caused by overuse of nasal decongestants (vasoconstrictive agents) like Neo-Synephrine and Afrin

        
        
      • 
        

        True cause of nasal congestion must be treated to eliminate need for decongestants.

        
        
        
        
        • 
          

          Allergic rhinitis, nasal polyposis, septal deviation, turbinate hypertrophy

        
        
      • 
        

        Treatment: Cessation of all decongestants, course of antihistamines, nasal steroids, and possibly an oral steroid taper

  
  
• 
  

  Ozena: Primary atrophic rhinitis

  
  
  
  
  • 
    

    Causes: Aggressive submucous septal resection, total turbinectomy

    
    
  • 
    

    Squamous metaplasia of normal columnar mucosal cells

    
    
  • 
    

    Treatment: Irrigation with saline solution, high-dose vitamin A, possible surgical closure of the nostrils

Aesthetic

• 
  

  Initiated by patient

  
  
• 
  

  Proper patient selection is critical.

  
  
  
  
  • 
    

    As with any aesthetic procedure, expectations must be realistic and achievable (see Chapter 1).

    
    
  • 
    

    This becomes more of a challenge in secondary rhinoplasty patients (see Chapter 46).

    
    
  • 
    

    SIMON: Acronym to describe male rhinoplasty patients

    
    
    
    
    • 
      

      Single, immature, male, obsessive, and narcissistic

      
      
    • 
      

      Used as a rough guide to remind surgeon of “problem rhinoplasty patients”

    
    
  • 
    

    Good communication must assimilate surgeon’s analysis and goals with those of patients.

    
    
    
    
    • 
      

      If surgeon’s and patient’s goals are vastly different, proceeding with rhinoplasty may be imprudent.

      
      
    • 
      

      Asking patients to list the top three things they want to have altered may be a good general idea (particularly for patients with nonspecific aesthetic goals and those unsure of their aesthetic goals).

    
    
  • 
    

    Generally, rhinoplasty should address the imbalances between the nose and face. ^{12 , 15 – 17}

    
    
    
    
    • 
      

      Specific desires and complaints should be addressed while pointing out other related deficiencies (when indicated), such as a deficient chin.

      
      
    • 
      

      For example, a patient may have a wide nasal tip but only wants “the hump gone.”

      
      
      
      
      • 
        

        Dynamic relationships must be discussed with patients.

        
        
      • 
        

        For example, significant hump reduction without elevation of a droopy tip will produce an imbalanced nose that appears flat and excessively droopy.

Functional

• 
  

  This chapter does not focus on functional techniques; however, when performing a rhinoplasty, comprehensively addressing the nasal airway is critical.

  
  
• 
  

  Patients without nasal airway obstruction before rhinoplasty may develop airway problems postoperatively unless preventative measures are taken.

  
  
  
  
  • 
    

    For example:

    
    
    
    
    • 
      

      Spreader grafts and flaps can help to reduce internal nasal valve narrowing when dorsal reduction and osteotomies are performed. ^{12 , 21}

      
      
    • 
      

      External valve dysfunction can be prevented by placing lateral crural strut and/or alar contour grafts and recognizing alar malposition.

  
  
• 
  

  Septoplasty ^{1 , 6 , 13 , 14 , 22}

  
  
  
  
  • 
    

    Important to perform simultaneously

    
    
  • 
    

    Best source of most grafts used in aesthetic rhinoplasty

    
    
  • 
    

    L-strut must be left intact with at least 1 cm (preferably up to 2 cm) dorsal and 1 cm caudal (Fig. 45-9).

    
    
  • 
    

    All bony protrusions and spicules should be excised to open airway effectively.

    
    
    
    
    • 
      

      Most critical location is across from inferior turbinate.

      
      
    • 
      

      A protuberant nasomaxillary crest is common and should be thoroughly addressed.

One of the most common reasons for unsuccessful straightening of a caudal nose deviation is failure to detect and reposition the dislodged caudal septum in the correct position on the nasal spine and maxillary crest. This requires removal of the redundant overlapping portion of the cartilage to facilitate repositioning the septum in the midline.

Anteroposterior View

Aesthetic Lines and Measurements

(fig. 45-11)

• 
  

  Dorsal aesthetic lines (Fig. 45-11, A)

  
  
  
  
  • 
    

    Symmetry, deviation, width, and shape are important.

    
    
  • 
    

    Should be gently diverging curvilinear lines extending from medial eyebrow (superciliary ridge) toward nasal tip-defining points

  
  
• 
  

  Width of bony base (Fig. 45-11, B)

  
  
  
  
  • 
    

    Should be 75%-80% of alar base width

    
    
  • 
    

    Asymmetries may exist from different angles of inclination of the nasal bones and ascending process of the maxilla.

    
    
  • 
    

    Commonly, one side is wider (projecting more laterally) than the other.

  
  
• 
  

  Width of alar base (Fig. 45-11, C)

  
  
  
  
  • 
    

    Should coincide with intercanthal width (generally)

    
    
  • 
    

    If wider than intercanthal width, then degree of alar flare will dictate operative plan

    
    
  • 
    

    Evaluation:

    
    
    
    
    • 
      

      Maximal alar flare width difference from width of alar base assessed

      
      
      
      
      • 
        

        If >2 mm, then alar flaring is present.

        
        
      • 
        

        If < mm, then the alar base itself is wide (excessive interalar distance).

• 
  

  Alar rims ^{25 – 27}

  
  
  
  
  • 
    

    Retraction or excess inherent “nostril show” is evaluated.

    
    
  • 
    

    On lateral view, alar-columellar relationship should be balanced.

    
    
  • 
    

    Should have a natural flare and inclination

    
    
  • 
    

    Outline of infratip breakpoint should appear like a “seagull in gentle flight.”

  
  
• 
  

  Nasal tip (Fig. 45-11, D)

  
  
  
  
  • 
    

    Four tip-defining points: One on each dome apex, a supratip break, and a columellar-lobule breakpoint

    
    
  • 
    

    Lines can be drawn to assess asymmetry.

    
    
  • 
    

    Domal angle and angle of domal divergence are assessed.

    
    
  • 
    

    Imbalance in nasal tip aesthetic contour has various descriptions, such as bulbous, boxy, amorphous, and wide.

Tip:

Evaluating tip aesthetics, as with other nasal proportions, requires careful attention to how the light reflects off the nose. External shadows and highlights on the nose provide important clues about the underlying framework. For example, asymmetry in the tip-defining point may reveal asymmetry in height, width, shape, and position of the lateral, middle, and medial crura.

Senior Author Tip:

The intercanthal midline should be used as a reference (not the point bisecting the intereyebrow distance), because patients may pluck their eyebrows differently to reduce the impact of the nose deviation on the face.

• 
  

  Lobule

  
  
  
  
  • 
    

    Excess columella or hanging columella leads to excess infratip lobule.

    
    
  • 
    

    Breakpoints should be in harmony making a diamond shape.

    
    
    
    
    • 
      

      Caveat: Ethnic and gender variations should be considered.

Basilar View

^{26 , 28 , 29}

(fig. 45-12)

• 
  

  Alar rims should form an equilateral triangle.

  
  
• 
  

  Nostril height (columellar length) to infratip lobule height ratio should be approximately 60:40, respectively.

  
  
• 
  

  Nostril inclination is approximately 60 degrees.

• 
  

  Nostril has teardrop shape.

  
  
• 
  

  Alar rims should not be excessively concave or convex, within the confines of an equilateral triangle.

Lateral View

• 
  

  Multiple lengths and angles contribute to an aesthetically pleasing lateral view (Fig. 45-13).

  
  
• 
  

  Nasofrontal angle (NFA)

  
  
  
  
  • 
    

    Located at upper lash line and supratarsal crease (Fig. 45-14)

    
    
  • 
    

    Formed by the intersection of the line between the glabella and the soft tissue nasion and the nasal dorsum tangent

    
    
  • 
    

    NFA should be approximately 140 degrees.

  
  
• 
  

  Dorsal curvature

  
  
  
  
  • 
    

    Determined by a line drawn from the radix at the NFA to the tip-defining point (Fig. 45-15)

    
    
  • 
    

    Female dorsum should be 2 mm posterior to this line.

    
    
  • 
    

    Male dorsum should be at or slightly anterior to this line.

    
    
  • 
    

    Angle of this line and where it begins can change the appearance of length.

    
    
    
    
    • 
      

      Radix can be high or low.

      
      
    • 
      

      Deep and inferiorly located radix has shortened nasal length (Fig. 45-16).

• 
  

  Tip projection (Fig. 45-17) ¹⁶

  
  
  
  
  • 
    

    Ideally tip projection should be 50%-60% of the distance of a line drawn from the alar-cheek crease to the most anterior tip point (see Fig. 45-17, A).

    
    
  • 
    

    Alternatively, tip projection is 0.67 × the nasal length. ⁵

    
    
  • 
    

    Can also be assessed on basilar view

    
    
  • 
    

    Must be proportionate to chin and lip projection

• 
  

  Tip rotation (Fig. 45-18)

  
  
  
  
  • 
    

    Draw line extending from anterior and posterior nostril rim.

    
    
  • 
    

    Draw plumb line that is perpendicular to natural horizontal facial plane.

    
    
  • 
    

    Angle between the nostril line and plumb line is the nasolabial angle (NLA) (see Fig. 45-18, A).

    
    
  • 
    

    NLA is 95-110 degrees in females and 90-95 degrees in males.

    
    
  • 
    

    Columellar-labial angle: Junction of columella with upper lip; varies with degree of columellar fullness and “hang”

    
    
  • 
    

    Columellar-lobular angle: Junction of columella with the infratip lobule (30-45 degrees)

Related posts:

31. Facial Analysis 32. Hair Transplantation 35. Lower Blepharoplasty 39. Blepharoptosis 36. Asian Blepharoplasty 48. Lip Augmentation

Stay updated, free articles. Join our Telegram channel

Join