Rhinoplasty

What are the indications for rhinoplasty?

1. Functional—for nasal airway obstruction

2. Reconstructive—congenital or traumatic

3. Cosmetic—to change the external appearance of the nose

What are the differences between the skin of the upper two-thirds of the nose and the lower one-third?

The skin of the upper two-thirds is thinner, more mobile, and less sebaceous than the lower one-third.

What is the significance of the skin quality in certain ethnicities and the role it plays in rhinoplasty?

Certain ethnic groups can have thicker and more sebaceous nasal skin, and therefore more dramatic changes to the underlying framework are needed to change the outer appearance.

In what plane and what subunits of the nose can filler safely be injected?

The sub-superficial musculoaponeurotic system plane just above the plane of the periosteum; the nasal dorsum and the nasal sidewalls. Injectable fillers should not be placed in the nasal tip or alae.

What are some general characteristics of the Asian nose?

Alar flare, a bulbous nasal tip, a short retracted columella, thick subcutaneous tissue, and wide flat nasal dorsum.

What are some differences between a Caucasian and Asian nose?

Upper and lower lateral cartilage height is shorter in the Asian nose compared to the Caucasian nose. When a cephalic trim is performed in an Asian nose, caution must be exercised in order to prevent over-resection.

What are some similarities between a Caucasian and Asian nose?

The lengths of the upper and lower lateral cartilages and the overlapping length of the upper lateral cartilage with the nasal bones are similar in the Caucasian and the Asian nose.

What is a tension nose?

A combination of thin, constricted nasal skin envelope with strong lower lateral cartilages leading to a potentially twisted or deviated nasal appearance.

Also defined as excessive growth of the quadrangular cartilage resulting in a high dorsum and displaced lower lateral cartilages.

What is the blood supply to the tip of the nose?

1. Lateral nasal artery arising from angular artery

2. Columellar vessel arising from superior labial artery

3. All originating from facial artery

Where are the lateral nasal vessels found, and what is the pitfall to avoid when performing alar resection with an open rhinoplasty?

The lateral nasal vessels are usually 2 to 3 mm above the alar groove, and thus alar resection cannot be extended to this level, as injury to the lateral nasal vessels would cause ischemia to the nasal tip (columellar vessels already transected in open rhinoplasty).

What is the sensory innervation of the nose?

The external branch of the anterior ethmoidal nerve supplies sensation to the distal nasal dorsum and nasal tip. This nerve is at increased risk of injury when an endonasal approach is used for rhinoplasty. The internal branch of the anterior ethmoidal nerve supplies sensation to the septum and the internal nasal walls. The septum also receives innervation from the nasopalatine nerve. The infraorbital nerve supplies innervation to the lower lateral half of the nose and columellar skin. The infratrochlear nerve supplies sensation to the cephalic portion of the nasal sidewalls and the skin overlying the radix. The supraorbital nerve also supplies the nasal radix.

What are the major tips supporting mechanisms of the nose?

1. The size and shape of the lower lateral cartilages.

2. The attachment of the lower lateral cartilages to the septum.

3. The attachments of the upper and lower lateral cartilages at the scroll area.

Describe the nasal vaults and its composition.

1. There are three nasal vaults: bony, upper cartilaginous, and lower cartilaginous.

2. The bony vault consists of the paired nasal bones and the frontal process of the maxilla and makes up the upper one-third to one-half of the nose.

3. The upper cartilaginous vault consists of the paired upper lateral cartilages and the dorsal cartilaginous septum, and goes from the keystone area to the scroll area.

4. The lower cartilaginous vault consists of the paired lower lateral cartilages and begins from the scroll area on down.

Describe the keystone area.

It is the area of approximately 4 to 6 mm where the nasal bones overlap the upper lateral cartilages and septum, and is usually the widest portion of the dorsum.

Describe the scroll area.

It is the area where the upper lateral cartilages interdigitate/overlap with the lower lateral cartilages, held by fibrous connections.

What is the significance of the fibrous connections and ligaments of the nasal tip in rhinoplasty?

The medial, middle, and lateral crura of the lower lateral cartilages are connected to each other, and to the upper lateral cartilages and septum by these fibrous connections and ligaments. Dissection/disruption of these fibrous connections and ligaments during rhinoplasty may result in decreased tip projection. Therefore, techniques to increase tip support/projection are usually needed.

What is the narrowest segment of the nasal airway?

The internal nasal valve, which can be responsible for up to 50% of the total airway resistance.

What is the internal nasal valve composed of?

1. It is the angle formed by the intersection of the caudal margin of the upper lateral cartilages and the nasal septum.

2. The angle is normally 10 to 15 degrees. If the angle is less than normal (narrowed/collapsed internal nasal valve), then airflow is reduced and may lead to airway obstruction.

What is Cottle’s sign?

A positive Cottle’s sign is improved airway with lateral traction on the cheeks, signifying collapse of the internal nasal valve. Spreader grafts are needed to increase the valve angle and thus improve the airway.

What tool is best to dynamically evaluate nasal cavity patency and nasal function?

Rhinomanometry.

What is the septum made up of?

1. The septum is made up of the septal cartilage, or quadrangular cartilage, the nasal crest of the maxilla, the perpendicular plate of the ethmoid, and the vomer.

2. Deformities of the septum can lead to airway obstruction, and may lead to compensatory turbinate pathology.

What is the pitfall to avoid when performing septal resection?

Fracture of the cribriform plate, which is contiguous with the perpendicular plate of the ethmoid. This can lead to cerebrospinal rhinorrhea and possible ascending infection/meningitis.

What are some signs and symptoms of a septal perforation?

Bleeding, whistling, and crusting along the septal defect. Causes of septal perforations include surgical trauma, infection, inflammatory conditions, and inhaling substances (e.g., cocaine). Asymptomatic perforations do not require intervention. Symptomatic perforations can be fixed with grafts or flaps. Larger perforations (>1.5 cm) are challenging to repair.

What is a nasal bone spur?

It is extra bone growth, usually along the crest of the maxilla at the base of the nasal airway, that can impede the flow of air and be a cause of nasal airway obstruction. If present, it should be removed during a septal resection.

What are the roles of turbinates?