Chapter 27

Rhinoplasty and Nasal Reconstruction

Anatomy of the Nose

1. The nose is a system of two closely related layers.

• Outer layer: Soft, elastic sleeve that slides over the semirigid inner framework

▪ Skin/soft tissue: Thinner and more loosely attached over the cartilaginous and bony framework and thicker and more adherent over the nasal tip

▪ Lower lateral cartilages (LLCs): Paired “alar cartilages” that contain medial, middle, and lateral crura that support the nasal tip and play a significant role in determining tip shape, size, and projection

• Inner layer: Semirigid framework

▪ Nasal bones make up the upper bony vault of the nasal dorsum and articulate with the upper lateral cartilages (ULCs) inferiorly and the nasal septum to form the “keystone area.”

▪ ULCs make up the cartilaginous midvault, articulate with the cephalic margin of the LLCs at the “scroll area,” and contribute to the internal nasal valve (INV) (see below).

▪ Septum: Formed by the perpendicular plate of the ethmoid bone; vomer, maxillary crest, crest of the palatine bone; and the septal or “quadrangular” cartilage; provides structural support to the nose and divides the airway

▪ Nasal lining: Mucosal inner layer (see Figure 27.1)

Figure 27.1 Diagrams of the cartilaginous and bony nose and septum. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 437–472.)

2. Muscles of the nose: Crucial to dynamic function of the nasal valve and airway

• Facial paralysis (cranial nerve [CN] VII) can cause nasal airway obstruction on side of lesion

• Levator labii superioris: Dilates the nares; paralysis of this muscle shows collapse of the external valve.

• Depressor septi nasi: Depresses nasal tip (see Figure 27.2)

Figure 27.2 Profile view illustration depicting the nasal musculature. (Reprinted from Guyuron, B. [Ed.], 2012. Rhinoplasty. Elsevier, 1–26.)

3. Nasal valves

• INV (between septum and ULC): 10 to 15 degrees; if <10 = spreader grafts.

▪ Cottle maneuver positive

▪ Contributes the most to nasal air-flow resistance

• External nasal valve (ENV; at genu of LLC and nares): Often from over-resection of LLC; treatment: Alar batten grafts (see Figure 27.3)

Figure 27.3 The nasal valves. The internal valves are formed by the articulation of the upper lateral cartilages with the anterior (dorsal) septal edge; the external valves are formed by the alar cartilage lateral crura and their associated, investing, soft-tissue cover. (Reprinted from Neligan, P.C., Buck, D.W. [Eds.], 2013. Core Procedures in Plastic Surgery. Elsevier, 46–70.)

4. Vascular supply to the nose

• Nasal tip: Columellar artery (superior labial a. → facial a. → external carotid a.), lateral nasal a. (angular a. → facial a. → external carotid a.)

▪ Limited dissection above the alar groove will spare injury to the lateral branch of the angular a., which could contribute to tissue loss if injured.

• Nasal sidewall, dorsum: Angular a. and lateral nasal a.

▪ The lateral nasal a. also perfuses the nasal tip during open rhinoplasty.

• Posterior nasal septum: Sphenopalatine a.

• Upper/central nasal septum: Posterior ethmoid a. (see Figure 27.4).

Figure 27.4 Nasal arterial anatomy. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 507–521.)

5. Sensory innervation of the nose

• External branch of the anterior ethmoidal nerve: Nasal tip; vulnerable to damage during endonasal rhinoplasty procedures

▪ Emanates from between the nasal bone and the lateral nasal cartilage, supplying sensation to the skin at the distal nasal dorsum and tip

• Infraorbital nerve: Lower lateral half of the nose and columellar skin

• Infratrochlear nerve: Cephalic portion of the nasal sidewalls and the skin overlying the radix

• Supraorbital nerve also innervates the skin of the radix.

• Supratrochlear nerve supplies sensation to the forehead skin.

• Nasopalatine nerve branches from the pterygopalatine ganglion to innervate the inferior septum and travels through the incisive foramen to join the greater palatine nerve from the palate.

6. Nasal subunits

• The nose is made up of 9 esthetic subunits.

▪ Nasal tip (see Figure 27.5)

Figure 27.5 Illustration of the sensory innervation of the nose from cranial nerve (CN) V. (Reprinted from Guyuron, B. [Ed.], 2012. Rhinoplasty. Elsevier, 1–26.)

Nasal Physiology

1. Nasal functions

• Conduit for oxygenated air to enter the lungs

• Reservoir for warming and humidifying inspired air

• Provides sense of smell

• Filters air and provides first-line immune defense against pathogens

2. Nasal airway obstruction

• The middle meatus marks the path of primary air flow within the nasal cavity.

• Causes of obstruction include any abnormality that results in increased nasal resistance and decreased air flow (e.g., septal deviation, trauma, nasal valve collapse, turbinate hypertrophy, intranasal masses)

▪ INV incompetence and/or collapse thought to be the most common cause

• In cases of rhinitis and turbinate hypertrophy, preoperative medical treatment is recommended.

▪ Viral rhinitis: Oral/topical decongestants

▪ Allergic rhinitis: Decongestants, 2nd-generation antihistamines, cromolyn sodium nasal spray (mast cell stabilizer), nasal topical corticosteroids, ipratropium bromide nasal spray (anticholinergic), and corticosteroid injection of the inferior turbinate

Ideal Nasal Analysis (see Figure 27.6)

Figure 27.6 Important nasal landmarks in profile view. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 437–472.)

1. Nasofrontal angle: Males, 120 to 130 degrees; females, 115 to 125 degrees

2. Nasolabial angle: Males, 90 to 95 degrees; females, 100 to 105 degrees

3. Tip projection: Equal to base width; 2/3 length of nose (see Figure 27.7)

Figure 27.7 Byrd method of determining tip projection based on ideal nasal length. Using this method, the patient’s nasal projection should be their nasal length. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 507–521.)

4. Base width: Equal to intercanthal distance

5. Angle of divergence refers to middle crura of LLC; the angle between R and L middle crus while looking at the nose from anterioposterior (AP) view.

• Ideal angle: 30 to 60 degrees; >60 = boxy tip, <30 = narrow tip (see Figure 27.8)

Figure 27.8 Variations in tip shape. (Reprinted from Aston, S.J., Steinbrech, D.S., Walden, J.L. [Eds.], 2009. Aesthetic Plastic Surgery. Saunders, 507–521.)

6. The nostrils should have a teardrop configuration, with the diameter of the base slightly larger than the diameter of the apex.

• The long axis of each nostril points in a slight medial direction (see Table 27.1).

Table 27.1

External Nasal Analysis

Frontal View
Facial proportions
Skin type/quality	Fitzpatrick type, thin or thick, sebaceous
Symmetry and nasal deviation	Midline, C-, reverse C-, S-, or S-shaped deviation
Bony vault	Narrow or wide, asymmetrical, short or long nasal bones
Midvault	Narrow or wide, collapse, inverted-V deformity
Dorsal esthetic lines	Straight, symmetrical or asymmetrical, well or ill defined, narrow or wide
Nasal tip	Ideal/bulbous/boxy/pinched, supratip, tip-defining points, infratip lobule
Alar rims	Gull shaped, facets, notching, retraction
Alar base	Width
Upper lip	Long or short, dynamic depressor septi muscles, upper lip crease
Lateral View
Nasofrontal angle	Acute or obtuse, high or low radix
Nasal length	Long or short
Dorsum	Smooth, hump, scooped out
Supratip	Break, fullness, pollybeak
Tip projection	Over- or underprojected
Tip rotation	Over- or under-rotated
Alar-columellar relationship	Hanging or retracted alae, hanging or retracted columella
Periapical hypoplasia	Maxillary or soft-tissue deficiency
Lip-chin relationship	Normal, deficient
Basal View
Nasal projection	Over- or underprojected, columellar-lobular ratio
Nostril	Symmetrical or asymmetrical, long or short
Columella	Septal tilt, flaring of medial crura
Alar base	Width
Alar flaring	Present or absent