Jeffrey C. Posnick, DMD, MD

Nasal Surface Anatomy

The external nose may be described as consisting of three parts: the osseocartilaginous vault, the lobule/tip, and the base (Fig. 38-1).

The osseocartilaginous vault consists of the bony vault (the nasal bones, the nasal process of the frontal bones, and the nasal process of the maxilla) and the cartilaginous vault (the upper lateral cartilages [ULCs] and the dorsal aspect of the cartilaginous septum). The transition from bony to cartilaginous dorsum is called the keystone area.⁴⁹ The caudal aspects of the nasal bones overlap the cephalic portions of the ULCs in the keystone area. The width of the nasal bones and ULCs is greater in the keystone area than at either the radix or the supratip regions.

Aesthetically, the dorsum of the nose is analyzed with regard to its height or anterior projection and its width and shape. Ideally, the dorsum of the nose, when viewed in profile, should be straight or slightly concave. The nasofacial angle is a soft-tissue measurement from the nasion to the tip and from the nasion to the glabella and should be approximately 34 to 36 degrees. The width of the dorsal lines of the nose should be roughly equal to that of the philtral columns. The maximum width of the bony vault (i.e., the dorsal width) of the nose is ideally less than that of the medial intercanthal width.

The lobule of the nose encompasses the entire area that overlies the lower lateral cartilages (LLCs), whereas the intrinsic nasal tip represents the area between the nasal-tip–defining points and the area between the infratip breakpoint and the supratip breakpoint. The ideal tip-defining points are approximately 6 to 8 mm apart in females and 8 to 10 mm apart in males. The LLCs are key anatomic points of reference that define the nasal tip. They are subdivided into the medial crus, the middle crus, and the lateral crus. Of aesthetic importance are the angles formed by the junction of the crura; these include the columella infratip breakpoint (i.e., the middle crura–medial crura angle) and the dome tip-defining points (i.e., the middle crura–lateral crura angle).

The columella is a critical region and component of the nose. It must be in balance between the adjacent alar rims and the medial crura. It should also form an attractive angle with the upper lip (i.e., the nasolabial or columella–labial angle). If the columella is either retracted or demonstrating excessive show, it will be less attractive and benefit from change (i.e., augmentation versus reduction).

The thickness and quality of the soft tissues over the nasal skeleton have a significant impact on the appearance and will also affect the final result of a rhinoplasty. In most individuals, the skin is thickest in the supratip region; it thins over the domal area.

To the experienced clinician, the appearance of the external nasal anatomy will give an indication of the anatomic causes of subjective nasal airway obstruction.²⁴⁹ Middle-vault collapse, pinched nasal sidewalls, asymmetric nostrils, and a crooked dorsum are all outward indications of obstructions to nasal airflow; this is discussed later in this chapter.

Classic Rhinoplasty Maneuvers

Classic rhinoplasty maneuvers include the following 1) nasal osteotomies (i.e., to reduce the nose’s width, to straighten a crooked nose, and to close an open roof) 2) dorsal reduction (bone and cartilage) 3) the selective removal of cephalic portions of the lower lateral crura (maintenance of 6 mm of caudal rim) 4) suturing of the LLCs (i.e., interdomal and transdomal areas) and 5) augmentation with cartilage grafts (i.e., caudal strut graft, alar contour grafts, lateral crural strut grafts, shield tip graft, columellar tip graft, spreader grafts, dorsal strut graft).47,51,69,93,138,142–144,182,207,219,237

Grafts are indicated when other lesser maneuvers to improve the projection and definition of the nasal tip are not adequate.* When indicated, a graft that will be used to alter the nasal tip can be fashioned from removed quadrangular cartilage or from another source (e.g., the conchal floor, the rib cartilage).²⁰¹ A caudal strut graft remains the workhorse for the addition of support to weak LLCs and for the control and maintenance of the nasal tip position. The caudal strut graft also functions as a central scaffold on which the tip structures can be unified. When a shield tip graft is used, it is placed over the domes with the inferior margin extending to the mid columella. A shield graft is effective for increasing infratip lobular definition and projection. Columellar tip grafts extend superiorly and are often secured to the ULC above and the caudal margin of the medial crura below. They are more useful in thick-skinned individuals in whom there is an additional need to improve tip definition beyond the usual rhinoplasty maneuvers. In thin-skinned individuals, tip grafts are only used cautiously, because they may result in visible irregularities.

Interdomal sutures are placed in mattress fashion in the region of the middle crura.89,98,199 This suturing technique is effective for reducing interdomal distance and thereby increasing tip projection and refinement. Medial crural fixation sutures are placed to unify the medial crura beneath the domes of the LLC and to reduce flaring. These sutures are typically placed after a caudal strut graft is secured. Transdomal sutures are placed in a horizontal mattress fashion and then across the dome of the middle crura. All of these suture techniques can be effective to alter the tip position, to narrow the distance between the tip-defining points, and to correct domal asymmetries.

Spreader grafts may be either horizontal or vertical, and they are used to correct deficiencies of the cartilaginous vault.24,38,46,87,88,92,95,97,208,209,255 Vertical spreader grafts are generally paired and extend from just deep to and then flush with the nasal bones. They are secured on each side of the dorsal septum and then generally to the ULCs with sutures. The caudal end of each vertical spreader graft may continue beyond the septal angle and below the LLCs to elongate the nose and to derotate the tip. They are typically 15 to 20 mm in length and approximately 2 to 4 mm in width. A horizontal spreader graft is a single dorsal graft that is inset between the ULCs and that forms a “T” with the dorsal septum. Spreader grafts are used as a technique to prevent or correct the narrowing of the internal nasal valve, to preserve or correct the nasal dorsum or dorsal aesthetic lines, and to correct and stabilize a “crooked” dorsal septum.

There are four aspects of the nasal base that may be considered for surgical modification⁵:

Facial versus Nasal Proportions and Effects on the Aesthetic Perspective

The surgeon must distinguish between the aesthetics of the nose (i.e., nasal proportions) and the aesthetics of the face (i.e., overall facial proportions) (Fig. 38-2).* Establishing the Euclidean proportions of the full face represents a different aesthetic objective than simply establishing pleasing proportions of the nose as an isolated aesthetic unit. The individual who is seeking rhinoplasty often perceives that his or her aesthetic objectives can be met by addressing the nose only. In these circumstances, after cosmetic rhinoplasty, the surgeon may be pleased with improvements in the nasal aesthetic unit, but the patient may express displeasure with the results. This will more frequently occur in the individual with either a long face growth pattern, a short face growth pattern, or an isolated sagittal mandibular deficiency growth pattern who perceives that he or she still has a “big” nose, even after rhinoplasty (Fig. 38-3). The patient may have initially sought out a cosmetic surgeon and requested a rhinoplasty with the goal of achieving a “smaller” nose. The surgeon may create a well-proportioned nasal aesthetic unit, but the nose may still remain “big” in proportion to the rest of the face. The surgeon may then be asked to revise the rhinoplasty to create a “smaller” nose.^192,193 When the surgeon further reduces the nasal bones and cartilage beneath the soft-tissue envelope, an “operated” look may result, and the overall facial proportions may move even further out of balance.

The Nasal Airway: Anatomy and Physiology

Symptomatic nasal obstruction is a condition in which the individual feels that he or she has inadequate nasal airflow. Although it is a subjective feeling, it should have a foundation in objective anatomic and physiologic findings (Fig. 38-4). Knowledge of both nasal anatomy and physiology is required for the accurate diagnosis and treatment of the subjective sensation of obstructed nasal breathing.*

Anatomic Locations and Causes of Nasal Obstruction

The etiology of nasal airway obstruction is often multifactorial and may include both anatomic aspects and physiologic effects of the nasal and sinus mucosa.

Evaluation of the Nasal Airway

Among the pertinent findings that require clarification from the patient are a history of nasal obstruction, sinusitis, or inflammatory sinonasal disease and the presence of a limited sense of smell or taste. A history of environmental or seasonal allergies, nasal surgery, or trauma should be correlated with physical findings.

With regard to the nasal airway, a complete external and internal nasal examination should be undertaken. Direct and speculum examination of the anterior septum, the head of the inferior turbinates, and the external nasal valves should proceed. Nasoendoscopy allows for a more thorough examination of the nasal airway and should be undertaken when indicated to fully visualize the septum, the turbinates, the meatus, the nasal mucosa, the nasal valves, the posterior aperture, and other nasal structures. Decongestants may also be used to further assess the airway. For cases in which radiologic studies are needed, a coronal sinus computed tomography scan is useful.

The functional aspects of the nose that a rhinoplasty surgeon may typically alter include the nasal valve areas and the turbinated cavity. When completing a septoplasty procedure with the removal of posterior bony septal deflections, it is important to avoid injury to the cribriform plate, because cerebrospinal fluid rhinorrhea would result. As previously stated, when performing a septoplasty that includes the removal of deflected portions of quadrangular cartilage, it is important to maintain adequate caudal and dorsal struts for support of the nasal dorsum and tip.

The internal nasal valve is defined by both the valve angle (i.e., the relationship of the ULCs to the septum), which is typically 10 to 15 degrees, and the valve circumference. Respiratory obstruction can occur when the valve area is decreased by septal deviation, mucosal disease (i.e., engorgement of the inferior turbinates), scarring, and traumatic, neoplastic, congenital, or surgical deformities (e.g., narrow pyriform rim width, elevated nasal floor).

An example of effective reconstruction occurs when the internal nasal valves are collapsed after the surgical overresection of the ULCs, and spreader grafts (placed between the nasal septum and the ULC) are used to widen the internal valve angles. This will decrease nasal airway resistance and improve respiration.

Nasal airway resistance is greatly affected by the inferior turbinates, which periodically swell and decrease the internal valve area. Inferior turbinate hypertrophy may be physiologic or pathologic. For the majority of the population, a normal “nasal cycle” of the congestion and decongestion of the turbinates and the nasal mucosa is ongoing, with reciprocal changes on the two sides. The total nasal airway resistance in the healthy nose is remarkably constant, with changes occurring every 2 to 4 hours in the turbinates and the mucosal lining. When the inferior turbinates are markedly enlarged and when the process is not reversible with the use of vasoconstrictors and anti-inflammatory agents, then surgical reduction of the turbinate hypertrophy (often in combination with septoplasty) is the treatment of choice and will generally relieve the symptoms. Doing so will often open the internal nasal valve and the whole turbinated cavity. A variety of surgical techniques are used to accomplish the goal of inferior turbinate reduction (e.g., partial excision, electrocautery, submucosal resection, radiofrequency ablation, microdebridement).157,173 The overaggressive resection of the inferior turbinates has, on occasion, resulted in rhinitis sicca or “dry nose.”

Surgical Approach to Open the Nasal Airway

The clarification of any anatomic structures of the internal nasal valve that are causing blockage should be identified. This may include the following: 1) the septum 2) the anterior head of the inferior turbinates 3) the bony nasal floor 4) the lateral nasal walls (i.e., the tight inlet) 5) the ULCs; and 6) the nasal mucosal lining (i.e., the synechiae).

The identification of any anatomic components that interfere with the external nasal valve is also clarified and the areas surgically corrected, if feasible. This may require reconstruction of the LLCs, via elevation of the nasal tip or through the release of scar contracture of the nasal skin or the vestibular mucosa.

The opening of the posterior nasal (choanae) aperture may require the following: 1) the reduction of the adenoid pad; 2) the recontouring of the posterior floor of the nose and the lateral nasal walls; 3) the resection of the vomer and the perpendicular plate of the ethmoid; or 4) the horizontal (sagittal) advancement of the maxilla (i.e., Le Fort I osteotomy).

The partial removal (by direct excision, submucosal resection, or cauterization) of hypertrophied middle turbinates can, at times, significantly improve a patient’s nasal airflow. If the middle turbinate is pneumatized (concha bullosa) and a cause of nasal obstruction found, it should be reduced by whatever means necessary.

Outcome Assessment of Surgery to Improve Nasal Breathing

Attempts to objectively measure alterations in nasal function after medical or surgical interventions that are carried out for the purpose of improving nasal breathing have proven to be difficult.31,113–115,118,128,152,171,185,187,189,190,195,215,222,223,226,243 Through acoustic rhinometry and rhinomanometry, attempts at objective postoperative assessments of the nasal airway have been carried out. Consistent findings with the use of these measurement techniques are mixed at best. A spectrum of studies by different investigators has demonstrated conflicting results with similar research designs. Studies by Lindemann and colleagues confirm that nasophysiologic functions (e.g., the heating and humidifying of inspired air) were improved after successful septoplasty and appropriate inferior turbinate reductions.¹²⁶ This positive effect is believed to be derived from increased volumes and the direction of physiologic airflow to key places within the nasal passage, which increases mucosal contact with the nasal airstream. The improved flow dynamics may also improve the filtration of particulate matter more effectively.

In addition to objective instrumentation measures of nasal breathing, researchers have sought a standardized assessment of results from the patient’s perspective. These efforts have taken the form of symptom-based questionnaires. The most rigorously developed disease-specific measure for nasal obstruction was created by the Nasal Obstruction Symptom Evaluation (NOSE) study investigators.233,234 The NOSE Scale generates an integral patient-specific score out of a possible 100 points and thus facilitates quantitative comparisons within subjects at different time points or among groups of subjects who are undergoing different treatments. The NOSE Scale is now considered the reference standard for the assessment of alterations in nasal breathing. Considering the extent of nasal obstructive treatment carried out in the United States alone, which is estimated to cost $5 billion per year, emphasis on standardization and measurable results seems to be indicated (see Chapter 10).

Initial Rhinoplasty Consultation

During the initial consultation, it is important for the patient to confirm any functional nasal difficulties and also to explain his or her facial aesthetic concerns. The individual may want a nose that is narrower (i.e., dorsal width reduction), less irregular (i.e., dorsal hump removal) and with a more attractive nasal tip (i.e., improved definition and projection). A frequently stated objective—or at least a personal desire that is expressed when an in-depth history is taken—is to have the ability to breathe better.

Aesthetic concerns often relate to an enlarged osseocartilagenous vault (e.g., dorsal hump, increased mid-dorsal width) or if a previous rhinoplasty was carried an over reduced dorsum and a narrow width. The lobule and tip may be drooped and bulbous, with a lack of definition, or they may be overreduced, pinched, and turned up as a result of a previous surgery. The nasal base may be overly wide or constricted, primarily as a reflection of the underlying skeletal or cartilaginous structures.

Difficulty with breathing through the nose is often chronic, with a longstanding mouth-breathing habit. If this is the case, the facial morphology may be that of a long face growth pattern (i.e., vertical maxillary excess typically with an anterior open-bite Class II malocclusion; see Chapter 21). The obstructive nasal breathing is often made worse in the presence of chronic allergies or with ambient changes in humidity. Examination of the internal nose may reveal septal deviations or perforations, external valve stenosis, internal nasal valve obstructions, posterior nasal aperture stenosis, turbinate enlargement, or an irritated nasal mucosal lining. Consideration should also be given to the adenoids and tonsils, which may be enlarged and obstructive. The internal nasal valves, the turbinated cavities, the external nasal valves, and the posterior nasal aperture may be obstructed by any one of a number of anatomic structures (e.g., turbinates, septum, ULC, LLC, nasal skeletal walls or floor, soft tissues).

During the initial consultation, consideration is given to the following: 1) the patient’s stated objectives 2) any patient-specific anatomic limitations 3) the surgeon’s concepts of the patient’s facial proportions (i.e., the presence of a dentofacial deformity or isolated microgenia) and 4) the patient’s nasal aesthetic unit (i.e., whether to reduce, augment, or sculpt one or more of the key regions of the nose).

It is also essential for the surgeon to understand the patient’s psychological reasons for requesting surgery on the nose and then to assess that patient’s emotional maturity and stability. Constantian has outlined specific red flags for the surgeon to be concerned about, including the patient who is seeking surgery for specific external gain (e.g., an individual who expects that nasal changes will improve his or her career); the narcissistic male; and the perfectionist.⁴¹ He also warns against operating on an individual whom “you just don’t like” (i.e., with whom you are not able to effectively communicate). Picavet and colleagues documented a high prevalence of body dysmorphic disorder symptoms among patients who are seeking rhinoplasty (see Chapter 7).¹⁷⁶ Individuals who request revision rhinoplasty and those with a psychiatric history are particularly at risk for ongoing dissatisfaction.

When the surgeon is satisfied that the patient has a problem or concern that can be physically and visually improved and that the patient is realistic with regard to his or her expectations and without notable psychopathology, further details of the proposed surgery can be outlined and frankly discussed.

Definitive Rhinoplasty Planning

A review of the patient’s history, physical findings, facial photographs, and, if indicated, sinus computed tomography scan or other facial radiographs (e.g., lateral cephalometric, Panorex) is generally followed by a second consultation visit to finalize the operative plan. The surgical objectives are clarified after 1) hearing the patient’s requests 2) analyzing the overall facial and specific nasal aesthetics and functional aspects 3) considering patient-specific anatomic limitations 4) discussing all options and 5) considering the surgeon’s ideal treatment plan.

Basic questions for the surgeon to consider include the following:

By the end of the second consultation visit, a definitive operative plan should be clear in the surgeon’s mind and accurately conveyed to the patient. The patient and the surgeon should be comfortable with any compromises that are agreed to and with the expected outcomes and the potential risks. If a comfort level is not reached, it is best not to proceed.

Most primary rhinoplasties require a combination of the reduction and augmentation of various aspects of the nose. This will often include the following: 1) the reduction of the bony and cartilaginous dorsum 2) the reduction of the cephalic portions of the LLCs (lateral crura) 3) middle crural suturing 4) cartilage (caudal strut) graft augmentation and 5) nasal osteotomies with in-fracturing (to narrow the width, to accomplish the closure of an open roof, or to straighten a crooked dorsum). When indicated, the removal of any septal deviations (i.e., cartilage and bone) and the reduction of the inferior turbinates will simultaneously diminish airway resistance and improve nasal breathing.

Open versus Closed Approach to the Nose

In the hands of a limited number of experienced nasal surgeons, the closed (endonasal) approach to gain exposure of the nose allows for the predictable management of the patient’s needs.91,198,202,217–221 In this author’s clinical practice, the open (columella-splitting and bilateral marginal incisions) approach provides the preferred direct exposure of the nasal structures in most patients. After elevation of the nasal soft-tissue envelope via an open approach, direct inspection of the osseocartilaginous framework and tip should confirm the preoperative clinical diagnosis. This direct exposure facilitates technical maneuvers such as the following: 1) bony and cartilaginous reduction 2) excision and suturing of the LLCs 3) the placement and stabilization of grafts and 4) septal modification. By understanding normal nasal physiology and what the osseocartilaginous framework and nasal tip should look like and then seeing the anatomy under direct vision, the intended results are achieved more often than not.

As pointed out by many authors, the open approach has advantages that include the following3,4,33,50,72–76,84,91,101,112:

An often-stated drawback of the open approach relates to tip swelling. The amount and duration of tip swelling after open rhinoplasty is generally greater than that seen with the closed approach. Therefore, it is reasonable to consider a closed rhinoplasty for those patients who may need only nasal osteotomies, dorsal hump reduction, or minimal tip alterations.

Complications Associated with Rhinoplasty

Fortunately, in the hands of an experienced nasal surgeon, the vast majority of well-informed patients undergo an uneventful operative and postoperative course and are pleased with their initial and long-term function and their aesthetic results. However, as with any surgical procedure, perioperative problems may occur (e.g., infection, bleeding, airway compromise) in addition to problems that are specific to rhinoplasty (e.g., septal perforation, persistent nasal obstruction, suboptimal cosmetic results).* These potential problems must be considered and openly discussed in advance to limit patient dissatisfaction.

Primary Septorhinoplasty: Step-by-Step Approach (Figs. 38-5 through 38-9)