Advanced Rhinoplasty Anatomy

Rod J. Rohrich • William P. Adams, Jr. • Jack P. Gunter

Rhinoplasty is precise surgery in which the margin of error is measured in mil­

limeters. Therefore excellent results can only be obtained if the surgeon has a
thorough knowledge of nasal anatomy, its variations, and the surgical relevance
of altering its structures. Lack of such understanding may result in inaccurate di­
agnosis and therefore incorrect surgical indications, leading to unfavorable aesthetic
outcomes and sometimes serious functional derangements.

The nose, like any other projecting structure, includes a framework, supporting
system, and external coverage. The framework consists of cartilage and bone,
16
supported and held together by connective tissue and ligaments. The skin and
soft tissue provide the external covering of the nose. These components are in­
tricately related and must be anatomically visualized in every step of the rhino­
plasty sequence. Basic principles of this sequence include the following:
1. Precise definition of anatomic goals preoperatively
2. Adequate anatomic exposure of the nasal deformity
3. Preservation/restoration of the normal anatomy
4. Correction of the specific deformity using incremental control
5. Maintenance/restoration of the nasal airway

11
12 Part One • Basic Perioperative Concepts

In this chapter we will review the clinically relevant anatomy encountered in

rhinoplasty as well as the clinical applications of these findings.

Excellent rhinoplasty results can only be obtained if the surgeon has a thorough
knowledge of nasal anatomy and the surgical relevance of alteration of the
anatomic structures.

SKIN

Previous anatomic studies have demonstrated that the nose possesses distinct
tissue layers. Proceeding from superficial to deep tissues, the layers encountered
are epidermis, dermis, subcutaneous fat, muscle and fascia (musculoaponeu­
rotic layer), areolar tissue, and perichondrium or periosteum overlying cartilage
7,8
or bone, respectively In fact, two natural planes of dissection have been de­
scribed (subcutaneous and deep areolar tissue planes), separating the nose into
the skin envelope, vascular musculoaponeurotic layer, and osteocartilaginous
framework. The skin is thinner and more mobile in the upper two thirds of the
nose. In the lower third and especially at the nasal lobule, the skin becomes
thicker, more sebaceous, and more adherent to the underlying structures.

Clinical Application
The type, texture, and sebaceous content of the skin must be carefully analyzed
because it will influence the approach for modifying the framework and there­
fore the final result. For example, in patients with thin skin, overzealous alter­
ation of the underlying framework may have adverse long-term effects. This is
because thin nasal skin has a high capacity to contract and redrape over the
sculpted framework. Additionally, slight imperfections of contour, asymmetries,
 Chapter 2 • Advanced Rhinoplasty Anatomy 13

and graft edges are more likely to be visible and/or palpable postoperatively. In
contrast, thick sebaceous skin tends to offer less postoperative contraction, war­
ranting more aggressive alterations of the underlying framework in order to ob­
tain a significant definition of contour.

The type, texture, and sebaceous content of the skin must be carefully analyzed
because it will influence the approach for modifying the framework and therefore
the final result.

MUSCLES

The muscles of the nose are divided into an intrinsic group of seven paired mus­
cles (having both origin and insertion within the perinasal area), and an extrin­
sic group containing three paired muscles.
14 Part One • Basic Perioperative Concepts

The intrinsic group includes the procerus, which raises the dorsum and lowers
the lateral cartilages. Its distal aponeurosis blends with the pars transversa of the
nasalis muscle to form the superficial musculoaponeurotic system of the nose.
The pars transversa provides lateral wall rigidity and can even be a dilatory mus­
cle. By contrast, the pars alaris is the primary dilatory muscle of the ala and is re­
sponsible for alar flaring. The remaining nasal intrinsic muscles are of doubtful
importance in nasal airway patency.

Of the extrinsic muscles, the levator labii superioris alaeque nasi is the most im­
portant dilator. The zygomaticus minor and orbicularis oris secondarily provide
lateral wall stability. When clinically significant, the depressor septi nasi muscle
may accentuate drooping of the nasal tip and shortening of the upper lip on an­
imation.

We performed a cadaver study to define the anatomic variations of the depres­

9
sor septi muscle. Three types of depressor septi muscles were identified. Type I
depressor septi muscles (62%) are visible and identifiable, and can be traced to
full interdigitation with the orbicularis oris from their origin at the medial crural
footplate. Type II muscles (22%) are visible and identifiable but, unlike the first
group, insert into the periosteum and demonstrate little or no interdigitation
with the orbicularis oris. In type III muscles (16%) no or only a rudimentary
depressor septi muscle is visible.
 Chapter 2 • Advanced Rhinoplasty Anatomy 15

Clinical Application
Routine preoperative examination of the rhinoplasty patient should easily iden­
tify those patients who demonstrate a drooping nasal tip and shortened upper
lip on animation, particularly when smiling. In such patients (types I and II)
dissection and transposition of the distal depressor septi muscles and suturing
together of the cut ends reliably and effectively correct this dynamic facial defor­
mity. Dissection and transposition rather than excision of tissue provide full­
ness to the central upper lip, enhancement of the tip-lip relationship, relative
upper lip lengthening, and maintenance of tip rotation/projection on animation.

An active depressor septi muscle can be identified on preoperative clinical analy­

sis, and its modification intraoperatively can enhance the tip/lip complex.

BLOOD SUPPLY
Artery

The arterial supply to the nose derives from two main arterial systems: oph­
thalmic artery and facial artery. The main artery of the ophthalmic system is the
dorsal nasal artery (also known as the anterior ethmoidal or terminal branch of
the ophthalmic artery), which emerges from the medial orbit and courses over
the anterior surface of the nasal bones toward the nasal tip. The dorsal nasal ar­
tery supplies the proximal portion of the nose and contributes to the subder-
mal plexus of the nasal tip.
16 Part One • Basic Perioperative Concepts

The nasal tip area is supplied primarily by the angular and the superior labial ar­
teries, which are derived from the facial artery. In general, the angular artery
originates the lateral nasal artery, which passes medially along the cephalic mar­
gin of the lateral crura and gives off caudal branches toward the nostril rim. The
superior labial artery originates from the columellar artery, which courses up
the columella to the region between the domes. The lateral nasal and columellar
arteries then meet over the dorsal region, forming an alar arcade that runs along
the cephalic margin of the lateral crura. This arcade runs above the musculo­
7,10
aponeurotic layer.

Superficial to the alar arcade is the subdermal plexus of the nasal tip skin that is
supplied by branches of both ophthalmic and facial artery systems.

Veins
The venous drainage system also runs above the musculoaponeurotic layer along
the lateral wall, dorsum, and supratip regions of the nose. Although the anatomy
of these veins is variable, most vessels drain into the facial vein inferiorly and/or
the angular vein as it courses toward the medial orbit. One of the most impor­
tant veins in the nose is the lateral nasal vein, which runs over the perichon­
drium of the middle nasal vault. Finally, there are no significant veins in the col­
umellar region.
 Chapter 2 • Advanced Rhinoplasty Anatomy 17

Lymphatic Drainage
Previous anatomic studies have demonstrated that the lymphatic drainage sys­
tem is also located superficial to the musculoaponeurotic layer. Drainage occurs
dynamically along the lateral aspect of the nose, cephalad to the lateral crus, to­
ward the piriform aperture and parotid lymph nodes. Additionally, lymphatic
7
drainage does not occur in the columella region.

Clinical Applications
There has been concern, especially with the growing popularity of the external
approach to rhinoplasty, that the transcolumellar incision may compromise
nasal tip blood supply. However, the most recent anatomic studies have demon­
8
strated the safety of this procedure. Before flap elevation, only the columellar ar­
teries are divided by the transcolumellar incision—adequate blood supply to the
tip will derive primarily from the lateral nasal arteries and will be available as
long as they are preserved during the procedure. However, caution is advised if
the alar base has been previously excised, if the alar base incisions extend more
than 2 mm above the alar groove, and the lateral nasal artery is damaged bilat­
erally. These studies have also shown that defatting may jeopardize the nasal tip
supply. In nasal tip procedures the surgeon should reconstruct the underlying
framework to redefine the tip instead of employing defatting techniques.

Surgical disruption of the venous and lymphatic vessels that run above the mus­
culoaponeurotic layer of the nasal tip results in increased supratip edema. There­
fore dissection of the nasal skin flap during rhinoplasty should be limited to the
deep areolar tissue plane just above the cartilage and bone, leaving the muscu­
loaponeurotic layer intact. This preserves the major arterial, venous, and lym­
phatic vasculature supplying the nose, which runs superficial or within the mus­
culoaponeurotic layer. Preservation of the vasculature ensures tissue viability
and more rapid resolution of the tissue edema that occurs postoperatively.

Dissection in the deep areolar plane will not ensure preservation of the lateral
nasal veins that pass over the perichondrium of the middle nasal vault. Although
there are usually multiple veins draining the nasal tip, division of the lateral nasal
veins may result in an increase in the supratip edema. Therefore blunt dissection
of the soft tissue overlying the middle vault is recommended to preserve these
vessels, in an attempt to maximize venous return and help minimize tip edema.
18 Part One • Basic Perioperative Concepts

NASAL VAULTS

The nose possesses three vaults: bony, upper carti­

11
laginous, and lower cartilaginous vaults.

Bony Vault

The bony vault is the principal structural base for

the nose. It is generally pyramidal in shape and
comprises one third of the external nose. Consist­
ing of the paired nasal bones and the ascending
frontal process of the maxilla, the vault acts as a can­
tilever, supporting the upper nose and the upper lat­
eral cartilages. The maxillary processes extend in a
cephalad direction from the piriform aperture to the
lacrimal crest, uniting with the frontal and nasal
bones. The nasal bones articulate with each other
medially, the frontal bone superiorly, the maxilla lat­
erally, the perpendicular plate of the ethmoid poste­
riorly, and the upper lateral cartilages inferiorly.

The nasal bones average 2.5 cm in length, are much thicker and denser above
the level of the medial canthus at the radix, and thin progressively toward the tip.
They are also widest at the nasofrontal suture, narrowest at the nasofrontal an­
gle, and tend to widen again inferior to the radix before narrowing near their
 Chapter 2 • Advanced Rhinoplasty Anatomy 19

inferior margin. A transition zone of bony thickness exists along the frontal
processes of the maxilla from the piriform aperture to the radix along the lateral
nasal wall. The bone in this region is less than 2.5 mm thick.

Clinical Applications
Osteotomies may be performed to narrow or widen the nasal base, repair an
open-roof deformity after dorsal hump resection, and correct symmetrical or
asymmetrical bone deformities. Reliable and predictable osteotomies may be ex­
ecuted at the transition zone of relatively thin bone along the frontal processes
of the maxilla, from the piriform aperture to the radix along the lateral nasal
wall. Osteotomies are rarely indicated above the canthal level because this area is
1214
quite narrow and has thick b o n e .

Osteotomies may be contraindicated in some patients with short nasal bones

(distal border 1 cm beneath the intercanthal line) and in certain non-Caucasian
races with extremely low and broad noses, because of the risk of middle vault
collapse and the associated functional airway compromise. Elderly patients with
excessively thin nasal bones, patients with heavy glasses, and patients with thick
skin over the dorsum should be approached with caution.

Upper Cartilaginous Vault

The most important component of the upper cartilaginous vault is the internal
nasal valve, which is bordered by the septum (medially), the nasal floor (interi­
orly), the inferior turbinate (laterally), and the caudal border of the upper lateral
cartilage (superiorly).
20 Part One • Basic Perioperative Concepts

The junction of the upper lateral cartilages with the nasal bones and the septum
defines the keystone area, which has a T-shaped contour. The nasal bones actu­
ally overlap the cephalic upper lateral border by 6 to 8 mm, thus producing a
firm adherence between both structures, enhancing support. The junction be­
tween the septum and upper lateral cartilage is normally 10 to 15 degrees. Cau-
dally the junction of the upper lateral cartilages with the cephalic edge of the
lateral crus defines the scroll area. Most patients have some overlap of the carti­
lages, which may enhance support at this level.
 Chapter 2 • Advanced Rhinoplasty Anatomy 21

Clinical Applications

Previous studies have indicated that the nasal valves contribute much more to
obstruction than previously realized and that the septum may play a much
smaller overall role. Therefore injury and/or destabilization of the keystone area
during rhinoplasty must be avoided at all costs because deformation of the nor­
mal 10- to 15-degree angle between the upper lateral cartilages and the septum
15,16
will result in impaired airflow through the internal valve. For example, dor­
sal reductions greater than 1 to 2 mm should be performed using an incremen­
tal component dorsal septal reduction technique, which avoids excessive resec­
tion of the upper lateral cartilages. This will tend to preserve the internal valve,
avoiding disruption of the dorsal aesthetic lines, an inverted V deformity, and
airway compromise. In secondary rhinoplasty patients with these deformities,
grafting, osteotomy, and suture techniques may be used to increase the cross-
sectional area of the internal valve, improving the functional and aesthetic sta­
tus of the nose.
22 Part One • Basic Perioperative Concepts

Lower Lateral Cartilaginous Vault

The external nasal valve exists at the level of the inner nostril. It is formed by the
caudal edge of the lateral crus of the lower lateral cartilage, the soft tissue alae,
the membranous septum, and the sill of the nostril.

The framework of the nasal tip is formed by the medial, middle, and lateral crura
of the lower lateral cartilages. Additionally, the accessory cartilages connect each
lateral crus to the piriform aperture. All of these cartilages are bound together by
a continuous perichondrium, which gives stability to the cartilages and causes
them to act as a single structural and functional unit. This unit will be referred
to as the lateral crural complex. The shape and position of this unit, the thickness
of the overlying skin, and the fibrous attachments to the adjacent anatomic
2,5,1719
structures are interrelated and determine the appearance of the t i p .
 Chapter 2 • Advanced Rhinoplasty Anatomy 23

The lateral crural complexes are supported by the suspensory ligament of the
tip, the ligamentous connection between the cephalic margins of the lower lat­
eral crura as they diverge from each other in the supratip area, and rest on the
septal angle as well as the fibrous connections to the upper lateral cartilages, and
abutment with the piriform aperture. The medial crura are supported by their
elastic fibrous attachments to the caudal septum and the soft tissue interposed
between their feet and the premaxillary area.

The fibrous attachments of the lower lateral cartilages to the septal angle, upper
lateral cartilages, piriform aperture, caudal septum, and premaxilla provide sup­
port and determine the position of the tip.

Clinical Applications
The external nasal valve is an occasional site of obstruction in rhinoplasty pa­
tients, particularly in secondary patients with a pinched alae deformity. This de­
formity may be caused by collapse of the lateral crura, which is generally caused
by overresection of cartilage and injury to its supporting structures, facial nerve
palsy, unstable lower lateral cartilages, and vestibular stenosis.

In rhinoplasty, numerous surgical techniques have been proposed to shape the

tip cartilages. Common reasons for modifying these structures are to change tip
projection, alter tip rotation, decrease the distance between the tip-defining
points, reduce tip fullness, create a supratip break, and adjust the relationship be­
tween the columella and the alar rims.
24 Part One • Basic Perioperative Concepts

Surgical maneuvers such as freeing the skin from the cartilages, transfixion inci­
sions, cephalic trim, intercartilaginous incisions, and division of the lower lateral
cartilages may disrupt the supporting system and change the position of these
cartilages.

The cartilaginous framework of the tip has been de­

scribed as a tripod. With the patient upright, the tri­
pod lies on its side with one lower leg and two upper
legs. The lower leg is represented by the medial crura,
whereas each upper leg consists of a lateral crural com­
plex based bilaterally on the piriform aperture. In the­
ory, if the base of the tripod is fixed, reduction (by re­
section and closing dead space) or augmentation (by
using grafts or struts) of the length of the legs should
change variables such as projection and tip rotation.

INTERNAL NASAL ANATOMY: SEPTUM AND TURBINES

The central supporting system of the nose is the septum, which articulates with
the perpendicular plate of the ethmoid posteriorly and the vomer inferi­
15 20,21
orly ' The vomer itself rests on the maxillary and palatine crest. The tongue-
and-groove articulation between the quadrangular cartilage and the maxillary
and palatine crest deserves special mention. The perichondrium of the cartilage
is only partially contiguous with the periosteum of the crests. Other fibers pass
through the articulation to join the contralateral perichondrium. This crossed
configuration makes a contiguous submucoperichondrial dissection difficult.
 Chapter 2 • Advanced Rhinoplasty Anatomy 25

This same anatomic configuration also allows some movement between the crest
and the septum, and it is this instability that explains the frequent posttraumatic
findings of a displaced quadrilateral septal cartilage from the groove of the crest.
The septum articulates caudally with the anterior nasal spine.

Parasagittal view of lateral nasal wall

The inferior turbinates are the most significant functional component in nasal
airway breathing because their anterior heads occupy a significant portion of
the nasal passage. They are composed of dense lamellar bone originating from
the medial maxillae and are covered with erectile mucosal tissue. This tissue is
under autonomic control and chronic inflammation can lead to fibrous deposi­
tion and chronic hypertrophy of the turbinate. In fact, the most common cause
of functional nasal airway obstruction is inferior turbinate hypertrophy.
26 Part One • Basic Perioperative Concepts

Clinical Applications
Autogenous septal cartilage is a valuable commodity with many indicated uses
in plastic surgery. In fact, it is the preferred material for numerous grafts in mod­
ern rhinoplasty. When harvesting these grafts, an intact L-strut (8 to 10 mm
wide) must be maintained for support.

Aesthetic shaping of the septum may be performed to sculpt the nasal dorsum,
help adjust the projection and rotation of the nasal tip, and improve alar/col­
umellar relationships.

The septum may play a less important role as a primary cause of nasal airway ob­
struction. In fact, not all deviated septa need correction, because it is common to
have an asymptomatic septal deviation. When deviation occurs anteriorly and
inferiorly (that is, in the area of the internal nasal valve), it is more likely to be a
source of obstruction. With these deviations, only the obstructive elements
should be excised and preservation of cartilage should always be prioritized.

When harvesting septal cartilage and/or removing posterior septal deviations, it

is important to perform a sidewise fracture/separation removal of the bony part
of the perpendicular plate of the ethmoid, which is in continuity with the crib­
riform plate. This avoids injury to the latter plate and the resulting cerebral
spinal fluid rhinorrhea.

Enlarged turbinates may cause and/or contribute toward airway compromise in

some patients. Numerous treatment options have been proposed in the literature
to reduce the mass of the turbinates and therefore improve the passage of air
through the internal valve. In general, more limited approaches to turbinoplasty
should be performed because complete turbinectomy may put the patient at in­
creased risk for developing atrophic rhinitis postoperatively.

The dorsal septum has a " T " geometry in cross section, and this anatomy is ex­
tending to recreate with techniques such as spreader grafts and flaps for both
functional and aesthetic reasons.

Excellent rhinoplasty results can only be obtained if the surgeon has a thor­
ough knowledge of nasal anatomy and the surgical relevance of alteration of
the anatomic structures.
The type, texture, and sebaceous content of the skin must be carefully ana­
lyzed, because it will influence the approach for modifying the framework and
therefore the final result.
 Chapter 2 • Advanced Rhinoplasty Anatomy 27

An active depressor septi muscle can be identified on preoperative clinical

analysis, and its modification intraoperatively can enhance the tip/lip com­
plex.
The fibrous attachments of the lower lateral cartilages to the septal angle, up­
per lateral cartilages, piriform aperture, caudal septum, and premaxilla provide
support and determine the position of the tip.

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