Atlas of Asian Rhinoplasty (Volume 1) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

Atlas of Asian Rhinoplasty

Man Koon SUH
Atlas of Asian Rhinoplasty
English Translator: Aram Harijan, M.D.
Medical Illustrator: Kim Sung Tae

Man Koon SUH
JW Plastic Surgery Center
Seoul
Soul-t´ukpyolsi
South Korea
ISBN 978-981-10-8644-1 ISBN 978-981-10-8645-8 (eBook)

Library of Congress Control Number: 2018947425
© Springer Nature Singapore Pte Ltd. 2018
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imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
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The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
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This book is dedicated to the most beautiful and lovely person in the world,
who also happens to be my wife, Jeongmin Kim.

vii
Preface
In South Korea, the expression “belly button bigger than belly” is used to describe a situation
in which a small part of a whole is larger or more significant than the whole. For rhinoplasty
surgeons in Asian countries, the practice of rhinoplasty has certainly felt this way, where the
practice of Asian rhinoplasty (the belly button) appears to span a much broader spectrum of
anatomic variation, materials, and techniques than what is described in the canonical rhino-
plasty textbooks (the belly).
Within this context, the current book was published to tackle the set of problems that
appeared outside of what was commonly known for rhinoplasty as practiced in Western coun-
tries. The book I had previously written was widely welcomed by rhinoplasty surgeons across
Asian countries, who shared much of the same frustrations I have felt. Though that was only 6
years ago, Asian rhinoplasty has advanced significantly during that interval, and a multitude of
parallel developments in anatomic understanding and techniques have prompted the prepara-
tion of the current text.
This book represents a complete overhaul, with completely new text and illustrations. It
delves deeply into topics relevant to aesthetic and functional rhinoplasty, such as nasal anatomy,
physiology, operative techniques, and secondary rhinoplasty. The manuscript for this book was
prepared not only for rhinoplasty surgeons in Asian countries but also for those surgeons in
Western countries where the demand for Asian rhinoplasty techniques is on the rise.
The significant volume of illustrations and photographs as well as the extensive text on
operative technique should provide the necessary details to guide the inexperienced surgeons,
while the seasoned rhinoplasty surgeons will find delight in new concepts and the recent
advancements in operative techniques. The operative techniques are not limited to the Asian
nose but have a wide range of applications in the Caucasian nose, especially for those patients
who present in less-than-ideal predicament.
The preparation of this text would not have been possible without the help of two persons.
Dr. Aram Harijan is a US-educated/trained physician and is responsible for the clarity of the
language in the text. His capability as a translator is singularly creative, and I still do not under-
stand how he can always conjure the expression that conveyed the exact meaning of my
intention.
My brother-in-law, Kim Sung Tae, is responsible for the outstanding illustration without
which the text would be much more difficult to digest and understand. The passion and extent
of his labor is plainly visible in the completeness of this book.
I trained at the Department of Plastic and Reconstructive Surgery at the Severance Hospital,
Yonsei University Medical College. The Department was founded by Prof. Jae-Duk Lew and
was the birthplace of plastic surgery training in South Korea. One topic for which I do not find
the need for self-deprecation is the pride I feel for the excellent training I received under the
guidance of professors and co-residents, as that is what has made possible this book and my
career in rhinoplasty.

viii
I dedicate this book to my completely beautiful and endlessly lovely wife, Jeongmin Kim.
While we were young, she was the most beautiful student at Ewha Womans University, and the
greatest deed and fortune of my life has been to earn her love and to be married together.
Through her, I found meaning, happiness, and fulfillment, and I cannot fathom a life without
her presence. To her, I am forever grateful.
Seoul, South Korea
Man Koon SUH
Preface

ix
Acknowledgments
Above all else, I want to express my endless appreciation to all of the patients who have
entrusted me to perform the rhinoplasty operations over all these years. It is because of this
trust I was able to learn and improve my study and craft of rhinoplasty. My patients are my
teachers.
I also wish to express my gratitude towards the board members at the Korean Association
of Rhinoplasty Research, who have provided the academic stimulation and inspiration through
discussions we have had over the past couple of decades.
I am thankful to Drs. Hong Lim Choi and Cheul Hwan Seul, with whom I have the honor
of training together in plastic surgery and the privilege of practicing together at JW Plastic
Surgery Center. I also wish to thank all of the staff and personnel at the center.
The publication of this book was made possible in large part by Prof. Joon Pio (J.P.) Hong
at Asan Medical Center, who has provided the bottomless encouragement and assistance I
desperately needed. He is a true friend who energizes and emboldens my path.
I thank Ms. Jenny Chun at the Springer Nature Publishing Company for helping to bring
this book to the international audience.
Lastly, I want to thank my son, Jeongsoo Suh, for never failing to provide the motivation
and life lessons that drive me to become a better person each and every day.
Man Koon SUH

xi
1 Surgical Anatomy and Physiology of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Anatomic Orientations for the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Surface Anatomy and Basic Terminology of the Nose . . . . . . . . . . . . . . . . . . . . . . . . 3
Frontal View of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Profile View of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Basal View of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Aesthetic Units of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Soft Tissues of the External Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Skin and Subcutaneous Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Muscles of the External Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Internal Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Venous Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Sensory Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
External Sensory Nerve Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Internal Sensory Nerve Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
External Nasal Frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Bony Vault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Cartilaginous Vault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Fibrous Connecting Tissues Supporting the Lower Lateral Cartilages. . . . . . . . . . . . 42
Suspensory Interdomal Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Fibrous Connection at Scroll Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Hinge Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Connection Between the Footplate and Caudal Septum . . . . . . . . . . . . . . . . . . . . . 46
Membranous Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Dermocartilaginous Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Anatomy of Internal Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Nasal Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Lateral Walls of the Internal Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Arterial Blood Supply . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Blood Supply to the Lateral Walls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Blood Supply to the Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Sensory Innervation of Internal Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Physiology of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Physiologic Functions of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Physiologic Nasal Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Anatomical Structures Involved in Nasal Obstruction . . . . . . . . . . . . . . . . . . . . . . 59
Salient Anatomic Features of the Nose in Asian Patients . . . . . . . . . . . . . . . . . . . . . . 64
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
2 Preoperative Evaluation for Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Patient Consultation and Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Contents

xii
Preoperative Interview and Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Preoperative Evaluation of General Health and Medical History . . . . . . . . . . . . . . . . 69
General Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Nasal Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Preoperative Examination and Tests of the Face and Nose . . . . . . . . . . . . . . . . . . . . 70
Preoperative Examination of the Face and Nose Should
Document the Following . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Preoperative Tests and Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Nasal Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Frontal View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Lateral View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Basal View. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
3 Incision, Approach, and Perioperative Medications and Instructions . . . . . . . . . 87
Incision and Approach for the Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Endonasal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Open Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Selection of the Incision and Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Endonasal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Open Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Preoperative Preparation and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Pre- and Intraoperative Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Postoperative Medications and Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
External Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Intranasal Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
4 Harvest of Autogenous Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Auricular Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Location of Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Injection of Local Anesthetic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Harvest of Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Complications of Auricular Cartilage Harvest . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Septal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Injection of Local Anesthetic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Cartilage Harvest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Intranasal Packing and Splinting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Complications of Septal Cartilage Harvest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Costal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Anatomy of the Rib Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Operative Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Complications of Costal Cartilage Harvest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Dermofat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Harvest Technique of Dermofat Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Temporal Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Anatomy of Temporal Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
5 Alloplastic Implants and Allograft Materials in Asian Rhinoplasty . . . . . . . . . . 137
Alloplastic Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Contents

xiii
Silicone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
e-PTFE (Gore-Tex®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Controversial Issues on Nasal Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
High-Density Porous Polyethylene (Medpor®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
PDS Plate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Allograft Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Allograft Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Allograft Dermis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Allograft Fascia Lata . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
6 Dorsal Augmentation Using the Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Preoperative Evaluation and Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
The Choice Between Silicone and e-PTFE Implant . . . . . . . . . . . . . . . . . . . . . . . . 150
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Implant Carving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Irrigation of Pocket . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Implant Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Management of Supratip Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Dorsal Augmentation in Thin Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
7 Dorsal Augmentation Using Autogenous Tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Radix Augmentation with Temporal Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Dorsal Augmentation with Dermofat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Indications for Dermofat Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Vertically Oriented Folded Dermal Graft Technique . . . . . . . . . . . . . . . . . . . . . . . 182
Dorsal Augmentation with Solid Block Costal Cartilage . . . . . . . . . . . . . . . . . . . . . . 189
Harvest of the Costal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Carving the Costal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Placement of the Graft on the Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Dorsal Augmentation with Diced Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Free Diced Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Diced Cartilage Wrapped in Temporal Fascia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Other Variable Techniques of Diced Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . . 206
Complications of Diced Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Advantages and Indications of Diced Cartilage Graft . . . . . . . . . . . . . . . . . . . . . . 207
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
8 Mid-Vault Surgery: Hump Reduction and Osteotomy . . . . . . . . . . . . . . . . . . . . . 209
Hump Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Pathology of the Hump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Complications of Hump Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Radix Deepening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
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Types of Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Osteotome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Lateral Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Position of Lateral Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Medial Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Transverse Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Intermediate Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Order of Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Considerations for Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Postoperative Dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Complications of Nasal Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Hump Nose Correction in Asians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Preoperative Evaluation and Planning of Asian Hump Nose . . . . . . . . . . . . . . . . . 257
Approach and Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Hump Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Correction of Open Roof After Hump Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Spreader Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Radix/Supratip/Dorsal Augmentation in Asian Hump Nose . . . . . . . . . . . . . . . . . 263
Tip Plasty in Asian Hump Noses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Order of Operations in Hump Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Correction of Wide Nasal Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Reduction of Wide Nasal Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
Reduction of Wide Upper Lateral Cartilages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Medial Osteotomy and Implant Use in Asians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
9 Nasal Tip Plasty: Suture Techniques and Cartilage Grafts . . . . . . . . . . . . . . . . . 285
Tip Suture Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Interdomal Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Intercrural Suture (Medial Crural Suture) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Transdomal Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
Medial Crura-Septal Suture (Columella-Septal Suture) . . . . . . . . . . . . . . . . . . . . . 308
Tip Rotation Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
Lateral Crural Spanning Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Convexity Control Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325
Derotation Suture (Caudal Rotation Suture of the Tip, Tip Extension Suture) . . . 328
Supratip Sutures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Lateral Crural Steal (Medialization of Lateral Crus) . . . . . . . . . . . . . . . . . . . . . . . 332
Interfootplate Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Cartilage Grafts of the Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Tip Onlay Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Shield Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Columellar Strut Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346
Spreader Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Indications of the Spreader Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Septal Extension Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Derotation Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390
Alar Rim Graft (Alar Contour Graft) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
Lateral Crural Onlay Graft (Lateral Crural Graft) . . . . . . . . . . . . . . . . . . . . . . . . . 416
Lateral Crural Strut Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418
Alar Batten Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Alar Spreader Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
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Interdomal Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Subdomal Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427
Plumping Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
Techniques for Tip Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Cephalic Rotation of the Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Caudal Rotation of the Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Correction of Asymmetric Lower Lateral Cartilages . . . . . . . . . . . . . . . . . . . . . . . . . 434
Height Discrepancy of Medial Crura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434
Deviated or Twisted Medial Crura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
Asymmetric Lateral Crura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
Tip Plasty in Asians with Thick Skin and Soft Tissue . . . . . . . . . . . . . . . . . . . . . . . . 440
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 440
Pathology of Thick-Skinned Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Pre- and Postoperative Skin Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
Surgical Principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442
Tip Plasty in Thin Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
Dissection of Thin SSTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Reinforcement of Thin SSTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Tip Plasty Principle in Thin-Skinned Noses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
10 Optimal Tip Projection in Asian Noses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
Ideal Tip Position in Asians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
Factors Determining the Tip Height in Asians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Major Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Inborn Anatomy of the Lower Lateral Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
Tip Skin/Soft-Tissue Thickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
Caudal Septal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Scroll Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Minor Determinants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Interdomal Ligament (Suspensor Ligament) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Footplate-Septal Connection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456
Surgical Techniques for Nasal Tip Projection in Asian Patients . . . . . . . . . . . . . . . . . 457
Tip Onlay/Shield Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Size of the Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Location of the Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Cautions in Tip Projection for Asian Noses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Interdomal Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462
Reinforcement of the Medial Crura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463
Aesthetic Consideration of the Infratip Lobule Ratio . . . . . . . . . . . . . . . . . . . . . . . 464
Medialization of Lateral Crura (Lateral Crural Steal) . . . . . . . . . . . . . . . . . . . . . . . . 464
Straightening the Curved Medial Crura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
Columellar Strut Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
Footplate Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Usefulness of Columellar Strut Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
Direct Suspension of Whole Lower Lateral Cartilage . . . . . . . . . . . . . . . . . . . . . . . . 470
Medial Crural-Septal Suture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
Septal Extension Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470
Fixed-Type Columellar Strut Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Tongue-in-Groove Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
Operative Algorithm for the Tip Projection in Asian Rhinoplasty . . . . . . . . . . . . . . . 475
Premaxillary Graft as an Adjunct Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 481
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Long-Term Stability of the Tip Projection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482
Problems of Thick Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483
Management of Supratip and Infratip Lobules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 484
Factors Involved in Tip Drooping After Long Term . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Short and Retruded Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
Hanging Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 488
Thick and Tight Skin Over the Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Strong DSN Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
Surgical Maneuvers to Decrease the Tip Projection . . . . . . . . . . . . . . . . . . . . . . . . 490
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 490
11 Tip-Reduction Surgery: Bulbous Tip Correction and Long-Nose Correction . . 491
Bulbous Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Ideal Shape of the Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
Classification of Bulbous Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 497
Several Techniques to Reduce the Tip Volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Illusion and Harmony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
Soft-Tissue Debulking and Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
Lower Lateral Cartilage Manipulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
Operative Techniques According to the Types of Bulbous Tip . . . . . . . . . . . . . . . . . . 513
Type I: Cartilage Predominant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513
Type II: Soft-Tissue Predominant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 516
Type III: Mixed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521
Manipulation of Curled-In Cephalic Margin of Lateral Crura . . . . . . . . . . . . . . . . 522
Operative Techniques for the Boxy Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525
Long Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 527
Type I: Correction of Long Nose with Drooping Tip . . . . . . . . . . . . . . . . . . . . . . . . . 529
Partial Resection of Cephalic Margin of Lateral Crura (Cephalic Trim) . . . . . . . . 531
Shortening of Caudal Septal Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 532
Shortening of Lateral Crura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 533
Shortening of Membranous Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Elongation of Medial Crura . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
Additional Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
How to Combine Procedures Described Above . . . . . . . . . . . . . . . . . . . . . . . . . . . 542
Treatment of Gummy Smile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
Botox in the Nasal Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548
Type II: Correction of Long Nose with Normal Tip Height . . . . . . . . . . . . . . . . . . . . 553
Type III: Correction of Long Nose with Overprojected Tip . . . . . . . . . . . . . . . . . . . . 554
Trimming of the Columella Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 556
Alar Base Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Long Nose with Retracted Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559
12 Short-Nose Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
Definition of Short Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
Short Nose Without Nostril Show/Retracted Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
Radix or Dorsal Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
Shield Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
Short Nose with Upturned Tip and Nostril Show . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Release of the Lower Lateral Cartilages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Release of the Skin and Soft-Tissue Envelope . . . . . . . . . . . . . . . . . . . . . . . . . . . . 569
Fixation of the Repositioned Lower Lateral Cartilages . . . . . . . . . . . . . . . . . . . . . 570
Correction of Short Nose Combined with Retracted Ala . . . . . . . . . . . . . . . . . . . . . . 586
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588
Contents

xvii
13 Correction of Alar-Columellar Disproportion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 589
Retracted Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Causes of Alar Retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591
Correction of Alar Retraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592
Hanging Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
Correction of Thick Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Correction of Thin Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614
Correction of Columellar Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
Hanging Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
Hanging Columella Combined with Retracted Ala . . . . . . . . . . . . . . . . . . . . . . . . 626
Retracted Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 628
Causes of Retracted Columella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 629
Operative Techniques of Primary Retracted Columella . . . . . . . . . . . . . . . . . . . . . 629
Correction of the Footplates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 639
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 640
14 Correction of Nostril and Alar Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641
Alar Base Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643
Causes and Types of Wide Alar Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643
Operative Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645
Effect of Tip Projection on Wide Alar Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659
Effects of Alar Base Reduction on the Tip and Alar Rim . . . . . . . . . . . . . . . . . . . . 660
Correction of Narrow Alar Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 661
Correction of Cephalically Malpositioned Alar Base . . . . . . . . . . . . . . . . . . . . . . . . . 661
Correction of Caudally Malpositioned Alar Base . . . . . . . . . . . . . . . . . . . . . . . . . . . . 662
Correction of Unpleasing Nostril Shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Short Nostril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Small Nostril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
Inverted Triangular Shaped Nostril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
15 Deviated Nose Correction and Functional Rhinoplasty . . . . . . . . . . . . . . . . . . . . 669
Causes of Nasal Deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
Iatrogenic Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669
Pathophysiologic Consideration and Classification of Deviated Nose . . . . . . . . . . . . 670
Preoperative Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
History and Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Radiologic Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Preoperative Plan and Explanation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Operative Techniques of Deviated Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Approach and Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677
Correction of Deviated Nasal Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
Correction of Mid-Vault (Cartilaginous Dorsum) and Deviated Septum . . . . . . . . 688
Deviated Nose Correction in Patients with Small Nasal Bone . . . . . . . . . . . . . . . . . . 729
Camouflage Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
Medial and Intermediate Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
Deviated Nose Correction and Dorsal Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . 731
Correction of Deviated Tip and Columella in the Deviated Noses . . . . . . . . . . . . . 735
Dressing After the Deviated Nose Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 740
Functional Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
Causes of Nasal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741
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xviii
Diagnosis of Nasal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
Manipulation of Inferior Turbinate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 742
Treatment of Concha Bullosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 746
Correction of Internal Valve Collapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747
Correction of External Valve Collapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 752
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 756
16 Secondary Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757
General Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757
Consultation and Nasal Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 757
Timing of the Secondary Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 761
How to Choose the Incision and Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 762
Implant-Related Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763
Movable Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 763
Deviated Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 764
Color Change of Dorsal Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 767
Implant Showing Through Thinned Dorsal Skin . . . . . . . . . . . . . . . . . . . . . . . . . . 773
The “Operated-Look” Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774
Implant Exposure Through Skin/Mucosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 781
Late Spontaneous Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 787
Calcification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 788
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 790
Secondary Tip and Columella Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 792
Unsatisfactory Tip Projection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 792
Asymmetric Nasal Tip and Columella Deviation . . . . . . . . . . . . . . . . . . . . . . . . . . 798
Pinched Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 807
Retracted Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 820
Supratip Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 822
Contracted Short Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 829
Operative Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 831
Mid-Vault Revisional Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845
Inverted-V Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 845
Dorsal Irregularities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 853
Saddle-Nose Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 874
17 Complications of the Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875
Intraoperative Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 875
Hemorrhage in the Immediate Postoperative Setting . . . . . . . . . . . . . . . . . . . . . . . . . 876
Delayed Postoperative Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877
Acute Injury to the Keystone Area (L-Strut Fracture) . . . . . . . . . . . . . . . . . . . . . . . . 879
Nasal Bone Collapse During Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 880
Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 881
Nasal Tip Numbness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882
Nasal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 882
Mucosal Synechiae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883
Septal Perforation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
Perforations Less Than 2 Cm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
Larger Perforations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 884
Empty Nose Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 885
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 886
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
Post-rhinoplasty Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 887
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Impairment of Olfaction (Respiratory Hyposmia or Anosmia) . . . . . . . . . . . . . . . . . 887
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888
Cacosmia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888
Post-rhinoplasty Fibrosis Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888
Skin Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 890
Contents

1
© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Surgical Anatomy and Physiology
of the Nose
As a three-dimensional structure, the nose is not only a central component of facial aesthetics but also a vital functional organ
that facilitates respiration and olfaction. The external appearance and anatomical structure of the nose can vary considerably
across ethnicities and individuals. Because the purpose of rhinoplasty is to alter the nose to a desired shape, the understand-
ing of the underlying anatomy is of utmost importance.
Having this solid understanding of nasal anatomy, the competent rhinoplasty surgeon must be able to assess the aesthetic
deficit or abnormality of a nose and come up with a sound operative solution that matches reasonable desires of the patient.
1

2
Anatomic Orientations for the Nose
To a novice rhinoplasty surgeon, the terminology used to describe anatomic orientations of the nose can be very confusing. This
confusion arises from the facts that the nose exists in a different protruding position from the standard up-and-down position
and orientation of the head (face), and surgeons use terminology differently for the direction and position of the nose (Fig. 1.1a).
“Superior” and “inferior” will be replaced by “cephalic” and “caudal,” while “anterior” and “posterior” are replaced by “dorsal”
and “basal,” respectively. In the columella and ala area, the conventional descriptors for the direction are “anterior,” “posterior,”
“medial,” and “lateral.” These terms denote slightly different directions from those used in the body (Fig. 1.1b).
a
b
Fig. 1.1 Anatomical orientations
for the nose. Many surgeons
certainly use these terms
interchangeably. The superior-
inferior axis is sometimes
confused with the cephalic-caudal
axis. The anterior-posterior axis is
analogous to the dorsal-basal axis
1 Surgical Anatomy and Physiology of the Nose

3
Surface Anatomy and Basic Terminology of the Nose
After the anatomic orientations, the second important foundation for understanding nasal anatomy is the terminology used
to describe the nasal surface. The vernacular used to designate each part of the nose is highly extensive, and various authors
tend to demonstrate different understanding of the terminology by the wide spectrum of word usage, which leads to a signifi-
cant confusion for the novice. To minimize this potential for misunderstanding, the author has tried to maintain a diction that
is the most logical from the perspective of the rhinoplasty operation.
Frontal View of the Nose
The frontal surface anatomy and bony framework are described using the terminology below (Figs. 1.2 and 1.3).
Radix: The radix is the area where the nasal bone fuses with the lower border of frontal bone, and is located between the
eye socket openings. It is the starting point of the nose and lowest portion of the nasal dorsum.
Dorsum: The dorsum is the anterior surface (ridge) that runs from the radix and the nasal tip. Upper one-third of dorsum is
the bony part, whereas the lower two-thirds is the cartilage part. Nasal dorsum is divided by bony vault, cartilaginous vault, and
supratip area. The dorsum is the narrowest at the level of medial canthus and becomes wider in caudal direction. It is widest at
the transition between bony vault and cartilaginous vault—the rhinion—and becomes slightly narrower near the ala domes.
Bony nasal vault: The bony vault refers to the upper third of nasal dorsum, which consists of the pair of nasal bones.
Midvault (middle vault, cartilaginous vault): The midvault refers to the middle one-third of the dorsum and is situated
between the bony nasal vault and the nasal tip. The most caudal portion of midvault represents the narrowest area of the nasal
airway, which is the internal nasal valve.
alar-facial
groove
alar groove
tip
ala
dorsum
radix
Fig. 1.2 Surface anatomy of the nose
Fig. 1.3 Bony and cartilage framework of the nose
Surface Anatomy and Basic Terminology of the Nose

4
Nasal tip: The nasal tip describes the most anterior point at the caudal end of the nose.
Tip-defining point (TDP): The tip-defining point refers to the two points of maximum projection on each side of the nasal
tip. These are identified by the highlight of the external light reflection on the frontal view and are created by the domes of
lower lateral cartilages.
Nasal lobule: The nasal lobule is sometimes used interchangeably with the nasal tip. More accurately, however, the lobule
describes the area bounded superiorly by the supratip area, laterally by the alar grooves, and posteriorly by the line connect-
ing both anterior nostril apexes. As such, the lobule describes a wider area that incorporates the nasal tip as its central area.
The lobule is further subdivided into the tip, supratip lobule, and infratip lobule (Fig. 1.4).
Ala: The ala refers to the tissue comprising the lateral boundary of the nostril, extending from the tip to the upper lip and
cheek.
Alar groove: The alar groove is the depressed oblique line between the lobule and the ala.
Alar rim (nostril rim): The alar rim describes the roof margin of the nostril, which extends from the lobule to the
base.
Alar base: Alar base refers to the round shape junction where the alar rim ends and the nose attaches to the cheek.
Fig. 1.4 Nasal lobule consists of supratip, tip, and infratip lobule
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5
Profile View of the Nose
The lateral surface anatomy and cartilage/bony framework are described using the terminology below (Figs. 1.5 and 1.6).
Nasion: The nasion is the midpoint (foremost point) of the nasofrontal suture line.
Soft-tissue nasion: The point on the radix skin that is directly over the bony nasion.
Sellion: The deepest point of the nasal bone or the nasofrontal angle.
Sellion is more inferior and posterior and should not be used as a substitute for nasion.
Radix: The center of radix is the sellion. The lower border of radix is defined by the horizontal line passed through the
lateral canthi. The upper limit is marked by a superior point that is at an equivalent distance from the sellion to the lateral
canthal line (Fig. 1.7).
Rhinion: The rhinion describes the lower end of the internasal suture and is at the junction between the nasal bone and
upper lateral cartilage.
Supratip break: The transitional area extending from the dorsal contour line to the more projected tip is called the supratip
break and occurs cephalad to the nasal tip. The amount of supratip break is dependent on both surgeon and patient preferences.
Supratip break is not desired among East Asian male patients. Excessive supratip break is avoided even by female patients.
Supratip lobule: The supratip lobule ranges from the supratip break point to the tip-defining point.
Infratip lobule: The infratip lobule is defined by the lowermost portion of the lobule between the tip-defining point and
the columellar-lobular junction (soft transition from the nasal tip to the columella). It is formed by the paired divergent
middle crura of lower lateral cartilages.
lower lateral
cartilage
cartilaginous
vault
bony vault
Fig. 1.6 Bony and cartilage framework of the nose from the profile
view
radix
dorsum
surpatip
break
tip
colunella
subnasale
Fig. 1.5 Surface anatomy of the nose from the profile view
Surface Anatomy and Basic Terminology of the Nose

6
Columellar-lobular junction: This junction delineates between the infratip lobule and columella and is also called colu-
mella breakpoint. It is located between vertically oriented medial crura and divergent angular middle crura, and is usually at
the level of nostril apex.
Columella: The columella is the structure between infratip lobule and nasal base and separates the two nostrils. It consists
of the medial crura of the lower lateral cartilages.
Alar-facial groove: This groove forms the junction between the nose and cheek.
Radix
sellion
Fig. 1.7 Radix area
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7
Basal View of the Nose (Fig. 1.8)
Soft triangle: Soft triangle is the small area of the nostril apex. This area is not supported by cartilage, consisting only of outer
and inner skin layers. Incisions in this area may result in conspicuous scarring and notching deformity.
Nostril sill: The nostril sill is the horizontal ridge of the nostril floor between the columellar base and alar base.
Subnasale: The subnasale is the intersecting point between columella and upper lip in the midsagittal plane.
ala
ala base
footplate of
medial crura
columella
infratip lobule
tip
nostril floor
nostril sill
Fig. 1.8 Basal view of the nose
Surface Anatomy and Basic Terminology of the Nose

8
Aesthetic Units of the Nose
The nasal skin is composed of nine unit areas, which are dorsum, side wall, ala, tip, columella, and soft triangle (Fig. 1.9).
Within each unit, the histologic features (i.e., skin thickness and characteristics) are uniform. In reconstructive surgery, skin
graft or flap should reconstruct not only the defect itself but also the whole of involved unit for improved aesthetic
outcome.
dorsum
columella
soft tirangle
tip
ala
lateral wall
Fig. 1.9 Aesthetic units of the nose
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9
Soft Tissues of the External Nose
Skin and Subcutaneous Tissue
Compared to the Caucasian nose, the skin and subcutaneous tissue are thicker and contain more sebaceous glands in the
Asian nose. However, exceptions exist to this observation, and it is perhaps more accurate to state that the nasal skin and soft
tissue have a wider variation in the East Asian population. A nose with thicker skin and subcutaneous tissue often requires a
different surgical technique and shows a different prognosis from those of a nose with thinner soft tissue (Fig. 1.10).
a
b
Fig. 1.10 Comparison of
nasal tip anatomy between an
Asian patient and a Caucasian
patient. (a) In this Asian
patient, the nasal tip consists
of small lower lateral
cartilages and thick soft
tissue. (b) The nasal tip in this
Caucasian patient has a
relatively thinner skin and soft
tissue overlying well-
developed lower lateral
cartilages
Soft Tissues of the External Nose

10
The thickness of the nasal soft tissue varies significantly from the radix to the tip/alar area. The soft tissue is thickest at
the radix (nasofrontal angle), becomes thinner in the central portion, and becomes thicker towards the tip and ala (Fig. 1.11).
However, the skin is relatively thin at the columella. The upper two-thirds of nasal skin and soft tissue are relatively more
mobile and contain a lower density of sebaceous glands. The lower third of nasal skin is relatively thicker and adheres
strongly to the underlying tissue. It also contains a higher density of sebaceous glands. Generally, the thicker nasal skin and
soft tissue allow for a degree of implant-based dorsal augmentation in Asian patients.
thick
thick
thin
Fig. 1.11 Thickness of the nasal skin and soft tissue. Nasal sin and soft tissue are
thick over the radix and supratip area and thin at rhinion. The skin and soft tissue are
mobile over the nasal bone and upper lateral cartilage but firmly adhere to the lower
lateral cartilage
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11
The Five Layers of Nasal Soft Tissue
The soft tissue overlying the osteocartilaginous frame is composed of five distinct layers (Fig. 1.12):
1. Skin
2. Superficial fatty layer
3. Fibromuscular layer
4. Deep fatty layer
5. Perichondrium/periosteum
The fibromuscular layer constitutes the nasal SMAS. This layer allows sliding of the skin and supplies the blood to the
skin. This is the central component behind soft-tissue contracture of the nose.
skin
superficial
fatty layer
fibromuscular
layer
deep fatty layer
periosteum
(perichondrium)
Fig. 1.12 Soft-tissue envelope of the
nose. The soft-tissue envelope is
composed of skin, superficial fatty layer,
fibromuscular layer, deep fatty layer, and
periosteum (or perichondrium)
Soft Tissues of the External Nose

12
Skin
A wide variation exists in the thickness of nasal skin across populations. As previously mentioned, the nasal skin is generally
thicker in Asian patients than it is for Caucasian patients.
The inter-ethnic and interpersonal variations in nasal skin thickness have a significant effect on outcomes and prognosis
after rhinoplasty. Thicker nasal skin does not transmit the shape of the underlying cartilage framework, and because of this
reason it is more difficult to remodel the nasal tip to a defined shape in patients with thicker nasal skin. In addition, thicker
nasal skin is more resistant to stretching (i.e., tip- lengthening surgery). Compared to the thin-skinned nose, the tip volume
reduction surgery in thicker skin may not present the well-defined tip, because of the less efficient “shrink-wrap effect,” which
means redrape of the skin over the underlying cartilage framework. Postoperative edema tends to be prolonged in patients with
thicker nasal skin, which can subsequently lead to fibrotic transformation. However, some properties of thick nasal skin
become an advantage when it comes to implant placement, as the thick skin tends to decrease implant showing through the
skin and to mask minor irregularities in contour. Because of these reasons, it is important to thoroughly evaluate the charac-
teristics of nasal skin and to apply different surgical techniques from those for Caucasians. In Caucasian patients with thinner
skin, a tip plasty by itself can create a defined nasal tip more easily. In such patients, however, the thinner skin may reveal
minor irregularities and contour of the underlying bone and cartilage frame, with a very low margin of error for the operator.
Commonly, the nasal skin is thickest at the radix and is thinnest at the rhinion (Fig. 1.11). The skin over the supratip area
is thicker than that of the rhinion and, occasionally, is thicker than the skin over the radix. During hump removal, the operator
must be aware of the fact that the skin thickness of the dorsum varies significantly and is thinnest at the rhinion. If the carti-
lage and bony hump are removed in a straight line, the resulting profile will have a depression near the rhinion when skin
envelope covers the dorsum, because of this difference in skin/soft-tissue thickness. And, when dorsal skin becomes stretched,
elongated, and moved caudally by tip extension technique, such as septal extension graft performed for the Asian short nose,
operator can see the dorsal irregularity changes slightly compared to the preoperative one, because of these anatomic features
of the different dorsal skin thickness.
The alar lobule skin thickness of Asians varies between 1 and 2.75 mm. The mid-alar area is thinner, with the ala base
being thicker. The columella has thin skin. In addition to thickness, nasal skin can vary in color, consistency, and porosity
across ethnicity and between individuals. The lower one-third of the nose has an abundance of sebaceous glands.
Soft-Tissue Layers Under the Skin
Soft-tissue coverings under the skin thicken gradually downwards from rhinion.
Between the skin and underling osteocartilaginous frame, there are four distinct layers: superficial fatty layer, fibromus-
cular layer, deep fatty layer, and periosteum/perichondrium. The superficial fatty layer is thicker at the radix and supratip,
and is thinner at the middorsum.
The fibromuscular layer contains the nasal superficial musculoaponeurotic system (SMAS). This structure is continu-
ous with the facial SMAS, galea, and platysma muscle. Some authors consider the superficial fatty layer to be a part of the
SMAS. The nasal SMAS is a sheet of dense, fibrous connective tissues that covers, invests, and forms the terminations of the
nasal muscles. This fibromuscular structure is well differentiated and is easily detached from the skin in the upper nose but is
tightly adhered to the skin and not well differentiated in the lower nose. Major blood vessels and nerves usually travel within
or above the nasal SMAS. To avoid injury to these vessels and minimize the amount of bleeding, any dissection carried in
the nose should be carried below the deep fatty layer. The deep fatty layer does not contain any fibrous septa and permits the
movement of the fibromuscular layer over the nasal framework.
1 Surgical Anatomy and Physiology of the Nose

13
The triangular apex of the nostril does not contain any cartilage and consists only of external skin and vestibular lining—
hence, the title of “soft triangle” (Fig. 1.13). Converse defines the soft triangle as comprising two adjacent layers of skin,
separated by loose areolar tissue. Ali-Salaam’s histologic study of the soft triangle indicates three distinct zones. Zone 1
contains fibers of the dilator naris muscle, beneath the dome of the lower lateral cartilage. More caudally, Zone 2 is composed
of dermis. Along the nostril rim, Zone 3 incorporates interdigitating muscles that are extensions of the nasalis muscle or
depressor nasi septi muscle within the dermal layers.
Incision in the soft triangle can result in the scar contracture and notching deformity (Fig. 1.14).
Fig. 1.14 Notching deformity from an incision through the
soft triangle (left nostril)
a
b
Fig. 1.13 Soft triangle. Soft triangle refers to the area which is not supported by cartilage and consists only of the outer and inner skin. Incision
should be avoided in this area
Soft Tissues of the External Nose

14
Muscles of the External Nose
Nasal muscles are not only involved in facial expression but also important for facial expression. Because they are extremely
thin, the muscles are not easily visualized during rhinoplasty. Under normal conditions, nasal muscle does not appear to serve
important functions. However, the functions of nasal muscles become apparent in facial paralysis. In patients with unilateral
paralysis of the nasal muscles, the nose will deviate away from the side of the paralysis, and nasal airway frequently becomes
obstructed on the side of paralysis.
All the nasal muscles are innervated by the VII cranial nerve.
The nasal muscles exist within the SMAS layer and can be categorized into four group (Fig. 1.15):
orbicularis oculi m.
levator labii superioris
alaeque nasi m.
dilator naris
anterior m.
dilator naris
posterior m.
(alar nasalis m.)
orbicularis oris m.
depressor septi
nasi m.
compressor narium
minor m.
anomalous nasi m.
transverse nasalis m.
procerus m.
Fig. 1.15 The nasal musculature
1 Surgical Anatomy and Physiology of the Nose

15
1. Nasal Elevators.
The elevators include procerus muscle, levator labii superioris alaeque nasi muscle, and anomalous nasi muscle. These
muscles shorten the nasal length and dilate the nostrils.
2. Nasal Depressor.
The depressors consist of alar nasalis muscle (dilator naris posterior muscle) and depressor septi nasi (DSN) muscle.
These muscles extend the nasal length and dilate the nostrils.
3. Minor Nasal Dilators.
The minor dilators include the dilator naris anterior muscle and dilator naris posterior muscle (alar nasalis muscle).
4. Nasal Compressors.
The compressors include transverse nasalis muscle and compressor narium minor muscle.
These nasal muscles animate the nose during facial expression and regulate nasal airflow, especially during times of
increased aerobic activity.
Procerus
The procerus is the cephalic-most of all nasal muscles. It arises from the glabella, descends caudally, and joins the wing-
shaped transverse nasalis muscle.
The main action of this muscle is to move the eyebrows caudally. With aging, this muscle is responsible for the transverse
wrinkle seen in the glabella area.
Nasalis Muscle
The nasalis muscle consists of two components:
1. The transverse nasalis muscle
2. The alar nasalis muscle (dilator naris posterior muscle)
Transverse Nasalis Muscle
The transverse nasalis muscle originates from the lateral cephalic portion of the subpiriform crescent and courses superome-
dially. It wraps around the upper lateral cartilage and joins the contralateral muscle at the midline. The muscle also joins with
procerus muscle and forms the nasalis- procerus aponeurosis.
Activation of this muscle extends the overall length of the nose while compressing the nostril and vestibule. Contraction
of this muscle is responsible for the pinched and narrow appearance of the nose.
In theory, resection of this muscle should result in shortening of the nose, but the muscle should not be excised during the
correction of long nose. In contrast, the transection of this muscle is helpful in correction of short nose because the muscle
is a limiting factor in the stretching of soft-tissue envelope. For effective skin lengthening, the transverse nasalis muscle can
be cut during the correction of short nose in Asian patients.
Alar Nasalis Muscle (Dilator Naris Posterior Muscle)
This muscle originates from maxilla more lateral and slightly caudal to the bony origin of the DSN muscle and some of this
muscle fibers cover the lateral crus of lower lateral cartilage. This muscle is involved in dilation of the nares.
Soft Tissues of the External Nose

16
Levator Labii Superioris Alaeque Nasi Muscle
Levator labii superioris alaeque nasi muscle originates from the superior frontal process of maxilla. This muscle runs
obliquely downward lateral to the nasal bone and ala base in a cephalocaudal direction, divides into two slips, and attaches
to the skin of nasolabial fold, ala base, and upper lip muscle (Fig. 1.16). It dilates the nostril, raises the upper lip, and elevates
the alar base. Paralysis of this muscle can result in the external valve collapse.
This muscle should not be confused with levator labii superioris muscle which lies laterally, originates from the infraor-
bital margin of maxilla, inserts to the skin of upper lip, and acts to raise and evert the upper lip.
levator labii superioris
alaeque nasi m.
depressor septi nasi m.
Fig. 1.16 Elevator and depressor muscles
of the nose. During a smile, the depressor
nasi septi muscle activates and pulls down
on the nasal tip, while the levator nasi
superioris alaeque nasi muscle elevates the
ala base
1 Surgical Anatomy and Physiology of the Nose

17
Depressor Septi Nasi Muscle
This muscle originates from the maxilla just below the anterior nasal spine, albeit with some anatomic variations, which has
been classified by Rohrich et al. (Fig. 1.17). Type I muscles originate from the orbicularis oris muscles with complete inter-
digitation. This type represents the most common form of depressor septi nasi muscles (62% of studied population). Type II
muscles originate from the maxillary periosteum with little or no interdigitation with orbicularis oris (22%). Type III muscles
are found in rudimentary form or are nonexistent (16%). This muscle ascends along the columella base and attaches to the
footplate of medial crura and membranous septum. Activation of this muscle will pull down on the nasal tip and elevate the
upper lip, which effectively decreases the labiocolumellar angle (Fig. 1.16). According to Hwang et al., the depressor septi
nasi muscle is contiguous with the dermatocartilaginous ligament. Release of this muscle will decrease nasal tip drooping
(smiling tip) and contribute to a minor degree of upper lip ptosis. This maneuver can be helpful for patients with gummy
smile but should be avoided in patients with long upper lips.
Type I
Type II
Fig. 1.17 Classification of depressor septi nasi muscle. Type I depressor septi nasi muscle has an origin that interdigitates with the orbicularis oris
muscle. Type II muscle originates from the maxillary periosteum with little or no interdigitation with orbicularis oris. Type III muscle is found in
rudimentary form or nonexistent
Soft Tissues of the External Nose

18
Gummy Smile
Gummy smile refers to the simultaneous elevation and shortening of the upper lip during smile animation, which results in
exposure of 4 mm or more of the upper gingiva (Fig. 1.18). Gummy smile has a variety of causes. Skeletal causes include
excessive vertical length of the maxilla and dentoalveolar protrusion. Soft-tissue causes include short upper lip and long
gingiva. Muscular causes include hyperactivity/tonicity of lip levator muscles. A gummy smile can also be caused by a com-
bination of these issues.
Lip levator muscles often responsible for gummy smile are depressor septi nasi muscle, levator labii superioris alaeque
nasi muscle, levator labii superioris muscle, and zygomaticus minor muscle (Fig. 1.19). Correction of gummy smile is dis-
cussed in Chap. 11.
Fig. 1.18 A patient with gummy smile
DSN m.
levator labii
superioris alaeque
nasi m.
levator labii
superioris m.
zygomaticus
minor m.
Fig. 1.19 Lip levator
muscles involved in the
gummy smile: depressor nasi
septi muscle, levator labii
superioris alaeque nasi
muscle, levator labii
superioris muscle, and
zygomaticus minor muscle
1 Surgical Anatomy and Physiology of the Nose

19
Dilator Naris Anterior Muscle
Dilator naris anterior muscle contracts to distract the ala and is the primary dilator of the nares. The muscle fibers originate
from the upper lateral cartilage and inserts into the caudal margin of lateral crus and the skin of the alar lobule.
This muscle is relatively well developed in Asian patients with wide nostrils and is less defined in Caucasian patients with
vertical nostrils. Generally, flared nostrils usually incorporate well-developed muscles of the alar lobule.
Compressor Narium Minor Muscle
Compressor narium minor muscle is a diminutive muscle located in the apex of the nostrils. In most Asian patients, this
muscle is not observed and is not clinically relevant.
Botulinum Toxin Injection on Nasal Muscles
Injection of botulinum toxin can improve conditions such as gummy smile, nasal tip drooping due to depressor septi nasi
muscle hyperactivity, involuntary contraction of dilator muscles, and facial expression wrinkle such as bunny line. The use
of botulinum toxin in nasal muscles requires an exact understanding of the anatomy and the action of the muscles. The injec-
tion techniques for botulinum toxin are discussed in Chap. 11.
Blood Supply
External Blood Supply
The main blood supply to external nose is supplied by the facial artery which originates from the external carotid artery.
However, the internal carotid artery does contribute to the blood supply to the external nose (Fig. 1.20).
External
nasal br.
Columellar br.
Supratrochlear a.
Supraorbital a.
Dorsal nasal br.
Lateral nasal a.
Angular a.
Facial a.
Superior
labial a.
Fig. 1.20 Blood supply to the external nose
Soft Tissues of the External Nose

20
External Carotid Artery
1. Superior Labial Artery
The facial artery originates from the external carotid artery and gives off the superior labial artery. The columellar artery
is a branch of the superior labial artery and provides the blood supply to the nostril sill, columellar base, and caudal portion
of the nasal septum.
2. Lateral Nasal Artery
The angular artery is the terminal branch of facial artery and supplies most of the lateral external nose. The lateral nasal
branch originates from the angular artery and supplies the lateral caudal nose and the nasal tip. The lateral nasal artery anas-
tomoses with the contralateral counterpart across the midline.
Internal Carotid Artery
1. Dorsal Nasal Branch of Ophthalmic Artery
The ophthalmic artery originates from the internal carotid artery, and the dorsal nasal branch of the ophthalmic artery
perforates through the orbital septum superior to the medial palpebral ligament. The artery descends the side wall of the
external nose and anastomoses with the lateral nasal artery.
2. External Nasal Branch of Anterior Ethmoidal Artery
The external nasal branch of anterior ethmoidal artery appears on the dorsum of the nose between the nasal bone and the
upper lateral cartilage and supplies the blood circulation to the nasal tip.
The major arterial, venous, and lymphatic vasculature runs within or above the nasal SMAS. As such, most dissections in
rhinoplasty should be carried in a plane deeper than SMAS layer.
To decrease the risk of postoperative blood supply impairment, the rhinoplasty surgeon must have a thorough understand-
ing of the blood supply to the nasal tip. The nasal tip is supplied by the following vessels:
1. Columellar branch of superior labial artery
2. Lateral nasal branch of angular artery
3. Dorsal nasal branch of ophthalmic artery
4. External nasal branch of anterior ethmoidal artery
Open rhinoplasty incision necessarily requires the sacrifice of the columellar branch of superior labial artery. To minimize
the risk of blood flow impairment to the nasal tip and columella, the following two cautions must be observed.
First, the lateral nasal artery must be protected during tissue dissection and hemostasis. During Weir incision, the incision
should not be extended too much in the cephalic direction, as this can injure the lateral nasal artery.
Second, postoperative dressing should not be made too tight, as excessive compression onto the dorsal nasal branch above
supratip area can limit blood flow to the nasal tip.
1 Surgical Anatomy and Physiology of the Nose

21
Internal Blood Supply
The internal nasal tissue receives most of its blood supply from the descending palatine artery and sphenopalatine artery
(Fig. 1.21).
Lateral
nasal br.
Anterior ethmoidal a.
Posterior ethmoidal a.
Sphenopalatine a.
Kisselbach’s plexus
Superior labial a.
External
nasal br.
Posterior lateral nasal br.
Posterior septal br. Greater palatine a.
Fig. 1.21 Blood supply to the internal nose
Soft Tissues of the External Nose

22
Blood Supply to the Side Wall of the Internal Nose
1. Posterior lateral nasal branch of sphenopalatine artery (major)
2. Partially supplied by lateral nasal branches of anterior ethmoidal artery and of the posterior ethmoidal artery
Blood Supply to the Nasal Septum
1. Caudal septum: Kiesselbach’s plexus (plexus of anterior ethmoidal artery, sphenopalatine artery, and superficial terminal
branch of superior labial artery)
2. Posterior septum:
(a) Posterior septal branch of sphenopalatine artery
(b) Septal branch of posterior ethmoidal artery
Venous Drainage
The venous drainage runs concomitantly with the arteries, and the veins have same names as their corresponding arteries.
Sensory Nerve
Nerve innervation to the nose comes from the maxillary and ophthalmic branches of trigeminal nerve (Fig. 1.22).
supraorbital n.
supratrochlear n.
labial br. of
infraorbital n.
external br. of
anterior ethmoidal n.
infratrochlear n.
Fig. 1.22 Sensory
innervation of the external
nose
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23
External Sensory Nerve Supply
1. Both supraorbital nerve and supratrochlear nerve are branches of the ophthalmic nerve. These are responsible for sensory
innervations to the nasal root and cephalic dorsum.
2. External nasal branch of the anterior ethmoidal nerve innervates the sensation of midvault, tip, and upper columella.
The external branch of the anterior ethmoidal nerve comes out between the caudal margin of nasal bone and the upper
lateral cartilage. To minimize the risk of postoperative nasal tip numbness, this nerve must be protected during the
dissection.
3. Labial branch of infraorbital nerve provides sensation to the bottom of the nose, lower columella, and ala.
Internal Sensory Nerve Supply
Most sensation of the internal nose is innervated by the nerves derived from the pterygopalatine ganglion located behind the
posterior end of the middle turbinate. Small anterior portion of the lateral wall, and the anterior septum, is innervated by the
internal branch of the anterior ethmoidal nerve (Fig. 1.23). Most of the nasal septum is innervated by the nasopalatine branch
of the pterygopalatine ganglion (Fig. 1.24).
olfactory bulb
pterygopalatine ganglion
posterior superior
lateral nasal n.
posterior inferior
lateral nasal n.
palatine n.
greater palatine n.
internal br.
external br.
anterior
ethmoidal n.
lesser palatine n.
Fig. 1.23 Sensory
innervation to the lateral wall
of the nasal cavity
Sensory Nerve

24
oflactor bulb
pterygopalatine ganglion
nasopalatine n.
internal nasal br.
of infraorbital n.
septal br. of
anterior ethemoidal n.
anterior
ethmoidal n.
Fig. 1.24 Nerve supply to
the septum
1 Surgical Anatomy and Physiology of the Nose

25
External Nasal Frame
The upper one-third of external nasal frame is composed of the bony vault, and the lower two-thirds are composed of the
cartilaginous vault (Fig. 1.25).
nasal bone
upper lateral
cartilage
lower lateral
cartilage
Fig. 1.25 External nasal frame. The external
nasal frame is composed of upper third of
bony vault and lower two-thirds of
cartilaginous vault
External Nasal Frame

26
Bony Vault
The bony vault of the nose consists of a pair of nasal bones and the frontal process of maxilla (Fig. 1.26). The bony vault is
narrowest at the intercanthal area. The two nasal bones meet each other in the midline. The cephalic portion of the bone is
thicker than the caudal portion. Individual variation exists in the nasal bone length. Generally, nasal bone tends to be shorter
in Asian patients compared to Caucasian patients.
Nasal bones join with the nasal process of frontal bone cephalically, join with the frontal process of maxilla laterally, and
join with the perpendicular plate of the ethmoid posteriorly (Fig. 1.27). The frontal process of maxilla is a lot thicker than
the nasal bone. Therefore, lateral osteotomy of nasal bone should incorporate a portion of the frontal process of maxilla,
which would aid in decreasing nasal bone width while minimizing the risk of step deformity.
Along with the lacrimal bone, the posterior portion of the frontal process of maxilla forms the lacrimal groove, within
which is the lacrimal sac. During low-to-low lateral osteotomy, care must be taken not to injure the lacrimal sac.
nasal process
of frontal bone
nasal bone
frontal process
of maxilla
perpendicular plate
of ethmoid
Fig. 1.27 The nasal bones are bordered by the nasal process of frontal
bone superiorly, the frontal process of maxilla laterally, and the perpen-
dicular plate of the ethmoid posteriorly
nasal bone
frontal process
of maxilla
Fig. 1.26 The bony vault of the nose consists of a pair of nasal bones
and the frontal process of maxilla
1 Surgical Anatomy and Physiology of the Nose

27
Pyriform Aperture
The pyriform aperture is the pear-shaped opening surrounded by the caudal margin of nasal bone, thin caudal margin of the
frontal process of the maxilla, and nasal spine (Fig. 1.27).
Keystone Area
The midline undersurface of nasal bone fuses with the superior edge of the perpendicular plate of the ethmoid bone (bony
septum). Keystone area is the confluence of the cartilaginous nasal septum, perpendicular plate of the ethmoid bone, and
nasal bone (Fig. 1.28).
The cephalic border of the upper lateral cartilage does not form end-to-end contact with the caudal margin of the nasal
bones; rather the cephalic portion of upper lateral cartilage is overlapped by the nasal bone. The amount of overlapping is
variable and ranges in 2–11 mm, and Asians have much less overlapping than Caucasians.
nasal bone
junction of cartilage-bony
septum
cephalic border of ULC
rhinion
Fig. 1.28 Keystone area. Keystone area is the
confluence of the cartilaginous nasal septum,
perpendicular plate of the ethmoid bone, and
nasal bone. The junction between cartilaginous
septum and bony septum is more cephalic than
the cephalic border of the upper lateral cartilage.
Thus, the junction of the cartilage-bony septum
is the most cephalic, followed by cephalic border
of upper lateral cartilage and then by rhinion
External Nasal Frame

28
a
b
Fig. 1.29 Saddle nose
deformity. In this patient,
injury to the keystone area has
resulted in the collapse of the
cartilaginous dorsum
The point at which cartilage septum meets the bony septum is more cephalic to the margin of upper lateral cartilage. In
other words, the rhinion is more caudal than cephalic border of upper lateral cartilage, which is more caudal than the junction
of cartilage-bony septum.
The keystone area is an extremely critical area as destabilization of this area during aggressive septal surgery or dorsal
hump resection may lead to saddle nose deformity (Fig. 1.29).
1 Surgical Anatomy and Physiology of the Nose

29
Webster’s Triangle
During lateral osteotomy, the osteotomy starts on the pyriform crest at the level of the attachment of the inferior turbinate. If
the osteotomy is made too low, the inferior turbinate can be incorporated within the osteotomy line, which can lead to medial
mobilization of the turbinate with subsequent nasal obstruction (Fig. 8.48). To prevent this, the osteotomy should begin at a
point 3–4 mm more cephalic to the nasal floor. The most caudal portion of the pyriform crest should not be incorporated into
the osteotomy. The triangular area preserved in this way is called the Webster’s triangle (Fig. 1.30).
Webster’s
triangle
Fig. 1.30 Webster’s triangle
External Nasal Frame

30
Cartilaginous Vault
The nasal cartilaginous frame consists of a pair of upper and lower lateral cartilages and the septal cartilage.
Upper Lateral Cartilages
The upper lateral cartilages (ULCs) are a pair of rectangular shaped cartilages. It firmly underlies the nasal bone cephalically
at the keystone area (Fig. 1.28) and articulates with the dorsal septum medially. The upper lateral cartilage articulates with
the frontal process of the maxilla laterally by means of the pyriform ligament, with a variable amount of overlap between the
upper lateral cartilage and maxilla, the upper lateral cartilage underlying the maxillary bone. At the keystone area, the septum
meets the upper lateral cartilage at right angles to form a T-shaped cross section. However, the angle between the two carti-
lages becomes narrower in the caudal direction (Fig. 1.31). Thus, the angle formed by the caudal margin of upper lateral
cartilage and septum is the narrowest area in the nasal airway passage, and this area is called the internal nasal valve. The
mucoperichondrium covering the septum continues under the upper lateral cartilage and covers its undersurface (Fig. 1.32).
Fig. 1.31 Upper lateral cartilage and septal cartilage. The upper lateral cartilages are almost perpendicular to the dorsal septum at the keystone
level, but this angle between upper lateral cartilage and septum becomes more acute in caudal area
Fig. 1.32 The mucoperichondrium of the septum is contiguous
with that of the upper lateral cartilage
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31
Internal Nasal Valve Area
Internal nasal valve area is the narrowest part of the nose internally. Its boundaries are the septum, the caudal margin of upper
lateral cartilage, the head of inferior turbinate, and by the floor of the pyriform aperture (Fig. 1.33). This area is the site of
the highest nasal resistance. The reported cross- sectional area ranges from 55 to 83 mm2 in Caucasian populations.
upper lateral
cartilage
inferior turbinate
floor of
nostril caviry
ANS
septum
lateral wall
(fibroareolar tissue)
Fig. 1.33 Cross-sectional illustration
of the internal nasal valve area
External Nasal Frame

32
Internal Nasal Valve
The internal nasal valve itself is the specific slit-like segment between the caudal margin of the upper lateral cartilage and the sep-
tum, within the internal nasal valve area. The valve is crucial for respiratory function of the nose (Fig. 1.34). The angle of this valve
is 10–15° in the Caucasian nose but is wider in African and Asian noses. Valve angle less than 10° can lead to nasal obstruction.
Within the nasal cavity, inspiration generates negative pressure, and expiration generates positive pressure. At the internal
valve, the upper lateral cartilage is thinner and more pliable, which controls the airway flow by valve movement according to
the airway pressure during the respiration. It can maintain the air passageway despite the inspiratory negative pressure. During
the deep inspiration, however, negative pressure is generated by Venturi principle and Bernoulli effect. These forces can lead
to medial mobilization of the upper lateral cartilages and can cause temporary airway obstruction. With weak or deformed
upper lateral cartilages, the valve can collapse more easily and may obstruct the passage even under normal inspiration.
internal valve
a
b
external valve
Fig. 1.34 The internal and external
nasal valve. Internal nasal valve is the
angle between caudal border of upper
lateral cartilage and septum. The angle
of this internal valve is 10–15° in
Caucasian patients, which is reported to
be wider in African and Asian patients
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33
External Lateral Triangle
The external lateral triangle is surrounded by caudal border of upper lateral cartilage, frontal process of the maxilla, and
cephalic border of the lower lateral cartilage (Fig. 1.35).
external
nasal triangle
Fig. 1.35 External lateral triangle
External Nasal Frame