Atlas of Asian Rhinoplasty (Volume 2) – Tác giả chưa rõ – Hướng Dẫn Giải Phẫu & Phẫu Thuật Mũi (file pdf)

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Medial Crus
The medial crura do not usually extend the entire length of the columella and rest on the soft tissue at the base of the colu-
mella. It is composed of two segments: the columellar and footplate segments.
The length of columellar segment varies across individuals. Longer columellar segments are associated with longer nostril
and higher nasal tip. In East Asian populations, the columellar segment is shorter and reported to have a mean length of
8.7 mm.
The medial crura are not always straight. According to Natvig et al., the most common type of medial crura is asym-
metric parallel type (75%) with flared symmetric type and straight symmetric type each occurring around 12.5%
(Fig. 1.37).
The footplates support the nasal tip and determine the columellar width and nostril shape. The length and lateral
angulation of the footplate vary across individuals. The angulation of footplate determines the width of columella base.
The footplate segment is usually longer and angulated more posteriorly in East Asian patients, compared to Caucasian
patients.
Correction of the lateral angulation of footplate (i.e., approximation of the footplates) can decrease the width of columella
base, push the base caudally, and rotate the tip cephalically.
a
c
b
Fig. 1.37 Variations in the medial crura and lobular segment of middle crura: (a) asymmetric, (b) flared symmetric, (c) straight symmetric
External Nasal Frame

36
Middle Crus
The middle crus is composed of lobular and domal segments.
1. Lobular Segment
The lobular segment lies between the medial crus and the dome. The configuration of the infratip lobule can be mainly
determined by the length, curvature, and width of this segment, even though the distinction between the lobular segment and
dome is not clear in many Asian patients.
2. Dome
The domal segment is the narrowest portion of lower lateral cartilage in patients with non-bulbous nasal tip. Both domes
are actually separated from each other. Most tip plasty techniques modify the shape and position of the domal segment.
Dome has two edges, which are cephalic and caudal edges. Cephalic edges are apposed in close proximity but caudal
edges are divergent (Fig. 1.38). Each of the domes has an axis from the cephalic edge to the caudal edge. The angle created
3
2
1
4
1: Angle of domal divergence, 2: Angle of domal separation
3: Angle of domal definition, 4: Base divergence angle
a
c
b
Fig. 1.38 Three important angles of the dome: angle of domal divergence, angle of domal separation, angle of domal definition
1 Surgical Anatomy and Physiology of the Nose

37
by these two axes is referred to as angle of domal separation, which ranges between 60 and 80 degrees among Caucasian
patients. The angle of domal separation is comparatively lower for Asian patients. If the cephalic edges of the domes are
divergent (i.e., separated), the nasal tip will usually be bulbous. In Caucasian patients with thinner nasal skin, interdomal
suture should be placed at the cephalic edge to bring the dome together while maintaining the divergence of both caudal
edges. This is important in creating beautiful tip-defining points (TDPs). A different technique is preferable for bulbous tip
with thick skin in Asian patients, which is further discussed in Chaps. 9 and 11.
From the basal view, both lower lateral cartilages diverge at the dome. The angle created by this divergence is called the
angle of domal divergence, for which 30 degrees or less is considered to be within normal range. The divergence can be
evaluated in frontal view with a pen light. The divergence is represented by the light-reflecting points and is called “tip-
defining points (TDPs).” These points are the highest and the most projected points of the nasal tip. In Asian patients, the
thick nasal skin and wide angle of domal divergence usually result in blunting of the tip-defining points.
A nose can be considered to have a broad tip with an angle of domal divergence greater than 30 degrees. A “boxy” tip,
one of the bulbous tips, has domal divergence angle greater than 30 degree and has a broad, rectangular shape for nasal tip
from the basal view (Fig. 1.39). Even with a domal divergence angle within normal range, a nasal tip can appear to be boxy
if the domal segment is wide. The issue of boxy nasal tips is further discussed in Chap. 11.
The angle between middle crus and lateral crus is called the angle of domal definition.
Together, the angle of domal divergence and angle of domal definition determine the shape and width of nasal tip.
Aesthetically pleasing nasal tip usually contains more adequate angle of domal divergence and domal definition.
Fig. 1.39 The boxy tip is
characterized by broad
rectangular shape of the nasal
lobule from basal view
External Nasal Frame

38
a
b
Fig. 1.40 Lateral crura
Lateral Crus
Lateral crus is the largest component of the lower lateral cartilage. The lateral crura are almost always longer than the medial
crura, and they extend to or near the margin of pyriform aperture. The cartilage has an elliptical three- dimensional shape. It
is widest in the midportion and is narrower towards both caudal and cephalic ends (Fig. 1.40). Medially, the lateral crus is
contiguous with the middle crus. Laterally, it is connected to the accessory cartilages. The caudal margin of the lateral crus
does not coincide the alar rim. In the anterior one-third of the alar rim, the lateral crus travels closely with the alar rim.
Laterally, however, the caudal margin of lateral crus turns in the cephalic direction and diverges away from alar rim. Thus,
the inframarginal incision is made close to the alar rim and in a parallel manner around the dome area, but diverges away
from the alar rim in the lateral direction (Fig. 1.41).
The size, convexity, and orientation of the lateral crura determine the shape of ala/nasal lobule and the position of the alar rim.
The lateral crus is relatively small in Asian patients with mean length and width of 17.9 and 10.0 mm, respectively.
The ideal shape for lateral crus is neither convex nor concave but is close to being flat. The shape of lateral crus varies
across individuals and can be classified into concave, convex, concave-convex, convex-concave, and flat (Fig. 1.42). The
concave type of lateral crus is more common for Asian patients than for Caucasian patients. In approximately 7% of patients,
the lateral crura are asymmetric.
Fig. 1.41 Inframarginal incision. The inframarginal
incision runs closely parallel to the alar rim in the dome
area. However, the incision veers away from the alar rim in
the lateral portion
1 Surgical Anatomy and Physiology of the Nose

39
a
b
c
e
d
Fig. 1.42 Anatomic variations of the lateral crura: (a) concave shape, (b) convex shape, (c) concave-convex shape, (d) convex-concave shape, (e) flat
External Nasal Frame

40
a
b
c
Fig. 1.43 In this patient
with thick nasal skin, the
lower lateral cartilage is
relatively small. The
cephalic edge of lateral
crura is curled in
Fig. 1.44 The orientation of lateral crura. The lateral crus has an angle of about
45 degrees to the midsagittal plane, with its axis pointing towards the lateral
canthus of the ipsilateral eye. The lateral crura are considered to be cephalically
malpositioned if the angle is less than 30 degrees and the axis points towards
the medial canthus (patient’s left side in this figure)
The cephalic edge of lateral crus has a curled shape—the curvature of which is variable. The curling is more extensive in
bulbous nasal tips. In Asian patients with small nasal tip, the lower lateral cartilages often do not have a curled cephalic edge
in the lateral crus. In Asian patients with bulbous tip and thick soft tissue, the curled-in cephalic edge is common in relatively
small lower lateral cartilages (Fig. 1.43).
Generally, the direction of lateral crura is about 45 degrees away from the vertical facial angle towards the lateral eye
canthus (Fig. 1.44). Acuteness of this angle is considered to be cephalic malposition, and is a cause for retracted ala.
1 Surgical Anatomy and Physiology of the Nose

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Supratip Break
The supratip break occurs cephalad to the nasal tip where the contour lines of the nasal dorsum rise towards the tip- defining
points. It is at the juncture between the upper lateral cartilage and lower lateral cartilage and forms the boundary between the
nasal dorsum and lobule (Fig. 1.45).
Fig. 1.45 Supratip break. The supratip
break is the point at which the upper lateral
cartilage and lower lateral cartilage
overlap, and delineates between the
dorsum and nasal lobule
External Nasal Frame

42
External Nasal Valve
The definition of external nasal valve varies across surgeons. When considering the wide variety of locations for cartilage
graft to correct external valve collapse, the author supports the following definition.
The external nasal valve is the region caudal to the internal nasal valve, bounded laterally by the lower lateral cartilage
and alar rim, medially by the caudal septum and columella, and inferiorly by nostril floor (Fig. 1.34).
Fibrous Connecting Tissues Supporting the Lower Lateral Cartilages
The lower lateral cartilages determine the shape of the nasal tip and maintain the tip height. However, the lower lateral car-
tilages itself are not supported directly by the septal cartilage but supported by connecting fibrous tissues (Fig. 1.46). The
collection of these connective tissues supports the lower lateral cartilages, which in turn supports the nasal tip. Because of
this, disruptions in these fibrous connective tissues can lead to drooping of the nasal tip.
The fibrous tissue connecting the lower lateral cartilages to the surrounding tissues is not rigid and allows the cartilages
to be highly mobile. The support from the connective tissues can be felt by the elastic recoil of the nasal tip upon finger pres-
sure on the tip. The fibrous connecting structures perform the following roles:
1. Supports the nasal tip
2. Allows mobility of the nasal tip
3. Provides cushion effect to the nasal tip under impact
During tip plasty, these fibrous connections are sometimes released to allow realignment of lower lateral cartilages. For
example, the lower lateral cartilages need to be moved caudally in the correction of short nose. The cartilages will not yield
to mobilization unless the connective tissue is released. In contrast, the connective tissue should be preserved when the car-
tilage onlay graft or the shield graft is performed.
The following are major tip-supporting structures:
Fig. 1.46 Major tip-supporting structures. (a) Suspensory
interdomal ligament. (b) Fibrous connection at the scroll area.
(c) Connection between lateral crura and pyriform aperture
at hinge complex. (d) Connection between footplate and caudal
septum. (e) Membranous septum
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Suspensory Interdomal Ligament
The loose connective tissue between the pair of lower lateral cartilages is referred to as the interdomal ligament. This tissue
suspends the dome at the septal angle and is sometimes called suspensory ligament (Fig. 1.47). Technically, however, this
structure is not a ligament but a ground substance of irregularly interwoven connective tissue, consisting of small amount of
collagen fibers and elastic fibers. The interdomal ligament is much more loose among East Asian patients than in Caucasian
patients.
Abundance of this tissue increases the interdomal distance and results in a bulbous nasal tip. This tissue is sometimes
removed to create a sharper appearing nasal tip. However, the release of this tissue can lead to tip drooping.
a
b
Fig. 1.47 The interdomal ligament is the loose connective tissue holding the two domes of the lower lateral cartilages
Fibrous Connecting Tissues Supporting the Lower Lateral Cartilages

44
a
c
b
Fig. 1.48 Scroll area. (a, b)
Scroll area release frees the
lower lateral cartilage away
from the upper lateral
cartilage. (c) Variations in
the scroll area
Fibrous Connection at Scroll Area
The scroll area is a junction between the upper lateral cartilage and the lateral crus of lower lateral cartilage. In the past, the
tissue of this area was referred to as intercartilaginous ligament, but this has fallen out of favor for the contemporary descrip-
tion of “scroll area.”
In this area, the lateral crus of lower lateral cartilage loosely overlaps the upper lateral cartilage. Scroll area allows smooth
gliding of lateral crus over the upper lateral cartilage. According to Lam SA et al., the ULC–LLC union, or scroll, assumes
various configurations (Fig. 1.48).
Dense fibrous tissues are visible macroscopically at this area. Microscopically, these tissues consist mainly of collagen
fibers connecting the two cartilages, some elastic fibers, and small amount of cells.
The scroll area is the most important part of the tip- supporting structure. Procedures that disrupt the scroll area (e.g.,
intercartilaginous incision) can induce weakening of the tip support.
However, the scroll area is also considered to be an important key structure to be manipulated during the surgery for short-
nose correction in Asian rhinoplasty. This is because the lower lateral cartilages cannot be repositioned in the caudal direc-
tion without adequate release of scroll area. The scroll area should be preserved for simple cartilage onlay/shield graft, but
may need to be released to allow significant anterior or caudal mobilization of the lower lateral cartilage in the case of septal
extension graft or fixed-type long columellar strut graft.
For bulbous tip with large lateral crura, the cephalic margin of the lateral crura is sometimes trimmed to reduce the tip
volume. However, such procedures can become a cause of tip drooping.
Therefore, the manipulation of scroll area has two opposing considerations. On the one hand, the scroll area is a tip-
supporting structure and should be preserved to avoid tip drooping. On the other hand, the fibrous connection of the scroll
area can limit caudal advance or anterior suspension of the lower lateral cartilages, for which case it is more advantageous to
release the scroll area.
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Hinge Complex
The hinge complex is the connecting portion between lateral crus of lower lateral cartilage and pyriform aperture and had
also been referred to as the accessory ligament in the past. Microscopically, the complex contains accessory cartilage, fibro-
muscular tissue, and some cells (Fig. 1.49).
In short-nose correction of Asian patients, the hinge complex is detached sometimes to allow caudal displacement of the
lower lateral cartilage.
Fig. 1.49 Hinge complex.
The hinge complex consists
of accessory cartilages and
fibromuscular tissue
Fibrous Connecting Tissues Supporting the Lower Lateral Cartilages

46
Connection Between the Footplate and Caudal Septum
Unlike in Caucasian patients, no clear supportive structure can be observed in this area for Asian patients (Fig. 1.50). Because
of this, Asian patients often have wider columella base with lesser nasal tip projection. Despite the lack of significant tissue,
detaching the space between the footplate and caudal septum can contribute to tip drooping. Therefore, this area should be
preserved as much as possible during septal dissection.
Detachment in this area requires a counter-procedure to project the drooped tip, such as elevation of the caudal mucoperi-
chondrial flap and fixation with quilting suture.
However, this area can be released to mobilize the medial crura more caudally in the correction of short nose or retruded
columella.
Fig. 1.50 Footplate-caudal septal connection
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47
Membranous Septum
The soft tissue between the columellar segment of medial crus and caudal septum contains the depressor septi nasi muscle.
Some authors have reported structural entities such as septocolumellar ligament or fibrous connective tissue, but the exis-
tence of these structures is a controversial topic. No special structure exists that could potentially provide support to the nasal
tip. However, the author believes that disruption of this area can contribute to tip drooping and requires an additional proce-
dure to overcome this tendency. Anterior suspension or caudal displacement of the lower lateral cartilage for the tip projec-
tion or nasal tip lengthening may require the release of fibrous tissue and muscle in this area. This will usually lead to tip
drooping and will require supplementary procedures such as quilting suture.
Dermocartilaginous Ligament
Dermocartilaginous ligament was first described by Pitangy to be a central, whitish, fibrous band-like tissue running verti-
cally from the center of the upper one-third of dorsum to the columella base. Significant debate exists to the histologic find-
ings and anatomic pathway of this ligament.
According to the study by Han et al., this fibrous tissue originates from the deep layer of the transverse nasalis muscle,
runs caudally, passes between medial crura, and terminates at the caudal edge of septal cartilage and, in some cases, the
orbicularis oris muscle (Fig. 1.51). Histologically, the tissue is not a ligament but is in fact a fascia. There is no direct con-
nection between the dermocartilaginous ligaments and dorsal nasal skin. Because of this, the term dermocartilaginous liga-
ment can be considered as a misnomer. Dermocartilaginous ligament can be observed more clearly in patients with bulbous
nose.
Fig. 1.51 Dermocartilaginous ligament
Fibrous Connecting Tissues Supporting the Lower Lateral Cartilages

48
Anatomy of Internal Nose
Nasal Septum
The septum supports the nasal dorsum and separates the inner nasal space into two cavities.
Components of the Septum
Septum consists of cartilage and membranous portion caudally and bony portion cephalically. The main components of
septal bone are perpendicular plate of ethmoid, vomer, nasal crest of maxilla, and palatine bone (Fig. 1.52). The perpendicu-
lar plate forms the upper third of bony septum and is continuous with cribriform plate and frontal bone. The plate joins with
the midline of undersurface of nasal bone. The junction of the perpendicular plate and cartilaginous septum under the nasal
bone is called the keystone area. The junction of septal cartilage and septal bone is usually located 5 mm cephalic to the
rhinion, with frequent variations.
The septal cartilage connects in the end-to-end fashion to the perpendicular plate and vomer, and the separation is rela-
tively easy at this junction. The cartilage is covered by a single layer or mucoperichondrium. However, the septal cartilage
connects strongly to the maxillary crest of vomer via a tongue-and-groove articulation. In this area, the perichondrium is
continuous with the periosteum of the maxillary crest. Portions of the fiber pass through the articulation and decussate with
the contralateral perichondrium (Fig. 1.53). Because of these connections, elevation of mucoperichondrium is very tough,
and it is difficult to separate the cartilage. The groove is deep in the caudal portion and becomes flatter in the cephalic
portion.
The cartilaginous septum contains three angles: anterior septal angle, intermediate septal angle, and posterior septal angle
(Fig. 1.54).
Septal cartilages are of variable sizes and shapes. Certain studies have reported that, while no difference in septal thick-
ness exists between Asian and Caucasian patients, the size of septal cartilage is much smaller for Asian patients than for
Caucasian patients. According to Hwang et al., the mean length and height of cartilaginous septum are 3.31 ± 0.53 cm and
2.99 ± 0.47 cm, respectively, for Korean patients.
sphenoid sinus
perpendicular plate
of ethmoid bone
nasal bone
upper lateral
cartilage
septal
cartilage
ANS
nasal crest of maxilla
vomer
nasal crest of
palatine bone
Fig. 1.52 Component of the
nasal septum
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49
In East Asian patients with short nose and flat dorsum, the septal cartilage is usually smaller and thinner than that of
Caucasian patients.
Commonly, the thickest portion of the septal cartilage is the posterior septum along the vomer and maxillary crest, fol-
lowed by intermediate thickness along the dorsal septum (Fig. 1.55). Just above this thickest portion, the thinnest portion is
located at the lower part of the midseptum. In the dorsal septum, the cephalic portion is usually thicker than the caudal por-
tion, with the thickest portion just below the nasal bone. In the caudal portion of the septum, the cartilage is thickest at the
ANS, is thinnest at the midportion, and is of moderate thickness at the septal angle.
The area between the septum and the caudal margin of upper lateral cartilage is the internal nasal valve. The normal angle
for this valve is 10–15 degrees and has the smallest cross-sectional area along the nasal passage (Fig. 1.34).
perichondrial
layers
periosteal
layers
maxillary/
palatine crest
septal
cartilage
crossed perichonodrial &
periosteal fibers
Fig. 1.53 Decussating perichondrial fibers at the septal cartilage-
maxillary and palatine crest junction (Rod J. Rohrich, 2001)
posterior
septal angle
middle
septal angle
anterior
septal angle
Fig. 1.54 Septal angle
Caudal
F
E
D
C
B
A 0
1
2
3
4
5
Cephalic
1.26 to 1.50 mm
1.01 to 1.25 mm
nasal bone
thicker than 1.5 mm
thicker than 1.0 mm
Fig. 1.55 A map of septal
cartilage thickness (Hwang K,
Huan F, Kim DJ. Mapping
thickness of nasal septal
cartilage. J Craniofac Surg.
2010 Jan;21 (1):243–244)
Anatomy of Internal Nose

50
Membranous Septum
There is no cartilage between the medial crura and the caudal border of the septal cartilage. This space is occupied by two
layers of soft tissue and is referred to as membranous septum (Fig. 1.56).
The membranous septum is highly mobile and performs an important role in facilitating the mobility of nasal tip and colu-
mella as well as providing cushion effect against any impact applied to the nose. The septum contains a yet-to-be- elucidated
intrinsic muscle and the depressor septi nasi muscle. Some have reported on a fibrous band referred to as septocolumellar
ligament. The lower lateral cartilages and the membranous septum allow the mobility of nasal tip and are the reason behind
the pliability of the nasal tip to palpation. To maintain this mobility of nasal tip, the surgeon should minimize the placement
of hard graft materials into the membranous septum.
Fig. 1.56 Membranous septum
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51
Mucoperichondrium of the Septum
The septal mucoperichondrium adheres very tightly to the cartilage at the caudal margin and the inferior portion (i.e., vomer
or maxillary crest area). The adhesion is looser in the dorsal, midportion, and cephalic areas (Fig. 1.57). As such, the muco-
perichondrial elevation should begin in the lesser adherent area and proceed into the tightly adherent area, in order to
decrease the risk of mucoperichondrial tearing.
Fig. 1.57 Adherence of
septal mucoperichondrium.
Septal mucoperichondrium is
tightly adherent to the septal
cartilage in the caudal border
(green) and floor of the
septum (pink)
Anatomy of Internal Nose

52
Lateral Walls of the Internal Nose
The lateral wall of the internal nose is composed of many bones: nasal, maxilla, lacrimal, and ethmoid bones, as well as the
inferior nasal concha, perpendicular plate of palatine, and medial pterygoid plate of sphenoid. The lateral wall has three
turbinates and passages of the sinuses (meatuses) (Fig. 1.58). The inferior turbinate is a separate bone, while the middle and
superior turbinates are portions of the ethmoid bone.
superior
meatus
middle
meatus
inferior
meatus
inferior
turinate
middle
turbinate
sphenoid
sinus
superior turbinate
superior turbinate
frontal sinus
superior meatus
middle meatus
middle turbinate
inferior
turbinate
inferior
meatus
maxillay
sinus
a
b
Fig. 1.58 Anatomy of lateral
wall of the nose. (a) Sagittal
section. (b) Coronal section
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53
Turbinates
The turbinates are protruding structures off the lateral wall of nasal cavity and run parallel to the nasal airway. Each turbinate
is composed of underlying bony structure, surrounded by the mucosal lining. The three turbinates are referred by their rela-
tive location, as superior, middle, or inferior turbinate (Fig. 1.58). Among these, the inferior turbinate is the largest.
The soft tissue of turbinate consists of mucosa, arterial and venous vascular channel, and smooth muscles. The turbinate
acts as a dynamic erectile organ. The inferior turbinate is angled to some degree both medially and inferiorly. This turbinate
directs the air during inspiration and modifies the temperature and humidity of the air, both of which are important physio-
logic functions. When the septum is deviated towards one side, the contralateral inferior and middle turbinates hypertrophy
in response to fill up the increased nasal space (Fig. 1.59). Because of this, correction and repositioning of deviated septum
require simultaneous reduction of the hypertrophied turbinate. If the hypertrophied turbinate is not corrected properly, the
repositioned septum will abut against the turbinate, which can both prevent proper repositioning of the septum and obstruct
the nasal passage with hypertrophied turbinate.
Fig. 1.59 Deviated septum
and compensatory
hypertrophy of the opposite-
side inferior turbinate
Anatomy of Internal Nose

54
Meatus
Nasal meatuses are the anteroposterior passages located on the lateral wall of the nasal cavity. There are three nasal meatuses
in the nasal cavity: the superior meatus, middle meatus, and inferior meatus. Each nasal meatus is located beneath each of
the corresponding turbinate (Fig. 1.58). Posterior ethmoidal cells and sphenopalatine foramen open into superior meatus.
Middle meatus communicates with the paranasal sinuses (frontal sinus, maxillary sinus, and anterior ethmoidal cells). The
nasolacrimal duct opens into the inferior meatus.
Arterial Blood Supply
There are two main arterial blood supplies to the internal nose: the anterior ethmoidal artery and sphenopalatine artery
(Fig. 1.21).
Blood Supply to the Lateral Walls
1. Mainly from the posterior lateral nasal branch of sphenoplalatine artery
2. Partially from the lateral internal nasal branch of the anterior ethmoidal artery and lateral nasal branch of the posterior
ethmoidal artery
Blood Supply to the Septum
1. Caudal septum: Kiesselbach’s plexus (branches of the medial internal nasal branch of the anterior ethmoidal artery, septal
branch of superior labial artery, and posterior septal branch of the sphenopalatine artery)
2. Cephalic septum: mainly from posterior septal branch of the sphenopalatine artery, partially from septal branch of poste-
rior ethmoidal artery
Sensory Innervation of Internal Nose
Two important sensory nerves for the internal nose are anterior ethmoidal nerve and nerves from the pterygopalatine gan-
glion (Figs. 1.23 and 1.24).
Anterior Ethmoidal Nerve
Internal branch from the anterior ethmoidal nerve innervates the anterior nasal septum and the anterior portion of the lateral
wall of nasal cavities. External nasal branch of the anterior ethmoidal nerve innervates the midvault and tip.
Nerves from the Pterygopalatine Ganglion
Sensory nerves of the internal nose are mostly innervated by the pterygopalatine ganglion located behind the middle turbi-
nate. Most of the lateral wall of nasal cavity is innervated by the lateral posterior superior nasal nerve and lateral posterior
inferior nasal nerve, both of which are branches of the pterygopalatine ganglion. The nasopalatine branch from this ganglion
innervates the nasal septum.
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Physiology of the Nose
Physiologic Functions of the Nose
The nose may appear to be relatively static. However, the organ is extremely dynamic and has a highly complex set of func-
tions. Rhinoplasty can affect a number of these functions in various ways, and patients who wish for aesthetic rhinoplasty
often want to treat the functional problems as well. Therefore, the rhinoplasty surgeons must thoroughly understand the
functions of the nose.
Respiration
The nose is a natural pathway for breathing. It serves as the only means of bringing warm humidified air into the lungs. It func-
tions as a mechanism for conditioning of inspired air, that is, warming and humidifying the air that flows into the lungs. Inspired
air is heated almost to body temperature while passing through the nasal airway. This action of conditioning the air occurs in the
vicinity of the mucosa of the inferior turbinate. By the time the air arrives in the lung, the air is saturated with 90–93% humidity
at 31–37 °C. Over the course of 24 h, approximately 1 L of water is used in the humidification process of nose.
Nasal obstruction can force a person to breathe through the mouth, with impaired humidification and temperature regula-
tion of the incoming air. The unfiltered, unconditioned air increases the risk of pharyngitis, laryngitis, and bronchitis.
Prior to the explanation of airflow dynamics through the nose, it is necessary to understand laminar flow and turbulent
flow.
Laminar flow is the flow of fluid (air or liquid) through a linear tube or pipe. In that case, the velocity of flow varies from
zero at the walls to a maximum along the centerline of the vessel (Fig. 1.60). The fluid moves in layers with successively
higher speed. Fluid near the walls of the tube is nearly still, whereas air in the central lumen flows more rapidly.
In contrast, turbulent flow is a type of fluid flow in which the fluid undergoes irregular fluctuations in both direction and
magnitude (Fig. 1.61).
By above definition, nasal airflow cannot be truly laminar, because airflow does not follow a straight course through
the nasal airway and the airway itself does not have smooth tubelike surface having convex and concave structures. The
inspiratory airflow has a parabolic curve through the nasal passage (Fig. 1.62). Of the total, approximately half of the
airflow passes through the middle meatus, with 35% passing through the inferior meatus and 15% passing through the
olfactory region.
With low inspiratory flow rate (i.e., slow quiet respiration with low pressures), airflow approximates laminar flow. The
flow becomes more turbulent at higher inspiratory flow rates (i.e., quick high-pressure respiration). Turbulent airflow also
exists when laminar flow is compromised (Fig. 1.63). During expiration, the airflow becomes purely turbulent.
In inspiration and expiration, slow inspiration creates the laminar flow and transits to a bit turbulent flow with increased
velocity of flow, and becomes pure turbulent flow in expiration. The moment of transition between turbulent and laminar flow
is important, as it creates the optimal situation for air-conditioning.
Fig. 1.60 Laminar flow. The velocity of flow through a linear tube var-
ies from zero at the walls to the maximal velocity along the centerline
of the vessel. The fluid moves in layers with successively higher speed
towards the center
Fig. 1.61 Turbulent flow. Turbulent flow undergoes irregular fluctua-
tions in both direction and magnitude
Physiology of the Nose

56
Fig. 1.62 Normal inspiratory airway stream follows parabolic curves
through the nasal passage
Fig. 1.63 The airflow
becomes turbulent at a higher
inspiratory flow rate or when
laminar flow is compromised
If there exists excessive turbulent flow in the nose, it can increase airway resistance and can cause nasal stuffiness despite
the lack of any anatomical obstruction.
According to Bernoulli’s principle, the velocity of the fluid increases at the narrow cross-sectional area, while the pressure
decreases (Fig. 1.64). In constricted areas, the velocity increases with generation of relatively negative pressure. If the airflow
is increased in the incompetent internal or external nasal valve, it creates a lowered negative internal pressure in relation to
the outer extranasal pressure, resulting in the valve collapse. This effect is exacerbated by forced inspiration (Fig. 1.65).
1 Surgical Anatomy and Physiology of the Nose

57
Patients with atrophic rhinitis and patients with a history of excessive turbinate resection often complain of nasal obstruc-
tion despite a wider cross-sectional area (empty nose syndrome). This stems from the loss of sensation for airflow due to the
disruption of mucosal cooling and neurosensory mechanisms, as well as the sensation of dryness and crust formation (see
Chap. 17 for further discussion).
The direction of airflow can change according to the nasolabial angle. If the angle is narrower than usual, the airflow
assumes a more cephalic direction. Conversely, a wider angle will direct the airflow towards the nasopharynx. Abnormal
airflow can lead to accumulation of mucosal secretion in specific areas of the nasal cavity, which can subsequently lead to
foul odor or infection.
A2V2
A2
P2
P1
A1
Flow velocity
V1
V2P2Fig. 1.64 Bernoulli’s
principle. Within a tube, a
decrease in the cross-sectional
area is associated with
increased flow velocity and
decreased pressure
a
b
Fig. 1.65 Demonstration of external valve collapse (right nostril) during the forced inspiration. (a) Normal respiration. (b) Forced inspiration
Physiology of the Nose

58
Front Line of Defense
Nose is an important organ for filtering out particles from the inspired air and serves to provide first-line immunologic
defense via mucus-coated membranes that contain immunoglobulin A (IgA).
Large particles in the inspired air are trapped by vibrissae. Any particulate matter not trapped by the vibrissae is then trapped
by the mucociliary blanket of nasal wall. The cilia, by their constant movement, move the mucociliary blanket entrapping the
particles towards the oropharynx; thus the inspired particles can be swallowed or expectorated from the respiratory system.
In addition to the mechanical defense, the nasal cavity also performed immunologic functions by macrophages, granulo-
cytes, and mast cells.
Ventilation and Drain of Sinuses
Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. These are frontal sinuses, maxil-
lary sinuses, ethmoidal sinuses, and sphenoidal sinuses. The three meatuses of the internal nose are important structures that
drain these sinuses. Normally, the sinuses are well ventilated via the meatuses. Through the ciliary movement along the
mucosal lining, the mucus secreted by the sinus drains via the respective meatuses. Factors which interrupt this drainage will
lead to stasis of secretion from the sinuses, and this can result in eventual sinusitis. Causes of sinus drainage problems
include septal deviation, hypertrophied turbinate, polyp, tumor, allergic rhinitis, and intranasal packing.
Olfaction
Olfaction is one of the crucial functions of the nose and is very important for quality of life. The olfactory nerve (cranial
nerve I) is the main nerve for olfaction, while vagus nerve and glossopharyngeal nerve are also partially involved. The olfac-
tory epithelium is present in the superior portion of nasal septum, superior lateral nasal wall, superior turbinate, and superior
part of middle turbinate. The epithelium contains approximately 6–10 million olfactory sensory neurons, which are bipolar
sensory cells. The signal passed from the receptor of these cells is conducted along the olfactory filament through the cribri-
form plate and into the overlying olfactory bulb. Of the inspired air, about 10–20% of the flow reaches the olfactory neurons
within the olfactory groove.
Postoperative hyposmia can be caused by several mechanisms. The inspired air could be prevented from entering the
olfactory cleft by a synechia between the septum and middle turbinate or by deficient aeration of the olfactory groove from
deformities of the turbinates (outfracture, atrophy). Osteotomy can cause hyposmia or anosmia by inadvertent injury to the
olfactory epithelium or cribriform plate.
Nasal Resistance of Airflow
Airway resistance is the resistance offered by the respiratory tract to the airflow during the inspiration and expiration. It is
one of the fundamental features of the mechanics of the respiratory system and plays a critical role in preventing catastrophic
total collapse of the lungs during exhalation. While the nose represents a small portion of the airway, it is responsible for
50–60% of the airway resistance. Three structures are involved in creating this resistance: the external valve (nasal vestibule),
internal valve, and turbinates. Among these, the internal valve creates the most amount of airway resistance and represents
the narrowest segment of the airway and thus a major flow-limiting area.
Vocal Resonance
The nose is an important factor in determining the characteristics of voice. In addition to the vocal cord, voice is also created
by the resonance from the air that is passing through the pharynx, mouth, and nose. It is a plausible assumption that rhino-
plasty will alter the resonant quality of voice in vocalists and singers, but no study has directly looked at this potential
problem.
Nasal Reflexes
The nose participates in various reflexes whose collective function is to protect the lower airway from insult. Of these, the
most representative is the nasonasal reflex, which triggers sneezes.
Physiologic Nasal Cycle
The nasal cycle is the unnoticed alternating partial congestion and decongestion of the nasal cavities. It is a physiological
congestion (enlargement) of the inferior turbinates that alternates from one side to the other, due to selective activation of one
half of the autonomic nervous system.
1 Surgical Anatomy and Physiology of the Nose

59
The function of the nasal cycle is not known. There have been several postulations for the reasons of this nasal cycle. It is
known that the cilia of the congested side suspend their motility, ensuring that one side of the nose is always moist, to facili-
tate humidification. Some odor chemicals bind with olfactory receptors easily, even under conditions of high airflow, while
other odors need more time, under low airflow conditions, to bind with receptors. With high airflow on one side and low
airflow on the other side, the olfactory center is able to detect a greater range of odorants. For these reasons, the nasal cycle
is believed to control the humidification and improve the olfactory function.
Nasal cycle is present in about 80% of the whole population and has a periodicity between 4 and 12 h. This alternating
congestion is not bothersome to individuals, who may not even be aware of the phenomenon. However, patients with septal
deviation or turbinate hypertrophy often experience nasal obstruction that alternates between the left and right nasal cavities.
Anatomical Structures Involved in Nasal Obstruction
Several anatomic sites can become points of nasal obstruction. In patients with nasal obstruction, these sites should be evalu-
ated during the preoperative consultation.
Mucosa
Mucosa origin of nasal obstruction consists of mucosal hypertrophy, synechiae, vasomotor rhinitis, allergy, physiologic nasal
cycle, and sleep position-dependent nasal congestion.
External Nasal Valve
External nasal valve is an area caudal to the internal nasal valve, from the nostril to the caudal border of upper lateral carti-
lage. The external valve is composed of the columella, caudal septum, foot plate of medial crus, alar rim, lateral crus of lower
lateral cartilage, and nostril sill (Fig. 1.34). Causes of external valve collapse include:
1. Excessive resection of lateral crus of lower lateral cartilage leading to alar collapse (Fig. 1.66)
2. Scar contracture leading to nostril narrowing
3. Caudal septal deviation
4. Aggressive alar base reduction
5. Palsy of dilator naris from facial nerve dysfunction
6. Congenital weakness of nose
7. Aging process
Fig. 1.66 External valve collapse.
This patient has a history of excessive
resection of the lateral crura in a
previous rhinoplasty operation. A
partial external valve collapse can be
observed during forced inspiration
Physiology of the Nose

60
Internal Nasal Valve
The internal nasal valve is the specific slit-like segment between the caudal margin of the upper lateral cartilage and the
septum (Fig. 1.34). Incompetence of internal nasal valve can be either primary or secondary (Fig. 1.67). Causes of internal
valve narrowing are as follows:
1. Convex deviation of high septum
2. Trauma
3. Excessive en bloc resection of cartilaginous hump including the upper lateral cartilage
4. Compression of upper lateral cartilage by deformed lateral crus of lower lateral cartilage
5. Scar contracture following intercartilaginous incision
6. Pyriform aperture narrowing by osteotomy
In certain cases, the nasal obstruction due to valve narrowing only becomes symptomatic in supine position. Composite
hump reduction can lead to internal valve insufficiency due to medialization of the upper lateral cartilage. In such cases, the
nose shows an inverted V-shaped depression between nasal bone and upper lateral cartilage, which becomes worse with
forced inspiration (Fig. 1.68).
The obstruction due to collapse of internal and external valves can be alleviated by lateral traction of the cheek skin, which
is called the Cottle maneuver (Fig. 1.69). However, Cottle maneuver is not specific to valve collapse, as it also improves nasal
obstruction for septal or inferior turbinate- related obstruction.
A more specific way to test obstruction due to valve collapse is to lift either the internal or the external valve using a cotton
swab or cerumen curette. Improvements in obstructive symptom with elevation of the valve represent a positive result, and
it is an accurate method to identify the level of obstruction. This is sometimes referred to as modified Cottle maneuver
(Fig. 1.70).
Fig. 1.67 Internal valve
collapse. In this patient, an
inverted V-shaped indentation
is seen between the nasal
bone and the upper lateral
cartilage. The collapse of
upper lateral cartilage is
caused by en bloc resection of
dorsal hump without spreader
graft and this can cause the
internal valve narrowing
1 Surgical Anatomy and Physiology of the Nose

61
a
b
Fig. 1.68 In this patient with post-humpectomy upper lateral cartilage collapse, the mild inverted V-shaped depression becomes more obvious
with forced inspiration (b)
Fig. 1.69 Cottle maneuver. For either the internal or the external valve
insufficiency, lateral traction of the cheek skin leads to improvements in
nasal obstruction
Fig. 1.70 Modified Cottle maneuver. Internal or external valve insuf-
ficiency can be specifically identified if nasal obstruction improves by
lifting out each valve with cotton-tipped applicator
Physiology of the Nose

62
Septum
A perfectly straight septum is a very rare occurrence, and mild deviation and spur are fairly common in the elderly popula-
tion. Not all deviated septum requires correction, but deviated septum is one of the most common causes of nasal obstruction.
When deviation occurs in the area of internal nasal valve, it is more likely to be a source of obstruction.
Turbinate
1. Enlargement of Inferior Turbinate
Enlargement of inferior turbinate can also cause nasal obstruction. In most cases, turbinate enlargement consists mostly
of soft-tissue enlargement, but bony enlargement is not extremely rare. Among a spectrum of disorders, allergic rhinitis is the
most common cause of inferior turbinate enlargement. Other causes for turbinate enlargement include URI, sinusitis, vaso-
motor rhinitis, situations that alter blood flow such as drugs and hormones, changes in temperature, and supine position. With
septal deviation, one of the inferior turbinates frequently undergoes compensatory enlargement (Fig. 1.59), which represents
enlargement of both mucosal and bony components.
Prior to a rhinoplasty operation, a patient with nasal obstruction should be evaluated for any potential turbinate pathology,
as this will need to be addressed.
2. Concha Bullosa
A concha bullosa is a pneumatization within the middle turbinate (Fig. 1.71). A concha bullosa within a large turbinate is
often associated with deviation of the nasal septum towards the opposite side of the nasal cavity, which will cause nasal
obstruction.
Fig. 1.71 Concha bullosa is
present in both of the middle
turbinates
1 Surgical Anatomy and Physiology of the Nose

63
3. Paradoxical Middle Turbinate
Paradoxical middle turbinate refers to a middle turbinate edge that has an abnormal curvature in the inferomedial orienta-
tion (Fig. 1.72), and is a rare developmental cause of nasal obstruction.
Fig. 1.72 Paradoxical middle
turbinate on right side
Physiology of the Nose

64
Nasal Bone
Nasal obstruction can be caused by deviated nasal bone or by nasal bone collapse after an improper osteotomy.
Others
Nasal polyps and tumors can present with nasal obstruction as the chief complaint.
Salient Anatomic Features of the Nose in Asian Patients
Several characteristics of nasal anatomy are different between Caucasian and Asian patients.
1. Compared to Caucasian patients, Asian patients tend to have dorsal skin that is thicker and less elastic. This characteristic
of the dorsal skin is advantageous for masking the visible contour of an implant, but makes elongation of soft tissue dif-
ficult in the case of short-nose correction.
2. In addition to the dorsal skin, Asian patients have thicker skin and soft tissue in the nasal tip. This thick skin and soft-
tissue envelope mask irregularities and asymmetry in the contour of the cartilage graft, which allows for a greater margin
of technical error. However, the thick skin represents a significant obstacle in obtaining a defined tip with poor outcomes
following tip plasty. Upon cartilage remodeling (especially for reduction of bulbous tip), the redraped skin over the carti-
laginous framework continues to shrink and tighten slowly over time, the skin shrink- wrapping over the new framework
of the tip. In patients with thicker skin, the skin does not shrink-wrap to the underlying framework as well as it does for
a nasal tip with thinner skin.
Thicker skin is associated with more postoperative edema that tends to subside more slowly. Post-rhinoplasty fibrosis
syndrome is more common in patients with thicker skin. The surgical management of thick skin over nasal tip is discussed
in Chap. 9.
3. The skin over the nasal ala is thicker and less elastic for Asian patients. This characteristic of the ala soft tissue represents
a significant challenge for advancement of alar rim in the caudal direction after an alar rim graft.
4. The lower lateral cartilages are smaller and mechanically less robust in Asian patients. This has several ramifications.
First, suture technique for lower lateral cartilages may be inadequate in achieving desired tip projection and volume
reduction. Second, cartilage suture technique or columella strut graft can result in cephalic rotation of the tip more easily
due to the weak lateral crura. Third, cartilage onlay graft or shield graft onto the weak and small medial crura may distort
the medial crura or compress down the foot plates, which results in loss of tip height.
5. Septal cartilages are usually smaller and thinner in Asian patients. As such, the septal cartilage often is not a good source
of sizeable donor graft. In addition, the risk of saddle nose deformity is higher for Asian patients because the thinner
L-strut of septal cartilage can deform over time. Following a septal extension graft, the weak L-strut of the remaining
septal cartilage becomes deviated over time, and it is not uncommon to observe the deviation of tip and columella or
nostril asymmetry. When performing septal extension graft in Asian patients, it is important to leave a wider L-strut
behind while learning the tips and tricks needed to maximize the use of small septal cartilage grafts as well as understand-
ing the alternative techniques to using septal extension graft.
1 Surgical Anatomy and Physiology of the Nose

65
Further Reading
1. Guyuron B. Footplates of the medial crura. Plast Reconstr Surg. 1998;101(5):1359–63.
2. Sheen JH, Sheen AP. Aesthetic rhinoplasty. 2nd ed. St Louis: Mosby; 1987.
3. Han SK, et al. Updated anatomy of the dermocartilaginous ligament of the nose. Ann Plast Surg. 2007;59(4):393–7.
4. Pitanguy I, et al. The surgical importance of the dermocartilaginous ligament of the nose. Plast Reconstr Surg. 1995;95(5):790–4.
5. Han SK, Lee DG, Kim JB, Kim WK. Anatomic study of nasal tip supporting structures. Ann Plast Surg. 2004;52(2):134–9.
6. Hummel T, Welge-Lüssen A. Taste and smell: an update. Basel: Karger Medical and Scientific Publishers; 2006. p. 1–22.
7. Sobel N, Khan RM, Saltman A, Sullivan EV, Gabrieli JD. The world smells different to each nostril. Nature. 1999;402(6757):35.
8. Sulsenti G, Palma P. The nasal valve area: structure, function, clinical aspects and treatment. Sulsenti’s technic for correction of valve deformi-
ties. Acta Otorhinolaryngol Ital. 1989;9(Suppl 22):1–25.
9. Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol. 1984;11096:349–58.
10. Gunter JP, Yu YL. The tripod concept for correcting nasal-tip cartilages. Aesth Surg J. 2004;24(3):257–60.
11. Converse JM. The cartilaginous structure of the nose. Ann Otol Rhinol Laryngol. 1955;64(1):220–9.
12. Ali-Salaam P, Kashgarian M, Persing J. The soft triangle revisited. Plast Reconstr Surg. 2002;110(1):14–6.
13. Guyuron B, Ghavami A, Wishnek SM. Components of the short nostril. Plast Reconstr Surg. 2005;116(5):1517–24.
14. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002;109(3):1128–44.
15. Hwang K, Huan F, Kim DJ. Mapping thickness of nasal septal cartilage. J Craniofac Surg. 2010;21(1):243–4.
16. Mowlavi A, Masouem S, Kalkanis J, et al. Septal cartilage defined: implications for nasal dynamics and rhinoplasty. Plast Reconstr Surg.
2006;117:2171–4.
17. Sinno S, Chang JB, Saadeh PB, Lee MR. Anatomy and surgical treatment of the depressor septi nasi muscle: a systematic review. Plast
Reconstr Surg. 2015 May;135(5):838e–48e.
18. Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr, Robinson JB Jr. Importance of the depressor septi nasi muscle in rhinoplasty: anatomic
study and clinical application. Plast Reconstr Surg. 2000;105:376–83. discussion 384–388
19. Daniel RK, Letourneau A. Rhinoplasty: nasal anatomy. Ann Plast Surg. 1988 Jan;20(1):5–13.
20. Lam SM, Williams EF III. Anatomic considerations in aesthetic rhinoplasty. Facial Plast Surg. 2002;18(4):209–14.
21. Hwang K, Kim DJ, Hwang G. Relationship between depressor septi nasi muscle and dermocartilagenous ligament; anatomic study and clinical
application. J Craniofac Surg. 2006;17:286–90.
22. Craig JR, Bied A, Landas S, Suryadevara A. Anatomy of the upper lateral cartilage along the lateral pyriform aperture. Plast Reconstr Surg.
2015 Feb;135(2):406–11.
23. Schlosser RJ, Park SP. Surgery for the dysfunctional nasal valve cadaveric analysis and clinical outcomes. Arch Facial Plast Surg. 1999;1:105–10.
24. Fischer H, Gubisch W. Nasal valves--importance and surgical procedures. Facial Plast Surg. 2006;22(4):266–80.
25. Han SK. Surgical anatomy of Korean nose. J Kor Soc Aesth Plast Surg. 2005;11(1):1–9.
26. Lessard M, Daniel RK. Surgical anatomy of septorhinoplasty. Arch Otolaryngol Head Neck Surg. 1985;111(1):25–9.
27. Downs BW. The inferior turbinate in rhinoplasty. Facial Plast Surg Clin North Am. 2017;25(2):171–7.
28. Akoglu E, Karazincir S, Balci A, et al. Evaluation of the turbinate hypertrophy by computed tomography in patients with deviated nasal sep-
tum. Otolaryngol Head Neck Surg. 2007;136:380–4.
29. Larrabee WF Jr. The tripod concept. Arch Otolaryngol Head Neck Surg. 1989;115(10):1168–9.
Further Reading

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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Preoperative Evaluation for Rhinoplasty
Patient Consultation and Examination
A thorough, comprehensive preoperative consultation and planning consists of the following steps:
1. The initial interview with patient to identify the patient’s goals and wishes
2. Physical examination and analysis of the nose and remainder of the face
3. Preoperative planning to delineate appropriate surgical techniques, needed materials, operative area, and operative goals
4. Final consultation to ensure that the patient understands the limitation of surgery and potential complications
Preoperative Interview and Consultation
Aesthetic rhinoplasty is a challenging discipline that requires a thorough understanding of a wide variety of surgical tech-
niques and materials. There exists a significant amount of controversy and diversity of opinions regarding surgical
planning.
Generally, a successful rhinoplasty rests on three factors. First is outstanding technical competency on the part of the
operator. Second is the artistic sense of the operator. This is especially the case for a surgeon practicing Asian rhinoplasty,
who needs to understand the variations in the aesthetic standards across the ethnicity of his or her patients, as well as to know
the relevant anthropometric data for facial features, to have a facial harmony, and to be able to turn the subjective wishes of
a patient into an objective anatomic change. Third is the ability to communicate with the patient.
The ever-increasing expectations from patients place greater demand for improvements in surgical outcomes, which is a
continually increasing burden to be worn by the surgeons. To overcome such challenges and obtain successful outcomes, it
is not enough for a surgeon to simply be skilled in the operations themselves. Instead, the surgeon must be meticulous in his/
her approach to understanding the patient as well as he/she is in preoperative planning.
Preoperative consultation for rhinoplasty should evaluate the patient’s face and nose, and the patient’s wishes and desires,
and plan for a successful operation. At the same time, preoperative consultation is also a psychological process through
which unrealistic portions of a patient’s expectations are identified and transformed into a realistic, achievable goal.
Communication, then, is the matching of a patient’s desired goal to what a surgeon is capable of achieving.
Extremely exacting and demanding patients are not rare for rhinoplasty. In the author’s experience, this has especially
been the case for male patients who have undergone many rhinoplasty operations.
Much of the expertise in becoming a rhinoplasty surgeon has to do with his/her ability to communicate with the patient.
The surgeon must be able to understand exactly what the patient wants, whether that desire is realistic, and if so whether
that desired shape is harmonious with the remainder of the face. The surgeon must also be able to communicate this
understanding with the patient, all the while assessing and adapting to the psychological factors influencing the patient’s
desires.
2

68
This communication with the patient should be specific and exact to the smallest of details. When a patient is unable or
unwilling to have an explicit discussion regarding the shape of the nose or the operative direction, the surgeon must be aware
of the potential for a disastrous consequence. Common examples of implicit (i.e., “dangerous”) communication by patients
include “please make it look natural” and “I trust your judgment, so please use your judgment to make my nose beautiful.”
Such implicit demands must be clarified under thorough discussion, such that most of what the patient wants and what the
operator is capable of is laid out plain for everyone to understand.
Rhinoplasty surgeon should strive to identify and help those patients with a constructive motive for a surgery and realistic
expectations and take care not to operate on patients with psychological hang-ups or unrealistic expectations. In practice,
much of the dissatisfaction after a rhinoplasty operation has little to do with actual operative outcomes or complications. In
many cases, postoperative shape of the nose is excellent, but the patient may express untoward dissatisfaction due to disso-
nance with the expectation of the patient. Because of this, the surgeon should never strongly recommend an operation nor
guarantee an unrealistic outcome.
With the Internet, it has become much easier to obtain information regarding materials and techniques employed in rhinoplasty.
This availability of information has led to many patients to erroneously demand specific operation for a self- diagnosed condition.
Such patients often reject the recommendation of surgeons and do not trust the operative decision-making process. Chances are
high that a patient who presents with self-diagnosis will be dissatisfied with an outcome following an operation—no matter the
surgical outcome. The following lists are red flags which require the full caution of a rhinoplasty surgeon:
1. Psychiatric disorders including schizophrenia and depression
2. High expectation
3. Unrealistic demands
4. Addiction to plastic surgery
5. Body dysmorphism
6. A patient with unwarranted level of suspicion or with whom building rapport is difficult
7. A patient who wants to compensate for feelings of inferiority or insecurity with plastic surgery
8. A patient with a history of lawsuits related to plastic surgery
9. Narcissistic or obsessive-compulsive personality
10. A patient with a history of rhinoplasty who wants to return to his/her original appearance
Plastic surgeons are not psychiatrists and should neither try to diagnose nor treat psychiatric conditions in patients pre-
senting for plastic surgery consultation. However, they should be able to identify and avoid operating on patients who are
highly likely to be dissatisfied with an operation, regardless of objective outcomes.
An experienced rhinoplasty surgeon understands that it is always better to obtain a good outcome in a moderately chal-
lenging case than to try to fight an uphill battle in a difficult case. It is the job of individual surgeons to decrease the mental
stress from work and also maintain the professional credibility. The surgeon must understand that a difficult case beyond the
scope of one’s capabilities usually represents small opportunities at success, often at larger chance of failure and loss of
personal energy and time.
2 Preoperative Evaluation for Rhinoplasty

69
Preoperative Evaluation of General Health and Medical History
General Health
At a simple glance, a patient being considered for an operation should appear healthy enough to undergo one.
The primary issue in preoperative evaluation is to identify any bleeding tendency. Bleeding tendency not only is a problem
during the operation but also increases the risk of postoperative hematoma, which can further lead to infection and changes
in soft-tissue shape. This is especially an issue for bulbous tip correction in Asian patients, for whom postoperative hema-
toma or excessive tissue swelling can lead to post-rhinoplasty fibrosis to the dismay of patient and surgeon alike. It is impor-
tant to review the medical history for easy bruising, bleeding in prior operations, uncontrolled hypertension, hemophilia,
other inherited coagulopathy, and use of aspirin and anticoagulants. If warranted by history, laboratory studies should be
ordered for bleeding time, PT, aPTT, and platelet count.
Patient history should also be reviewed for the following chronic diseases: hypertension, diabetes, renal disease,
immune disease or immune-suppressed condition, liver disease, cardiac disease, pulmonary problem, hematologic dis-
ease, etc.
Well-controlled hypertension or diabetes does not interfere with an operation. However, it is prudent to seek consultation
from appropriate specialists for preoperative fitness, potential for complications, and special treatments that may be needed
before and after an operation. In patients with controlled hypertension, patients may not bleed much during the operation
itself but can experience delayed bleeding in the postoperative period, as the blood pressure begins to rise.
Patients with diabetes often exhibit delayed or impaired wound healing and can experience greater scar formation and
higher chance of infection than patients with normal glucose levels.
Aesthetic rhinoplasty or use of implant does not represent absolute contraindication for patients with suppressed immune
function. However, these patients do require extra attention and care. If at all possible, the recommendation should be to
employ minimally invasive operation and autologous tissue.
In Asian patients, herb medications such as ginseng and gingko are used frequently. Many such medications and nutri-
tional supplements increase bleeding tendency. Patients should be instructed to cease the intake of such agents at least 2
weeks prior to an operation.
Nasal Diseases
Patients should be asked for nasal trauma history, sinusitis, allergic rhinitis, and previous septorhinoplasty operation. It
is important to check for any breathing difficulty. However, not all patients who breathe through the mouth are aware
that they have difficulty in breathing. Therefore, it is not enough to depend on a patient’s report but also to examine the
patient during the interview. Any sinusitis with purulent discharge should be treated prior to any aesthetic rhinoplasty
operation.
Preoperative Evaluation of General Health and Medical History

70
Preoperative Examination and Tests of the Face and Nose
Preoperative Examination of the Face and Nose Should Document the Following
Face Evaluation
A comprehensive rhinoplasty examination should evaluate not only the nose but also the remainder of the patient’s face. The
face should be evaluated for overall asymmetry or palsy. The proportion should be checked between the nose and the face.
Common rhinoplasty operations in Asian patients, such as tip projection and dorsal augmentation, are highly sensitive to
imbalances in harmony between the nose and remainder of the face.
Tip projection can make a retruded chin appear even more retruded. In such patients, chin augmentation is helpful in
maintaining a harmonious balance with projected tip (Fig. 2.1). An operator should avoid a rhinoplasty that improves the
shape of the nose to the detriment to the overall harmony of the face.
In patients with decreased intercanthal distance, radix augmentation can give the appearance of even less of a distance
between the eyes, which is obviously undesirable.
With flat forehead, dorsal augmentation can make the radix appear too prominent. To avoid this issue, the radix portion
should not be augmented as it is for a patient with prominent forehead.
Both dorsal augmentation and short-nose correction can give the illusion of elongated midface. In addition, dorsal augmen-
tation adds a lot of voluminous contour to the facial center, which can decrease the appearance of a broad face and restore the
balance between the nose and the broad midface. This is one example in which dorsal augmentation brings the whole face
closer to harmony in Asian rhinoplasty.
Short upper lip with gingival exposure can become worse with nasal tip projection with columella strut graft. In converse,
tip lowering can elongate and decrease the tightness of the upper lip in patients with short tight upper lip and over- projected
nasal tip.
Nose Examination
Skin and Subcutaneous Tissue
The nasal skin should be evaluated for tissue thickness and presence of scar or pigmentation. Thin skin can make for a con-
spicuous implant or cartilage graft contour. Thick skin can mask minor underlying irregularities but can prevent obtaining a
defined nasal tip in bulbous tip correction. For short-nose correction, thick and tight skin resists stretching and requires a
much wider dissection. Any preexisting skin redness and visible vein can become more conspicuous after a dorsal
augmentation.
Nasal Dorsum (Nasal Bone and Upper Lateral Cartilages)
The dorsum should be evaluated for hump, depression, or axis deviation. The length of the nasal bone itself is also important,
as short nasal bones tend to be more unstable after osteotomy.
For excessively wide nasal bone, osteotomy to decrease the nasal bone width also mobilizes the upper lateral cartilages in
the medial direction, which can cause internal valve narrowing. Additional procedures may be necessary to prevent this issue.
Also, the dorsum should be evaluated for inverted-V deformity or internal valve problem from a previous operation.
In patients with huge cartilaginous hump, lowering of the caudal dorsum is most likely to result in immediate nasal tip
droop. If a patient requires a significant lowering of caudal dorsum, preoperative planning should review the need for a tip
projection technique, such as columellar strut graft or tip onlay graft.
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a
b
d
f
c
e
Fig. 2.1 Simultaneous
augmentation of nose and chin in a
female patient. (a–c) Preoperative
photograph of a patient with flat
nose and retruded chin. (d–f)
Photographs after rhinoplasty
(dorsal augmentation using
silicone implant and tip projection
with conchal cartilage graft) and
chin augmentation (silicone
implant). Without the chin
augmentation, the rhinoplasty by
itself would have worsened the
appearance of retruded chin
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72
c
d
a
b
Fig. 2.2 Different types of bulbous tip. (a, b): Bulbous tip of cartilage origin. (c, d) Bulbous tip of soft-tissue origin
Nasal Tip
The nasal tip should be evaluated for volume (bulbousness), projection, asymmetry, and tip drooping when smiling. Of these
factors, neglecting of the smiling tip from hyperactive depressor septi nasi muscle can lead to inappropriate tip projection.
In Asian patients, bulbous tip is not a simple problem limited only to the lower lateral cartilage, and examination of the
nasal tip should delineate big lower lateral cartilage, domal separation, or a combination of skin and soft tissue problem
(Fig. 2.2).
In a low nasal tip, the stability of medial crura should be evaluated by depressing the nasal tip with a fingertip. In patients
with weak medial crura, a simple cartilage onlay graft may not provide adequate tip projection for the longer term. In such
patients, a columellar strut graft is needed to bolster the weak medial crura.
At the time of examination of nasal tip, the lower lateral cartilages should also be evaluated for cephalic malpositioning.
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Nasal Base
The width of alar base (interalar base distance) should ideally be the same or 1–2 mm wider than the intercanthal distance
(32–35 mm).
The columella should be evaluated for width and deviation from midline. Columellar deviation is usually accompanied
by caudal septal deviation. Columella should be placed 2–3 mm caudal to the alar rim, as long as the alar rim is in the optimal
position.
Simple cartilage onlay graft for projection of a nasal tip with hanging or retracted columella (Fig. 2.3) can result in ineffective
tip projection or tip drooping over time. For effective tip projection, the cause of hanging or retracted columella should be
addressed.
Asymmetry of nostril is frequently caused by columellar deviation, but can also be caused by height discrepancy
of the nostril apex without any columella involvement.
The alar side wall should be evaluated for the contour and tissue thickness. Amongst Asian patients, mild retraction of ala
is not uncommon and can easily aggravate by suture techniques on the lower lateral cartilages.
Competency of external valve cannot be evaluated with simple observation but requires forced inspiration for identifica-
tion (Fig. 1.66). A tip plasty performed in ignorance of external valve problem can aggravate the respiratory problem for the
patient.
The foot plate should be evaluated for the shape and protrusion. Foot plate protrusion can become worse with patients with
hanging columella correction or long-nose correction.
a
b
Fig. 2.3 Hanging columella (a) and retruded columella (b)
Preoperative Examination and Tests of the Face and Nose

74
Relationship with Upper Lip
The upper lip should be evaluated for the nasolabial angle, upper lip length, and gummy smile.
Intranasal Examination
The septum should be checked for any deviation. Any deviation should be noted for the location and type. The septum should
also be examined for perforation, synechiae, and stenosis.
The turbinates are then checked for size, color, and whether they are kissing the septum.
Internal valve should be checked, whether there is any stricture or collapse. Physical examination of the nasal valve is
described in Chap. 1.
It is not rare to encounter patients with underlying airway problem but who are not cognizant of the problem himelf/her-
self. It is the job of the surgeon to recognize and address such problems with the patient prior to any operation. Otherwise, a
reduction rhinoplasty can worsen the underlying problem.
Preoperative Tests and Imaging
For preoperative assessment of rhinoplasty, radiologic examination is most commonly performed to assess deviated nose and
usually includes nasal bone view and Waters’ view. Computed tomography is used as well.
Endoscopic examination can provide additional information regarding the septum, turbinate, and mucosa. Rhinometry
can be useful for objective evaluation of nasal obstruction.
Nasal Analysis
Achieving the best result in rhinoplasty is based on careful preoperative analysis of the nose and precise planning. Every ethnicity
has a set of ideal proportions for facial features that is somewhat unique to each ethnic group. During a preoperative assessment,
a rhinoplasty surgeon should be able to compare each patient’s anthropometry (height, shape, angles, and ratios) to the ideal
standards. In Asia, the standard of facial beauty has changed over time, but it has been important to preserve the ethnic identity of
the patient. The anthropometry data from Caucasian populations is not appropriate for rhinoplasty in Asian patients.
Certain facial measurements are clearly different between Caucasian and Asian populations. As such, surgeons who prac-
tice Asian rhinoplasty should be versed in the average anthropometry of the ethnic groups within Asian countries.
Of course, a rhinoplasty should not be practiced to change the nasal shape to meet ideal, standardized measurements.
The final surgical outcomes should result in a nose that is harmonious with the remainder of the face. While it is important
to analyze the proportions of the face, it is also important for the surgeon to have a good intuition about what is ultimately
the proper shape for a given patient. Beyond this fine detail, consistent result demands objective measurements.
Unfortunately, the literature is dearth of anthropometric data regarding the nose in Asian patients, and there is a significant
variation in the reported measurements.
Preoperative assessment of the nose includes many of the parameters listed below. The first step of analysis is the analysis
of relationship between the nose and the face.
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75
Frontal View
The vertical height of the face can be divided into the upper, middle, and lower thirds (Fig. 2.4). The horizontal line
that delineates these 1/3 sections are at the hairline, eyebrows, nasal base, and menton. The lower face is defined pre-
cisely by the distance from the alar base to the chin. This is divided into two divisions: upper division is from the alar
base to lip crease being one-third of the lower face.
The face can also be divided into five horizontal sections, with delineating planes at the lateral canthi and the medial
canthi. In this scheme, the central section contains the entirety of the nose (Fig. 2.5).
Fig. 2.5 The face can be divided into five horizontal sections, with dividing lines at the medial and lateral canthi
1/3
1/3
1/3
1/3
1/3
1/3
1/3
2/3
a
b
Fig. 2.4 The face can be divided as equal thirds of the upper, middle, and lower face. Each horizontal line passes through the hairline, eyebrows,
nasal base, and menton. The lower face is the distance from the alar base to the chin. This can be further divided into two subdivisions. The upper
division is from the alar base to the lip crease, and consists of one-third of the lower face
Nasal Analysis

76
a
b
Fig. 2.6 Intermedial canthal distance is equal to the width of one eye (the distance from lateral canthus to medial canthus). The vertical line pass-
ing each of the medial limbus usually passes through the ipsilateral oral commissure
Nasal Width and Length
Intermedial canthal distance is equal to the width of one eye (the distance from the lateral canthus to the medial canthus). In
most patients, the vertical lines that pass through the medial limbus also pass through each of the oral commissures (Fig. 2.6).
In Caucasian patients, the ideal intercanthal distance is 31–33 mm. For Asian patients, the mean distance is reported to be
37 mm for males and 36 mm for females.
In Caucasian patients, the nasal width ideally takes up about 1/5 of the facial width. The ideal width for alar base is approxi-
mately equal to or 2 mm wider than the intercanthal distance. In Korean patients, the mean nasal width is reported to be 4.0 cm
in males and 3.6 cm in females. Because of the greater width, Korean patients can appear to have a shorter nose in comparison
to Caucasian patients with narrower nose. The nasal base is even wider for patients from Southeast Asia.
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Fig. 2.7 The length of a nose is measured from the nasion to the nasal
tip
Fig. 2.8 In Caucasians, the width of bony base is around 80% of the
width of the alar base
Nasal length is the distance from the nasion to the nasal tip. The ideal length will be different between Asian and Caucasian
patients. Byrd suggested the ideal nasal length to be two-thirds the length of the midface height (glabella to subnasale). Other
authors suggested that the nasal length to tip height should be approximately 1:0.67 in ideal nose of Caucasians (Fig. 2.7).
However, ideal length will be different between Asian and Caucasian patients, and is subjective across individuals. Also, the
ideal length may change depending on the length and width of the overall face as well as those of the chin and lips. Therefore,
the ideal standards cannot stand as absolute surgical goals, and each operation should be performed according to individual
needs of the patients.
The bony base width should be 80% of the width of alar base in Caucasian patients. In Asian patients, the proportion
should be around 2/3 (Fig. 2.8).
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78
Dorsal Aesthetic Lines of Nose
The dorsal aesthetic lines are determined by lines drawn from the medial eyebrow to the nasal dorsum and down to the tip-
defining points (Fig. 2.9). The space between the lines has a rough hourglass shape with the narrowest point near the septal angle.
The lines should be gently curved but can be less than definite in female Asian patients.
Lateral View
The major facial points are marked from the lateral view (Fig. 2.10). From this view, the Frankfort horizontal plane exists in
the line drawn from the external auditory canal to the inferior orbital rim. The vertical facial line meets the Frankfort hori-
zontal plane at a right angle.
Fig. 2.9 Dorsal aesthetic lines
R
T
A
S
M
a
b
Fig. 2.10 Important landmarks of the nose on profile view. On lateral view, the Frankfort horizontal plane is the line from the external auditory
canal to the inferior orbital rim. The facial vertical line meets the Frankfort horizontal plane at right angle. A alar base, M menton, R radix, S sto-
mium, T tip
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79
Radix
In Caucasian patients, the midportion of radix is at the level between the eyelash line and supratarsal crease. In compari-
son, the radix is at a lower position for Asian patients. The height of midportion of radix is about 9–14 mm anterior to
the anterior corneal plane in the Caucasian population, which is a significant component of the nasal profile. In Asian
patients, the same height of radix may appear unnaturally high. Such high radix can give illusion of a long nose and
aggressive countenance. Too low of a radix can make the nose appear to be smaller than it really is.
If an imaginary line is drawn from the radix to the nasal tip, the actual dorsal line should be slightly lower than the line
without a slight curvature (Fig. 2.11). However, male Asian patients do not desire such curved dorsal line.
Nasofrontal Angle
The nasofrontal angle is the angle formed between tangential lines drawn along the nasal dorsum and glabella (Fig. 2.12).
In Caucasian patients, the ideal nasofrontal angle is around 120–130° in males and 115–125° in females. In female
Korean patients, the ideal value is 137–139°.
A less-than-average nasofrontal angle is associated with a low radix and also contributes to a nasal profile that appears
short. Conversely, a greater nasofrontal angle can make the nose appear too long in some situations.
The sellion points are typically located deeper and lower on the nose in Asians than in Caucasians. Asian patients with
deeply located sellion can appear to have disrupted dorsal aesthetic lines as well as abrupt transition between the upper face
and midface. The face may appear wider as well.
Fig. 2.11 The actual outline of the dorsum is located behind the refer-
ence line from radix to nasal tip
Fig. 2.12 Nasofrontal angle is the angle formed between tangential
lines drawn along the nasal dorsum and glabella
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80
Nasal Length
Nasal length is the distance from the nasion to the nasal tip (Fig. 2.7). Among Korean males, the usual range for nasal length
is between 38 and 47 mm, with female patients having shorter nose. On the whole, the nose is shorter for Korean patients
when compared to Caucasians. In Asian patients, operations frequently used to increase nasal length are dorsal augmentation
and derotation of the tip.
Supratip Break
The supratip break is located slightly cephalic to the nasal tip-defining point, and is 2–3 m behind the line between the radix
to the nasal tip (Fig. 2.13). The supratip break is appropriate for female Asian patients who prefer to have the slightly curved
lateral dorsal profile. However, most male patients do not wish for supratip break. Even among female patients, too deep of
a supratip break is a cause for postoperative dissatisfaction. The curvature of the dorsal line should not depend solely on the
supratip break. Rather, the curvature should span the whole length of the nose.
Nasolabial Angle
The nasolabial angle is formed between the vertical facial line and the line that connects the anterior and posterior ends of
the nostril (Fig. 2.14).
nasofrontal
angle
supratip break
tip-defining
point
columellolabial
angle
Fig. 2.13 Supratip break is determined by the relationship between tip
height and caudal mid-vault height
Frankfort hozontal
line
95-100°
Fig. 2.14 The nasolabial angle is formed between the vertical facial
line and the line that connects the anterior and posterior ends of the
nostril
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81
In the Caucasian population, the nasolabial angle measures 95°–100° in females and 90°–95° in males. In East Asians, the
angle is reported to be 90°–93°. Nasolabial angles wider than these angles are associated with over- rotated tip, which is com-
monly referred to as pig nose because more of the nostrils is visible from the front. Most Asians do not like the appearance
of this over-rotated upturned nose.
Among Asians, a small nasolabial angle can make for a prominent mouth protrusion because of the recessed subnasal point.
In such cases, a simple augmentation rhinoplasty for a relatively flat nose may not be adequate in compensating for the pro-
truded mouth. Simultaneous columella projection or ANS augmentation may be necessary to increase the nasolabial angle.
Columellar-labial angle is sometimes used interchangeably with nasolabial angle, but these two are not technically the
same. The columellar-labial angle is formed between the upper lip and the columella (Fig. 2.15) and can be affected by pro-
trusion of the upper lip or by a prominent caudal septum. In Korean females, the mean columellar-labial angle is reported to
be 95.2°. This angle is larger for Caucasians.
Columellar-Lobular Angle
Columellar-lobular angle is the angle formed by the columella and the infratip lobule, and represents the junction between
the medial crura and middle crura (Fig. 2.16). The ideal angle is between 30° and 45° among Caucasian females.
Fig. 2.15 The columellar-labial angle is formed between the upper lip
and the columella
Fig. 2.16 Columellar-lobular angle is an angle formed by the colu-
mella and the infratip lobule
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82
Columellar Show (Alar-Columellar Relationship)
A line is drawn through the long axis of nostril that should bisect the distance between the alar rim and the columellar under-
surface (Fig. 2.17). In Caucasians, the distance between alar rim and columellar undersurface is 3–4 mm. Among Koreans,
the mean distance is reported to be 4.9 mm in males and 4.3 mm in females.
An increase in the distance between the long axis and alar rim indicates alar retraction, and a decrease in this distance
indicates hanging ala. An increase in the distance between the axis and undersurface indicates a hanging columella, while a
decrease in this distance can be an indication of retracted columella.
Fig. 2.17 Normal alar-columellar relationship. A line is drawn through the long axis of nostril that should bisect the distance between the
alar rim and the columellar undersurface
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83
Tip Projection
Compared with Caucasians, the nasal tip is underprojected and is often not as defined in Asians.
Tip projection is the horizontal distance from the alar crease to the nasal tip (Fig. 2.18). Among Koreans, the mean dis-
tance is 2.7 cm for males and 2.4 cm in females.
Tip projection should be evaluated using two methods.
First, the nasal length-to-tip projection ratio needs to be evaluated (Fig. 2.18a). A tip can be considered to be underpro-
jected if the ratio between the nasal length and tip projection is less than 0.67.
Second, the tip projection needs to be evaluated in relation to the upper lip. The length of tip projection can be
divided into anterior and posterior sections by a line drawn from the anterior-most point of the upper lip (Fig. 2.18b).
Ideally, the anterior portion should represent 50–60% of the total nasal tip projection. If this anterior section takes up
more than 60%, the tip is most likely overprojected. Conversely, the anterior portion taking up less than 50% of the tip
projection should point to an underprojected tip.
a
b
Fig. 2.18 Tip projection is the
horizontal distance from the
alar crease to the nasal tip and
is evaluated by two methods
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84
Basal View
Tip projection, nostril shape, and alar shape and width are evaluated from the basal view (Fig. 2.19). The width of alar base
is measured from one ala-facial groove to the other and should ideally be equal to the intercanthal distance. The alar flare is
the alar convexity above the ala-facial groove, and ideally this should not be beyond more than 2 mm outside the groove.
From the basal perspective, the nose should have a shape of an equilateral triangle. The height of infratip lobule should be
one-third of the distance from alar base to the tip.
1/3
2/3
Fig. 2.19 From the basal perspective, the nose should have a shape of an equilateral triangle. The height of infratip lobule should be one-third of
the distance from alar base to the tip
2 Preoperative Evaluation for Rhinoplasty