Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

Advanced Aesthetic Rhinoplasty

(Trang không có chữ)

Melvin A. Shiffman • Alberto Di Giuseppe
Editors
Advanced Aesthetic
Rhinoplasty
Art, Science, and New Clinical
Techniques

ISBN 978-3-642-28052-8
ISBN 978-3-642-28053-5 (eBook)
DOI 10.1007/978-3-642-28053-5
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2013936437
© Springer-Verlag Berlin Heidelberg 2013
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Editors
Melvin A. Shiffman, M.D., J.D.
Section of Surgery
Newport Specialty Hospital
Tustin
CA
USA
Alberto Di Giuseppe, M.D.
Department of Plastic
and Reconstructive surgery
Torrette hospital
Ancona
Italy

This book is dedicated to the memory of Dr. Antonella Belligolli
M.D., Plastic Surgeon, aged 48, who died after a long struggle
with breast cancer, which affected her 15 year back.
She was part of the staff of the Department of Plastic and
Reconstructive Surgery of the University of Ancona, since its
foundation.
She worked since 1991 in the Ancona General Regional
Hospital, and she was a prominent Breast Plastic Surgeon.
But mostly, she was a real doctor: she came to learn plastic
surgery, but fi nally she taught and showed us how a doctor
should be.
Honesty, humanity, tenderness and fi rmness were her
principles, which she applied to her life and her work.
We had the great privilege to work closely with her, and to
learn from her.

To her dear husband Massimo, to her lovely daughter Ilaria
and to her son Pietro, the tough job of continuing their lives,
inspired by the great heart of this splendid woman.
Ciao Antonella
Alberto, Giovanni, Alessandro, Antonello, Marina, and all the
Medical and Paramedical Staff of the Plastic Surgery
Department 1991–2012

vii
Foreword
Head Professor of the Post-Graduate Courses in Plastic Surgery of the
Ponti fi cal Catholic University of Rio de Janeiro and the Carlos Chagas Post-
Graduate Medical Institute. Visiting professor, I.S.A.P.S.
For many years, I have been involved in the teaching of plastic surgery,
having trained many generations of young surgeons eager to learn the prac-
tice of our specialty. Among the diverse anatomical regions that fall under our
care, I believe the nose presents – even to the experienced surgeon – one of
our greatest challenges. Placed in the fulcrum of the face, this complex struc-
ture commands our full attention. A slight defect, a minimal asymmetry, and
harmony is unbalanced. The nasal pyramid must be approached with a per-
fect understanding of anatomy and function, through many different options
of tissue manipulation, with an aesthetic result that is pleasing and in equilib-
rium with the patient’s physiognomy. To operate a primary case, and espe-
cially a secondary nose, requires our utmost skill. The editors of this book
have excelled in bringing together a large team of experts in the art and sci-
ence of rhinoplasty. All aspects of this fascinating area of plastic surgery are
covered, starting with the fundamental principles, moving on to the clinical
evaluation and planning, and including a rich description of surgical tech-
niques, elaborated by authors of large practice. Novel concepts and nonsurgi-
cal approaches are introduced, expanding the scope of a traditional textbook
on rhinoplasty. I congratulate Dr. Shiffman and his collaborators for this
important book, as it will prove to be a valuable contribution to the literature
of plastic surgery.
Rio de Janeiro, Brazil
Ivo Pitanguy

(Trang không có chữ)

ix
Preface
There are many books on rhinoplasty, but most are limited to the editor’s
techniques or those of a few contributors. These give restricted information
on the variety of procedures that are available and are mainly for teaching the
inexperienced and somewhat experienced surgeons how to do rhinoplasty
and possibly stay out of trouble.
This book on Advanced Aesthetic Rhinoplasty: Art, Science, and New
Clinical Techniques gives a detailed analysis of the newer techniques that are
available in primary and secondary rhinoplasty. This allows the presentation
by international experts of the very newest procedures available with subjects
covering nasal anatomy, psychological aspects of rhinoplasty, surgical tech-
niques of primary rhinoplasty and secondary rhinoplasty, the use of fi llers in
rhinoplasty, and the possible risks and complications of rhinoplasty. This
concept of gathering new techniques from international experts is not present
in any other book on rhinoplasty, and the information is extensive and quite
different from even recent books on rhinoplasty. The book is for the inexpe-
rienced, experienced, and the very experienced surgeon doing rhinoplasties.
The editors wish to present advanced technology and clinical techniques
in rhinoplasty from unique contributors experienced with these procedures
that are modi fi ed or original procedures. The contributors are inventive and
eloquent in presenting to the reader a way to progress from inexperienced or
experienced surgeons in rhinoplasty to better understanding that there is more
than following simpli fi ed techniques as a template to performing a procedure
that is fraught with possible risks and complications. Understanding the
patient through psychological pro fi ling will make it easier for the surgeon
to stay out of trouble with patients who are not really candidates for
rhinoplasty.
All cosmetic surgeries are potential problems if the patient is not properly
evaluated preoperatively, not only physically but also mentally. This is most
true with the patient considering rhinoplasty. However, the satisfaction of the
patient who has a good result is inestimable.
Tustin, CA, USA
Melvin A. Shiffman, M.D., J.D.

(Trang không có chữ)

xi
Contents
Part I Anatomy
1 Muscles, SMAS, and Vascular Anatomy of the Nose . . . . . . . .
3
Yves Saban, Chiara Andretto Amodeo, and Roberto Polselli
2 Neurologic Anatomy of the Nose . . . . . . . . . . . . . . . . . . . . . . . .
17
Peter M. Prendergast
3 Anatomy of the Dermocartilaginous Ligament
of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25
Seung-Kyu Han
4 Surgical Anatomy of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . .
33
Robert M. Oneal and Richard J. Beil
Part II Perspectives and Psychology
5 Rhinoplasty in the Ageing Face . . . . . . . . . . . . . . . . . . . . . . . . .
63
James W. Rainsbury and Darryl J. Hodgkinson
6 Self-Esteem and Personality in Patients with Body
Dysmorphic Disorder Undergoing
Cosmetic Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
77
Carla Gramaglia and Enrica Marzola
7 Psychological Aspects of Rhinoplasty . . . . . . . . . . . . . . . . . . . .
93
Mauro Ercolani and Alessandro Agostini
8 Psychological Considerations in Revision Rhinoplasty . . . . . .
99
Bryan T. Ambro and Richard J. Wright
Part III Preoperative
9 Computer Simulated Imaging in Rhinoplasty . . . . . . . . . . . . .
109
Robert T. Adelson
10 Rhinometry: Clinical Index for Evaluation of the Nose . . . . .
119
Abdoljalil Kalantar-Hormozi and Arash Beiraghi-Toosi

xii
Preface
Part IV Primary Rhinoplasty
11 History of Cosmetic Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . .
133
Melvin A. Shiffman
12 Trends in Functional Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . .
137
Joshua D. Weissman and Sam P. Most
13 Primary Caucasian Female Rhinoplasty . . . . . . . . . . . . . . . . .
147
Babak Azizzadeh and Michael J. Reilly
14 Asian Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
163
Yong Ju Jang
15 Hispanic Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
175
Ali Sajjadian
16 Middle Eastern Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . .
187
Ali Sajjadian
17 Rhinoplasty in the Multiracial Nose . . . . . . . . . . . . . . . . . . . . .
197
Thomas Romo III, Manoj T. Abraham, and Whitney Pafford
18 Aesthetic Rhinoplasty Utilizing Various
Techniques Depending on the Abnormality . . . . . . . . . . . . . . .
207
Fernando D. Burstein
19 Sonic Rhinoplasty: Sculpting with the Ultrasonic
Bone Aspirator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
225
Edmund A. Pribitkin, Leela S. Lavasani,
Carol Shindle, and Jewel D. Greywoode
20 Extracorporeal Rhinoseptoplasty . . . . . . . . . . . . . . . . . . . . . . .
233
Francois Disant, Delphine Vertu-Ciolino, and Nicolas Beck
21 External Marginal Approach Rhinoplasty
(EMA Rhinoplasty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
241
Peter Chanwoo Kim and Dae Hwan Park
22 The Controversy Between Open and Closed
Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
295
Arturo Grau
23 Open Technique Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . .
327
Alberto Di Giuseppe
24 The Upper Buccal Sulcus Approach
in Posttrauma Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
349
Christian Vacher
25 Rhinoplasty: Open Techniques . . . . . . . . . . . . . . . . . . . . . . . . .
357
Vladimir Kljajic, Jovan Radmanovic, Ljiljana Vlaski,
and Slobodan Savovic
26 The Intranasal Z-Plasty for Nasal Valve Collapse . . . . . . . . . .
367
Jay M. Dutton, John S. Schneider, and Catherine A. Ray

xiii
Preface
27 Nasal Alar Rim Reconstruction for Nasal
Rim and Valve Collapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
373
Robert J. Troell
28 Lateral Osteotomy in Rhinoplasty . . . . . . . . . . . . . . . . . . . . . .
387
Rauf Tahamiler and Murat Yener
29 Double-Guarded Osteotome for Internal
Lateral Nasal Osteotomies to Prevent Mucosa Tearing . . . . .
401
A. Aldo Mottura
30 Correcting the Convex Lateral Crura
of the Lower Alar Cartilages . . . . . . . . . . . . . . . . . . . . . . . . . . .
409
Alexis D. Furze, Lynn L. Chiu-Collins, Jason Gilde,
and Brian J.F. Wong
31 Alar Base Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
425
Sara R. Dickie, Peter A. Adamson, and Jeremy P. Warner
32 The Anchor Graft: A Technique for Pinched
Nasal Tip and/or Retracted Nasal Ala . . . . . . . . . . . . . . . . . . .
435
C.W. David Chang
33 Stabilizing Cartilage Grafts in Functional-Aesthetic
Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
445
Wolfgang Wagner, Frank Riedel, and Gregor M. Bran
34 Costal Cartilage Grafting for Dorsal Augmentation . . . . . . . .
479
Waleed H. Ezzat and Babak Azizzadeh
35 Split Calvarial Bone Grafting in Rhinoplasty . . . . . . . . . . . . .
491
Babak Azizzadeh and Grigoriy Mashkevich
36 Ultradiced Rib Cartilage Graft Without Wrapping
for Augmentation Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . .
497
Peter Chanwoo Kim and Dae Hwan Park
37 Biomechanical Properties of Facial Cartilage Grafts . . . . . . .
533
Sepehr Oliaei, Cyrus Manuel, Dmitriy Protsenko,
and Brian J.F. Wong
38 Structural Grafts and Suture Techniques
in Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
543
Uwe Mueller-Vogt and Holger G. Gassner
39 Fascia Lata Graft for Nasal Dorsal Contouring
in Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
557
Mehmet Veli Karaaltin
40 Augmentation Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
585
Jose Guerrerosantos
41 Sublabial Approach for Columellar
Reconstruction in Corrective Rhinoplasty . . . . . . . . . . . . . . . .
657
Sarit Cohen and J. Shem Tov

xiv
Preface
42 Caudal Septal Extension Grafts . . . . . . . . . . . . . . . . . . . . . . . .
667
Lynn L. Chiu-Collins, Alexis D. Furze, and Brian J.F. Wong
43
Septal Surgery in the Crooked Nose . . . . . . . . . . . . . . . . . . . . .
679
Hossam M.T. Foda
44 Secondary Cleft Rhinoplasty: Combining an
Open Rhinoplasty with the Dibbell Technique
and Tajima Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
689
Roberto L. Flores and Court B. Cutting
45 Rhinoplasty for Cleft and
Hemangioma-Related Deformities . . . . . . . . . . . . . . . . . . . . . .
699
Judy Pan and Sherard A. Tatum III
46 Postoperative Care of the Rhinoplasty Patient . . . . . . . . . . . .
711
C. Spencer Cochran
Part V Fillers
47 Use of Integra™ in Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . .
721
Jorge Planas
48 Fat Grafting to the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
733
Juan Monreal
49 Orbital Fat Pad for Nasal Tip Augmentation
in Far Eastern Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . .
745
Young Kyoon Kim
50 Permacol in Augmentation Rhinoplasty . . . . . . . . . . . . . . . . . .
753
Claire Hopkins and David Roberts
51 Use of Aquamid as a Filler
for Rhinoplasty in Orientals. . . . . . . . . . . . . . . . . . . . . . . . . . . .
767
Yoichi Yagi
52 Nonsurgical Rhinoplasty: Cosmetic
Nasal Contouring Through the Use of Fillers . . . . . . . . . . . . .
773
Cameron K. Rokhsar and Molly M. Murray
53 Spreader Graft Injection with Calcium
Hydroxylapatite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
783
Christopher P. Nyte
54 Filler, Botulinum Toxin, and Rhinoplasty:
The Medical Rhinoplasty Concept . . . . . . . . . . . . . . . . . . . . . .
791
Frédéric Braccini and Alessio Redaelli
55 Non-surgical Nasal Augmentation and Correction
of Post-rhinoplasty Contour Asymmetries
with Hyaluronic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
799
Dominic Bray

xv
Preface
56 GORE-TEX Implants in Rhinoplasty . . . . . . . . . . . . . . . . . . . .
809
Krzysztof Conrad and Andrew J. Conrad
57 Simultaneous Rhinoplasty and Orthognathic
Double Jaw Procedures: How to Get the Nasolabial
Unit Harmony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
819
Mirco Raffaini
Part VI Tip Procedures
58 Suture Nasal Tip Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
837
Hassan Abbas Khawaja and Melvin A. Shiffman
59 Resection of Strips of Alar Cartilages
for the Difficult Projected Tip with Thin Skin . . . . . . . . . . . . .
845
Abder-Rahman Mounir and Edward Latimer-Sayer
60 Tip Shaping in Primary Rhinoplasty . . . . . . . . . . . . . . . . . . . .
853
Ashkan Ghavami
61 A Modified Delivery Approach . . . . . . . . . . . . . . . . . . . . . . . . .
869
Rui Xavier
62 The Double Columellar Strut: An Adjunct
to Improve the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
877
Mark Berman
63 Surgery on the Primary Nasal Tip: New Domes
Technique and Banner Technique . . . . . . . . . . . . . . . . . . . . . . .
887
Eduardo Morera Serna and Felipe Culaciati Tapia
64 The Medial Crural Suture Technique:
Long-Term Columellar Narrowing Resulting
in Increased Tip Projection and Rotation . . . . . . . . . . . . . . . . .
911
Helen Perakis and Achih H. Chen
65 The Onlay Folded Flap (OFF) for Nasal
Tip Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
919
Hani Abou Mayaleh
Part VII Complications
66 Complications of Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . .
933
Brian C. Harsha
Part VIII Revision Rhinoplasty
67 Functional and Aesthetic Concerns
of Patients Seeking Revision Rhinoplasty . . . . . . . . . . . . . . . . .
947
Kathy Yu, Alyn Kim, and Steven J. Pearlman

xvi
Preface
68 Revision Rhinoplasty: Evaluating the Patient
and the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
957
Keith Ladner and Edward H. Farrior
69 Airway Patency in Aesthetic Rhinoplasty:
Primary and Revisional Techniques . . . . . . . . . . . . . . . . . . . . .
969
Fernando D. Burstein
70 Secondary Rhinoplasty in the Middle Eastern Patient . . . . . .
983
Ashkan Ghavami
71 Revision Rhinoplasty of Asian Noses . . . . . . . . . . . . . . . . . . . . 1001
Chan Hum Park
72 Open Rhinoplasty in Secondary Cases . . . . . . . . . . . . . . . . . . . 1037
Alberto Di Giuseppe and Luca Grassetti
73 The Decision Process in Choosing Costal
Cartilage During Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . 1057
Robert J. DeFatta
74 Harvesting Rib Cartilage Grafts
for Secondary Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067
Vincent P. Marin and C. Spencer Cochran
75 Aesthetic and Functional Restoration Using
Dorsal Saddle-Shaped Medpor Implant
in Secondary Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1075
Murat Türegün
76 Management of the Middle Third
in Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1083
Jonathan Liang, Ji-Eon Kim, and Jonathan Sykes
77 Restoring the Drooping Tip and Hanging
Columella in Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . 1095
A. Joshua Zimm and Samieh Sam Rizk
Part IX Miscellaneous
78 Advancing the Art of Rhinoplasty
with Tissue Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107
Deborah Watson and Marsha S. Reuther
79 Algorithm for Posttraumatic Rhinoplasty . . . . . . . . . . . . . . . . 1119
Tirbod Fattahi
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1123

Part I
Anatomy

3
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_1, © Springer-Verlag Berlin Heidelberg 2013
1
1.1
Nasal Muscles and Concept
of Nasal SMAS
Multiple layers form the soft tissues overlying
the nasal bony and cartilaginous framework: skin,
subcutaneous fat tissue, fi bromuscular, deep are-
olar, and perichondral/periosteal layers.
The fi bromuscular layer can be described fol-
lowing three different approaches: anatomical,
physiological, and surgical.
1.1.1 Classical Descriptive Anatomy
of Nasal Muscles
Classic anatomy treatises [ 1 ] describe several
constant nasal muscles, even if some variations
can be present, especially in the tip area and over
the lateral wall of the bony pyramid (Figs. 1.1
and 1.2 ) (Table 1.1 ):
1. The procerus (Figs. 1.1 and 1.3 ) covers the
nasion lying between the frontalis muscle
cephalically to aponeurosis of the transversus
nasalis muscle caudally. In some cases, it can
be considered as a muscular link between the
frontalis muscle and the nose. It gets adherences
to the periosteum of the nasal bones and to the
perichondrium of ULC, close to the midline of
the dorsum.
2. The transversus nasalis (Figs. 1.1 and 1.4 ) is
adherent on the midline over ULC, forming a
common aponeurosis which is part of both
symmetric muscles. They are composed by two
expansions: the caudal one inserts onto the deep
aspect of the skin, and the cranial one intermin-
gles with the lateral part of the myrtiformis
muscle, covered by levator labii alaeque nasi.
3. The levator labii superioris alaeque nasi
(Figs. 1.1 and 1.4 ) inserts on the frontal pro-
cess of the maxilla and splits into two chiefs:
one goes to the philtrum of the upper lip, the
other one to the ala of the LLC.
4. The dilator naris (Fig. 1.1 ) forms the lateral
framework of the nostril. It is located between
LLC, nostrils margin, and pyriform aperture
in an anatomic area absolutely free of any car-
tilage. It has also been sometimes described as
part of the levator labii superioris muscle, so
forming the deep levator labii superioris.
5. The compressor naris major and minor
(Fig. 1.1 ) are accessory and inconstant mus-
cles which lay in the subcutaneous tissue over
the tip area; especially when LLC lateral crura
are concave, these muscles are located in the
Muscles, SMAS, and Vascular
Anatomy of the Nose
Yves Saban , Chiara Andretto Amodeo ,
and Roberto Polselli
Y. Saban , M.D. (*)
Head and neck- Facial Plastic Surgery
Institute of the French Riviera ,
25 av. Jean Médecin , Nice 06000 , France
e-mail: yves.saban@gmail.com
C. A. Amodeo , M.D.
Department of Plastic and Reconstructive Surgery,
University of Pavia , “Salvatore Maugeri” Foundation
Research and Care Institute Pavia , Italy
R. Polselli
Head and neck- Facial Plastic Surgery ,
Marina di Carrara , Italy

4
Y. Saban et al.
concavity of these cartilages and get insertion
on the nostril margin.
6. The myrtiformis (Figs. 1.5 and 1.6 ) from the
myrtiform fossa splits into an anterior chief
which goes to the upper lip (Fig. 1.7 ) and a
posterior chief which inserts on the nostril’s
fl oor.
7. The depressor septi nasi muscle (Fig. 1.6 )
goes from the orbicularis oris muscle to the
skin of the columella and inserts on the feet of
LLC medial crura after having split into ante-
rior and posterior chiefs.
Micheli -Pellegrini (personal communication,
2005) has proposed a classi fi cation of facial mus-
cles dividing them into three groups depending
on their bony insertion: inserted, semi-inserted,
and not inserted; on the nose, only semi-inserted
and not inserted muscles can be identi fi ed
(Table 1.1 ).
1.1.2 Surgical Applications
Aesthetically, many nasal muscles are involved
in determining the aspect of the pro fi le, affecting
the nasal frontal and nasal-labial angles. In par-
ticular, ancillary surgical procedures performed
on the myrtiformis or the depressor septi nasi
muscles can be useful to open the nasolabial
angle, to rotate the nasal tip, or to lengthen the
upper lip. In the same way, to deepen the fronto-
nasal angle, muscular resection of hypertrophic
procerus muscle has been proposed [ 2 ] .
Depending on anatomic variations of frontal
process of the maxilla, in some anatomical situa-
tions, levator labii superioris alaeque nasi muscle
may insert very high onto this bone; in these cases,
lateral osteotomies carried “low to low” from
pyriform aperture, without periosteal elevation,
can cause hematomas and partial postoperatively
upper lip ptosis due to direct muscle trauma.
Laterally, there is no dissection plane between
the dilator naris muscle and the external nostrils
skin; on the contrary, during alar base resection,
it is possible to remove only the nostril skin, leav-
ing the muscle intact in depth.
1.1.3 Physiologic Anatomy
From a physiological point of view, among the
nasal muscles, we can identify those involved in
respiratory function and those involved in mimic
function. Some muscles have both mimic and
respiratory functions. Many may have synergistic
Fig. 1.1 Anatomical dissection showing nasal muscles:
nasal-labial area after skin resection. Note the bony inser-
tion of the medial canthal tendon on the frontal process of
the maxilla just beneath the radix. Nasal muscles can be
identi fi ed following their topography, shape, and color.
This is the anatomical basis of the so-called medical rhi-
noplasty. All these muscles form a unique musculoaponeu-
rotic layer, so-called nasal SMAS; this layer is separated
from the bony cartilaginous framework by connective tis-
sue which is the right plane for undermining during rhino-
plasty. Note also the yellowish band of soft tissue overlying
the ULC and LLC cartilaginous junction ( a ) procerus
muscle ( b ) transversus nasalis. ( c ) levator labii superioris
alaeque nasi ( d ) dilator naris ( e – f ) compressor naris major
and minor

5
1 Muscles, SMAS, and Vascular Anatomy of the Nose
or antagonistic actions with others, depending on
muscles insertion and topography.
1.1.4 Medical Applications: Use
of Botulinum Toxin
Botulinum toxin, which produces a chemical
denervation of muscles, has been used during
recent past years to open the nasolabial angle
during medical rhinoplasties and to correct nasal
wrinkles in medical facial rejuvenation proce-
dures according to muscles actions [ 3 ] .
1.1.5 Medical Rhinoplasties
To open the nasolabial angle, botulinum toxin
could be injected in the depressor septi nasi as
this muscle has a strong action on lowering nasal
tip. The dilator naris can be injected to correct the
“ fl aring nostrils” effect. Botulinum toxin injec-
tions can also be useful on:
1. Procerus for the horizontal lines over the radix
2. Levator labii superioris alaeque nasi whose
contractions create bunny lines
3. Transversus nasalis in case of vertical wrin-
kles over the lateral wall
Fig. 1.2 Anatomical
dissection showing procerus
muscles: radix after skin
resection. ( a ) The medial
borders of procerus muscles
have been dissected to
facilitate their identi fi cation.
Note the bony insertion on
frontal nasal suture and the
direction of muscle fi bers
cephalically toward frontalis
muscles. Corrugator muscle
is not visible at this step of
dissection as it lays deeper
and is covered by super fi cial
muscles: frontalis, procerus,
and orbicularis oculi muscles
Table 1.1 Nasal muscles
Muscle
Insertion
Function
Morpho-aesthetic implications
Transversus nasalis
Not inserted
Constrictor of the nasal
valve
Vertical wrinkles over nasal dorsum
Procerus
Semi-inserted
Nasal and frontal mimic Horizontal wrinkles over nasal radix and
glabella
Levator labii superioris
alaeque nasi
Semi-inserted
Dilating
Bunny lines
Dilator naris
Not inserted
Dilating
Flaring nostrils
Depressor septi nasi
Not inserted
Nasal mimic
Tip ptosis
Myrtiformis
Semi-inserted
Dilating
Displacement of nostrils lower margins
Horizontal philtral wrinkles
Compressor naris major
Not inserted
Constrictor
Alar margin retraction
Dome depression
Compressor naris minor
Not inserted
Constrictor
Alar margin retraction
Dome depression

6
Y. Saban et al.
Botulinum toxin is very effective in pathological
situations like hemifacial spasm and blepharos-
pasm when nasal muscles are concerned in the
pathology.
1.1.6 Surgical Anatomy, Nasal SMAS,
and Nasal Ligaments
1.1.6.1 Nasal SMAS
From a surgical point of view, the fi bromuscular
layer covering the nasal skeleton can be
considered as a continuous anatomical layer, so-
called nasal SMAS (Fig. 1.2 ). Composed by
muscular and aponeurotic anatomical structures,
it extends from the nasofrontal angle (radix) to
nostril margin, continuing medially onto the col-
umella down to the nasolabial angle. Laterally, it
is connected to facial SMAS [ 4– 6 ] .
1.1.6.2 The SMAS as the Vessels
Carrying Layer
It is important to notice that all nasal vessels run
inside the nasal SMAS, and from this fi bromuscular
layer, the arteries give off perforating branches,
Fig. 1.3 Anatomical dissection showing nasal muscles:
nasal pyramid after skin resection. ( a ) Transversus nasa-
lis. ( b ) Levator labii alaeque nasi muscles. Note how the
levator labii alaeque nasi muscle splits into two separate
chiefs: the upper one, which disappears under the nostril
skin, corresponds to the ala portion; the lower one turns
around the alar-facial groove and goes to the philtrum,
crossing super fi cially the upper lip
Fig. 1.4 Anatomical dissection showing myrtiformis and
depressor septi nasi muscles: nasal-labial area after upper
lip, separation of inferior nostril rim, section of buccal
mucosa, and lifting of the left upper lip. ( a ) Main portion of
myrtiformis muscle is exposed as it inserts onto myrtiformis
fossa delimitated laterally by the canine tooth. Note the ver-
tical direction of muscular fi bers. The anterior nasal spine,
where the ( b ) depressor septi nasi muscle inserts, is visible.
One can notice the ( c ) subnasal artery sectioned and elevated
in the lip fl ap; this artery lies between two muscular layers,
myrtiformis in depth and orbicularis oris super fi cially
Fig. 1.5 Anatomical dissection showing myrtiformis
muscle nostril expansion: labial nasal area. Hooks elevate
the nostril fl oor. Note the orbicularis oris muscle covering
myrtiformis muscle main chief; the ( a ) expansion of myr-
tiformis muscle fi bers to nostril fl oor is identi fi ed

7
1 Muscles, SMAS, and Vascular Anatomy of the Nose
which form the subdermal plexus and reach the
skin (Fig. 1.8 ). Forming a unique layer on the nasal
dorsum, it can also be considered a protective layer
in between the skin and the nasal framework.
1.1.6.3 Composition of Nasal SMAS
At the level of the intercartilaginous junction
(i.e., internal nasal valve), the nasal SMAS splits
into super fi cial and deep layers; each layer is
composed of two wings (medial and lateral):
1. The super fi cial layer gives two wings: the lateral
wing (alar wing) passes over the LLC to insert
into the skin of the alar margin; medially, the
medial wing (columellar wing) runs over nasal tip
then into the columella, between the skin and car-
tilage, to reach the depressor septi nasi muscle.
2. The deep layer divides into lateral and medial
wings: the lateral wing (valve wing) is composed
of yellowish tissue and inserts onto the carti-
laginous junction between ULC and LLC in the
scroll, forming the internal nasal valve. The
medial wing (septal wing) runs inside the mem-
branous septum, between the anterior septal
angle and the interdomal ligament, down to the
anterior nasal spine (Figs. 1.9 and 1.10 ) The
septal wing may correspond to the Pitanguy’s
ligament as it can connect the deep aspect of
the dorsal skin to the anterior septal angle [ 7 ] .
According to these statements, the nasal SMAS
can be described as a unique layer overlying the
whole nasal pyramid from the forehead to the
nostrils margins, getting intermediate insertions
onto the nasal valve.
1.1.6.4 Nasal Ligaments
Besides the interdomal ligament that connects
together the domes of LLC, the nasal SMAS is
connected to the perichondral and periosteal lay-
ers by expansions containing perforating vessels,
so-called nasal ligaments.
Fig. 1.6 Anatomical dissection showing depressor septi
and myrtiformis muscles: left nostril inferior view after
skin resection, separation of nostril fl oor expansions of
myrtiformis muscle retracted laterally. ( a ) Lateral expan-
sion of myrtiformis muscle, visible in depth, goes upward,
and intermingles with transversus nasalis muscle. ( b )
Anteriorly above anterior nasal spine, muscular fi bers of
depressor septi nasi muscle goes into the columella
Fig. 1.7 Nasal SMAS
anatomical dissection: skin
has been removed exposing
the SMAS layer which covers
the whole nasal pyramid from
radix to tip and nasolabial
angle. Nasal muscles and
vessels running in the SMAS
layer can be identi fi ed: black
arrow , constrictor naris
muscle; green arrow , dilator
naris muscle; yellow arrow ,
levator labial alaeque nasi
muscle; light blue arrow ,
transversus nasalis muscle

8
Y. Saban et al.
Two nasal ligaments can be identi fi ed onto the
lateral portion of the nasal pyramid:
1. The superior one is halfway over the lateral
aspect of the upper lateral cartilages, at the
osteocartilaginous junction between the nasal
bones and the ULC (Fig. 1.11 ).
2. The inferior one is located laterally at the level
of the pyriform aperture in the fi brous triangle
(Fig. 1.11 ).
1.1.6.5 Medial Canthal Tendon
The medial canthal tendon is a fi brous band
formed by the junction of the superior and infe-
rior tarsal lamellae. It runs medially toward the
medial orbital wall and splits into two chiefs: the
super fi cial one inserts onto the anterior lachrymal
crest, on the frontal process of the maxilla, as the
deep one, called also the Horner’s muscle formed
by pretarsal portions of orbicularis oculi muscle,
inserts onto the posterior lachrymal crest. Both
chiefs surround the lachrymal sac.
1.1.6.6 Surgical Applications
Nasal SMAS divides subcutaneous plane into
two planes of dissection: subcutaneous and sub-
SMAS [ 8 ] . While performing rhinoplasty, the
right surgical plane of dissection is always sub-
SMAS, even if the dissection above the nasal
SMAS in the subcutaneous fatty plane is feasible.
But especially in supratip area, this super fi cial
plane is crossed by perforating vessels running
from the nasal SMAS to dermis. So, super fi cial
dissection which interrupts these small vessels in
this subcutaneous plane is not recommended.
1.1.7 Open Rhinoplasty and
SMAS Undermining
Transcolumellar incision and SMAS columellar
wing section: when performing open rhino-
plasties, it is necessary to cut the columellar wing
of the nasal SMAS in which small columellar
arteries run. Then sub-SMAS dissection of the
Fig. 1.8 Nasal SMAS anatomic dissection: note that in
the SMAS layer run all the main vessels
Fig. 1.9 Nasal SMAS deep layer: the deep wings of the
nasal SMAS are exposed. The columellar wing has been
transacted and nasal SMAS fl ap elevated. Black arrow ,
columellar wing; green arrow , LLC; blue arrow , valve
wing; light blue arrow , septal wing

9
1 Muscles, SMAS, and Vascular Anatomy of the Nose
columella can be performed in close contact of
the caudal edge of LLC medial crura, staying in
the same surgical plane medially up to supratip
area without cutting any other anatomical struc-
ture. At this point, a vertical fi brous band running
from super fi cial soft tissues toward the nasal spine
is present, and it is impossible to reach the nasal
dorsum without cutting this structures which is
actually the septal wing of the nasal SMAS. Sub-
SMAS undermining will not cross any other
obstacle up to frontonasal angle, except on nasal
bones where procerus muscles take insertion.
During the same procedure, or while perform-
ing marginal extended approach, the nasal SMAS
is elevated laterally from nostril margins until the
cranial border of the LLC. At this point, to reach
the dorsum, it is mandatory either to transect or,
better, to elevate the yellowish tissue (which is in
fact the valve wing of nasal SMAS) which inserts
onto the internal nasal valve and where lateral
nasal artery lies (Fig. 1.12 ).
1.1.8 Rhinoplasty and
Nasal Ligaments
Nasal ligaments can be considered as lateral lim-
its for the lateral sub-SMAS dissection; Joseph’s
elevator is blocked by these ligaments and vessels
during both external and endonasal rhinoplasty.
When performing low to low lateral osteotomies,
the super fi cial chief of the medial canthal tendon
can be damaged. Furthermore, several muscles of
the nasal area insert either onto or below the
super fi cial chief of the medial canthal tendon:
preseptal portion of orbicularis oculi, levator labii
Fig. 1.10 Nasal SMAS deep layer: ( a ) the transection of
septal wing and ( b ) allows exposition of anterior septal
angle and surgical access to the cartilaginous dorsum
Fig. 1.11 Nasal SMAS
ligaments: the SMAS layer
has been elevated and
transacted on the midline,
then laid laterally on right
side. Note that over the
lateral wall of the nasal
pyramid, deep vertical fi brous
structures ( a – b ) connect the
SMAS to the nasal skeleton.
In these bands run vessels. To
perform sub-SMAS
dissection laterally, it is
necessary to cut these
ligaments, and this can
expose to intraoperative
bleeding

10
Y. Saban et al.
superioris alaeque nasi, depressor supercilii, and
levator genae. Injuries to these structures can lead
to major swelling, hematoma, palpebral ecchy-
mosis, temporary medial dystopia, and upper lip
ptosis (Fig. 1.13 ).
1.1.9 Nasal SMAS Injury
During Rhinoplasty
Partial or total accidental loss of nasal SMAS dur-
ing hump removal can lead to adherences between
dermis and cartilaginous/bony framework. If it
happens many consequences can occur:
1. From an aesthetic point of view, the cartilagi-
nous and bony framework become visible
under the skin as they are not anymore hidden
by the fi bromuscular soft tissue layer.
2. Open roof syndrome can occur due to adher-
ences between the internal nasal mucosa and
the external dermis through the hiatus of the
open roof. This syndrome leads to pain and
vasomotor problems.
3. Adherences between skin and nasal framework
are extremely dif fi cult to dissect if a revision is
needed; skin injuries, perforations, scars, and
retractions can occur. In this situation, it is nec-
essary to insert a connective layer between skin
and bony/cartilaginous framework.
4. Neoangiogenesis and telangiectasia of skin
over the nasal dorsum can be observed.
Fig. 1.12 Nasal SMAS deep
layer: valve wings have been
transacted allowing elevation
of the entire SMAS overlying
nasal dorsum. The dissection
has been performed above the
perichondrial and periosteal
layer. Note the vessels
running in this layer
Fig. 1.13 Muscular injuries due to low to low osteoto-
mies. Note the path of low to low osteotomies which can
cause muscles injury

11
1 Muscles, SMAS, and Vascular Anatomy of the Nose
1.1.10 Nasal SMAS Surgery
and Rhinoplasty
1.1.10.1 Rhinoplasty Access
and Nasal SMAS
When performing marginal incision, the surgeon
has to transect muscular insertions of compressor
narium muscles which appear as brown pink tissue
that is very adherent onto LLC lateral crura sur-
face. The alar wing is fi rmly adherent to cartilage
from which it has to be undermined in order to
give proper access to the dorsum, avoiding bleed-
ing due to vessels running in this layer and allow-
ing better appreciation of the cartilage shape.
1.1.10.2 Tip Rotation and Valve
Improvement
To allow easier tip rotation during endonasal rhi-
noplasty, it is recommended to transect the septal
wing of the nasal SMAS. In some cases, the
depressor septi nasi muscle inserts on the feet of
LLC medial crura. Its action may produce tip
drooping and nasolabial angle deepening. Section
or resection of these insertions may be necessary
to allow tip rotation and to maintain surgical
result in good position.
1.2
External Nasal Vascularization
1.2.1 Primary Nasal Blood Supply
Blood supply to the external nose is provided both
by facial and ophthalmic arteries, the branches of
the external and internal carotid arteries. During
the anatomic dissections, the author has noticed
several variations in nasal blood supply, and this
is con fi rmed by many different anatomical varia-
tions of nasal arteries described in literature. For
example, angular artery may be considered in
some cases the terminal branch of either facial or
ophthalmic arteries. In usual practice and to make
it simple, one can consider four main arteries –
two facial and two ophthalmic – and their branches
forming a unique anastomotic system which guar-
antees nasal vascularization in any physiological
or pathological situations. The entire arterial sys-
tem is located within the nasal SMAS.
1.2.2 Description of Nasal Arteries
The facial artery gives rise to the superior labial
artery which meets the contralateral artery over the
upper lip. At this level, a vertical branch runs
cephalically into the philtrum to columella. This
small branch runs upward, meets the columellar
branch of the subnasal artery forming the columel-
lar artery which lies in the columella, and gives
rise to its terminal branches over the tip area.
The lateral nasal artery branches off from
facial artery at the level of the alar-facial groove
and gives off two or three branches which form
little arteries over the lateral crura, the dorsum,
and the lobule area. The small distal branches of
lateral nasal artery form several anastomoses
with contralateral branch and with columellar
arteries. More recent studies focused on nasal
blood supply have shown that the lateral nasal
artery, one of the three major blood supplies to
the nasal tip, can branch off either from the facial
artery or from the superior labial artery [ 9 ] .
Toriumi has reported that lateral nasal artery
runs along the cephalic margin of lateral crura of
the lower lateral cartilages, giving off little
branches which pass over the lateral crura toward
the nostril rim. These little vessels reach the tip
and meet the columellar arteries over the domal
area to form the alar arcade, which lies over the
alar lobule [ 10 ] .
The last branch of the facial artery is the angular
artery which runs over the medial canthal area to
meet the nasal artery branch of ophthalmic artery.
Another blood supply to the nasal area comes from
the dorsal nasal artery which, at its origin at the
level of the medial canthus, is considered a termi-
nal branch of the ophthalmic artery (Fig. 1.14 ).
1.2.3 Variations of Nasal Blood Supply
A recent study has classi fi ed the distribution of
the arteries that form the primary blood supply of
nasal tip in Asians into four types, depending on
their origins: in type I, vessels to nasal tip come
from ipsilateral lateral nasal artery (62.7%), in
type II from ipsilateral dorsal nasal artery
(15.7%), in type III from contralateral lateral

12
Y. Saban et al.
nasal artery (15.7%), and type IV from contralat-
eral dorsal nasal artery (5.9%) [ 11 ] .
When regarding nasal tip blood supply, in the
majority of cases lateral nasal artery is the main
blood supply to the tip, then dorsal nasal artery and
variable contributions come from columellar artery.
1.2.4 The Concept of Anastomosis
Between Internal and External
Carotid
Lassau and Mitz in 1973 [ 12 ] stated that blood
supply to the whole face is always preserved by
the presence of many anastomosis. They have
shown that the main arteries run in or under the
SMAS layer, giving off perforating branches to
dermis which form the subdermal plexus
(super fi cial anastomosis). These vascular anasto-
moses are also present at the level of the nasal
area, mainly at the level of the radix and the tip.
Authors call these anastomosis superior nasal
arcades and inferior nasal arcade.
Following Salmon’s work, Taylor has intro-
duced the concept of angiosome which are three-
dimensional composite anatomic structures
whose blood supply is provided by a single vas-
cular pedicle. This concept is of great surgical
interest especially for composite fl aps used in
postoncological defects corrections. Concerning
the nose, Houseman and Taylor have described
two angiosomes which correspond to external
and internal carotid systems. It is impossible to
identify speci fi c nasal angiosomes because four
arteries (the facial and the ophthalmic arteries on
both sides) are responsible for the vascularization
of the same area, depending on blood pressure
and on patient’s anatomy [ 13– 15 ] .
1.2.5 Nasal Anastomotic Polygonal
Blood Supply Concept
According to our anatomical and physiological
experience, we consider nasal blood supply as a
polygonal arterial anastomotic system. This
mesh-pattern multidirectional system connects
both external and internal carotid systems, and it
works like a transfacial anastomosis (Fig. 1.15 ).
This arterial system is composed of three hori-
zontal vessels:
1. Lateral nasal artery, running over the cephalic
margin of the lateral crura
2. Marginal alar artery branching off either from
the facial artery or sometimes from the lateral
nasal artery, prior to and more caudally than
the lateral nasal artery
3. Radix artery branching off from the angular
artery and running transversally at the level of
the radix of the nose
All the vessels running transversally meet the
contralateral homologue artery over the midline.
Fig. 1.14 External arterial vascularization of the nose:
facial arteries have been injected bilaterally with red-dyed
liquid. Cadaver dissection was performed following the
arteries after skin resection. Nasal blood supply is provided
by a transfacial polygonal arterial anastomotic system that
connects the internal and external carotid systems. Note
the vessels which form this system: ( a ) right facial artery,
( b ) subnasal artery, ( c ) marginal artery, ( d ) lateral artery,
( e ) radix artery, ( f ) angular artery, ( g ) right dorsal artery, ( h )
left dorsal artery, ( i ) nasal artery, ( l ) philtrum artery, and
( m ) superior labial artery

13
1 Muscles, SMAS, and Vascular Anatomy of the Nose
These vessels are connected by three longitudinal
vessels:
1. Columellar artery, which runs upward from
subnasal artery toward the tip
2. Angular artery, running laterally and longitu-
dinally from alar-facial groove to medial can-
thal tendon
3. Dorsal nasal artery running over the nasal
dorsum
Sometimes, a longitudinal inconstant intermedi-
ate artery can be observed, running longitudinally
over the lateral nasal wall, from the lateral nasal
artery to the radix artery.
So, one can consider the horizontal vessels
(marginal, lateral nasal, and radix artery) forming
three arterial arcades: the marginal, the nasal valve,
and the radix arcades which are connected by the
anastomotic longitudinal arteries. Furthermore,
the marginal arcade forms with the columellar
arteries and the subnasal artery, an arterial circle
around the nostrils.
In this system, the major blood fl ow can be
provided both by the internal and the external
carotid arteries of both sides depending on the
patient’s anatomy (absence of some vessels),
physical features (higher blood pressure in inter-
nal or external carotid artery), and blood can run
from nasal tip to radix and vice versa.
This polygonal system explains the physio-
logical blood supply to the nose and the possible
inversion of the fl ow, depending on the blood
pressure in internal and external carotid arteries.
This has been con fi rmed by our ultrasound
Doppler work showing inversion of arterial nasal
blood fl ow. In physiological situation, the main
nasal fl ow is provided by facial artery. Compression
of facial artery causes inversion of the blood fl ow
direction. Then compression of ipsilateral oph-
thalmic artery may cause either complete inter-
ruption or lowering of the fl ow registered by echo
Doppler (Figs. 1.16 and 1.17 ).
1.2.6 Surgical Applications
During external rhinoplasty approach, dissection
in sub-SMAS plane is absolutely safe because
blood supply to nasal tip is extremely rich, and
a
b
Fig. 1.15 External arterial vascularization of the nose:
( a ) the skin of the tip has not been resected. ( a ) Marginal
arcade, ( b ) nasal valve arcade, and ( c ) radix arcade. ( b )
Note the transfacial anastomosis formed by the arcades

14
Y. Saban et al.
even closure of a major vessel does not cause
necrosis. While performing rhinoplasties, precise
and careful elevation of soft tissues in sub-SMAS
plane allows protection of nasal arteries. In recon-
structive procedures, the presence of this multidi-
rectional polygonal fl ow system allows the use of
fl aps with longitudinal or transverse pedicles to
reconstruct nasal defects in order to respect the
nasal subunits as described by Burget [ 16 ] .
While performing medical primary rhino-
plasties using fi llers, if intravascular injections
are performed, presence of so many anastomoses
forming this system limits the risk of necrosis.
On the contrary, sometimes it may create (1) a
real risk of antegrade arterial embolism, which
anyway in the majority of cases does not cause
tissue necrosis, thanks to blood supply coming
from other vessels, and (2) a risk of retrograde
Fig. 1.16 Doppler
ultrasound of facial artery
showing intercarotid
anastomosis: The two fi rst
spikes correspond to
physiological fl ow coming
from the facial artery. After
facial artery compression, an
inversion of the blood fl ow
occurs, and it comes from the
ophthalmic artery
Fig. 1.17 Doppler ultra-
sound of facial artery
showing intercarotid
anastomosis: after releasing
of the compression on facial
artery, the blood fl ow returns
to the previous physiological
situation

15
1 Muscles, SMAS, and Vascular Anatomy of the Nose
arteriolar microembolism into ophthalmic artery,
which can lead to temporary or permanent visual
loss [ 17, 18 ] .
In revision rhinoplasties, prior to fi ller injec-
tions, it is mandatory especially in tip area to
evaluate the presence of (1) any adherence
between dermis and bony/cartilaginous frame-
work (in this case, the main nasal vascularization
is compromised) and (2) subcutaneous grafts
(i.e., shield graft, umbrella graft; in this area, the
space between LLC and dermis is very thin, and
the grafts placed there compress the subdermal
vessels). In our opinion, injections performed in
this area after placement of tip grafts can lead to
skin necrosis, especially after using external rhi-
noplasty approach, which interrupts de facto
blood supply from columellar arteries.
When blood supply to the tip is compromised,
every fi ller injection performed in this area may
cause a further compression on vessels, even if
the injection is performed correctly.
References
1. Testut L (1900) Traité d’Anatomie Humaine, 4th edn.
Octave Dom, Paris
2. Meyer R (2002) Residual bony deformity. Nasofrontal
angle. In: Meyer R (ed) Secondary rhinoplasty: includ-
ing reconstruction of the nose, 2nd edn. Springer, New
York, p 68 (Chapter 11)
3. Redaelli A, Braccini F (2010) Medical rhinoplasty.
Basic principles and clinical practice. OEO, Firenze
4. Saban Y, Andretto AC, Hammou JC, Polselli R (2008)
An anatomical study of the nasal super fi cial muscu-
loaponeurotic system: surgical applications in rhino-
plasty. Arch Facial Plast Surg 10(2):109–115
5. Saban Y, Polselli R (1994) Atlas of surgical anatomy
of the face and neck. Masson, Paris
6. Saban Y, Polselli R (2009) Atlas d’Anatomie
Chirurgicale de la Face et du Cou. SEE, Firenze
7. Pitanguy I, Salgado F, Radwanski HN, Bushkin SC
(1995) The surgical importance of the dermocartilagi-
nous ligament of the nose. Plast Reconstr Surg 95(5):
790–794
8. Sterzi G (1910) Il Tessuto Sottocutaneo (Tela
Subcutanea). Niccolai, Firenze
9. Nakajima H, Imanishi N, Aiso S (2002) Facial artery
in the upper lip and nose: anatomy and clinical appli-
cation. Plast Reconstr Surg 109(3):855–861
10. Toriumi DM, Mueller RA, Grosch T, Bhattacharyya
TK, Larrabee WF Jr (1996) Vascular anatomy of the
nose and the external rhinoplasty approach. Arch
Otolaryngol Head Neck Surg 122(1):24–34
11. Jung DH, Kim HJ, Koh KS, Oh CS, Kim KS, Yoon
JH, Chung IH (2000) Arterial supply of the nasal tip
in Asians. Laryngoscope 110(Pt 2):308–311
12. Lassau JB, Mitz V, Ricbourg B (1975) Les branches
faciales de l’artère faciale. In: Memoires du
Laboratoire d’ Anatomie de la Faculté de Paris,
Paris
13. Salmon M (1936) Artères des muscles de la tête et du
cou. Ed Masson, Paris, pp 9–75
14. Taylor GI, Palmer JH (1987) The vascular territories
(angiosomes) of the body: experimental study and
clinical applications. Br J Plast Surg 40(2):113–141
15. Houseman ND, Taylor GI, Pan WR (2000) The angio-
somes of the head and neck: anatomic study and clini-
cal applications. Plast Reconstr Surg 105(7):
2287–2313
16. Burget GC, Mehick FJ (1985) The subunit principle
in nasal reconstruction. Plast Reconstr Surg 76(2):
239–347
17. Mc Cleve DE, Goldstein JC (1995) Blindness second-
ary to injections in the nose, mouth and face: cause
and prevention. Ear Nose Throat J 74(3):182–188
18. Sung MS, Kim HG (2010) Ocular Ischemia and isch-
emic oculomotor nerve palsy after vascular emboliza-
tion of injectable calcium hydroxyhapatite fi ller.
Ophthal Plast Reconstr Surg 26(4):289–291

17
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_2, © Springer-Verlag Berlin Heidelberg 2013
2
2.1
Introduction
The external nose and nasal cavity receive a rich
sensory innervation through branches of the fi rst
and second divisions of the trigeminal nerve
(Fig. 2.1 ). Autonomic nervous supply to the nose
arises from the superior salivatory nucleus in the
brain stem (parasympathetic) and superior cervi-
cal ganglion (sympathetic) via the pterygopala-
tine ganglion. Knowledge of the neurologic
anatomy of the nose is important for the facial
and rhinoplasty surgeon who must place inci-
sions strategically to avoid inadvertent injury to
sensory nerves. Regional nerve blocks also
require a detailed knowledge of the sensory
innervation of the nose and the locations of the
foramina from which they emerge.
The soft tissues and skin of the external nose
are innervated by the infratrochlear and external
nasal nerves. These are branches of the ophthalmic
division of the trigeminal nerve. Nasal branches of
the infraorbital and anterior superior alveolar
nerves, both terminal branches of the maxillary
nerve, provide further sensory innervation to the
sides and part of the tip and columella (Fig. 2.2 ).
Within the nasal cavity, special sensory inner-
vation relating to olfaction is provided by the fi rst
cranial nerve. General sensation in the nasal cav-
ity is relayed through branches of the ophthalmic
and maxillary nerves. These include the anterior
ethmoidal, infraorbital, and posterior superior
alveolar nerves. Further innervation is provided
indirectly through the pterygopalatine ganglion
by the posterior superior nasal, greater palatine,
and nasopalatine nerves (Fig. 2.3 ).
Neurologic Anatomy of the Nose
Peter M. Prendergast
P. M. Prendergast , M.D., MBBCh, MRCSI
Venus Medical , Heritage House, Dundrum
Of fi ce Park , Dundrum, Dublin 14 , Ireland
e-mail: peter@venusmed.com
Fig. 2.1 Sensory innervation of the face. The nose is sup-
plied by branches of the fi rst (V1 ophthalmic), second (V2
maxillary), and third (V3 mandibular) divisions of the
trigeminal nerve

18
P.M. Prendergast
2.2
Olfactory Nerves
The olfactory nerves transmit the special sense
of smell and arise from olfactory cells that lie in
the mucosa of the superior conchae and supe-
rior part of the nasal septum. From the neural
plexus that lies in the nasal mucosa arise about
20 branches of unmyelinated nerves. These
branches are ensheathed in dura, pia, and arach-
noid mater and pass through the cribriform
plate to reach the olfactory bulb in the anterior
cranial fossa. The extension of the meningeal
layers from the brain to the nasal cavity is a
potential avenue for the transmission of infec-
tion through the subarachnoid space to the
intracranial cavity.
2.3
Sensory Nerves
2.3.1 Anterior Ethmoidal Nerve
The anterior ethmoidal nerve is a direct continua-
tion of the nasociliary nerve when the latter arrives
at the medial orbital wall after crossing the optic
nerve and running below the superior rectus and
superior oblique muscles. After traversing the
anterior ethmoidal foramen and canal, the anterior
ethmoidal nerve runs along the cribriform plate
before passing through a slit lateral to the crista
galli to enter the nasal cavity. Medial and lateral
branches supply the mucosa of the nasal septum
and lateral nasal wall, respectively. At the caudal
end of the nasal bone, the nasociliary nerve
External nasal n.
Anterior superior aIveolar n.
Infraorbital n.
Infratrochlear n.
Maxillary n.
Ophthalmic n.
Fig. 2.2 Nerves to the external nose

19
2 Neurologic Anatomy of the Nose
appears 6.5–8.5 mm from the midline as the exter-
nal nasal nerve. From this position between the
nasal bone and the upper lateral cartilage, it runs
parallel to the midline toward the nasal tip.
Variations in the external nasal nerve exist [ 1 ] .
The nerve may appear as two branches superiorly,
branch as it approaches the apex of the nose, or
remain as a single branch along its course. The
external nasal nerve passes deep to the nasalis and
super fi cial musculoaponeurotic layer of the nose,
through the deep fatty layer, to the alar cartilages.
The nerve supplies sensation to the distal aspect
of the nasal dorsum and tip of the nose, as well as
the skin of the nasal ala. Injudicious endonasal
incisions or dissection during rhinoplasty surgery
can easily lead to transection of the external nasal
nerve resulting in nasal tip dysesthesias. Nerve
injuries may be minimized by avoiding deep inter-
cartilaginous or intracartilaginous incisions,
restricting the dissection to within 6.5 mm of the
midline, and limiting dorsal nasal onlay grafts to
13 mm at the rhinion [ 1 ] .
2.3.2 Infratrochlear Nerve
The infratrochlear nerve, a branch of the nasocili-
ary nerve, arises near the anterior ethmoidal fora-
men and runs along the medial wall of the orbit
before exiting above the medial canthus. The
nerve runs inferiorly and supplies sensation to the
medial eyelid, lateral part of the nose above the
medial canthus, medial conjunctiva, and lacrimal
apparatus. The infratrochlear nerve also receives a
branch from the supratrochlear nerve lateral to it.
2.3.3 Infraorbital Nerve
The infraorbital nerve is the largest terminal branch
of the maxillary nerve. The latter arises between
the fi rst and third divisions of the trigeminal nerve
as a broad band, passes through the foramen
rotundum, and becomes more cord-like as it
enters the pterygopalatine fossa. It sends two gan-
glionic branches to the pterygopalatine ganglion
External nasal n.
Posterior superior nasal n.
Nasopalatine n.
Anterior ethmoidal n.
Olfactory n.
Pterygopalatine ganglion
Internal nasal branches
External nasal n.
Lateral posterior superior nasal n.
Greater Palatine n.
Lesser Palatine n.
a
b
Fig. 2.3 Innervation of the
nasal cavity. ( a ) Medial
branches supply the septum.
( b ) Lateral branches supply
the lateral walls and conchae

20
P.M. Prendergast
before continuing anteriorly to give off its sensory
branches that innervate the midface. Nasal sen-
sory nerves arise from both the anterior superior
alveolar nerve and the larger infraorbital nerve.
The anterior superior alveolar nerve arises in the
infraorbital canal and traverses the canalis sinuo-
sus, passes below the infraorbital foramen on the
maxilla, and then turns inferiorly lateral to the
nose before sending branches to the central lip,
incisors, columella, and tip of the nose. The
infraorbital nerve traverses the infraorbital canal
in the fl oor of the orbit. It emerges as fi ve branches
at the infraorbital foramen about 6–8 mm below
the inferior orbital rim in line vertically with the
pupil. These sensory branches consist of the infe-
rior palpebral, external, and internal nasal branches
and medial and lateral subbranches of the superior
labial branch of the infraorbital nerve [ 2 ] . The
infraorbital nerve branches emerge into the
infraorbital space over the maxilla, where they are
amenable to nerve block or susceptible to both
traumatic and iatrogenic injuries. This space is
bounded superiorly by the origin of levator labii
superioris, laterally by levator anguli oris, medi-
ally by levator labii superioris alaeque nasi, and
inferiorly by orbicularis oris. Hu [ 2 ] describes
four branching patterns of the infraorbital nerve
as it appears from its foramen (excluding the infe-
rior palpebral branch): type I, where all four
branches are separated; type II, where the two
nasal branches are separated but the superior
labial branches are fused; type III, where the supe-
rior labial branches are separated but the nasal
branches are merged; and type IV, where the two
nasal branches and the two labial branches are
fused. The external nasal branch of the infraor-
bital nerve innervates the lateral part of the nose
and ala. The internal nasal nerve arises from the
lateral part of the infraorbital foramen and runs
down along the nose and around the ala to inner-
vate the nasal septum and vestibule.
2.3.4 Anterior Superior Alveolar Nerve
This branch of the infraorbital nerve arises before
the latter reaches the infraorbital foramen. It
supplies a small part of the external nose at the tip
and columella (Fig. 2.2 ).
2.3.5 Posterior Superior Nasal Nerves
These branches of the maxillary nerve innervate
the nasal cavity through a number of smaller
medial and lateral branches. Lateral branches
supply the mucosa of the superior and middle
nasal conchae, whereas medial branches send
fi bers to the nasal septum (Fig. 2.3 ). The naso-
palatine nerve represents the largest of the medial
posterior superior nasal nerves. It passes antero-
inferiorly in a groove on the vomer to reach the
fl oor of the nasal cavity. From here, it passes
through the incisive fossa of the hard palate and
communicates with the greater palatine nerve to
supply the mucosa of the hard palate. The poste-
rior superior nasal nerves pass through the ptery-
gopalatine ganglion without synapsing and onto
the maxillary nerve via its ganglionic branches.
2.3.6 Palatine Nerves
The greater and lesser palatine nerves are also
sensory branches of the maxillary nerve, via the
pterygopalatine ganglion. From the ganglion,
they pass inferiorly through the greater palatine
canal. In the canal, the larger greater palatine
nerve gives off branches that perforate the per-
pendicular plate of the palatine bone to enter
the nasal cavity. These posterior inferior
branches supply sensation to the mucosa over
the inferior nasal concha and the inferior and
middle meatuses. The greater palatine nerve
emerges from its canal through the greater pala-
tine foramen and passes anteriorly in the roof of
the palate, innervating the mucosa and gingivae
and communicating with the nasopalatine nerve
anteriorly. The lesser palatine nerve runs with
the greater palatine nerve, emerging through
the lesser palatine foramen to send sensory
fi bers to the tonsils, uvula, and soft palate. It
does not contribute to the innervation of the
nose or nasal cavity.

21
2 Neurologic Anatomy of the Nose
2.4
Regional Anesthesia
of the Nose
Nerve blocks are valuable techniques that facili-
tate outpatient nasal surgery, including rhino-
plasty, and obviate the need for general anesthesia
and even sedation in selected cases [ 3 ] . The tip of
the nose is anesthetized by blocking the external
nasal nerve with an injection over the periosteum
at the junction of the nasal and cartilaginous parts
of the nose on either side of the midline.
Anesthesia of the bridge of the nose requires a
block of the infratrochlear nerve. Since the naso-
ciliary nerve gives off the infratrochlear nerve
and continues as the anterior ethmoidal nerve,
blocking this nerve achieves anesthesia of the
root, dorsum, and tip of the nose. To block the
nasociliary nerve, a 30-mm 25-gauge needle is
inserted 1 cm above the medial canthus and
passed posterolaterally along the bone to a depth
of 1.5 cm. At this point, 2 mL anesthetic is placed
to block the anterior ethmoidal nerve. The needle
is advanced 1 cm further to reach the posterior
ethmoidal foramen and a further 1.5-mL solution
is placed. Pressure should be applied immedi-
ately on withdrawing the needle to prevent ecchy-
mosis. To block the infraorbital nerve, about
2 mL anesthetic solution is placed around the
infraorbital foramen. The foramen appears on the
maxilla in line with the pupil, about 6–8 mm infe-
rior to the inferior rim of the orbit. It can be
reached by a percutaneous or intraoral injection,
with the needle directed superolaterally toward
the foramen. The noninjecting hand protects the
orbit as the needle approaches the foramen below
the eye. For complete anesthesia of the columella
and nasal tip, an additional injection in the upper
labial frenulum may be required to block fi bers of
the anterior superior alveolar nerve that arise sep-
arately from the infraorbital nerve. For anesthesia
of the mucous membrane of the superior and
middle conchae and the posterior nasal septum,
topical anesthesia is used to block the sensory
nerves arising from the pterygopalatine ganglion.
Gauze soaked in local anesthetic with vasocon-
strictor is passed along the middle concha until it
rests over the pterygopalatine ganglion posterior
to the middle meatus. After 10 min, adequate
anesthesia and vasoconstriction are achieved.
2.5
Autonomic Nerves
Autonomic control of the vessels and glands of
the nose and nasal cavity occurs through both
parasympathetic and sympathetic pathways
(Fig. 2.4 ). Postganglionic sympathetic fi bers
pass from the superior cervical ganglion to the
internal and external carotid artery plexuses.
Sympathetic fi bers continue as the deep petrosal
nerve toward the pterygopalatine fossa. The
parasympathetic nerves arise in the superior sali-
vatory nucleus in the brain stem. Preganglionic
parasympathetic fi bers then pass via the sensory
root of the facial nerve to the greater petrosal
branch. The deep petrosal and greater petrosal
nerves merge to form the nerve of the pterygoid
canal or vidian nerve. Upon exiting the canal, it
enters the pterygopalatine ganglion. Parasym-
pathetic fi bers synapse in the ganglion, and post-
ganglionic secreto motor fi bers are transmitted to
the nasal cavity with the posterior superior, naso-
palatine, posterior inferior, and greater palatine
nerves. Sympathetic fi bers pass through the
pterygopalatine ganglion without synapsing,
reaching their targets in the nasal cavity by run-
ning with the sensory nerves. A second sympa-
thetic pathway exists, represented by fi bers that
pass from the vidian nerve to periarterial plex-
uses associated with the maxillary and descend-
ing palatine arteries [ 4 ] .
2.6
Motor Nerves
The small nasal muscles include procerus, nasa-
lis, and depressor septi (Fig. 2.5 ). Nasalis con-
sists of compressor naris and dilator naris. The
motor nerves to these muscles arise from the buc-
cal branch of the facial nerve. Super fi cial branches
supply procerus, whereas lower zygomatic or
upper deep buccal branches supply the two parts
of nasalis and depressor septi.

22
P.M. Prendergast
Lacrimal gland
Pterygopalatine ganglion
parasympathetic
sympathetic
sensory
Cervical sympathetic ganglion
Carotid plexus
Deep petrosal n.
Vidian n.
Superior salivatory nucleus
Greater petrosal n.
Fig. 2.4 Autonomic nerve supply to the nose. Sympathetic
fi bers pass through the pterygopalatine ganglion without
synapsing, whereas parasympathetic fi bers synapse in the
ganglion. Sympathetic and parasympathetic secretomotor
and vasomotor fi bers pass with the sensory nerves to the
tissues of the nasal cavity and to the lacrimal gland
Procerus
Compressor naris
Dilator naris
Depressor septi
Fig. 2.5 Muscles of the nose

23
2 Neurologic Anatomy of the Nose
References
1. Han SK, Shin YW, Kim WK (2004) Anatomy of the
external nasal nerve. Plast Reconstr Surg 114(5):
1055–1059
2. Hu KS, Kwak HH, Song WC, Kang HJ, Kim HC,
Fontaine C, Kim HJ (2006) Branching patterns of the
infraorbital nerve and topography within the infraor-
bital space. J Craniofac Surg 17(6):1111–1115
3. Molliex S, Navez M, Baylot D, Prades JM, Elkhoury Z,
Auboyer C (1996) Regional anaesthesia for outpatient
nasal surgery. Br J Anaesth 76(1):151–153
4. Rusu MC, Pop F (2010) The anatomy of the sympa-
thetic pathway through the pterygopalatine fossa in
humans. Ann Anat 192(1):17–22

25
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_3, © Springer-Verlag Berlin Heidelberg 2013
3
3.1
Introduction
Successful rhinoplasty depends on nasal tip sup-
port and its in fl uence on nasal tip projection.
Although there has not yet been a clear determina-
tion of the structures responsible for nasal tip sup-
port, it is generally agreed that the important
components of nasal tip support include the attach-
ment between the upper and lower lateral carti-
lages, the attachment between the lateral crus of the
lower lateral cartilage and the pyriform aperture,
the attachment between the paired domes of the
lower lateral cartilages, the medial crural attach-
ment of the lower lateral cartilage to the caudal sep-
tum, and dermocartilaginous ligament (Fig. 3.1 ).
Although studies of these nasal tip supporting
structures have been performed by many research-
ers, the terms and de fi nitions for these structures
have not been universally agreed upon. Furthermore,
most of the research refers to macroscopic fi ndings,
making it dif fi cult to exactly de fi ne the supporting
structures of the nasal tip. Since the nasal tip sup-
porting structures play an important role in a nasal
tip plasty, a clear understanding of these structures
is essential to rhinoplasty surgeons. The author has
tried to exactly de fi ne the supporting structures of
the nasal tip by microscopic investigation in paral-
lel with the macroscopic fi ndings utilizing fresh
cadavers [ 1 ] . In this chapter, the detailed anatomy
for the dermocartilaginous ligament is described.
3.2
Pitanguy’s Findings
The dermocartilaginous ligament of the nose is a
narrow, central, fi brous, white structure in the cen-
ter of the nasal dorsum, which was fi rst described
by Pitanguy [ 2 ] . Since its anatomy was fi rst reported
in 1965, few series have been conducted upon its
anatomy study. More detailed reviews were pub-
lished in 1995 and 2001 by the same author [ 3, 4 ] .
This structure has been believed to unite the dermis
of the upper third of the nose to the junction of the
medial crura, and to reach down to the subseptum.
Previous histologic studies of this structure
have revealed the presence of collagen and elastic
fi bers, chondrocytes, and muscle fi bers [ 3 ] .
However, microphotographs of these histologic
fi ndings have not been provided in published arti-
cles. In addition, detailed descriptions and histol-
ogies of the initiation and termination of this
structure have not been clearly demonstrated.
3.3
Author’s Findings
In order to name a structure, precise information
is required regarding its location, composition,
origin, and insertion. However, despite its clini-
cal importance, available information on the
Anatomy of the Dermocartilaginous
Ligament of the Nose
Seung-Kyu Han
S.-K. Han , M.D., Ph.D.
Department of Plastic Surgery , Korea University Guro
Hospital , 97 Guro-Dong , Guro-Ku, Seoul 152-703 ,
South Korea
Department of Plastic Surgery , Korea University
College of Medicine , Seoul , South Korea
e-mail: pshan@kumc.or.kr

26
S.-K. Han
dermocartilaginous ligament was insuf fi cient. In
addition, it was dif fi cult to believe that chondro-
cytes and muscle fi bers are present in the
ligament structure. Nevertheless, several other
authors had adopted the same concept [ 5– 8 ] . The
author has performed a study to clearly deter-
mine the nature of the dermocartilaginous liga-
ment both grossly and histologically by dissecting
fresh cadavers [ 9 ] .
3.4
Gross Findings
The dermocartilaginous ligament, which is a
white dense fi brous band running vertically
between the transverse nasalis muscle and colu-
mellar base, is observed in midline of the nose.
This structure is discrete from surrounding sub-
cutaneous tissue and presented as a single conti-
nuity up to its terminal insertion. It originates
from the deep layer of the transverse nasalis mus-
cle and terminates at the caudal edge of the septal
cartilage. However, in some patients (19%), the
insertion is found to extend to the orbicularis oris
muscle (Figs. 3.2 and 3.3 ). The strength of the
structure varies from patient to patient. However,
no relationship is observed between insertion,
structure strength, and nasal dorsum convexity.
3.5
Histologic Findings
Histologically the dermocartilaginous ligament is
an easily identi fi able soft tissue layer observed
between subcutaneous tissue and the periosteum or
perichondrium (Fig. 3.4 ). The origin of the struc-
ture consists of intertwined fi brous and muscular
tissue, and a distinct fi brous layer is also present
beneath the muscular tissue. No direct connection
is found between this soft tissue layer and the der-
mis layer of dorsal skin. The structure itself is
mainly composed of a condensation of thin colla-
gen bundles, which are interwoven and without
regular orientation. Although coarse collagen fi bers
are the main component, elastic fi bers are also pres-
ent in small numbers. No signi fi cant relation is
found between elastic fi ber quantity and structure
strength. Few amorphous ground substances are
observed, and no muscle fi bers or chondrocytes are
identi fi ed within the structure (Figs. 3.5 , 3.6 , and
3.7 ). No relationship is found between the histo-
logic fi ndings and nasal dorsum convexity.
Fig. 3.1 ( Left ) Nasal tip
supporting structures include
the attachment between the
upper and lower lateral
cartilages, the attachment
between the lateral crus of
the lower lateral cartilage and
the pyriform aperture, the
attachment between the
paired domes of the lower
lateral cartilages, the medial
crural attachment of the
lower lateral cartilage to the
caudal septum. ( Right ) The
dissected midline tissue of
the nasal dorsum. Arrows
denote the dermocartilagi-
nous ligament

27
3 Anatomy of the Dermocartilaginous Ligament of the Nose
In Pitanguy’s fi ndings, which described the
presence of chondrocytes and muscle fi bers
within the structure, there may be a possibility
that perichondrial layer tissues were inattentively
included among “ligament” samples. Regarding
the presence of muscle fi bers, this may have been
due to the fusion of the dermocartilaginous liga-
ment and transverse nasalis or depressor septi
nasi muscles at its origin or insertion. In some
cases, these muscles are well developed and mus-
cle fi bers may extend into either end of the “liga-
ment.” Therefore, muscle fi bers might have
appeared to have been a component of the dermo-
cartilaginous ligament.
Fig. 3.2 Dermocartilaginous
ligament ( arrows ) that inserts
only to the caudal edge of the
septal cartilage.
Fig. 3.3 Dermocartilaginous
ligament ( arrows ) that inserts
into orbicularis oris muscle
tissue as well as septal
cartilage (the septal cartilage
insertion portion has been
divided). ASA anterior septal
angle

28
S.-K. Han
Based on the author’s fi ndings, it is dif fi cult to
agree that this structure is a “ligament.” Although
abundant amounts of dense collagen fi bers are
present in the dermocartilaginous ligament, they
are irregularly arranged, and thus the structure
cannot be viewed as a ligament histologically.
Rather, the fi ndings indicate that it is a “fascia,”
i.e., dense irregularly arranged connective tissue
[ 10, 11 ] . Therefore, the term “dermocartilaginous
ligament” of the nose may be a misnomer. Rather,
“musculocartilaginous fascia” may be correct.
For optimal postoperative rhinoplasty results, sur-
geons are required to have a thorough understand-
ing of the anatomy involved, and a comprehension
of the various tip support mechanisms should be a
prerequisite of nasal tip surgery. However, tradi-
tionally in medicine, structures that were initially
termed by someone many years ago are not lightly
renamed. Hence, out of courtesy to the original
investigator, we can continue to use this term.
3.6
Clinical Signi fi cance
The dermocartilaginous ligament is considered to
in fl uence the equilibrium of the dorsum-tip rela-
tionship, especially in bulbous or Negroid noses.
The division of this structure allows the tip of the
nose to assume a slightly more cephalic position,
thus correcting the displeasing aspect of a droop-
ing nose [ 3, 4 ] . Although histologically this struc-
ture is a fascia rather than a ligament, division of
this structure should allow elevation of the nasal
tip since this fascia is also consisted of dense
connective tissue.
Based on Pitanguy’s investigations, the der-
mocartilaginous ligament united the dermis of
the upper third of the nose to the junction of the
crus mediale, and penetrated anteroposteriorly to
fuse with the structure of the subseptum [ 3, 4 ] .
However, in the author’s study, this structure was
not found to directly adhere to the dermis, but
rather to be attached to transverse nasalis muscu-
lar tissue at the midline of the nose. Thus, the der-
mocartilaginous ligament is actually a layer
separated from the dermis. This fi nding can pro-
vide important information for use in augmenta-
tion rhinoplasty using dermis-fat graft, which is a
common procedure, particularly in Asian patients
whose skin and subcutaneous tissue is thicker
than those of Caucasians [ 12 ] . Since dermis-fat is
grafted into the subcutaneous layer for augmen-
tation of the nasal dorsum, division of the dermo-
cartilaginous ligament was previously thought to
be an unavoidable consequence. However,
author’s fi ndings demonstrate that subcutaneous
dissection of the nasal dorsum does not injure
this structure (Fig. 3.8 ).
Fig. 3.4 Excised nasal
midline tissue. ( Left ) H&E
stain (no original
magni fi cation). ( Right ) Van
Gieson elastin stain (no
original magni fi cation).
Tissue between arrows is the
dermocartilaginous ligament

29
3 Anatomy of the Dermocartilaginous Ligament of the Nose
a
b
Fig. 3.5 ( a ) Histology of the dermocartilaginous liga-
ment (between arrows ) in the nasal dorsum (×40, Masson’s
trichrome stain). ( b ) Histology of the “dermocartilaginous
ligament” (between arrows ) in columella (×40, Masson’s
trichrome stain)

30
S.-K. Han
a
b
Fig. 3.6 ( a ) Histology of the “dermocartilaginous liga-
ment” in the nasal dorsum (×40, Masson’s trichrome
stain). ( b ) Histology of the “dermocartilaginous ligament”
in columella (×40, Masson’s trichrome stain). SC septal
cartilage, AC middle crus of the alar cartilage

31
3 Anatomy of the Dermocartilaginous Ligament of the Nose
Fig. 3.7 Histology of the “dermocartilaginous ligament” (between arrows ) in a nose with a severely convex nasal dorsum
(×40, Masson’s trichrome stain); when compared with other cadaver noses, no signi fi cant differences are noted
a
Fig. 3.8 ( a ) ( Left ) Preoperative. ( Right ) Postoperative after
a silicone implant was inserted in a subperiosteal pocket.
( b ) ( Left ) Preoperative. ( Right ) Postoperative after dermis-
fat was inserted in a subcutaneous pocket. The division of
the dermocartilaginous ligament during subperiosteal dis-
section allowed the tip of the nose to rotate a slightly more
cephalic position in the case above. On the other hand,
nasal tip position was maintained in the case below

32
S.-K. Han
References
1. Han SK, Lee DG, Kim JB, Kim WK (2004) An ana-
tomic study of nasal tip supporting structures. Ann
Plast Surg 52(2):134–140
2. Pitanguy I (1965) Surgical importance of a dermocar-
tilaginous ligament in bulbous noses. Plast Reconstr
Surg 36:247–253
3. Pitanguy I, Salgado F, Radwnski HN, Bushkin SC
(1995) The surgical importance of the dermocartilagi-
nous ligament of the nose. Plast Reconstr Surg
95(5):790–794
4. Pitanguy I (2001) Revisiting the dermocartilaginous
ligament. Plast Reconstr Surg 107(1):264–266
5. McCollough EG (1993) Surgery of the nasal tip: pru-
dent selection of alternatives. In: Daniel R (ed)
Aesthetic plastic surgery: rhinoplasty. Boston, Little,
Brown and Co, Boston, p 415
6. Oneal RM, Izenberg PH, Schlesinger J (1993) Surgical
anatomy of the nose. In: Daniel R (ed) Aesthetic
plastic surgery: rhinoplasty. Boston, Little, Brown and
Co, Boston, p 16
7. De Souza Pinto EB, Rocha RP, Filho WQ, Neto ES,
Zacharias KG, Amâncio A, Braz de Camargo A
(1998) Anatomy of the median part of the septum
depressor muscle in aesthetic surgery. Aesthetic Plast
Surg 22(2):111–115
8. Song R, Ma H, Pan F (2002) The “levator septi nasi
muscle” and its clinical signi fi cance. Plast Reconstr
Surg 109(5):1707–1712
9. Han SK, Jeong SH, Lee BI, Kim WK (2007) Updated
anatomy of the dermocartilaginous ligament of the
nose. Ann Plast Surg 59(4):393–397
10. Leeson TS, Leeson CR, Paparo AA (1988) Text/atlas
of histology. Saunders, Philadelphia, p 126
11. Zhai LJ, Bruintjes TD, Boschma T, Huizing EH
(1995) The interdomal ligament does not exist.
Rhinology 33(3):135–137
12. Han SK (2006) Skin and subcutaneous tissue. In: Han
SK (ed) Asian rhinoplasty. Seoul, Koonja, pp 8–9
b
Fig. 3.8 (continued)

33
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_4, © Springer-Verlag Berlin Heidelberg 2013
4
4.1 Introduction
Assessing the external nose requires an under-
standing of the anatomic components that contrib-
ute to its normal topographic features. Structures
that in fl uence the external appearance include the
skin, which varies in thickness, and the underlying
bony/cartilaginous skeletal framework. Because
skin thickness is greatest at areas of skeletal nar-
rowness, the external appearance of the nose from
the frontal view is one of a soft, gentle curve ema-
nating from the medial brows and extending to the
tip-de fi ning points (dorsal esthetic line) (Fig. 4.1 ).
The lobule can be de fi ned as an area including the
tip of the nose and bounded by a line connecting
the upper edge of the nostrils, the supratip break-
point, and the anterior half of the lateral alar wall.
The lobule is subdivided into the tip, supratip, and
infratip lobule. On lateral view, one should be
aware of the marked differences in the thickness of
the soft tissue (Fig. 4.2 ).
The internal structure most frequently respon-
sible for the prominence of the lateral tip-de fi ning
point or pronasalae is the cephalic edge of the
domal segment of the middle crus. On lateral
view, the tip of the nose is the apex of the lobule
and ideally the most de fi ned element on the
pro fi le [ 2– 4 ] . In non-Caucasian, however, the tip
tends to lack de fi nition [ 5 ] . The infratip lobule is
between the tip and the apex of the nostrils. The
con fi guration of the infratip lobule depends on
the shape, size, and angulation of the medial and
middle crura of the alar cartilage (Fig. 4.2 ). The
supratip lobule lies between the pronasalae and
the supratip breakpoint. The nasolabial angle is
de fi ned as the angle formed by a line drawn from
the anterior to the posterior nostril apices and that
intersects with the vertical facial plane. It deter-
mines the amount of cephalic rotation of the tip.
In an esthetically pleasing nose, the columella
projects as a gentle curve below the alar margin
as seen on lateral view. In the non-Caucasian
nose, however, a common variation is for the ala
to overhang the columella posteriorly [ 5 ] . The
columella and infratip lobule projection are
in fl uenced by the con fi guration of the medial and
middle crura. Because of the thin, adherent skin,
asymmetries or prominences in these structures
are easily visible in external con fi guration. In
addition, projections of the caudal edge of the
septum can produce a prominence of the colu-
mella also. On base view (Fig. 4.3 ), the fl aring of
the caudal edges of the medial and middle crura
Surgical Anatomy of the Nose
Robert M. Oneal and Richard J. Beil
R. M. Oneal , M.D.
Department of Surgery University of Michigan
501 Onondaga St. , Ann Arbor , MI 48106 , USA
e-mail: boboneal@comcast.net
R. J. Beil , M.D. (*)
Section of Plastic Surgery , University of Michigan,
Center for Plastic and Reconstructive Surgery,
St. Joseph Mercy Hospital , 5333 McAuley Drive,
Suite 5001 , Ann Arbor , MI 48106 , USA
e-mail: rjbeil@earthlink.net
This article is adapted from Oneal RM, Beil Jr RJ, Schlesinger
J. Surgical anatomy of the nose. Clinics in Plastic Surgery
1996;23(2):195–222 and Clinics in Plastic Surgery 37 (2010)
191–211. 2010 Elsevier Inc. All rights reserved.

34
R.M. Oneal and R.J. Beil
Nasal bone
Medial canthus
Rhinion
Upper lateral
cartilage
Infratip lobule
Pyriform process
of maxilla
Ascending process
of maxilla
Alar cartilage
Tip-defining point
Alar margin
Soft triangle
Fig. 4.1 Nose – frontal view
(Courtesy of Jaye Schlesinger,
Ann Arbor, MI)
Radix
Nasal bone
Rhinion
Upper lateral
cartilage
Supratip breakpoint
Supratip Lobule
Pronasalae
Infratip lobule
Middle crus
Lateral crus
Medial crus
Anterir nasal spine
of maxilla
Columella
Fibro-areolar
tissue
Accessory
cartilages
Sesamoid
Cartilage
Lower
lateral
(alar)
cartlage
Fig. 4.2 Nose – lateral view.
Note the distance of the
lateral crus from the skin
edge of the nostril (Data from
Daniel [ 1 ] ; Courtesy of Jaye
Schlesinger, Ann Arbor, MI)

35
4 Surgical Anatomy of the Nose
is noted. The degree of fl are plus the lateral curve
of the medial crural footplates determines the
width of the columella and infratip lobule.
Columellar deviations and asymmetries are fre-
quently caused by de fl ections in the caudal sep-
tum. Medially, the relationship of the anterior
nasal spine to the depressor septi muscle, which
is paired and inserts into the medial crural foot
plates, should be noted. Laterally, the alar part of
the nasalis muscle should be noted.
4.2
Soft Tissue Covering
of the Nose
4.2.1 Skin
Skin thickness is one of the most important fea-
tures to assess preoperatively in planning rhino-
plasty. The skin tends to be thinner and more
mobile in the upper half of the nose and thicker
and more adherent distally. In dissections reported
by Lessard and Daniel [ 6 ] , average skin thickness
was noted to be greatest at the nasofrontal groove
(1.25 mm) and least at the rhinion (0.6 mm).
There are usually more sebaceous glands in the
lower half of the nose, causing oiliness and thick-
ness in the skin that may limit topographic
de fi nition, sometimes obscuring entirely the
underlying framework and the natural esthetic
lines normally visible, particularly in the non-
Caucasian nose, which may have a larger subcu-
taneous dense fi brofatty layer than the Caucasian
nose [ 5 ] . Some of the nasal changes seen with
aging (i.e., tip droop, nasal lengthening) may be
caused by changes in skin character [ 7 ] . The skin
is usually thinner along the alar margin and in the
columella, where the con fi guration of the alar
cartilages may be visualized through a thin skin
cover. The skin-to-skin approximations in the
soft triangle area at the nostril apex make it
extremely vulnerable to notching and irregulari-
ties due to scarring when intranasal incisions vio-
late this delicate area.
4.2.2 Subcutaneous Layer
The soft tissue intervening between the skin and
the osteocartilaginous skeleton is made up of four
layers [ 6 ] . They are the super fi cial fatty pannicu-
lus, the fi bromuscular layer, the deep fatty layer,
and the periosteum or perichondrium. The
fi bromuscular layer includes the nasal super fi cial
muscular aponeurotic system (SMAS). The nasal
SMAS is a continuation of the super fi cial muscu-
lar aponeurotic system, which covers the entire
face, interconnecting the facial musculature, the
galeal frontalis layer, and the platysma. Ignorance
of the importance of this level or inadvertent sur-
gical or traumatic division of the SMAS leads to
its bilateral retraction. This retraction exposes the
deeper skeletal components to possible adher-
ence through scar tissue to the super fi cial fatty
Columella.
Infrtip lobule
Depressor septi m.
Anterior nasal spine
Flared portion
of columella
Alar cartilage:
Lateral crus
Middle crus
Medial crus
Alar nasalis m.
Fig. 4.3 Nose – base view
(Courtesy of Jaye Schlesinger,
Ann Arbor, MI)

36
R.M. Oneal and R.J. Beil
layer, which is directly connected to the dermis
[ 8, 9 ] . The major super fi cial blood vessels and
motor nerves run within the deep fatty layer [ 10 ] .
Just beneath it and super fi cial to the periosteum
and perichondrium is the proper plane of dissec-
tion, similar to the areolar layer beneath the galea
aponeurotica in the scalp.
4.2.3 Muscles
Griesman [ 11, 12 ] subdivided the nasal muscles
into four groups. Letourneau and Daniel [ 10 ]
substantiated these fi ndings in 30 fresh cadaver
dissections (Fig. 4.4 ). The elevator muscles,
which shorten the nose and dilate the nostrils,
include (1) the procerus, (2) the levator labii
superioris alaeque nasi, and (3) the anomalous
nasi. The depressor muscles, which lengthen
the nose and dilate the nostrils, include (4) the
alar portion of the nasalis muscle (dilator naris
posterior) and (5) the depressor septi. The minor
dilator muscle is the (6) dilator naris anterior.
The compressor muscles, which lengthen the
nose and narrow the nostrils, include (7) the
transverse portion of the nasalis and (8) the
compressor narium minor. An in-depth discus-
sion of these muscles can be found in articles
by Griesman [ 11 ] and Letourneau and Daniel
[ 10 ] . All the muscles are innervated by the
zygomaticotemporal division of the facial
nerve.
Procerus m.
Dilator naris
anterior m.
Compressor narium
minor m.
Depressor septi m.
Orbicularis oris m.
Alar nasalis m.
Levator labii superioris
alaeque nasi m.
Transverse nasalis m.
Anomalous nasi m.
Fig. 4.4 Nasal muscles of facial expression (Courtesy of Jaye Schlesinger, Ann Arbor, MI)