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Rhinoplasty: The Experts' Reference

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Rhinoplasty: The Experts Reference is a comprehensive text that provides guidance from world-renowned experts on every aspect of rhinoplasty, from the functional to the cosmetic. The book opens with a section on initial patient assessment and consultation, moves on to such topics as surgery of the septum, with separate sections on the nuances of functional nasal surgery and revision rhinoplasty, and concludes with a section on avoiding and managing surgical complications. Each chapter is written by an expert on a specific topic and presents tried-and-true rhinoplasty techniques that can be readily implemented by facial plastic surgeons.

Key Features:

  • Includes a section on ethnic rhinoplasty with chapters written by Drs. Tae-Bin Won, Russell W.H. Kridel, and Roxana Cobo
  • Written by over 100 of the most well-known surgeons in the world, including Yong Ju Jang (Asia), Ira Papel, Stephen Park, Peter Adamson, and Rollin K. Daniel (North America), Wolfgang Gubisch, Charles East, Gilbert Nolst Trenite, and Pietro Palma (Europe), and Simon Robinson (Australia)
  • Offers expert solutions to a particular problem in each chapter

Practicing plastic surgeons and facial plastic surgeons, as well as residents and fellows in these fields, will consult this excellent desk reference whenever they are faced with a particularly challenging case.

Thieme eOtolaryngology is the premier online resource for otolaryngology-head and neck surgery. For a free trial, go to: thieme.com/eototrial

Year:
2015
Edition:
1
Publisher:
Thieme
Language:
english
Pages:
708
ISBN 10:
1604068671
ISBN 13:
9781604068672
File:
PDF, 69.57 MB
Download (pdf, 69.57 MB)

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Rhinoplasty
The Experts' Reference

Anthony P. Sclafani, MD, FACS
Surgeon Director, Director of Facial Plastic Surgery
The New York Eye and Ear Infirmary of Mount Sinai
Professor, Department of Otolaryngology
Icahn School of Medicine at Mount Sinai
New York, New York

790 illustrations

Thieme
New York • Stuttgart • Delhi • Rio de Janeiro

Executive Editor: Timothy Y. Hiscock
Managing Editor: J. Owen Zurhellen IV
Editorial Assistant: Mohammad Ibrar
Senior Vice President, Editorial and Electronic
Product Development: Cornelia Schulze
Production Editor: Sean Woznicki
International Production Director: Andreas Schabert
International Marketing Director: Fiona Henderson
International Sales Director: Louisa Turrell
Director of Sales, North America: Mike Roseman
Vice President, Finance and Accounts: Sarah Vanderbilt
President: Brian D. Scanlan
Cover Illustration: Jill K. Gregory, MFA, CMI; printed with
permission from © Mount Sinai Health System
Printer: Replika Press Pvt. Ltd.

Library of Congress Cataloging-in-Publication Data
Rhinoplasty (Sclafani)
Rhinoplasty: the experts' reference / [edited by]
Anthony P. Sclafani.
p.; cm.
Includes bibliographical references.
ISBN 978-1-60406-867-2 (hardback) —
ISBN 978-1-60406-868-9 (eISBN)
I. Sclafani, Anthony P., editor. II. Title.
[DNLM: 1. Rhinoplasty. WV 312]
RD119.5.N67
617.5'230592—dc 3

Important note: Medicine is an ever-changing science undergoing
continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of
proper treatment and drug therapy. Insofar as this book mentions
any dosage or application, readers may rest assured that the
authors, editors, and publishers have made every effort to ensure
that such references are in accordance with the state of knowledge
at the time of production of the book.
Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any
dosage instructions and forms of applications stated in the boo; k.
Every user is requested to examine carefully the manufacturers’
leaflets accompanying each drug and to check, if necessary in
consultation with a physician or specialist, whether the dosage
schedules mentioned therein or the contraindications stated by
the manufacturers differ from the statements made in the present
book. Such examination is particularly important with drugs that
are either rarely used or have been newly released on the market.
Every dosage schedule or every form of application used is entirely
at the user’s own risk and responsibility. The authors and publishers
request every user to report to the publishers any discrepancies or
inaccuracies noticed. If errors in thiswork are found after publication, errata will be posted at www.thieme.com on the product
description page.
Some of the product names, patents, and registered designs
referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not
always made in the text. Therefore, the appearance of a name
without designation as proprietary is not to be construed as a
representation by the publisher that it is in the public domain.

2014013349
Copyright © 2015 by Thieme Medical Publishers, Inc.
Thieme Publishers New York
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+1 800 782 3488, customerservice@thieme.com
Thieme Publishers Stuttgart
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Printed in India
ISBN: 978-1-60406-867-2
Also available as an e-book:
eISBN: 978-1-60406-868-9

54321

This book, including all parts thereof, is legally protected by
copyright. Any use, exploitation, or commercialization outside the
narrow limits set by copyright legislation without the publisher's
consent is illegal and liable to prosecution. This applies in particular
to photostat reproduction, copying, mimeographing or duplication
of any kind, translating, preparation of microfilms, and electronic
data processing and storage.

This book is dedicated to the generations of otolaryngologists
who have pioneered and refined the theory and technique of rhinoplasty.

| 28.11.14 - 10:44

Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xiii

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xv

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Rhinoplasty Assessment
1

Functional Anatomy of the Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

Thomas Koppe, Evangelos I. Giotakis, and Werner J. Heppt

2

The Effect of Facial Asymmetry on Nasal Deviation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

Richard W. Westreich, David Burstein, and Marika Fraser

3

The Rhinoplasty Consult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24

Jacob D. Steiger

4

A Guide to the Assessment and Analysis of the Rhinoplasty Patient. . . . . . . . . . . . . . . . . . . . . . . .

27

Pietro Palma, Iman Khodaei, and Abel-Jan Tasman

5

Perioperative Settings in Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38

Petros Socrates Economou and Charles East

Management of the Septum
6

Surgery of the Nasal Septum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44

Gunter Mlynski

7

Septal Surgery in Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

49

Werner J. Heppt and Wolfgang Gubisch

8

The Importance of the Nasal Septum in the Deviated Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

61

Jonathan M. Sykes, Ji-Eon Kim, David Shaye, and Armando Boccieri

9

Evolution of the Septal Crossbar Graft Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

68

Armando Boccieri

10

Twenty-five Years of Experience with Extracorporeal Septoplasty. . . . . . . . . . . . . . . . . . . . . . . . . .

77

Wolfgang Gubisch

11

The Severely Deviated Septum: The Way I Solve the Problem. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85

Lucien Gomulinski

12

Reconstructive Septal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

94

Miriam Boenisch and Gilbert J. Nolst Trenité

13

Treatment of Septal Hematomas and Abscesses in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

99

Dirk Jan Menger, Ivar C. Tabink, and Gilbert J. Nolst Trenité

vii

| 28.11.14 - 10:44

Contents

Management of the Dorsum
14

Management of the Nasal Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Jonathan M. Sykes, Vanesa Tapias, and Ji-Eon Kim

15

Management of Naso-septal L-strut Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
David W. Kim and Theresa Gurney

16

Aligning the Bony Nasal Vault in Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Anil R. Shah and Minas Constantinides

17

Osteotomies in the Crooked Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Jason D. Bloom, Sara B. Immerman, and Minas Constantinides

18

The Crooked Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Taha Z. Shipchandler and Ira D. Papel

19

The Current Trend in Augmentation Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Jeffrey M. Ahn

20

Sonic Rhinoplasty: Innovative Applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Edmund Pribitkin and Jewel Greywoode

21

Endoscopic-Guided Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Hans Behrbohm and Johanna May

Functional Nasal Surgery
22

The Concept of Rhinorespiratory Homeostasis: A New Approach to
Nasal Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Thomas Günter Hildebrandt, Werner J. Heppt, Ulrich Kertzscher, and Leonid Goubergrits

23

Evaluation of the Intranasal Flow Field through Computational Fluid Dynamics. . . . . . . . . . . 180
Thomas Günter Hildebrandt, Leonid Goubergrits, Werner J. Heppt, Stephan Bessler, and Stefan Zachow

24

Structural Approach to Endonasal Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Anil R. Shah and Philip J. Miller

25

Nasal Valves: Importance and Surgical Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Helmut Fischer and Wolfgang Gubisch

26

Nasal Valve Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Fazil Apaydin

27

Functional Rhinoplasty: Treatment of the Dysfunctional Nasal Sidewall. . . . . . . . . . . . . . . . . . . . 215
John A. Ballert and Stephen S. Park

28

Surgical Approach to Nasal Valves and the Midvault in Patients
with a Crooked Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Marcelo B. Antunes and Stephen A. Goldstein

29

Suspension Suture Techniques in Nasal Valve Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Meile S. Page and Dirk Jan Menger

viii

| 28.11.14 - 10:44

Contents

30

The Lateral Crural Underlay Spring Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Ferdinand C. A. Timmer, Jason A. Roth, Pontus K. E. Börjesson, and Peter J. F. M. Lohuis

Tip Rhinoplasty
31

Normal and Variant Anatomy of the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Amy S. Ketcham and Eric J. Dobratz

32

Structural Support and Dynamics at the Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
J. Jared Christophel and Stephen S. Park

33

Applications of the M-Arch Model in Nasal Tip Refinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Peter A. Adamson and Jason A. Litner

34

Functional Support of the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Oren Friedman, Cody A. Koch, and William R. Smith

35

Nuances in Tip Modification: Specific Applications of Cartilage
Splitting in Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
Anil R. Shah and Minas Constantinides

36

Nasal Tip Projection: Nuances in Understanding, Assessment,
and Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
Simon Robinson and Mona Thornton

37

Control of Tip Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
Abel-Jan Tasman and Peter J. F. M. Lohuis

38

Rhinoplasty: Open Tip Suture Techniques – A 25-Year Experience . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Rollin K. Daniel

39

Creating Elegance and Refinement at the Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304
Vito C. Quatela and Christopher Kolstad

40

Versatile Grafting at the Nasal Tip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Trimartani Koento

41

Nuances of the Nasal Tip: Rhinoplasty of the Thin-Skinned Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Edward H. Farrior and John A. Ballert

42

The Crooked Nasal Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
Jeremy P. Warner and Peter A. Adamson

43

The Asymmetric Nasal Tip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
Scott Stephan and Tom D. Wang

44

Correction of the Retracted Alar Base. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
William D. Losquadro, Anthony Bared, and Dean M. Toriumi

45

Improving the Hanging Ala . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352
Eduarda C. Yap

ix

| 28.11.14 - 10:44

Contents

46

Surgical Treatment of the Nasolabial Angle in Balanced Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . 358
Steven J. Pearlman

47

Alar Base Reduction: The Boomerang-Shaped Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Hossam M. T. Foda

Revision Rhinoplasty
48

An Anatomic Basis for Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Steven J. Pearlman and Benjamin Talei

49

Psychological Considerations in Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
Bryan T. Ambro and Richard J. Wright

50

Common Technical Causes of the Failed Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Richard E. Davis and Michael Bublik

51

Revision of the Functionally Devastated Nasal Airway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
Stephen S. Park and Brian B. Hughley

52

Functional Considerations in Revision Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402
John A. Ballert and Stephen S. Park

53

Revision Rhinoplasty: An Overview of Deformities and Techniques . . . . . . . . . . . . . . . . . . . . . . . . . 410
Santdeep H. Paun and Gilbert J. Nolst Trenité

54

Revision Rhinoplasty Using the Endonasal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Fred G. Fedok

55

Five Techniques That I Can’t Live without in Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Daniel G. Becker and Jason D. Bloom

56

The Decision Process in Choosing Costal Cartilage for Use in Revision
Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439
Scott Chaiet, Robert J. DeFatta, and Edwin F. Williams III

57

Secondary Rhinoplasty: Revising the Crooked Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445
Matthew A. Kienstra

58

Correction of Dorsal Abnormalities in Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
Roxana Cobo

59

Management of the Middle Nasal Third in Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
Jonathan M. Sykes

60

Secondary Rhinoplasty: Management of the Overresected Dorsum . . . . . . . . . . . . . . . . . . . . . . . . 464
Rollin K. Daniel and Ali Sajjadian

61

Revision of the Surgically Overshortened Nose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474
Dean M. Toriumi and Anthony Bared

62

Management of the Short Nose Deformity in Revision Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . 483
Henry D. Sandel IV and Stephen W. Perkins

x

| 28.11.14 - 10:44

Contents

63

Deprojection of the Nasal Tip in Revision Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
Russell W. H. Kridel and Samir Undavia

Age Considerations in Rhinoplasty
64

Rhinosurgery in Children: Basic Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
Carel D. A. Verwoerd and Henriette L. Verwoerd-Verhoef

65

Pediatric Rhinoplasty in an Academic Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
Munish Shandilya, Cindy Den Herder, Simon C. R. Dennis, and Gilbert J. Nolst Trenité

66

Open Rhinoplasty in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
Simon C. R. Dennis, Cindy den Herder, Munish Shandilya, and Gilbert J. Nolst Trenité

67

Management of the Aging Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531
Vito C. Quatela and James M. Pearson

Ethnic Rhinoplasty
68

Special Considerations in Northern European Primary Aesthetic Rhinoplasty . . . . . . . . . . . . . 538
Julian Rowe-Jones and F. Carl van Wyk

69

The Surgical Approach to the Mediterranean Nose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547
Armando Boccieri

70

Rhinoplasty for the East Asian Nose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557
Yong Ju Jang and Myeong Sang Yu

71

Nuances with the Asian Tip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
Tae-Bin Won and Hong Ryul Jin

72

Complications Found in Asian Tip Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 573
Tae K. Kwon

73

Revision Rhinoplasty for the East Asian Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577
Samuel M. Lam

74

Rhinoplasty for the African Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582
Anand D. Patel and Russell W.H. Kridel

75

Tip Nuances for the African Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592
Chuma J. Chike-Obi, Kofi Boahene, Jamal M. Bullocks, and Anthony E. Brissett

76

Nuances with the Mestizo Tip. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601
Roxana Cobo

77

Rhinoplasty for the Hispanic Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Anand D. Patel and Russell W.H. Kridel

78

Rhinoplasty for the Middle Eastern Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623
Rollin K. Daniel

79

Ethnic Considerations of the Crooked Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 630
Roxana Cobo

xi

| 28.11.14 - 10:44

Contents

Complications in Rhinoplasty
80

Complications in Septoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
Gerhard Rettinger and Hanspeter Kirsche

81

Rhinoplasty and Bony Vault Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649
Paul Nassif and Jonathan S. Kulbersh

82

Avoiding Complications of the Middle Vault in Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 656
Steven Pearlman and Roxana Baratelli

83

Nasal Tip Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
Richard E. Davis

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 672

xii

Preface

Preface
Rhinoplasty profoundly affects the lives of our patients.
When well-performed, it can enhance self-esteem and
improve the quality and comfort of life; poorly performed,
rhinoplasty can create chaos from relative order, distorting
the nasal appearance and potentially crippling the respiratory function of the nose. Visually and structurally, the
difference between these two drastically opposite outcomes may be only a matter of a few millimeters. The true
difference between these two outcomes is the foundational
understanding of the nasal anatomy, the proper analysis,
planning of the aesthetic result, the skill techniques, and
care of the rhinoplasty surgeon.
Much like Michaelangelo Buonaroti sculpting his David
incrementally, using a model partially submerged in milk to
reveal only the area upon which he worked, the successful
rhinoplasty surgeon must comprehend the internal form of
the nose and work to reveal its inner beauty without
compromising, but instead exalting, its structure. But how
does one become a true rhinoplasty ''artist''? Artistic ability
can be guided and refined, not bought or sold. However, the
technical ability to understand the nature and structure of
the nasal form, as well as how this form can be manipulated,
can be learned.
The journal Facial Plastic Surgery was founded and first
published in 1984 in order to develop, refine, and promote
the craft of aesthetic surgery of the face and neck. The
founding editors, M. Eugene Tardy and Tony Bull, sought

to share the expertise of the world's best facial plastic
surgeons on specific themes. Throughout the past 30 years,
many authors from many countries have shared their
knowledge on many topics, and specific issues in rhinoplastic surgery have been covered in many articles. In this,
the 30th year of Facial Plastic Surgery, we have brought
together the best of these articles into a single volume,
Rhinoplasty, The Experts' Reference. The unique perspective
this book brings to the field of rhinoplasty is the focus each
chapter gives to a particular topic in rhinoplasty. Some
topics are covered in more than one chapter, as different
authors demonstrate different approaches to similar problems, much the way Michaelangelo's David must be appreciated from 360 degrees.
The rhinoplasty surgeon, at his/her best, is ultimately a
humanist. The ability to understand the goals and desires of
the patient, the ability to provide care in a compassionate
way, and the ''artist's eye'' to see the inner beauty and true
functioning of the nose must be intimately intertwined
with technical expertise and finesse to alter these structures in an organic way to achieve the desired rhinoplasty
result. The perfect rhinoplasty may not be an achievable
result, but in this quest we strengthen and refine our
abilities in forming and reforming the nose. I hope this book
serves you well on your journey.
Anthony P. Sclafani, MD, FACS

xiii

Acknowledgments

Acknowledgments
I would like to thank Timothy Hiscock, J. Owen Zurhellen,
and the entire Thieme Publishers team for their assistance
in the preparation of this book. I would also like to express

my appreciation to all the authors who have contributed
articles on rhinoplasty or other aesthetic or reconstructive
facial surgery topics to the journal Facial Plastic Surgery.

xv

Contributors

Contributors
Peter A. Adamson, MD, FRCSC, FACS
Professor and Head
Department of Otolaryngology–Head and Neck Surgery
University of Toronto
Toronto, Ontario
Jeffrey M. Ahn, MD
Columbia University
New York, New York
Bryan T. Ambro, MD, MS
Director
Facial Plastic and Reconstructive Surgery
Assistant Professor of Otolaryngology–Head
and Neck Surgery
University of Maryland School of Medicine
Baltimore, Maryland
Marcelo B. Antunes, MD
Department of Otorhinolaryngology–Head
and Neck Surgery
University of Pennsylvania
Philadelphia, Pennsylvania
Fazil Apaydin, MD
Professor of Otorhinolaryngology,
Head and Neck Surgery
General Secretary of the European
Academy of Facial Plastic Surgery
Ege University
Izmir, Turkey
John A. Ballert, MD
Private Practice
Ballert Facial Plastic Surgery
Paducah, Kentucky
Roxana Baratelli, MD
Department of Otolaryngology
Lenox Hill Hospital
New York, New York
Anthony Bared, MD
Private Practice
Facial Plastic Surgery
Miami, Florida

Daniel G. Becker, MD, FACS
Clinical Professor
Department of Otolaryngology–Head and Neck Surgery
University of Pennsylvania Medical Center
Philadelphia, Pennsylvania
Becker Nose and Sinus Center, LLC
Sewell, New Jersey
Hans Behrbohm, MD
Department of Otorhinolaryngology
and Facial Plastic Surgery
Park Klinik Weißensee
Berlin, Germany
Stephan Bessler, MD
Private Practice of Otorhinolaryngology
Zurich, Switzerland
Jason D. Bloom, MD
Facial Plastic and Reconstructive Surgery
Main Line Center for Laser Surgery
Ardmore, Pennsylvania
Kofi D. O. Boahene, MD, FACS
Associate Professor
Department of Otolaryngology, Head and Neck Surgery
Johns Hopkins University School of Medicine
Baltimore, Maryland
Armando Boccieri, MD
Department of Maxillo-Facial Surgery
S. Camillo Hospital
Rome, Italy
Miriam Boenisch, MD, PhD
ENT and Facial Plastic Surgery
Medicent Linz
Linz, Austria
Pontus K. E. Börjesson, MD, PhD
Department of Otolaryngology, Head and Neck Surgery
Center for Facial Reconstructive Surgery
Diakonessenhuis, Utrecht/Zeist
The Netherlands

xvii

Contributors

Anthony E. Brissett, MD, FACS
Associate Professor of Otolaryngology–Head
and Neck Surgery
Director of Facial Plastic Surgery Center
Division of Facial Plastic and Reconstructive Surgery
Bobby R. Alford Department of Otolaryngology–Head and
Neck Surgery
Baylor College of Medicine
Houston, Texas
Michael Bublik, MD
Medical Director
Los Angeles Institute for Facial Beauty
Private Practice
Los Angeles, California
Jamal M. Bullocks, MD, FACS
Director
Department of Plastic Surgery
Kelsey-Seybold Clinic
Assistant Clinical Professor
Division of Plastic Surgery
Baylor College of Medicine
Houston, Texas
David Burstein, MD
Private Practice
Facial Plastic and Reconstructive Surgery
Otolaryngology–Head and Neck Surgery
Summit Medical Group
Berkeley Heights, New Jersey
Scott Chaiet, MD
Clinical Instructor
Department of Surgery
School of Medicine and Public Health
University of Wisconsin
Madison, Wisconsin
Chuma J. Chike-Obi, MD
Plastic Surgery
Private Practice
Austin, Texas
J. Jared Christophel, MD, MPH
Assistant Professor
Dept of Otolaryngology–Head and Neck Surgery
University of Virginia Health System
Charlottesville, Virginia

xviii

Roxana Cobo, MD
Private Practice
Facial Plastic Surgery/Otolaryngology
Coordinator
Service of Otolaryngology
Centro Medico Imbanaco
Cali, Colombia
Minas Constantinides, MD
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology
New York University School of Medicine
New York, New York
Rollin K. Daniel, MD
Clinical Professor
Aesthetic and Plastic Surgery Institute
University of California–Irvine
Irvine, California
Richard E. Davis, MD, FACS
Director
The Center for Facial Restoration
Miramar, Florida
Voluntary Professor of Facial Plastic Surgery
Department of Otolaryngology
University of Miami Miller School of Medicine
Miami, Florida
Robert J. DeFatta, MD, PhD
Williams Center Plastic Surgery Specialists
Latham, New York
Facial Plastic and Reconstructive Surgery
Department of Surgery
Division of Otolaryngology–Head and Neck Surgery
Albany Medical Center
Latham, New York
Simon C. R. Dennis, FRCS (ORL-HNS)
Wessex ENT Programme Director
ENT Consultant
Salisbury District Hospital
Wiltshire, United Kingdom
Eric J. Dobratz, MD
Director
Facial Plastic and Reconstructive Surgery
Assistant Professor Department of
Otolaryngology–Head and Neck Surgery
Eastern Virginia Medical School
Norfolk, Virginia

Contributors
Charles East, FRCS
Consultant
Facial Plastic Surgeon
Director
Rhinoplasty London
Consultant Surgeon
University College Hospitals
Honorary Senior Lecturer
University College London
London, United Kingdom
Petros Socrates Economou, MD
ENT–Facial Plastic Surgeon
Oberarzt für HNO
HELIOS Hanseklinikum Stralsund
Stralsund, Germany
Edward H. Farrior, MD
Affiliate Associate Professor
Department of Otolaryngology,
University of Virginia
Charlottesville, Virginia
Fred G. Fedok, MD, FACS
The McCollough Plastic Surgery Clinic
Gulf Shores, Alabama
Professor
Facial Plastic and Reconstructive Surgery
Department of Otolaryngology–Head and Neck Surgery
Hershey Medical Center
Pennsylvania State University
Hershey, Pennsylvania
Helmut Fischer, MD
Vice Director
Department of Facial Plastic Surgery
Klinik für Plastische Gesichtschirurgie
Marienhospital
Stuttgart, Germany
Hossam M. T. Foda, MD
Professor and Head of Facial Plastic Surgery Division
Otolaryngology Department
Alexandria Medical School
Alexandria, Egypt
Marika Fraser, MD
Department of Otolaryngology
SUNY Downstate
Brooklyn, New York
Oren Friedman, MD
Director, Facial Plastic Surgery
Associate Professor, Otorhinolaryngology
University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Evangelos I. Giotakis, MD, PhD
Consultant and Associate Director for Otolaryngology
ENT Department
Städtisches Klinikum Karlsruhe
Karlsruhe, Germany
Stephen A. Goldstein, MD, FACS
Associate Professor of Surgery
Division of Otolaryngology
Director of Facial Plastic and Reconstructive Surgery
University of Arizona
Tucson, Arizona
Lucien Gomulinski, MD
Department of Otolaryngology–Head and Neck Surgery
Longjumeau's Hospital
Longjumeau, France
Leonid Goubergrits, Dr (Eng)
Biofluid Mechanics Laboratory
Charité-Universitaetsmedizin Berlin
Berlin, Germany
Jewel Greywoode, MD
Facial Plastic and Reconstructive Surgery
Head and Neck Surgery–Microvascular
Reconstructive Surgery
Permanente Medical Group
Los Angeles, California
Wolfgang Gubisch, MD, Dr hc
Director
Department Facial Plastic Surgery
Plastic and Aesthetic Surgeon, ENT Surgeon
Stuttgart, Germany
Thomas Günter Hildebrandt, MD
Otorhinolaryngologist
Private Practice in Association with the Limmatklinik
Zurich, Switzerland
Theresa Gurney, MD
Department of Otolaryngology–Head and Neck Surgery
University of California
San Francisco, California
Werner J. Heppt, MD
Professor and Director
Department of Otorhinolaryngology
Head and Neck Surgery and Facial Plastic Surgery
Klinikum Karlsruhe
Clinical Director
Skin and Face Clinic
Karlsruhe, Germany

xix

Contributors

Cindy Den Herder, MD
Department of Otorhinolaryngology
and Facial Plastic Surgery
Academic Medical Center of the University of Amsterdam
Amsterdam, The Netherlands

Ji-Eon Kim, MD
Facial Plastic and Reconstructive Surgery
Head and Neck Surgery
Kaiser Permanente Medical Center
Modesto, California

Brian B. Hughley, MD
Otolaryngology–Head and Neck Surgery
University of Virginia
Charlottesville, Virginia

Hanspeter Kirsche, MD
ENT-Department
University of Ulm
Ulm, Germany

Sara B. Immerman, MD
Department of Otolaryngology
New York University Langone Medical Center
New York, New York

Cody A. Koch, MD, PhD
Koch Facial Plastic Surgery
West Des Moines, Iowa

Yong Ju Jang, MD, PhD
Department of Otolaryngology
Asan Medical Center
University of Ulsan College of Medicine
Seoul, South Korea
Hong Ryul Jin, MD, PhD
Professor and Chair
Department of Otorhinolaryngology–Head and Neck Surgery
Seoul National University
Boramae Medical Center
Seoul, Korea

Christopher Kolstad, MD
Kolstad Facial Plastic Surgery
La Jolla, Callifornia

Ulrich Kertzscher, Dr (Eng)
Head of Biofluid Mechanics Laboratory
Charité-Universitaetsmedizin Berlin
Berlin, Germany

Thomas Koppe, DDS
Adjunct Professor
Department of Anatomy and Cell Biology
Greifswald, Germany

Amy S. Ketcham, MD
Department of Otolaryngology–Head and Neck Surgery
Eastern Virginia Medical School
Norfolk, Virginia

Russell W. H. Kridel, MD, FACS
Clinical Professor and Chief
Department of Otorhinolaryngology–Head and Neck Surgery
University of Texas Health Science Center
Houston, Texas

Iman Khodaei, MD
Newferry, Wirral, United Kingdom
Matthew A. Kienstra, MD, FACS
Facial Plastic Surgery
Section Head, ENT and Oral Surgery
Mercy Hospital and Clinics
Springfield, Missouri
Clinical Faculty
Department of Otolaryngology–Head and Neck Surgery
University of Missouri
Columbia, Missouri
David W. Kim, MD
Department of Otolaryngology–Head and Neck Surgery
University of California–San Francisco
San Francisco, California

xx

Trimartani Koento, MD, PhD
Head of Department
Plastic Reconstructive Consultant
Department of Otorhinolaryngology–HNS
Faculty of Medicine
University Indonesia
Dr. Cipto Mangunkusumo Hospital
Jakarta, Indonesia

Jonathan Kulbersh, MD
Carolina Facial Plastics
Charlotte, North Carolina
Tae K. Kwon, MD
Aone Plastic and Aesthetic Surgery
Giheung-gu Yongin-si Gyeonggi-do
Seoul, South Korea
Samuel M. Lam, MD, FACS
Director
Willow Bend Wellness Center
Plano, Texas

Contributors
Jason A. Litner, MD, FRCSC
Co-Director
Profiles Beverly Hills and Profiles Surgery Center
Private Practice
Los Angeles, California
Peter J. F. M. Lohuis, MD, PhD
Department of Otolaryngology, Head Neck Surgery
Diakonessen Hospital
Utrecht, The Netherlands
William D. Losquadro, MD
Mount Kisco Medical Group
Katonah, New York
Johanna May, MD
Department of Otorhinolaryngology
and Facial Plastic Surgery
Park Klinik Weißensee
Berlin, Germany
Dirk Jan Menger, MD, PhD
Consultant Otolaryngology–Facial Plastic Surgery
University Medical Center
Onze Lieve Vrouwe Gasthuis Amsterdam.
Utrecht, The Netherlands
Philip J. Miller, MD, FACS
Director
Gotham Facial Plastic Surgery
Assistant Professor
Facial Plastic Surgery
Department of Otolaryngology
New York University School of Medicine
New York, New York
Gunter Mlynski, MD
Department of Otorhinolaryngology, Head and Neck Surgery
Ernst-Moritz-Arndt-University
Greifswald, Germany
Paul S. Nassif, MD, FACS
Assistant Clinical Professor
Department of Otolaryngology–Head and Neck Surgery
University of Southern California School of Medicine
Los Angeles, California
Meile S. Page, MD
Department of General and Paediatric Surgery
Haga Hospital
The Hague, The Netherlands

Pietro Palma, MD
The Milan Face Clinic
Milan, Italy
Clinical Professor
Department of Otorhinolaringology–Head and Neck Surgery
University Hospital
Varese, Italy
Ira D. Papel, MD, FACS
Associate Professor
Facial Plastic and Reconstructive Surgery
The Johns Hopkins University
Baltimore, Maryland
Stephen S. Park, MD
Professor and Vice-Chairman
Director
Facial Plastic Surgery
Department of Otolaryngology–Head and Neck Surgery
University of Virginia
Charlottesville, Virginia
Anand D. Patel, MD
Visage Facial Plastic Surgery, SC
Brookfield, Wisconsin
Santdeep H. Paun, FRCS (ORL-HNS)
Department of Otorhinolaryngology
St. Bartholomew's and The Royal London Hospitals
London, United Kingdom
Steven J. Pearlman, MD, FACS
Director
Center for Aesthetic Surgery for the Head and Neck Institute
of the North Shore/LIJ Hospital System
Associate Professor of Clinical Otolaryngology,
Columbia University
New York, New York
James M. Pearson, MD, FACS
Facial Plastic and Reconstructive Surgery
Private Practice
Beverly Hills, California
Stephen W. Perkins, MD, FACS
Clinical Associate Professor
Department of Otolaryngology–Head and Neck Surgery
Indiana University School of Medicine
Private Practice
Meridian Plastic Surgery Center
Indianapolis, Indiana

xxi

Contributors
Edmund Pribitkin, MD
Professor and Academic Vice Chairman
Department of Otolaryngology–Head and Neck Surgery
Thomas Jefferson University
Philadelphia, Pennsylvania
Vito C. Quatela, MD, FACS
Facial Plastic and Reconstructive Surgery Unit
Lindsay House Center for Cosmetic
and Reconstructive Surgery
Rochester, New York
Gerhard Rettinger, MD
ENT-Department University of Ulm
Ulm, Germany
Simon Robinson, MBChB, FRACS
Director
Wakefield Sinus and Facial Plastic Centre
Wellington, New Zealand
Jason A. Roth, MD
Department of Otolaryngology Head and Neck Surgery
Center for Facial Plastic Reconstructive Survery
Diakonessenhuis, Utrecht/Zeist
The Netherlands
Julian Rowe-Jones, FRCS
Private Practice
The Nose Clinic
London and Guildford
Surrey, United Kingdom
Ali Sajjadian, MD
Private Practice
Newport Beach, California
Henry D. Sandel IV, MD
Department of Otolaryngology–Head and Neck Surgery
University Hospital
Indianapolis, Indiana
William R. Schmitt, MD
Spokane Ear, Nose, and Throat
Spokane, Washington
Anil R Shah, MD, FACS
Assistant Clinical Professor of Facial Plastic Surgery
University of Chicago
Chicago, Illinois
Munish Shandilya, MS, FRCS (ORL-HNS)
Consultant Otolaryngology
Head, Neck, and Reconstructive Surgery, Nasal Plastic Surgery
Bon Secours Hospital
Dublin, Ireland

xxii

David Shaye, MD
Division of Facial Plastic and Reconstructive Surgery
Massachusetts Eye and Ear Infirmary
Instructor
Department of Otology and Laryngology
Harvard Medical School
Boston, Massachusetts
Taha Z. Shipchandler, MD, FACS
Director
Facial, Plastic, and Reconstructive Surgery
Residency Program Director, Otolaryngology
Director, Center for Facial Paralysis
Department of Otolaryngology–Head and Neck Surgery
Indiana University School of Medicine
Indianapolis, Indiana
William R. Smith, MD
Department of Otorhinolaryngology–Head and Neck Surgery
Mayo Clinic College of Medicine
Rochester, Minnesota
Scott Stephan, MD
Assistant Professor
Facial Plastic and Reconstructive Surgery
Otolaryngology and Head and Neck Surgery
Vanderbilt University Medical Center
Nashville, Tennessee
Jacob D Steiger, MD
Facial Plastic and Reconstructive Surgeon
Boca Raton, Florida
Jonathan M. Sykes, MD
Professor and Director
Facial Plastic Surgery
University of California, Davis Medical Center
Medical Director
Mercy San Juan Medical Center
Sacramento, California
Ivar C. Tabink, MD
Otolaryngologist
Maasstad Hospital
Rotterdam, The Netherlands
Benjamin Talei, MD
Facial, Cosmetic, and Reconstructive Surgery, Vascular and
Congenital Anomalies
Beverly Hills Center for Plastic and Laser Surgery
Beverly Hills, California
Vanesa Tapias, MD
Pontificia Universidad Javeriana
Bogota, Colombia

Contributors

Abel-Jan Tasman, MD
HNO-Klinik
Kantonsspital St. Gallen
St. Gallen, Switzerland

Richard W. Westreich, MD, FACS
Department of Otolaryngology
Lenox Hill Hospital
New York, New York

Mona Thornton, FRCSI
Royal Victoria Eye and Ear Hospital
Dublin, Ireland
Ferdinand C. A. Timmer, MD, PhD
ENT surgeon
Amphia Hospital
Breda, The Netherlands

Edwin F. Williams III, MD, FACS
Williams Center Plastic Surgery Specialists
Latham, New York
Facial Plastic and Reconstructive Surgery
Department of Surgery
Division of Otolaryngology–Head and Neck Surgery
Albany Medical Center
Latham, New York

Dean M. Toriumi, MD
Professor
Department of Otolaryngology–Head and Neck Surgery
University of Illinois at Chicago
Chicago, Illinois

Tae-Bin Won, MD, PhD
Associate Clinical Professor
Department of Otorhinolaryngology-Head and Neck Surgery
Seoul National University Hospital
Seoul, South Korea

Gilbert J. Nolst Trenité, MD, PhD
Department of Otorhinolaryngology
Academic Medical Center
University of Amsterdam
Amsterdam, The Netherlands

Richard J. Wright, MD
Department of Otorhinolaryngology–Head and Neck Surgery
University of Maryland Medical Center
Baltimore, Maryland

Samir Undavia, MD
Princeton Eye and Ear
Princeton, New Jersey
Carel D. A. Verwoerd, MD, PhD
Emeritus Professor of Otorhinolaryngology
Erasmus University Medical Center
Rotterdam, The Netherlands
Henriette L. Verwoerd-Verhoef, MD, PhD
Erasmus University Medical Center
Department of ORL
Rotterdam, The Netherlands
Tom D. Wang, MD, FACS
Professor
Facial Plastic and Reconstructive Surgery
Oregon Health and Science University
Portland, Oregon
Jeremy P. Warner, MD, FACS
Director, Facial Plastic Surgery
NorthShore University Health System
Division of Plastic Surgery
Northbrook, Illinois
Assistant Clinical Professor
Section of Plastic and Reconstructive Surgery
University of Chicago Pritzker School of Medicine
Chicago, Illinois

F. Carl van Wyk, FRCSEd (ORL-HNS)
Ear, Nose, and Throat Surgeon
Rhinologist and Nasal Plastic Surgeon
Private Practice
Mediclinic Morningside
Johannesburg, South Africa
Eduardo C. Yap, MD
ENT-Facial Plastic Surgeon
Belo Medical Group and
Metropolitan Medical Center
Manila, Philippines
Myeong Sang Yu, MD, PhD
Assistant Professor
Department of Otorhinolaryngology
Konkuk University School of Medicine
Chungju Hospital
Seoul, South Korea
Stefan Zachow, Prof Dr, Dr hc mult MGrötschel
Department of Scientific Visualization and Data Analysis
Zuse Institute
Berlin, Germany

xxiii

| 11.12.14 - 13:59

Part 1

2

1

Functional Anatomy of the Nose

2

The Effect of Facial Asymmetry on
Nasal Deviation

12

3

The Rhinoplasty Consult

24

4

A Guide to the Assessment and
Analysis of the Rhinoplasty Patient

27

Perioperative Settings in Rhinoplasty

38

Rhinoplasty Assessment

5

1

| 11.12.14 - 13:59

Rhinoplasty Assessment

1 Functional Anatomy of the Nose
Thomas Koppe, Evangelos I. Giotakis, and Werner J. Heppt

1.1 Introduction
The external nose is formed by a framework of bony and cartilaginous structures that are covered by soft tissue such as
muscles and skin. The external protruding nose is a unique formation of human beings. It provides the face with a characteristic shape and profile. It is noteworthy that the typical human
nose with downward-facing nostrils appeared first in Homo
erectus, some 1.6 million years ago.1 Despite the numerous ethnic differences in the shape of the external nose,2 harmonious
nasal proportions are prerequisites for facial harmony.3

1.2 Nasal Appearance
The external nose is pyramidal in shape and can be divided into
a dorsum or radix nasi, a nasal tip or apex, and the base of the
nose. The triangular base of the nose faces downward, like in all
catarrhine primates, and is formed by two alae nasi and the
external nares or nostrils. It is further divided by a mobile bar,
the columella nasi. The shape of the base of the nose varies
greatly among ethnic groups. Hwang and Kang4 distinguish up
to seven shapes of nostrils.

1.3 Angles of the Nose
The most important angles to be considered in nasal analysis
are the nasofrontal and the nasolabial angles (▶ Fig. 1.1). The
nasofrontal angle measures ~150 degrees in white adults. In
Asians and blacks, there is a wider angle. The nasolabial angle

Fig. 1.1 Lateral view of the face with the nasofrontal and nasolabial
angles.

2

measures ~80 to 90 degrees in white males and ~90 to 110
degrees in white females. Like the nasofrontal angle, the nasolabial angle is wider in Asians and blacks. Whereas the nasofrontal angle is not related to the nasal airflow, clinical experience
shows that the nasolabial angle plays a definite role in nasal
function. The narrower this latter angle, the more vertically the
inspiratory airstream enters the nose. From an aesthetic point
of view, the nasolabial angle is considered more important than
the nasofrontal angle.

1.4 Important Dimensions of the
External Nose
Apart from the above-mentioned angles, several measurements
exist to evaluate the external nose. Whereas most of these
dimensions are based on the measurement between anatomic
landmark points, some dimensions measure the distance to a
reference plane, such as the nasal basal line (NBL). NBL is
defined as an oblique line from the medial canthus to the alar
facial groove. The nasal measurements comprise the following
dimensions (▶ Fig. 1.2, ▶ Fig. 1.3, ▶ Fig. 1.4):
1. Nasal pyramid height (nasion to columellar base)
2. Nasal pyramid length (nasion to nasal tip)
3. Bony projection (NBL to most prominent part of the osseous
dorsum)
4. Cartilaginous projection (NBL to most prominent part of the
cartilaginous dorsum)
5. Lobular projection (NBL to most prominent part of the
lobule)

Fig. 1.2 NBL and projection of the bony and cartilaginous pyramid and
of the lobule.

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1.5 Nasal Pyramid
The major parts of the external nose are the bony pyramid, the
cartilaginous pyramid, the lobule, and soft tissue areas.

1.6 Bony Pyramid

Fig. 1.3 Nasal length, tip projection, and tip rotation in the lateral view.

6. Tip projection (nasal tip to alar facial groove)
7. Tip rotation (tip movement along a circular arc centered at
the alar base)
8. Bony pyramid width (NBL at the height of the keystone area,
the keystone being the border of bony and cartilaginous
dorsum)
9. Lobular width (distance between the right and left lateral
walls of the alar cartilages)
10. Tip width (distance between the two nasal
domes)

Fig. 1.4 Pyramidal, lobular, and tip width in the frontal view.

The bony framework forming the external nose is composed of
the frontal process of the maxilla and the nasal bones
(▶ Fig. 1.5). Depending on the size of the nasal bones, the base
of the frontal bone may contribute in part to the formation of
the radix nasi as well. Lang5 describes eight different types of
ossa nasalia. The nasal bones may be reduced in size or even
absent.6 In some cases, the nasal bones may be subdivided into
several pieces. The facial surface of the nasal bone may contain
a foramen for an emissary vein. The inferior border of the nasal
bone articulates with the lateral nasal cartilage (▶ Fig. 1.5). The
external ramus of the anterior ethmoidal nerve passes through
the junction of the nasal bone and the lateral nasal cartilage or
the lower region of the nasal bone.
The external bony opening of the nasal cavity is the pyriform
aperture. Whereas the nasal bones and the frontal process of
the maxilla form the upper and lateral margin of the pyriform
aperture, the body of the maxilla shapes its lower margin. The
lower margin of the external nasal aperture exhibits with
the anterior nasal spine a sharp midline anterior projection of
the inferior nasal border. From anterior to posterior we can find

Fig. 1.5 Bony and cartilaginous framework of the external nose from a
lateral view. 1, nasal septum; 2, medial crus of greater alar cartilage; 3,
lateral crus of greater alar cartilage; 4, lateral nasal cartilage; 5, nasal
bone; 6, frontal process of maxillary bone; 7, minor alar cartilage.

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Fig. 1.6 Sagittal section through the facial skeleton with depiction of the nasal septum. 1,
cribriform lamina; 2, perpendicular plate of the
ethmoid bone; 3, vomer; 4, posterior nasal spine;
5, palatine crest; 6, maxillary crest; 7, premaxilla;
8, anterior nasal spine; 9, (sphenoidal recess of
septa) cartilage; 10, septal cartilage; 11, nasal
bone.

the premaxilla, the maxillary crest, and the palatine crest. The
posterior end of the palatine crest is the posterior nasal spine
(▶ Fig. 1.6).

obstruction in infants together with septal displacements,
nasopharyngeal mass, choanal stenosis, and atresia, is the congenital nasal pyriform aperture stenosis.11

1.6.1 Clinical Pathology of the Bony
Pyramid

1.7 Cartilaginous Pyramid

Exact anatomic knowledge of the bony framework helps in
understanding various pathologic entities and surgical procedures. Pathologic conditions after trauma, like nasal bone fractures, need to be accurately analyzed before deciding the
appropriate reduction technique. Apart from a good physical
examination, new diagnostic methods like nasal bone sonography7 and digital volume tomography8 have started to play an
important role in the analysis of a nasal bone fracture. In addition to the new diagnostic methods come new reduction techniques like the endoscopically assisted nasal bone fracture
reduction.9 To perform osteotomies during a rhinoplasty
(importance of NBL) or to analyze a crooked nose with a bony
deviation, the anatomic knowledge of the bony nasal skeleton is
of great importance. Moreover, a prominent frontal process of
the maxilla should always be considered as a possible cause of
nasal obstruction. Submucosal reduction of this part of the
maxilla can be proved helpful in functional endoscopic sinus
surgery or in cases of nasal obstruction; minimizing the
mucosal trauma results in lower complication rates and faster
patient recovery. Premaxillary retrusion or deviations are also
anatomic features that should be corrected as they may cause
both functional problems and distortions of the aesthetic
appearance of the nasolabial area. Various premaxillary augmentation techniques are described in the literature (e.g., cartilage and bone grafts or Mersilene [Ethicon Inc., Somerville, NJ]
mesh).10 Another important pathology of the maxilla, which
should be considered in the differential diagnosis of nasal

4

The cartilaginous pyramid, consisting of the cartilaginous nasal
septum and the upper lateral cartilages (▶ Fig. 1.5, ▶ Fig. 1.6,
▶ Fig. 1.7), is a T-shaped construction with a variable angle
ranging from 15 degrees at the valve area to 80 degrees at the
K-area (keystone area). This anatomic feature of the external
nose is of great importance in conditioning the inspired air and
breathing. The cartilaginous nasal septum connects caudally,
from ventral to dorsal, with the anterior nasal spine, the premaxilla, and the vomer (▶ Fig. 1.6). Cranially, it is connected to
the two upper lateral cartilages. Caudally, it has a free connection with the columella, and dorsally it is connected to the perpendicular plate of the ethmoid bone. The perpendicular plate
of the ethmoid bone connects cranially to the cribriform plate
of the skull base and dorsal and caudal to the vomer and the
sphenoidal crest. The olfactory fibers run through the cribriform lamina and end intracranially at the olfactory bulb. Antonio Scarpa in 1785 was the first to describe an extensive plexus
of olfactory nerve fibers. The upper lateral cartilages are connected cranially to the caudal margin of the nasal bones (underlap of ~1 to 2 mm). The caudal margin of the upper lateral cartilage (ULC) is free and protrudes into the vestibule. Its lateral
side is covered by skin and is named “cul de sac.” Dorsally, it is
connected with the lateral soft tissue (or “hinge”) area. The
medial third of the caudal margin is usually rotated upward
160 to 180 degrees (returning, scrolling, or curling). There are a
variety of possible connections of the ULC and the lower lateral
cartilage (LLC). The most common finding is an overlap of the
caudal margin of the ULC by the cranial margin of the lateral

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Functional Anatomy of the Nose
crus of the LLC. Variations include end to end connection, scrolling, or opposite scrolling. In the connective tissue between the
two cartilages, several sesamoid cartilages can be found.
The cartilaginous pyramid also contributes to the formation
of the nasal valve area, first described by Mink.12 The nasal
valve area consists of an internal or inner nasal valve and an
external or outer nasal valve. The nasal valve area controls the
inspiratory air flow and can be considered as the area of maximum nasal flow resistance.13 The internal nasal valve is located
supero-lateral between the lower margin of the ULC, which is
overlapped by the greater alar cartilage (see later) and the anterior part of the nasal septum. The external nasal valve corresponds essentially with the nostrils and is formed by the lower
margin of the alar cartilage, the columella, and by the skin.

1.7.1 Septal Cartilage
Whereas the septal cartilage (or quadrangular cartilage) is a
perpendicular plate, the lateral nasal cartilages are flat extensions of this movable part of the nasal septum. Together with
the perpendicular lamina of the ethmoid bone and the vomer,
the septal cartilage is part of the nasal septum (▶ Fig. 1.6).
Recently, it has been demonstrated in pigs that the septal cartilage may be involved in absorbing energy from masticatory
loads.14
Depending on the degree of enchondral ossification of the
nasal septum, the septal cartilage may be enlarged by a posterior or sphenoidal recess that can reach the anterior border of
the body of the sphenoid bone (▶ Fig. 1.6). The septal cartilage
is 2 to 4 mm thick.5 It is thicker at its anterior and posterior
margins and thinnest in the middle. The cartilaginous septum
widens at several locations, such as its base, the junction of the
ULCs, and the anterior septal body. At the region of the anterior
septal body, we can find thickened areas of mucosa, the anterior tubercle, and the septal intumescentia (▶ Fig. 1.7). The

mucosa at these two regions resembles erectile tissue. The
lower margin of the septal cartilage is connected to the hard
palate by rim-like cartilaginous tissue. The position of the anterior septal angle varies to some degree. Studying 35 cadavers,
Potter et al15 found the septal angle in 68% of cases below the
lower margin of the lateral nasal cartilage. Only 32% of specimens showed a septal angle at the lower margin of the lateral
nasal cartilage. In addition, it should be noted that the anterior
part of the septal cartilage is connected to the anterior nasal
spine by a special arrangement of collagenous fibers. This connection is of great importance when performing a septumplasty. If this connection is disturbed during the surgery, it has
to be reconstructed to secure stability of the nasal septum with
the nasal spine (e.g., using a figure-of-eight suture).
A distinct feature of the lower anterior part of the nasal septum of many mammals, including primates and humans, is the
vomeronasal organ, or Jacobson’s organ (▶ Fig. 1.7). It is related
to the detection of pheromones.

1.7.2 Lateral Nasal Cartilage (Upper
Lateral Cartilage)
Even though the current Nomina Anatomica considers both the
septal and lateral nasal cartilages as distinct, non-united cartilages, clinical workers found that both cartilages are usually
connected with each other to some degree.15 The position of
either the septal or lateral nasal cartilage (or triangular cartilage) in relation of the lower margin of the nasal bones is of
great clinical importance. There is a tight connection between
the ULC and the nasal bone. In addition, the perichondrium of
the ULC is continuous with the periost of the nasal bone.16 In a
study of white cadavers, Potter et al15 observed that the lateral
nasal cartilage underlapped the nasal bone on average by
14.97 mm laterally. Sagittally, the greatest underlap of 8.63 mm

Fig. 1.7 Sagittal section through the facial skeleton with depiction of the nasal septum. The
arrow points to the opening of the organon
vomeronasale (Jacobson’s organ). 1, nasal septum; 2, sphenoidal sinus; 3, incisive canal; 4,
lateral nasal cartilage; 5 septal intumescentia; 6,
frontal sinus.

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was found in the median plane and the least underlap of
3.24 mm on the lateral margin of the lateral nasal cartilage. It
should be noted, however, that there is a great variation in the
connection between ULC and the nasal septum. Potter et al15
observed only in 20% of cases a complete connection. Therefore,
the caudal medial part of the ULC may show a free floppy segment that is not connected with the nasal septum. Taking into
consideration that some nasal muscles (see later) are attached
in this area, this construction may cause an additional
unwanted mobility of the nasal valve area.

1.7.3 Paraseptal Cartilage
Lateral to the caudal part of the septal cartilage and below
Jacobson’s organ, a thin cartilage can be found, also known as
paraseptal cartilage.5,17 The two processes of the V-shaped cartilage may partially ossify.

1.8 Clinical Pathology of the
Cartilaginous Pyramid
The most frequent pathologies include deviated nose syndromes (deviated pyramid, C- or S- shaped pyramid), hump
nose, tension nose, saddle nose, and alar collapse syndrome.
The understanding of this complex anatomy, the preoperative
evaluation, and the precise surgical planning are the key in performing functional or aesthetic nasal surgery. There are various
surgical techniques described in the literature to correct nasal
pathologies. The desired surgical outcome should combine the
two major characteristics of the external nose: rigidity and elasticity. The most frequently used surgical techniques include
cartilage reshaping (septal repositioning, spreader grafts,18
wedging, scoring, morselizing, suture techniques, tongue-ingroove technique, batten grafting) and cartilage reconstruction
(extracorporeal resection19 with or without polydioxanone
foil,20,21 use of conchal or rib cartilage22). According to the
underlying pathology, a closed or open rhinoplasty approach
can be chosen. Most of the surgical techniques can be done with
a closed rhinoplasty, but cases with more severe pathology
should be approached by an open technique, which allows better visualization and easier dissection.

Fig. 1.8 Basal view of the lobule with major anatomic structures.

lobule. The vestibule is the skin-covered cavity between the
nostril and the valve area.
The LLCs are the cartilages that form the lobule and determine the form of the tip, alae, and columella (▶ Fig. 1.10). For
surgical reasons, the alar cartilage is divided into the medial,
intermediate (or middle), and lateral crura as well as the dome.
The lateral crus is the lateral part of the LLC and varies in form.
It can be convex, concave, convex-concave, or concave-convex.
Its length varies from 16 to 30 mm and its height from 6 to
16 mm. The middle or intermediate crus is the anteriorly

1.8.1 Lobule
The lobule is made up of the two LLCs, connective and fatty tissue, and muscle fibers, and it is covered by thick skin with sebaceous glands. The subareas of the lobule are the tip, the alae,
the columella, the nostril, and the vestibule. The tip of the nose
consists of the supratip area (‘‘the dip before the tip’’), the tip
defining points (most prominent areas of the domes producing
light reflex), and the infratip area. The alae are the lateral walls
of the nose and are made of, from inside to outside, the lateral
crura of the LLC, muscles, and skin. Anatomically, the ala is divided into the alar rim, alar base, facet, vertical alar groove,
supra-alar groove, and alar facial groove. The columella consists
of the medial crura of the LLC. Important aesthetic features of
the columella are the columella break and the midcolumellar
groove (▶ Fig. 1.8, ▶ Fig. 1.9). The nostril is the orifice of the

6

Fig. 1.9 Main structures of the lobule in the lateral view.

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Functional Anatomy of the Nose
convex curved part that is composed of two segments, the
upper domal segment and the antero-caudal lobular segment.
The two domes together form the nasal tip. The medial crus is
the medial part of the LLC. It forms together with the anterior
lower part of the septal cartilage the columella. Like the middle
crus, the medial crus is composed of two segments, the columellar segment and the footplate segment.23 Whereas the columellar segment is vertically curved and continuously connected
at the columellar-lobular junction to the lobular segment, the
two footplate segments diverge to some extent. The inferior
view of the columella reveals that both the paired columellar
segments and the paired footplate segments of the medial crus
diverge to some degree. Whereas the angle of domal divergence
refers to the anterior divergence of the columellar segment, the
angle of footplate divergence refers to the posterior divergence
of the paired footplate segments.23 There is a debate regarding
the connection between the medial crus of LLC and the anterocaudal part of the septal cartilage (see later).
Even though the two LLCs tend to join, there is always a gap
between the lower anterior margin of the septal cartilage and
the medial side of the intermediate crus of the LLC, also known
as weak triangle. There is a debate about the contents of this
area. Whereas some researchers identified a well-organized
dense fibrous tissue in this region, also known as interdomal
ligament,24,25 Han et al26 found only loose tissue with a small
amount of collagen and elastic fibers in the interdomal region.
According to Copcu et al,27 who studied 24 human cadavers, a
well-developed interdomal fat pad (also known as domal fat
body) was always detectable, also with ultrasonography.

1.8.2 Greater Alar Cartilage (Lower
Lateral Cartilage)
The greater or major alar cartilages form the underlying structure of the nostrils (▶ Fig. 1.5, ▶ Fig. 1.10). In addition, they are
the main components of the nasal tip. Each alar cartilage is
composed of a medial, intermediate (middle), and a lateral crus
that are curved around the naris. The medial crus is attached by
fibrous tissue with the antero-caudal part of the septal cartilage, thus forming a part of the columella. Notably, Han et al26
found no special tissue (neither loose nor dense connective tissue) between the medial crus and the anterior caudal part of
the septal cartilage. The lateral crus usually overlaps the lower
margin of the ULC. Most researchers found dense fibrous tissue
connecting these two cartilages.26,28 The alar scroll area is the
interval structure between the lower and upper lateral cartilages. It is of great importance as it supports and gives form to
the tip of the nose and provides rigidity to the internal nasal
valve, thus playing an important role in the nasal function. In
addition, dense fibrous tissue connects the lateral crus to the
bony margin of the pyriform aperture.26 According to new
investigations,29 a so-called pyriform ligament exists between
the pyriform margin and the lateral cartilages. This area represents the lateral crural complex. The posterior border of the lateral crus is anchored to the frontal process of the maxilla by
dense fibrous tissue and contains several small minor alar cartilages.28 Because the lateral crus is too short to support completely the lower lateral part of the ala nasi, fibroareolar tissue
fills the gap.

Fig. 1.10 Bony and cartilaginous framework of
the external nose from an inferior view. 1, lateral
crus of greater alar cartilage; 2, medial crus of
greater alar cartilage; 3, anterior nasal spine; 4,
septal cartilage; 5, middle (intermediate) crus of
greater alar cartilage; 6, dome.

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1.9 Soft Tissue Areas
The four soft tissue areas described in the literature have
multiple terminologies. We support the terminology given by
Huizing and de Groot30:
1. Paraseptal soft tissue area: A narrow triangular opening
between the cartilaginous septum and the lower third of the
medial margin of the ULC.
2. Lateral soft tissue area: The area between the lateral margin
of the ULC and the lateral wall of the pyriform aperture.
3. Caudal lobular notch: The area medial to the lower margin of
the lateral crus of the LLC also known as soft triangle or facet.
4. Alar soft tissue area: The most dorsal and caudal part of the
ala, inferior to the lateral crus of the LLC.

1.10 Skin of the Nose
The thickness of the nasal skin varies considerably and depends
largely on the number and distribution of sebaceous glands.31 In
the upper two thirds of the nose, which comprises the nasal dorsum and sidewalls, the skin is relatively thin and contains no
sebaceous glands.32 The caudal third of the nose shows a high
number of sebaceous glands. In this area, the skin is thicker and
closely connected to the muscles. Thus, the skin at the nasal tip
and at the ala is rather thick. Nevertheless, it should be noted
that the thickness of the nasal tip may also vary from thin to
medium to thick.33,34 This knowledge is of great importance
when performing rhinoplasty. The dissection in the area should
be precisely performed to prevent skin perforations and scarring.

1.12.1 Procerus
The procerus originates from the nasal bone and the lateral nasal
cartilage and attaches within the skin of the glabellar region. It
causes transverse wrinkles of the bridge of the nose. It is partially
covered by medial muscle fibers of the orbicularis oculi muscle.

1.12.2 Levator Labii Superioris
Alaeque Nasi
This muscle originates from the frontal process of the maxilla,
medial to the origin of the lower part of the orbicularis oculi. In
addition to the lip insertion (see below), some of the fibers are
attached to the skin of the ala of the nose. Together with levator
labii superioris and the zygomaticus minor, the levator labii
superioris alaeque nasi is considered to be a direct tractor of
the upper lip.28 These direct tractors form a distinct continuous
sheet of fibers that insert into the lip anterior to the orbicularis
oris muscle. This muscle elevates both the lip and the ala nasi.
Therefore, it is of great importance for dilating the nostrils.

1.11 Nasal Superficial
Musculoaponeurotic System
The bony and cartilaginous framework of the external nose is covered by skin (see earlier) and the nasal superficial musculoaponeurotic system (SMAS).24,25 The latter consists of up to five layers
including (1) the skin, (2) the superficial areolar layer, (3) the
fibromuscular layer, (4) the deep areolar layer, and (5) the perichondral/ periosteal layer.25 The fibromuscular layer is composed
of numerous muscles of facial expression, innervated by branches
of the facial nerve. According to Saban et al,25 the nasal SMAS covers the external nose continuously from the glabellar region to
the lower margin of the nostrils. Because all nasal muscles are
connected to each other by aponeuroses,24,35 aesthetic rhinoplasty
always has an impact on the whole nasal SMAS.

1.12 Nasal Muscles
There is an extensive literature about the nasal muscles.16,24,35–37
In addition to the below-mentioned muscles, a great number of
additional muscles have been described. Because most of the
muscles of facial expression are interconnected to each other,
facial motion can influence the motion of the nose.38 To avoid
any confusion, however, only the most common and clinically
important nasal muscles are considered below. Within the nasal
SMAS, the following muscles can be identified: M. procerus, M.
levator labii superioris alaeque nasi, M. nasalis, M. depressor
septi, M. dilatator naris, and M. apicis nasi (▶ Fig. 1.11).

8

Fig. 1.11 Nasal muscles according to Bruintjes. 1, nasal bone; 2, M.
levator labii superioris alaeque nasi; 3, M. dilatator naris; 4, M.
depressor septi; 5, M. procerus; 6, M. nasalis, pars transversa; 7, M.
apicis nasi; 8, nasal septum; 9, medial crus of greater alar cartilage.

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Functional Anatomy of the Nose

Fig. 1.12 Sagittal section through the facial
skeleton with depiction of the arterial supply of
the nasal cavity. 1, posterior ethmoidal artery; 2,
sphenopalatine artery; 3, internal carotid artery;
4, external carotid artery; 5, anterior ethmoidal
artery.

1.12.3 Nasalis

1.13 Blood Supply

The nasalis muscle consists of two parts, a pars transversa
and a pars alaris. The transverse portion originates from the
canine ridge of the maxilla and inserts on the aponeurosis of
the dorsum nasi together with its contralateral counterpart.
According to Bruintjes et al,35 the transverse part is not
attached to the nose. The alar portion (dilatator naris posterior muscle) arises from the incisive fossa of the maxilla,
above the lateral incisor. Its fibers run into the skin of ala nasi.
Some of the fibers also insert into the nasal septum and the
upper lip.39 Whereas the alar part dilates the ala nasi, the
transverse part serves to stabilize the nasal aperture at
the valve area.35

1.12.5 M. Dilatator Naris

According to Toriumi et al,40 the most arterial, venous, and lymphatic vessels can be found within or slightly above the nasal
SMAS.
The blood supply of the external nose arises mainly from
branches of the facial and the ophthalmic arteries (▶ Fig. 1.12,
▶ Fig. 1.13). The facial artery gives rise to the superior labial
artery, which divides into a septal nasal ramus and a lateral
nasal ramus.41 In some cases, the superior labial artery is connected to the infraorbital artery.41 The superior labial artery is
the main vessel supplying the nasal tip region.42 Further
branches for the nasal tip are the dorsal nasal artery (ophthalmic artery) and some columellar branches (inferior alar ramus,
facial artery) of small diameter.40,42 The anterior ethmoidal
artery gives off a branch that runs through a small foramen on
the dorsum nasi.5
Veins can be found laterally along the lateral side of the
nose, usually beneath the nasal SMAS in the submuscular areolar tissue.40 The venous drainage from the external nose runs
from the external nasal veins both to the angular vein and
further to the superior ophthalmic vein or the facial vein.
Venous valves exist throughout the facial region, suggesting a
well-directed venous blood flow.43 Of special importance is
the possible drainage toward the angular vein and the pterygoid plexus.

This muscle originates from the lateral crus of the greater alar
cartilage and runs somewhat downwards to the alar skin. It
may be considered as a dilator of the alar region.27

1.14 Lymphatics

1.12.4 Depressor Septi Nasi
This muscle arises from the maxilla above the central incisor,
perhaps also from the anterior nasal spine,24,37 and inserts into
the membranous part of the nasal septum. Medial fascicles
insert fan-shaped into the upper lip.37 This muscle not only
pulls down the medial crus of the greater alar cartilage but may
also have an impact on widening the nostrils.35

1.12.6 M. Apicis Nasi
This is a small muscle running from the lateral crus of the
greater alar cartilage to the skin of the nasal tip without having
significant functions.35

The lymph at the region of the pyriform aperture drains within
the subcutaneous fatty tissue or beneath the SMAS toward the
facial vein and further to the sub-mandibular lymph nodes.5
Lymphoscintigraphic studies on the nasal tip of patients
revealed drainage toward the lateral crura of the nose and further to the preparotid lymph nodes.40 There is obviously no

9

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Rhinoplasty Assessment

Fig. 1.13 Variation in the distribution of arteries
at the nasal tip after Jung et al: (a) type I; (b) type
II; (c) type III; (d) type IV. FA, facial artery; AA,
angular artery; LNA, lateral nasal artery; DNA,
dorsal nasal artery; SLA, superior labial artery.

lymphatic drainage down the columella. The root of the nose
and the lateral part of the dorsum of the nose drain in close
proximity to the inferior margin of the orbital cavity toward the
lymph nodes at the parotid gland, sometimes along buccal
lymph nodes.5

1.15 Nerves
Like most parts of the human facial region, the external nose is
innervated by branches of the trigeminal nerve, especially by
branches of the ophthalmic and maxillary nerves (▶ Fig. 1.14).

Fig. 1.14 Sagittal section through the facial
skeleton with depiction of the innervation pattern of the nasal cavity. 1, olfactory bulb; 2,
pterygopalatine ganglion; 3, nasal branches; 4,
greater palatine nerve; 5, external nasal nerve.

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Functional Anatomy of the Nose
Whereas the nerve supply of the radix nasi consists of supratrochlear nerve, the dorsum nasi is innervated by the infratrochlear
nerve and the external ramus of the anterior ethmoidal nerve
(external nasal nerve). This external nasal nerve passes usually
through the nasal bone beneath the nasal SMAS toward the apex
of the nostril.44 It may run as a single branch or divide into several small branches.44 The alar region is supplied by branches of
the infraorbital nerve of the maxillary nerve. Another nerve of
the nose that should be definitely mentioned is the incisive
nerve, which runs through the incisive canal. It passes through
the incisive canal together with the incisive artery and supplies
the incisive teeth. The dissection in this region, cm posterior to
the anterior nasal spine, should be done with care to avoid complications, such as sensibility dysfunctions, of the hard palate and
color alterations of devitalized incisive teeth.

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[3] Farkas LG, Kolar JC, Munro IR. Geography of the nose: a morphometric study.
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[4] Hwang TS, Kang HS. Morphometry of nasal bases and nostrils in Koreans.
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[5] Lang J. Clinical Anatomy of the Nose, Nasal Cavity and Paranasal Sinuses.
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[6] Schaeffer JP. The Nose, Paranasal Sinuses, Nasolacrimal Passageways and
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[14] Al Dayeh AA, Rafferty KL, Egbert M, Herring SW. Deformation of nasal septal
cartilage during mastication. J Morphol 2009; 270: 1209–1218
[15] Potter JK, Rogers T, Finn R. Macroscopic and microscopic details of the cartilaginous nasal pyramid. J Oral Maxillofac Surg 2000; 58: 867–876
[16] Bruintjes TD. On the Functional Anatomy of the Nasal Valve and Lobule. [Ph.
D. thesis]Utrecht, The Netherlands: Universiteit Utrecht; 1996
[17] Fawcett E. A complete common paraseptal cartilage in a primate. J Anat 1943;
77: 176–178
[18] Mendelsohn M. Straightening the crooked middle third of the nose: using
porous polyethylene extended spreader grafts. Arch Facial Plast Surg 2005; 7:
74–80

[19] Gubisch W. Extracorporeal septoplasty for the markedly deviated septum.
Arch Facial Plast Surg 2005; 7: 218–226
[20] Boenisch M, Tamás H, Nolst Trenité GJ. Influence of polydioxanone foil on
growing septal cartilage after surgery in an animal model: new aspects of
cartilage healing and regeneration (preliminary results). Arch Facial Plast
Surg 2003; 5: 316–319
[21] Gerlinger I, Kárász T, Somogyvári K et al. Extracorporal septal reconstruction
with polydioxanone foil. Clin Otolaryngol 2007; 32: 465–470
[22] Daniel RK. Rhinoplasty: septal saddle nose deformity and composite reconstruction. Plast Reconstr Surg 2007; 119: 1029–1043
[23] Oneal RM, Beil RJ, Izenberg PH, Schlesinger J. Surgical anatomy of the nose.
Oper Tech Plast Reconstr Surg 2000; 7: 158–167
[24] Letourneau A, Daniel RK. The superficial musculoaponeurotic system of the
nose. Plast Reconstr Surg 1988; 82: 48–57
[25] Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An anatomical study of
the nasal superficial musculoaponeurotic system: surgical applications in rhinoplasty. Arch Facial Plast Surg 2008; 10: 109–115
[26] Han SK, Lee DG, Kim JB, Kim WK. An anatomic study of nasal tip supporting
structures. Ann Plast Surg 2004; 52: 134–139
[27] Copcu E, Metin K, Ozsunar Y, Culhaci N, Ozkök S. The interdomal fat pad of
the nose: a new anatomical structure. Surg Radiol Anat 2004; 26: 14–18
[28] Williams PL, Warwick R, Dysen M, Bannister LH. Gray’s Anatomy. 37th ed.
Edinburgh, UK: Churchill Livingstone; 1989
[29] Rohrich RJ, Hoxworth RE, Thornton JF, Pessa JE. The pyriform ligament. Plast
Reconstr Surg 2008; 121: 277–281
[30] Huizing EH, De Groot JAM. Functional Reconstructive Nasal Surgery. Stuttgart, Germany: G. Thieme; 2003
[31] Haring A. Topographische Anatomie der Nase und dreidi-mensionale Darstellung auf der Basis plastinationshistolo-gischer Schnittserien. [med dissertation]Lubeck, Germany: Universitet zu Lubeck; 2006
[32] Gloster HM. The use of full-thickness skin grafts to repair nonperforating
nasal defects. J Am Acad Dermatol 2000; 42: 1041–1050
[33] Anderson KJ, Henneberg M, Norris RM. Anatomy of the nasal profile. J Anat
2008; 213: 210–216
[34] Solomon PS, Rival R, Mabini A, Boyd J. Transfixion incision as an initial technique in nasal tip deprojection. Can J Plast Surg 2008; 16: 224–227
[35] Bruintjes TD, van Olphen AF, Hillen B, Huizing EH. A functional anatomic
study of the relationship of the nasal cartilages and muscles to the nasal valve
area. Laryngoscope 1998; 108: 1025–1032
[36] Figallo EE, Acosta JA. Nose muscular dynamics: the tip trigonum. Plast
Reconstr Surg 2001; 108: 1118–1126
[37] de Souza Pinto EB. Relationship between tip nasal muscles and the short
upper lip. Aesthetic Plast Surg 2003; 27: 381–387
[38] Lai A, Cheney ML. External nasal anatomy and its application to rhinoplasty.
Aesthetic Plast Surg 2002; 26: Suppl 1:S9
[39] Schumacher GH. Anatomie. Lehrbuch and Atlas. Band 1.2. Auflage. Leipzig,
Germany: J. A. Barth; 199
[40] Toriumi DM, Mueller RA, Grosch T, Bhattacharyya TK, Larrabee WF, Jr . Vascular anatomy of the nose and the external rhinoplasty approach. Arch Otolaryngol Head Neck Surg 1996; 122: 24–34
[41] Thumfart WF, Platzer W, Gunkel AR, Maurer H, Brenner E. Operative
Zugangswege in der HNO-Heilkunde. Stuttgart, Germany: G. Thieme; 1998
[42] Jung DH, Kim HJ, Koh KS et al. Arterial supply of the nasal tip in Asians. Laryngoscope 2000; 110: 308–311
[43] Miyake M, Ito M, Nagahata S, Takeuchi Y, Fukui Y. Morphological study of the
human maxillofacial venous vasculature: examination of venous valves using
the corrosion resin cast technique. Anat Rec 1996; 244: 126–132
[44] Han SK, Shin YW, Kim WK. Anatomy of the external nasal nerve. Plast
Reconstr Surg 2004; 114: 1055–1059

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2 The Effect of Facial Asymmetry on Nasal Deviation
Richard W. Westreich, David Burstein, and Marika Fraser

2.1 Introduction
Facial growth and development is a complex process in which
multiple independent structures interact at various stages to
produce a unified form. This progression occurs over a person’s
entire life, with the majority of changes determined in the
embryological, childhood, and adolescent periods. Involutional
changes continue to occur with advancing age, resulting in
issues such as senile nasal tip ptosis and nasal collapse.
The aesthetic definition of the nose as an anatomic structure
is inherently linked to those structures that surround it. Modification of these structures, such as the midface, can greatly
affect not only the appearance of the nose but also its function.
The embryological origin of the nose is a complex combination
of contributions of the frontal prominence, the merged medial
nasal prominences, the lateral nasal prominences, and the cartilage nasal capsule.
Within this context, it is reasonable to conclude that nasal
form and function can be affected by asymmetries in the underlying facial skeleton and soft tissue envelope. A nose that develops on an uneven facial platform may grow in a deviated fashion. This may produce various amounts of nasal obstruction,
depending on the degree of deviation and the underlying
genetically programmed nasal anatomy. Anecdotally, many
patients relate new-onset nasal deviations during adolescence,
typically a period of robust nasal growth.
Nasal surgeons have routinely accepted that facial asymmetry
has a role in nasal deviation, the most startling and obvious
example being patients with cleft lip and palate. For many decades, the classic pattern seen in those patients has been
extrapolated to patients without facial clefts. The senior author
has previously investigated this hypothesis and found it to be
untrue.1
The literature surrounding facial asymmetry is sparse.
Recently, there appears to be a renewed interest in this concept,
and several authors have shown significant associations
between nasal deviation and asymmetries of the face.2–4
Although conventional wisdom has previously looked at hemifacial asymmetries, there appears to be emerging evidence that
discrete zonal facial hypoplasia can occur and can exist across a
spectrum of severity.
Previous descriptions of hypoplasia in relation to the nose have
included brow height discrepancies, dystopic lateral canthi,
retracted ala, nasal deviation, commissure asymmetry, and deviation of the mentum. However, not all patients have upper, middle, and lower facial asymmetries that fit into this hemifacial pattern. Additionally, not all descriptions are in agreement as to
whether an affected area is higher, lower, retracted, and so on.
The concept of zonal hypoplasia is not a new one, as it has
been considered in the dental and oral surgery literature for
some time.5,6 Mandibular hypoplasia often results in occlusive
deformities, for which patients commonly seek orthodontic or
surgical correction. Associated deviation of the mentum and
vertical mandibular height discrepancies are often seen. These
underlying bony abnormalities result in surface cosmetic issues
that are corrected with orthognathic surgery. This includes not

12

only mandibular symmetry but also mentum position and lip
line cant or commissure asymmetry. Binder and Azizzadeh have
previously discussed malar asymmetry or hypoplasia as it relates
to involutional changes in the midface with advancing age.7

2.2 Embryology of Nasal
Development
The nose originates from a complex combination of contributions. The frontal prominence forms the bridge, the merged
medial nasal prominences form the median ridge and tip of
nose, the lateral nasal prominences forms the alae, and the cartilage nasal capsule forms the septum and the nasal conchae.8 A
complex interplay of feedback inhibition and cellular communication orchestrates the relative growth and development of
these structures into a final form.
During development at the third week of gestation, neural
crest cells complete their caudal migration toward the midface.
The frontonasal process migrates inferiorly and differentiates
into two projections known as the nasal placodes. These nasal
placodes will ultimately incorporate ectoderm and mesenchyme as they fuse to become the nasal cavity and primitive
choana. The primitive choana forms the point of development
of the posterior pharyngeal wall and the various paranasal
sinuses.
The surrounding tissues are converted to olfactory pits,
which indent the frontonasal process and divide it into a medial
and two lateral nasal processes. The rounded lateral angles of
the medial process constitute the globular processes of His. The
olfactory pits form the rudiments of the nasal cavities, and from
their ectodermal lining the epithelium of the nasal cavities,
with the exception of that of the inferior meatus, is derived.9
The globular processes elongate posteriorly as plates, termed
the nasal laminae. These laminae are at first some distance
apart, but ultimately fuse and form the nasal septum; the processes themselves meet in the midline to form the premaxilla
and the philtrum. The depressed part of the medial nasal process between the globular processes forms the lower part of the
nasal septum or columella. Above this, a prominent angle
becomes the future apex of the nasal tip, and more cephalically,
the future bridge of the nose is formed. The paired lateral nasal
processes converge to form the alae of the nose.
The external nares approach each other as the frontonasal
process becomes narrower and its deep part forms the nasal
septum. Mesoderm becomes heaped up in the median plane to
form the prominence of the nose. Simultaneously, a groove
appears between the region of the nose and the bulging forebrain. As the nose becomes prominent, the external nares come
to open downward instead of forward.8
The oronasal membrane, which is fully formed by the end of
fifth week of development, gives rise to the floor of the nose.
The palate later develops from this membrane. The continuing
growth of the embryo brings both the nasal placodes and the
maxillary processes together in midline to form the maxilla and
the beginning of the external nose. The frontonasal prominence

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The Effect of Facial Asymmetry on Nasal Deviation
gives rise to an inferior mesodermic projection, which goes on
to form the nasal septum dividing the nose into two cavities.10
At any stage in this complex process, growth asymmetry or
retardation has the potential to create zonal areas of hypoplasia
that may ultimately become relevant for nasal positioning.

2.3 Cleft Lip Model of Nasal
Deviation
Unilateral cleft lip and palate is a classic example of how facial
asymmetry leads to nasal deviation. The well-described and relatively consistent pattern of nasal deformity seen in these
patients is likely a result of both the asymmetric bony base that
supports the nose and the unbalanced biomechanical forces acting on the nose. Certainly, there is maxillary hypoplasia and
abnormal positioning of the lateral maxillary segment on the side
with the cleft deformity, which results in a posterolateral displacement of the piriform rim and alar base. In addition, anomalous muscular and ligamentous insertions create atypical and
uneven forces on the nasal cartilage, bone, and soft tissues.11,12
The most striking features of the cleft lip nasal deformity
involve the septum and nasal tip. As a midline structure, the
nasal septum is typically exposed to equal opposing forces from
both sides of the face. In a normal situation, the septopremaxillary ligament attaches the anterior septum to the premaxilla,
and the orbicularis oris inserts into the anteroinferior septum
and nasal spine bilaterally. When there is a cleft, these insertions are disrupted unilaterally, and the caudal septum is pulled
to the noncleft side by the unopposed forces. Posteriorly, bowing and deviation of the cartilaginous and bony septum toward
the cleft side cause considerable obstruction.
The nasal tip cartilages and soft tissues are secondarily
deformed by the underlying facial malformations. On the noncleft side, the orbicularis exerts force on the columella and contributes to the septocolumellar deviation away from the cleft.
On the cleft side, orbicularis oris inserts into the alar base and
pulls it laterally and inferiorly; the alar base also assumes a

more posterior position on this side due to the underlying
hypoplastic maxilla. The pull of orbicularis on the lateral crus of
the lower lateral cartilage creates a lateral crural steal effect.
Though the lower lateral cartilage is the same size as on the
opposite side, the medial crus is shortened, the lateral crus is
elongated, and the dome is flattened with a more obtuse angle.
The nostril then appears widened and horizontally oriented.13

2.4 Zonal Model of Nasal
Deviation
The cantilever model for nasal tip biomechanics represents an
extension of the original tripod theory that incorporates several
new concepts into predicting nasal tip position after surgery.14
The model takes into consideration the elastic potential energy
of the cartilage and helps to explain why certain maneuvers
project or rotate the nose. Modifications to the nasal tip cartilages generally produce an upward force vector, which is stored
in the paired tip cartilages as elastic potential energy. This
energy is balanced by gravitational and isometric forces that
are derived from the surrounding supporting elements of the
face and nose. Of particular importance is the frontal process of
the maxilla, as it has a role in tip, upper lateral cartilage, and
nasal bone stabilization. The push and pull of these force vectors determine the ultimate position of the nasal tip after modification maneuvers in a craniocaudal direction. However, the
balance of these forces will also determine nasal position along
a mediolateral vector.
A simplification of these surrounding force elements is to
view the nose as a series of successive triangles, each with a
central supporting element (that determines projection, height,
and stability) and lateral stabilizing elements that determine
midline positioning.1 The lateral stabilization is provided either
through isometric contact between adjacent structures (i.e.,
upper and lower lateral cartilages at the scroll region) or direct
fibrous sesamoid complex or bony attachments (nasomaxillary
suture line; ▶ Fig. 2.1).

Fig. 2.1 Cross-sectional schematic of the upper, middle, and lower thirds of the nose in the setting of right maxillary deficiency. The effect of a
retrusive medial maxilla is seen throughout the different regions of the nose. Despite relatively equal development of the nasal suprastructure, a
significant linear external deviation is seen in all areas of the nose. (Reprinted with permission from Archives of Facial Plastic Surgery 2009; 11(3):157–
164. Copyright (2009) American Medical Association. All rights reserved.1)

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If one views the upper, middle, and lower thirds of the nose
in this light, it is easy to see how projection deficiencies in the
maxilla could result in a deviation to that segment. If the upper,
middle, and lower aspects of the medial maxilla are hypoplastic, then the entire nose will often lean off toward that side.
When viewing the face and its relationship to the nose, the
most critical vector of hypoplasia would therefore be the anteroposterior height of the medial maxillary buttress. This is
essentially the frontal process of the maxilla. Deficiency in this
region results in nasal deviation toward the hypoplastic side.
Typically, if the anteroposterior vector is deficient, then the
other vectors of the maxilla will be deficient as well (craniocaudal and mediolateral). This should ultimately result in lowering
of the orbit, flattening of the zygoma, and superior ascent of the
commissure on the side of maxillary hypoplasia. A pattern then
emerges where these four findings are often but not exclusively
seen together. These abnormalities also exist along a continuum
where subtle differences may only be seen after strict photographic analysis (▶ Fig. 2.2, ▶ Fig. 2.3).
Although mandibular and frontal bone hypoplasia can coexist
with maxillary hypoplasia, it is not absolutely required. There
structures are derived from different processes during embryological development and can independently develop in a symmetrical manner. Findings often cited, such as a higher eyebrow
or chin deviation toward the side of hypoplasia, are again sometimes but not always associated with midfacial hypoplasia and
nasal deviation (▶ Fig. 2.4).2,15

Multiple investigators have tried to quantify methods of analyzing facial asymmetry. Most oral surgery studies have found
significant issues related to deviation of the mentum or lip line
cant from the horizontal.5,6 This likely reflects a selection bias
to some degree. Plastic surgery and facial plastic surgery literature often neglects analysis of the lower facial one-third. Chatrath et al showed an association with the perception of facial
asymmetry and disparities in the lateral excursion of the ala off
the midline.3 Hafezi et al showed an association between clinically asymmetric faces and nasal deviation.2 To date, we have
not found a relevant analysis of the upper facial third.
The study by Hafezi et al demonstrated maxillary hypoplasia
in association with nasal deviation by viewing photographs of
671 patients who underwent cosmetic nasal surgery.2 They
found a strong relationship between “crooked noses and facial
growth retardation.” A total of 153 patients were identified as
asymmetric. These patients were subdivided into three groups:
those with deviated noses and asymmetric faces (57.5%), deviated noses with normal faces (24.8%), and asymmetric faces
with straight noses (17.6%).
Their analysis utilized measurements between the lateral
canthus and mouth corner as well as the distance between the
rhinion to the most lateral cheek projecting point. In essence,
these frontal views measured the craniocaudal and mediolateral or transverse maxillary vectors but did not assess the anteroposterior vector. These measurements were compared with
the patient’s normal side.

Fig. 2.2 Congenital facial asymmetry with nasal
deviation. Pre- and postoperative photographs
showing deviation correction using foundation
rhinoplasty techniques alone.

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The Effect of Facial Asymmetry on Nasal Deviation

Fig. 2.3 Nasal deviation in the setting of midfacial and upper facial zonal hypoplasia. Pre- and
postoperative views of a combined foundation
rhinoplasty and cosmetic rhinoplasty approach.

Fig. 2.4 Midfacial and mandibular facial asymmetry with nasal deviation. Foundation rhinoplasty alone without nasal bone osteotomy
provided airway correction. The patient did not
desire cosmetic correction but did want airway
straightening. Persistent right midvault asymmetry due to partial onlay graft resorption is
present. The patient did not desire additional
corrective maneuvers and was pleased with the
outcome.

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Rhinoplasty Assessment
Significant differences were noted in those individuals with nasal
deviation and facial asymmetry in several of the measured parameters. Vertical height differences (lateral canthus to mouth corner)
were greater in those patients with deviated noses and asymmetric
faces than those with midline noses and asymmetric faces.
There was an even higher degree of association between the
lateral or transverse measurements (rhinion to lateral cheek
point) than the vertical one. This is not surprising because commissure position is also affected by mandibular development
and is not specifically dependent on maxillary volume. This
echoes other investigations, which have shown lateral alar displacement to be the most significant anatomic issue in nasal
deviation and the perception of facial asymmetry. Overall, 76%
of their patients with facial asymmetry had nasal deviation, and
only 26% had midline noses (p < 0.05).
Another important finding within this study was the high
rate of revision (28%) in the 88 patients with both nasal deviation and facial asymmetry. A significant number of those
patients had also had orthodontic interventions during their
lifetime (57/61 questionnaire respondents). A 72% satisfaction
rate was noted within this group of respondents. Causes of dissatisfaction included persistent deviation, asymmetric nostrils,
and asymmetric alar rims.

Chatrath et al assessed frontal photography of 300 patients
requesting rhinoplasty surgery; 234 patients were identified as
having facial asymmetry.3 Comparison of various soft tissue
points on the face to the vertical midline facial meridian was
done. Lateral alar, medial canthus, and lateral canthus excursion
was noted to be a significant predictor of the face as asymmetric. Commissure deviation and tragal height differences were
not noted to be predictive.
A follow-up study by the same group of authors was done for
those patients who had undergone rhinoplasty correction.4
They found a significant correlation between rhinoplasty surgery and objective improvement in these measurements. They
reported a subjective improvement in the perception of facial
asymmetry in these patients as well.
A previous study by Yao et al used base view analysis
of patients with nasal deviation and facial hypoplasia.1
Measurements of nasal deviation on frontal view were compared with angulation of the alar attachment to the face on
base view. A nearly linear association was seen (R = 0.8)
between these two measurement points, indicating a high
degree of correlation. This base-view soft tissue analysis indirectly looks at the anteroposterior maxillary volume
(▶ Fig. 2.5, ▶ Fig. 2.6).1

Fig. 2.5 Typical measurements taken before and
after foundation and aesthetic rhinoplasty correction. Deviation correction can only be taken as
far as the face will accommodate. Note the
starting nasal point between the pupils and the
tip position essentially at the philtrum (vertical
lines). Postoperatively, an improved but persistent nasal axis deviation is present (horizontal
lines).

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The Effect of Facial Asymmetry on Nasal Deviation

Fig. 2.6 Typical pre- and postoperative measurements in patient with isolated zonal midfacial
asymmetry. Note the increased deviation correction and alignment of facial structures on the
vertical plane compared with the patient in
▶ Fig. 2.4

It becomes clear that a zonal view of the facial skeleton that
separates the face into thirds and also considers the threedimensional development of each segment emerges. Any one
area or vector can be deficient in isolation, but typically the
entire maxilla is hypoplastic. With respect to the nose, it is the
medial maxillary projection that matters most. This theory
could be investigated using computer tomography and volume
analysis as answering this question could further our understanding of nasal and facial development.

●

●
●

●

2.5 Linear Versus Curvilinear Nasal
Deformities
As a surgeon becomes more experienced with nasal corrective
procedures, certain patterns of deformity typically become
internalized into the individual physician’s thought process and
surgical treatment plan. Drawing upon past patient experiences
helps one to define corrective maneuvers that will work and
those that will not. Analogy from patient to patient then occurs
and, as more patients fit within that mold, a surgeon can begin
to recognize patterns of anatomic variation. The nose is no
exception.
The senior author has had significant experience correcting
deviated noses for both functional and cosmetic reasons.
Within the context of this experience, a pattern for congenital
nasal deviation associated with midfacial hypoplasia has developed and, although not exclusive, represents a starting point for
developing a surgical plan for deviation correction.
Congenitally deviated noses are typically linear, but traumatically deviated noses are typically curvilinear. A linear deviation,
which is almost exclusively seen with midfacial hypoplasia, is
one in which the following anatomic variations are seen:
● Nasal bone deviates toward the hypoplastic side.
● Dorsal septal deviates toward the hypoplastic side.

Posterior septal deflects off the maxillary crest. This propagates as a vomerine spur with bony septal deviation toward
the normal side. The caudal septum may traverse the crest to
ultimately lie on the side of tip deviation (ipsilateral) or
remain on the same side (contralateral) as the deeper
dislocation.
Nasal tip deviates toward the hypoplastic side.
Dome lateralization on the hypoplastic lower lateral cartilage
is evident.
Vertical cephalic lower lateral cartilage is hypertrophied on
the hypoplastic side with convexity compared with the opposite lower lateral cartilage (▶ Fig. 2.7).

Several significant variations may be seen in these patients. Significant difficulties arise with asymmetric development of the
anterior nasal spine. The position of the anterior nasal spine
should be determined preoperatively and verified intraoperatively. If the spine lies in a paramedian position, then deviation
correction must be done using a method that transposes the
posterior septal angle to the opposite side of the spine, rather
than on top of it.16 An alternate approach is to remove the paramedian portion of the crest and leave a remnant in a midline
position. This is only possible with bifid crests that are a few
millimeters off midline. The surgeon should also be aware of
the increased potential for postoperative deprojection, unless
columellar strut placement is part of the operative protocol.
The degree of deviation correction with paramedian crests, in
the senior author’s experience, is also harder to achieve and
predict.
Another significant variation is seen in patients with midline
nasal bones. Deviation correction does not mandate osteotomies, as corrective maneuvers of the lower nasal two-thirds are
reliably predictable in this circumstance (▶ Fig. 2.8).
The congenital deviation stands in contradistinction to the traumatically deviated nose, where curvilinear deformities are typically
present. Deviation is typically most pronounced at the rhinion due

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Fig. 2.7 Congenital deviation with midline nasal
bones and ipsilateral caudal deflection. Combined foundation and cosmetic rhinoplasty outcome shown.

Fig. 2.8 Linear congenital nasal deviation with
midline bones and ipsilate