Rhinoplasty ( grc, ῥίς, rhī́s, nose + grc, πλάσσειν, plássein, to shape), commonly called nose job, medically called nasal reconstruction is a

plastic surgery Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes cranio ...

procedure for altering and reconstructing the

nose A nose is a protuberance in vertebrates that houses the nostrils, or nares, which receive and expel air for respiration alongside the mouth. Behind the nose are the olfactory mucosa and the sinuses. Behind the nasal cavity, air next passe ...

. There are two types of plastic surgery used –

reconstructive surgery Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition. Description Reconstructive surgery is a term with training, clinical, and reimbursement implicat ...

that restores the form and functions of the nose and

cosmetic surgery Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes cranio ...

that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal

injuries An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or o ...

caused by various

trauma Trauma most often refers to: *Major trauma, in physical medicine, severe physical injury caused by an external source *Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic inju ...

s including

blunt Blunt may refer to: * Blunt (surname), a surname (and list of people with the name) * Blunt (cigar), a term used in the cigar industry to designate blunt-tipped, usually factory-rolled cigars * Blunt (cannabis), a slang term used in cannabis cult ...

, and

penetrating trauma Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or ''non-penetrating'' trauma may have some deep da ...

and trauma caused by

blast injury A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives. These injurie ...

. Reconstructive surgery can also treat

birth defect A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities ca ...

breathing problems Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing dis ...

, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty. In closed rhinoplasty and open rhinoplasty surgeries – a plastic surgeon, an

otolaryngologist Otorhinolaryngology ( , abbreviated ORL and also known as otolaryngology, otolaryngology–head and neck surgery (ORL–H&N or OHNS), or ear, nose, and throat (ENT)) is a surgical subspeciality within medicine that deals with the surgical a ...

(ear, nose, and throat specialist), or an oral and maxillofacial surgeon (jaw, face, and neck specialist), creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the

soft tissues Soft tissue is all the tissue in the body that is not hardened by the processes of ossification or calcification such as bones and teeth. Soft tissue connects, surrounds or supports internal organs and bones, and includes muscle, tendons, liga ...

from the nasal framework, altering them as required for form and function,

suturing A surgical suture, also known as a stitch or stitches, is a medical device used to hold body tissues together and approximate wound edges after an injury or surgery. Application generally involves using a needle with an attached length of thre ...

the incisions, using tissue glue and applying either a package or a

stent In medicine, a stent is a metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. A wide variety of stents are used for different purposes, from expandab ...

, or both, to immobilize the altered nose to ensure the proper healing of the surgical incision.

History

Treatments for the plastic repair of a broken nose are first mentioned in the

Edwin Smith Papyrus The Edwin Smith Papyrus is an ancient Egyptian medical text, named after Edwin Smith who bought it in 1862, and the oldest known surgical treatise on trauma. From a cited quotation in another text, it may have been known to ancient surgeons as t ...

, a transcription of text dated to the

Old Kingdom In ancient Egyptian history, the Old Kingdom is the period spanning c. 2700–2200 BC. It is also known as the "Age of the Pyramids" or the "Age of the Pyramid Builders", as it encompasses the reigns of the great pyramid-builders of the Fourth ...

from 3000 to 2500 BCE. The '' Ebers Papyrus'' ( 1550 BC), an Ancient Egyptian medical papyrus, describes rhinoplasty as the plastic surgical operation for reconstructing a nose destroyed by rhinectomy. Such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time and culture. Rhinoplasty techniques are described in the

ancient Indian The following outline is provided as an overview of and topical guide to ancient India: Ancient India is the Indian subcontinent from prehistoric times to the start of Medieval India, which is typically dated (when the term is still used) to t ...

text ''

Sushruta samhita The ''Sushruta Samhita'' (सुश्रुतसंहिता, IAST: ''Suśrutasaṃhitā'', literally "Suśruta's Compendium") is an ancient Sanskrit text on medicine and surgery, and one of the most important such treatises on this subje ...

'' by

Sushruta Sushruta, or ''Suśruta'' (Sanskrit: सुश्रुत, IAST: , ) was an ancient Indian physician. The '' Sushruta Samhita'' (''Sushruta's Compendium''), a treatise ascribed to him, is one of the most important surviving ancient treatises o ...

, where a nose is reconstructed by using a flap of skin from the cheek. During the

Roman Empire The Roman Empire ( la, Imperium Romanum ; grc-gre, Βασιλεία τῶν Ῥωμαίων, Basileía tôn Rhōmaíōn) was the post-Roman Republic, Republican period of ancient Rome. As a polity, it included large territorial holdings aro ...

(27 BC – 476 AD) the encyclopaedist

Aulus Cornelius Celsus Aulus Cornelius Celsus ( 25 BC 50 AD) was a Roman encyclopaedist, known for his extant medical work, ''De Medicina'', which is believed to be the only surviving section of a much larger encyclopedia. The ''De Medicina'' is a primary source on ...

( 25 BC – 50 AD) published the 8-tome ''

De Medicina ''De Medicina'' is a 1st-century medical treatise by Aulus Cornelius Celsus, a Roman encyclopedist and possibly (but not likely) a practicing physician. It is the only surviving section of a much larger encyclopedia; only small parts still survi ...

'' (On Medicine, 14 AD), which described plastic surgery techniques and procedures for the correction and the reconstruction of the nose and other body parts. At the

Byzantine The Byzantine Empire, also referred to as the Eastern Roman Empire or Byzantium, was the continuation of the Roman Empire primarily in its eastern provinces during Late Antiquity and the Middle Ages, when its capital city was Constantinopl ...

Roman court of the Emperor

Julian the Apostate Julian ( la, Flavius Claudius Julianus; grc-gre, Ἰουλιανός ; 331 – 26 June 363) was Roman emperor from 361 to 363, as well as a notable philosopher and author in Greek. His rejection of Christianity, and his promotion of Neoplat ...

(331–363 AD), the royal physician Oribasius ( 320–400 AD) published the 70-volume ''Synagogue Medicae'' (Medical Compilations, 4th century AD), which described facial-defect reconstructions that featured loose sutures that permitted a

surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

wound to heal without distorting the facial flesh; how to clean the bone exposed in a wound;

debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy. I ...

, how to remove damaged tissue to forestall

infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable di ...

and so accelerate healing of the

wound A wound is a rapid onset of injury that involves lacerated or punctured skin (an ''open'' wound), or a contusion (a ''closed'' wound) from blunt force trauma or compression. In pathology, a ''wound'' is an acute injury that damages the epider ...

; and how to use autologous skin flaps to repair damaged cheeks, eyebrows, lips, and nose, to restore the patient's normal visage. In Italy,

Gasparo Tagliacozzi Gaspare Tagliacozzi (his last name has also been spelled Taliacotius, Tagliacoze or Tagliacozzio; Bologna, March 1545 – Bologna, 7 November 1599) was an Italian surgeon, pioneer of plastic and reconstructive surgery. Biography Tagliacozzi w ...

(1546–1599), professor of

surgery Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pa ...

and

anatomy Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having i ...

at the

University of Bologna The University of Bologna ( it, Alma Mater Studiorum – Università di Bologna, UNIBO) is a public research university in Bologna, Italy. Founded in 1088 by an organised guild of students (''studiorum''), it is the oldest university in contin ...

, published ''Curtorum Chirurgia Per Insitionem'' (The Surgery of Defects by Implantations, 1597), a technico–procedural manual for the

repair and reconstruction of facial wounds in soldiers. The illustrations featured a re-attachment rhinoplasty using a biceps muscle pedicle flap; the graft attached at 3-weeks post-procedure; which, at 2-weeks post-attachment, the surgeon then shaped into a nose. In Great Britain, Joseph Constantine Carpue (1764–1846) published the descriptions of two rhinoplasties: the reconstruction of a battle-wounded nose, and the repair of an

arsenic Arsenic is a chemical element with the symbol As and atomic number 33. Arsenic occurs in many minerals, usually in combination with sulfur and metals, but also as a pure elemental crystal. Arsenic is a metalloid. It has various allotropes, b ...

-damaged nose. (cf. Carpue's operation).Muley G. Sushruta: Great Scientists of ancient India. URL: http://www.vigyanprasar.gov.in/dream/july2000.article.htm.Accessed on 07/07/2007 (s) Artificial nose, 17th-18th century

In Germany, rhinoplastic technique was refined by surgeons such as the

Berlin University Humboldt-Universität zu Berlin (german: Humboldt-Universität zu Berlin, abbreviated HU Berlin) is a German public research university in the central borough of Mitte in Berlin. It was established by Frederick William III on the initiative o ...

professor of surgery Karl Ferdinand von Gräfe (1787–1840), who published ''Rhinoplastik'' (Rebuilding the Nose, 1818) wherein he described 55 historical plastic surgery procedures, and his technically innovative free-graft nasal reconstruction (with a tissue-flap harvested from the patient's arm), and surgical approaches to eyelid,

cleft lip A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The te ...

, and

cleft palate A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The ...

corrections. Dr. von Gräfe's

protégé Mentorship is the influence, guidance, or direction given by a mentor. A mentor is someone who teaches or gives help and advice to a less experienced and often younger person. In an organizational setting, a mentor influences the personal and p ...

, the

medical Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practic ...

and

polymath A polymath ( el, πολυμαθής, , "having learned much"; la, homo universalis, "universal human") is an individual whose knowledge spans a substantial number of subjects, known to draw on complex bodies of knowledge to solve specific pro ...

Johann Friedrich Dieffenbach (1794–1847), who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published ''Die Operative Chirurgie'' (Operative Surgery, 1845), which became a foundational medical and plastic surgical text (see

strabismus Strabismus is a vision disorder in which the eyes do not properly align with each other when looking at an object. The eye that is focused on an object can alternate. The condition may be present occasionally or constantly. If present during a ...

torticollis Torticollis, also known as wry neck, is a dystonic condition defined by an abnormal, asymmetrical head or neck position, which may be due to a variety of causes. The term ''torticollis'' is derived from the Latin words ''tortus, meaning "twisted ...

). Moreover, the

Prussia Prussia, , Old Prussian: ''Prūsa'' or ''Prūsija'' was a German state on the southeast coast of the Baltic Sea. It formed the German Empire under Prussian rule when it united the German states in 1871. It was ''de facto'' dissolved by an e ...

n Jacques Joseph (1865–1934) published ''Nasenplastik und sonstige Gesichtsplastik'' (Rhinoplasty and other Facial Plastic Surgeries, 1928), which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions. In the United States, in 1887, the otolaryngologist John Orlando Roe (1848–1915) performed the first modern endonasal rhinoplasty (closed rhinoplasty) and about his management of saddle nose deformities. In the early 20th century, Freer, in 1902, and Killian, in 1904, pioneered the submucous resection septoplasty (SMR) procedure for correcting a deviated

septum In biology, a septum (Latin for ''something that encloses''; plural septa) is a wall, dividing a cavity or structure into smaller ones. A cavity or structure divided in this way may be referred to as septate. Examples Human anatomy * Interat ...

; they raised mucoperichondrial tissue flaps, and resected the

cartilaginous Cartilage is a resilient and smooth type of connective tissue. In tetrapods, it covers and protects the ends of long bones at the joints as articular cartilage, and is a structural component of many body parts including the rib cage, the neck a ...

and bony

(including the

vomer bone The vomer (; lat, vomer, lit=ploughshare) is one of the unpaired facial bones of the skull. It is located in the midsagittal line, and articulates with the sphenoid, the ethmoid, the left and right palatine bones, and the left and right maxil ...

and the perpendicular plate of the ethmoid bone), maintaining septal support with a 1.0-cm margin at the dorsum and a 1.0-cm margin at the caudad, for which innovations the technique became the foundational, standard septoplastic procedure. In 1921, A. Rethi introduced the open rhinoplasty approach featuring an incision to the nasal septum to facilitate modifying the tip of the nose. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1947, Maurice H. Cottle (1898–1981) endonasally resolved a septal deviation with a minimalist hemitransfixion incision, which conserved the septum; thus, he advocated for the practical primacy of the closed rhinoplasty approach. In 1957, A. Sercer advocated the "decortication of the nose" (''Dekortication des Nase'') technique which featured a columellar-incision open rhinoplasty that allowed greater access to the

nasal cavity The nasal cavity is a large, air-filled space above and behind the nose in the middle of the face. The nasal septum divides the cavity into two cavities, also known as fossae. Each cavity is the continuation of one of the two nostrils. The nasal ...

and to the nasal septum. The endonasal rhinoplasty was the usual approach to nose surgery until the 1970s, when Padovan presented his technical refinements, advocating the open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the later 1970s, and by Jack P. Gunter in the 1990s. Goodman impelled technical and procedural progress and popularized the open rhinoplasty approach. In 1987, Gunter reported the technical effectiveness of the open rhinoplasty approach for performing a secondary rhinoplasty; his improved techniques advanced the management of a failed nose surgery.

Anatomy of the human nose

The structures of the nose

For plastic surgical correction, the structural anatomy of the nose comprises: A. the nasal soft tissues; B. the aesthetic subunits and segments; C. the blood supply arteries and veins; D. the nasal lymphatic system; E. the facial and nasal nerves; F. the nasal bone; and G. the nasal cartilages.

A. The nasal soft tissues

*Nasal skin – Like the underlying

bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...

-and-

cartilage Cartilage is a resilient and smooth type of connective tissue. In tetrapods, it covers and protects the ends of long bones at the joints as articular cartilage, and is a structural component of many body parts including the rib cage, the neck ...

(osseo-cartilaginous) support framework of the nose, the external skin is divided into vertical thirds (anatomic sections); from the

glabella The glabella, in humans, is the area of skin between the eyebrows and above the nose. The term also refers to the underlying bone that is slightly depressed, and joins the two brow ridges. It is a cephalometric landmark that is just superior t ...

(the space between the eyebrows), to the bridge, to the tip, for corrective plastic surgery, the nasal skin is anatomically considered, as the: # Upper third section – the skin of the upper nose is thin, subcutaneous fat layer is thicker and relatively distensible (flexible and mobile), but then tapers, adhering tightly to the osseo-cartilaginous framework, and becomes the thinner skin of the dorsal section, the bridge of the nose. # Middle third section – the skin overlying the bridge of the nose (mid-dorsal section) is the thinnest, least distensible, nasal skin, because it most adheres to the support framework. # Lower third section – the skin of the lower nose is as thicker and less mobile, because it has more sebaceous glands, especially at the nasal tip. Subcutaneous fat layer is very thin. * Nasal lining – At the vestibule, the human nose is lined with a

mucous membrane A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It i ...

of squamous epithelium, which tissue then transitions to become columnar respiratory epithelium, a pseudo-stratified,

ciliated The cilium, plural cilia (), is a membrane-bound organelle found on most types of eukaryotic cell, and certain microorganisms known as ciliates. Cilia are absent in bacteria and archaea. The cilium has the shape of a slender threadlike proj ...

(lash-like) tissue with abundant seromucous glands, which maintains the nasal moisture and protects the respiratory tract from bacteriologic infection and foreign objects. * Nasal muscles – The movements of the human nose are controlled by groups of facial and neck muscles that are set deep to the skin; they are in four functional groups that are interconnected by the nasal superficial

aponeurosis An aponeurosis (; plural: ''aponeuroses'') is a type or a variant of the deep fascia, in the form of a sheet of pearly-white fibrous tissue that attaches sheet-like muscles needing a wide area of attachment. Their primary function is to join muscl ...

—the superficial musculoaponeurotic system (SMAS)—which is a sheet of dense, fibrous,

collagen Collagen () is the main structural protein in the extracellular matrix found in the body's various connective tissues. As the main component of connective tissue, it is the most abundant protein in mammals, making up from 25% to 35% of the whol ...

ous

connective tissue Connective tissue is one of the four primary types of animal tissue, along with epithelial tissue, muscle tissue, and nervous tissue. It develops from the mesenchyme derived from the mesoderm the middle embryonic germ layer. Connective tiss ...

that covers, invests, and forms the terminations of the muscles.

= The movements of the nose are affected by

= # the elevator muscle group – which includes the

procerus muscle The procerus muscle (or pyramidalis nasi) is a small pyramidal slip of muscle deep to the superior orbital nerve, artery and vein. ''Procerus'' is Latin, meaning tall or extended. Structure The procerus muscle arises by tendinous fibers from t ...

and the

levator labii superioris alaeque nasi muscle The levator labii superioris alaeque nasi muscle is, translated from Latin, the "lifter of both the upper lip and of the wing of the nose". It has the longest name of any muscle in an animal. The muscle is attached to the upper frontal process o ...

. # the depressor muscle group – which includes the alar nasalis muscle and the depressor septi nasi muscle. # the compressor muscle group – which includes the transverse nasalis muscle. # the dilator muscle group – which includes the

dilator naris muscle The dilator naris muscle (or alae nasi muscle) is a part of the nasalis muscle. It has an anterior and a posterior part. It has origins from the nasal notch of the maxilla and the major alar cartilage, and a single insertion near the margin of th ...

that expands the nostrils; it is in two parts: (i) the dilator nasi anterior muscle, and (ii) the dilator nasi posterior muscle. Rhinoplasty-nose diagram-nasal subunits-labelled

Rhinoplasty-nose diagram-nasal subunits-labelled

B. Aesthetics of the nose – nasal subunits and nasal segments

To plan, map, and execute the surgical correction of a nasal defect or deformity, the structure of the external nose is divided into nine aesthetic nasal subunits, and six aesthetic nasal segments, which provide the plastic surgeon with the measures for determining the size, extent, and topographic locale of the nasal defect or deformity.

= The surgical nose as nine ''aesthetic nasal subunits''

= # tip subunit # columellar subunit # right alar base subunit # right alar wall subunit # left alar wall subunit # left alar base subunit # dorsal subunit # right dorsal wall subunit # left dorsal wall subunit In turn, the nine aesthetic nasal subunits are configured as six aesthetic nasal segments; each segment comprehends a nasal area greater than that comprehended by a nasal subunit.

= The surgical nose as six ''aesthetic nasal segments''

= # the dorsal nasal segment # the lateral nasal-wall segments # the hemi-lobule segment # the soft-tissue triangle segments # the alar segments # the columellar segment Gray513

Using the co-ordinates of the subunits and segments to determine the topographic location of the defect on the nose, the plastic surgeon plans, maps, and executes a rhinoplasty procedure. The unitary division of the nasal topography permits minimal, but precise, cutting, and maximal corrective-tissue coverage, to produce a functional nose of proportionate size, contour, and appearance for the patient. Hence, if more than 50 percent of an aesthetic subunit is lost (damaged, defective, destroyed) the surgeon replaces the entire aesthetic segment, usually with a regional tissue graft, harvested from either the face or the head, or with a tissue graft harvested from elsewhere on the patient's body.

C. Nasal blood supply – arteries and veins

Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the cir ...

. The principal arterial blood-vessel supply to the nose is two-fold: (i) branches from the

internal carotid artery The internal carotid artery (Latin: arteria carotis interna) is an artery in the neck which supplies the anterior circulation of the brain. In human anatomy, the internal and external carotids arise from the common carotid arteries, where these ...

, the branch of the anterior ethmoidal artery, the branch of the posterior ethmoidal artery, which derive from the

ophthalmic artery The ophthalmic artery (OA) is an artery of the head. It is the first branch of the internal carotid artery distal to the cavernous sinus. Branches of the ophthalmic artery supply all the structures in the orbit around the eye, as well as some s ...

; (ii) branches from the

external carotid artery The external carotid artery is a major artery of the head and neck. It arises from the common carotid artery when it splits into the external and internal carotid artery. External carotid artery supplies blood to the face and neck. Structure T ...

, the sphenopalatine artery, the

greater palatine artery The greater palatine artery is a branch of the descending palatine artery (a terminal branch of the maxillary artery) and contributes to the blood supply of the hard palate and nasal septum. Course The descending palatine artery branches off of ...

, the superior labial artery, and the

angular artery The angular artery is an artery of the face. It is the terminal part of the facial artery. It ascends to the medial angle of the eye's orbit. It is accompanied by the angular vein. It ends by anastomosing with the dorsal nasal branch of the ...

. The external nose is supplied with blood by the facial artery, which becomes the angular artery that courses over the superomedial aspect of the nose. The sellar region (

sella turcica The sella turcica ( Latin for 'Turkish saddle') is a saddle-shaped depression in the body of the sphenoid bone of the human skull and of the skulls of other hominids including chimpanzees, gorillas and orangutans. It serves as a cephalometr ...

, "Turkish chair") and the dorsal region of the nose are supplied with blood by branches of the internal

maxillary artery The maxillary artery supplies deep structures of the face. It branches from the external carotid artery just deep to the neck of the mandible. Structure The maxillary artery, the larger of the two terminal branches of the external carotid artery, ...

( infraorbital artery) and the ophthalmic arteries that derive from the internal

common carotid artery In anatomy, the left and right common carotid arteries (carotids) (Entry "carotid"
in
the Little area), which is a region in the anteroinferior-third of the nasal septum, (in front and below). Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the

cavernous sinus The cavernous sinus within the human head is one of the dural venous sinuses creating a cavity called the lateral sellar compartment bordered by the temporal bone of the skull and the sphenoid bone, lateral to the sella turcica. Structure The cave ...

, which makes possible the potential intracranial spreading of a bacterial infection of the nose. Hence, because of such an abundant nasal blood supply,

tobacco smoking Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is beli ...

does therapeutically compromise post-operative healing.

D. Lymphatic system of the nose

The pertinent nasal

lymphatic system The lymphatic system, or lymphoid system, is an organ system in vertebrates that is part of the immune system, and complementary to the circulatory system. It consists of a large network of lymphatic vessels, lymph nodes, lymphatic or lymphoid ...

arises from the superficial mucosa, and drains posteriorly to the retropharyngeal nodes (in back), and anteriorly (in front), either to the upper deep cervical nodes (in the neck), or to the

submandibular gland The paired submandibular glands (historically known as submaxillary glands) are major salivary glands located beneath the floor of the mouth. They each weigh about 15 grams and contribute some 60–67% of unstimulated saliva secretion; on stimul ...

s (in the lower jaw), or into both the nodes and the glands of the neck and the jaw. Gray778 Trigeminal

E. Nerves of the nose

The sensations registered by the human nose derive from the first two branches of cranial nerve V, the

trigeminal nerve In neuroanatomy, the trigeminal nerve ( lit. ''triplet'' nerve), also known as the fifth cranial nerve, cranial nerve V, or simply CN V, is a cranial nerve responsible for sensation in the face and motor functions such as biting and che ...

. The

nerve A nerve is an enclosed, cable-like bundle of nerve fibers (called axons) in the peripheral nervous system. A nerve transmits electrical impulses. It is the basic unit of the peripheral nervous system. A nerve provides a common pathway for the ...

listings indicate the respective innervation (sensory distribution) of the trigeminal nerve branches within the nose, the face, and the upper jaw (maxilla). Cranial nerve VII

;The indicated nerve serves the named anatomic facial and nasal regions:

= Ophthalmic division innervation

= * Lacrimal nerve – conveys sensation to the skin areas of the lateral orbital (eye socket) region, except for the

lacrimal gland The lacrimal glands are paired exocrine glands, one for each eye, found in most terrestrial vertebrates and some marine mammals, that secrete the aqueous layer of the tear film. In humans, they are situated in the upper lateral region of each or ...

. * Frontal nerve – conveys sensation to the skin areas of the forehead and the scalp. *

Supraorbital nerve The supraorbital nerve is one of two branches of the frontal nerve, itself a branch of the ophthalmic nerve. The other branch of the frontal nerve is the supratrochlear nerve. Structure The supraorbital nerve branches from the frontal nerve mi ...

– conveys sensation to the skin areas of the eyelids, the forehead, and the scalp. * Supratrochlear nerve – conveys sensation to the medial region of the eyelid skin area, and the medial region of the forehead skin. *

Nasociliary nerve The nasociliary nerve is a branch of the ophthalmic nerve, itself a branch of the trigeminal nerve (CN V). It is intermediate in size between the other two branches of the ophthalmic nerve, the frontal nerve and lacrimal nerve. Structure The na ...

– conveys sensation to the skin area of the nose, and the mucous membrane of the anterior (front) nasal cavity. * Anterior ethmoid nerve – conveys sensation in the anterior (front) half of the nasal cavity: (a) the internal areas of the ethmoid sinus and the frontal sinus; and (b) the external areas, from the nasal tip to the rhinion: the anterior tip of the terminal end of the nasal-bone suture. * Posterior ethmoid nerve – serves the superior (upper) half of the nasal cavity, the sphenoids, and the ethmoids. * Infratrochlear nerve – conveys sensation to the medial region of the eyelids, the palpebral

conjunctiva The conjunctiva is a thin mucous membrane that lines the inside of the eyelids and covers the sclera (the white of the eye). It is composed of non-keratinized, stratified squamous epithelium with goblet cells, stratified columnar epithel ...

, the

nasion The nasion () is the most anterior point of the frontonasal suture that joins the nasal part of the frontal bone and the nasal bones. It marks the midpoint at the intersection of the frontonasal suture with the internasal suture joining the nasa ...

(nasolabial junction), and the bony dorsum.

= The maxillary division innervation

= *

Maxillary nerve In neuroanatomy, the maxillary nerve (V) is one of the three branches or divisions of the trigeminal nerve, the fifth (CN V) cranial nerve. It comprises the principal functions of sensation from the maxilla, nasal cavity, sinuses, the pala ...

– conveys sensation to the upper jaw and the face. * Infraorbital nerve – conveys sensation to the area from below the

eye socket In anatomy, the orbit is the cavity or socket of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents. In the adult human, the volume of the orbit is , of ...

to the external nares (nostrils). * Zygomatic nerve – through the

zygomatic bone In the human skull, the zygomatic bone (from grc, ζῠγόν, zugón, yoke), also called cheekbone or malar bone, is a paired irregular bone which articulates with the maxilla, the temporal bone, the sphenoid bone and the frontal bone. It is s ...

and the

zygomatic arch In anatomy, the zygomatic arch, or cheek bone, is a part of the skull formed by the zygomatic process of the temporal bone (a bone extending forward from the side of the skull, over the opening of the ear) and the temporal process of the zygo ...

, conveys sensation to the cheekbone areas. * Superior posterior dental nerve – sensation in the teeth and the gums. * Superior anterior dental nerve – mediates the sneeze reflex. * Sphenopalatine nerve – divides into the lateral branch and the septal branch, and conveys sensation from the rear and the central regions of the

The supply of

parasympathetic The parasympathetic nervous system (PSNS) is one of the three divisions of the autonomic nervous system, the others being the sympathetic nervous system and the enteric nervous system. The enteric nervous system is sometimes considered part of ...

nerves to the face and the upper jaw (maxilla) derives from the greater superficial petrosal (GSP) branch of cranial nerve VII, the

facial nerve The facial nerve, also known as the seventh cranial nerve, cranial nerve VII, or simply CN VII, is a cranial nerve that emerges from the pons of the brainstem, controls the muscles of facial expression, and functions in the conveyance of taste ...

. The GSP nerve joins the deep petrosal nerve (of the sympathetic nervous system), derived from the carotid plexus, to form the

vidian nerve The nerve of the pterygoid canal (Vidian nerve) is formed by the junction of the greater petrosal nerve and deep petrosal nerve, which passes from the foramen lacerum to the pterygopalatine fossa through the pterygoid canal. Structure The nerve ...

(in the vidian canal) that traverses the

pterygopalatine ganglion The pterygopalatine ganglion (aka Meckel's ganglion, nasal ganglion, or sphenopalatine ganglion) is a parasympathetic ganglion found in the pterygopalatine fossa. It is largely innervated by the greater petrosal nerve (a branch of the facial ner ...

(an autonomic ganglion of the maxillary nerve), wherein only the parasympathetic nerves form synapses, which serve the

and the glands of the nose and of the palate, via the (upper jaw) maxillary division of cranial nerve V, the

F. Bony anatomy of the nose

In the upper portion of the nose, the paired

nasal bones The nasal bones are two small oblong bones, varying in size and form in different individuals; they are placed side by side at the middle and upper part of the face and by their junction, form the bridge of the upper one third of the nose. Ea ...

attach to the

frontal bone The frontal bone is a bone in the human skull. The bone consists of two portions.'' Gray's Anatomy'' (1918) These are the vertically oriented squamous part, and the horizontally oriented orbital part, making up the bony part of the forehead, ...

. Above and to the side (superolaterally), the paired nasal bones connect to the

lacrimal bone The lacrimal bone is a small and fragile bone of the facial skeleton; it is roughly the size of the little fingernail. It is situated at the front part of the medial wall of the orbit. It has two surfaces and four borders. Several bony landmarks of ...

s, and below and to the side (inferolaterally), they attach to the ascending processes of the

maxilla The maxilla (plural: ''maxillae'' ) in vertebrates is the upper fixed (not fixed in Neopterygii) bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. T ...

(upper jaw). Above and to the back (posterosuperiorly), the bony nasal septum is composed of the

perpendicular plate of the ethmoid bone The perpendicular plate of the ethmoid bone (vertical plate) is a thin, flattened lamina, polygonal in form, which descends from the under surface of the cribriform plate, and assists in forming the septum of the nose; it is generally deflected ...

. The

vomer The vomer (; lat, vomer, lit=ploughshare) is one of the unpaired facial bones of the skull. It is located in the midsagittal line, and articulates with the sphenoid, the ethmoid, the left and right palatine bones, and the left and right max ...

bone lies below and to the back (posteroinferiorly), and partially forms the choanal opening into the nasopharynx, (the upper portion of the

pharynx The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus and trachea (the tubes going down to the stomach and the lungs). It is found in vertebrates and invertebrates, though its st ...

that is continuous with the nasal passages). The floor of the nose comprises the premaxilla bone and the

palatine bone In anatomy, the palatine bones () are two irregular bones of the facial skeleton in many animal species, located above the uvula in the throat. Together with the maxillae, they comprise the hard palate. (''Palate'' is derived from the Latin ...

, the roof of the mouth. The nasal septum is composed of the quadrangular cartilage, the vomer bone (the perpendicular plate of the ethmoid bone), aspects of the premaxilla, and the palatine bones. Each lateral nasal wall contains three pairs of

turbinate In anatomy, a nasal concha (), plural conchae (), also called a nasal turbinate or turbinal, is a long, narrow, curled shelf of bone that protrudes into the breathing passage of the nose in humans and various animals. The conchae are shaped lik ...

s (nasal conchae), which are small, thin, shell-form bones: (i) the

superior concha The superior nasal concha is a small, curved plate of bone representing a medial bony process of the labyrinth of the ethmoid bone. The superior nasal concha forms the roof of the superior nasal meatus. Anatomy Anatomical relations The superi ...

, (ii) the middle concha, and (iii) the inferior concha, which are the bony framework of the turbinates. Lateral to the turbinates is the medial wall of the

maxillary sinus The pyramid-shaped maxillary sinus (or antrum of Highmore) is the largest of the paranasal sinuses, and drains into the middle meatus of the nose through the osteomeatal complex.Human Anatomy, Jacobs, Elsevier, 2008, page 209-210 Structure It i ...

. Inferior to the nasal conchae (turbinates) is the meatus space, with names that correspond to the turbinates, e.g. superior turbinate, superior meatus, et alii. The internal roof of the nose is composed by the horizontal, perforated

cribriform plate In mammalian anatomy, the cribriform plate (Latin for lit. ''sieve-shaped''), horizontal lamina or lamina cribrosa is part of the ethmoid bone. It is received into the ethmoidal notch of the frontal bone and roofs in the nasal cavities. It supp ...

(of the ethmoid bone) through which pass sensory filaments of the

olfactory nerve The olfactory nerve, also known as the first cranial nerve, cranial nerve I, or simply CN I, is a cranial nerve that contains sensory nerve fibers relating to the sense of smell. The afferent nerve fibers of the olfactory receptor neurons t ...

(cranial nerve I); finally, below and behind (posteroinferior) the cribriform plate, sloping down at an angle, is the bony face of the sphenoid sinus.

G. The cartilaginous pyramid of the nose

The cartilaginous

(''septum nasi'') extends from the nasal bones in the midline (above) to the bony septum in the midline (posteriorly), then down along the bony floor. The septum is quadrangular; the upper half is flanked by two triangular-to-trapezoidal cartilages: the upper lateral-cartilages, which are fused to the dorsal septum in the midline, and laterally attached, with loose ligaments, to the bony margin of the pyriform (pear-shaped) aperture, while the inferior ends of the upper lateral-cartilages are free (unattached). The internal area (angle), formed by the septum and upper lateral-cartilage, constitutes the internal valve of the nose; the sesamoid cartilages are adjacent to the upper lateral-cartilages in the fibroareolar connective tissue. Beneath the upper lateral-cartilages lay the lower lateral-cartilages; the paired lower lateral-cartilages swing outwards, from medial attachments, to the caudal septum in the midline (the medial crura) to an intermediate crus (shank) area. Finally, the lower lateral-cartilages flare outwards, above and to the side (superolaterally), as the lateral crura; these cartilages are mobile, unlike the upper lateral cartilages. Furthermore, some persons present anatomical evidence of nasal scrolling—i.e., an outward curving of the lower borders of the upper lateral-cartilages, and an inward curving of the cephalic borders of the alar cartilages.

The external nose

External nasal anatomy

The form of the nasal subunits—the dorsum, the sidewalls, the lobule, the soft triangles, the alae, and the columella—are configured differently, according to the race and the ethnic group of the patient, thus the nasal physiognomies denominated as: African, platyrrhine (flat, wide nose); Asiatic, subplatyrrhine (low, wide nose); Caucasian, leptorrhine (narrow nose); and Hispanic, paraleptorrhine (narrow-sided nose). The respective external valve of each nose is variably dependent upon the size, shape, and strength of the lower lateral cartilage.

Internal nasal anatomy

In the midline of the nose, the septum is a composite (osseo-cartilaginous) structure that divides the nose into two similar halves. The lateral nasal wall and the

paranasal sinuses Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sph ...

, the superior concha, the middle concha, and the inferior concha, form the corresponding passages, the superior meatus, the middle meatus, and the inferior meatus, on the lateral nasal wall. The superior meatus is the drainage area for the posterior ethmoid bone cells and the sphenoid sinus; the middle meatus provides drainage for the anterior ethmoid sinuses and for the maxillary and frontal sinuses; and the inferior meatus provides drainage for the

nasolacrimal duct The nasolacrimal duct (also called the tear duct) carries tears from the lacrimal sac of the eye into the nasal cavity. The duct begins in the eye socket between the maxillary and lacrimal bones, from where it passes downwards and backwards. T ...

. The internal nasal valve comprises the area bounded by the upper lateral-cartilage, the septum, the nasal floor, and the anterior head of the inferior turbinate. In the narrow (leptorrhine) nose, this is the narrowest portion of the nasal airway. Generally, this area requires an angle greater than 15 degrees for unobstructed breathing; for the correction of such narrowness, the width of the nasal valve can be increased with spreader grafts and flaring sutures.

Nasal analysis

The surgical management of nasal defects and deformities divides the nose into six anatomic subunits: (i) the dorsum, (ii) the sidewalls (paired), (iii) the hemilobules (paired), (iv) the soft triangles (paired), (v) the alae (paired), and (vi) the columella. Surgical correction and reconstruction comprehend the entire anatomic subunit affected by the defect (wound) or deformity, thus, the entire subunit is corrected, especially when the resection (cutting) of the defect encompasses more than 50 percent of the subunit. Aesthetically, the nose—from the nasion (the midpoint of the nasofrontal junction) to the columella-labial junction—ideally occupies one-third of the vertical dimension of the person's face; and, from ala to ala, it ideally should occupy one-fifth of the horizontal dimension of the person's face. The nasofrontal angle, between the frontal bone and the nasion usually is 120 degrees; the nasofrontal angle is more acute in the male face than in the female face. The nasofacial angle, the slope of the nose relative to the plane of the face, is approximately 30–40 degrees. The nasolabial angle, the slope between the columella and the

philtrum The philtrum ( la, philtrum from Ancient Greek ''phíltron,'' lit. "love charm"), or medial cleft, is a vertical indentation in the middle area of the upper lip, common to therian mammals, extending in humans from the nasal septum to the tuberc ...

, is approximately 90–95 degrees in the male face, and approximately 100–105 degrees in the female face. Therefore, when observing the nose in profile, the normal show of the columella (the height of the visible nasal aperture) is 2 mm; and the dorsum should be rectilinear (straight). When observed from below (worm's-eye view), the alar base configures an isosceles triangle, with its apex at the infra-tip lobule, immediately beneath the tip of the nose. The facially proportionate projection of the nasal tip (the distance of the nose's tip from the face) is determined with the Goode Method, wherein the projection of the nasal tip should be 55–60 percent of the distance between the nasion (nasofrontal junction) and the tip-defining point. A columellar double break might be present, marking the transition between the intermediate crus of the lower-lateral cartilage and the medial crus. The Goode Method determines the extension of the nose from the facial surface by comprehending the distance from the alar groove to the tip of the nose, and then relating that measurement (of nasal-tip projection) to the length of the nasal dorsum. The nasal projection measurement is obtained by delineating a right triangle with lines parting from the nasion (nasofrontal juncture) to the alar–facial–groove. Then, a second, perpendicular delineation, that traverses the tip-defining point, establishes the ratio of projection of the nasal tip; hence, the range of 0.55:1 to 0.60:1, is the ideal nasal-tip-to-nasal-length projection. File:Class_I_nose.jpg, Rhinoplasty: Nasal Class I. The

Roman nose Roman Nose ( – September 17, 1868), also known as Hook Nose ( chy, Vóhko'xénéhe, also spelled Woqini and Woquini), was a Native American of the Northern Cheyenne. He is considered to be one of, if not the greatest and most influential war ...

. (''Nasology'' Eden Warwick, 1848) File:Class_II_nose.jpg, Rhinoplasty: Nasal Class II. The Greek nose. (''Nasology'' Eden Warwick, 1848) File:Class_III_nose.jpg, Rhinoplasty: Nasal Class III. The African nose. (''Nasology'' Eden Warwick, 1848) File:Class_IV_nose.jpg, Rhinoplasty: Nasal Class IV. The Hawk nose. (''Nasology'' Eden Warwick, 1848) File:Class_V_nose.jpg, Rhinoplasty: Nasal Class V. The Snub nose. (''Nasology'' Eden Warwick, 1848) File:Class_VI_nose.jpg, Rhinoplasty: Nasal Class VI. The celestial nose. (''Nasology'' Eden Warwick, 1848) 3D simulations and planning can be used to communicate the patients existing deformities, and plan or propose the desired approach. 3-dimensional cameras allow photographic capture, inspection, analysis, and modification to understand the existing nasal anatomy, and communicate a potential result to the patient.

Patient characteristics

To determine the patient's suitability for undergoing a rhinoplasty procedure, the surgeon clinically evaluates them with a complete

medical history The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...

(anamnesis) to determine their physical and

psychological health Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. It likewise determines how an individual handles stress, interpersonal relationships, and decision-making. Mental health ...

. The prospective patient must explain to the physician–surgeon the functional and aesthetic nasal problems that they have. The surgeon asks about the ailments' symptoms and their duration, past surgical interventions, allergies, drugs use and drugs abuse (prescription and commercial medications), and a general medical history. Furthermore, additional to physical suitability is psychological suitability—the patient's psychological motive for undergoing nose surgery is critical to the surgeon's pre-operative evaluation of the patient. The complete physical examination of the rhinoplasty patient determines if he or she is physically fit to undergo and tolerate the physiologic stresses of nose surgery. The examination comprehends every existing physical problem, and a consultation with an anaesthesiologist, if warranted by the patient's medical data. Specific facial and nasal evaluations record the patient's skin-type, existing surgical scars, and the symmetry and asymmetry of the aesthetic nasal subunits. The external and internal nasal examination concentrates upon the anatomic thirds of the nose—upper section, middle section, lower section—specifically noting their structures; the measures of the nasal angles (at which the external nose projects from the face); and the physical characteristics of the naso-facial bony and soft tissues. The internal examination evaluates the condition of the nasal septum, the internal and external nasal valves, the turbinates, and the nasal lining, paying special attention to the structure and the form of the nasal dorsum and the tip of the nose. Furthermore, when warranted, specific tests—the mirror test, vasoconstriction examinations, and the Cottle maneuver—are included to the pre-operative evaluation of the prospective rhinoplasty patient. Established by Maurice H. Cottle (1898–1981), the Cottle maneuver is a principal diagnostic technique for detecting an internal nasal-valve disorder; whilst the patient gently inspires, the surgeon laterally pulls the patient's cheek, thereby simulating the widening of the cross-sectional area of the corresponding internal nasal valve. If the maneuver notably facilitates the patient's inspiration, that result is a positive Cottle sign—which generally indicates an airflow-correction to be surgically effected with an installed spreader-graft. Said correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. Nonetheless, the Cottle maneuver occasionally yields a false-positive Cottle sign, usually observed in the patient affected by alar collapse, and in the patient with a scarred nasal-valve region.

Surgical rhinoplasty

There is limited evidence that a single dose of corticosteriods decreases oedema and bleeding first two days post operation but the difference is not maintained after this. Swelling and edema can take at least 1-year to diminish. Certain adjuncts, including fat grafting may help quicken the time to edema and bruising resolution.

Open rhinoplasty versus closed rhinoplasty

The plastic surgical correction of

congenital A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...

and acquired abnormalities of the

restores functional and aesthetic properties by the surgeon's manipulations of the nasal skin, the subcutaneous (underlying) cartilage-and-bone support framework, and the

lining. Technically, the plastic surgeon's incisional approach classifies the nasal surgery either as an open rhinoplasty or as a closed rhinoplasty procedure. In open rhinoplasty, the surgeon makes a small, irregular incision to the

columella Lucius Junius Moderatus Columella (; Arabic: , 4 – ) was a prominent writer on agriculture in the Roman Empire. His ' in twelve volumes has been completely preserved and forms an important source on Roman agriculture, together with the wo ...

, the fleshy, exterior-end of the nasal septum; this columellar incision is additional to the usual set of incisions for a nasal correction. In closed rhinoplasty, the surgeon performs every procedural incision endonasally (exclusively within the nose), and does not cut the columella. Cleftlipandpalate

Procedural differences

Except for the columellar incision, the technical and procedural approaches of open rhinoplasty and of closed rhinoplasty are similar; yet closed rhinoplasty procedure features: * Reduced dissection (cutting) of the nasal tissues—no columellar incision * Decreased potential for the excessive reduction (cutting) of the nasal-tip support * Reduced post-operative

edema Edema, also spelled oedema, and also known as fluid retention, dropsy, hydropsy and swelling, is the build-up of fluid in the body's tissue. Most commonly, the legs or arms are affected. Symptoms may include skin which feels tight, the area ma ...

* Decreased visible

scar A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a ...

ring * Decreased

iatrogenic Iatrogenesis is the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence. "Iatrogenic", ''Merriam-Webster.com'', Merriam-Webster, Inc., accessed 27 ...

(inadvertent) damage to the

, by the surgeon * Increased availability for effecting ''in situ'' procedural and technical changes * Palpation that allows the surgeon to ''feel'' the interior changes effected to the nose * Shorter operating room time * Quicker post-surgical recovery and convalescence for the patient

The "ethnic nose"

The open rhinoplasty approach affords the plastic surgeon advantages of ease in securing grafts (

skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different ...

) and, most importantly, in securing the nasal cartilage properly, and so better to make the appropriate assessment and remedy. This procedural aspect can be especially difficult in revision surgery, and in rhinoplastic alteration of the thick-skinned "ethnic nose" of the person of color. The study, ''Ethnic Rhinoplasty: a Universal Preoperative Classification System for the Nasal Tip'' (2009), reports that a nasal-tip classification system, based upon skin thickness, has been proposed to aid the surgeon in determining if an open rhinoplasty or a closed rhinoplasty can best correct the defect or deformity affecting the patient's nose.

Cause

Cause, the open and closed approaches to rhinoplastic correction resolve: (i) nasal pathologies (diseases intrinsic and diseases extrinsic to the nose); (ii) an unsatisfactory aesthetic appearance (disproportion); (iii) a failed primary rhinoplasty; (iv) an obstructed airway; and (v) congenital nose defects and deformities.

Congenital abnormalities

Cleft lip and palate A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The ...

in combination; cleft lip (''cheiloschisis'') and cleft palate (''palatoschisis''), individually. * Congenital nasal abnormalities * Genetically derived ethnic-nose abnormalities

Acquired abnormalities

Allergic Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic der ...

and vasomotor rhinitis – inflammations of the

of the nose caused by an allergen, and caused by circulatory and nervous system disorders. * Autoimmune system diseases * Bites – animal and human *

Burn A burn is an injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or ultraviolet radiation (like sunburn). Most burns are due to heat from hot liquids (called scalding), solids, or fire. Burns occur ma ...

s – caused by

chemicals A chemical substance is a form of matter having constant chemical composition and characteristic properties. Some references add that chemical substance cannot be separated into its constituent elements by physical separation methods, i.e., wit ...

electricity Electricity is the set of physical phenomena associated with the presence and motion of matter that has a property of electric charge. Electricity is related to magnetism, both being part of the phenomenon of electromagnetism, as describe ...

friction Friction is the force resisting the relative motion of solid surfaces, fluid layers, and material elements sliding against each other. There are several types of friction: *Dry friction is a force that opposes the relative lateral motion of ...

heat In thermodynamics, heat is defined as the form of energy crossing the boundary of a thermodynamic system by virtue of a temperature difference across the boundary. A thermodynamic system does not ''contain'' heat. Nevertheless, the term is ...

light Light or visible light is electromagnetic radiation that can be perceived by the human eye. Visible light is usually defined as having wavelengths in the range of 400–700 nanometres (nm), corresponding to frequencies of 750–420 t ...

, and

radiation In physics, radiation is the emission or transmission of energy in the form of waves or particles through space or through a material medium. This includes: * ''electromagnetic radiation'', such as radio waves, microwaves, infrared, visi ...

. * Connective-tissue diseases * Inflammatory conditions * Nasal fractures * Naso-orbito-ethmoidal fractures – damages to the nose and the eye-sockets; and damage to the bones and the walls of the nasal cavity; it is the ethmoid bone that separates the

brain A brain is an organ (biology), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as Visual perception, vision. I ...

from the

. *

Neoplasm A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

s – malignant and benign

tumor A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...

s * Septal

hematoma A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is ...

– a mass of (usually) clotted blood in the septum * Toxins – chemical damages caused by inspired substances – e.g. powdered

cocaine Cocaine (from , from , ultimately from Quechua: ''kúka'') is a central nervous system (CNS) stimulant mainly used recreationally for its euphoric effects. It is primarily obtained from the leaves of two Coca species native to South Am ...

, aerosol

antihistamine Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provide ...

medications, et cetera. * Traumatic deformities caused by

blunt trauma Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue ...

, and blast trauma. * Venereal infection – e.g.,

syphilis Syphilis () is a sexually transmitted infection caused by the bacterium '' Treponema pallidum'' subspecies ''pallidum''. The signs and symptoms of syphilis vary depending in which of the four stages it presents (primary, secondary, latent, a ...

Ultrasonic rhinoplasty

Recently, ultrasonic rhinoplasty which was introduced by Massimo Robiony in 2004 has become an alternative to traditional rhinoplasty. Ultrasonic rhinoplasty uses

piezoelectric Piezoelectricity (, ) is the electric charge that accumulates in certain solid materials—such as crystals, certain ceramics, and biological matter such as bone, DNA, and various proteins—in response to applied mechanical stress. The word '' ...

instruments to reshape atraumatically nasal bones, also known as rhinosculpture. Ultrasonic rhinoplasty uses piezoelectric instruments (scrapers rasps, saws) that affect only the bones and the stiff cartilages through ultrasonic vibrations, as the instruments used in

dental surgery Dental surgery is any of a number of medical procedures that involve artificially modifying dentition; in other words, surgery of the teeth, gums and jaw bones. Types Some of the more common are: * Endodontic (surgery involving the pulp or root ...

. The use of piezoelectric instruments requires a more extended approach than the isial one, allowing to visualize the whole bony vault, to reshape it with rhinosculpture or to mobilize and stabilize bones after controlled osteotomies.

Surgical procedure

A rhinoplastic correction can be performed on a person who is under

sedation Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...

, under

general anaesthesia General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...

, or under

local anaesthesia Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...

; initially, a

local anaesthetic A local anesthetic (LA) is a medication that causes absence of pain sensation. In the context of surgery, a local anesthetic creates an absence of pain in a specific location of the body without a loss of consciousness, as opposed to a general a ...

mixture of

lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lid ...

and

epinephrine Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...

is injected to numb the area, and temporarily reduce vascularity, thereby limiting any bleeding. Generally, the

plastic surgeon Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniof ...

first separates the nasal skin and the

from the osseo-

nous nasal framework, and then reshapes them, sutures the incisions, and applies either an external or an internal stent, and tape, to immobilize the newly reconstructed nose, and so facilitate the healing of the surgical cuts. Occasionally, the surgeon uses either an autologous cartilage graft or a bone graft, or both, in order to strengthen or to alter the nasal . The autologous grafts usually are harvested from the

nasal septum The nasal septum () separates the left and right airways of the nasal cavity, dividing the two nostrils. It is depressed by the depressor septi nasi muscle. Structure The fleshy external end of the nasal septum is called the columella or co ...

, but, if it has insufficient cartilage (as can occur in a revision rhinoplasty), then either a costal cartilage graft (from the

rib cage The rib cage, as an enclosure that comprises the ribs, vertebral column and sternum in the thorax of most vertebrates, protects vital organs such as the heart, lungs and great vessels. The sternum, together known as the thoracic cage, is a sem ...

) or an auricular cartilage graft ( concha from the ear) is harvested from the patient's body. When the rhinoplasty requires a bone graft, it is harvested from either the

cranium The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone. However two parts are more prominent: the cranium and the mandible. In humans, th ...

, the hips, or the rib cage; moreover, when neither type of autologous graft is available, a synthetic graft ( nasal implant) is used to augment the nasal bridge. The main types of grafts to support and reposition the nasal tip (or the central/medial limb of the tripod) are either columellar strut, or the septal extension graft. Both are useful and effective, but the septal extension graft (SEG) is shown to impart greater control, and less changes over time.

Photographic records

For the benefit of the patient and the physician–surgeon, a photographic history of the entire rhinoplastic procedure is established; beginning at the pre-operative consultation, continuing during the surgical operation procedures, and concluding with the post-operative outcome. To record the "before-and-after" physiognomies of the nose and the face of the patient, the specific visual perspectives required are photographs of the nose viewed from the anteroposterior (front-to-back) perspective; the lateral view (profiles), the worm's-eye view (from below), the bird's-eye view (overhead), and three-quarter-profile views. * Photograph A. – Open rhinoplasty: At rhinoplasty's end, after the plastic surgeon has sutured (closed) the incisions, the corrected (new) nose will be dressed, taped, and splinted immobile to permit the uninterrupted healing of the surgical incisions. The purple-ink guidelines ensured the surgeon's accurate cutting of the defect correction plan. * Photograph B. – Open rhinoplasty: The new nose is prepared with paper tape in order to receive the metal nasal-splint that will immobilize it to maintain its correct shape as a new nose. File:RhinoplastySplint1.jpg, Photograph A. Open rhinoplasty:
Pre-operative, the guidelines (purple) ensured the surgeon's accurate incisions in cutting the nasal defect correction plan. File:RhinoplastySplint2.jpg, Photograph B. Open rhinoplasty:
Post-operative, the taped nose, prepared to receive the metal nasal splint that immobilizes and protects the newly corrected nose. File:RhinoplastySplint3.jpg, Photograph C. Open rhinoplasty:
The metal nasal splint aids wound healing by protecting the tender tissues of the new nose. File:RhinoplastySplint4.jpg, Photograph D. Open rhinoplasty:
The taped, splinted, and dressed nose completes the rhinoplasty. * Photograph C. – Open rhinoplasty: After the preliminary taping of the nose, a custom-made, metal nasal-splint, designed, cut, and formed by the surgeon, is emplaced to immobilize and protect the tender tissues of the new nose during convalescence. * Photograph D. – Open rhinoplasty: The taping, emplacement of the metal splint, and dressing of the new nose complete the rhinoplasty procedure. The patient then convalesces, and the wound dressing will be removed at 1-week post-procedure. RhinoplastyIncisions2

* Photograph 1. – Open rhinoplasty: The incisions are endonasal (in the nose), and thus are hidden. The skin-incision to the

aids the plastic surgeon in precisely suturing to hide the

—except for the columellar incision (red-dot guideline) across the

nasal Nasal is an adjective referring to the nose, part of human or animal anatomy. It may also be shorthand for the following uses in combination: * With reference to the human nose: ** Nasal administration, a method of pharmaceutical drug delivery * ...

base. The columellar incision allows the surgeon to view the size, shape, and condition of the nasal cartilages and bones to be corrected. * Photograph 2. – Open rhinoplasty: The nasal interior. The scissors indicate the lower lateral cartilage (blue), which is one of the wing-shaped cartilages that conform the tip of the nose. The jagged red delineation indicates the locale of the columellar incision. Once the skin has been lifted from the bone-and-cartilage framework, the surgeon performs the nasal correction tasks. * Photograph 3. – Open rhinoplasty: To narrow the tip of a too-wide nose, the surgeon first determines the cause of the excess nasal width. The suture being emplaced will narrow the tip of the nose. The red delineation indicates the edge of the nose-tip cartilage, which is narrowed when the surgeon tightens the folded cartilage apex. The suture (light blue) ends in the needle (white); tweezers (green) hold the nasal cartilage in place for the suturing. * Photograph 4. – Nasal hump excision: The black delineation indicates the desired nose-reduction outcome: a straight nose. The nasal hump is bone (red) above the scalloped grey line, and cartilage (blue) below the scalloped grey line. The surgeon cuts the cartilage portion of the hump with a

scalpel A scalpel, lancet, or bistoury is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, podiatry and various arts and crafts (either called a hobby knife or an X-acto knife.). Scalpels may be single-use dispos ...

, and chisels the bone portion with an osteotome (bone chisel). After chiselling away the main mass of the nasal hump with an osteotome, the surgeon then sculpts, refines, and smoothens the cut nasal bones with rasps (files). File:RhinoplastyRasps.jpg, Rhinoplastic instruments:
Bone-scraping rasps, of various grades and types, that the plastic surgeon uses to refine the corrections required to produce a new nose.

Types of rhinoplasty – primary and secondary

In plastic surgical praxis, the term primary rhinoplasty denotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The term secondary rhinoplasty denotes the revision of a failed rhinoplasty, an occurrence in 5–20 per cent of rhinoplasty operations, hence a revision rhinoplasty. The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of a functional breathing deficit from an over aggressive rhinoplasty, asymmetry, deviated or crooked nose, areas of collapses, hanging columella, pinched tip, scooped nose and more. Although most revision rhinoplasty procedures are "open approach", such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from the ear (auricular cartilage graft) or from the

(costal cartilage graft). Results Can be good if performed by an experienced practitioner. As in all plastic surgery procedures, there can be some unpredictability, and biologic systems can heal in different ways.

Nasal reconstruction

In reconstructive rhinoplasty, the defects and deformities that the

encounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose; congenital defect,

(

, penetrating,

blast Blast or The Blast may refer to: *Explosion, a rapid increase in volume and release of energy in an extreme manner *Detonation, an exothermic front accelerating through a medium that eventually drives a shock front Film * ''Blast'' (1997 film), ...

autoimmune disorder An autoimmune disease is a condition arising from an abnormal immune response to a functioning body part. At least 80 types of autoimmune diseases have been identified, with some evidence suggesting that there may be more than 100 types. Nearly ...

cancer Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal b ...

, intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). When

is disrupted,

for re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial) nose prostheses, because of the reduced incidence of histologic rejection and medical complications.

Surgical anatomy for nasal reconstruction

The

human nose The human nose is the most protruding part of the face. It bears the nostrils and is the first organ of the respiratory system. It is also the principal organ in the olfactory system. The shape of the nose is determined by the nasal bone ...

is a sensory organ that is structurally composed of three types of tissue: (i) an osseo-

support framework (nasal skeleton), (ii) a mucous membrane lining, and (iii) an external skin. The anatomic

topography Topography is the study of the forms and features of land surfaces. The topography of an area may refer to the land forms and features themselves, or a description or depiction in maps. Topography is a field of geoscience and planetary sc ...

of the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose into nasal subunits: (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures. ;Nasal skeleton Therefore, the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three anatomic layers: # the osseo-cartilagenous framework – The upper lateral cartilages that are tightly attached to the (rear) caudal edge of the

and the

; said attachment suspends them above the

. The paired alar cartilages configure a tripod-shaped union that supports the lower third of the nose. The paired medial crura conform the central-leg of the tripod, which is attached to the anterior nasal spine and septum, in the midline. The lateral crura compose the second-leg and the third-leg of the tripod, and are attached to the (pear-shaped) pyriform aperture, the nasal-cavity opening at the front of the skull. The dome of the nostrils defines the apex of the alar cartilage, which supports the nasal tip, and is responsible for the light reflex of the tip. # the nasal lining – A thin layer of vascular

mucosa A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It i ...

that adheres tightly to the deep surface of the bones and the cartilages of the nose. Said dense adherence to the nasal interior limits the mobility of the mucosa, consequently, only the smallest of mucosal defects (< 5 mm) can be sutured primarily. # the nasal skin – A tight envelope that proceeds inferiorly from the glabella (the smooth prominence between the eyebrows), which then becomes thinner and progressively inelastic (less distensible). The skin of the mid-third of the nose covers the cartilaginous dorsum and the upper lateral cartilages and is relatively elastic, but, at the (far) distal-third of the nose, the skin adheres tightly to the alar cartilages, and is little distensible. The skin and the underlying soft tissues of the alar lobule form a semi-rigid anatomic unit that maintains the graceful curve of the alar rim, and the patency (openness) of the nostrils (anterior nares). To preserve this nasal shape and patency, the replacement of the alar lobule must include a supporting cartilage graft—despite the alar lobule not originally containing cartilage; because of its many sebaceous glands, the nasal skin usually is of a smooth (oiled) texture. Moreover, regarding , when compared to the skin of other facial areas, the skin of the nose generates fine-line scars that usually are inconspicuous, which allows the surgeon to strategically hide the surgical scars.

Principles of rhinoplastic reconstruction

;Principles The technical principles for the

reconstruction of a

derive from the essential operative principles of

: that the applied procedure and yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of the

;

battens to brace against tissue contraction and depression (topographic collapse); axial skin flaps designed from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting of

, cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the reconstructed nasal subunit is not a nose proper, but a

-glued collage—of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments of ear cartilage—which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose. ;Restoration In nasal reconstruction, the plastic surgeon's ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patient's "normal nose", as perceived at conversational distance (c. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach, which requires that the surgeon balance the patient's required rhinoplasty, with the patient's aesthetic ideal (body image). In the context of surgically reconstructing the patient's physiognomy, the "normal nose" is the three-dimensional (3-D) template for replacing the missing of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials—such as

, and flaps of skin and of tissue. In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the "normal nose" and from photographs of the patient before they sustained the nasal damage. The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining with

, cartilage with cartilage, bone with bone, and skin with skin that best match the native skin color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notable

ring propensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude. The most effective nasal reconstruction for repairing a defect (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in the

topographic Topography is the study of the forms and features of land surfaces. The topography of an area may refer to the land forms and features themselves, or a description or depiction in maps. Topography is a field of geoscience and planetary scie ...

transition between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose with skin flaps. Nonetheless, in the final stage of nasal reconstruction—replicating the "normal nose" anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars, and render them (more) inconspicuous.

Reasons for reconstruction

Reconstruction rhinoplasty is indicated for the correction of defects and deformities caused by: # Skin cancer. The most common cause (

etiology Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiología'') "giving a reason for" (, ''aitía'', "cause"); and ('' -logía''). More completely, ...

) for a nasal reconstruction is

skin cancer Skin cancers are cancers that arise from the skin. They are due to the development of abnormal cells that have the ability to invade or spread to other parts of the body. There are three main types of skin cancers: basal-cell skin cancer (BCC) ...

, especially the lesions to the nose of

melanoma Melanoma, also redundantly known as malignant melanoma, is a type of skin cancer that develops from the pigment-producing cells known as melanocytes. Melanomas typically occur in the skin, but may rarely occur in the mouth, intestines, or eye ( ...

and basal-cell carcinoma. This oncologic

epidemiology Epidemiology is the study and analysis of the distribution (who, when, and where), patterns and determinants of health and disease conditions in a defined population. It is a cornerstone of public health, and shapes policy decisions and evi ...

occurs more readily among the aged and people who reside in very sunny geographic areas; although every type of

is susceptible to skin cancer, white-skin is most epidemiologically prone to developing skin cancer. Furthermore, regarding plastic surgical scars, the age of the patient is a notable factor in the timely, post-surgical healing of a skin cancer defect (lesion); in terms of , the very elastic skin of young people has a greater regenerative propensity for producing scars that are thicker (stronger) and more noticeable. Therefore, in young patients, the strategic placement (hiding) of the rhinoplastic scars is a greater aesthetic consideration than in elder patients; whose less elastic skin produces scars that are narrower and less noticeable. # Traumatic nasal defect. Although

is a less common rhinoplastic occurrence, a nasal defect or deformity caused by blunt trauma (impact),

(piercing), and blast trauma (blunt and penetrating) requires a surgical reconstruction that abides the conservational principles of plastic surgery, as in the corrections of cancerous lesions. # Congenital deformities. The unique plastic properties of the

, and

of patients' affected by congenital defects, and associated anomalies, are considered separately.

Surgical techniques

The effectiveness of a rhinoplastic reconstruction of the external nose derives from the contents of the surgeon's armamentarium of skin-flap techniques applicable to correcting defects of the nasal skin and of the mucosal lining; some management techniques are the bilobed flap, the nasolabial flap, the paramedian forehead flap, and the septal mucosal flap. ;I. Bilobed flap The design of the bilobed flap derives from the creation of two adjacent random transposition flaps (lobes). In its original design, the leading flap is applied to cover the defect, and the second flap, is emplaced where the skin flexes more, and fills the donor-site wound (from where the first flap was harvested), which then is closed primarily, with sutures. The first flap is oriented geometrically, at 90 degrees from the long axis of the wound (defect), and the second flap is oriented 180 degrees from the axis of the wound. Although effective, the bilobed flap technique did create troublesome "dog ears" of excess flesh that required trimming and it also produced a broad skin-donor area that was difficult to confine to the nose. In 1989, J. A. Zitelli modified the bilobed flap technique by: (a) orienting the leading flap at 45 degrees from the long axis of the wound; and (b) orienting the second flap at 90 degrees from the axis of the wound. Said orientations and emplacements eliminated the excess-flesh "dog ears", and thus required a smaller area of donor skin; resultantly, the broad-based, bilobed flap is less prone to the "trap door" and the "pin cushion" deformities common to skin-flap transposition procedure. Nasalis

;Surgical technique – the bilobed flap The design of the bilobed flap co-ordinates its lobes with the long axis of the nasal defect (wound); each lobe of the flap is emplaced at a 45-degree angle to the axis. The two lobes of the bilobed flap rotate along an arc, of which all points are equidistant from the apex of the nasal defect. * Based upon the available area of nasal skin, the surgeon selects the locale for the bilobed flap, and orients the pedicle. If the defect is in the lateral aspect of the nose, the pedicle is based medially. If the defect is at the nasal tip, or at the nasal dorsum, the pedicle is based laterally. An ideal location for the second flap is along the junction of the nasal dorsum and the lateral nasal wall. * The nasal wound is cut and shaped into a teardrop form, by the cutting out of a Burrow's triangle of flesh on the side of pedicle base. Cutting out the Burrow's triangle (skin and subcutaneous fat) permits the moving the pedicle flap, to emplace it without buckling the tissues adjacent to the graft. * Using a 20 mm calliper as a

protractor A protractor is a measuring instrument, typically made of transparent plastic or glass, for measuring angles. Some protractors are simple half-discs or full circles. More advanced protractors, such as the bevel protractor, have one or two sw ...

—one tip at the apex of the wound—the surgeon delineates two semi-circles, an inner semi-circle, and an outer semi-circle. The outer semi-circle defines the necessary length of the two lobes of the skin flap. The inner semi-circle bisects the center of the original wound, and continues across the donor skin, establishing limit measure of the pedicle common to the two lobes of the flap. The surgeon then draws two lines from the apex of the wound; the first line drawn is at an angle of 45 degrees from the long axis of the wound, and the second line drawn is at a 90-degree angle from the axis of the wound. The two lines delineate the central axes of the two lobes of the bilobed flap. * The delineation of each of the two lobes of the flap begins and ends at the inner semi-circle, and extends to the outer semi-circle, to the point where it intersects its central axis. The width of the first lobe is approximately 2 mm narrower than the width of the wound; the width of the second lobe is approximately 2 mm narrower than the width of the first lobe. * After the cutting from the tissue donor-site, the bilobed flap is elevated to a plane between the subcutaneous fat and the nasalis muscle. The wound is deepened, down to the nasal skeleton, to accommodate the tissue thickness of the bilobed flap. Technically, cutting the wound, enlarging it, is preferable, and safer, than trimming (thinning) the flap to fit the wound. * Undermining the donor site for the second lobe allows closing it primarily; it also eliminates excess-skin "dog-ears" at the donor site. Moreover, if the donor site cannot be closed with sutures, or if the skin blanches (whitens) when sutured, usually because of excessively tight sutures, the tension is decreased by reducing the size (length, width, depth) of the wound with deep sutures that will allow it to heal more readily. ;II. Nasolabial flap In the 19th century, the surgical techniques of J.F. Dieffenbach (1792–1847) popularized the nasolabial flap for nasal reconstruction, for which it remains a foundational nose surgery procedure. The nasolabial flap can be either superiorly based or inferiorly based; of which the superiorly based flap is the more practical rhinoplastic application, because it has a more versatile arc of rotation, and the donor-site scar is inconspicuous. Depending upon how the defect lay upon the nose, the flap pedicle-base can be incorporated either solely to the nasal reconstruction, or it can be divided into a second stage procedure. The blood supply for the flap pedicle are the transverse branches of the contralateral

(the facial artery terminus parallel to the nose), and by a confluence of blood vessels from the angular artery and from the

supraorbital artery The supraorbital artery is a branch of the ophthalmic artery. It passes anteriorly within the orbit to exit the orbit through the supraorbital foramen or notch alongside the supraorbital nerve, splitting into two terminal branches which go on to f ...

in the medial canthus, (the angles formed by the meeting of the upper and lower eyelids). Therefore, the incisions for harvesting the nasolabial flap do not continue superiorly beyond the medial canthal tendon. The nasolabial flap is a random flap that is emplaced with the proximal (near) portion resting upon the lateral wall of the nose, and the distal (far) portion resting upon the cheek, which contains the main angular artery, and so is perfused with retrograde arterial flow. ;Surgical technique – the nasolabial flap The pedicle of the nasolabial flap rests upon the lateral nasal wall, and is transposed a maximum of 60 degrees, in order to avoid the "bridge effect" of a flap emplaced across the nasofacial angle. * The surgeon designs the nasolabial flap and sets its central axis at a 45-degree angle from the (long) axis of the nasal dorsum. The shape of the skin flap is cut from the wound template fabricated by the surgeon. * An incision is made to the flap (without an anaesthetic injection of

), which then is elevated and oriented, in an inferior-to-superior direction, between the subcutaneous fat and the muscle fascia. * The cutting continues until the skin flap can be freely transposed upon the nasal defect. A Burrow's triangle is excised from the skin between the medial border of the flap and the nasal dorsum; the triangle can be cut either before or after the elevation of the nasolabial. * The flap then is bent back (reflected), and can be thinned (cut) under loupe magnification; however, a nasolabial flap cannot be thinned as easily as an axial skin-flap. * After the nasolabial flap has been emplaced, the flap donor-site wound is sutured closed. For a wound of the lateral nasal wall that is less than 15 mm wide, the flap donor-site can be closed primarily, with sutures. For a wound wider than 15 mm—especially a wound that comprehends the alar lobule and the lateral wall of the nose—primary closure is not indicated, because such a wound closure imposes excessive stresses upon the skin flap, thereby risking either blanching (whitening) or distortion, or both. Such risks are avoided by advancing (moving) the skin of the cheek towards the nasofacial junction, where it is sutured to the deep tissues. Furthermore, a narrow wound, less than 1 mm wide can be allowed to heal by secondary intention (autonomous re-epithelialisation). ;III. Paramedian forehead flap The paramedian forehead flap is the premier autologous skin graft for the reconstruction of a nose, by replacing any of the aesthetic nasal subunits, especially regarding the problems of different tissue thickness and skin color. The forehead flap is an axial skin flap based upon the

(an ophthalmic artery branch) and the supratrochlear artery (an ophthalmic artery terminus), which can be thinned to the subdermal plexus in order to enhance the functional and aesthetic outcome of the nose. Restricted length is a practical application limit of the paramedian forehead flap, especially when the patient has a low frontal hairline. In such a patient, a small portion of scalp skin can be included to the flap, but it does have a different skin texture and does continue growing hair; such mismatching is avoided with the transverse emplacement of the flap along the hairline; yet that portion of the skin flap is random, and so risks a greater incidence of

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated diges ...

. The paramedian forehead flap has two disadvantages, one operational and one aesthetic: Operationally, the reconstruction of a nose with a paramedian forehead flap is a two-stage surgical procedure, which might a problem for the patient whose health (surgical suitability) includes significant, secondary medical risks. Nonetheless, the second stage of the nasal reconstruction can be performed with the patient under local anaesthesia. Aesthetically, although the flap donor-site scar heals well, it is noticeable, and thus difficult to conceal, especially in men. Flap design

;Surgical technique – the paramedian forehead flap The surgeon designs the paramedian forehead flap from a custom-fabricated three-dimensional metal foil template derived from the measures of the nasal defect to be corrected. Using an ultrasonic scanner, the flap-pedicle is centre-aligned upon the Doppler signal of the supraorbital artery. Afterwards, the distal one-half of the flap is dissected and thinned to the subdermal plexus. * The surgeon fabricates a metal foil template derived from the dimensions of the nasal wound. * Applying a Doppler ultrasonic scanner, the surgeon identifies the axial pedicle of the tissue-flap (composed of the

and the

supratrochlear artery The supratrochlear artery (or frontal artery) is one of the terminal branches of the ophthalmic artery. It arises within the orbit. It exits the orbit alongside the supratrochlear nerve. It contributes arterial supply to the skin, muscles and per ...

), usually at the base, next to the medial brow; the point usually is between the midline and the supraorbital notch. * Tracing the Doppler pulse of the blood flow of the supraorbital artery as far as possible, its delineation is continued as a vertical line, until it intersects with the hairline of the patient. The line extended from the pulse of the blood flow is the central axis of the forehead flap. * The length of the flap is determined by placing an un-folded, un-stretched 4 × 4-inch gauze upon the wound, and with it measuring from the pedicle base to the distal (farthest) point of the wound. This measure is the length of the central axis of the skin flap. * The template is rotated 180 degrees and placed over the distal (far) portion of the axis of the skin flap; the surgeon outlines it with a surgical marker. The outline markings are continued proximally and parallel to the central axis, maintaining a 2-cm width for the proximal flap. * Without applying an injection of anaesthetic

, the flap is incised (cut), and the distal one-half is elevated between the

frontalis muscle The frontalis muscle () is a muscle which covers parts of the forehead of the skull. Some sources consider the frontalis muscle to be a distinct muscle. However, Terminologia Anatomica currently classifies it as part of the occipitofrontalis muscle ...

and the subcutaneous fat. * At approximately the mid-portion of the forehead, the surgeon deepens the plane of the dissection down to the submuscular plane. The dissection continues toward the brow and the glabella (the smooth prominence between the eyebrows) until the skin flap is sufficiently mobile to allow its relaxed transposition upon the nose. * Under loupe magnification, the distal portion of the forehead flap is de-fatted, down to the subdermal plexus. Yet, the fat-removal should be conservative, especially if the patient is either a

tobacco Tobacco is the common name of several plants in the genus '' Nicotiana'' of the family Solanaceae, and the general term for any product prepared from the cured leaves of these plants. More than 70 species of tobacco are known, but the ...

smoker or a

diabetic Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...

, or both, because such health factors negatively affect blood circulation and tissue perfusion, and thus the timely and correct healing of the surgical scars to the nose. * The flap is allowed to perfuse, while the donor site is sutured closed by means of the wide undermining deep to the

. At that time, diluted epinephrine can be injected to the forehead skin, but not to the near the pedicle of the forehead flap. Moreover, if the distal wound is wider than 25 mm, it usually is not closed by primary intention, with sutures, but is allowed to heal by secondary intention, by re-epithelialisation. * The forehead flap is attached to the nasal wound with subcutaneous sutures and skin sutures. If the excess tension of a suture compromises the color of the skin flap, the suture can be loosened, with a skin hook, and observed for 10–15 minutes; if the skin color remains compromised (white), the suture is removed. * Upon the complete attachment of the paramedian forehead flap to the nose, the surgical wounds are dressed only with antibiotic ointment. ;IV. Septal mucosal flap The septal mucosal tissue flap is the indicated technique for correcting defects of the distal half of the nose, and for correcting almost every type of large defect of the mucosal lining of the nose. The septal mucosal tissue flap, which is an anteriorly based pedicle-graft supplied with blood by the septal branch of the superior labial artery. To perform such a nasal correction, the entire septal mucoperichondrium can be harvested. ;Surgical technique – the septal mucosal flap The surgeon cuts the anteriorly based septal mucosal tissue-flap as widely as possible, and then releases it with a low, posterior back-cut; but only as required to allow the rotation of the tissue-flap into the nasal wound. * The surgeon measures the dimensions (length, width, depth) of the nasal wound, and then delineates them upon the

, and, if possible, incorporates an additional margin of 3–5 mm of width to the wound measurements; furthermore, the base of the mucosal tissue flap should be at least 1.5-cm wide. * The surgeon then makes two parallel incisions along the floor and the roof of the

; the incisions converge anteriorly, towards the front of the nasal spine. * Using an elevator, the flap is dissected in a sub-mucoperichondrial plane. The (far) distal edge of the flap is cut with a right-angle Beaver blade, and then is transposed into the wound. The exposed cartilages will reepithelialise (regenerate the

epithelium Epithelium or epithelial tissue is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. It is a thin, continuous, protective layer of compactly packed cells with a little intercellul ...

), provided the opposite (contralateral) side of the septal mucosa is undisturbed. A technical variant of the septal mucosal flap technique is the trap-door flap, which is used to reconstruct one side of the upper half of the nasal lining. It is emplaced in the contralateral

, as a superiorly based septal mucosal flap of rectangular shape, like that of a "trap-door". This septomucosal flap variant is a random flap with its pedicle based at the junction of the septum and the lateral nasal skeleton. The surgeon elevates the flap of septal mucosa to the roof of the nasal septum, and then traverses it into the contralateral (opposite) nasal cavity through a slit made by removing a small, narrow portion of the dorsal roof of the septum. Afterwards, the septomucosal flap is stretched across the wound in the mucosal lining of the lateral nose.

Surgical management

The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) reconstruction; and (iv) total nasal reconstruction. ;I. Partial-thickness defects A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary intention closure, with sutures. Based upon the locale of the wound, the surgeon has two options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10 mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed. In the event, larger nasal wounds (defects) do successfully heal by secondary intention, but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is a small wound directly upon the nasal tip. Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient's ear is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient's neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and sebaceous glands, thus is unlike the oily skin of the nose. The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue

morbidity A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...

. The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural histologic tendency for such skin grafts to contract, which might distort the shape of the corrected nose. ;II. Full-thickness defects Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately and in combination. ;(a) Medial canthus The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of wound contracture; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is aesthetically hidden by the shadows of the nasal dorsum and of the supraorbital rim, thereby obscuring any differences in the quality of the color and of the texture of the replacement skin (epithelium). Healing by secondary intention (re-epithelialisation) occurs even when the wound extends to the nasal bone. Although the rate of healing depends upon the patient's wound-healing capacity, nasal wounds measuring up to 10 mm in diameter usually heal in at 4-weeks post-operative. Nonetheless, one potential, but rare, complication of this nasal correction approach is the formation of a medial canthal web, which can be corrected with two opposing

Z-plasties Z-plasty is a versatile plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision (the central ele ...

, technique which relieves the disfiguring tensions exerted by the scar tissue's contracture, its shape, and location on the nose. Basal cell carcinoma2

;(b) Nasal dorsum and lateral nasal wall defect The size of the nasal defect (wound) occurred, in either the dorsum or the lateral wall, or both, determines the reconstructive skin-flap technique applicable to the corresponding aesthetic nasal subunits. * A wound of less than 10 mm in diameter can be managed either by primary intention healing (suturing) or by secondary intention healing (re-epithelialisation). * A wound measuring 10–15 mm in diameter can be reconstructed with a single-stage modified bilobed flap, because it best matches the skin color and the skin texture of the wounded aesthetic subunit. Although not every scar can be hidden at the margins of the aesthetic nasal subunits concerned, the superior scarring ability of those nasal skin areas minimizes such an histologic disadvantage. In a patient whose basal-cell carcinoma was excised with

Mohs surgery Mohs surgery, developed in 1938 by a general surgeon, Frederic E. Mohs, is microscopically controlled surgery used to treat both common and rare types of skin cancer. During the surgery, after each removal of tissue and while the patient waits, ...

, the scar of the nasal reconstruction (an 11 mm full-thickness, laterally based, bilobed-flap applied down to the bone and the cartilage), was hidden by aligning the axis of the second lobe to and emplacing the skin graft at the junction of the nasal dorsum and the lateral wall of the nose. * A wound greater than 15 mm in diameter can be corrected with a paramedian forehead flap, which will reconstruct either the entire nasal dorsum or the lateral wall of the nose, as required. The surgical management of such wounds (< 15 mm dia.) usually requires enlarging the wound as necessary, in order for the skin graft to comprehend the entire aesthetic subunit being corrected. Moreover, if the wound comprehends the dorsum and the lateral wall of the nose, then a cheek-advancement skin flap is the applicable correction for replacing the lateral nasal skin up to its junction with the dorsum; afterwards, a paramedian forehead flap is applied to resurface the nasal dorsum. * A wound in the lateral nasal wall that is greater than 15 mm in diameter can also be corrected with a superiorly based, nasolabial-flap, which is especially suited for correcting distal defects that lay among the convexities of the nasal tip and the alar lobule. The nasolabial flap can correct defects that comprehend the distal two-thirds of the nose, if there is a supply of skin sufficient for constructing the base of the flap pedicle; and the donor sites cannot be closed primarily. Yet, bulkiness is the principal disadvantage of the nasolabial flap—except in elderly patients with atrophic cheek skin; nonetheless, it is technically effective for patients unsuitable for a two-stage rhinoplasty with a paramedian forehead flap. * Nasal defects involving either the bone or the cartilage of the lateral nose are best managed with free grafts of flat septal bone and of cartilage. Small defects of the nasal dorsum can be covered with cartilage grafts harvested from either the septum or the concha of the ear. The correction of large-area defects of the nasal dorsum requires the stable support of a bone graft affixed either with a lag screw or with a low-profile plate. A costal graft (from the rib cage) is ideal for such a repair, because it can be harvested with an attached extension of cartilage that can be sculpted to blend into the nasal tip; other potential donor sites for nasal dorsum reconstruction materials are the outer table of the skull, the iliac crest, and the inner table of the ilium proper. * To correct a defect of the nasal lining of the upper two-thirds of the nose, the wound dimensions (length, width, depth) determine the technique. A nasal-lining defect of less than 5 mm in diameter can be closed primarily, with sutures. A nasal-lining defect 5–15 mm in diameter can be closed with a random transposition flap harvested from a nasal area that remains protected, either by the

or by the upper lateral cartilages; and the flap donor-site can be healed by secondary intention, re-epithelialisation. For a mucosa defect greater than 15 mm in diameter, the indicated correction is a superiorly based "trap door" septal mucosal flap, grafted to the roof of the nasal septum. ;(c) Nasal tip defect The width of the human nasal-tip ranges 20–30 mm; the average width of the nasal tip, measured between the two alar lobules, is approximately 25 mm. * A nasal skin defect of less than 15 mm in diameter can be managed with a bilobed flap; the surgeon trims the edges of the wound (defect) to match its dimensions (length, width, depth) to the natural curve at the border of the nasal tip. If the wound is eccentric, the skin-flap is positioned so that the lateral base of the graft occupies the largest portion of the wound's surface. * If the nasal-tip wound is greater than 15 mm in diameter, the surgeon enlarges it to comprehend the entire aesthetic subunit affected by the defect, and the reconstruction of the nasal subunit done with a forehead flap. If the nasal-tip defect also involves the nasal dorsum, a forehead flap is indicated for reconstructing the entire nasal-tip and dorsum. * If an alar cartilage is missing, either partially or entirely, it is reconstructed with cartilage grafts. The defect of an alar dome, which retains adequate anatomic support-tripod configuration, can be corrected with an onlay graft harvested either from the nasal septum or from the conchal cartilage of an ear. The surgeon forms the cartilage graft into the shape of a shield—its widest margins become the replacement alar domes. Typically, the shield cartilage graft is stacked in two layers, in order to transmit the desired light reflex characteristic of the nasal tip. * Defects of the lateral crura can be corrected with a flat strut of formed cartilage, but, if the support of the medial crura is absent, then a columella strut must be inserted, and attached at the level of the anterior nasal spine. If a strut of nasal-septum cartilage proves too weak, then a rib cartilage strut can be applied to provide the adequate nasal support; afterwards, the strut is covered with onlay grafts. * Absent alar cartilages can be replaced using all of the conchal cartilage from both ears; two strips, each 10 mm wide, are harvested from the antihelical fold, and then are applied as replacement alar wings. The surgeon attaches them to the anterior nasal spine, and to each side of the (pear-shaped) pyriform aperture; the remainder of the harvested conchal cartilage is applied as onlay grafts to augment the nasal tip. * A nasal-tip lining defect is unusual, because of its midline location; yet, the reconstruction is with an anteriorly based septal mucosal flap that is rotated into place to provide adequate coverage and correction of the nasal lining defect. * Vertical lobule division (VLD) is a common technique for nasal tip refinement, which involves the medial crural angle and the lateral crural angle. ;(d) Alar lobule defect The appropriate surgical management of an alar lobule defect depends upon the dimensions (length, width, depth) of the wound. Anatomically, the nasal skin and the underlying soft tissues of the alar lobule form a semi-rigid aesthetic subunit that forms the graceful curve of the alar rim, and provides unobstructed airflow through the nostrils, the ''anterior nares''. * When most of the alar lobule tissue is missing, the nose collapses; the correction is with an ear concha cartilage-graft harvested from the antihelix, a donor site where the cartilage is most rigidly curved, thus is ideal for replacing an alar lobule. * Nasal skin defects can be corrected with a medially based bilobed flap, which is emplaced to provide adequate skin coverage for wounds limited to the alar lobule. If the entire lobule is missing, it might be necessary to leave the second-lobe donor-site wound partially open; it will close at 2–4 weeks post-operative; afterwards, the scar can be revised. Nonetheless, the alternative surgical correction is a two-stage, superiorly based, nasolabial flap. * If the alar lobule defect also comprehends the lateral wall of the nose, the defect can be closed either with a superiorly based nasolabial-flap or with a forehead flap. If the cheek skin is thin and atrophic, a nasolabial flap is the recommended reconstruction; otherwise, a forehead flap is recommended, because the thickness of forehead skin is a superior match for nasal skin and tissue.

Mucosal lining A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It ...

defects of the alar lobule can be resurfaced with a bipedicled mucosal advancement-flap harvested from inside the lateral wall of the nose. Likewise, larger defects of the mucosa do require correction with an anteriorly based septal mucosal flap. ;III. and total nasal reconstruction The reconstruction rhinoplasty of an extensive defect or of a total nasal defect is an extension of the plastic surgical principles applied to resolving the loss of a regional aesthetic subunit. The skin layers are replaced with a paramedian forehead flap, but, if forehead skin is unavailable, the alternative corrections include the Washio retroauricular-temporal flap and the Tagliacozzi flap. The nasal skeleton is replaced with a rib-graft nasal dorsum and lateral nasal wall; septal cartilage grafts and conchal cartilage grafts are applied to correct defects of the nasal tip and of the alar lobules. The nasal lining of the distal two-thirds of the nose can be covered with anteriorly based septal mucosal flaps; however, if bilateral septal-flaps are used, the septal cartilage does become devascularized, possibly from

septal perforation. Furthermore, if the nasal defect is beyond the wound-correction scope of a septal mucosal flap, the alternative techniques are either an inferiorly based pericranial-flap (harvested from the frontal bone) or a free flap of temporoparietal fascia (harvested from the head), either of which can be lined with free grafts of mucosa to achieve the nasal reconstruction.

Corrections of defect and deformity

* Cancer – The excision of cancerous nasal skin can cause the loss of skin and internal support cartilage; such resections (surgical removal) usually are via the Mohs' chemosurgical technique. After removing the cancerous tissues, the reconstructive rhinoplasty will provide skin coverage using either skin grafts or pedicle flaps, (see Nasal Reconstruction, Paramedian Forehead Flap). If the resection of the cancerous skin leads to losing the nose tip, cartilage grafts can be used for support, and to prevent long-term distortion consequent to the force of the contracture of scar tissue.

* Congenital deformity – The correction of

vascular The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away f ...

malformations and

cleft lip and palate A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The ...

abnormalities. In vascular malformations, the progression of the disease distorts the skin and the underlying structure of the nose. Cleft lip and cleft palate defects usually distort the size, position, and orientation of the nasal-tip cartilages. Reconstruction of vascular malformations can involve

laser A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The ...

treatment of the skin, and surgical excision of the deformed tissues. When the underlying cartilage support structure is disturbed, cartilage grafts and suturing of the native nasal cartilages can help improve nasal aesthetics by re-orienting the nasal tip cartilages; and cartilage-graft refinements to the nose tip are performed as required. * Obstructed airways – The restoration of normal breathing by correcting nasal obstruction caused by a cosmetic rhinoplasty wherein nasal cartilages were over-aggressively trimmed, and the nose appears pinched, which compromises nasal potency (airflow), especially when the patient attempts deep inspiration. These grafting techniques restore normal breathing by increasing the size of the nose tip with baton grafts (internal cartilage), and spreader grafts to widen the nasal middle vault. Furthermore, to improve breathing a septoplasty can be performed concurrent to the reconstructive surgery; likewise, if there is

hypertrophy Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It is distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number.Updated by Linda J. ...

, an inferior turbinectomy can be performed. * Perforated septum – The reconstruction of a saddle nose caused by a (collapsed) perforated septum, or by autoimmune problems such as

granulomatosis with polyangiitis Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis (WG), is a rare long-term systemic disorder that involves the formation of granulomas and inflammation of blood vessels (vasculitis). It is a form of vasculitis ...

(GPA),

sarcoidosis Sarcoidosis (also known as ''Besnier-Boeck-Schaumann disease'') is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph nodes. Less commonly af ...

eosinophilic granulomatosis with polyangiitis Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as allergic granulomatosis, is an extremely rare autoimmune condition that causes inflammation of small and medium-sized blood vessels (vasculitis) in persons with a history of ...

(EGPA),

relapsing polychondritis Relapsing polychondritis is a multi-systemic condition characterized by repeated episodes of inflammation and deterioration of cartilage. The often painful disease can cause joint deformity and be life-threatening if the respiratory tract, hear ...

, by intranasal drug use, and by excessive nasal aerosol use. The saddle nose deformity resulting from lost dorsum support is reconstructed using autologous bone grafts and rib cartilage grafts. * Rhinophyma – The correction of late-stage

Rosacea Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, enlarg ...

, wherein the nasal skin is infected with

acne rosacea Acne, also known as ''acne vulgaris'', is a long-term skin condition that occurs when dead skin cells and oil from the skin clog hair follicles. Typical features of the condition include blackheads or whiteheads, pimples, oily skin, and po ...

that reddens, thickens, and enlarges the nose tip; an exemplar case is the American actor

W.C. Fields WC or wc may refer to: * Water closet or flush toilet Arts and entertainment * ''W.C.'' (film), an Irish feature film * WC (band), a Polish punk rock band * WC (rapper), a rapper from Los Angeles, California * Westside Connection, former h ...

. Although antibiotic acne treatments (e.g. Acutane) can halt the progression of Rosacea, the thickened skin and the fleshy obscuring of the nasal tip can only be corrected with rhinoplasty.

Laser A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word "laser" is an acronym for "light amplification by stimulated emission of radiation". The ...

excision of abnormally thickened skin is the best rhinoplastic treatment for Rhinophyma; the CO₂ laser and the infrared Erbium: YAG laser are the most effective treatments. RhinoplastySkullOsteo

* Wide nose – To narrow a too-wide nose, the plastic surgeon cuts, contours, and rearranges the craniofacial bones to achieve the desired functional and aesthetic outcome of a narrower, straighter nose. To leave no visible, surgical scars upon the new nose, the surgeon effects the osteotome (bone chisel) incisions to the nasal bones beneath the facial skin. Illustration 1: The surgeon cuts the excessively wide bones of the upper nasal dorsum (violet) with an osteotome (bone chisel), then detaches, corrects, and relocates them inwards, to a position, between the ocular orbits (red), that narrows the width of the nasal dorsum. Illustration 2: The surgeon chisels two cuts (incisions) to the nasal bones, each incision begins at the nasal cavity. The first incision begins at the yellow dot and extends upwards, along the green arrow, until meeting the zig-zag line (red). The second incision begins at the blue dot and extends upwards, along the black arrow, until meeting the zig-zag line (red). Once cut and loosened from the face, the nasal bone pieces are corrected, then pushed inwards and re-set, thus narrowing the nose. File:RhinoplastyOsteotomeHammer.jpg, Rhinoplastic instruments:
An osteotome (bone chisel) and a surgical hammer for sculpting craniofacial bones.

Post–surgical recovery

;Convalescence The rhinoplasty patient returns home after surgery, to rest, and allow the nasal cartilage and bone tissues to heal the effects of having been forcefully cut. Assisted with prescribed medications—

antibiotics An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and preventio ...

analgesic An analgesic drug, also called simply an analgesic (American English), analgaesic (British English), pain reliever, or painkiller, is any member of the group of drugs used to achieve relief from pain (that is, analgesia or pain management). It ...

steroid A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and ...

s—to alleviate pain and aid wound healing, the patient convalesces for about 1-week, and can go outdoors. Post-operatively, external sutures are removed at 4–5 days; the external cast is removed at 1-week; the stents are removed within 4–14 days; and the "panda eyes" periorbital bruising heal at 2-weeks. If an alar base reduction is performed conjunctively within the Rhinoplasty, these sutures need to be removed within 7–10 days post operatively. Throughout the first year post-operative, in the course of the rhinoplastic wounds healing, the tissues will shift moderately as they settle into being a new nose.

Risks

Rhinoplasty is safe, yet complications can arise; post-operative bleeding is uncommon, but usually resolves without treatment.

Infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable di ...

is rare, but, when it does occur, it might progress to become an

abscess An abscess is a collection of pus that has built up within the tissue of the body. Signs and symptoms of abscesses include redness, pain, warmth, and swelling. The swelling may feel fluid-filled when pressed. The area of redness often extends ...

requiring the surgical drainage of the pus, whilst the patient is under

. Adhesions, scars that obstruct the airways can form a bridge across the nasal cavity, from the

to the turbinates, and require surgical removal. If too much of the osseo-cartilaginous framework is removed, the consequent weakening can cause the external nasal skin to become shapeless, resulting in a "polly beak" deformity, resembling the beak of a

parrot Parrots, also known as psittacines (), are birds of the roughly 398 species in 92 genera comprising the order Psittaciformes (), found mostly in tropical and subtropical regions. The order is subdivided into three superfamilies: the Psittacoide ...

. Likewise, if the septum is unsupported, the bridge of the nose can sink, resulting in a "saddle nose" deformity. The tip of the nose can be over-rotated, causing the nostrils to be too visible, resulting in a

porcine The pig (''Sus domesticus''), often called swine, hog, or domestic pig when distinguishing from other members of the genus '' Sus'', is an omnivorous, domesticated, even-toed, hoofed mammal. It is variously considered a subspecies of ''Sus ...

nose. If the cartilages of the nose tip are over-resected, it can cause a pinched-tip nose. If the columella is incorrectly cut, variable-degree numbness might result, which requires a months-long resolution. Furthermore, in the course of the rhinoplasty, the surgeon might accidentally perforate the septum (septal perforation), which later can cause chronic nose bleeding, crusting of nasal fluids, difficult breathing, and whistling breathing. A turbinectomy may result in empty nose syndrome.

Non-surgical rhinoplasty

Non-surgical rhinoplasty Non-surgical rhinoplasty is a medical aesthetic procedure in which injectable fillers, most commonly hyaluronic acid ones like Restylane and Juvederm or calcium hydroxyapatite (Radiesse), are used to alter and shape a person's nose without a surge ...

is a medical procedure in which injectable fillers, such as

or hyaluronic acid, are used to alter and shape a person's nose without invasive surgery. The procedure fills in depressed areas on the nose, lifting the angle of the tip or smoothing the appearance of bumps on the bridge. The procedure does not alter nose size, though it can be used to correct some functional

birth defects A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...

. Originally developed at the turn of the twenty-first century, early attempts used biologically harmful soft-tissue fillers such as

paraffin wax Paraffin wax (or petroleum wax) is a soft colorless solid derived from petroleum, coal, or oil shale that consists of a mixture of hydrocarbon molecules containing between 20 and 40 carbon atoms. It is solid at room temperature and begins t ...

and

silicone A silicone or polysiloxane is a polymer made up of siloxane (−R2Si−O−SiR2−, where R = organic group). They are typically colorless oils or rubber-like substances. Silicones are used in sealants, adhesives, lubricants, medicine, cookin ...

. After 2000, physicians minimally invasive techniques using modern fillers.

History

Anatomy of the human nose

The structures of the nose

A. The nasal soft tissues

= The movements of the nose are affected by

B. Aesthetics of the nose – nasal subunits and nasal segments

= The surgical nose as nine ''aesthetic nasal subunits''

= The surgical nose as six ''aesthetic nasal segments''

C. Nasal blood supply – arteries and veins

D. Lymphatic system of the nose

E. Nerves of the nose

= Ophthalmic division innervation

= The maxillary division innervation

F. Bony anatomy of the nose

G. The cartilaginous pyramid of the nose

The external nose

External nasal anatomy

Internal nasal anatomy

Nasal analysis

Patient characteristics

Surgical rhinoplasty

Open rhinoplasty versus closed rhinoplasty

Procedural differences

The "ethnic nose"

Cause

Congenital abnormalities

Acquired abnormalities

Ultrasonic rhinoplasty

Surgical procedure

Photographic records

Types of rhinoplasty – primary and secondary

Nasal reconstruction

Surgical anatomy for nasal reconstruction

Principles of rhinoplastic reconstruction

Reasons for reconstruction

Surgical techniques

Surgical management

Corrections of defect and deformity

Post–surgical recovery

Risks

Non-surgical rhinoplasty

References

Further reading