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and periosteal fibers
Chapter Advanced Rhinoplasty Anatomy 25
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INTERNAL NASAL ANATOMY: SEPTUM AND TURBINATES
e central supporting system of the nose is the septal cartilage, which articulates posteriorly with the perpendicular plate of the ethmoid superiorly and the
vomer inferiorly.
e tongue-and-groove articulation between the quadrangular cartilage and the
maxillary and palatine crest deserves special mention.
,,
e vomer itself rests on the maxillary-palatine crests.
Perichondrial layers
Septal cartilage
Maxillary/
palatine crest
Crossed perichondrial
Periosteal layers
e perichondrium of the cartilage is only partially contiguous with the periosteum of the crests. Other bers pass through the articulation to join the
contralateral perichondrium. is crossed conguration makes a contiguous
submucoperichondrial dissection dicult at the osteocartilaginous junctions.
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is same anatomic conguration also allows some movement between the crest
and the septum, and it is this instability that explains the frequent posttraumatic
ndings of a displaced quadrangular septal cartilage from the groove of the crest.
e anterior septum articulates caudally with the anterior nasal spine.
Middle
turbinate
Superior
turbinate
Inferior
turbinate
Parasagittal view of lateral nasal wall
e inferior turbinates are a key functional component in nasal airway breathing,
because their anterior heads occupy a signicant portion of the nasal passage.
ey are composed of dense lamellar bone originating from the medial maxillae and are covered with erectile mucosal tissue. is tissue is under autonomic
control, and chronic inammation can lead to brous deposition and chronic
hypertrophy of the turbinate so tissues and/or bone.
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Clinical Applications
Autologous septal cartilage is a valuable commodity, with many indicated uses in
plastic surgery. In fact, it is the preferred material for numerous gras in modern
rhinoplasty. When harvesting these gras, an intact L-strut must be maintained
for support. e width of the dorsal and caudal aspects of the L-strut will depend
on the quality of the septal cartilage. With thick, strong cartilage, a minimum of
to mm may be enough to ensure long-term stability. More commonly, the
L-strut should be approximately mm wide.
Aesthetic shaping of the septum may be performed to sculpt the nasal dorsum,
help adjust the projection and rotation of the nasal tip, and improve the alarcolumellar relationship.
e septum may play a less important role as a primary cause of nasal airway
obstruction. In fact, not all deviated septa need correction, because it is common
to have an asymptomatic septal deviation. When deviation occurs anteriorly and
inferiorly (that is, in the area of the internal nasal valve), it is more likely to be a
source of obstruction as a result of the smaller cross-sectional area of the airway
in this region. Portions of the septum causing airway obstruction should be repositioned to the midline or removed. However, cartilage preservation should
always be prioritized.
When harvesting septal cartilage and/or removing posterior septal deviations,
it is important to perform a gentle sidewise fracture of the bony part of the perpendicular plate of the ethmoid, which is in continuity with the cribriform plate.
ese fractured bony fragments should be easy to remove. Otherwise, any remaining bony or so tissue attachments should be completely detached. is
avoids injury to the cribriform plate and the resulting cerebrospinal uid rhinorrhea.
Enlarged turbinates may cause and/or contribute to airway compromise in some
patients. Numerous treatment options have been proposed in the literature to reduce the mass of the turbinates and therefore improve the passage of air through
the internal valve. In general, more limited approaches to turbinoplasty should
be performed, because complete turbinectomy may put the patient at increased
risk for developing atrophic rhinitis postoperatively.
e dorsal septum has a T geometry in cross-section. Techniques such as component dorsal hump reduction, spreader gras, and aps for both functional and
aesthetic reasons aim to preserve or recreate this anatomy.
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KEY POINTS
■
Excellent rhinoplasty results can only be obtained if the surgeon has a thorough
knowledge of nasal anatomy and a grasp of the surgical relevance of alteration
of the anatomic structures.
■
e type, texture, and sebaceous content of the skin must be carefully analyzed,
because it will inuence the approach for modifying the framework and therefore the nal result.
■
An active depressor septi nasi muscle can be identied on preoperative clinical analysis, and its modication intraoperatively can enhance the tip-lip relationship.
■
When the open approach is used, alar base excisions that extend more than
mm superior to the alar groove and defatting the nasal tip should be avoided
to prevent vascular compromise of the nasal tip.
■
e brous attachments of the lower lateral cartilages to the septal angle, upper lateral cartilages, piriform aperture, caudal septum, and premaxilla provide
support and determine the position of the tip.
REFERENCES
1. Hewell TS, Tardy ME. Nasal tip renement: reliable approaches and sculpture techniques. Facial
Plast Surg :, .
2. McCollough EG, Mangat D. Systematic approach to correction of nasal tip in rhinoplasty. Arch
Otolaryngol :-, .
3. Bernstein L. A basic technique for surgery of the nasal lobule. Otolaryngol Clin North Am :-
, .
4. Dingman RO, Natvig P. e infracartilaginous incision for rhinoplasty. Plast Reconstr Surg :-
, .
5. Janeke JB, Wright WK. Studies on the support of the nasal tip. Arch Otolaryngol :-, .
6. Beekhuis GJ. Nasal septoplasty. Otolaryngol Clin North Am :-, .
7. Toriumi DM, Mueller RA, Grosch T, et al. Vascular anatomy of the nose and the external rhino-
plasty approach. Arch Otolaryngol Head Neck Surg :-, .
8. Wu WT. e Oriental nose: an anatomical basis for surgery. Ann Acad Med Singapore :-,
.
9. Cakir B, Oreroğlu AR, Doğan T, et al. A complete subperichondrial dissection technique for rhino-
plasty with management of the nasal ligaments. Aesthet Surg J :-, .
10. Rohrich RJ, Huynh B, Muzaar AR, Adams WP Jr, Robinson JB Jr. Importance of the depressor septi
nasi muscle in rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg :; discussion -, .
11. Daniel RK, Glasz T, Molnar G, et al. e lower nasal base: an anatomical study. Aesthet Surg J
:-, .
12. Rohrich RJ, Gunter JP, Friedman RM. Nasal tip blood supply: an anatomic study validating the
safety of the transcolumellar incision in rhinoplasty. Plast Reconstr Surg :-; discussion
-, .
13. Sheen JH, Sheen AP. Aesthetic Rhinoplasty, ed . St Louis: Quality Medical Publishing, .
14. Ford CN, Battaglia DG, Gentry LR. Preservation of periosteal attachment in lateral osteotomy. Ann
Plast Surg :-, .
15. Tardy ME, Denney JC. Micro-osteotomies in rhinoplasty. Facial Plast Surg :-, .
Chapter Advanced Rhinoplasty Anatomy 29
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16. Hilger JA. e internal lateral osteotomy in rhinoplasty. Arch Otolaryngol :-, .
17. Constantian MB. e incompetent external nasal valve: pathophysiology and treatment in primary
and secondary rhinoplasty. Plast Reconstr Surg :-; discussion -, .
18. Constantian MB, Clardy RB. e relative importance of septal and nasal valvular surgery in cor-
recting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg :-;
discussion -, .
19. Sheen JH. Spreader gra: a method of reconstructing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg :-, .
20. Gunter JP, Rohrich RJ. e external approach for secondary rhinoplasty. Plast Reconstr Surg :-
, .
21. Peck GC. e onlay gra for nasal tip projection. Plast Reconstr Surg :-, .
22. Horton CE. Achieving more nasal tip projection by use of small autogenous vomer or septal car-
tilage gras. Plast Reconstr Surg :, .
23. Adams WP Jr, Rohrich RJ, Hollier LH, et al. Anatomic basis and clinical implications for nasal tip
support in open versus closed rhinoplasty. Plast Reconstr Surg :-; discussion -,
.
24. Lee MR, Malafa M, Roostaeian J, Unger JG, Geissler P, Rohrich RJ. So tissue composition of the
columella and clinical relevancy in rhinoplasty. Plast Reconstr Surg (in press).
25. Pollock RA, Rohrich RJ. Inferior turbinate surgery: an adjunct to the successful treatment of nasal
obstruction in patients. Plast Reconstr Surg :-, .
26. Gunter JP, Rohrich RJ. Management of the deviated nose: the importance of the septal reconstruc-
tion. Clin Plast Surg :-, .
27. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr
Surg :-, .
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3
Nasal Physiology
Michael R. Lee Rod J. Rohrich Jamil Ahmad
A thorough understanding of nasal physiology is essential to provide opti-
mal results in rhinoplasty. Although achieving aesthetic improvement is oen
the focus of surgery, nasal function is of equal and, occasionally, primary importance. Surgeons should understand the basic functions of the nose and its internal structures. An intimate relationship exists between the anatomy of the nose
and its associated functions. An understanding of normal physiology and the
aberrations that occur in disease states enable the surgeon to provide a comprehensive approach to treatment. When this understanding guides surgical planning and execution, existing deformities are corrected and untoward functional
consequences can be avoided.
ere is an intimate relationship between the anatomy of the nose and its associated physiology. An understanding of this relationship provides the basis for
both nasal analysis and treatment planning.
Approximately half of the total airway resistance occurs in the nasal cavity, underscoring its signicant role in the regulation of airow through the respiratory
tract. However, nasal function extends beyond the role of the nose as a simple
conduit. Inspired air is ltered, humidied, and warmed in preparation for continued passage toward the nasopharynx. e nose also contributes to such functions as smell and phonation.
31
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e nasal airway is responsible for 50% of overall airway resistance, underscoring its importance in nasal airow
Nasal physiology is inuenced by the external and internal structures of the nose.
Nasal structures can be conceptually divided into the bony and cartilaginous
framework and the nasal mucosa and so tissues. ese two components work
in concert to provide optimal function of the nose and nasal cavity. Surgeons
should be aware of the interplay between these two components, because both
are crucial to properly addressing nasal dysfunction.
Mucosal disease is infrequently cured with surgical manipulation alone and often requires medical management. Improvement in mucosal disease may occur
if the condition is caused by underlying anatomic deformities that are addressed
during surgery. With normal mucosal behavior and isolated anatomic deformities, surgery should result in an improvement in nasal airow.
Nasal airway obstruction may have a structural and/or functional cause, and
accurate diagnosis will guide appropriate treatment planning.
NASAL FUNCTION
e primary function of the nose is to provide a passageway for external air to
be transported to the pulmonary system for blood oxygenation. Despite the relatively short length of the nasal cavity compared with the length of the remaining airway, approximately half of total airway resistance occurs within the nose.
Airow patterns through the nose and upper airway are well understood, since
they follow basic physical laws.
In addition to respiration, the nose and nasal cavity perform an additional six
functions: particle ltration, air humidication, temperature modication, olfaction, phonation, and chemoreception.
Respiration
External air is transported into and through the nasal cavity by a generated pressure dierential. e negative intranasal pressure generated during inspiration
allows air movement and is inuenced by the velocity of airow and resistance
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along the nasal cavity. Initiation of inspiration is associated with nostril enlargement to accommodate the inux of external air into the nose and through the
external nasal valve. Inspired air continues through the nasal cavity in a parabolic curve pattern following this pressure gradient. Most of the air continues
over the inferior turbinate, passing through the middle meatus; the greatest resistance occurs at the internal nasal valve.
,
Superior turbinate
Middle turbinate
Internal nasal valve
Inferior turbinate
Most of the air continues over the inferior turbinate, passing through the middle
meatus; the greatest resistance occurs at the internal nasal valve.
Approximation of the caudal upper lateral cartilage and nasal septum creates an
angle at the internal nasal valve. is anatomic location is frequently susceptible
to collapse from negative pressure generated at the beginning of inspiration. Expiration has the converse eect as the internal nasal valve is enlarged and nostril
size becomes smaller.
Airow may be described as laminar or turbulent. Laminar ow is organized
and predictable, following a straight pattern. Such a ow pattern exhibits high
eciency, with centrally rapidly moving particles anked by more stagnant peripheral particle movement. Conversely, turbulent ow is less predictable and
follows a more random pattern. Such ow is the result of disrupted laminar ow
and requires an increased pressure gradient to correct. Turbulent ow is composed of whorls and eddies that allow increased particle contact with mucosal
surfaces. Because the nasal cavity is not a tubular structure, nasal airow is not
truly laminar in nature. Instead, the parabolic curve pattern of airow is another
mechanism that contributes to turbulent airow and increases resistance to airow. At low pressures less than cm of water, airow approximates laminar ow.
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us quiet respiration tends to create a more laminar ow pattern, whereas more
labored inspiration is associated with turbulent ow patterns.
Nasal airow is best described using several basic physical laws. Air is introduced
through both nostrils and directed into the nasal vestibule. e following formula relates nasal airow with resistance at the level of the external nasal valve:
1/Total resistance 5 /Le nostril resistance 1 /Right nostril resistance
Inspired air may meet resistance at the external nasal valve before reaching the
internal nasal valve. Obstruction or dysfunction of either nostril leads to an
overall increase in nasal airway resistance. Airow follows the path of least resistance. For example, air may be shunted in the case of an anterior septal perforation. By following the path of least resistance, a perforation allows the airow
from the more resistant side to redirect to the less resistant side, thus lowering
total resistance.
Ohm’s Law
Ohm’s law has been used to describe uid ow and states that ow is directly
proportional to the dierence in pressure (dP) and inversely proportional to the
resistance:
Flow 5 dP/Resistance
Ohm’s law applied to nasal physiology stresses the importance of structural integrity and patency to accommodate airow pressure gradients. e cartilaginous
infrastructure must be sucient to withstand the negative pressures generated
during inspiration, or collapse will exacerbate obstructive symptoms during inspiration. Anatomic deformities that lead to increased resistance will decrease
airow. us increased pressure is required to generate airow. is increased
pressure may result in greater deformation of nasal structures leading to yet
greater obstructive symptoms.
Bernoulli’s Principle
Bernoulli’s principle establishes that airow is equal at opposing ends of a tube
when the diameter is equivalent. A decrease in diameter leads to a lower pressure and increased velocity. An example of this eect can be seen at the level
of the nasal valves. If the internal nasal valve is restricted, velocity of airow is
increased, generating greater negative pressure. Greater negative pressure potentiates further internal valve collapse and may worsen obstructive symptoms.
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