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4
ty
Septum nasal
Fig. 1.3 External nose
anatomy (skeletal support)
Dorsum
Upper lateral
cartilages
Lower lateral
cartilages
P. Rossell-Perry
Nasal bone
Alar fibrofat
tissue
For example, any cartilaginous structure deciency after primary nose repair
may be more evident in Caucasian nose than other races because of the nature of the
nasal tip skin.
Regarding the skeletal structure, the upper third of the nose is composed of the
nasal bones. This rectangular structure limits with superolaterally to the lacrimal
bone and inferolaterally to the nasomaxillary process of the maxilla. Its lower border overlaps with the upper lateral cartilages.
The middle third contains the upper lateral cartilages of the nose also known as
the cartilaginous middle vault area. Medially, these cartilages fuse with the nasal
septum creating the internal nasal valve, an important functional structure of the
nose. The lateral wall of this area is composed of the lower turbinate and the pyriform aperture.
The lower third contains the nasal tip composed by the lower lateral cartilages and caudal septum covered by soft tissues to create the nasal tip (lateral
crus and dome), alae, and columella (medial crus). This is the nasal valve area
of the nose.
Internal Nose
The internal nose is covered by a mucous membrane and is composed of two important structures: the septum (medially) and the lateral wall (Figs.1.4 and 1.5).
The nasal mucosa has a pseudostratied columnar ciliated epithelium and mucus
goblet cells. It functions to humidify, warm, lter, protect, and eliminate debris.
The anatomy of the nasal cavity allows time and enough surface area through the
turbinates for the inhaled air to be warmed and moistened.
Upper
Ethmoidal
or meatus
1 Anatomy andPhysiology
5
Orbit
Fig. 1.4 Internal nose anatomy diagram
turbinate
Hard palate
cells
Superi
Middle turbinate
Middle meatus
Nasal septum
Lower turbinate
Maxillary sinus
Lower meatus
The nasal septum is usually located at the midline and is made of cartilage anteriorly and bone posteriorly (Figs.1.4 and 1.5).
The anterior segment of the septum is known as the caudal septum and has a
membranous portion caudal to the columella. This section is part of the nasal valve.
The posterior segment is composed mostly of the vomer, palatine bones, and the
ethmoid bone (Fig.1.5).
The nasal septum commonly deviates in individuals with unilateral cleft lip and
palate resulting in variable degrees of nasal obstruction. It tends to deviate toward
the cleft side with the septal base displaced off the maxillary crest (Fig.1.6).
Early septal repositioning during primary cleft lip repair may improve aesthetic
and functional nasal outcomes.
The lateral wall includes the turbinates (upper, lower, and middle) which are in
communication with the meatus for nasal sinus and lacrimal drainage.
These structures are four pairs of air-lled cavities responsible for humidifying
and warming inspired air (Fig.1.4).
The meatuses are three spaces beneath each of the turbinates. The upper one
drains for the sphenoid and posterior ethmoid sinuses, and the middle meatus drains
for the frontal, anterior ethmoid and maxillary sinuses. Finally, the lower drain was
through the nasolacrimal duct (Fig.1.4).
The triangular shape of the nose is completed by the nasal oor which is composed by four segments: vestibular (nasal sill), primary palate (alveolus), secondary
palate (hard palate), and soft palate (functional oor) (Fig.1.7).
6
Septal car
Cranial base
Sphenoid sinus
Frontal sinua
Perpendicular
plate of
ethmoid bone
P. Rossell-Perry
tilage
Hard palate
Fig. 1.5 Nasal septum diagram
Fig. 1.6 Nasal septum
deviation in unilateral cleft
lip patients observed
during secondary cleft
rhinoplasty. 1. Cleft side
alar cartilage. 2. Noncleft
side alar cartilage 3. Nasal
septum
Nasopharynx
Vomer
Different protocols have been developed to correct the nasal oor during cleft lip
and palate repair. The Oslo protocol repairs the vestibular and vestibular nasal oor
during the lip and hard palate repair while other protocols repair the primary palate
segment during the mixed dentition period.
Functionally, these structures create two valves: external and internal (Fig.1.8).
The external nasal valve is composed of the columella (medially), nasal sill
(inferiorly), and nasal rim (superiorly) including the alar cartilages and nasal ala.
The internal nasal valve is limited by the septum (medially), laterally to the upper
lateral cartilage and inferiorly to the head of the lower turbinate.
Pe
Sphenoid sinus
e
e
1 Anatomy andPhysiology
Frontal sinus
7
5
rpendicular plate
of ethmoid bone
Septal cartilage
Premaxilla
Fig. 1.7 Anatomy of the oor of the nose
Fig. 1.8 External and
internal nasal valves
Vomer
Hard palate
Soft palate
Hard palate
Primary palate
Nasal sill
Lateral
nose wall
Internal
nasal valv
External
nasal valv
8
P. Rossell-Perry
Finally, two opening structures (nares) exist, the external (anterior) structures are
the nostrils, and the internal (posterior) structures are the choanae, the opening from
the nasal cavity to the pharynx.
Surgical Anatomy oftheNose
The bases of nasal anatomy are presented here.
Nasal Surface Anatomy (Fig.1.9)
The surface anatomy (or visual anatomy) includes the external features of the nose;
its knowledge enables the surgeons to locate anatomical structures exteriorly,
improving their clinical and surgical skills. It includes the root (superiorly), apex
(inferiorly), dorsum, nostrils, and columella. A good description of the external
anatomy is required using correct terminology to assist in the diagnosis and facilitate the selection of surgical options.
The following terms used for describing the surface anatomy of the nose
are used:
Root: It is dened as the top of the nose and is limited to the forehead. It is above
the nasal bridge and below the glabella. The depressed midpoint between them is
the nasion at the point where the frontal bone meets the nasal bones.
Nasal bridge: It is also known as the nasal dorsum. This is an area that includes the
nasal root and lateral borders of the nose, extending laterally to the inner canthi.
It limits inferiorly to the nasal tip. The upper half of the dorsum is made of nasal
bones, and the lower half of the dorsum is made of nasal cartilages. The most
inferior portion of the nasal dorsum, which is limited by the nasal tip, is known
as the supratip area.
Fig. 1.9 Surface anatomy
of the nose (lateral view).
A.Root. B.Bridge.
C.Rinion D.Supraalar
crease E.Supratip. F.Tip
denition point. G.Soft
triangle. H.Columella.
I.Philtrum. J.Alar nasal
sulcus. K.Nasofacial angle
1 Anatomy andPhysiology
Nasal tip: This is the most prominent area of the nose and represents the medial
cephalic portion (domes) of the alar cartilage.
Nasal lobule: It is an area limited by a line connecting the upper edge of the nostrils,
the supratip, and the lateral alar wall. This area is subdivided into the tip, supra-
tip, and infratip.
Ala: It is also known as the wings of the nostrils. The nasal tissue lateral to the nasal
tip represents the lateral boundary of the nose and inferiorly surrounds the
nostrils.
Alar lobule: It is composed of vascular broareolar tissue, muscle, and fat. They are
the most lateral components of the nasal base. The muscular composition of the
alar lobule comprises the alar portion of the nasalis, running posterior to anterior
while the dilator naris anterior muscle runs cephalic to caudal.
Alar base: It represents the bottom parts of the ala and limits medially with the nasal
sill [2].
Alar rim: It represents the roof of the nostrils. They surround the nostril aperture [3].
Columella: It is a bridge of tissue located between the nostril and linking the nasal
tip with the upper lip. It represents the eshy external end of the caudal septum.
Nostrils or external nares: They are a pair of openings at the end of the nose leading
from the nasal cavity to the outside.
Nasal sill: The nasal sill is a protuberant soft tissue bridge, extending from columel-
lar base to the ala of the nose and limiting inferiorly to the upper lip.
Soft triangle: It is named as “soft” triangle because of the lack of cartilage and sub-
cutaneous tissue support. It is located between the dome and the alar lobule. It is
a triangular thin skin located lateral to the tip of the nose and above the nostrils.
They can be visually identied in subjects with thin skin [4].
Nasolabial angle: It denotes the angle between the columella and the upper lip. The
angle between the line drawn through the midpoint of the nostril and the line
drawn perpendicular to the Frankfurt line while intersecting the subnasale point
is also considered.
Alar groove: It is the depression observed between the nostril and lateral nasal wall. It
lies at the junction of the lower lateral crus and the alar lobule and represents a curved
line that extends from the nasal tip and joins the alar facial sulcus. The groove is
produced by muscular attachment between the perichondrium of the lower lateral
cartilage and the vestibular mucosa as a result of bulging in the fatty layer on one side
of the groove [3]. The alar groove is also known as the alar crease or alar sulcus.
Alar facial sulcus: It is also referred as alar facial groove. This depression repre-
sents a junctional area of the nasal base, the medial aspect of the cheek and the
upper lip.
9
Nasal Aesthetic Subunits
The facial aesthetic subunit is a concept that organizes the facial skin into units
that are classied by their color, texture, and thickness. There are six facial aesthetic subunits: forehead, nose, eyelids, cheeks, upper and lower lips, and scalp
10
P. Rossell-Perry
and ears [5]. Each one includes its respective subunits; thus, the nose has the following subunits: tip, dorsum, sidewalls, alar lobules, soft triangles, and columella
(Fig.1.10).
Tip lobule: It is located between the junction of the inferior border of the nasal dor-
sum superiorly and the columella inferiorly.
Nasal dorsum: This is limited by the nasal roof superiorly and the nasal tip inferi-
orly. Laterally it is in continuity with the nasal sidewalls.
Alar lobules: They are the sidewalls of the nasal base. It is outlined by the alar
groove beginning at the nostril rim and then continues in a circular shape
down to the alar crease. It is composed of subcutaneous tissue and mus-
cles [2].
Soft triangle: Or facet, located at the apex of the nostril and limited superiorly by
the medial and lateral crus of the alar cartilage and inferiorly by the nostril. It was
rst described by Converse and is also referred as the “Bermuda triangle of the
nose” [5]. Since there is no cartilage support for the soft triangles, notching is a
common complication following primary cleft rhinoplasty. The soft triangle is
considered one of the most challenging nasal subunits to reconstruct, and it is
extremely vulnerable [6].
Columella: It is limited by the nasal tip superiorly and nasolabial angle inferiorly.
Fig. 1.10 Aesthetic nasal
subunits of the nose
BB
D
A - Nasal dorsum
B - Lateral side wall
C - Alar lobule
A
F
D
CC
E
D - Soft triangle
E - Columella
F - Nasal tip
1 Anatomy andPhysiology
11
Nasal Components
The Nasal Tip
The nasal tip is dened as the most projecting part of the nose and located in its
lower third. It is composed of the following structures:
Cartilaginous Framework (Figs.1.11 and1.12)
It is represented by the alar cartilages (lower lateral cartilages) and the caudal septum. Each alar cartilage has three segments: lateral crura, medial crura, and the
intermediate (dome). The structural support works in combination with ligamentous
structures including intercartilaginous ligaments between the upper and lower lateral cartilages, ligaments between the medial crura and the caudal septum through
the membranous septum, attachments between both medial cruras, interdomal ligaments, and nally ligaments from the skin to the nasal domes [7] (Fig.1.13).
The paired cartilages support the nasal tip as a tripod, and both medial cruras are
the components of the nasal columella which together with the septum make up the
support the nasal tip.
The dome (intermediate crura) provides the projection and denition to the nasal
tip. There is approximately 60° of divergence between the two domes, and the point
of projection of the nose is located within at the intermediate and lateral crus junction. The area between the domes is known as the supratip area or the weak triangle
of Converse [8] (Fig.1.14).
The lateral crura provides lateral support to the nasal tip, and its affection may
cause aesthetic (pinched nose) and functional (airway obstruction) disorders [9].
The alar cartilage (lateral crura) is attached to the upper lateral cartilage through
brous ligaments, and its most lateral border is attached to small sesamoid cartilages and brofatty tissue extending to the pyriform aperture.
Nasal bone
Upper lateral
cartilage
Lower lateral
cartilage
Fig. 1.11 Cartilaginous framework of the nose diagram
12
(columelar segment)
(footplate segment)
Fig. 1.12 Lower lateral
cartilage anatomy diagram
P. Rossell-Perry
Lateral crus
Middle crus
(domal segment)
Middle crus
(lobular segment)
Medial crus
Medial crus
Vertical scroll
ligament
Horizontal scroll
ligament
Pyriform
ligament
Interdomal
ligament
Intercrural
ligament
Fig. 1.13 Ligament structures of the nose diagram
The lower lateral cartilage is curving over the caudal edge of the upper lateral
cartilage; this anatomical relation between the lateral cartilages of the nose is distorted in patients with cleft lip and should be corrected during primary cleft rhinoplasty (Figs.1.15, 1.16, 1.17 and 1.18).
The caudal septum forms the central support of the nasal tip in combination with
the medial crura. They are attached through ligaments.
Most of its anterior section is membranous, composed by brous tissue and
located between the caudal end of the cartilaginous septum (anterior septal angle)
and the medial crura. There is a muscular component in this area, the depressor septi
iangle
Medial canthal
1 Anatomy andPhysiology
ligament
Keystone área
Upper lateral
cartilage
Fig. 1.14 Supratip area of the nose diagram (weak triangle of converse)
13
Nasofrontal suture
Nasofrontal groove
Weak tr
of Converse.
Soft triangle
Fig. 1.15 Lower lateral
cartilage displacement in
unilateral cleft lip patient.
A.Alar cartilage noncleft
side. B.Alar cartilage cleft
side. C.Alae. D.Columella
E.Medial lip segment.
F.Lateral lip segment.
G.Premaxilla
nasi [10]. The caudal septum is also attached to the nasal spine at the posterior septal angle.
Overlaying soft tissues: The soft tissue components include skin, muscles,
nerves, and vascular tissues. Depending on the thickness of the soft tissues, they
may have stronger tip support than the cartilaginous structure. The thickness of the