Nasal Anatomy and Image Fayetteville
Nasal anatomy is so important that it can affect an individual’s entire image. As a result, the Plastic surgeon should always consider the patient’s image when discussing the rhinoplasty procedure. A Plastic surgeon’s detailed knowledge of normal nasal anatomy is a critical factor for the successful rhinoplasty. It is also very important for the Plastic surgeon to understand normal anatomic variation, how this relates to the appearance of the nose, and how the nasal shape relates to the facial structures and the patients image, meaning self image and the patient’s image to the public. In addition to the anatomy of the nose, it is also important for the Plastic surgeon to understand the physiology (function) of the nose and how this relates to the anatomy. When planning a rhinoplasty, the surgeon should consider facial shape, the gender of the patient, the ethnicity of the patient, and most importantly, the patient’s goals. Many (but not all) rhinoplasty procedures result in very subtle changes. Even the most subtle changes in the nasal aesthetics can make an enormous difference in the general appearance. An example of this phenomenon is the well known actress Jennifer Grey. In her Dirty Dancing years she was pre-rhinoplasty and was very attractive. Sometime after that movie was filmed, she underwent a rhinoplasty. While the changes in her rhinoplasty were subtle and very appropriate, she now has a completely different appearance. The rhinoplasty procedure that changed a small part of her anatomy completely changed her appearance and image. She was attractive before rhinoplasty, and is attractive after rhinoplasty, but is very different.
Jennifer Grey – before rhinoplasty
Jennifer Grey – after rhinoplasty
The major structures of the nose include the nasal bones, the nasal septum, the lower lateral cartilages (alar cartilages), and the upper lateral cartilages. There are many other anatomical entities that heave been described in addition to the aforementioned that can be addressed at the time of rhinoplasty. The nasal septum is the main support of the nose. It is in the midline of the nose and consists of cartilage and bone. The nasal septum is composed of bone in (approximately) the upper one half, and cartilage in (approximately) the lower one half. If this structure is damaged or is missing, the result is a depressed dorsum that is sometimes called a “saddle nose”. This requires a reconstructive rhinoplasty procedure to repair. Both of the components of the septum are frequently altered during the rhinoplasty procedure. Overgrowth of the nasal septum can result in many anatomic variations, including a drooping nasal tip, the over projecting nose, and the nasal “hump”. Of course, all of these conditions can exist at the same time.
The lower lateral (alar) cartilages give the nasal tip its shape. They also serve a physiologic purpose in keeping the nares open during inspiration. There are enormous variations in the shape of the lower lateral (alar) cartilages, which give enormous variation in the shapes of the tip of the nose. The lower lateral cartilages cause the broad (“boxy”) nasal tip, the drooping nasal tip, and the over projecting nasal tip. The alar cartilages are almost always altered to some degree during the rhinoplasty procedure.
In some circumstances the anatomy of the lower lateral (alar) cartilages can be quite striking and overpower the other features of the face. Karl Malden represents an example of the classic “broad nasal tip”. This appearance is caused by the overgrowth and broadening of the alar (lower lateral) cartilages. The actor Jimmy Durante is another classic example of the nose overpowering the face. In his case, there was overgrowth of the lower lateral cartilages and the nasal septum. So dramatic was the nasal anatomy of these actors, that it became their trademark.
The upper lateral cartilages of the nose serve an aesthetic and physiologic purpose. The upper lateral cartilages of the nose support the middle vault and prevent a “pinched” appearance, which can occur if these cartilages are damaged or are under developed. The upper lateral cartilages also maintain the patency of the “internal nasal valve” which is the term for the narrow aperture just inside the nose. The “internal nasal valve” is bordered by the caudal (bottom) edge of the upper lateral cartilage, the nasal septum, and the floor of the nose. Collapse of the internal nasal valve can result in breathing difficulties and may require surgery to correct. When the “internal nasal valve” is collapsed, it can usually be improved with a “spreader graft” which is placed between the upper lateral cartilage and the septum. Special consideration is allowed for the upper lateral cartilages during rhinoplasty to minimize the alteration of the airway with aesthetic surgery.
The skin anatomy of the nose also plays an important role in the appearance of the nose. There are two factors related to the nasal skin that affect the appearance. The first factor is nasal skin thickness. The thickness of the nasal skin varies widely from patient to patient, and can be very thin, or very thick. When the nasal skin is very thick, changes to the nasal skeleton (cartilage and bone) will be less noticeable after rhinoplasty. In other words, it is more difficult to achieve nasal tip definition in the patient with thick nasal skin. This is because the thickness of the nasal skin somewhat conceals the detailed anatomy of the nasal skeleton. The advantage of thick nasal skin is that irregularities and small asymmetries will be less noticeable in the patient with thick nasal skin. The second factor is the amount of subcutaneous fat. When more definition is desired in the patient with thick nasal skin, the nasal tip can be “defatted” during the rhinoplasty. This will increase the tip definition to some degree. Some patients have very thin nasal skin, in which case small irregularities or asymmetries are more likely to be visible. If an irregularity of the nasal skeleton does exist after rhinoplasty, it will become more obvious as the swelling subsides. The advantage of thin nasal skin is that excellent tip definition can be obtained with rhinoplasty. If nasal grafts are needed, thin nasal skin may make the graft borders more visible so this should be taken into account when designing and placing the graft.