Skin envelope: Due to the presence of sebacious glands, skin is thickest in the lower third of the nose. The skin envelope of the upper/ middle thirds is thinner and more mobile.

Musculature: Nasal muscles can be categorized according to their function.

Innervation:

Primary blood supply:

Nasal vaults: The nasal framework is formed by an upper osseous nasal vault and two lower cartilaginous vaults.

Septum: Consists of a membranous, quadrangular cartilaginous and an osseous portion (anterior nasal spine of maxilla, perpendicular plate of ethmoid, vomer).

Nasal tip: Medial and lateral crura of LLC supported by accessory ligamentous structures (e.g., domal suspensory ligament, fibrous attachments between LLC and ULC, connections of LLC and piriform aperture) define the nasal tip7.

Internal nasal valve: Region of greatest nasal airflow resistance9. Formed by junction of dorsal septum, caudal ULC and inferior turbinate. An ideal angle measures between 10-15°. More acute angles lead to airway obstruction.

External nasal valve: Formed by caudal septum, caudal LLC and columellar/ alar soft tissues. Patency is maintained by M. levator labii superioris alaeque nasi.

Aesthetic nasal analysis31214:

Nasal airway obstruction: Seasonal airway obstruction may be caused by allergic rhinitis. A thorough history may unveil nasal airway obstruction that benefits from surgical repair such as the following: 

Cartilage incision:

Septal incision:

Skin incision:

Skin flap elevation: Dissection has to be slow and meticulous. Elevate the flap as close to the cartilage as possible and expose the nasal tip. Domal ligamentous structures are encountered. Dissection is continued to the nasofrontal angle. The ideal dissection planes with minimum bleeding are supraperichondrial and then subperiosteal. Use of an Aufricht retractor allows optimal exposure.

Septoplasty: Injection of diluted epinephrine solution (1: 200 000 – 100 000) facilitates exposition of the septum tremendously. Separation of domal ligaments exposes the septum. Incise the mucoperichondrium parallel to the columella on each side and elevate mucoperichondrial flaps using a Freer or Cottle elevator. Be careful to avoid septal perforation. In case of septal deviations preparation of mucoperichondrial flaps should start on the side of septal convexity. This strategy lowers the risk of iatrogenic septal perforations. To fully mobilize the septum identify and release the chondro-osseous junctions to the perpendicular plate of the ethmoid and the vomer. Try to maintain the attachment of the septum to the anterior nasal spine of the maxilla. Reduce and straighten the septum for correction of mild septal deviation. In case of a decentralized attachment of the septum at the anterior nasal spine, it can be translocated to the midline and re-anchored according to the swinging-door technique25. Severe septum deviation can also be corrected by extracorporeal septoplasty26. Either the entire septum or an L-framed septal strut can be relocated27.

Hump reduction: Cartilaginous humps can be tangentially removed with a scalpel blade under direct vision. Address osseous/ composite osseo-cartilaginous humps conventionally by an osteotome and hammer or by the use of an ultrasonic piezoelectric device28. Osseo-cartilaginous humps were traditionally removed en-bloc (composite reduction). To avoid destabilization of the keystone area resulting in a collapse of the ULC and a conspicuous inverted-V deformity, dorsal strip component reduction (dorsal split hump technique) with sharp separation of ULC from the dorsal septum has been implemented29.

Osteotomy: An open roof is the natural and inevitable consequence of a hump reduction. Closure can be achieved by medial and lateral osteotomies. Osteotomies are required to mobilize the bony vault thereby closing an open roof or changing the width of the nasal base. Lateral osteotomy can be performed either percutaneous or open, while medial osteotomy should be done under direct vision. Lateral osteotomy is carried out along a line connecting the supero-lateral border of the piriform aperture and the intercanthal line following specific patterns (e.g., high-low-high)30. It is safer to perform internal medial osteotomies with large osteotomes (8-10 mm) to reduce the risk for skull base penetration. Bilateral medial oblique osteotomies are designed to form a V-pattern. Most importantly, osteotomies should not extend more cranial than the intercanthal line to avoid the thick bone of the radix and prevent a rocker deformity31.

Spreader grafts: Spreader grafts or spreader flaps are used for reconstruction of the internal nasal valve. Spreader grafts are rectangular bars (usually sizing about 20-30 x 3-5 x 1-2 mm) fashioned from septal (or conchal) cartilage and placed bilaterally between the dorsal septum and ULC16. Alternatively, autospreader flaps can be formed by rolling the dorsal edge of the ULC on itself and securing it to the dorsal edge of the reduced septum32.

Tip modification: The Tripod concept helps to understand how elongation or shortening of medial and/ or lateral crura affect tip rotation and projection. Medial and lateral crura of LLC represent the legs of a tripod. Isolated shortening (elongation/ strengthening) of the medial crura decreases (increases) tip rotation only. On the contrary, isolated shortening (elongation/ strengthening) of the lateral crura increases (decreases) tip rotation. Shortening (elongation/ strengthening) of both lateral and medial crura maintains rotation while decreasing (increasing) tip projection8. Based on this concept various suturing techniques and cartilage grafts can be used for nasal tip modeling.    

Other selected cartilage grafts:

Wound closure: Soft, rapidly absorbable sutures (e.g., Vicryl rapide 5-0) can be used for vestibular and transcolumellar wound closure to avoid painful suture removal in this sensitive region.

Dressing/ splints: The external nasal splint should be molded precisely to secure the final rhinoplasty result36. If any septal manipulation is performed, internal silicone splints are commonly used in addition. 

Aesthetic complications: Most rhinoplasty complications are associated with poor aesthetics or contour irregularities. Most importantly the surgeon must ensure realistic patients’ expectations prior to performing rhinoplasty.


Specific aesthetic rhinoplasty complications include the following deformities12:

Septal hematoma: Use internal nasal splints to avoid dead space and hemorrhage between septum and mucoperichondrial flaps when performing extracorporeal septoplasty to avoid septal hematoma/ necrosis2.

Septal perforation: Handle delicate nasal cartilaginous structures carefully during the course of the surgery to avoid iatrogenic injury2.

Soft tissue edema: Avoidance of hypertensive blood pressure, extensive physical activities, head elevatation and use cool compresses in the early postoperative period to reduce swelling. Persistent edema can mask the final result for months following rhinoplasty3. 

Nasal airway obstruction: Most commonly functional impairment is temporary and results from soft tissue edema34.

Skin necrosis: Meticulous dissection in the supraperichondrial and subperiosteal plane is key to maintain a stable skin envelope34. 

A thorough understanding of nasal anatomy and aesthetic principles is fundamental.

Successful rhinoplasty begins with a detailed preoperative analysis of nasal shape and function.

Nasal obstruction is often caused by impairment of external or internal nasal valve patency, septal deviation and inferior turbinate hypertrophy.

Aesthetic concerns that rhinoplasty patients seek advice for commonly regard the correction of cartilaginous/ composite cartilaginous-osseous humps, nasal deviation, broad nasal root/ middle vault, tip refinement and alteration of tip projection/ rotation.

Rhinoplasty can be performed through an open or closed approach.

An open-roof deformity is a surgical complication caused by failure of nasal dorsum reconstruction following hump reduction.

Revision rhinoplasty is even more challenging than primary rhinoplasty.