Recent trends in cosmetic and plastic surgery have promoted achieving aesthetically pleasing yet natural appearing results. Rhinoplasty surgery has benefited from maneuvers to modify existing nasal cartilages rather than introducing distant grafts thereby avoiding the operated look. Local Orange County surgeon, Arian Mowlavi M.D., has been recognized for his surgical expertise and natural rhinoplasty outcomes.
Dr. Arian Mowlavi is a Board Certified Plastic and Reconstructive Surgeon who has dedicated his practice to providing prospective nasal surgery patients the nose they desire yet avoid the operated look. Rhinoplasty Natrelle TM is dedicated to restoring nasal aesthetics in a natural appearing manner.
Dr. Mowlavi is Board Certified by the American Board of Plastic Surgery, as well as Member of the Alpha Omega Alpha Honor Medical Society and Orange County Society of Plastic Surgeons. Dr. Mowlavi has published over 50 nationally recognized scientific articles, received several nationally distinguished awards in the field of plastic surgery, and been featured in the Orange Coast Magazine, Los Angeles Times, Orange County Register, The Washington Post, and Self Magazine to name a few.
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Rhinoplasty is a surgical discipline dedicated to correcting not only the aesthetics of the external nasal contour but also the internal functional breathing capacity. It is a surgery that is unique to a small area of the body but one that is disproportionately important as it is located in the center of your face. Although it owns a small real estate when considering your entire body structure, it never the less possesses very intricate structures as one acknowledges the complexity of its architecture. The following manuscript was written by Dr. Mowlavi to help prospective rhinoplasty patients appreciate and educate themselves on the anatomy of the nose and the fine details that make rhinoplasty one of the more challenging surgeries in field of cosmetic surgery.
Prior to expanding on the various maneuvers utilized during nasal surgery, it is important to review the details of the nasal anatomy. To start with, lets review the three components to the nose. These include the upper, middle, and lower 1/3rds (Figure 1).
The nose is much like an A Frame house which supports two airway passages, i.e. the nares. This A Frame is composed of two lateral supporting elements as well as the central supporting beams. These structural supporting structures are present throughout each of the above mentioned 1/3rd components of the nose. The upper third of the nose is made up of bony elements which include the nasal bones that are one of the thinner bones of our body which extend form the lateral facial foundation (maxillary bone) over to the midline of the nose where they fuse and create the “A frame” design (Figure 2). Of note, there is a midline bony pillar element composed of the ethmoid bone, although this structure is not typically altered during rhinoplasty surgery. The middle third of the nose, spans from the upper bony elements to the nasal tip elements, i.e. lower third, and is composed of cartilaginous supporting structures which are defined by the upper lateral cartilages laterally and the nasal septum centrally (Figure 3). The upper lateral cartilages meet centrally as they fuse to the very important central pillar structure termed the septal cartilage. The lower 3rd of the nose is also cartilaginous and shaped by two “umbrella” looking structures that meet at the midline and define the nasal tip proper (Figure 4). Each of “umbrella looking structure is composed of a “lateral crura” which extends to the lateral maxillary foundation via foot plates, a middle crura” which is the bend in the umbrella and defines the degree of your tip “highlight”, and the medial crura which come together and attach intimately with the anterior/lower aspect of the above septum cartilage as well as down to the nasal spine completing the central pillar support beam. These structural elements are important to recognize and review as they provide the premise for all rhinoplasty maneuvers used to either correct or alter nasal deformities.
The external nasal contour and aesthetically pleasing parameters have been described in detail and should be reviewed. The nasal dorsum extends from the forehead down to the nasal tip. The upper part of the dorsum is cha termed the radix which should ideally provide a natural drop off from the forehead and to the start of the nasal dorsum proper. In men, a strong radix is preferred whereas in females a larger drop may be acceptable (Figure 5). The dorsum of the nose then should extend in a gentle concave curve(females) or as a straight line down to the tip. In an aesthetically pleasing dorsum to tip relationship, the tip should lead the dorsum by 1 to 2 mm.(Figure 6) More generous lead or elevation of tip is acceptable in females. The dorsum width should also provide a gentle arc starting from the medial eyebrows to its deepest point at the mid nose and then gently curve back out at the nasal tip. This arc is often termed the dorsal aesthetic line (Figure 7). Thus the nasal dorsum width should be widest at the upper radix, narrowest at the mid nose, and slightly wider as it approaches the nasal tip. The nasal length is defined by the length from the start of the radix down to the nasal tip; the nasal projection is defined by the distance from the tip down to the upper lip. The aesthetically pleasing nasal length to nasal projection ration is approximately 3 to 1(Figure 8 ). The nasal tip should project to just slightly higher than the nasal dorsum; in females a higher tip is acceptable. The nasal dorsum should obviously be straight and not leaning to one side or other termed a crooked nasal deformity.
The aesthetically pleasing tip is described by a refined tip structure one which is narrower than the dorsum width but one which is not too sharp. The nasal tip shape is determined by not only the arc created by the lower lateral cartilage middle crural bend but also by how the two middle crura of each nares come together; the confluence of the two middle crural angles is termed the dome and determines the shape of the tip. The tip shape can infrequently be blunted in patients who have excessive fat overlying the cartilage infrastructure. Looking up at the nose (termed the worm’s eye view), one will appreciate a triangular shape esthetics is best appreciated by three “legs” including the base created by the upper lip and two slanting lateral alar rims converging at the tip. This triangle is bisected by the central structure called the columella (Figure 9). The columella houses the two converging medial crura that create the lowest component of the central pillar. On the lateral view the nasal alar rims should be just behind the columella(central) structure described above. A gentle ellipse should be able to be drawn between the offset of the alar rims from the columella. When the ellipse is wide, this an indication of either retracted ala or prominent columella; when the ellipse is narrowed then this is an indication of droopy or overhanging alar rims or retracted columella.(Figure 10) Finally, the alar rim should lie in a vertical line dropping from the medial canthi. (Figure 11)
The internal nares or nasal passage opening is best described two cylindrical tubes that start at the nasal opening and which reconnect at the back of the nose at the start of the throat. These two passages should create two straight and equally sized tubes that provide for smooth flow of air termed laminar flow. When either of these two tubes is narrowed at any point along the tube length, then this will create unequal flow of air through the two tubes. Unequal flow of air through the two tubes results in turbulent flow at the back of the nose where the two passages come back together. The turbulence created by unequal air flow will result in irritation of the nasal mucosa which results in mucosal swelling and further construction of both tubes. There are two bones which project into the nose called the inferior turbinates which maintain a high vascular flow of blood and function to heat the air as it is sucked in to prevent “brain freeze” that you might have the unfortunate experience of feeling if you eat ice cream too fast. Well these bones have a secondary function which involves attempting to equalize the air flow when unequal flow is perceived. The larger side nares or tube will compensate by having growth and projection of the turbinate into the nares in an attempt to slow down the flow of air to mach the more constricted side. (Figure 12) Unfortunately, this creates a positive feedback of continuing to narrow over all nasal flow and making your breathing more difficult.
Causes of nasal passage narrowing can occur throughout the tube at specific locations which will be described by utilizing knowledge of anatomical structures described above. The most common cause of nasal passage narrowing is caused by a deviated cartilaginous septum as described by the midline pillar structure extending along the middle 1/3rd. When this septum is deviated to one side or other, it will cause narrowing of the internal nasal passage on one side and a compensatory overgrowth of the inferior turbinate. Correction of this deformity requires dissection of the septal cartilage off of the nasal mucosa typically on the side of the larger nares opening and then removal of the deviated portion of the cartilage. It is of extreme importance to maintain a rim of septal cartilage extending from the nasal bones over to the tip and down to the nasal spine often referred to as an “L strut”.(Figure 13) Once the deviated cartilage has been removed, then the nasal mucosal covering will automatically move back to the midline. It is then important to also reduce the enlarged turbinate in order to ensure return of symmetric sized tubes.
Other less frequent constriction sites can occur at the external valve, the internal valve, or the middle 1/3rd of the nose in the midvault. The external valve refers to the opening of the nose where the air stream enters the tube. The external nasal valve is created by the nostril alar rim which is help up by the lateral portion of the lower lateral cartilage. Diagnosis of this constriction can be made by patients who demonstrate pinching of their alar rims on deep inspiration. Correction of a collapsing external valve requires placement of a cartilage graft which is placed in the alar rim below the lateral alar rim; this graft is called an alar contour graft which basically stents out the alar rim and does not allow it to collapse. Internal nasal valve tightness occurs at the junction of the upper and middle 1/3rd of the nose at the junction of the upper lateral cartilages and the nasal bones secondary to a narrow upper lateral to septal angle; this angle is termed the internal nasal valve and when it is < than 30 degrees in angulation, it is felt to be constriction site. Correction of this deformity requires placement of cartilaginous grafts between the upper lateral cartilage and septal cartilage in order to increase the space and angulation between the upper lateral cartilage and septal cartilage and is called spreader grafts. Most recently, collapse of the middle 1/3rd of the nose has been described which can be located anywhere between the external nasal valve and the internal nasal valve in the midvault area. Diagnosis of this constriction is best appreciated by a cheek distraction test by placing the thumbs along the base of the midvault over the medial cheeks and pulling out; if this maneuver improves breathing ability, then one can consider correction of this constriction site. Correction of this deformity requires placement of a cartilage graft which spans from the lateral edge of the upper lateral cartilage down to the lateral maxillary bony foundation. (Figure 14)
When considering improving the aesthetics of nasal contour, it is important to determine if functional restraints are present which may be further compromised by planned alterations of infrastructure components. When assessing nasal contour deformities it is important to not only consider aesthetic standards set by previous investigators but also to consider the patient’s own nasal contour dislikes. It can be quite surprising what patients perceive as desired corrections. Sometimes educating patients can help resolve discrepancies between what the surgeon feels is an appropriate correction versus what the patient perceives as the appropriate correction. In most situations however, patients will find set standards involving nasal correction in line with their desires. Morphing technology can be used by your surgeon to ensure that the changes you are recommended are agreeable to you. Now lets, discuss how honing on the region of nasal correction determines which one of the two approaches will be required for your surgery.
Two approaches are available for nasal recontouring and these include the closed (endonasal) rhinoplasty approach versus open rhinoplasty approach (Figure 15). The closed rhinoplasty approach requires two separate incisions that are made inside each of the nares in a semicircular pattern which are placed at the junction of the middle and lower 1/3rd of the nose. These two incisions allow access to the upper and middle 2/3rd of the nose. As such, the nasal tip, or lower 1/3rd of nose, is not accessible and not alterable by virtue of this incision. In contrast, open rhinoplasty utilizes a modified form of closed rhinoplasty incisions which are then connected across the lower aspect of the columella. By connecting these two incisions, then entire nasal skin envelop can be elevated and the infrastructure of all three components of the nose are visualized and alterable. As such, the open rhinoplasty provides full access of the entire nasal infrastructure mainly including the nasal tip. One might enquire why the open rhinoplasty approach is not utilized for all prospective rhinoplasty patients since it allows for recontouring of the entire nose. The reason for not utilizing this approach for all patients is multifold. First of all, the open rhinoplasty requires substantially longer operative times to complete by virtue of requiring increased dissection. Longer operative times equals increased financial constraints on patients since prices of operations are often related to operative times lengths. Additionally, placing an incision on the columella and dissection of the nasal tip structures, followed by reapproximation and repair of this columella incision has reprecautions on the nasal tip projection. By virtue of the healing of this columella incision line, the tip structures are more vulnerable to collapse and development of a secondary deformity. As a result, further reinforcement of the nasal tip structure s is required to avoid nasal tip collapse. This reinforcement and attention to avoiding nasal tip collapse by the surgeon may introduce further risk to nasal contour complications and increasing operative times unnecessarily. In contrast, when the nasal tip requires alteration and improvement in highlights, then the open rhinoplasty cannot be surpassed by the closed rhinoplasty technique.
Most commonly sought out nasal contouring procedure involves lowering and/or narrowing of the nasal dorsal hump (Figure 16). The dorsal hump is the undesirable prominence that is frequently seen on the dorsum of the nose which is comprised of two components. The upper part of the dorsal hump is made up of prominent nasal bones located over the upper 1/3rd of the nose. The lower part of the dorsal hump is made up of a prominent upper lateral cartilage and septum located over the middle 1/3rd of the nose. The treatment of an isolated wide and prominent dorsal hump only requires a closed rhinoplasty, as this incision provides access to both of these regions as described above. First, the lower part of the hump is addressed. This procedure requires isolation of the fusion point of the upper lateral cartilage and septum, which is then detached bilaterally. This maneuver then allows for differential lowering and narrowing of the dorsal hump. To lower the dorsal hump height, the dorsal septum is trimmed down and to narrow the dorsal width the medial aspect of the upper lateral cartilages are trimmed down which allows the upper lateral cartilages to medialize (Figure 17). Following reduction of the cartilaginous component of the hump, the bony component of the hump is addressed. First the roof of the hump is lowered to lower the dorsal bony height; this is done by a combination of a medial osteotome and/or rasp. This maneuver completes reduction of the dorsal hump height, but results in a disconnect of the bony dome, often referred to as an open roof deformity (Figure 18). Thus, the lateral base of the nasal bones where they rise off of the maxillary foundation requires release by use of a lateral osteotome. This maneuver allows the nasal bones to be transposed medially thus re-establishing the bony dome as well as to narrow the nasal bony dorsum width. Less frequently, patients may have some asymmetry of the actual dorsum in addition to a hump. Minor asymmetries are correctable by adjusting degree of nasal bone medialization during the above infracture. For example, if one side is narrower than the other, then naturally the narrower side does not have to be brought in as much. Any and all medialization of nasal bones are secured into their permanent position by use of an external splint which is kept in place as a cast for one week until the nasal bones heal and fuse into position. Others might have nasal dorsum assymetries related to having a crooked/or twisted dorsum. Minor crooked/twisted noses can be set back to the center by medialization of the nasal bones as above, and differential fixation of the upper lateral cartilages back to the septum. This maneuver allows the two upper lateral cartilages to act as cantilevers; for example if the nose is crooked and leaning to the right, one can use the left upper lateral cartilage to pull over the septum to the middle.
The second most common nasal contour procedure sought involves improving the look of the nasal tip. When trying to access the nasal tip it is important for your surgeon to be able to directly visualize the shape of your lower lateral cartilages; each of these cartilages looks like an umbrella or a modified boomerang as described above which then meet together at the tip of the nose to provide what you see as the shape of your tip. Patients seeking to improve their tip may feel that their tip is too wide or rounded in appearance and has been described by a variety of descriptions such as a “bulbous” or “platypus” tip (Figure 19). This appearance is caused by several factors including 1)an obtuse middle crura; 2)poor approximation of the two middle crura at the tip area, and/or 3)extraneous fat under the nasal tip skin. Thus treatment of a wide tip requires correction of one or all of the above deformities; 1)a stitch placed to make the middle crura more acute called an intra-crural stitch; 2)a stitch placed to make the two middle crura better approximated called an inter-crural stitch; and/or 3) defat the fat from the tip.
Finally, there are certain proportions that must be kept in mind when altering the nasal structures and these include keeping the nasal tip as the lead point of the nasal dorsum. This means that the nasal tip must be just slightly higher than the nasal dorsum. For females, this nasal tip projection can be slightly more pronounced as depicted by a supratip break; in contrast, males should have a suttle tip lead (Figure 20). This is an extremely important consideration especially following open rhinoplasty, in which the tip must be appropriately supported as it will be pulled down by the scarring resulting from tissue healing that takes place over the columella area. Your surgeon may use a variety of methods to reinforce the tip structure including setting back the lower lateral cartilages on to the septal cartilage, providing a columellar strut graft, or utilizing medial crural fixation stitches in order to provide necessary tip reinforcement to avoid a droopy tip. The use of these maneuvers if partly determined by the nasal dorsum to tip projection preoperatively but also based on the naso-labial angle. The naso-labial angle is determined by the angle between the nasal tip projection vector to upper lip vector. In females this angle is more open and approximately 100 to 105 degrees; in males this angle is more closed and approximately 90 to 95 degrees(Figure 21). The reinforcement techniques described above will affect the nasolabial angle and must be chosen appropriately. Additionally, the reinforcing techniques used above will further affect the nasal projection to nasal tip length which should approximate 1:3 in length ratio (Figure 22).
The nose is a complex structure affected by the above described intricate infrastructural elements. As such evaluation of the nose requires visualization by multiple angles. Plastic surgeons will typically obtain five independent views of the nose including the front view (AP view), two lateral views (profile views), and two oblique views (45 degree view). It is important to consider nasal modifications following analysis of the nose by all of these views.(Figure 23) For example, the lateral view demonstrates another nasal contour parameter described above, namely the alar rim columellar relationship. There needs to be a balance between these structures as depicted by a gentle ellipse bisecting the above structures. Then the alar rim is retracted, then an alar contour graft can be placed to stent down the alar rim. If the alar rim is hanging or too generous, then a trim of the lower lateral crura will allow the alar rim to push back up. If the columellar is hanging or too generous, then medial crural set back onto the septum may be utilized; and if the columella is retracted, then a columellar strut graft that is fixed to the septum may be used.
The nose is one of the most complicated organs of the body. This understanding as well as its precious location over the central face, makes rhinoplasty one of the most technically challenging surgeries of the human body. The art of closed and/or open rhinoplasty is one that is mastered through extensive surgical training and years of experience. Although Dr. Mowlavi has provided a thorough review of the nasal anatomy, most common deformities, and various contour changing maneuvers, there are numerous other considerations that have not been discussed. Rhinoplasty Natrelle strives to provide improvements in nasal contour that are natural in appearance and specifically not operated in appearance. Dr. Mowlavi achieves these results by minimizing addition of distant cartilage grafts into areas affecting the nasal contour with the exception of patients requiring functional breathing correction as described above. It is encouraged that you seek the guidance of a qualified surgeon to help you realize the changes and nasal improvements that you could expect.