Residency · Residency · Otolaryngology
Rhinoplasty: Functional and Aesthetic Principles
Introduction
Rhinoplasty is one of the most technically demanding procedures in facial plastic surgery, requiring a thorough understanding of both nasal aesthetics and functional anatomy. The modern rhinoplasty surgeon must address airway obstruction while achieving a natural, balanced appearance that harmonizes with the patient's overall facial proportions. The combination of functional and aesthetic goals is termed functional rhinoplasty.
Nasal Anatomy
External Framework
Bony vault: Paired nasal bones and ascending processes of the maxilla. Upper lateral cartilages (ULCs): Fused to the dorsal septum in the middle vault. Lower lateral cartilages (LLCs): Composed of medial, intermediate, and lateral crura. Scroll area: Cephalic margin of the LLC overlapping the caudal margin of the ULC. Keystone area: Critical junction of the nasal bones, ULCs, and perpendicular plate of the ethmoid.
Internal Nasal Valve
Defined by the angle between the caudal edge of the ULC and the nasal septum. Normal angle is 10-15 degrees. The most common site of nasal airway obstruction. Cottle maneuver: Lateral displacement of the cheek to open the valve; positive result indicates valve collapse.
Blood Supply and Innervation
Arterial supply from branches of the ophthalmic and facial arteries. External nasal nerve (branch of V1) provides sensation to the nasal tip. Marginal incisions should preserve the columellar branch of the superior labial artery.
Preoperative Evaluation
Patient Assessment
Thorough nasal history: obstruction, trauma, prior surgery, medications. Standardized photography: Frontal, lateral, oblique, and basal views. Anterior rhinoscopy and nasal endoscopy to assess septum, turbinates, and valves. Assess skin thickness (thin skin shows every irregularity; thick skin limits tip definition). Evaluate patient expectations and psychological readiness; screen for body dysmorphic disorder.
Nasal Analysis
Nasofrontal angle: 115-130 degrees. Nasolabial angle: 90-95 degrees (males), 95-110 degrees (females). Tip projection: Goode ratio (tip projection / nasal length = 0.55-0.60). Tip rotation: Defined by the nasolabial angle. Dorsal aesthetic lines should form smooth, gently diverging curves from brow to tip.
Surgical Approaches
Open vs. Closed Rhinoplasty
Open approach: Transcolumellar incision with marginal incisions; provides direct visualization. Preferred for complex tip work, revision cases, and teaching. Disadvantage: Columellar scar (usually heals well), longer operative time, more edema. Closed (endonasal) approach: All incisions inside the nose. Intercartilaginous, transfixion, or delivery approaches. Advantages: No external scar, less edema, shorter recovery. Limited visualization of the tip and dorsum.
Key Surgical Maneuvers
Dorsal hump reduction: Sequential reduction of cartilaginous and bony dorsum; avoid over-resection. Osteotomies: Lateral and medial osteotomies to narrow the bony vault after hump removal. Spreader grafts: Placed between the ULC and septum to maintain or widen the internal nasal valve. Tip suturing techniques: Interdomal, transdomal, and columellar-septal sutures for tip refinement. Cephalic trim: Conservative resection of the cephalic margin of the LLC (preserve at least 6-8 mm). Alar batten grafts: Placed laterally to prevent external valve collapse.
Functional Considerations
Septoplasty
Performed concurrently to correct septal deviation contributing to obstruction. Preserve an L-strut of at least 10-15 mm dorsally and caudally for structural support. Harvested septal cartilage serves as autologous graft material.
Turbinate Reduction
Inferior turbinate hypertrophy is a common contributor to nasal obstruction. Submucosal resection, radiofrequency ablation, or outfracture techniques. Avoid aggressive mucosal resection to prevent empty nose syndrome.
Nasal Valve Repair
Spreader grafts for internal valve stenosis. Alar batten grafts or lateral crural strut grafts for external valve collapse. Butterfly graft: Conchal cartilage graft spanning the dorsum to open the internal valve.
Grafting Materials
| Graft Source | Primary Use | Advantages | Disadvantages |
|---|---|---|---|
| Septal cartilage | First choice for most grafts | Readily available, easy to carve, no donor morbidity | Limited quantity |
| Auricular (conchal) cartilage | When septal cartilage insufficient | Good for batten/shield grafts | Curved, limited rigidity |
| Costal cartilage | Major reconstruction, revision | Abundant quantity, strong | Warping risk, donor site pain |
| Irradiated homologous rib | Alternative to autologous rib | Avoids harvest morbidity | Higher resorption rate |
| Diced cartilage fascia (DCF) | Dorsal augmentation | Smooth contour, natural feel | Less structural support |
Septal cartilage: First choice; readily available and easy to carve. Auricular (conchal) cartilage: When septal cartilage is insufficient. Costal cartilage: For major reconstruction; risk of warping. Irradiated homologous rib cartilage: Alternative to autologous rib; higher resorption rate. Diced cartilage fascia graft (DCF): Useful for dorsal augmentation.
Complications
Over-resection of the dorsum: Saddle nose deformity or inverted-V deformity. Pollybeak deformity: Fullness of the supratip area from excess cartilage or scar tissue. Nasal valve collapse: From inadequate structural support. Asymmetry: Most common reason for revision rhinoplasty. Rocker deformity: Medial displacement of the nasal bone from incomplete osteotomy.
Key Clinical Pearls
The internal nasal valve is the most common site of nasal airway obstruction and must be assessed in every rhinoplasty patient. Preserve at least 6-8 mm of the lateral crus during cephalic trim to prevent alar collapse. Spreader grafts should be placed routinely after dorsal hump reduction to prevent inverted-V deformity. Always undercorrect rather than overcorrect; revision for residual fullness is simpler than reconstruction of over-resected structures. Thick-skinned patients require strong structural grafting for tip definition; thin-skinned patients require meticulous graft contouring.
References
- Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;128(2):49e-73e.
- Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8(3):156-185.
- Constantian MB. The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty. Plast Reconstr Surg. 1994;93(5):919-931.
- Papel ID, et al. Facial Plastic and Reconstructive Surgery. 4th ed. Thieme; 2016.