Residency · Residency · Plastic Surgery
Rhinoplasty: Structural Approach
Introduction
Rhinoplasty is one of the most technically demanding operations in plastic surgery, requiring mastery of both aesthetic principles and nasal functional anatomy. The structural approach (championed by Jack Gunter and Rod Rohrich) emphasizes cartilage grafting and suture techniques to create a strong, long-lasting nasal framework rather than relying on reductive techniques alone. Goals: achieve aesthetic harmony with the face while maintaining or improving nasal airway function. Understanding the nasal tripod concept and the relationship between the structural components is fundamental.
Nasal Anatomy
External Nose
Skin-soft tissue envelope (SSTE): varies in thickness; thinnest at the rhinion (bony-cartilaginous junction), thickest at the supratip and alar lobule. Thick skin conceals structural changes; thin skin reveals every irregularity — critical to assess preoperatively. Musculoaponeurotic layer (SMAS equivalent): nasal muscles; elevate and depress the nasal tip.
Skeletal Framework
Bony vault: paired nasal bones; frontal process of the maxilla forms lateral walls. Upper cartilaginous vault: paired upper lateral cartilages (ULC); fused with the dorsal septum in the midline. Internal nasal valve: angle between the ULC and the dorsal septum; normally 10-15 degrees; the narrowest point of the nasal airway. Lower cartilaginous vault: paired lower lateral cartilages (LLC), each with three crura: Medial crura: provide columellar support. Middle crura (intermediate): define the infratip lobule. Lateral crura: form the alar lobule; contribute to tip definition and support. Nasal septum: quadrangular cartilage (anteroinferior), perpendicular plate of ethmoid (posterosuperior), vomer (posteroinferior).
Keystone area: junction of nasal bones, ULC, and perpendicular plate of ethmoid; critical structural area; disruption leads to dorsal irregularity or collapse. Anterior septal angle: determines tip projection and rotation. L-strut: minimum 1.5 cm dorsal and 1.5 cm caudal struts must be preserved to prevent saddle nose deformity.
Nasal Tip Support
Major tip support mechanisms: size, shape, and resilience of LLC; attachment of LLC to ULC (scroll); attachment of medial crura to caudal septum. Minor tip support mechanisms: interdomal ligament, sesamoid cartilages, nasal spine, membranous septum, skin and soft tissue envelope.
Nasal Tripod Model (Anderson)
The lower lateral cartilages form a tripod: two lateral crura (two legs) and the conjoined medial crura (one leg). Shortening any leg changes tip position predictably: Shortening the medial crural leg: decreases projection, increases rotation. Shortening lateral crural legs: increases projection and rotation. Lengthening any leg: opposite effect.
Preoperative Analysis
Facial Analysis
Assess facial proportions: face divided into horizontal thirds (trichion-glabella, glabella-subnasale, subnasale-menton). Ideal nasal length: approximately equal to the middle third of the face. Nasofacial angle: angle between the facial plane and nasal dorsum; ideal 30-40 degrees. Nasolabial angle: angle between columella and upper lip; ideal 90-95 degrees in males, 95-110 degrees in females.
Tip projection: ratio of tip projection to nasal length; Goode ratio approximately 0.55-0.60. Tip rotation: assessed by nasolabial angle and degree of nostril show on lateral view. Evaluate for facial asymmetry, chin projection (mentoplasty may be needed), and skin thickness.
Nasal Analysis
Dorsum: assess for hump, deviation, width, saddle deformity, open roof. Tip: bulbous, boxy, pinched, amorphous, ptotic, overprojected, underprojected. Base: alar width should approximately equal intercanthal distance; alar flaring, nostril asymmetry. Septum: deviation, perforation, caudal deflection.
Functional Assessment
Nasal airway obstruction: Cottle test (cheek retraction improves breathing suggests internal valve collapse). Anterior rhinoscopy: septal deviation, turbinate hypertrophy, mucosal pathology. History: chronic rhinosinusitis, allergies, prior nasal surgery, cocaine use, prior trauma.
Surgical Approach
Open (External) Approach
Transcolumellar incision (inverted-V or stair-step) connected to bilateral marginal incisions. Complete exposure of the nasal framework; allows precise graft placement and suture techniques. Advantages: excellent visualization, bimanual control, teaching value. Disadvantages: columellar scar (usually imperceptible), slightly more tip edema, longer operative time. Preferred for complex tip work, revision rhinoplasty, and structural grafting.
Closed (Endonasal) Approach
All incisions are intranasal (intercartilaginous, transfixion, marginal). Advantages: no external scar, less tip edema, faster recovery. Disadvantages: limited visualization, more technically demanding for complex tip work. Appropriate for isolated dorsal reduction, simple tip refinement, and septoplasty.
Structural Techniques
Dorsal Management
Component dorsal reduction: separate reduction of bony and cartilaginous dorsum; preserves ULC attachment to septum ("T-junction"). Prevents inverted-V deformity by maintaining ULC height. Spreader grafts: rectangular cartilage grafts placed between the ULC and the dorsal septum; restore internal nasal valve angle; prevent middle vault collapse. Standard dimensions: 2-4 mm wide, 15-25 mm long.
Indications: dorsal hump reduction (almost always needed), internal valve collapse, narrow middle vault, deviated nose. Osteotomies: medial, lateral, and intermediate osteotomies to narrow the bony vault and close an open roof after hump reduction. Lateral osteotomy: low-to-low or low-to-high path; performed percutaneously (2mm osteotome) or intranasally. Medial osteotomy: along the junction of the nasal bone and perpendicular plate of ethmoid.
Tip Refinement
Suture Techniques
Interdomal suture: narrows the interdomal distance; defines the tip. Transdomal suture: narrows each dome; increases tip definition. Columellar septal suture: sets tip rotation and projection by fixing the medial crura to the caudal septum. Lateral crural steal (advancement): advances the lateral crura medially; increases tip rotation and projection. Lateral crural repositioning: corrects cephalically oriented lateral crura (most common cause of a bulbous tip).
Grafting Techniques
Columellar strut graft: cartilage graft placed between the medial crura; stabilizes the tip and columella; foundation for tip grafts. Shield (infralobular) graft: placed on the domes to increase tip definition and projection; visible through thin skin. Cap graft: thin cartilage over the domes; less projection than shield graft. Alar rim grafts: placed along the alar margin to prevent alar retraction and support the lateral crura.
Lateral crural strut grafts: placed beneath the lateral crura to flatten, straighten, and support them; prevents external valve collapse. Alar batten grafts: placed lateral to the lateral crura in the alar lobule; correct external valve collapse. Caudal extension graft: extends the caudal septum to increase tip projection and set rotation; attached to the existing caudal septum with sutures or plate fixation.
Septoplasty
Correction of deviated septum for functional improvement and to harvest cartilage for grafting. Graft sources (in order of preference): septal cartilage (best quality, flat, strong), auricular cartilage (curved, softer), costal cartilage (strongest, abundant, risk of warping). Preserve the L-strut: minimum 1.5 cm dorsal and 1.5 cm caudal struts; violation leads to saddle nose deformity or columellar retraction.
<image>Illustration of key structural rhinoplasty grafts and their placement on the nasal framework. The illustration shows an open rhinoplasty view from below with the skin-soft tissue envelope elevated to expose the cartilaginous skeleton. The following grafts are shown in place and labeled: spreader grafts depicted as two rectangular cartilage strips placed bilaterally between the upper lateral cartilages and the dorsal septum, widening the internal nasal valve; a columellar strut graft shown as a rectangular cartilage piece placed vertically between the two medial crura in the columella; a shield graft shown as a small triangular cartilage piece sutured to the anterior aspect of the domes to increase tip projection and definition; lateral crural strut grafts shown as rectangular cartilage strips placed on the undersurface of each lateral crus, extending from near the dome laterally along the crus; and a caudal extension graft shown as a cartilage piece sutured to the end of the caudal septum extending the septal framework inferiorly. Each graft is shown in a slightly different color for distinction. The upper lateral cartilages, lower lateral cartilages with their medial, middle, and lateral crura, and the septum are all labeled. Sutures attaching each graft are depicted.</image>
Alar Base Modification
Alarplasty: narrowing of the alar base; performed as a separate step at the end of the procedure. Weir excision: excision of alar tissue at the alar-facial groove to narrow alar flaring. Sill excision: excision from the nasal sill to narrow the nostril floor. Conservative approach: minimize excision; asymmetric results are conspicuous.
Revision Rhinoplasty
Revision rate: 5-15% for primary rhinoplasty. More challenging due to scar tissue, altered anatomy, and limited cartilage availability. Rib cartilage is frequently needed for structural grafting in revision cases when septal and ear cartilage are insufficient. Wait minimum 12-18 months after primary surgery for scar maturation and tissue softening before revision. Open approach preferred for most revision rhinoplasties.
Complications
Bleeding/epistaxis: usually self-limited; significant hemorrhage rare. Infection: rare (<1%); more common with implant use. Nasal obstruction: from internal valve narrowing, synechiae, or turbinate enlargement; spreader grafts reduce this risk. Asymmetry: most common complaint; some degree is unavoidable.
Pollybeak deformity: supratip fullness with loss of the supratip break; caused by scar tissue accumulation or inadequate cartilaginous dorsal reduction relative to bony reduction. Inverted-V deformity: visible upper lateral cartilage collapse after dorsal reduction; prevented by spreader grafts. Saddle nose deformity: over-reduction of the dorsum or violation of the L-strut. Bossae: cartilage knuckling at the tip; more common in thin-skinned patients. Open roof deformity: failure to close the bony vault after dorsal hump reduction; requires osteotomies.
<image>Illustration showing common rhinoplasty complications. Four panels depict different complications in lateral profile views. Panel A shows pollybeak deformity: a convex fullness in the supratip area above the tip with loss of the supratip break, creating the appearance of a parrot beak. The ideal supratip break point is indicated with a dotted line. Panel B shows inverted-V deformity: a frontal view showing visible shadow lines along the upper lateral cartilage edges after dorsal reduction without spreader grafts, with the cartilages collapsed medially creating an inverted-V pattern of shadowing on each side of the dorsum. Panel C shows saddle nose deformity: a concave depression of the dorsum in the cartilaginous middle vault region due to over-resection of the dorsal septum or L-strut violation, with the ideal dorsal profile indicated by a dotted line. Panel D shows an open roof deformity: a frontal view showing a wide, flat dorsum after hump reduction without osteotomies, with the nasal bones separated laterally and a palpable gap in the midline where the hump was removed.</image>
Key Clinical Pearls
The structural approach to rhinoplasty prioritizes building a strong cartilaginous framework through grafting and suture techniques rather than relying solely on resective methods; this produces more predictable and lasting results with lower revision rates. Spreader grafts should be placed in virtually every rhinoplasty involving dorsal reduction; they maintain internal nasal valve patency, prevent middle vault collapse and inverted-V deformity, and are the single most important structural graft in rhinoplasty. The L-strut (minimum 1.5 cm dorsal and 1.5 cm caudal struts) must be preserved during septoplasty; violation of the L-strut is the most common cause of iatrogenic saddle nose deformity and is extremely difficult to correct secondarily. Skin thickness is the most important factor in predicting how structural changes translate to external appearance; thick skin conceals refinements while thin skin reveals every graft edge and irregularity; tailor the surgical plan accordingly. Computer imaging is a communication tool, not a promise; always present simulations as approximations and document that the patient understands the distinction between a simulation and a surgical guarantee.
References
- Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;128(2):49e-73e.
- Gunter JP, Rohrich RJ, Adams WP Jr. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. CRC Press; 2014.
- Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8(3):156-185.
- Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230-239.
