Anatomy

• Blood Supply: ophthalmic artery and facial arteries supply main blood supply to nose (internal and external carotid)
• Branches of the ophthalmic artery include anterior ethmoidal, dorsal nasal, and external nasal arteries
• Branches of facial artery include superior labial artery and angular artery from which arise  the lateral nasal artery. This is primary blood supply in open tip rhinoplasty due to sacrifice of the columellar arteries. 
• Division of lateral arteries can compromise nasal tip after open rhinoplasty
• Guidelines for safe dissection of lateral nasal arteries include “hugging” the cartilage of lateral crura and staying in a subperichondrial plane
• Labial artery found 2-3 mm above the alar groove
• Innervation: primarily from the trigeminal nerve of ophthalmic and maxillary branches.  These include supratrochlear and supraorbital, anterior ethmoidal branch and the *** for the septum
• Muscles: important muscles in nasal anatomy include levator labii suerioris alaeque nasi which contributes to external nasal valve patency and depressor septi which can shorten the lip and decrease tip projection – this is caused “smiling deformity”

Nasal Vaults: 

• Upper Vault: paired nasal bones, approximately 2.5cm in length, widest at nasofrontal suture and narrowest at nasofrontal angle
• Rocker Deformity: occurs when osteotomies extend into nasal bones above the level of the medial canthus–> this causes fragment lateralization
• Middle Vault: include upper lateral cartilages, dorsal septum. The ULC extend cephalically 6-8 mm underneath or posterior to nasal bones 
• Internal nasal valve: include caudal border ULC, septum, and anterior portion of the inferior turbinate and nasal floor, bony edge of pyriform aperture
• Regulates airflow resistance, normal angle 10-15 degrees, narrowest portion of nasal aperture and may contribute to 50% of airway resistance
• Cottle maneuver: cheek pulled laterally to displace the lateral nasal wall to identify internal nasal valve collapse
• Lower Vault: composed of lower lateral cartilages. This begins with scroll area which is the region of abutment between the ULC and LLCs
• Medial, middle and lateral crura: 
• Angle of divergence: considered wide if greater than 60 degrees, normal is 30-60, defined by middle crura b/l
• External nasal valve: defined by lateral crus and septum, ala, collapse may be seen by nostril collapse on inspiration

Septum: composed of quadrangular septal cartilage, perpendicular plate of ethmoid and vomer
Turbinates: paired bony structures that regulate and humidify inspired air. 

• Inferior turbinate: separate bone, deviated septum may cause contralateral turbinate hypertrophy –> this may lead to increased airway resistance

Surgical Approaches

• Closed: advantages include decreased edema, operative time, faster recovery and lack of scars; disadvantages include poor visualization and difficult dissection
• Incisions: 
• Alar:  
• Intercartilaginous (located between ULC and LLC)- follows the caudal border of the ULC and is located between it and the cephalad border of the lateral crus
• transcartilaginous (located at level of LLC),
• and marginal: made at caudal aspect of the LLC
• Rim incision: located in alar rim, may be used with intercartilaginous incision to deliver LLC)
• Septal incisions: 
• transfixion (entire septum incised at membranous and cartilaginous junctions)– great for access of hanging collumella and access to caudal septum
• limited transfixion (leaves attachments of medial crural footplates), 
• hemitransfixion (unilateral incision at junction of caudal septum and columella), 
• high septal transfixion (does not violate junction of caudal septum)
• Killian incision: incision made 1-2cm posterior to caudal septum (not ideal for visualization of caudal septum), used for more focused approach to deviation of the septum
• Preserves tip support

Nasal Differences: in Asian population, ULC and LLC lengths are similar. Heights much shorter. Should take care with cephalic trim
Surgical Technique
Grafts

• Autologous tissue (septal cartilage, ear, rib)
• Allografts: acellular dermal matrix, irradiated rib, silicone PTFE
• Irradiated rib cartilage can be a good alternative to autologous but has somewhat higher risk profile over autologous
• Nasal Tip (and grafts):tip projection is dependent on LLC, soft tissue and suspensory ligaments of LLC and LLC/ULC.
  Increasing tip projection: Grafts and sutures are aimed for tip projection and infratip/lobule definition

• Medial crural sutures: between medial crura, stabilize collumellar strut, may also use medial crural septal sutures which include septum and causes rotation of drooping nasal tip
• Interdomal sutures: placed between domes of LLC, increase projection
• Transdomal sutures: placed between medial and lateral portions of single LLC
• Columellar strut: between medial crura –> increase tip projection
• Onlay tip graft: lies horizontally over LLC and alar domes
• Shield Graft: rests on anterior middle crura
• Subdomal graft: used mainly to correct pinched nasal tip deformity –> bar shaped graft in pocket under the domes

• Pinched nasal deformity: occurs from decreased interdomal distances
• Septal extension graft
• Inadequate projection? –> cephalic trim, columellar strut, septal extension, medial crural suture, transdomal sutures
• Decreasing tip projection: may decrease soft tissue attachments of LLC as well as transection of lateral and medial crura
• Tip rotation: increased tip rotation may be obtained with cephalic trim of LLC, caudal septum resection, columellar strut grafts. Suture techniques used to suspend the LLC. 
• Cephalic trim can be used to aid in tip rotation. 6mm should be left behind to prevent instability (retraction notching, external nasal valve dysfunction)
• Pollybeak deformity: fullness of supratip area that results in underprojection of nasal tip
• Tip Definition: wide angle of divergence can create variations of a boxy tip. This is usually corrected with suture techniques of the LLC as well as lateral crural strut grafts. 
• Parenthesis tip:  caused by vertical orientation of LLC, corrected with lateral crural strut grafts
• Bulbous tip: caused by convexity of LLC or wide angle of divergence, treated by cephalic trim and transdomal sutures, and lateral crural mattress sutures if the LLC is convex
• Nasal Dorsum: 
• Hump Reduction: remember to perform prior to septal harvest and tip work; typically used with rasp
• Inverted V deformity: refers to the visibility of the caudal edge of the nasal bones caused by collapse of the upper  lateral cartilages

• Dorsal reduction rhinoplasty removes the structural support provided by the connection of the dorsal septum to the paired upper lateral cartilages –> ULC can then splay and distort –> can cause airway narrowing and distortion of aesthetic lines 
• Use upper lateral spanning sutures are used to re-establish the relationship of the dorsal medial edges of the UCL and septum
• Open Roof Deformity: separation of septum and dorsal sidewalls
• Dorsal augmentation: Via septal cartilage grafts, auricular or costal cartilage (tends to warp), irradiated costal cartilage, diced cartilage grafts (turkish delight), synthetic implants (used as dorsal onlay grafts)
• Dorsal onlay graft to improve contour
• Radix graft for upper dorsal defects, augments nasofrontal angle 
• Nasal sidewall onlay grafts
• Filler: hydroxyapetite may be used for dorsal augmentation, would inject just about the periosteum or in SMAS plane otherwise known subperichondrial plane. Should only be used for nasal dorsum and sidewalls
• Remember risk of intravascular injection (retrograde through ophthalmic artery) and can cause blindness –> treatment is retrobulbar injection of hyaluronidase (for blindness)
• Osteotomies: 
• Medial osteotomies: consist of medial oblique or paramedian. Used to narrow or widen bony vault and will displace vault from septum. Perform this prior to lateral osteotomies
• Lateral osteotomies: narrow the bony vault or correct open roof deformity
• Complications: Rocker deformity- occurs after medial osteotomy that goes beyond thick portion of the radix, causes rocking of lateral portion distally after positioning of proximal portion medially
• Nasal Alae: grafts mainly for alar contour, may be anatomic or nonanatomic grafts
• Overresection of LLC may cause alar rim deformities
• Alar batten graft: pocket from piriform aperture to paramedian position in alar sidewall –> used for external nasal valve collapse
• Alar rim graft: subcutaneous pocket above and parallel to alar rim, corrects retraction
• Lateral crural strut graft: placed underneath lateral crura typically after cephalic trim, extending to piriform aperture inferior to alar groove, corrects lateral crural malposition or external nasal valve collapse, convexity of lateral crura and boxy tip
• Can be used to correct external valve collapse
• Lateral crural turnover graft: cephalic portion of lateral crura turned over onto remaining caudal lateral crura, improves shape of lateral crura
• Wide Alae: corrected with wedge excisions
• Airway: reasons for nasal obstruction. Airway patency and function typically evaluated with rhinomanometry for dynamic evaluation as well as nasal endoscopy, CT scan. 
• Deviated Septum: treated with septal work including resection, scoring , strut, suture or graft
• Septal resection or septoplasty (scoring of the quadrangle cartilage to influence its shape in an attempt to straighten it)
• Septoplasty cannot straighten C shape deformity- need septal resection
• L strut: when harvesting septal cartilage, one must ensure 1cm of caudal and dorsal septum remain to prevent saddle nose deformity (collapsed dorsum), L strut fractures should be amended with spreader grafts
• Spreader grafts: fixed between dorsal septum and ULC in submucoperichondreal pocket–> goal is to improve internal nasal valve patency (increase angle), straighten septum, correction of open roof or inverted V deformity
• Turbinate Hypertrophy: two techniques for reduction
• Outfracture: performed with boise elevator, typically inferior turbinate outfractured and displaced laterally.
• Used for simple submucolsa thickening 
• Submucosal resection: removal of anterior bone, mucosa stays in place
• Used for bony hypertrophy of the inferior turbinate
• Empty nose syndrome: recalcitrant and paradoxical symptoms of ansal obstruction and suffocation despite a widely patent nasal airway
• may result from complete removal of inferior turbinate
• Nasal Valve: internal and external nasal valves
• Internal nasal valve obstruction: treated by increasing angle, typically with spreader grafts
• External nasal valve:  collapse occurs from weakened LLC

Complications of Rhinoplasty:

• When performing septorhinoplasty, CSF leak may result from disruption of perpendicular plate. Test for beta-2-transferrin. Symptoms include headache and watery rhinorrhea
• Septal Perforation: may occur after bilateral mucosal tears. Typically present as crusting, whistling and bleeding –> treat with local flaps and cartilage grafts
• Innovations:
• Perioperative medications- cortisone shown to decrease edema and ecchymosis