Rhinoplasty
Overview
Rhinoplasty also nose job, is a plastic surgery
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 procedure for correcting and reconstructing
Reconstructive surgery
Reconstructive surgery is, in its broadest sense, the use of surgery to restore the form and function of the body, although Maxillo-Facial Surgeons, Plastic Surgeons and Otolaryngologists do reconstructive surgery on faces after trauma and to reconstruct the head and neck after cancer.Other...

 the form, restoring the functions, and aesthetically
Aesthetics
Aesthetics is a branch of philosophy dealing with the nature of beauty, art, and taste, and with the creation and appreciation of beauty. It is more scientifically defined as the study of sensory or sensori-emotional values, sometimes called judgments of sentiment and taste...

 enhancing the nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

, by resolving nasal trauma
Trauma (medicine)
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

 (blunt
Blunt trauma
In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

, penetrating
Penetrating trauma
Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...

, blast
Blast injury
A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives...

), congenital defect, respiratory
Respiratory system
The respiratory system is the anatomical system of an organism that introduces respiratory gases to the interior and performs gas exchange. In humans and other mammals, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles...

 impediment, and a failed primary rhinoplasty. In the surgeries — closed rhinoplasty and open rhinoplasty — an otolaryngologist
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....

 (ear, nose, and throat specialist), a maxillofacial surgeon (jaw, face, and neck specialist), or a plastic surgeon, creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the soft tissues from the osseo
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

-cartilaginous
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

 nasal framework, correcting them as required for form and function, suturing the incisions, and applying a stent to immobilize the corrected (new) nose to ensure the proper healing of the surgical cuts.
Surgical rhinoplasty
Antiquity
Rhinoplasty (reconstructive nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

 surgery) was first developed in ancient India
History of India
The history of India begins with evidence of human activity of Homo sapiens as long as 75,000 years ago, or with earlier hominids including Homo erectus from about 500,000 years ago. The Indus Valley Civilization, which spread and flourished in the northwestern part of the Indian subcontinent from...

, by the ayurvedic
Ayurveda
Ayurveda or ayurvedic medicine is a system of traditional medicine native to India and a form of alternative medicine. In Sanskrit, words , meaning "longevity", and , meaning "knowledge" or "science". The earliest literature on Indian medical practice appeared during the Vedic period in India,...

 physician Sushruta (ca.
Encyclopedia
Rhinoplasty also nose job, is a plastic surgery
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 procedure for correcting and reconstructing
Reconstructive surgery
Reconstructive surgery is, in its broadest sense, the use of surgery to restore the form and function of the body, although Maxillo-Facial Surgeons, Plastic Surgeons and Otolaryngologists do reconstructive surgery on faces after trauma and to reconstruct the head and neck after cancer.Other...

 the form, restoring the functions, and aesthetically
Aesthetics
Aesthetics is a branch of philosophy dealing with the nature of beauty, art, and taste, and with the creation and appreciation of beauty. It is more scientifically defined as the study of sensory or sensori-emotional values, sometimes called judgments of sentiment and taste...

 enhancing the nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

, by resolving nasal trauma
Trauma (medicine)
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

 (blunt
Blunt trauma
In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

, penetrating
Penetrating trauma
Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...

, blast
Blast injury
A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives...

), congenital defect, respiratory
Respiratory system
The respiratory system is the anatomical system of an organism that introduces respiratory gases to the interior and performs gas exchange. In humans and other mammals, the anatomical features of the respiratory system include airways, lungs, and the respiratory muscles...

 impediment, and a failed primary rhinoplasty. In the surgeries — closed rhinoplasty and open rhinoplasty — an otolaryngologist
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....

 (ear, nose, and throat specialist), a maxillofacial surgeon (jaw, face, and neck specialist), or a plastic surgeon, creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the soft tissues from the osseo
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

-cartilaginous
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

 nasal framework, correcting them as required for form and function, suturing the incisions, and applying a stent to immobilize the corrected (new) nose to ensure the proper healing of the surgical cuts.

History

Surgical rhinoplasty
Antiquity
Rhinoplasty (reconstructive nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

 surgery) was first developed in ancient India
History of India
The history of India begins with evidence of human activity of Homo sapiens as long as 75,000 years ago, or with earlier hominids including Homo erectus from about 500,000 years ago. The Indus Valley Civilization, which spread and flourished in the northwestern part of the Indian subcontinent from...

, by the ayurvedic
Ayurveda
Ayurveda or ayurvedic medicine is a system of traditional medicine native to India and a form of alternative medicine. In Sanskrit, words , meaning "longevity", and , meaning "knowledge" or "science". The earliest literature on Indian medical practice appeared during the Vedic period in India,...

 physician Sushruta (ca. 800 BC), who described reconstruction of the nose in the Sushruta samhita
Sushruta Samhita
The Sushruta Samhita is a Sanskrit text, attributed to one Sushruta, foundational to Ayurvedic medicine , with innovative chapters on surgery....

(ca. 500 BC), his medico–surgical compendium. The physician Sushruta and his medical students developed and applied plastic surgical
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 techniques for reconstructing noses, genitalia, earlobes, et cetera, that were amputated as religious, criminal, or military punishment. Sushruta also developed the otoplastic
Otoplasty
Otoplasty denotes the surgical and non-surgical procedures for correcting the deformities and defects of the pinna ; and for reconstructing a defective, or deformed, or absent external ear, consequent to congenital conditions and trauma...

 technique for reconstructing an earlobe
Ear
The ear is the organ that detects sound. It not only receives sound, but also aids in balance and body position. The ear is part of the auditory system....

 with skin from the cheek, and the forehead flap rhinoplasty
Nasal reconstruction using a paramedian forehead flap
Warning: this page contains pictures of surgery that can be shockingNasal reconstruction using a paramedian forehead flap is a surgical technique to reconstruct different kinds of nasal defects . In this operation a reconstructive surgeon uses skin from the forehead above the eyebrow and pivots it...

 procedure that remains contemporary plastic surgical practice. In the Sushruta samhita compendium, the physician Sushruta describes the (modern) free-graft Indian rhinoplasty as the Nasikasandhana, wherein:

The portion of the nose to be covered should be first measured with a leaf. Then, a piece of skin of the required size should be dissected from the living skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...

 of the cheek
Face
The face is a central sense organ complex, for those animals that have one, normally on the ventral surface of the head, and can, depending on the definition in the human case, include the hair, forehead, eyebrow, eyelashes, eyes, nose, ears, cheeks, mouth, lips, philtrum, temple, teeth, skin, and...

, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw, by cutting the nasal stump
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

 with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated, by inserting two tubes of eranda
Castor oil plant
The castor oil plant, Ricinus communis, is a species of flowering plant in the spurge family, Euphorbiaceae. It belongs to a monotypic genus, Ricinus, and subtribe, Ricininae. The evolution of castor and its relation to other species are currently being studied.Its seed is the castor bean which,...

 (the castor-oil plant) in the position of the nostrils, so that the new nose has proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder of liquorice, red sandal-wood
Santalum album
Santalum album or Indian sandalwood is a small tropical tree, the most commonly known source of sandalwood. This species has been utilised, cultivated and traded for many years, some cultures placing great significance on its fragrant and medicinal qualities. For these reasons it has been...

, and barberry plant. Finally, it should be covered with cotton, and clean sesame oil
Sesame oil
Sesame oil is an edible vegetable oil derived from sesame seeds. Besides being used as a cooking oil in South India, it is often used as a flavor enhancer in Chinese, Japanese, Korean, and to a lesser extent Southeast Asian cuisine.The oil from the nutrient rich seed is popular in alternative...

 should be continually applied. When the skin has united and granulated, if the nose is too short or too long, the middle of the flap should be divided, and an endeavour made to enlarge or shorten it. (Sushruta samhita 1.16)

Classical antiquity
During the Roman Empire
Roman Empire
The Roman Empire was the post-Republican period of the ancient Roman civilization, characterised by an autocratic form of government and large territorial holdings in Europe and around the Mediterranean....

 (27 BC – AD 476) the encyclopaedist Aulus Cornelius Celsus
Aulus Cornelius Celsus
Aulus Cornelius Celsus was a Roman encyclopedist, known for his extant medical work, De Medicina, which is believed to be the only surviving section of a much larger encyclopedia. The De Medicina is a primary source on diet, pharmacy, surgery and related fields, and it is one of the best sources...

 (ca. 25 BC – AD 50) published the 8-tome De Medicina
De Medicina
De Medicina is a 1st-century medical treatise by Aulus Cornelius Celsus, a Roman encyclopedist and possibly a practicing physician. It is the only surviving section of a much larger encyclopedia; only small parts still survive from sections on agriculture, military science, oratory, jurisprudence...

(On Medicine, ca. AD 14), which described plastic surgery techniques and procedures for the correction and the reconstruction of the lips, the ears
Otoplasty
Otoplasty denotes the surgical and non-surgical procedures for correcting the deformities and defects of the pinna ; and for reconstructing a defective, or deformed, or absent external ear, consequent to congenital conditions and trauma...

, the nose, et cetera, and for the amputation
Amputation
Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for...

 of diseased and damaged parts of the human body.

At the Byzantine
Byzantium
Byzantium was an ancient Greek city, founded by Greek colonists from Megara in 667 BC and named after their king Byzas . The name Byzantium is a Latinization of the original name Byzantion...

 Roman court of the Emperor Julian the Apostate
Julian the Apostate
Julian "the Apostate" , commonly known as Julian, or also Julian the Philosopher, was Roman Emperor from 361 to 363 and a noted philosopher and Greek writer....

 (AD 331–363), the royal physician Oribasius
Oribasius
Oribasius or Oreibasius was a Greek medical writer and the personal physician of the Roman emperor Julian the Apostate. He studied at Alexandria under physician Zeno of Cyprus before joining Julian's retinue. He was involved in Julian's coronation in 361, and remained with the emperor until...

  (ca. AD 320–400) published the 70-volume Synagogue Medicae (Medical Compilations, AD 4th c.), which described facial-defect reconstructions that featured loose sutures that permitted a surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 wound to heal without distorting the facial flesh; how to clean the bone exposed in a wound; debridement
Debridement
Debridement is the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue...

, how to remove damaged tissue to forestall infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

 and so accelerate healing of the wound
Wound
A wound is a type of injury in which skin is torn, cut or punctured , or where blunt force trauma causes a contusion . In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.-Open:...

; and how to use autologous skin flaps to repair damaged cheeks, eyebrows, lips, and nose, to restore the patient’s normal visage
Face
The face is a central sense organ complex, for those animals that have one, normally on the ventral surface of the head, and can, depending on the definition in the human case, include the hair, forehead, eyebrow, eyelashes, eyes, nose, ears, cheeks, mouth, lips, philtrum, temple, teeth, skin, and...

.

The Dark Ages
Nonetheless, during the centuries of the European Dark Ages (AD 5th – 15th centuries) that followed the Imperial Roman collapse (AD 476), the fifth-century BC Asian plastic surgery
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 knowledge of the Sushruta samhita went unknown to the West
Western world
The Western world, also known as the West and the Occident , is a term referring to the countries of Western Europe , the countries of the Americas, as well all countries of Northern and Central Europe, Australia and New Zealand...

 until the tenth century AD, with the publication, in Old English, of the Anglo-Saxon physician’s manual Bald's Leechbook
Bald's Leechbook
The Leechbook of Bald is an Old English medical text probably compiled in the ninth-century, possibly under the influence of Alfred the Great's educational reforms....

(ca. AD 920) describing the plastic repair of a cleft lip; as a medical compendium, the Leechbook is notable for categorizing ailments and treatments as internal medicine
Internal medicine
Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists. They are especially skilled in the management of patients who have undifferentiated or multi-system disease processes...

 and as external medicine, for providing herbal medical
Herbalism
Herbalism is a traditional medicinal or folk medicine practice based on the use of plants and plant extracts. Herbalism is also known as botanical medicine, medical herbalism, herbal medicine, herbology, herblore, and phytotherapy...

 remedies, and for providing supernatural incantations (prayers), when required.

In the eleventh century, at Damascus, the Arab physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...

 Ibn Abi Usaibia (1203–1270) translated the Sushruta samhita from Sanskrit
Sanskrit
Sanskrit , is a historical Indo-Aryan language and the primary liturgical language of Hinduism, Jainism and Buddhism.Buddhism: besides Pali, see Buddhist Hybrid Sanskrit Today, it is listed as one of the 22 scheduled languages of India and is an official language of the state of Uttarakhand...

 to Arabic. In due course, Sushruta’s medical compendium travelled from Arabia to Persia to Egypt
Egypt
Egypt , officially the Arab Republic of Egypt, Arabic: , is a country mainly in North Africa, with the Sinai Peninsula forming a land bridge in Southwest Asia. Egypt is thus a transcontinental country, and a major power in Africa, the Mediterranean Basin, the Middle East and the Muslim world...

, and, by the fifteenth century, Western European medicine
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

 had encountered it as the medical atlas Cerrahiyet-ul Haniye (Imperial Surgery, 15th c.), by Şerafeddin Sabuncuoğlu
Serafeddin Sabuncuoglu
Sabuncuoğlu Şerafeddin was a medieval Ottoman surgeon and physician.Sabuncuoğlu was the author of the Cerrahiyyetu'l-Haniyye , the first illustrated surgical atlas, and the Mücerrebname .The Cerrahiyyetu'l-Haniyye was the first surgical atlas and the last...

 (1385–1468); among its surgical techniques featured a breast reduction
Breast reduction
Reduction mammoplasty is the plastic surgery procedure for correcting over-sized breasts...

 procedure.

16th century
In Italy, Gasparo Tagliacozzi
Gasparo Tagliacozzi
Gaspare Tagliacozzi was an Italian surgeon.Tagliacozzi was born in Bologna. He studied at the University of Bologna under Gerolamo Cardano and others, and, at the age of twenty-four, earned his degree in philosophy and medicine. First he was appointed professor of surgery and later was appointed...

 (1546–1599), professor of surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 and anatomy
Human anatomy
Human anatomy is primarily the scientific study of the morphology of the human body. Anatomy is subdivided into gross anatomy and microscopic anatomy. Gross anatomy is the study of anatomical structures that can be seen by the naked eye...

 at the University of Bologna, published Curtorum Chirurgia Per Insitionem (The Surgery of Defects by Implantations, 1597), a technico–procedural manual for the surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 repair and reconstruction of facial wounds in soldiers. The illustrations featured a re-attachment rhinoplasty using a biceps muscle pedicle flap; the graft attached at 3-weeks post-procedure; which, at 2-weeks post-attachment, the surgeon then shaped into a nose.

18th century;
In time, the fifth-century BC Indian rhinoplasty technique — featuring a free-flap graft — was (re) discovered by Western medicine in the eighteenth century, during the Third Anglo–Mysore War (1789–1792) of colonial annexation, by the British against Tipu Sultan, when the East India Company
East India Company
The East India Company was an early English joint-stock company that was formed initially for pursuing trade with the East Indies, but that ended up trading mainly with the Indian subcontinent and China...

 surgeons Thomas Cruso and James Findlay witnessed Indian rhinoplasty procedures at the British Residency in Poona. In the English-language Madras Gazette, the surgeons published photographs of the rhinoplasty procedure and its nasal reconstruction outcomes; later, in the October 1794 issue of the Gentleman's Magazine of London, the doctors Cruso and Findlay published an illustrated report describing a forehead pedicle-flap rhinoplasty that was a technical variant of the free-flap graft technique that Sushruta had described some twenty-three centuries earlier:

A thin plate of wax is fitted to the stump of the nose, so as to make a nose of good appearance; it is then flattened and laid on the forehead. A line is drawn around the wax, which is then of no further use, and the operator then dissects off as much skin [the flap] as [the wax plate] had covered, leaving undivided a small slip [the flap-pedicle] between the eyes. This slip preserves the blood circulation till a union has taken place between the new and the old parts. The cicatrix
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...

 of the stump of the nose is next pared off, and, immediately behind the new part, an incision is made through the skin, which passes around both alae, and goes along the upper lip. The skin, now brought down from the forehead, and being twisted half-around, is inserted into this incision, so that a nose is formed with a double hold above, and with its alae and septum below, fixed in the incision.

A little Terra Japonica (pale-catechu) is softened with water, and after being spread on slips of cloth, five or six of these are placed over each other to secure the joining. No other dressing, but this cement, is used for four days. It is then removed, and cloths dipped in ghee
Ghee
Ghee is a class of clarified butter that originated in South Asia and is commonly used in South Asian cuisine....

 are applied. The connecting slip of skin is divided at about the twentieth day, when a little more dissection is necessary to improve the appearance of the new nose. For five or six days after the operation, the patient is made to lie on his back, and on the tenth day, bits of soft cloth are put into the nostrils to keep them sufficiently open. This operation is always successful. The artificial nose is secured and looks nearly as well as the natural nose, nor is the scar on the forehead very observable after a length of time. (Gentleman’s Magazine of London, October 1794)


19th century
Pre-dating the Indian Sushruta samhita medical compendium is the Ebers Papyrus
Ebers papyrus
The Ebers Papyrus, also known as Papyrus Ebers, is an Egyptian medical papyrus dating to circa 1550 BC. Among the oldest and most important medical papyri of ancient Egypt, it was purchased at Luxor, in the winter of 1873–74 by Georg Ebers...

(ca. 1550 BC), an Ancient Egyptian medical papyrus that describes rhinoplasty as the plastic surgical
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 operation for reconstructing a nose destroyed by rhinectomy, such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time and culture. In the event, the Indian rhinoplasty technique perdured in nineteenth-century Western European medicine; in Great Britain, Joseph Constantine Carpue
Joseph Constantine Carpue
Joseph Constantine Carpue was an English surgeon who was born in London. He was associated with St. George's Hospital and Duke of York Hospital in Chelsea. He was a skilled surgeon and popular lecturer of anatomy....

 (1764–1846) published the Account of Two Successful Operations for Restoring a Lost Nose (1815), which described two rhinoplasties: the reconstruction of a battle-wounded nose, and the repair of an arsenic
Arsenic
Arsenic is a chemical element with the symbol As, atomic number 33 and relative atomic mass 74.92. Arsenic occurs in many minerals, usually in conjunction with sulfur and metals, and also as a pure elemental crystal. It was first documented by Albertus Magnus in 1250.Arsenic is a metalloid...

-damaged nose. (cf. Carpue’s operation
Joseph Constantine Carpue
Joseph Constantine Carpue was an English surgeon who was born in London. He was associated with St. George's Hospital and Duke of York Hospital in Chelsea. He was a skilled surgeon and popular lecturer of anatomy....

)

In Germany, rhinoplastic technique was refined by surgeons such as the Berlin University professor of surgery Karl Ferdinand von Gräfe (1787–1840), who published Rhinoplastik (Rebuilding the Nose, 1818) wherein he described fifty-five (55) historical plastic surgery procedures (Indian rhinoplasty, Italian rhinoplasty, etc.), and his technically innovative free-graft nasal reconstruction (with a tissue-flap harvested from the patient’s arm), and surgical approaches to eyelid, cleft lip, and cleft palate corrections. Dr. von Gräfe’s protégé, the medical
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

 and surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 polymath
Polymath
A polymath is a person whose expertise spans a significant number of different subject areas. In less formal terms, a polymath may simply be someone who is very knowledgeable...

 Johann Friedrich Dieffenbach
Johann Friedrich Dieffenbach
Johann Friedrich Dieffenbach was a German surgeon who specialized in skin transplantation and plastic surgery. His work in rhinoplastic and maxillofacial surgery established many modern techniques of reconstructive surgery. He endeavours comprehended subcutaneous operations such as tenotomy, the...

 (1794–1847), who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published Die Operative Chirurgie (Operative Surgery, 1845), which became a foundational medical and plastic surgical
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 text. (see strabismus
Strabismus
Strabismus is a condition in which the eyes are not properly aligned with each other. It typically involves a lack of coordination between the extraocular muscles, which prevents bringing the gaze of each eye to the same point in space and preventing proper binocular vision, which may adversely...

, torticollis
Torticollis
Torticollis, or wryneck, is a stiff neck associated with muscle spasm, classically causing lateral flexion contracture of the cervical spine musculature...

) Moreover, the Prussian Jacques Joseph
Jacques Joseph
Jacques Joseph was a German plastic surgeon.Born Jakob Lewin Joseph in Königsberg, Prussia, he was the third child of Rabbi Israel Joseph and his wife Sara. He was an innovator in modern plastic surgery and reconstructive surgery who developed methods for aesthetic plastic surgery, including...

 (1865–1934) published Nasenplastik und sonstige Gesichtsplastik (Rhinoplasty and other Facial Plastic Surgeries, 1928), which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions.

In the United States, in 1887, the otolaryngologist John Orlando Roe (1848–1915) performed the first, modern endonasal rhinoplasty (closed rhinoplasty), about which he reported in the article The Deformity Termed “Pug Nose” and its Correction, by a Simple Operation (1887), and about his management of saddle nose deformities.

20th century
In the early twentieth century, Freer, in 1902, and Killian, in 1904, respectively pioneered the submucous resection septoplasty (SMR) procedure for correcting a deviated septum; they raised mucoperichondrial tissue flaps, and resected the cartilaginous
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

 and bony
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

 septum
Nasal septum
The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

 (including the vomer bone and the perpendicular plate of the ethmoid bone
Ethmoid bone
The ethmoid bone is a bone in the skull that separates the nasal cavity from the brain. As such, it is located at the roof of the nose, between the two orbits. The cubical bone is lightweight due to a spongy construction. The ethmoid bone is one of the bones that makes up the orbit of the eye...

), maintaining septal support with a 1.0-cm margin at the dorsum and a 1.0-cm margin at the caudad, for which innovations the technique became the foundational, standard septoplastic
Septoplasty
Septoplasty is a corrective surgical procedure done fix to straighten the nasal septum, the partition between the two nasal cavities. Ideally, the septum should run down the center of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Often the...

 procedure. In 1921, A. Rethi introduced the open rhinoplasty approach featuring an incision to the columella to facilitate modifying the tip of the nose. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1947, Maurice H. Cottle (1898–1981) endonasally resolved a septal deviation with a minimalist hemitransfixion incision, which conserved the septum; thus, he advocated for the practical primacy of the closed rhinoplasty approach. In 1957, A. Sercer advocated the “decortication of the nose” (Dekortication des Nase) technique which featured a columellar-incision open rhinoplasty that allowed greater access to the nasal cavity
Nasal cavity
The nasal cavity is a large air filled space above and behind the nose in the middle of the face.- Function :The nasal cavity conditions the air to be received by the other areas of the respiratory tract...

 and to the nasal septum
Nasal septum
The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

.

Nonetheless, at mid–twentieth century, despite such refinement of the open rhinoplasty approach, the endonasal rhinoplasty was the usual approach to nose surgery — until the 1970s, when Padovan presented his technical refinements, advocating the open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the later 1970s, and by Jack P. Gunter in the 1990s. Goodman impelled technical and procedural progress with the article External Approach to Rhinoplasty (1973), which reported his technical refinements and popularized the open rhinoplasty approach. In 1982, Jack Anderson reported his refinements of nose surgery technique in the article Open Rhinoplasty: An Assessment (1982). During the 1970s, the principal application of open rhinoplasty was to the first-time rhinoplasty patient (i.e. a primary rhinoplasty), not as a revision surgery (i.e. a secondary rhinoplasty) to correct a failed nose surgery. In 1987, in the article External Approach for Secondary Rhinoplasty (1987), Jack P. Gunter reported the technical effectiveness of the open rhinoplasty approach for performing a secondary rhinoplasty; his improved techniques advanced the management of a failed nose surgery.

Hence does contemporary rhinoplastic praxis derive from the primeval (ca. 600 BC) Indian rhinoplasty (nasal reconstruction via an autologous forehead-skin flap) and its technical variants: Carpue’s operation, the Italian rhinoplasty (pedicle-flap reconstruction, aka the Tagliocotian rhinoplasty); and the closed-approach endonasal rhinoplasty, featuring exclusively internal incisions that allow the plastic surgeon to palpate (feel) the corrections being effected to the nose.

Non-surgical rhinoplasty
19th century
Non-surgical rhinoplasty originated at the turn of the nineteenth century, when the New York City neurologist James Leonard Corning (1855–1923) and the Viennese physician Robert Gersuny (1844–1924) pioneered the technique of using liquid paraffin
Paraffin
In chemistry, paraffin is a term that can be used synonymously with "alkane", indicating hydrocarbons with the general formula CnH2n+2. Paraffin wax refers to a mixture of alkanes that falls within the 20 ≤ n ≤ 40 range; they are found in the solid state at room temperature and begin to enter the...

 to elevate the collapsed nasal dorsum that characterizes the saddle nose deformity. Yet, despite its corrective efficacy, liquid paraffin proved biologically harmful, and its medical use as a nasal soft-tissue filler, was abandoned because it caused paraffinoma (wax cancer), a serious medical complication.

20th century
During the 1960s, soft-tissue fillers of medical-grade silicone
Silicone
Silicones are inert, synthetic compounds with a variety of forms and uses. Typically heat-resistant and rubber-like, they are used in sealants, adhesives, lubricants, medical applications , cookware, and insulation....

 gel were introduced to the rhinoplastic armamentarium, however, like liquid paraffin, silicone gels also proved biologically harmful, because they caused medical complications such as the corrective soft-tissue filler migrating from the nasal tissues to elsewhere in the patient’s face and body, and the development of ulcers and granulomas
Granuloma
Granuloma is a medical term for a tiny collection of immune cells known as macrophages. Granulomas form when the immune system attempts to wall off substances that it perceives as foreign but is unable to eliminate. Such substances include infectious organisms such as bacteria and fungi as well as...

. To minimize the risk of these medical complications for the patient, practitioners such as D.S. Orentreich advocated effecting the non-surgical correction by “microdroplet technique”, minute doses of silicone injected in the course of multiple correction sessions.

21st century
Contemporary non-surgical rhinoplasty was established with the Australian study Rhinoplasty Using Injectable Polyacrylamide Gel — A Patient Study (2005), wherein Dr. Andrew Tuan-anh Le reported successful corrective outcomes using the soft-tissue filler polyacrylamide gel (PAAG), a hydrophilic colloid
Colloid
A colloid is a substance microscopically dispersed evenly throughout another substance.A colloidal system consists of two separate phases: a dispersed phase and a continuous phase . A colloidal system may be solid, liquid, or gaseous.Many familiar substances are colloids, as shown in the chart below...

 injected to the tissues of the nasal defect or deformity in order to (re)create a functional and aesthetically proportionate nose for the patient. Among the subcutaneous soft-tissue filler agents employed to achieve non-surgical rhinoplasty are: injectable silicone, calcium hydroxyapatite, hyaluronic acid, collagen
Collagen
Collagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...

 (human, bovine, and porcine), and polymethylmethacrylate. Possible complications include infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

, hematoma
Hematoma
A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...

, discomfort, anatomic asymmetry, foreign body reaction (rejection) or granuloma
Granuloma
Granuloma is a medical term for a tiny collection of immune cells known as macrophages. Granulomas form when the immune system attempts to wall off substances that it perceives as foreign but is unable to eliminate. Such substances include infectious organisms such as bacteria and fungi as well as...

, or both, over-correction, under-correction, intravascular injection (with potential for thromboembolism), adverse medication reaction (anaphylaxis
Anaphylaxis
Anaphylaxis is defined as "a serious allergic reaction that is rapid in onset and may cause death". It typically results in a number of symptoms including throat swelling, an itchy rash, and low blood pressure...

), allergic reaction, the need for additional “touch up” injections of the tissue filler, palpability, visibility, distortion with muscular contraction, the need for secondary revisions, and the physician’s inability to guarantee a specific cosmetic result to the patient.

Anatomy of the human nose

Embryologic development
At four (4) weeks of gestational development, the neural crest
Neural crest
Neural crest cells are a transient, multipotent, migratory cell population unique to vertebrates that gives rise to a diverse cell lineage including melanocytes, craniofacial cartilage and bone, smooth muscle, peripheral and enteric neurons and glia....

 cells (the precursors of the nose) begin their caudad migration (from the posterior) towards the midface. Two symmetrical nasal placode
Nasal placode
The nasal placode gives rise to the olfactory epithelium of the nose.The terms "nasal sac" or "nasal pit" are sometimes used to describe an intermediate structure arising between the placode and epithelium chronologically....

s (the future olfactory epithelium) develop inferiorly, which the nasal pits then divide into the medial and the lateral nasal processes
Medial nasal prominence
The medial nasal prominence is an embryological structure that forms the upper lip and nose.They join to form the intermaxillary segment....

 (the future upper lip and nose). The medial processes then form the septum
Nasal septum
The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

, the philtrum
Philtrum
The philtrum , is a medial cleft common to many mammals, extending from the nose to the upper lip, and, together with a glandular rhinarium and slit-like nostrils, is believed to constitute the primitive condition for mammals in general...

, and the premaxilla of the nose; the lateral processes form the sides of the nose; and the mouth forms from the stomodeum
Stomodeum
The stomodeum, also called stomatodeum or stomatodaeum, is a depression between the brain and the pericardium in an embryo, and is the precursor of the mouth and the anterior lobe of the pituitary gland.-Structure:...

 (the anterior ectodermal portion of the alimentary tract), which is inferior to the nasal complex.

A nasobuccal membrane separates the mouth from the nose; respectively, the inferior oral cavity (the mouth) and the superior nasal cavity (the nose). As the olfactory pits deepen, said development forms the choanae, the two openings that connect the nasal cavity and the nasopharynx (upper part of the pharynx that is continuous with the nasal passages). Initially, primitive-form choanae develop, which then further develop into the secondary, permanent choanae.

At ten (10) weeks of gestation, the cells differentiate into muscle
Muscle
Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to...

, cartilage
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

, and bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

. If this important, early facial embryogenesis fails, it might result in anomalies such as choanal atresia (absent or closed passage), medial nasal clefts (fissures), or lateral nasal clefts, nasal aplasia (faulty or incomplete development), and polyrrhinia (double nose).

This normal, human embryologic development is exceptionally important — because the newborn infant breathes through his or her nose during the first 6 weeks of life — thus, when a child is afflicted with bilateral choanal atresia, the blockage of the posterior nasal passage, either by abnormal bony tissue or by abnormal soft tissue, emergency remedial action is required to ensure that the child can breathe.

The structures of the nose
For plastic surgical correction, the structural anatomy of the nose comprehends: A. the nasal soft tissues; B. the aesthetic subunits and segments; C. the blood supply arteries and veins; D. the nasal lymphatic system; E. the facial and nasal nerves; F. the nasal bones; and G. the nasal cartilages.

A. The nasal soft tissues
  • Nasal skin — Like the underlying bone
    Bone
    Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

    -and-cartilage
    Cartilage
    Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

     (osseo-cartilaginous) support framework of the nose, the external skin is divided into vertical thirds (anatomic sections); from the glabella (the space between the eyebrows), to the bridge, to the tip, for corrective plastic surgery, the nasal skin is anatomically considered, as the:

  1. Upper third section — the skin of the upper nose is thick, and relatively distensible (flexible and mobile), but then tapers, adhering tightly to the osseo-cartilaginous framework, and becomes the thinner skin of the dorsal section, the bridge of the nose.
  2. Middle third section — the skin overlying the bridge of the nose (mid-dorsal section) is the thinnest, least distensible, nasal skin, because it most adheres to the support framework.
  3. Lower third section — the skin of the lower nose is as thick as the skin of the upper nose, because it has more sebaceous glands, especially at the nasal tip.

  • Nasal lining — At the vestibule, the human nose is lined with a mucous membrane
    Mucous membrane
    The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...

     of squamous epithelium
    Squamous epithelium
    In anatomy, squamous epithelium is an epithelium characterised by its most superficial layer consisting of flat, scale-like cells called squamous epithelial cells...

    , which tissue then transitions to become columnar respiratory epithelium
    Respiratory epithelium
    Respiratory epithelium is a type of epithelium found lining the respiratory tract, where it serves to moisten and protect the airways. It also functions as a barrier to potential pathogens and foreign particles, preventing infection and tissue injury by action of the mucociliary escalator.-...

    , a pseudo-stratified, ciliated
    Cilium
    A cilium is an organelle found in eukaryotic cells. Cilia are slender protuberances that project from the much larger cell body....

     (lash-like) tissue with abundant seromucinous glands, which maintains the nasal moisture and protects the respiratory tract from bacteriologic infection and foreign objects.

  • Nasal muscles — The movements of the human nose are controlled by groups of facial and neck muscles that are set deep to the skin; they are in four (4) functional groups that are interconnected by the nasal superficial aponeurosis — the superficial musculoaponeurotic system (SMAS) — which is a sheet of dense, fibrous, collagenous
    Collagen
    Collagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...

     connective tissue
    Connective tissue
    "Connective tissue" is a fibrous tissue. It is one of the four traditional classes of tissues . Connective Tissue is found throughout the body.In fact the whole framework of the skeleton and the different specialized connective tissues from the crown of the head to the toes determine the form of...

     that covers, invests, and forms the terminations of the muscles.


The movements of the nose are effected by:
  1. the elevator muscle group — which includes the procerus muscle
    Procerus muscle
    The Procerus is a small pyramidal slip of muscle deep to the superior orbital nerve, artery and vein.-Origin and insertion:It arises by tendinous fibers from the fascia covering the lower part of the nasal bone and upper part of the lateral nasal cartilage....

     and the levator labii superioris alaeque nasi muscle
    Levator labii superioris alaeque nasi muscle
    The levator labii superioris alaeque nasi muscle is, translated from Latin, the "lifter of the upper lip and of the wing of the nose". It has the longest name of any muscle in an animal...

    .
  2. the depressor muscle group — which includes the alar nasalis muscle
    Nasalis muscle
    The nasalis is a sphincter-like muscle of the nose whose function is to compress the nasal cartilage.It consists of two parts, transverse and alar:...

     and the depressor septi nasi muscle
    Depressor septi nasi muscle
    The depressor septi arises from the incisive fossa of the maxilla.Its fibers ascend to be inserted into the nasal septum and back part of the alar part of nasalis muscle....

    .
  3. the compressor muscle group — which includes the transverse nasalis muscle
    Nasalis muscle
    The nasalis is a sphincter-like muscle of the nose whose function is to compress the nasal cartilage.It consists of two parts, transverse and alar:...

    .
  4. the dilator muscle group — which includes the dilator naris muscle that expands the nostrils; it is in two parts: (i) the dilator nasi anterior muscle, and (ii) the dilator nasi posterior muscle.

B. Aesthetics of the nose — nasal subunits and nasal segments
To plan, map, and execute the surgical correction of a nasal defect or deformity, the structure of the external nose is divided into nine (9) aesthetic nasal subunits, and six (6) aesthetic nasal segments, which provide the plastic surgeon with the measures for determining the size, extent, and topographic
Topography
Topography is the study of Earth's surface shape and features or those ofplanets, moons, and asteroids...

 locale of the nasal defect or deformity.

The surgical nose as nine (9) aesthetic nasal subunits
  1. tip subunit
  2. columellar subunit
  3. right alar base subunit
  4. right alar wall subunit
  5. left alar wall subunit
  6. left alar base subunit
  7. dorsal subunit
  8. right dorsal wall subunit
  9. left dorsal wall subunit


In turn, the nine (9) aesthetic nasal subunits are configured as six (6) aesthetic nasal segments; each segment comprehends a nasal area greater than that comprehended by a nasal subunit.
The surgical nose as six (6) aesthetic nasal segments
  1. the dorsal nasal segment
  2. the lateral nasal-wall segments
  3. the hemi-lobule segment
  4. the soft-tissue triangle segments
  5. the alar segments
  6. the columellar segment


Using the co-ordinates of the subunits and segments to determine the topographic
Topography
Topography is the study of Earth's surface shape and features or those ofplanets, moons, and asteroids...

 location of the defect on the nose, the plastic surgeon plans, maps, and executes a rhinoplasty procedure. The unitary division of the nasal topography permits minimal, but precise, cutting, and maximal corrective-tissue coverage, to produce a functional nose of proportionate size, contour, and appearance for the patient. Hence, if more than 50 per cent of an aesthetic subunit is lost (damaged, defective, destroyed) the surgeon replaces the entire aesthetic segment, usually with a regional tissue graft, harvested from either the face or the head, or with a tissue graft harvested from elsewhere on the patient’s body.

C. Nasal blood supply — arteries and veins
Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant blood
Blood
Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....

. The principal arterial blood-vessel supply to the nose is two-fold: (i) branches from the internal carotid artery
Internal carotid artery
In human anatomy, the internal carotid arteries are two major arteries, one on each side of the head and neck. They arise from the common carotid arteries where these bifurcate into the internal and external carotid artery, and they supply the brain....

, the branch of the anterior ethmoid artery, the branch of the posterior ethmoid artery, which derive from the ophthalmic artery
Ophthalmic artery
The ophthalmic artery is the first branch of the internal carotid artery distal to the cavernous sinus. Branches of the OA supply all the structures in the orbit as well as some structures in the nose, face and meninges...

; (ii) branches from the external carotid artery
External carotid artery
In human anatomy, the external carotid artery is a major artery of the head and neck. It arises from the common carotid artery when it bifurcates into the external and internal carotid artery.-Course:...

, the sphenopalatine artery, the greater palatine artery, the superior labial artery, and the angular artery.

The external nose is supplied with blood by the facial artery
Facial artery
The facial artery is a branch of the external carotid artery that supplies structures of the superficial face.-Structure:...

, which becomes the angular artery
Angular artery
The angular artery is the terminal part of the facial artery; it ascends to the medial angle of the eye's orbit, imbedded in the fibers of the angular head of the Quadratus labii superioris, and accompanied by the angular vein....

 that courses over the superomedial aspect of the nose. The sellar region (sella turcica
Sella turcica
-External links:*...

, “Turkish chair”) and the dorsal region of the nose are supplied with blood by branches of the internal maxillary artery (infraorbital) and the ophthalmic arteries that derive from the internal common carotid artery
Common carotid artery
In human anatomy, the common carotid artery is an artery that supplies the head and neck with oxygenated blood; it divides in the neck to form the external and internal carotid arteries. - Structure :...

 system.

Internally, the lateral nasal wall is supplied with blood by the sphenopalatine artery
Sphenopalatine artery
The sphenopalatine artery is an artery of the head, commonly known as the artery of epistaxis.-Course:The sphenopalatine artery is a branch of the maxillary artery which passes through the sphenopalatine foramen into the cavity of the nose, at the back part of the superior meatus...

 (from behind and below) and by the anterior ethmoid artery and the posterior ethmoid artery (from above and behind). The nasal septum also is supplied with blood by the sphenopalatine artery, and by the anterior and posterior ethmoid arteries, with the additional circulatory contributions of the superior labial artery
Superior labial artery
The superior labial artery is larger and more egregious than the inferior labial artery.It follows a similar course along the edge of the upper lip, lying between the mucous membrane and the Orbicularis oris, and anastomoses with the artery of the opposite side.It supplies the upper lip, and gives...

 and of the greater palatine artery. These three (3) vascular supplies to the internal nose converge in the Kiesselbach plexus (the Little area
Kiesselbach's plexus
Kiesselbach's area, also Kiesselbach's plexus, Kiesselbach's triangle, and Little's area, is a region in the anteroinferior part of the nasal septum, where four arteries anastomose to form a vascular plexus called Kiesselbach's plexus...

), which is a region in the anteroinferior-third of the nasal septum, (in front and below). Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the sinus caverns, which makes possible the potential intracranial spreading of a bacterial infection of the nose. Hence, because of such an abundant nasal blood supply, tobacco
Tobacco
Tobacco is an agricultural product processed from the leaves of plants in the genus Nicotiana. It can be consumed, used as a pesticide and, in the form of nicotine tartrate, used in some medicines...

 smoking
Tobacco smoking
Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...

 does therapeutically compromise post-operative healing.

D. Lymphatic system of the nose
The pertinent nasal lymphatic system
Lymphatic system
The lymphoid system is the part of the immune system comprising a network of conduits called lymphatic vessels that carry a clear fluid called lymph unidirectionally toward the heart. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated...

 arises from the superficial mucosa, and drains posteriorly to the retropharyngeal nodes (in back), and anteriorly (in front), either to the upper deep cervical nodes (in the neck), or to the submandibular glands (in the lower jaw), or into both the nodes and the glands of the neck and the jaw.

E. Nerves of the nose
The sensations registered by the human nose derive from the first two (2) branches of cranial nerve V, the trigeminal nerve
Trigeminal nerve
The trigeminal nerve contains both sensory and motor fibres. It is responsible for sensation in the face and certain motor functions such as biting, chewing, and swallowing. Sensory information from the face and body is processed by parallel pathways in the central nervous system...

 (nervus trigeminis). The nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...

 listings indicate the respective innervation (sensory distribution) of the trigeminal nerve branches within the nose, the face, and the upper jaw (maxilla).
The indicated nerve
Nerve
A peripheral nerve, or simply nerve, is an enclosed, cable-like bundle of peripheral axons . A nerve provides a common pathway for the electrochemical nerve impulses that are transmitted along each of the axons. Nerves are found only in the peripheral nervous system...

 serves the named anatomic facial and nasal regions:
Ophthalmic division innervation
  • Lacrimal nerve — conveys sensation to the skin areas of the lateral orbital
    Orbit (anatomy)
    In anatomy, the orbit is the cavity or socket of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents...

     (eye socket) region, except for the lacrimal gland.

  • Frontal nerve — conveys sensation to the skin areas of the forehead and the scalp.

  • Supraorbital nerve — conveys sensation to the skin areas of the eyelids, the forehead, and the scalp.

  • Supratrochlear nerve — conveys sensation to the medial region of the eyelid skin area, and the medial region of the forehead skin.

  • Nasociliary nerve — conveys sensation to the skin area of the nose, and the mucous membrane of the anterior (front) nasal cavity
    Nasal cavity
    The nasal cavity is a large air filled space above and behind the nose in the middle of the face.- Function :The nasal cavity conditions the air to be received by the other areas of the respiratory tract...

    .

  • Anterior ethmoid nerve — conveys sensation in the anterior (front) half of the nasal cavity: (a) the internal areas of the ethmoid sinus and the frontal sinus; and (b) the external areas, from the nasal tip to the rhinion: the anterior tip of the terminal end of the nasal-bone suture.

  • Posterior ethmoid nerve — serves the superior (upper) half of the nasal cavity, the sphenoids, and the ethmoids.

  • Intratrochlear nerve — conveys sensation to the medial region of the eyelids, the palpebral conjunctiva, the nasion (nasolabial junction), and the bony dorsum.


The maxillary division innervation
  • Maxillary nerve — conveys sensation to the upper jaw and the face.

  • Infraorbital nerve — conveys sensation to the area from below the eye socket
    Orbit (anatomy)
    In anatomy, the orbit is the cavity or socket of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents...

     to the external nares (nostrils).

  • Zygomatic nerve — through the zygomatic bone and the zygomatic arch, conveys sensation to the cheekbone areas.

  • Superior posterior dental nerve — sensation in the teeth and the gums.

  • Superior anterior dental nerve — mediates the sneeze reflex.

  • Sphenopalatine nerve — divides into the lateral branch and the septal branch, and conveys sensation from the rear and the central regions of the nasal cavity
    Nasal cavity
    The nasal cavity is a large air filled space above and behind the nose in the middle of the face.- Function :The nasal cavity conditions the air to be received by the other areas of the respiratory tract...

    .


The supply of parasympathetic nerves to the face and the upper jaw (maxilla) derives from the greater superficial petrosal (GSP) branch of cranial nerve VII, the facial nerve. The GSP nerve joins the deep petrosal nerve
Deep petrosal nerve
The deep petrosal nerve is given off from the carotid plexus, and runs through the carotid canal lateral to the internal carotid artery....

 (of the sympathetic nervous system), derived from the carotid plexus, to form the vidian nerve (in the vidian canal) that traverses the pterygopalatine ganglion
Pterygopalatine ganglion
The pterygopalatine ganglion is a parasympathetic ganglion found in the pterygopalatine fossa. It is one of four parasympathetic ganglia of the head and neck....

 (an autonomic ganglion of the maxillary nerve), wherein only the parasympathetic nerves form synapses, which serve the lacrimal gland
Lacrimal gland
The lacrimal glands are paired almond-shaped glands, one for each eye, that secrete the aqueous layer of the tear film. They are situated in the upper, outer portion of each orbit, in the lacrimal fossa of the orbit formed by the frontal bone. Inflammation of the lacrimal glands is called...

 and the glands of the nose and of the palate, via the (upper jaw) maxillary division of cranial nerve V, the trigeminal nerve
Trigeminal nerve
The trigeminal nerve contains both sensory and motor fibres. It is responsible for sensation in the face and certain motor functions such as biting, chewing, and swallowing. Sensory information from the face and body is processed by parallel pathways in the central nervous system...

.

F. Bony anatomy of the nose
In the upper portion of the nose, the paired nasal bones attach to the frontal bone. Above and to the side (superolaterally), the paired nasal bones connect to the lacrimal bones, and below and to the side (inferolaterally), they attach to the ascending processes of the maxilla (upper jaw). Above and to the back (posterosuperiorly), the bony nasal septum is composed of the perpendicular plate of the ethmoid bone. The vomer
Vomer
The vomer is one of the unpaired facial bones of the skull. It is located in the midsagittal line, and articulates with the sphenoid, the ethmoid, the left and right palatine bones, and the left and right maxillary bones.-Biology:...

 bone lies below and to the back (posteroinferiorly), and partially forms the choanal opening into the nasopharynx, (the upper portion of the pharynx
Pharynx
The human pharynx is the part of the throat situated immediately posterior to the mouth and nasal cavity, and anterior to the esophagus and larynx. The human pharynx is conventionally divided into three sections: the nasopharynx , the oropharynx , and the laryngopharynx...

 that is continuous with the nasal passages). The floor of the nose comprises the premaxilla bone and the palatine bone, the roof of the mouth.

The nasal septum is composed of the quadrangular cartilage, the vomer bone (the perpendicular plate of the ethmoid bone
Ethmoid bone
The ethmoid bone is a bone in the skull that separates the nasal cavity from the brain. As such, it is located at the roof of the nose, between the two orbits. The cubical bone is lightweight due to a spongy construction. The ethmoid bone is one of the bones that makes up the orbit of the eye...

), aspects of the premaxilla, and the palatine bones. Each lateral nasal wall contains three pairs of turbinate
Turbinate
In anatomy, a nasal concha is a long, narrow and curled bone shelf that protrudes into the breathing passage of the nose...

s (nasal conchae), which are small, thin, shell-form bones: (i) the superior concha, (ii) the middle concha, and (iii) the inferior concha, which are the bony framework of the turbinates. Lateral to the turbinates is the medial wall of the maxillary sinus. Inferior to the nasal conchae (turbinates) is the meatus space, with names that correspond to the turbinates, e.g. superior turbinate, superior meatus, et alii. The internal roof of the nose is composed by the horizontal, perforated cribriform plate (of the ethmoid bone) through which pass sensory filaments of the olfactory nerve
Olfactory nerve
The olfactory nerve, or cranial nerve I, is the first of twelve cranial nerves. It is instrumental in the sense of smell. Derived from the embryonic nasal placode, the olfactory nerve is capable of regeneration.-Anatomy:...

 (Cranial nerve I); finally, below and behind (posteroinferior) the cribriform plate, sloping down at an angle, is the bony face of the sphenoid sinus.

G. The cartilaginous pyramid of the nose
The cartilaginous septum
Nasal septum
The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

 (septum nasi) extends from the nasal bones in the midline (above) to the bony septum in the midline (posteriorly), then down along the bony floor. The septum is quadrangular; the upper-half is flanked by two (2) triangular-to-trapezoidal cartilages: the upper lateral-cartilages, which are fused to the dorsal septum in the midline, and laterally attached, with loose ligaments, to the bony margin of the pyriform (pear-shaped) aperture, while the inferior ends of the upper lateral-cartilages are free (unattached). The internal area (angle), formed by the septum and upper lateral-cartilage, constitutes the internal valve of the nose; the sesamoid cartilages are adjacent to the upper lateral-cartilages in the fibroareolar connective tissue.

Beneath the upper lateral-cartilages lay the lower lateral-cartilages; the paired lower lateral-cartilages swing outwards, from medial attachments, to the caudal septum in the midline (the medial crura) to an intermediate crus (shank) area. Finally, the lower lateral-cartilages flare outwards, above and to the side (superolaterally), as the lateral crura; these cartilages are mobile, unlike the upper lateral cartilages. Furthermore, some persons present anatomical evidence of nasal scrolling — i.e. an outward curving of the lower borders of the upper lateral-cartilages, and an inward curving of the cephalic borders of the alar cartilages.

The external nose
External nasal anatomy
The form of the nasal subunits — the dorsum, the sidewalls, the lobule, the soft triangles, the alae, and the columella — are configured differently, according to the race and the ethnic group of the patient, thus the nasal physiognomies denominated as: African, platyrrhine (flat, wide nose); Asiatic, subplatyrrhine (low, wide nose); Caucasian, leptorrhine (narrow nose); and Hispanic, paraleptorrhine (narrow-sided nose). The respective external valve of each nose is variably dependent upon the size, shape, and strength of the lower lateral cartilage.

Internal nasal anatomy
In the midline of the nose, the septum is a composite (osseo-cartilaginous) structure that divides the nose into two (2) similar halves. The lateral nasal wall and the paranasal sinuses, the superior concha, the middle concha, and the inferior concha, form the corresponding passages, the superior meatus, the middle meatus, and the inferior meatus, on the lateral nasal wall. The superior meatus is the drainage area for the posterior ethmoid bone
Ethmoid bone
The ethmoid bone is a bone in the skull that separates the nasal cavity from the brain. As such, it is located at the roof of the nose, between the two orbits. The cubical bone is lightweight due to a spongy construction. The ethmoid bone is one of the bones that makes up the orbit of the eye...

 cells and the sphenoid sinus; the middle meatus provides drainage for the anterior ethmoid sinuses and for the maxillary and frontal sinuses; and the inferior meatus provides drainage for the nasolacrimal duct.

The internal nasal valve comprises the area bounded by the upper lateral-cartilage, the septum, the nasal floor, and the anterior head of the inferior turbinate. In the narrow (leptorrhine) nose, this is the narrowest portion of the nasal airway. Generally, this area requires an angle greater than 15 degrees for unobstructed breathing; for the correction of such narrowness, the width of the nasal valve can be increased with spreader grafts and flaring sutures.
Nasal analysis: angles and projection
The surgical management of nasal defects and deformities divides the nose into six (6)
anatomic subunits: (i) the dorsum, (ii) the sidewalls (paired), (iii) the hemilobules (paired), (iv) the soft triangles (paired), (v) the alae (paired), and (vi) the columella. Surgical correction and reconstruction comprehend the entire anatomic subunit affected by the defect (wound) or deformity, thus, the entire subunit is corrected, especially when the resection (cutting) of the defect encompasses more than 50 per cent of the subunit. Aesthetically, the nose — from the nasion (the mid-point of the nasofrontal junction) to the columella-labial junction — ideally occupies one-third of the vertical dimension of the person’s face; and, from ala to ala, it ideally should occupy one-fifth of the horizontal dimension of the person’s face.

The nasofrontal angle, between the frontal bone and the nasion usually is 120 degrees; the nasofrontal angle is more acute in the male face than in the female face. The nasofacial angle, the slope of the nose relative to the plane of the face, is approximately 30–40 degrees. The nasolabial angle, the slope between the columella and the philtrum
Philtrum
The philtrum , is a medial cleft common to many mammals, extending from the nose to the upper lip, and, together with a glandular rhinarium and slit-like nostrils, is believed to constitute the primitive condition for mammals in general...

, is approximately 90–95 degrees in the male face, and approximately 100–105 degrees in the female face. Therefore, when observing the nose in profile, the normal show of the columella (the height of the visible nasal aperture) is 2–mm; and the dorsum should be rectilinear (straight). When observed from below (worm’s-eye view), the alar base configures an isosceles triangle, with its apex at the infra-tip lobule, immediately beneath the tip of the nose. The facially proportionate projection of the nasal tip (the distance of the nose’s tip from the face) is determined with the Goode Method, wherein the projection of the nasal tip should be 55-60 per cent of the distance between the nasion (nasofrontal junction) and the tip-defining point. A columellar double break might be present, marking the transition between the intermediate crus of the lower-lateral cartilage and the medial crus.

The Goode Method determines the extension of the nose from the facial surface by comprehending the distance from the alar groove to the tip of the nose, and then relating that measurement (of nasal-tip projection) to the length of the nasal dorsum. The nasal projection measurement is obtained by delineating a right triangle with lines parting from the nasion (nasofrontal juncture) to the alar–facial–groove. Then, a second, perpendicular delineation, that traverses the tip-defining point, establishes the ratio of projection of the nasal tip; hence, the range of 0.55:1 to 0.60:1, is the ideal nasal-tip-to-nasal-length projection.



Patient characteristics
Surgical suitability: the medical and mental histories of the patient
To determine the patient’s suitability for undergoing a rhinoplasty procedure, the surgeon clinically evaluates him or her with a complete medical history
Medical history
The medical history or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information , with the aim of obtaining information useful in formulating a diagnosis and providing...

 (anamnesis) to determine his or her physical and psychological health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...

. The prospective patient must explain to the physician–surgeon the functional and aesthetic nasal problems that he or she suffers. The surgeon asks about the ailments’ symptoms and their duration, past surgical interventions, allergies, drugs use and drugs abuse (prescription and commercial medications), and a general medical history. Furthermore, additional to physical suitability is psychological suitability — the patient’s psychological motive for undergoing nose surgery is critical to the surgeon’s pre-operative evaluation of the patient. In the case of men, the surgeon must identify prospective patients presenting the mental traits denoted by the psychiatric acronym SIMON (single, immature, male, over-expectant, and narcissistic
Narcissism
Narcissism is a term with a wide range of meanings, depending on whether it is used to describe a central concept of psychoanalytic theory, a mental illness, a social or cultural problem, or simply a personality trait...

), which might indicate a man over-valuing the outcome of a rhinoplasty.

The complete physical examination of the rhinoplasty patient determines if he or she is physically fit to undergo and tolerate the physiologic
Physiology
Physiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...

 stresses of nose surgery. The examination comprehends every existing physical problem, and a consultation with an anaesthesiologist, if warranted by the patient’s medical data. Specific facial and nasal evaluations record the patient’s skin-type, existing surgical scars, and the symmetry and asymmetry of the aesthetic nasal subunits. The external and internal nasal examination concentrates upon the anatomic thirds of the nose — upper section, middle section, lower section — specifically noting their structures; the measures of the nasal angles (at which the external nose projects from the face); and the physical characteristics of the naso-facial bony and soft tissues. The internal examination evaluates the condition of the nasal septum, the internal and external nasal valves, the turbinates, and the nasal lining, paying especial attention to the structure and the form of the nasal dorsum and the tip of the nose.

Furthermore, when warranted, specific tests — the mirror test, vasoconstriction examinations, and the Cottle maneuver — are included to the pre-operative evaluation of the prospective rhinoplasty patient. Established by Maurice H. Cottle (1898–1981), the Cottle maneuver is a principal diagnostic technique for detecting an internal nasal-valve disorder; whilst the patient gently inspires, the surgeon laterally pulls the patient’s cheek, thereby simulating the widening of the cross-sectional area of the corresponding internal nasal valve. If the maneuver notably facilitates the patient’s inspiration, that result is a positive Cottle sign — which generally indicates an airflow-correction to be surgically effected with an installed spreader-graft. Said correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. Nonetheless, the Cottle maneuver occasionally yields a false-positive Cottle sign, usually observed in the patient afflicted with alar collapse, and in the patient with a scarred nasal-valve region.

Surgical rhinoplasty

The approaches — open rhinoplasty and closed rhinoplasty
The plastic surgical correction of congenital and acquired abnormalities of the nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

 restores functional and aesthetic properties by the surgeon’s manipulations of the nasal skin, the subcutaneous (underlying) cartilage-and-bone support framework, and the mucous membrane
Mucous membrane
The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...

 lining. Technically, the plastic surgeon’s incisional approach classifies the nasal surgery either as an open rhinoplasty or as a closed rhinoplasty procedure. In open rhinoplasty, the surgeon makes a small, irregular incision to the columella
Nasal septum
The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

, the fleshy, exterior-end of the nasal septum; this columellar incision is additional to the usual set of incisions for a nasal correction. In closed rhinoplasty, the surgeon performs every procedural incision endonasally (exclusively within the nose), and does not cut the columella.
Procedural differences — except for the columellar incision, the technical and procedural approaches of open rhinoplasty and of closed rhinoplasty are similar; yet closed rhinoplasty procedure features:
  • Reduced dissection (cutting) of the nasal tissues — no columellar incision

  • Decreased potential for the excessive reduction (cutting) of the nasal-tip support

  • Reduced post-operative edema
    Edema
    Edema or oedema ; both words from the Greek , oídēma "swelling"), formerly known as dropsy or hydropsy, is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling...


  • Decreased visible scarring
    Scar
    Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...


  • Decreased iatrogenic
    Iatrogenesis
    Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...

     (inadvertent) damage to the nose
    Human nose
    The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

    , by the surgeon

  • Increased availability for effecting in situ procedural and technical changes

  • Palpation that allows the surgeon to feel the interior changes effected to the nose

  • Shorter operating room time

  • Quicker post-surgical recovery and convalescence for the patient


The “ethnic nose”
The open rhinoplasty approach affords the plastic surgeon the advantages of ease in securing the grafts (skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...

, cartilage
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

, bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

) and, most important, in seeing the nasal cartilages proper, and so make the appropriate diagnosis. This procedural aspect can be especially difficult in revision surgery, and in rhinoplastic corrections of the thick-skinned “ethnic nose” of the colored man or woman. The study, Ethnic Rhinoplasty: a Universal Preoperative Classification System for the Nasal Tip (2009), reports that a nasal-tip classification system, based upon skin thickness, has been proposed to aid the surgeon in determining if an open rhinoplasty or a closed rhinoplasty shall best correct the defect or deformity afflicting the patient’s nose.

Etiology
Etiologically
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....

, the open and closed approaches to rhinoplastic correction resolve: (i) nasal pathologies (diseases intrinsic and diseases extrinsic to the nose); (ii) an unsatisfactory aesthetic appearance (disproportion); (iii) a failed primary rhinoplasty; (iv) an obstructed airway; and (v) congenital nose defects and deformities.

Congenital abnormalities such as:
  • Cleft lip and palate in combination; cleft lip (cheiloschisis) and cleft palate (palatoschisis), individually.

  • Congenital nasal abnormalities

  • Genetically derived ethnic-nose abnormalities


Acquired abnormalities such as:
  • Allergic
    Allergic rhinitis
    Allergic rhinitis, also known as pollenosis or hay fever, is an allergic inflammation of the nasal airways.It occurs when an allergen, such as pollen, dust or animal dander is inhaled by an individual with a sensitized immune system...

     and vasomotor rhinitis — inflammations of the mucous membrane
    Mucous membrane
    The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...

     of the nose caused by an allergen, and caused by circulatory and nervous system disorders.

  • Autoimmune system diseases
    Autoimmune disease
    Autoimmune diseases arise from an overactive immune response of the body against substances and tissues normally present in the body. In other words, the body actually attacks its own cells. The immune system mistakes some part of the body as a pathogen and attacks it. This may be restricted to...


  • Bites — animal and human

  • Burn
    Burn
    A burn is an injury to flesh caused by heat, electricity, chemicals, light, radiation, or friction.Burn may also refer to:*Combustion*Burn , type of watercourses so named in Scotland and north-eastern England...

    s — caused by chemicals, electricity
    Electricity
    Electricity is a general term encompassing a variety of phenomena resulting from the presence and flow of electric charge. These include many easily recognizable phenomena, such as lightning, static electricity, and the flow of electrical current in an electrical wire...

    , friction
    Friction
    Friction is the force resisting the relative motion of solid surfaces, fluid layers, and/or material elements sliding against each other. There are several types of friction:...

    , heat
    Heat
    In physics and thermodynamics, heat is energy transferred from one body, region, or thermodynamic system to another due to thermal contact or thermal radiation when the systems are at different temperatures. It is often described as one of the fundamental processes of energy transfer between...

    , light
    Light
    Light or visible light is electromagnetic radiation that is visible to the human eye, and is responsible for the sense of sight. Visible light has wavelength in a range from about 380 nanometres to about 740 nm, with a frequency range of about 405 THz to 790 THz...

    , and radiation
    Radiation
    In physics, radiation is a process in which energetic particles or energetic waves travel through a medium or space. There are two distinct types of radiation; ionizing and non-ionizing...

    .

  • Connective-tissue diseases
    Connective tissue disease
    A connective tissue disease is any disease that has the connective tissues of the body as a target of pathology. Connective tissue is any type of biological tissue with an extensive extracellular matrix that supports, binds together, and protects organs...


  • Inflammatory conditions

  • Nasal fractures

  • Naso-orbito-ethmoidal fractures — damages to the nose and the eye-sockets
    Orbit (anatomy)
    In anatomy, the orbit is the cavity or socket of the skull in which the eye and its appendages are situated. "Orbit" can refer to the bony socket, or it can also be used to imply the contents...

    ; and damage to the bones and the walls of the nasal cavity; it is the ethmoid bone
    Ethmoid bone
    The ethmoid bone is a bone in the skull that separates the nasal cavity from the brain. As such, it is located at the roof of the nose, between the two orbits. The cubical bone is lightweight due to a spongy construction. The ethmoid bone is one of the bones that makes up the orbit of the eye...

     that separates the brain
    Brain
    The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...

     from the nose
    Human nose
    The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

    .

  • Neoplasms — malignant and benign tumor
    Tumor
    A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...

    s

  • Septal hematoma
    Hematoma
    A hematoma, or haematoma, is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This distinguishes it from an ecchymosis, which is the spread of blood under the skin in a thin layer, commonly called a bruise...

     — a mass of (usually) clotted blood in the septum

  • Toxins — chemical damages caused by inspired substances — e.g. powdered cocaine
    Cocaine
    Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...

    , aerosol antihistamine
    Antihistamine
    An H1 antagonist is a histamine antagonist of the H1 receptor that serves to reduce or eliminate effects mediated by histamine, an endogenous chemical mediator released during allergic reactions...

     medications, et cetera.

  • Traumatic
    Trauma (medicine)
    Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

     deformities caused by blunt trauma
    Blunt trauma
    In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

    , penetrating trauma
    Penetrating trauma
    Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...

    , and blast trauma
    Blast injury
    A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives...

    .

  • Venereal infection — e.g. syphilis
    Syphilis
    Syphilis is a sexually transmitted infection caused by the spirochete bacterium Treponema pallidum subspecies pallidum. The primary route of transmission is through sexual contact; however, it may also be transmitted from mother to fetus during pregnancy or at birth, resulting in congenital syphilis...



Surgical précis

A rhinoplastic correction can be performed on a patient who is under sedation
Sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure...

, under general anaesthesia
General anaesthesia
General anaesthesia is a state of unconsciousness and loss of protective reflexes resulting from the administration of one or more general anaesthetic agents...

, or under local anaesthesia; initially, a local anaesthetic mixture of lidocaine
Lidocaine
Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...

 and epinephrine
Epinephrine
Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...

 is injected to numb the area, and temporarily reduce vascularity, thereby limiting any bleeding. Generally, the plastic surgeon
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 first separates the nasal skin and the soft tissues from the osseo
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

-cartilage
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

nous nasal framework, and then corrects (reshapes) them as required, afterwards, sutures the incisions, and then applies either an external or an internal stent, and tape, to immobilize the newly reconstructed nose, and so facilitate the healing of the surgical cuts. Occasionally, the surgeon uses either an autologous
Autotransplantation
Autotransplantation is the transplantation of organs, tissues or even proteins from one part of the body to another in the same individual. Tissue transplanted by such "autologous" procedure is referred to as an autograft or autotransplant. It is contrasted with xenotransplantation and...

 cartilage graft or a bone graft, or both, in order to strengthen or to alter the nasal contour(s). The autologous grafts usually are harvested from the nasal septum
Nasal septum
The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

, but, if it has insufficient cartilage (as can occur in a revision rhinoplasty), then either a costal cartilage graft (from the rib cage
Rib cage
The rib cage is an arrangement of bones in the thorax of animals. It is formed by the vertebral column, ribs and sternum and encloses the heart and lungs....

) or an auricular cartilage graft (concha
Concha
Concha can refer to:* The bowl-shaped part of the pinna nearest the ear canal* Concha or Concho, a round decorative piece of metal seen on a western saddle and other horse equipment descended from the Spanish tradition....

 from the ear
Ear
The ear is the organ that detects sound. It not only receives sound, but also aids in balance and body position. The ear is part of the auditory system....

) is harvested from the patient’s body. When the rhinoplasty requires a bone graft, it is harvested from either the cranium, the hips, or the rib cage; moreover, when neither type of autologous graft is available, a synthetic graft (nasal implant) is used to augment the nasal bridge.

Photographic records of the rhinoplasty
For the benefit of patient and the physician–surgeon, a photographic history of the entire rhinoplastic procedure is established; beginning at the pre-operative consultation, continuing during the surgical operation procedures, and concluding with the post-operative outcome. To record the “before-and-after” physiognomies of the nose and the face of the patient, the specific visual perspectives required are photographs of the nose viewed from the anteroposterior (front-to-back) perspective; the lateral view (profiles), the worm’s-eye view (from below), the bird’s-eye view (overhead), and three-quarter-profile views.

Sample photographic record
  • Photograph A. — Open rhinoplasty: At rhinoplasty’s end, after the plastic surgeon has sutured (closed) the incisions, the corrected (new) nose will be dressed, taped, and splinted immobile to permit the uninterrupted healing of the surgical incisions. The purple-ink guidelines ensured the surgeon’s accurate cutting of the defect correction plan.

  • Photograph B. — Open rhinoplasty: The new nose is prepared with paper tape in order to receive the metal nasal-splint that will immobilize it to maintain its correct shape as a new nose.



  • Photograph C. — Open rhinoplasty: After the preliminary taping of the nose, a custom-made, metal nasal-splint, designed, cut, and formed by the surgeon, is emplaced to immobilize and protect the tender tissues of the new nose during convalescence.

  • Photograph D. — Open rhinoplasty: The taping, emplacement of the metal splint, and dressing of the new nose complete the rhinoplasty procedure. The patient then convalesces, and the wound dressing will be removed at 1-week post-procedure.


Sample photographic records
  • Photograph 1.Open rhinoplasty: The incisions are endonasal (in the nose), and thus are hidden. The skin-incision to the columella
    Columella
    Lucius Junius Moderatus Columella is the most important writer on agriculture of the Roman empire. Little is known of his life. He was probably born in Gades , possibly of Roman parents. After a career in the army , he took up farming...

     aids the plastic surgeon in precisely suturing to hide the scar
    Scar
    Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...

     — except for the columellar incision (red-dot guideline) across the nasal
    Human nose
    The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

     base. The columellar incision allows the surgeon to view the size, shape, and condition of the nasal cartilages and bones to be corrected.

  • Photograph 2.Open rhinoplasty: The nasal interior. The scissors indicate the lower lateral cartilage
    Greater alar cartilage
    The greater alar cartilage is a thin, flexible plate, situated immediately below the lateral nasal cartilage, and bent upon itself in such a manner as to form the medial wall and lateral wall of the naris of its own side....

     (blue), which is one of the wing-shaped cartilages that conform the tip of the nose. The jagged red delineation indicates the locale of the columellar incision. Once the skin has been lifted from the bone-and-cartilage framework, the surgeon performs the nasal correction tasks.

  • Photograph 3.Open rhinoplasty: To narrow the tip of a too-wide nose, the surgeon first determines the cause of the excess nasal width. The suture being emplaced will narrow the tip of the nose. The red delineation indicates the edge of the nose-tip cartilage, which is narrowed when the surgeon tightens the folded cartilage apex. The suture (light blue) ends in the needle (white); tweezers (green) hold the nasal cartilage in place for the suturing.

  • Photograph 4.Nasal hump excision: The black delineation indicates the desired nose-reduction outcome: a straight nose. The nasal hump is bone (red) above the scalloped grey line, and cartilage (blue) below the scalloped grey line. The surgeon cuts the cartilage portion of the hump with a scalpel
    Scalpel
    A scalpel, or lancet, is a small and extremely sharp bladed instrument used for surgery, anatomical dissection, and various arts and crafts . Scalpels may be single-use disposable or re-usable. Re-usable scalpels can have attached, resharpenable blades or, more commonly, non-attached, replaceable...

    , and chisels the bone portion with an osteotome
    Osteotome
    An osteotome is an instrument used for cutting or preparing bone.The instrument was invented by Bernhard Heine, a German physician in Würzburg, in 1830. Heine's invention was used as a bone saw, especially for opening the skull. It was a kind of chain saw moved by turning a winder.Today osteotomes...

     (bone chisel). After chiselling away the main mass of the nasal hump with an osteotome, the surgeon then sculpts, refines, and smoothens the cut nasal bones with rasps (files).




Types of rhinoplasty
In plastic surgical
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 praxis, the term primary rhinoplasty denotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The term secondary rhinoplasty denotes the revision of a failed rhinoplasty, an occurrence in 5–20 per cent of rhinoplasty operations, hence a revision rhinoplasty. The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of an unaddressed nasal fracture; a defective tip of the nose, i.e. pinched (too narrow), hooked (parrot beak), or flattened (pug nose); and the restoration of clear airways. Although most revision rhinoplasty procedures are “open approach”, such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from the ear
Ear
The ear is the organ that detects sound. It not only receives sound, but also aids in balance and body position. The ear is part of the auditory system....

 (auricular cartilage graft) or from the rib cage
Rib cage
The rib cage is an arrangement of bones in the thorax of animals. It is formed by the vertebral column, ribs and sternum and encloses the heart and lungs....

 (costal cartilage graft).

Nasal reconstruction
In reconstructive rhinoplasty, the defects and deformities that the plastic surgeon encounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose; congenital defect, trauma
Trauma (medicine)
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

 (blunt
Blunt trauma
In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

, penetrating
Penetrating trauma
Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...

, blast
Blast injury
A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives...

), autoimmune disorder, cancer
Cancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...

, intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). When cartilage
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

 is disrupted, suturing for re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial) prostheses, because of the reduced incidence of histologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...

 rejection and medical complications.

Surgical anatomy for nasal reconstruction
The human nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

 is a sensory organ that is structurally composed of three types of tissue: (i) an osseo
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

-cartilaginous
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

 support framework (nasal skeleton), (ii) a mucous membrane lining, and (iii) an external skin. The anatomic topography
Topography
Topography is the study of Earth's surface shape and features or those ofplanets, moons, and asteroids...

 of the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose into nasal subunits: (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures.

Nasal skeleton
Therefore, the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three (3) anatomic layers:
  1. the osseo-cartilagenous framework — The upper lateral cartilages that are tightly attached to the (rear) caudal edge of the nasal bones and the nasal septum
    Nasal septum
    The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

    ; said attachment suspends them above the nasal cavity
    Nasal cavity
    The nasal cavity is a large air filled space above and behind the nose in the middle of the face.- Function :The nasal cavity conditions the air to be received by the other areas of the respiratory tract...

    . The paired alar cartilages configure a tripod-shaped union that supports the lower third of the nose. The paired medial crura conform the central-leg of the tripod, which is attached to the anterior nasal spine and septum, in the midline. The lateral crura compose the second-leg and the third-leg of the tripod, and are attached to the (pear-shaped) pyriform aperture, the nasal-cavity opening at the front of the skull. The dome of the nostrils defines the apex of the alar cartilage, which supports the nasal tip, and is responsible for the light reflex of the tip.
  2. the nasal lining — A thin layer of vascular mucosa
    Mucous membrane
    The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...

     that adheres tightly to the deep surface of the bones and the cartilages of the nose. Said dense adherence to the nasal interior limits the mobility of the mucosa, consequently, only the smallest of mucosal defects (< 5-mm) can be sutured primarily.
  3. the nasal skin — A tight envelope that proceeds inferiorly from the glabella (the smooth prominence between the eyebrows), which then becomes thinner and progressively inelastic (less distensible). The skin of the mid-third of the nose covers the cartilaginous dorsum and the upper lateral cartilages and is relatively elastic, but, at the (far) distal-third of the nose, the skin adheres tightly to the alar cartilages, and is little distensible. The skin and the underlying soft tissues of the alar lobule form a semi-rigid anatomic unit that maintains the graceful curve of the alar rim, and the patency (openness) of the nostrils (anterior nares). To preserve this nasal shape and patency, the replacement of the alar lobule must include a supporting cartilage graft — despite the alar lobule not originally containing cartilage; because of its many sebaceous glands, the nasal skin usually is of a smooth (oiled) texture. Moreover, regarding scarrification
    Scar
    Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...

    , when compared to the skin of other facial areas, the skin of the nose generates fine-line scars that usually are inconspicuous, which allows the surgeon to strategically hide the surgical scars.


Principles of rhinoplastic reconstruction
The technical principles for the surgical
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 reconstruction of a nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

 derive from the essential operative principles of plastic surgery
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

: that the applied procedure and technique(s) yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of the mucosa; cartilage
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

 battens to brace against tissue
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...

 contraction and depression (topographic collapse); axial skin flaps designed from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting of bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

, cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the reconstructed nasal subunit is not a nose proper, but a collagen
Collagen
Collagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...

-glued collage — of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments of ear cartilage — which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose.

Restoration of the “normal nose”
In nasal reconstruction, the plastic surgeon’s ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patient’s “normal nose”, as perceived at conversational distance (ca. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach, which requires that the surgeon balance the patient’s required rhinoplasty, with the patient’s aesthetic ideal
Body image
Body image refers to a person's perception of the aesthetics and sexual attractiveness of their own body. The phrase body image was first coined by the Austrian neurologist and psychoanalyst Paul Schilder in his masterpiece The Image and Appearance of the Human Body...

 (body image). In the context of surgically reconstructing the patient’s physiognomy, the “normal nose” is the three-dimensional (3-D) template for replacing the missing part(s) of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials — such as bone
Bone
Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

, cartilage
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

, and flaps of skin and of tissue. In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the “normal nose” and from photographs of the patient before he or she suffered the nasal damage.

The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining with mucosa
Mucous membrane
The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...

, cartilage with cartilage, bone with bone, and skin with skin that best match the native skin color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notable scarring
Scar
Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...

 propensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude.

The most effective nasal reconstruction for repairing a defect (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in the topographic
Superficial anatomy
Superficial anatomy is a descriptive science dealing with anatomical features that can be studied by sight, without dissecting an organism...

 transition zone(s) between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose with skin flaps. Nonetheless, in the final stage of nasal reconstruction — replicating the “normal nose” anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars, and render them (more) inconspicuous.

Indications and techniques
Reconstruction rhinoplasty is indicated for the correction of defects and deformities caused by:
  1. Skin cancer. The most common cause (etiology
    Etiology
    Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....

    ) for a nasal reconstruction is skin cancer, especially the lesions to the nose of melanoma
    Melanoma
    Melanoma is a malignant tumor of melanocytes. Melanocytes are cells that produce the dark pigment, melanin, which is responsible for the color of skin. They predominantly occur in skin, but are also found in other parts of the body, including the bowel and the eye...

     and basal-cell carcinoma. This oncologic
    Oncology
    Oncology is a branch of medicine that deals with cancer...

     epidemiology
    Epidemiology
    Epidemiology is the study of health-event, health-characteristic, or health-determinant patterns in a population. It is the cornerstone method of public health research, and helps inform policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive...

     occurs more readily among the aged and people who reside in very sunny geographic areas; although every type of skin
    Skin
    -Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...

     is susceptible to skin cancer, white-skin is most epidemiologically prone to developing skin cancer. Furthermore, regarding plastic surgical
    Plastic surgery
    Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

     scars, the age of the patient is a notable factor in the timely, post-surgical healing of a skin cancer defect (lesion); in terms of scarrification
    Scar
    Scars are areas of fibrous tissue that replace normal skin after injury. A scar results from the biological process of wound repair in the skin and other tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in...

    , the very elastic skin of young people has a greater regenerative propensity for producing scars that are thicker (stronger) and more noticeable. Therefore, in young patients, the strategic placement (hiding) of the rhinoplastic scars is a greater aesthetic consideration than in elder patients; whose less elastic skin produces scars that are narrower and less noticeable.
  2. Traumatic nasal defect. Although trauma
    Trauma (medicine)
    Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...

     is a less common rhinoplastic occurrence, a nasal defect or deformity caused by blunt trauma
    Blunt trauma
    In medical terminology, blunt trauma, blunt injury, non-penetrating trauma or blunt force trauma refers to a type of physical trauma caused to a body part, either by impact, injury or physical attack; the latter usually being referred to as blunt force trauma...

     (impact), penetrating trauma
    Penetrating trauma
    Penetrating trauma is an injury that occurs when an object pierces the skin and enters a tissue of the body, creating an open wound. In blunt, or non-penetrating trauma, there may be an impact, but the skin is not necessarily broken. The penetrating object may remain in the tissues, come back out...

     (piercing), and blast trauma
    Blast injury
    A blast injury is a complex type of physical trauma resulting from direct or indirect exposure to an explosion. Blast injuries occur with the detonation of high-order explosives as well as the deflagration of low order explosives...

     (blunt and penetrating) requires a surgical reconstruction that abides the conservational principles of plastic surgery, as in the corrections of cancerous lesions.
  3. Congenital deformities. The unique plastic properties of the bone
    Bone
    Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

    , cartilage
    Cartilage
    Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...

    , and skin
    Skin
    -Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...

     of patients’ afflicted with congenital defects, and associated anomalies, are considered separately.


Surgical techniques for nasal reconstruction
The effectiveness of a rhinoplastic reconstruction of the external nose
Human nose
The visible part of the human nose is the protruding part of the face that bears the nostrils. The shape of the nose is determined by the ethmoid bone and the nasal septum, which consists mostly of cartilage and which separates the nostrils...

 derives from the contents of the surgeon’s armamentarium of skin-flap techniques applicable to correcting defects of the nasal skin and of the mucosal lining; some management techniques are the Bilobed flap, the Nasolabial flap, the Paramedian forehead flap, and the Septal mucosal flap.

I. The bilobed flap
The design of the bilobed flap derives from the creation of two (2) adjacent random transposition flaps (lobes). In its original design, the leading flap is applied to cover the defect, and the second flap, is emplaced where the skin flexes more, and fills the donor-site wound (from where the first flap was harvested), which then is closed primarily, with sutures. The first flap is oriented geometrically, at 90 degrees from the long axis of the wound (defect), and the second flap is oriented 180 degrees from the axis of the wound. Although effective, the bilobed flap technique did create troublesome “dog ears” of excess flesh that required trimming and it also produced a broad skin-donor area that was difficult to confine to the nose. In 1989, J. A. Zitelli modified the bilobed flap technique by: (a) orienting the leading flap at 45 degrees from the long axis of the wound; and (b) orienting the second flap at 90 degrees from the axis of the wound. Said orientations and emplacements eliminated the excess-flesh “dog ears”, and thus required a smaller area of donor skin; resultantly, the broad-based, bilobed flap is less prone to the “trap door” and the “pin cushion” deformities common to skin-flap transposition procedure.
Surgical technique — the bilobed flap
The design of the bilobed flap co-ordinates its lobes with the long axis of the nasal defect (wound); each lobe of the flap is emplaced at a 45-degree angle to the axis. The two lobes of the bilobed flap rotate along an arc, of which all points are equidistant from the apex of the nasal defect.
  • Based upon the available area of nasal skin, the surgeon selects the locale for the bilobed flap, and orients the pedicle. If the defect is in the lateral aspect of the nose, the pedicle is based medially. If the defect is at the nasal tip, or at the nasal dorsum, the pedicle is based laterally. An ideal location for the second flap is along the junction of the nasal dorsum and the lateral nasal wall.

  • The nasal wound is cut and shaped into a teardrop form, by the cutting out of a Burrow’s triangle of flesh on the side of pedicle base. Cutting out the Burrow’s triangle (skin and subcutaneous fat) permits the moving the pedicle flap, to emplace it without buckling the tissues adjacent to the graft.

  • Using a 20-mm calliper as a protractor
    Protractor
    In geometry, a protractor is a circular or semicircular tool for measuring an angle or a circle. The units of measurement utilized are usually degrees.Some protractors are simple half-discs; these have existed since ancient times...

     — one tip at the apex of the wound — the surgeon delineates two semi-circles, an inner semi-circle, and an outer semi-circle. The outer semi-circle defines the necessary length of the two lobes of the skin flap. The inner semi-circle bisects the center of the original wound, and continues across the donor skin, establishing limit measure of the pedicle common to the two lobes of the flap. The surgeon then draws two lines from the apex of the wound; the first line drawn is at an angle of 45 degrees from the long axis of the wound, and the second line drawn is at a 90-degree angle from the axis of the wound. The two (2) lines delineate the central axes of the two lobes of the bilobed flap.

  • The delineation of each of the two lobes of the flap begins and ends at the inner semi-circle, and extends to the outer semi-circle, to the point where it intersects its central axis. The width of the first lobe is approximately 2-mm narrower than the width of the wound; the width of the second lobe is approximately 2-mm narrower than the width of the first lobe.

  • After the cutting from the tissue donor-site, the bilobed flap is elevated to a plane between the subcutaneous fat and the nasalis muscle
    Nasalis muscle
    The nasalis is a sphincter-like muscle of the nose whose function is to compress the nasal cartilage.It consists of two parts, transverse and alar:...

    . The wound is deepened, down to the nasal skeleton, to accommodate the tissue thickness of the bilobed flap. Technically, cutting the wound, enlarging it, is preferable, and safer, than trimming (thinning) the flap to fit the wound.

  • Undermining the donor site for the second lobe allows closing it primarily; it also eliminates excess-skin “dog-ears” at the donor site. Moreover, if the donor site cannot be closed with sutures, or if the skin blanches (whitens) when sutured, usually because of excessively tight sutures, the tension is decreased by reducing the size (length, width, depth) of the wound with deep sutures that will allow it to heal more readily.


II. Nasolabial flap
In the nineteenth century, the surgical techniques of J.F. Dieffenbach
Dieffenbach
Dieffenbach may refer to:People* Ernst Dieffenbach , German physician, geologist and naturalist* Johann Friedrich Dieffenbach , German surgeonMusic* Diefenbach Danish musical groupPlaces...

 (1792–1847) popularized the nasolabial flap for nasal reconstruction, for which it remains a foundational nose surgery procedure. The nasolabial flap can be either superiorly based or inferiorly based; of which the superiorly based flap is the more practical rhinoplastic application, because it has a more versatile arc of rotation, and the donor-site scar is inconspicuous. Depending upon the how the defect lay upon the nose, the flap pedicle-base can be incorporated either solely to the nasal reconstruction, or it can be divided into a second stage procedure. The blood supply for the flap pedicle are the transverse branches of the contralateral angular artery
Angular artery
The angular artery is the terminal part of the facial artery; it ascends to the medial angle of the eye's orbit, imbedded in the fibers of the angular head of the Quadratus labii superioris, and accompanied by the angular vein....

 (the facial artery terminus parallel to the nose), and by a confluence of blood vessels from the angular artery and from the supraorbital artery in the medial canthus, (the angles formed by the meeting of the upper and lower eyelids). Therefore, the incisions for harvesting the nasolabial flap do not continue superiorly beyond the medial canthal tendon. The nasolabial flap is a random flap that is emplaced with the proximal (near) portion resting upon the lateral wall of the nose, and the distal (far) portion resting upon the cheek, which contains the main angular artery, and so is perfused with retrograde arterial flow.

Surgical technique — the nasolabial flap
The pedicle of the nasolabial flap rests upon the lateral nasal wall, and is transposed a maximum of 60 degrees, in order to avoid the “bridge effect” of a flap emplaced across the nasofacial angle.
  • The surgeon designs the nasolabial flap and sets its central axis at a 45-degree angle from the (long) axis of the nasal dorsum. The shape of the skin flap is cut from the wound template fabricated by the surgeon.

  • An incision is made to the flap (without an anaesthetic injection of epinephrine
    Epinephrine
    Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...

    ), which then is elevated and oriented, in an inferior-to-superior direction, between the subcutaneous fat and the muscle fascia.

  • The cutting continues until the skin flap can be freely transposed upon the nasal defect. A Burrow’s triangle is excised from the skin between the medial border of the flap and the nasal dorsum; the triangle can be cut either before or after the elevation of the nasolabial.

  • The flap then is bent back (reflected), and can be thinned (cut) under loupe magnification; however, a nasolabial flap cannot be thinned as easily as an axial skin-flap.

  • After the nasolabial flap has been emplaced, the flap donor-site wound is sutured closed. For a wound of the lateral nasal wall that is less than 15 mm wide, the flap donor-site can be closed primarily, with sutures. For a wound wider than 15 mm — especially a wound that comprehends the alar lobule and the lateral wall of the nose — primary closure is not indicated, because such a wound closure imposes excessive stresses upon the skin flap, thereby risking either blanching (whitening) or distortion, or both. Such risks are avoided by advancing (moving) the skin of the cheek towards the nasofacial junction, where it is sutured to the deep tissues. Furthermore, a narrow wound, less than 1-mm wide can be allowed to heal by secondary intention (autonomous re-epithelialisation).


III. The paramedian forehead flap
The paramedian forehead flap is the premier autologous
Autotransplantation
Autotransplantation is the transplantation of organs, tissues or even proteins from one part of the body to another in the same individual. Tissue transplanted by such "autologous" procedure is referred to as an autograft or autotransplant. It is contrasted with xenotransplantation and...

 skin graft for the reconstruction of a nose, by replacing any of the aesthetic nasal subunits, especially regarding the problems of different tissue thickness and skin color. The forehead flap is an axial skin flap based upon the supraorbital artery (an ophthalmic artery branch) and the supratrochlear artery (an ophthalmic artery terminus), which can be thinned to the subdermal plexus in order to enhance the functional and aesthetic outcome of the nose. Restricted length is a practical application limit of the paramedian forehead flap, especially when the patient has a low frontal hairline. In such a patient, a small portion of scalp skin can be included to the flap, but it does have a different skin texture and does continue growing hair; such mismatching is avoided with the transverse emplacement of the flap along the hairline; yet that portion of the skin flap is random, and so risks a greater incidence of necrosis
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...

.

The paramedian forehead flap has two disadvantages, one operational and one aesthetic: Operationally, the reconstruction of a nose with a paramedian forehead flap is a two-stage surgical procedure, which might a problem for the patient whose health (surgical suitability) includes significant, secondary medical risks. Nonetheless, the second stage of the nasal reconstruction can be performed with the patient under local anaesthesia. Aesthetically, although the flap donor-site scar heals well, it is noticeable, and thus difficult to conceal, especially in men.
Surgical technique — the paramedian forehead flap
The surgeon designs the paramedian forehead flap from a custom-fabricated three-dimensional metal foil template derived from the measures of the nasal defect to be corrected. Using an ultrasonic scanner
Medical ultrasonography
Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...

, the flap-pedicle is centre-aligned upon the Doppler signal of the supraorbital artery. Afterwards, the distal one-half of the flap is dissected and thinned to the subdermal plexus.
  • The surgeon fabricates a metal foil template derived from the dimensions of the nasal wound.

  • Applying a Doppler ultrasonic scanner
    Medical ultrasonography
    Diagnostic sonography is an ultrasound-based diagnostic imaging technique used for visualizing subcutaneous body structures including tendons, muscles, joints, vessels and internal organs for possible pathology or lesions...

    , the surgeon identifies the axial pedicle of the tissue-flap (composed of the supraorbital artery and the supratrochlear artery
    Supratrochlear artery
    The supratrochlear artery , one of the terminal branches of the ophthalmic artery, branches off where the ophthalmic travels posterior to the trochlea.-Course:...

    ), usually at the base, next to the medial brow; the point usually is between the midline and the supraorbital notch.

  • Tracing the Doppler pulse of the blood flow of the supraorbital artery as far as possible, its delineation is continued as a vertical line, until it intersects with the hairline of the patient. The line extended from the pulse of the blood flow is the central axis of the forehead flap.

  • The length of the flap is determined by placing an un-folded, un-stretched 4 x 4-inch gauze upon the wound, and with it measuring from the pedicle base to the distal (farthest) point of the wound. This measure is the length of the central axis of the skin flap.

  • The template is rotated 180 degrees and placed over the distal (far) portion of the axis of the skin flap; the surgeon outlines it with a surgical marker. The outline markings are continued proximally and parallel to the central axis, maintaining a 2-cm width for the proximal flap.

  • Without applying an injection of anaesthetic epinephrine
    Epinephrine
    Epinephrine is a hormone and a neurotransmitter. It increases heart rate, constricts blood vessels, dilates air passages and participates in the fight-or-flight response of the sympathetic nervous system. In chemical terms, adrenaline is one of a group of monoamines called the catecholamines...

    , the flap is incised (cut), and the distal one-half is elevated between the frontalis muscle
    Frontalis muscle
    The Frontalis muscle , also known as the occipitofrontalis or epicranius, is thin, of a quadrilateral form, and intimately adherent to the superficial fascia. It is broader than the Occipitalis and its fibers are longer and paler in color...

     and the subcutaneous fat.

  • At approximately the mid-portion of the forehead, the surgeon deepens the plane of the dissection down to the submuscular plane. The dissection continues toward the brow and the glabella (the smooth prominence between the eyebrows) until the skin flap is sufficiently mobile to allow its relaxed transposition upon the nose.

  • Under loupe magnification, the distal portion of the forehead flap is de-fatted, down to the subdermal plexus. Yet, the fat-removal should be conservative, especially if the patient is either a tobacco
    Tobacco
    Tobacco is an agricultural product processed from the leaves of plants in the genus Nicotiana. It can be consumed, used as a pesticide and, in the form of nicotine tartrate, used in some medicines...

     smoker
    Tobacco smoking
    Tobacco smoking is the practice where tobacco is burned and the resulting smoke is inhaled. The practice may have begun as early as 5000–3000 BCE. Tobacco was introduced to Eurasia in the late 16th century where it followed common trade routes...

     or a diabetic, or both, because such health factors negatively affect blood circulation and tissue perfusion, and thus the timely and correct healing of the surgical scars to the nose.

  • The flap is allowed to perfuse, while the donor site is sutured closed by means of the wide undermining deep to the frontalis muscle
    Frontalis muscle
    The Frontalis muscle , also known as the occipitofrontalis or epicranius, is thin, of a quadrilateral form, and intimately adherent to the superficial fascia. It is broader than the Occipitalis and its fibers are longer and paler in color...

    . At that time, diluted epinephrine can be injected to the forehead skin, but not to the area(s) near the pedicle of the forehead flap. Moreover, if the distal wound is wider than 25 mm, it usually is not closed by primary intention, with sutures, but is allowed to heal by secondary intention, by re-epithelialisation.

  • The forehead flap is attached to the nasal wound with subcutaneous sutures and skin sutures. If the excess tension of a suture compromises the color of the skin flap, the suture can be loosened, with a skin hook, and observed for 10–15 minutes; if the skin color remains compromised (white), the suture is removed.

  • Upon the complete attachment of the paramedian forehead flap to the nose, the surgical wounds are dressed only with antibiotic ointment.


IV. Septal mucosal flap
The septal mucosal tissue flap is the indicated technique for correcting defects of the distal half of the nose, and for correcting almost every type of large defect of the mucosal lining of the nose. The septal mucosal tissue flap, which is an anteriorly based pedicle-graft supplied with blood by the septal branch of the superior labial artery. To perform such a nasal correction, the entire septal mucoperichondrium can be harvested.

Surgical technique — the septal mucosal flap
The surgeon cuts the anteriorly based septal mucosal tissue-flap as widely as possible, and then releases it with a low, posterior back-cut; but only as required to allow the rotation of the tissue-flap into the nasal wound.
  • The surgeon measures the dimensions (length, width, depth) of the nasal wound, and then delineates them upon the nasal septum
    Nasal septum
    The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

    , and, if possible, incorporates an additional margin of 3–5 mm of width to the wound measurements; furthermore, the base of the mucosal tissue flap should be at least 1.5-cm wide.

  • The surgeon then makes two (2) parallel incisions along the floor and the roof of the nasal septum
    Nasal septum
    The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

    ; the incisions converge anteriorly, towards the front of the nasal spine.

  • Using an elevator, the flap is dissected in a sub-mucoperichondrial plane. The (far) distal edge of the flap is cut with a right-angle Beaver blade, and then is transposed into the wound. The exposed cartilages will reepithelialise (regenerate the epithelium
    Epithelium
    Epithelium is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body, and also form many glands. Functions of epithelial cells include secretion, selective...

    ), provided the opposite (contralateral) side of the septal mucosa is undisturbed.


A technical variant of the septal mucosal flap technique is the Trap-door flap, which is used to reconstruct one side of the upper half of the nasal lining. It is emplaced in the contralateral nasal cavity
Nasal cavity
The nasal cavity is a large air filled space above and behind the nose in the middle of the face.- Function :The nasal cavity conditions the air to be received by the other areas of the respiratory tract...

, as a superiorly based septal mucosal flap of rectangular shape, like that of a “trap-door”. This septomucosal flap variant is a random flap with its pedicle based at the junction of the septum and the lateral nasal skeleton. The surgeon elevates the flap of septal mucosa to the roof of the nasal septum, and then traverses it into the contralateral (opposite) nasal cavity through a slit made by removing a small, narrow portion of the dorsal roof of the septum. Afterwards, the septomucosal flap is stretched across the wound in the mucosal lining of the lateral nose.

Surgical management
The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) heminasal reconstruction; and (iv) total nasal reconstruction.

I. Partial-thickness defects
A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary intention closure, with sutures. Based upon the locale of the wound, the surgeon has two (2) options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10-mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed.

In the event, larger nasal wounds (defects) do successfully heal by secondary intention, but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is a small wound directly upon the nasal tip.

Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient’s ear is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient’s neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and sebaceous glands, thus is unlike the oily skin of the nose.

The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue morbidity
Necrosis
Necrosis is the premature death of cells in living tissue. Necrosis is caused by factors external to the cell or tissue, such as infection, toxins, or trauma. This is in contrast to apoptosis, which is a naturally occurring cause of cellular death...

. The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural histologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...

 tendency for such skin grafts to contract, which might distort the shape of the corrected nose.

II. Full-thickness defects
Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately and in combination.

(a) Medial canthus
The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of wound contracture; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is aesthetically hidden by the shadows of the nasal dorsum and of the supraorbital rim, thereby obscuring any differences in the quality of the color and of the texture of the replacement skin (epithelium).

Healing by secondary intention (re-epithelialisation) occurs even when the wound extends to the nasal bone. Although the rate of healing depends upon the patient’s wound-healing capacity, nasal wounds measuring up to 10 mm in diameter usually heal in at 4-weeks post-operative. Nonetheless, one potential, but rare, complication of this nasal correction approach is the formation of a medial canthal web, which can be corrected with two (2) opposing Z-plasties
Z-plasty
Z-plasty is a plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It can elongate a contracted scar or rotate the scar tension line. The middle line of the Z-shaped incision is made along the line of greatest tension or contraction, and triangular...

, technique which relieves the disfiguring tensions exerted by the scar tissue’s contracture, its shape, and location on the nose.

(b) Nasal dorsum and lateral nasal wall defect
The size of the nasal defect (wound) occurred, in either the dorsum or the lateral wall, or both, determines the reconstructive skin-flap technique applicable to the corresponding aesthetic nasal subunits.
  • A wound of less than 10 mm in diameter can be managed either by primary intention healing (suturing) or by secondary intention healing (re-epithelialisation).

  • A wound measuring 10–15 mm in diameter can be reconstructed with a single-stage modified bilobed flap, because it best matches the skin color and the skin texture of the wounded aesthetic subunit. Although not every scar can be hidden at the margins of the aesthetic nasal subunits concerned, the superior scarring ability of those nasal skin areas minimizes such an histologic
    Histology
    Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...

     disadvantage. In a patient whose basal-cell carcinoma was excised with Mohs surgery
    Mohs surgery
    Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Frederic E. Mohs, is microscopically controlled surgery used to treat common types of skin cancer. It is one of the many methods of obtaining complete margin control during removal of a skin cancer using frozen section...

    , the scar of the nasal reconstruction (an 11-mm full-thickness, laterally based, bilobed-flap applied down to the bone and the cartilage), was hidden by aligning the axis of the second lobe to and emplacing the skin graft at the junction of the nasal dorsum and the lateral wall of the nose.

  • A wound greater than 15 mm in diameter can be corrected with a paramedian forehead flap, which will reconstruct either the entire nasal dorsum or the lateral wall of the nose, as required. The surgical management of such wounds (< 15-mm dia.) usually requires enlarging the wound as necessary, in order for the skin graft to comprehend the entire aesthetic subunit being corrected. Moreover, if the wound comprehends the dorsum and the lateral wall of the nose, then a cheek-advancement skin flap is the applicable correction for replacing the lateral nasal skin up to its junction with the dorsum; afterwards, a paramedian forehead flap is applied to resurface the nasal dorsum.

  • A wound in the lateral nasal wall that is greater than 15-mm in diameter can also be corrected with a superiorly based, nasolabial-flap, which is especially suited for correcting distal defects that lay among the convexities of the nasal tip and the alar lobule. The nasolabial flap can correct defects that comprehend the distal two-thirds of the nose, if there is a supply of skin sufficient for constructing the base of the flap pedicle; and the donor sites cannot be closed primarily. Yet, bulkiness is the principal disadvantage of the nasolabial flap — except in elderly patients with atrophic cheek skin; nonetheless, it is technically effective for patients unsuitable for a two-stage rhinoplasty with a paramedian forehead flap.

  • Nasal defects involving either the bone or the cartilage of the lateral nose are best managed with free grafts of flat septal bone and of cartilage. Small defects of the nasal dorsum can be covered with cartilage grafts harvested from either the septum or the concha of the ear. The correction of large-area defects of the nasal dorsum requires the stable support of a bone graft affixed either with a lag screw or with a low-profile plate. A costal graft (from the rib cage) is ideal for such a repair, because it can be harvested with an attached extension of cartilage that can be sculpted to blend into the nasal tip; other potential donor sites for nasal dorsum reconstruction materials are the outer table of the skull, the iliac crest, and the inner table of the ilium proper.

  • To correct a defect of the nasal lining of the upper two-thirds of the nose, the wound dimensions (length, width, depth) determine the technique. A nasal-lining defect of less than 5-mm in diameter can be closed primarily, with sutures. A nasal-lining defect 5–15 mm in diameter can be closed with a random transposition flap harvested from a nasal area that remains protected, either by the nasal bones or by the upper lateral cartilages; and the flap donor-site can be healed by secondary intention, re-epithelialisation. For a mucosa defect greater than 15-mm in diameter, the indicated correction is a superiorly based “trap door” septal mucosal flap, grafted to the roof of the nasal septum.


(c) Nasal tip defect
The width of the human nasal-tip ranges 20–30 mm; the average width of the nasal tip, measured between the two alar lobules, is approximately 25 mm.
  • A nasal skin defect of less than 15 mm in diameter can be managed with a bilobed flap; the surgeon trims the edges of the wound (defect) to match its dimensions (length, width, depth) to the natural curve at the border of the nasal tip. If the wound is eccentric, the skin-flap is positioned so that the lateral base of the graft occupies the largest portion of the wound’s surface.

  • If the nasal-tip wound is greater than 15 mm in diameter, the surgeon enlarges it to comprehend the entire aesthetic subunit affected by the defect, and the reconstruction of the nasal subunit done with a forehead flap. If the nasal-tip defect also involves the nasal dorsum, a forehead flap is indicated for reconstructing the entire nasal-tip and dorsum.

  • If an alar cartilage is missing, either partially or entirely, it is reconstructed with cartilage grafts. The defect of an alar dome, which retains adequate anatomic support-tripod configuration, can be corrected with an onlay graft harvested either from the nasal septum or from the conchal cartilage of an ear. The surgeon forms the cartilage graft into the shape of a shield — its widest margins become the replacement alar domes. Typically, the shield cartilage graft is stacked in two layers, in order to transmit the desired light reflex characteristic of the nasal tip.

  • Defects of the lateral crura can be corrected with a flat strut of formed cartilage, but, if the support of the medial crura is absent, then a columella strut must be inserted, and attached at the level of the anterior nasal spine. If a strut of nasal-septum cartilage proves too weak, then a rib cartilage strut can be applied to provide the adequate nasal support; afterwards, the strut is covered with onlay grafts.

  • Absent alar cartilages can be replaced using all of the conchal cartilage from both ears; two strips, each 10 mm wide, are harvested from the antihelical fold, and then are applied as replacement alar wings. The surgeon attaches them to the anterior nasal spine, and to each side of the (pear-shaped) pyriform aperture; the remainder of the harvested conchal cartilage is applied as onlay grafts to augment the nasal tip.

  • A nasal-tip lining defect is unusual, because of its midline location; yet, the reconstruction is with an anteriorly based septal mucosal flap that is rotated into place to provide adequate coverage and correction of the nasal lining defect.

  • Verticle lobule division (VLD) is a common technique for nasal tip refinement, which involves the medial crural angle and the lateral crural angle.


(d) Alar lobule defect
The appropriate surgical management of an alar lobule defect depends upon the dimensions (length, width, depth) of the wound. Anatomically, the nasal skin and the underlying soft tissues of the alar lobule form a semi-rigid aesthetic subunit that forms the graceful curve of the alar rim, and provides unobstructed airflow through the nostrils, the anterior nares.
  • When most of the alar lobule tissue is missing, the nose collapses; the correction is with an ear concha cartilage-graft harvested from the antihelix, a donor site where the cartilage is most rigidly curved, thus is ideal for replacing an alar lobule.

  • Nasal skin defects can be corrected with a medially based bilobed flap, which is emplaced to provide adequate skin coverage for wounds limited to the alar lobule. If the entire lobule is missing, it might be necessary to leave the second-lobe donor-site wound partially open; it will close at 2–4 weeks post-operative; afterwards, the scar can be revised. Nonetheless, the alternative surgical correction is a two-stage, superiorly based, nasolabial flap.

  • If the alar lobule defect also comprehends the lateral wall of the nose, the defect can be closed either with a superiorly based nasolabial-flap or with a forehead flap. If the cheek skin is thin and atrophic, a nasolabial flap is the recommended reconstruction; otherwise, a forehead flap is recommended, because the thickness of forehead skin is a superior match for nasal skin and tissue. Mucosal lining
    Mucous membrane
    The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...

     defects of the alar lobule can be resurfaced with a bipedicled mucosal advancement-flap harvested from inside the lateral wall of the nose. Likewise, larger defects of the mucosa do require correction with an anteriorly based septal mucosal flap.


III. Heminasal and total nasal reconstruction
The reconstruction rhinoplasty of an extensive heminasal defect or of a total nasal defect is an extension of the plastic surgical principles applied to resolving the loss of a regional aesthetic subunit. The skin layers are replaced with a paramedian forehead flap, but, if forehead skin is unavailable, the alternative corrections include the Washio retroauricular-temporal flap and the Tagliacozzi flap. The nasal skeleton is replaced with a rib-graft nasal dorsum and lateral nasal wall; septal cartilage grafts and conchal cartilage grafts are applied to correct defects of the nasal tip and of the alar lobules.

The nasal lining of the distal two-thirds of the nose can be covered with anteriorly based septal mucosal flaps; however, if bilateral septal-flaps are used, the septal cartilage does become devascularized, possibly from iatrogenic
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...

 septal perforation. Furthermore, if the nasal defect is beyond the wound-correction scope of a septal mucosal flap, the alternative techniques are either an inferiorly based pericranial-flap (harvested from the frontal bone) or a free flap of temporoparietal fascia (harvested from the head), either of which can be lined with free grafts of mucosa to achieve the nasal reconstruction.

Corrections of defect and deformity
  • Cancer — The excision of cancerous nasal skin can cause the loss of skin and internal support cartilage; such resections (surgical removal) usually are via the Mohs’ chemosurgical technique
    Mohs surgery
    Mohs surgery, also known as chemosurgery, created by a general surgeon, Dr. Frederic E. Mohs, is microscopically controlled surgery used to treat common types of skin cancer. It is one of the many methods of obtaining complete margin control during removal of a skin cancer using frozen section...

    . After removing the cancerous tissues, the reconstructive rhinoplasty will provide skin coverage using either skin grafts or pedicle flaps, (see Nasal Reconstruction, Paramedian Forehead Flap). If the resection of the cancerous skin leads to losing the nose tip, cartilage grafts can be used for support, and to prevent long-term distortion consequent to the force of the contracture of scar tissue
    Scar tissue
    Scar tissue can refer to:*Granulation tissue, a product of healing in major wounds*The tissue of a scar*"Scar Tissue", a Red Hot Chili Peppers song*Scar Tissue , the autobiography of Anthony Kiedis, lead singer of the Red Hot Chili Peppers...

    .

  • Congenital deformity — The correction of vascular
    Circulatory system
    The circulatory system is an organ system that passes nutrients , gases, hormones, blood cells, etc...

     malformations and cleft lip and palate abnormalities. In vascular malformations, the progression of the disease distorts the skin and the underlying structure of the nose. Cleft lip and cleft palate defects usually distort the size, position, and orientation of the nasal-tip cartilages. Reconstruction of vascular malformations can involve laser treatment of the skin, and surgical excision of the deformed tissues. When the underlying cartilage support structure is disturbed, cartilage grafts and suturing of the native nasal cartilages can help improve nasal aesthetics by re-orienting the nasal tip cartilages; and cartilage-graft refinements to the nose tip are performed as required.

  • Obstructed airways — The restoration of normal breathing by correcting nasal obstruction caused by a cosmetic rhinoplasty wherein nasal cartilages were over-aggressively trimmed, and the nose appears pinched, which compromises nasal potency (airflow), especially when the patient attempts deep inspiration. These grafting techniques restore normal breathing by increasing the size of the nose tip with baton grafts (internal cartilage), and spreader grafts to widen the nasal middle vault. Furthermore, to improve breathing a septoplasty
    Septoplasty
    Septoplasty is a corrective surgical procedure done fix to straighten the nasal septum, the partition between the two nasal cavities. Ideally, the septum should run down the center of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Often the...

     can be performed concurrent to the reconstructive surgery; likewise, if there is turbinate
    Turbinate
    In anatomy, a nasal concha is a long, narrow and curled bone shelf that protrudes into the breathing passage of the nose...

     hypertrophy
    Hypertrophy
    Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It should be distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number...

    , an inferior turbinectomy can be performed.

  • Perforated septum — The reconstruction of a saddle nose caused by a (collapsed) perforated septum, or by autoimmune problems such as Wegener’s Granulomatosis, Sarcoidosis
    Sarcoidosis
    Sarcoidosis , also called sarcoid, Besnier-Boeck disease or Besnier-Boeck-Schaumann disease, is a disease in which abnormal collections of chronic inflammatory cells form as nodules in multiple organs. The cause of sarcoidosis is unknown...

    , Churg-Strauss Syndrome
    Churg-Strauss syndrome
    Churg–Strauss syndrome is a medium and small vessel autoimmune vasculitis, leading to necrosis. It involves mainly the blood vessels of the lungs , gastrointestinal system, and peripheral nerves, but also affects the heart, skin and kidneys. It is a rare disease that is non-inheritable and...

    , Relapsing Polychondritis, by intranasal drug use, and by excessive nasal aerosol use. The saddle nose deformity resulting from lost dorsum support is reconstructed using autologous bone grafts and rib cartilage grafts.

  • Rhinophyma
    Rhinophyma
    Rhinophyma is a descriptive term for a large, bulbous, ruddy appearance of the nose caused by granulomatous infiltration, commonly due to untreated rosacea.- Causes :...

    — The correction of late-stage Rosacea
    Rosacea
    Rosacea is a chronic condition characterized by facial erythema . Pimples are sometimes included as part of the definition. Unless it affects the eyes, it is typically a harmless cosmetic condition...

    , wherein the nasal skin is infected with acne rosacea that reddens, thickens, and enlarges the nose tip; an exemplar case is the American actor W.C. Fields. Although antibiotic acne treatments (e.g. Acutane) can halt the progression of Rosacea, the thickened skin and the fleshy obscuring of the nasal tip can only be corrected with rhinoplasty. Laser excision of abnormally thickened skin is the best rhinoplastic treatment for Rhinophyma; the CO2 laser
    Carbon dioxide laser
    The carbon dioxide laser was one of the earliest gas lasers to be developed , and is still one of the most useful. Carbon dioxide lasers are the highest-power continuous wave lasers that are currently available...

     and the infrared Erbium: YAG laser
    Er:YAG laser
    Er:YAG lasers are solid-state lasers whose lasing medium is erbium-doped yttrium aluminium garnet . Er:YAG lasers typically emit light with a wavelength of 2940 nm, which is infrared light. Unlike Nd:YAG lasers, the output of an Er:YAG laser is strongly absorbed by water because of atomic resonances...

     are the most effective treatments.


  • Wide nose — To narrow a too-wide nose, the plastic surgeon cuts, contours, and rearranges the craniofacial bones to achieve the desired functional and aesthetic outcome of a narrower, straighter nose. To leave no visible, surgical scars upon the new nose, the surgeon effects the osteotome (bone chisel) incisions to the nasal bones beneath the facial skin.




Illustration 1: The surgeon cuts the excessively wide bones of the upper nasal dorsum
Dorsum (biology)
In anatomy, the dorsum is the upper side of animals that typically run, fly, or swim in a horizontal position, and the back side of animals that walk upright. In vertebrates the dorsum contains the backbone. The term dorsal refers to anatomical structures that are either situated toward or grow...

 (violet) with an osteotome
Osteotome
An osteotome is an instrument used for cutting or preparing bone.The instrument was invented by Bernhard Heine, a German physician in Würzburg, in 1830. Heine's invention was used as a bone saw, especially for opening the skull. It was a kind of chain saw moved by turning a winder.Today osteotomes...

 (bone chisel), then detaches, corrects, and relocates them inwards, to a position, between the ocular orbits (red), that narrows the width of the nasal dorsum.


Illustration 2: The surgeon chisels two cuts (incisions) to the nasal bones, each incision begins at the nasal cavity. The first incision begins at the yellow dot and extends upwards, along the green arrow, until meeting the zig-zag line (red). The second incision begins at the blue dot and extends upwards, along the black arrow, until meeting the zig-zag line (red). Once cut and loosened from the face, the nasal bone pieces are corrected, then pushed inwards and re-set, thus narrowing the nose.



Post–surgical recovery
Convalescence
The rhinoplasty patient returns home after surgery, to rest, and allow the nasal cartilage and bone tissues to heal the effects of having been forcefully cut. Assisted with prescribed medications — antibiotics, analgesic
Analgesic
An analgesic is any member of the group of drugs used to relieve pain . The word analgesic derives from Greek an- and algos ....

s, steroid
Steroid
A steroid is a type of organic compound that contains a characteristic arrangement of four cycloalkane rings that are joined to each other. Examples of steroids include the dietary fat cholesterol, the sex hormones estradiol and testosterone, and the anti-inflammatory drug dexamethasone.The core...

s — to alleviate pain and aid wound healing, the patient convalesces for about 1-week, and can go outdoors. Post-operatively, external sutures are removed at 4–5 days; the external cast is removed at 1-week; the stents are removed within 4–14 days; and the “panda eyes” periorbital bruising
Raccoon eyes
Raccoon eyes or periorbital ecchymosis is a sign of basal skull fracture, a craniotomy that ruptured the meninges, or certain cancers. Bilateral subconjunctival hemorrhage occurs when damage at the time of a facial fracture tears the meninges and causes the venous sinuses to bleed into the...

 heal at 2-weeks. Throughout the first year post-operative, in the course of the rhinoplastic wounds healing, the tissues will shift moderately as they settle into being a new nose.

Surgical risks
Rhinoplasty is safe, yet complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...

 can arise; post-operative bleeding is uncommon, but usually resolves without treatment. Infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...

 is rare, but, when it does occur, it might progress to become an abscess
Abscess
An abscess is a collection of pus that has accumulated in a cavity formed by the tissue in which the pus resides due to an infectious process or other foreign materials...

 requiring the surgical drainage of the pus
Pus
Pus is a viscous exudate, typically whitish-yellow, yellow, or yellow-brown, formed at the site of inflammatory during infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule or...

, whilst the patient is under general anaesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...

. Adhesions, scars that obstruct the airways can form a bridge across the nasal cavity, from the septum
Nasal septum
The nasal septum separates the left and right airways in the nose, dividing the two nostrils.It is depressed by the Depressor septi nasi muscle.-Composition:The fleshy external end of the nasal septum is sometimes also called columella....

 to the turbinates, and require surgical removal. If too much of the osseo-cartilaginous framework is removed, the consequent weakening can cause the external nasal skin to become shapeless, resulting in a “polly beak” deformity, resembling the beak of a parrot
Parrot
Parrots, also known as psittacines , are birds of the roughly 372 species in 86 genera that make up the order Psittaciformes, found in most tropical and subtropical regions. The order is subdivided into three families: the Psittacidae , the Cacatuidae and the Strigopidae...

. Likewise, if the septum is unsupported, the bridge of the nose can sink, resulting in a “saddle nose” deformity. The tip of the nose can be over-rotated, causing the nostrils to be too visible, resulting in a porcine
Pig
A pig is any of the animals in the genus Sus, within the Suidae family of even-toed ungulates. Pigs include the domestic pig, its ancestor the wild boar, and several other wild relatives...

 nose. If the cartilages of the nose tip are over-resected, it can cause a pinched-tip nose. If the columella is incorrectly cut, variable-degree numbness might result, which requires a months-long resolution. Furthermore, in the course of the rhinoplasty, the surgeon might accidentally
Iatrogenesis
Iatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...

 perforate the septum (septal perforation), which later can cause chronic nose bleeding, crusting of nasal fluids, difficult breathing, and whistling breathing.

Non-surgical rhinoplasty

The visage
Because it is the anchor-feature at the center of the face, an aesthetically proportionate nose balances the physiognomic features of a person to produce a handsome face in a man, and a beautiful face in a woman. Therefore, the rhinoplastic correction (surgical or non-surgical) of any defect or deformity (functional and aesthetic) is important, lest an aesthetically disproportionate nose distract the beholder’s attention from the other features of the face, such as the eyes, the lips, the cheekbones, and the jaw line.

Non-surgical précis
A non-surgical rhinoplastic correction is performed upon a patient under local
Local anesthesia
Local anesthesia is any technique to induce the absence of sensation in part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It allows patients to undergo surgical and dental procedures with...

 anaesthesia; the plastic surgeon
Plastic surgery
Plastic surgery is a medical specialty concerned with the correction or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic: plastic surgery includes many types of reconstructive surgery, hand...

 uses a syringe and a hypodermic needle (e.g. 27-G, 25-mm) to inject and emplace the soft-tissue filler under the nasal skin, most commonly in the deep subcutaneous tissues, and, occasionally, immediately above the (periosteum), in order to correct the nasal defect or deformity, or to achieve the desired modification. Filler-injection technique makes feasible corrections such as the augmentation of a flat nasal bridge (depressed dorsum); the added projection of the nasal tip; the camouflage diminution of a nasal hump; the filling of a nasal sidewall depression; the enhancement of a retracted anterior nasal spine; the enhancement of a retracted maxilla lateral to the pyriform (pear-shaped) aperture, to displace the anterior plane; the elevation of a saddle nose deformity caused by a failed primary rhinoplasty; and traumatic injury. The technical procedures for injecting and emplacing the soft-tissue filler require approximately 1-hour to perform in the surgeon’s consultation room; thus, upon completion of the filler-injection operation, the patient convalesces at home, and resumes his or her normal life activities.

Indications and technique
Non-surgical correction is indicated for the rhinoplasty patient who presents an innate, treatment-suitable aesthetic defect, or one occurred after a surgical rhinoplasty (either primary or secondary). Nonetheless, the functional and corrective limitations of the soft-tissue-filler medium indicate a surgical correction for the patient whose nasal defect requires extensive anatomic correction that exceeds the (aesthetic) technical scope of filler-injection procedure — which does not increase, nor does it decrease the size of the nose, and does not correct functional defects.

The corrective and technical efficacy of non-surgical rhinoplasty — achieved with syringe-and-hypodermic-needle injections of fillers to the soft tissues of the nose — was confirmed with the Australian study Rhinoplasty Using Injectable Polyacrylamide Gel — A Patient Study (2005), by Dr. Andrew Tuan-anh Le, which reported the pilot study assessment of injection techniques for emplacing a non-biodegradable colloid-filler to the soft tissues of the nose for the correction of a nasal dorsum defect; and ascertained the medical suitability of non-surgical rhinoplasty as a treatment alternative to surgical rhinoplasty.

Non-surgical technique
An aesthetically proportionate and functional nose for the patient was the satisfactory corrective outcome required of the assessed filler-injection techniques. In the 12-month pilot study, the nasal dorsum defects of 89 patients (84 women, 5 men, 32 yrs. avg. age) were non-surgically corrected with filler-injection treatments of polyacrylamide gel (PAAG), a non-biodegradable, hydrophilic filler for soft tissues (commercially: Aquamid). As a soft-tissue filler, PAAG is a chemically dynamic, hydrophilic colloid
Colloid
A colloid is a substance microscopically dispersed evenly throughout another substance.A colloidal system consists of two separate phases: a dispersed phase and a continuous phase . A colloidal system may be solid, liquid, or gaseous.Many familiar substances are colloids, as shown in the chart below...

 that continually exchanges water molecules with the surrounding nasal tissues, thus minimizing the risk of histologic
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...

 rejection.

Pre-operatively
  • local
    Local anesthesia
    Local anesthesia is any technique to induce the absence of sensation in part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It allows patients to undergo surgical and dental procedures with...

     anaesthesia of the pertinent aesthetic nasal subunit was via direct infiltration with lidocaine
    Lidocaine
    Lidocaine , Xylocaine, or lignocaine is a common local anesthetic and antiarrhythmic drug. Lidocaine is used topically to relieve itching, burning and pain from skin inflammations, injected as a dental anesthetic or as a local anesthetic for minor surgery.- History :Lidocaine, the first amino...

     and adrenaline.

  • Aseptic operating technique was achieved with a Betadine
    Betadine
    Povidone-iodine is a stable chemical complex of polyvinylpyrrolidone and elemental iodine. It contains from 9.0% to 12.0% available iodine, calculated on a dry basis....

     preparation complemented with alcohol
    Alcohol
    In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....

     swabs and hydrogen peroxide
    Hydrogen peroxide
    Hydrogen peroxide is the simplest peroxide and an oxidizer. Hydrogen peroxide is a clear liquid, slightly more viscous than water. In dilute solution, it appears colorless. With its oxidizing properties, hydrogen peroxide is often used as a bleach or cleaning agent...

     at 3.0 per cent concentration.


Operatively
  • The nasal-correction work area was the anatomic triangle delineated from the glabella (at the apex), the nasolabial folds (at the base), and the external nose proper (at the center).

  • The operating field for applying the injections of the PAAG filler (polyacrylamide hydrogel) was the midline strip (1–2 mm wide) along the length of the nasal dorsum.

  • For the initial injection of PAAG hydrogel filler, the syringe was perpendicular to the nasal skin surface. On penetrating the nasal skin, the surgeon advanced the hypodermic needle until it reached the nasal bone, and then penetrated under the periosteum
    Periosteum
    Periosteum is a membrane that lines the outer surface of all bones, except at the joints of long bones. Endosteum lines the inner surface of all bones....

     membrane of connective tissue.

  • The hydrogel filler was injected with a 27-gauge, 25-mm hypodermic needle, at bevel up, that was poised at a 30º–45° angle to the nasal area being corrected.

  • The surgeon gently injected the hydrogel filler to the nasal defect, and emplaced it by simultaneously and slowly withdrawing the needle from the nose, thus dispersing the filler to the pertinent soft tissues.

  • The nasal defect correction was realized with a thin wall of PAAG filler emplaced between the roof (the superficial tissues of skin- and fat-layers) and the base (the deep tissues of bone and cartilage) of the nasal dorsum.

  • The corrective filler-injections of polyacrylamide hydrogel were repeated until achieving the desired degree of nasal dorsum height and shape.


Post-operatively
  • Because of the immediate, post-operative nasal swelling, consequent to the mechanical pressures of the filler-injection procedure, the height of the (new) corrected nasal bridge is approximately 20–30 per cent greater than the true height of the correction; resolution of the post-operative nasal swelling was aided with 4-times-daily applications of chloramphenicol
    Chloramphenicol
    Chloramphenicol is a bacteriostatic antimicrobial that became available in 1949. It is considered a prototypical broad-spectrum antibiotic, alongside the tetracyclines, and as it is both cheap and easy to manufacture it is frequently found as a drug of choice in the third world.Chloramphenicol is...

     ointment.

  • At 12-months post-operative, all short-term side effects occurred had been minor and transient; the follow-up examinations of the 89-patient cohort of the pilot study indicated their satisfaction with the outcomes of their non-surgical rhinoplasty — an aesthetically proportionate nose of natural form, look, and feel.


Photographic non-surgical records



See also

  • Otolaryngology
    Otolaryngology
    Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....


  • Oral and Maxillofacial Surgery
    Oral and maxillofacial surgery
    Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...


  • Nasal Reconstruction, Paramedian Forehead Flap

External links

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