RHINOPLASTY- NOSE JOB ANATOMY AND ESSENTIAL PHYSIOLOGY

Schematic Anatomy of Nasal Bones and Cartilages. Nomenclature of Anatomy of External Nose

 

 

The Anatomy of the Nose

 

The human nose has a complex structure with many anatomical variations which result in different shapes and sizes of nose from large, small, short, drooping, long, hooked, humped, bulbous, turned up, crooked, internal deviations and at least a possible two hundred other variations. Rhinoplasty nose job anatomy knowledge is crucial to successful shaping surgery.

 

The nasal cartilages, the nasal bones, the nasal septum, nasal skin envelope, the angles, triangles and the angles it makes with the face are all variable and unique to every nose.

 

The arrangement, size and proportions of the anatomical structures of the nose in relation to the face, convey beauty or otherwise to our aesthetic experience. The nerve supply, blood supply, the anatomical organisation, intricacies and structure of the external and internal nose are a minefield of anatomy and physiology which every specialised nasal surgeon spends years of study in mastering.

 

The angles, triangles, orientation, width, length positioning and facial proportions of the nose have artistic parameters that need to be considered by the surgeon in every surgical, cosmetic nose shaping. These are not going to be discussed here, as they are the concern of the nasal surgeon and this knowledge will not aid you in making a decision for better surgery.

 

Suffice it to say that the 'skeleton’ of the nose which gives it its shape and form, is complex but can be basically explained in that it consists of the nasal cartilages and the nasal bones (which are two and abut on each other centrally and on each side-<laterally> on the maxilla) form the hard roof or bridge of the nose. The shape of these bones and cartilages is inherited but they are also often broken in nose injury and may heal in such a way that they may become very prominent or deviated from the midline causing a ‘crooked nose’, a ‘humped nose’, a ‘deviated nose’ or a ‘flat’ nose. The nasal surgeon often has to narrow a broad bridge by in-fracturing the nasal bones and repositioning them, as well as chiseling and rasping them to remove a hump or bump.

 

Don’t be fooled about the hump- most ‘humps’ that protrude from the midline of the nose are often mainly cartilaginous (rather than bony). The hump may appear to you to be huge, but it is usually only millimeters thicker than what it should be. The surgical expertise and aesthetic values of the surgeon are tested to the limit as to how many millimeters he has to remove in order to achieve an aesthetic, proportionate nose. In some cases the paradox of augmentation (rather than removal of tissue) to the nose is necessary in order to obtain an aesthetically beautiful nose! It's often all a matter of art and aesthetics rather than surgery. So we repeat, choose your surgeon!

 

In the African and Oriental nose the nasal bones are flatter than the Caucasian or European nose and a prominent hump or fracture in Caucasian noses is quite common but hardly possible in the African nose. The African nose that has a low bridge also has a septal cartilage that is not well defined, and for this reason cartilage for grafting is usually not taken in African nose surgery.

 

The tip of the nose may 'broad' or ' an amorphous bulb' or 'square like'. This is most often due to asymmetry of the upper, lower and alar cartilages (there are two lower and two upper cartilages on each side which form the tip of the nose, as well as so-called alar cartilages - (wing-like cartilages- which form the sides of the lower tip of the nose). In African noses these can be broad, thin and flattened, whereas in the Caucasian nose, they are sturdy and more erect and contribute to the triangle of the nose tip. (The triangle is seen from the bottom view of the nose, with the tip being the apex of the nose and the base of the nose being just above the upper lip). Cosmetic surgery of the tip is probably the most important and difficult part of nasal cosmetic surgery because the cartilages of the tip have to be modified, replaced, sectioned, turned around, sutured and sometimes grafted in order to optimize the aesthetic result.

 

The nasal passages are separated in the midline by a bony and cartilaginous structure known as the septum. The nasal passages are lined by mucous membrane which also cover protuberances on the side walls of the nose called conchae (or turbinates). These conchae are the air conditioners and filters of the nose-(see physiology). The septum is often deviated, causing restriction to airflow. This deviation combined with swollen side walls (turbinates-may become swollen) may also cause airflow obstruction. There can also be valve-like obstructions in the nose which with time and age become worse. These complications can only be surgically corrected by the expertise of a surgeon trained in nasal anatomy and physiology and are generally beyond the expertise of a general plastic surgeon.

 

Acknowledgements: Reproduction of anatomy diagrams. 
Reconstructive Plastic Surgery-Converse W.B. Saunders Company 
Dallas Rhinoplasty-Nasal Surgery by the Masters-Quality Medical Publishing, Inc


PHYSIOLOGY OF THE NOSE

 

The nose is a complex organ with important anatomical and functional structures. By means of its mucous membrane lining it causes warming, cooling, moistening and filtering of inhaled air. The sense of smell and stimulation of reflex pathways responsible for many bronchial and heart functions are mediated by nerve pathways inside the nose.

 

On the side wall of each nasal passage are located the nasal turbinates which are the air conditioners of the nose. These turbinates are tissue masses with a rich blood supply and millions of mucous and serous glands, which when stimulated produce copious nasal fluid which is often misinterpreted as 'post nasal drip' or 'sinusitis'. The normal physiological functions and reflexes of the nose are important for comfortable and healthy living and should be respected in any cosmetic surgical intervention. The most common cause of over stimulation of the nasal turbinate mucosa is allergy-this causes swelling of the mucous membrane and blockage. If the septum of the nose is off centre then this can cause severe blockage and even sinus infections by blockage of the sinus openings into the nose.

 

One of the most important physiological functions of the nose is smell. This is a primitive and an important function of the nose which is important to the survival of the species. With smell mammals detect 'food', often from great distances. Smell also alerts them to danger of predators and to the presence of the opposite sex. Females and males are sensitive to the odour of ovulatory cycles. Pheromones attract and it is well known that sexuation stimulation in men often produces nose blockage due to the engorgement of the nose turbinates. There is therefore also a very important sexual function of the nose. A multi-billon dollar industry (perfume), is built around the physiology of smell and pheromones, so don't under estimate its importance. 

 

The para-nasal sinuses open into the nasal passages and can be the seat of various pathologies, the most common one being allergy and 'sinusitis'.

 

Very often people have a partially blocked nose usually more on one side than on the other. It is beyond our scope on this web page to discuss the various causes of nasal blockage. Suffice it to say that the most common cause of nasal blockage in people presenting for cosmetic nasal surgery, is allergy or a narrowing of the nasal passages due to a nasal valve problem or a deviation of the septum. Narrowing of the nasal passages can also be the result of nasal bone and cartilage deviations. In many cases there is mucous membrane lining thickening-most often due to allergy, polyp formation or infection-which contributes to nasal blockage and possibly to snoring.

 

Nasal inspiratory flow obstruction (this usually is combined with expiratory flow obstruction) does cause major cardiac and bronchial medical complications. These obstructions cause compromise of respiratory, ventilatory and cardiac functions which become manifest in many young, healthy sports people especially in sports exertion. Ask any sports trainer and he/she will verify that optimal, physical sport exertion cannot be attained when breathing cannot be easily conducted through the nose. The nasal passages are extremely rich in nerve supply that affect bronchial dilatation and heart rate during exercise. This affects oxygenation, metabolism and muscle function. Not only is the volume of air inspired important, but the intranasal inspiratory and expiratory pressures are also important. Probably the most important first organ that has to work effectively and efficiently, especially during physical training and exertion, is the nose.

 

Often people have poor quality sleep because of nasal obstruction which commonly is due to anatomical or septal deviation, thickened mucous membranes, polyps or mid-vault narrowing of the nasal passages. This leads to snoringinadequate lung ventilation and sleep apnoea resulting in lack of pep and vitality, general tiredness and a variety of medical consequences. Treatment commonly consists of relieving the obstruction by plastic surgery of the nasal septum with repositioning and insertion of spreader grafts. This highly specialised surgery falls under the scope of nasal cosmetic or plastic surgeons trained in nose and throat surgery. During noseplasty surgery nasal patency is optimised in order to prevent the possibility of snoring and the preservation of healthy mucous membranes and physiology of the nose is respected.

 

Be cautioned! A severe complication of septal cartilage surgery is the perforation or excessive surgical removal of the nasal septum. If the nasal septum is surgically partially or wholly removed (usually performed by nasal surgeons to relieve nasal obstruction) or has been perforated due to a variety of medical, toxic or other causes, then if cosmetic surgery has to be performed or cartilage is required for grafting purposes, it will not be available and the reconstructive, cosmetic surgery will be compromised. The partial absence or a large perforation of the nasal septal cartilage can also cause considerable problems to nasal physiology. This over time leads to a collapse of the nasal bridge and interference with normal nasal physiology, resulting in nasal dryness, crusting, discharge, impairment of smell, chronic infections and foetid odour.

 

It is therefore advisable, optimal and important to have the necessary septal surgery performed at the same time as the cosmetic nasal surgery and not prior or after the rhinoplasty.

 

We don’t intend to give you more than an overview of the physiology and anatomy of the nose, because you can look up detail in anatomy and physiology books or in web sites. The nasal passages are often involved in common functional problems such as obstructions to airflow, nasal allergies, bleeding, headaches, snoring, polyp formation, migraines, sinus infections and tumors etc. We want to impress on you that only specialist surgeons, trained in inner nasal anatomy, pathology, physiology, function, and surgery can safely diagnose, treat and perform surgery on the above mentioned problems of the inner nose, from which grafting material often needs to be obtained for nose shaping cosmetic surgery. The nose is important from the point of view of aesthetics of the face, but more important to you the individual, is that the nose functions are preserved. So be sure that your aesthetic or plastic surgeon is well trained in nose function. A nose that loses it's exquisite functions, no matter how good it looks, is disastrous! There are many plastic surgeons who might do excellent modelling of the aesthetics of the nose but have no ENT training. See Understanding Rhinoplasty
Choose your nose surgeon carefully!

 

 

Text 21 Feb 2017