Nasal Anatomy and Rhinoplasty

The appearance and function of the nose depend on a framework of bone and cartilage covered by skin and soft tissue. Understanding these structures is important in rhinoplasty because changing one part of the nose can influence the shape, support and function of other parts.

The nasal bones and bridge

The upper part of the nasal bridge is formed primarily by the paired nasal bones. Below the nasal bones, the bridge continues as a cartilaginous structure formed by the septum and the paired upper lateral cartilages.

Together, these structures contribute to the nasal dorsum — the line of the bridge seen particularly clearly from the side and three-quarter views.

A prominence along the bridge is commonly described as a dorsal hump. A dorsal hump may contain bone, cartilage or a combination of both. Its appearance is also influenced by the height of the upper bridge and the position and projection of the nasal tip.

The nasal septum

Inside the nose, the nasal septum separates the left and right nasal cavities. The front portion of the septum is predominantly cartilage, while further back it is formed by bone.

The septum has two important roles in rhinoplasty. It contributes to the central structural support of the nose and can also influence nasal breathing when it is significantly deviated.

Septal cartilage is also a useful source of the patient's own cartilage for grafting during rhinoplasty. Depending on what is required, cartilage may be used to support or reconstruct different parts of the nasal framework. In revision rhinoplasty, where septal cartilage may have previously been removed, cartilage from the ear or rib may sometimes be considered.

The upper lateral cartilages and nasal airway

The upper lateral cartilages form part of the middle third of the nose and have an important relationship with the nasal septum.

These structures contribute to both the shape of the middle nasal vault and the internal nasal valve, an important region of the nasal airway.

This is one reason that changing the bridge of the nose cannot always be considered independently of nasal function. When a dorsal hump is reduced or the middle part of the nose is reconstructed, the relationship between the septum and upper lateral cartilages needs to be considered.

The nasal tip and alar cartilages

The lower part of the nose is supported principally by the paired lower lateral cartilages, also known as the alar cartilages. Their shape, strength and position contribute to the appearance and support of the nasal tip and nostril margins.

Tip appearance is also influenced by the overlying skin and soft tissues. A relatively thick skin envelope, for example, can make the underlying cartilage less visible and may influence how much tip definition can reasonably be achieved.

For this reason, nasal tip surgery is not simply a matter of changing cartilage shape. The existing cartilage, its structural support and the characteristics of the overlying tissues all need to be considered.

Nasal structure, breathing and appearance

The structures responsible for the appearance of the nose are closely related to those responsible for its function.

A deviated septum, narrow nasal valve, weakness of the lateral nasal wall or changes following previous surgery or trauma can contribute to nasal obstruction. Some people seeking cosmetic rhinoplasty therefore also have functional concerns that need to be assessed separately.

Conversely, changing the external shape of the nose can alter relationships within the nasal framework. My approach to rhinoplasty is therefore to consider appearance, nasal breathing and structural support together, rather than treating the external nose in isolation.

Anatomy and rhinoplasty planning

No single nasal shape or proportion is appropriate for every face. Assessment considers the nasal bones, bridge, septum, upper and lower lateral cartilages, nasal tip, airway and skin and soft-tissue envelope, as well as their relationship with the surrounding facial features.

These structures also have their own mechanical characteristics. Cartilage and soft tissues have tension and elasticity, while healing and scar remodelling continue to influence the nose after surgery.

This is why I think about rhinoplasty not only in three-dimensional anatomical terms, but also in terms of tissue mechanics and change over time.

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