The Anatomy of the Nose
Although the nose looks like a structure with continuous, flowing lines, it is made up of many separate components that need to fit together in a very specific way to create those lines. The smooth, seamless continuity that nature can create needs to be replicated or mimicked by the rhinoplasty surgeon.
The nose is unique compared to most other parts of the human body subjected to esthetic surgery. It is a hollow organ with an outer skeleton containing empty space. In addition, form and function are very closely related. Specifically, the breathing function of the nose is intimately linked to its shape. Therefore, it is very important that the nose’s function be considered during rhinoplasty surgery. Esthetic modification needs to avoid disrupting the delicate balance that allows the nose to function properly as a breathing organ. Furthermore, if a patient undergoing a rhinoplasty also has breathing difficulties, form and function need to be addressed simultaneously. Therefore, the surgeon needs to have expertise and experience in both esthetic and functional nasal surgery.
Components of the Nose
The nose is composed of a skeleton covered by “the skin-soft tissue envelope”. The skeleton is composed of several bones and cartilages of different shape connected together. Another very important component of the skeleton, which is inside the nose, is the nasal septum. The septum is a vertical wall separating the two nostrils into right and left. It is similar to a pole holding up a tent. The tent, in this case, is the remaining skeleton of cartilage and bones of the nose, as well as the skin and soft tissue envelope covering them.
The skin-soft tissue envelope is composed of layers of soft tissue, muscle, and skin. It envelops the skeleton. In certain areas of the nose where there is no skeleton underneath, it alone provides shape to the nose. An example of this is the nostrils where no skeleton exists and the shape of the nostrils is formed by the soft tissue itself.
The Skeleton of the Nose
The top third of the nasal skeleton, near the eyes, is composed of the nasal bones. The middle third is composed of cartilage. The lower third at the tip, also composed of cartilage, is perhaps the most complex. The cartilages of the tip have a very specific shape that varies for each person. Their bend and curvature give the nasal tip its very characteristic shape. In addition, the strength of the tip cartilages is responsible for holding up the tip, supporting it, and maintaining the nose open to allow for adequate breathing. Alteration of these cartilages needs to be planned correctly and performed meticulously to produce the desired esthetic result while maintaining or even enhancing the breathing ability of the nose.
The septum also forms an integral part of the nasal skeleton. It is a vertical wall that separates the two sides of the nose. It is not a visible component of the nasal anatomy, but perhaps the most important one. The septum is effectively a sheet, composed of cartilage and bone, which is “sandwiched” between two layers of mucosa (the pink moist cover lining the inside of the nose, which is similar to the lining of the mouth).
Many people have a certain degree of deviation of this septum rendering the space in the two sides of the nose asymmetrical. This does not usually pose a problem. However, a small number of people have a deviation severe enough to cause a significant narrowing of the breathing passage on one or both sides of the nose. This causes nasal obstruction that is only correctable surgically. In certain instances, a marked deviation of the septum may take the external nose with it leading to a crooked nose. This is similar to a tent pole that is leaning toward one side or another. As a result, the tent will be deviated in the same direction as the pole.
The Skin-soft Tissue Envelope
This is a very important component of nasal anatomy that is frequently overlooked by inexperienced surgeons. Skin types vary a great deal among different ethnic groups and a significant variability also exists within members of the same ethnic group. People with fair skin and/or freckles, frequently have thin skin and soft tissues. People with darker skin or people of southern European, Mediterranean or Middle-Eastern descent generally have thicker, oilier skin. A “medium” type of skin is frequently found among people with a northern European background. In addition, certain groups of people have nasal anatomy that requires specific needs, for example Asians and people of African descent.
Generally speaking, when skin is very thick, it limits what can be done surgically on the nose. Rhinoplasty targets mainly the skeleton of the nose, the cartilages and bones. When skin is very thick, particularly at the tip of the nose, it camouflages the appearance of the tip cartilages and, in the same way, blunts any refinements made to those cartilages. Given that very little can be done to modify this skin, this poses a limitation on the degree of refinement or reshaping that can be accomplished with rhinoplasty. Very thin skin and soft tissues pose a different challenge. The bone and cartilage are clearly visible under this kind of skin. As a result, even minor imperfections in the underlying structures, whether they are inherent to the patient’s anatomy or as a result of surgical alteration, will be evident.
People with very thick or very thin skin can still be good candidates for surgery. Excellent results can be achieved with rhinoplasty, particularly if the surgeon takes into careful consideration the patient’s particular skin type.
The Septum
A deviated septum should be repaired surgically when it causes either an internal nasal obstruction or, in certain instances, an external cosmetic deformity. To obtain the best results, the deviated septum should be surgically repaired during the rhinoplasty. This repair can include removal of certain deviated portions of cartilage or bone that form the septum. However, there are certain areas of the cartilage of the septum that are critical to the support of the nose and cannot be removed. In these areas, the cartilage needs to be reshaped into a straighter configuration. Not surprisingly, considerable experience in septoplasty is required in order to accomplish this successfully. Therefore, rhinoplasty surgeons should have experience not only in repairing the outer esthetics of the nose, but also in repairing the functional aspects of the nose.
The Cartilage has a “Memory”
As mentioned, the structure of the nose is made up of a combination of cartilage and bone. The upper third of the nose is mainly bone while the lower two thirds are entirely made of cartilage. However, cartilage and bone differ a great deal in their composition, and therefore the techniques used to modify them are different.
To alter the shape of a bone, the surgeon can simply break it, reposition it, and place a splint to support it and let it heal in the desired position. Cartilage is quite different, however. If one looks at the ear, which is composed entirely of cartilage, it has a very characteristic shape with a variety of curvatures and folds. If one bends the ear and then releases it, it immediately returns to its original shape. This elasticity is what is sometimes referred to as the ”memory” of the cartilage. This makes cartilage more challenging for the surgeon to work with. He needs to employ various maneuvers to overcome this memory and ensure that the modifications will be permanent.
Summary
Knowledge and consideration of the nasal anatomy is a key requirement for successful rhinoplasty surgery. A surgeon who is mindful of achieving an optimal esthetic result while maintaining the key anatomic components of the nose is most likely to obtain the best results for his patients.
If you would like to learn more about the anatomy of the nose, please contact our office to set up a consultation.