The human nose is a remarkable structure that serves both a cosmetic and functional role. Functionally, the nose serves as a primary airway, allowing for oxygenation (breathing oxygen in) and ventilation (breathing carbon dioxide out). The functionality of the nose is largely defined by its structure, which is incredibly complex. The patient and the plastic surgeon must respect and understand this functionality before surgery, as a beautiful but non-functional nose is not a desired endpoint for either of us. In other words, each procedure must balance beauty and function to be truly spectacular.
Nasal structure is defined in several different ways. From a structural standpoint, it is divided into three different vaults:
- Upper Vault/Bony Vault
- Middle Vault
- Lower Vault/Nasal Tip
As shown in the photograph, the vertical division also corresponds to the support structures in the nose. The upper 1/3 is almost exclusively bone internally, surrounded by a thin layer of subcutaneous fat and skin. The middle 1/3, or middle vault, shows a transition from the bony structure of the nose into a complex cartilaginous structure. The lower vault, or nasal tip, comprises cartilage only, covered by nasal skin and a thin layer of subcutaneous fat. The nose’s cartilage structure is crucial for its functionality and appearance, especially in the lower vault or nasal tip.
There are three cartilage components in the nose:
- Septal cartilage
- Upper lateral cartilages
- Lower Lateral cartilages
Diagram of Internal nasal support structures.
The size, position, and orientation of the nasal bones and the nose’s cartilaginous structures primarily define the nose’s shape and aesthetics. As such, any rhinoplasty procedure must be designed to improve the positioning of the nasal bones and cartilage without removing their ability to support the nose. Maintaining support of the nose is critical to success in rhinoplasty. To create a beautiful and functional nose, a balance must be struck between nasal beauty and structure/support during surgery.
The nose is evaluated by several fixed points and angles, as shown in the figure below. There are three angles of critical importance:
- The Nasofacial angle
- The Nasofrontal angle
- The Nasolabial angle.
As shown in the figure below, the size of each angle and their relationships to each other define the overall aesthetic of the nose. During a rhinoplasty procedure, Dr. Durkin will strive to create an ideal set of angles for your best possible result without compromising nasal function.
Diagram of the analytic nasal angles evaluated before rhinoplasty.
The last crucial analytic step in nasal analysis is how the nose relates to the face. The nose must be harmonious with the overall facial structure, especially from a profile standpoint. As such, the nasocervical angle, as shown below, must be evaluated and managed. Rhinoplasty will almost always impact the overall profile of the face, and its success can be minimized with an underprojected chin. Because of this, the face profile must be evaluated during rhinoplasty analysis. Combining chin implantation with rhinoplasty in the context of an underprojected chin is very common.
We believe in creating beauty by supporting the nasal structure rather than removing or resecting it. Besides prominent nasal bumps, we try to create a more ideal and pleasing nose by adding to its support structure rather than removing it. This does not mean that we seek to increase the size of people’s noses. Quite the contrary, we seek to refine and improve an individual’s nose by repairing the natural anatomy present in every nose rather than removing it. We do not believe in resectional approaches to the upper and lower lateral cartilages.
Moreover, we believe in repositioning these critical structures into their ideal positions and reinforcing their new position with support techniques, such as cartilage grafting, allograft cartilage grafting, and suture techniques. The only time that we stress a resectional approach is when patients present with large nasal humps. In these cases, we will resect the excess cartilage and bone present in the dorsum of the nose. However, in dealing with the middle and lower vaults of the nose, we are very conservative with resectional techniques, and we always attempt to improve nasal support rather than remove it.
