Incisions at the alar base used to narrow the nostrils. There are many ways to reduce nostril size. The larger category term for reduction of nostrils is called alar base reduction. Weir Incisions are the most commonly referred to type of nostril reduction using external incisions.
The incisions are designed to be camouflaged really well inside the grooves of the edge of the nostril where it meets the face.
These are the hairs on the inside of the nose which lie along the edge of the nasal cartilages. These are used for filtration of large air particles, and serve to keep the inside of the nose relatively clean.
These are often trimmed at the beginning of a rhinoplasty to help make the procedure easier.
This is narrowing of the middle third of the nose which can lead to nasal breathing issues. This can be congenital (since birth) or from trauma or previous surgery. Vestibular stenosis repair is the process by which surgeons widen the middle third of the nose, usually by using grafting such as spreader grafts.
The upper paired cartilages. There are two of these in each nose. They are one of two pairs of nasal cartilages in the nose. The other paired cartilages are the lower lateral cartilages. Lateral refers to being on each side of the nose. They are attached superiorly to the nasal bones. Inferiorly, their articulate (interconnected with connective tissue) to the lower lateral cartilages, which are paired as well. The upper lateral cartilages have a lot of effect on breathing. They must be carefully managed during rhinoplasty both for form and shape. If they are not addressed, there may be an undesirable cosmetic or functional outcome.
The arrows show the two paired Upper Lateral Cartilages.
Horizontal columns of bone and tissue on the inside of the nose. There are three levels: Inferior, middle, and superior. The inferior is the largest of the three, and it is the turbinate most likely to cause nasal obstruction. Turbinoplasty or turbinate reduction is reduction in the size of the inferior turbinate. This is often done during rhinoplasty for breathing purposes. It can be done in a number of ways including outfracture, submucous resection (removing some of the underlying bone), cautery (burning it), etc.
An endoscopic view from inside the nose, right in front of the inferior turbinate.
An incision in the septum in front of where it starts inside the nose. This incision is used to access the septum for septoplasty and for harvesting septum to be used in rhinoplasty or vestibular stenosis repair.
An incision through the columellar skin used in open (external rhinoplasty). This incision is between the nostrils and can be placed anywhere, depending on the surgeon’s preference. This is the lower end and connecting incision for the marginal incisions on each side.
The areas of the tip that project the most. There is usually one area on each side of the tip. These points produce a light reflex, which is white in photographs. A good rhinoplasty result has two tip-defining points at a proper distance between each other.
The angle of rotation of the tip. If the tip is too high, this is called an “over-rotated” tip. If the tip is low (ptotic tip), then the nose is “counter-rotated”. Males and females have different degrees of rotation, and also cultural factors must be taken into account when it comes to setting the proper angle for rhinoplasty.
The distance from where the lateral part of the nostril meeting the cheek to the most anterior edge of the tip. The distance of how much the nose projects from the face.
A straight portion of cartilage taken from the ear for rhinoplasty. It is most often used in secondary, or revision rhinoplasty. The incision can be made in front or in back of the ear, in the ear crease.
This is the area just above the tip. This term is an anatomic location which is specifically discussed and analyzed before surgery and after surgery in many patients. This area can swell after surgery which can be treated with steroid injections.
In some patients, the supratip area retains fullness related to excess cartilage that was left behind.
This is the process of removing cartilage or bone which is underneath mucosa. Mucosa is the inner lining of the nose. So submucous resection refers to elevating the internal lining of the nose to remove either cartilage or bone. Submucous resection is performed for septoplasty, septal cartilage harvest, as well as some types of turbinate reduction (turbinoplasty).
Content: A strut graft is used to strengthen a certain part of the nose. They can be used on the columella which is between the nostrils.
They can also be used on the sides of the nasal valve to strengthen the airway. Typically, they are made from cartilage taken from the septum, ear, or rib.
Grafts of cartilage placed between the upper lateral cartilages and the septum to widen the middle third of the nose. These graft help with vestibular stenosis as well as prevent depressions/concavity in the middle third of the nose which can be a cosmetic issue. Spreader grafts can also help camouflage a crooked nose as well as deal with asymmetries. They are some of the most commonly used grafts in rhinoplasty and functional nasal surgery (functional rhinoplasty).
Image from Bailey’s Otolaryngology Textbook. Chapter 183. Management of the Crooked Nose by Drs. Murakami and Zoumalan.
On the outside a splint is used after rhinoplasty to keep the bones in place as well as decrease swelling and bruising. If splints are used on the inside after septoplasty, they are used to minimize swelling and decrease healing issues.
The skin area between the alar rim (nostril rim) and the curved border of the junction of the medial and lateral crura. Sometimes, this is well defined, and it is referred to as a facet.
Very small cartilages found in the space between the upper lateral cartilage and lower lateral cartilages. Their role is still a topic of controversy. They are rarely encountered during rhinoplasty and do not affect surgical plans significantly.
The combination of septoplasty and rhinoplasty. Rhinoplasty can be done on its own. However, when septoplasty is combined with rhinoplasty, it is called septorhinoplasty.
Septorhinoplasty is commonly done when patients want improvement of both the functional (breathing) and aesthetic (cosmetic) aspects of the nose. This is done at the same time because the incisions and approach are shared between the two procedures and the cartilage taken out during septoplasty can be used for structuring in rhinoplasty.
Surgical repair and alteration of the septum. Literally, this term describes reshaping the septum. This is usually done for functional breathing purposes, but sometimes it is done for cosmetic purposes, as the septum is responsible for the deviation of the lower two-thirds of the nose.
Septoplasty can be done using an endonasal technique, which means it can be done with no external incisions. This is the way it is most commonly done. The ways a septoplasty can be done vary greatly.
A graft consisting of cartilage which increases the length of the septum. This is used to change the length of the nose or change the angle of rotation of the nose. This is mostly done during revision rhinoplasty, but also done in some primary rhinoplasties. It can be done either via the open or closed approach.
When the septum is crooked and blocking one side of the nasal cavity, or both. See below how the septum is deviated into the right side in this diagram:
The dark opening seen here is the pyriform aperture.
The upper lateral cartilages and lower lateral cartilages interconnect, almost like a handshake. Some noses have more of an interconnection, or scroll. This interconnection is a recurvature of the lateral crus of the lower lateral cartilage as it comes up and over the inferior edge of the upper lateral cartilage.
The red arrow shows the area of the scroll on both sides. This is an important support area for the tip.
An incision on the edge of the nostril. This is seldom used in rhinoplasty. Sometimes a small rim incision is made to place a small graft at the nostril edge.
Cartilage grafted from the rib which is used in providing significant structure to the nose. It is most often used in revision rhinoplasty. At times, for noses that need more structure, it can be used in primary rhinoplasty.
Thick cyst-like growths all over the nose which distort the nose. This originates with the process of rosacea. There are laser, dermabrasion, and surgical options that can help with this.
The junction between the frontal bone and the dorsum of the nose. This is an area that can be deep in some people, requiring a graft during rhinoplasty. Other times, the radix can be too elevated and requires a technique called radix rasping, which reduces the prominence of the radix.
Deformity caused by fullness in the supratip. The lower portion of the septum is left too high, or if there is redundant scar tissue above the tip, the nose appears as similar to that of a parrot…… “Polly wana cracker?”
This is an example of a patient with Polly-beak deformity. This is NOT one of Dr. Zoumalan’s results.
Cuts through bone. There are many types of rhinoplasty osteotomies (medial, lateral, intermediate). In rhinoplasty, osteotomies are used mainly to narrow the nose and straighten the nose.
Image from Bailey’s Otolaryngology Textbook. Chapter 183. Management of the Crooked Nose by Drs. Murakami and Zoumalan.
This is a graft that is used to lift or augment the nose. It can be comprised of cartilage taken from the septum, ear, or rib. This graft lifts the bridge up for cosmetic purposes during primary or revision rhinoplasty.
This is most often done in Asian or African American rhinoplasty where the dorsum (bridge) needs to be built up. There are multiple ways to do this, and sometimes the onlay graft is used to deal with small depressions for camouflage purposes.
When the central part of the nostril peaks upwards. This can be a natural finding for a nostril or it can be a result of over-resection of the lateral cartilages during rhinoplasty.
Some patients like the way this looks, but most are unhappy if there is too much notching. Rhinoplasty surgeons can fix this by using grafts that use cartilage taken from the ear, septum or rib.
The upper part of the pharynx located in the back of the nasal cavity. This area in children sometimes has excess adenoid tissue which can cause nasal obstruction or be contributing to it. This is why during evaluation of people with nasal obstruction, including kids, it’s important to look all the way in the back of the nasal cavity, which may necessitate the use of an endoscope which is a small thin camera that allows you to see this area.
The angle between the lip and columella. If too elevated, then this is called an over-rotated nose. Rhinoplasty surgeons set the tip in the right angle for profile management.
The angle between the nose and the forehead. It is the angle of demarcation between forehead and dorsum of the nose. This is an anatomic location used in analysis of the face, especially on profile views.
It is used to define the overall size and angle of the nose in comparison to the rest of the face. There are typical angles for this.
The thin piece of cartilage and bone which separates the left side from the right side of the nasal cavity. If deviated, this is a deviated septum and can cause nasal obstruction. Septoplasty is the surgery which helps with this.
The middle third of the nose. This “vault” is important for breathing and cosmetic outcome. If it is too narrowed, it poses a problem with breathing and may create an “Inverted V deformity”.
The most inferior part of the chin on a lateral photo or x-ray. This defines the most bottom part or inferior part of the chin.
This is an anatomic location on the face that can serve importance in facial cosmetic surgery as well as reconstructive surgery. This is taken into account during genioplasty (chin procedures).
This is an incision performed during both endonasal (closed) and external (open) rhinoplasty. This incision is made along the inferior (caudal) border of the lower lateral cartilages to expose the nose for rhinoplasty.
These are one of two sets of paired cartilages in the nose. The others are the upper lateral cartilage. The lower lateral cartilages determine the shape of the tip. There is one lower lateral cartilage on each side of the tip. Tip rhinoplasty or tip-plasty is shaping the tip by mostly reshaping these cartilages, although other factors such as the septum and soft tissue are also involved.
The entire blue structure which is pointed to by the red arrow is the Lower Lateral Cartilage. There are two paired cartilages in each person.
Cuts in the bone made with an osteotome (similar to a chisel) to create small fracture to allow the nasal bones to move. This is used to narrow a nose and/or straighten it.
The remaining structure after the central portion of the cartilage has been removed. Leaving a strong L-strut is the goal in septoplasty and septal cartilage harvest. Adequate amount of cartilage has to be left on the top (dorsal) and caudal (bottom-near columella) to support the whole structure of the nose.
An incision used for septoplasty and septal cartilage harvest. It is placed just beyond where the septum starts and is less destabilizing than a hemitransfixion or full transfixion incision.
The point where the septum joins the nasal bones and the upper lateral cartilage. This point can be found in the midline of the nose, just caudal (below) the central edge of the nasal bones. This area must be carefully maintained during rhinoplasty.
If the middle third of the nose (middle vault) is collapsed, the edges of the nasal bones can show. They create a shadow similar to an upside down V. This is usually the result of reducing the nasal bridge and not supporting the middle third. This is prevented by supporting the middle third with grafts such as spreader grafts.
An important structure for breathing. This is an area inside the nose where the septum meets the upper lateral cartilages. This valve cross sectional area affects breathing significantly. Dr. Zoumalan has done a study on how rhinoplasty affects the cross sectional area of the internal nasal valve. This landmark study showed that if the internal nasal valve is treated properly, rhinoplasty can maintain or improve breathing consistently.
An incision that goes between the bottom edge of the upper lateral cartilage and upper edge of the lower lateral cartilage. This approach is used in rhinoplasty to access the dorsum.
The part of the lobule (midline tip of nose) between the most anterior tip-defining point and the top of the columella. This cosmetic area is important in management during rhinoplasty.
A hemi-transfixion incision is an incision on one side of the septum used to perform a septoplasty or to obtain cartilage for cartilage grafting.
Unlike a full incision transfixion, a hemi-transfixion doesn’t go through the full membranous septum. Therefore, it affects the support of the tip much less than a full transfixion incision.
The columella is located between the nostrils. When it hangs significantly lower than the nostrils, this is called hanging columella.
A hanging columella curves downwards towards the lips. This is something that patients are typically looking to improve and make less prominent during primary rhinoplasty as well as revision rhinoplasty. Great improvement in all angles can be made with improving a hanging columella and making a more straight columella that doesn’t hang as much.
Changing the shape of the chin either by augmenting (making it bigger) or reducing the size of the chin. Genio is the Latin term for the chin. Plasty is the Latin term for changing the shape of.
Chin augmentation can be done with either filler or a chin implant. It can also be done by making bony cuts in the anterior part of the chin and sliding it forward or backwards. It can be done in really any number of ways to both the soft tissue and bone.
The portion of the face between the eyebrows. This anatomic area is found directly above the root of the nose. It is used in analysis of the nose for rhinoplasty as well as generally for facial analysis. This is an area that can be augmented with filler. This is also an area that can develop wrinkles, and botox can help with this.
Facial analysis the process of analyzing a face in every dimension. This can be done in a variety of ways, and there is no consistent way to do this. Every surgeon is different in the way that they both analyze the face, and this is based on both their training/knowledge and their general sense of taste of ideal facial features. Facial analysis is integral to the initial meeting with a facial plastic surgeon.
A horizontal plane extending through the lateral facial profile with the head in a normal relaxed position. If an imaginary line were drawn from the ear canal to the area just under the eye (infraorbital rim), this should be parallel to the ground. This is a neural natural horizontal facial plane. Before and after photos are taken with people’s heads in this neutral position.
The black line in the image on the right is the Frankfurt Horizontal Plane. It is the proper angle to take profile images for before and after images in plastic surgery. It is drawn from the ear canal to the bony ridge under the eye (infraorbital rim). We ask rhinoplasty patients who travel from internationally or from afar to send photos with the appropriate angles. As a result, the rhinoplasty surgeon can best analyze the photos during the virtual consultation.
In photos, this is the view from the front. This is used to analyze over facial symmetry, dorsal deviation, the curves of the facial features, skin, cheekbone height, and it is integral in the analysis of a nose to determine if the nose is straight, has symmetry, is drooping, and how much nostril shows from the front.
A type of incision to access the septal cartilage for septal cartilage. It is done at the front of the septum where access is the closest to the surgeon. If it is only done on one side, this is a hemi-transfixion incision. If it is done on both sides, it is a full transfixion incision.
Both of these incisions can cause weakening of the nasal tip support, so this has to be taken into account during rhinoplasty to ensure that the tip will have proper support after rhinoplasty.
Epistaxis is a medical term for nosebleed. Epistaxis can occur after surgery within the first couple weeks. It often occurs because patients exercise or get their blood pressure increased after surgery. However, it can happen even in the absence of this.
Epistaxis also occurs a lot in children and adults due to exposed small blood vessels. Often compression of the front of the nose can help with bleeding, but we DO NOT RECOMMEND THIS for patients who have had rhinoplasty. Call your surgeon if you have excessive bleeding.
Nostril opening. Along with the internal nasal valve, this area is important for breathing. Nasal surgeons need to evaluate the strength of this area. Modified Cottle maneuvers during your exam can help determine the strength of this area. Rhinoplasty must take into account the strength of this valve.
Rhinoplasty performed with part of the incision going onto the skin between the nostrils. There is one incision on the columella (incision between the nostrils).
Top of the nose, from the top of the tip to the glabella (between the eyebrows). When the dorsum is high, this is called a “bump” or a “hump”. Management of the dorsum is one of the key aspects during rhinoplasty. Some want a straight dorsum (no hump or scoop). Others want to maintain a small amount of elevation of dorsum. Communication between you and your rhinoplasty surgeon is key to having your aesthetic goals realized.
Dorsal deviation is another name for crooked nose. The dorsum is the top of the nose. Deviation means crookedness. Dorsal deviation is therefore having a crooked nose.
This is something that can be helped with proper rhinoplasty techniques. Dorsal deviation improvement is one of the most complex things in rhinoplasty. The amount of improvement will depend on the amount of healing as well.
Dorsal augmentation is building the bridge up during rhinoplasty. This can be done surgically with permanent cartilage or fascia grafts, with implants like silicone, implants using irradiated cartilage or dermis (skin), as well as the use of fillers like Restylane, Voluma, or Juvederm.
Building up a bridge is very common for certain ethnic groups like Asians and African Americans. It is sometimes also done in revision rhinoplasty when too much of the bridge was taken off previously.
An old tip rhinoplasty technique whereby the cartilages of the tip are split. This helps create definition and narrows the tip. This technique has fallen out of favor, given its relatively high rate of unsatisfactory cosmetic results. Some surgeons still perform this.
Lateral or medial. Lateral crus are the wings of the tip. Medial crus make up the structure of the columella, which is cartilage and soft tissue between the nostrils.
White arrows show the lateral Crus. Red arrows show the medial Crus.
Physical maneuvers used to test breathing before and after nasal surgery. This is a subjective measure of how good breathing is on each side. When the cheek is pulled away from the nose, patients are asked how much their breathing score improves. This gives an idea of whether vestibular repair can help with breathing. This is part of a functional rhinoplasty consultation.
Cartilage grafted from the ear. The concha is the bowl of the ear just outside of the ear canal. It is curved and can be used to reconstruct the lateral crura.
The angle formed between the columella and the lip. This angle is really important for profile management. Rhinoplasty surgeons have to know the exact angles.
A graft which extends from the columella and all the way to the anterior portion of the nasal tip. This provides tip projection, definition, and tip support.
These images show placement of the Columellar strut tip graft (extended). These images were taken from Dr. Zoumalan’s publication with Dr. Norman Pastorek, who has used this endonasal rhinoplasty technique for decades.
Columellar show is used to describe a gap between the columella (the part of the nose between the nostrils which resembles a column) and the nostril edge. If the amount of “show” of this gap is more than about 2 mm from the profile view, then this begins to show too much of the inside of the nose from the profile view. So this is termed excess columellar show.
This is a complex situation to improved and requires the use of grafting and tip reshaping maneuvers to improve. Often patients complain about increased columellar show if a reductive rhinoplasty was done that doesn’t take into account the necessary structures that need to be respected during rhinoplasty.
The midline column of nose between the nostrils. It is composed of skin, soft tissue, and cartilage. This is the location of the incision for external (open) rhinoplasty.
A collapsed nose due to long-term, heavy cocaine use. The cocaine breaks down the soft tissue, cartilage, and the bone as well. Patients with this problem have a nose that is flattened, does not breathe well, bleeds often, and has tremendous crusting. Sometimes the erosion can even include the roof of the mouth (palate). Nasal reconstruction requires complex grafting and usually required rib cartilage graft with total reconstruction of the L-strut.
Patients with cleft lips often have abnormal nasal anatomy which requires rhinoplasty. The nose usually sways to one side, and the cartilages are mis-shaped.
Inferior border of the septum, which is interacting with the medial crura of the cartilages. This can affect breathing, deviation (crookedness), as well as how high or low the tip sits.
Richard Zoumalan is a leading Rhinoplasty doctor and facial plastic surgeon in LA and California. We offer the best natural nose job and plastic surgery in Beverly Hills, Los Angeles, Las Vegas, San Diego, San Francisco and the whole CA.