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Rhinopedia By Dr. Richard Zoumalan MD

RHINOPLASTY ENCYCLOPEDIA

Information on terminology used in rhinoplasty and nose surgery

In an effort to help patients understand rhinoplasty and all of its terminology, Dr. Zoumalan has created the Rhinopedia. This explains, in simpler terms, what different

rhinoplasty terms mean. This is an education tool for patients who are seeking to understand more about rhinoplasty and nasal surgery.

A Accessory cartilages - Cartilages which connect the lateral ends of the lateral crura (cartilages in the tip) to the bony edge of the medial face. These cartilages are rarely approached during rhinoplasty and are usually a non-factor when it comes to the surgical plan. Adenoid: Tissue composed of lymph located in the posterior of the nose. Enlarged adenoids can cause nasal obstruction. This diagnosis requires examination with a mirror or with a scope. Aging nose: The process by which the nose ages. The tip slowly drops, the soft tissues thin and expose new contours, bone weakens, and cartilage weakens. The result is a nose that changes over time. When these changes culminate in significant age-related changes, this is called an aging nose. Alae: Alae is plural. Ala is singular. Alae are the lateral aspects of the nostrils. Lateral wings of the nose. The round shape forming the lateral nostril wall that goes from the tip to the upper lip. When they are elevated (high), retracted alae can be notched and unattractive. Alar base: The base of the nostrils. The alar base and width can be altered in rhinoplasty.

LEFT ALA ALAR GROOVE

Alar base reduction: Making the nostrils smaller by reducing the width of the nostrils. There are various techniques for this. This is commonly done in African Americans, some Asians, some Caucasians, and some Middle-Eastern rhinoplasty.

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Alar batten grafts: Grafts made from cartilage to help support the ala. The way these are placed will determine what part of the nose they strengthen. Alar batten grafts are placed above the lower lateral cartilage (on top of the lateral crus) or just above. These help to strengthen the internal nasal valve for breathing. Sometimes, depending on how they are placed, they can also strengthen the external nasal valve (nostril strength). Alar strut grafts: Similar to alar batten grafts, but these are placed underneath the alar instead of on top. Both alar batten and alar strut grafts can not only help with breathing, but they can also help reshape the lower third of the nose (tip) by straightening the lateral crus of the lower lateral cartilage and making the tip less “round” and less “boxy.” Allograft: Tissue transplanted between the same species. Alloderm is an allograft. So is irradiated cadaveric rib. Alar groove: The skin depression between the nostril and the lateral nasal wall. There is a blood vessel in this area that is important for the rhinoplasty surgeon or injector to be careful of. Allergic rhinitis: A runny nose due to allergies. This can be treated medically. Alloderm: A material manufactured using human dermis. It is processed by a company, and different thicknesses are made. In rhinoplasty, its most common use is to be placed underneath thick skin to hide potential contours from showing in thin-skinned people. Another option with similar and sometimes better results is fascia taken from the temple region with a small incision (temporalis fascia). Anosmia: Inability to smell. This can be helped with treatment of sinus disease. Anatomic dome of nose: Where the medial and lateral crura of the nose cartilage meet. This is part of the tip. Rhinoplasty surgeons sculpt this carefully, as it will define the tip. Anterior septal angle: The angle where the dorsal (top) septum and caudal (bottom) part of the septum meet, an important landmark for rhinoplasty. Leaving this area too high can result in a “polly-beak deformity.” Augmentation: Making something bigger. Dorsal augmentation in rhinoplasty can be done with grafts, implants, and allografts. Auto-spreader grafts: Using the existing medial edge of the upper lateral cartilage and flipping it internally to create space between the septum and upper lateral cartilage. This is another option different from a spreader graft taken from the septum, ear, or rib cartilage.

B

Base view: The view from the bottom of the nose. This view is an essential part of nasal analysis and diagnosis.

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Batten graft: In rhinoplasty, a graft which gives support and thickness by being placed on top of native cartilages.

Bernoulli’s principle: This describes how airflow at each end of a tube like the nose can collapse the walls of the tube if the air flow is quick enough to create negative pressure. This principle is central to why the internal and/or external nasal valves collapse when you breathe in through your nose.

Boxy tip: When a tip resembles a box from the base view.

Bump: Elevated dorsum. High dorsum. Also known as a “hump.”

C Canthus: The medial (middle) corner of the eye. Cap graft: Graft placed on the tip of the nose to increase tip definition and give more projection (increased nasal length). This is usually made from septal cartilage. Cartilage-splitting incision (Intra-cartilaginous incision): An incision used in endonasal (closed) rhinoplasty to access the dorsum which goes through the lateral crus. Tip cartilage can also be removed through this access point during rhinoplasty. Caudal: Inferior when referring to the nose Caudal extension graft: A graft comprised of cartilage which is placed on the end of the septum to extend, rotate, or counter-rotate the tip, among other purposes. Caudal septum: 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. Cephalic: Superior when referring to the nose. Directed towards the top of the head. Chronic sinusitis: Continued, regular sinus infections. There are certain medical criteria that patients have to meet in order to be given this diagnosis. Cleft lip-nose: 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. Closed rhinoplasty = endonasal rhinoplasty. Rhinoplasty performed with all incisions inside the nose. There is no incision on the columella (incision between the nostrils). Cocaine nose: 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.

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Columella: 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.

THE WHITE ARROW SHOWS THE COLUMELLA

Columellar-labial angle (nasolabial angle): 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. Columellar show: The width of columella seen on lateral and frontal views. Columellar strut tip graft, extended: 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.

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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. Conchal cartilage: 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. Concave lateral crura: When the lateral crura bow into the nasal cavity. This can cause breathing and cosmetic issues. Sometimes, this is a result of previous rhinoplasty. Convex lateral crura: When the lateral crura curve out too much. This can cause a large, bulbous, round, and sometimes even boxy tip. This is the opposite of concave lateral crura. Tip maneuvers during rhinoplasty help with this. Costal cartilage: A portion of rib taken as a graft or rib graft. This is done in some revision rhinoplasties. Cottle maneuvers: 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. Crus: 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.

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WHITE AREAS SHOW THE LATERAL CRUS. RED ARROWS SHOWS THE MEDIAL CRUS.

D

Dome delivery: Exposing the lower lateral cartilages via an endonasal (closed) approach. This

is used to expose the tip so that tip contouring can be performed.

Dome division: 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.

Donor site: Area where cartilage is taken from. If rib grafting is performed, the donor site is the

rib.

Dorsal graft: A piece of cartilage or other material used to make the dorsum bigger. This

procedure is also known as dorsal augmentation.

Dorsum: 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.

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Dorsal augmentation: Making the bridge of the nose higher.

Dorsal reduction: Decreasing the hump or bump. Making the top of the nose lower. This does

not involve the tip.

Dorsal deviation: Crooked dorsum, or a crooked nose.

E

Edema: Swelling. Edema is a normal part of rhinoplasty and revision rhinoplasty recovery.

Some rhinoplasty patients experience more edema than others.

Endonasal rhinoplasty = Closed rhinoplasty. Rhinoplasty performed with all incisions inside the nose. There is no incision on the columella (incision between the nostrils).

Epistaxis: Also known as a nose bleed.

External Nasal Valve: 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

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maneuvers during your exam can help determine the strength of this area. Rhinoplasty must

take into account the strength of this valve.

External rhinoplasty = Open rhinoplasty. 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).

F

Facial analysis: Analysis of the different angles, widths, lengths, and proportions of the nose.

Frankfurt Horizontal Plane: 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.

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Frontal view: The view of the face from the front.

Full transfixion incision: An incision through the entire septum in front of the edge of the caudal

septum edge.

G

Genioplasty: Changing the shape of the chin either by augmenting (making it bigger) or

reducing the size of the chin.

Glabella: The hairless space between the eyebrows.

H

Hanging columella: When the columella droops too low.

Hanging Columella

Hemi transfixion incision: An incision made only on one side of the septum to access the

septum for septoplasty or cartilage harvest for rhinoplasty.

Hump: Another word for Bump, or high Dorsum.

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Hump

This patient had her hump reduced by Dr. Zoumalan.

I

Infratip lobule: 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.

Inter-cartilaginous incision: 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.

Internal nasal valve: 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.

Inverted V Deformity: 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.

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K

Kenalog: A steroid whose medical name is Triamcinalone acetonide. Kenalog injections after

rhinoplasty can help decrease swelling and scar tissue.

Kirschner wire (K-wire): A wire used to stabilize the structure of a nose during healing. An

internal stabilization technique, often used for rib cartilage grafts.

Keystone area: 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.

Killian incision: 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.

L

L-strut: 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.

Lateral osteotomies: Cuts in the bone made with An osteotome (similar to a chisel) to create

small fracture to allow to nasal bones to move. This is used to narrow a nose and/or straighten

it.

Lower lateral cartilage: 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.

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THE ENTIRE BLUE STRUCTURE WHICH IS POINTED OUT BY THE RED ARROW IS THE LOWER

LATERAL CARTILAGE. There are two paired cartilages in each person.

M

Marginal incision: 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.

Menton: The chin.

Middle vault: 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.”

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N

Nasal cycle: The natural cycle of the nose is to have internal swelling alternate from one side to

the other. This happens regularly and is normal.

Nasal lobule: The lower portion of the nose. This is the tip.

Nasal obstruction: Disruption in normal breathing through the nose. This can be from a variety

of factors.

Nasal septum: 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.

Nasofrontal angle: The angle of demarcation between forehead and dorsum of the nose.

Nasolabial angle: The angle between the lip and columella. If too elevated than this is called an

over-rotated nose. Rhinoplasty surgeons set the tip in the right angle for profile management.

Nasopharynx: The upper part of the pharynx located in the back of the nasal cavity.

Notching of the ala: When the central part of the nostril peaks upwards.

O

Onlay graft: A graft placed placed top of cartilage or bone of the nose during rhinoplasty to help

with

Open roof: The gap that exists on top of the nasal bones after the hump/bump is removed.

Osteotomies are performed to bring the bones closer and close the roof.

Osteotomies: 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.

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Image from Bailey’s Otolaryngology Textbook. Chapter 183. Management of the Crooked Nose by Drs.

Murakami and Zoumalan.

P

Piriform aperture: The bony opening into the nasal cavity. It is pear-shaped and consists of the

maxillary bone.

Polly-beak deformity: 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?”

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This is an example of a patient with Polly-beak deformity. This is NOT one of Dr. Zoumalan’s results.

Primary rhinoplasty: First time rhinoplasty. The patient has never had rhinoplasty before.

Ptotic tip: A tip that hangs inferiorly, decreasing the nasolabial angle. This can be improved with

rhinoplasty.

R

Radix: 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 require a technique called radix rasping, which reduces the prominence of the

radix.

RADIX SHOWN WITH A RED ARROW

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Radix graft: A graft that is placed to increase the height of the radix. This is done in rhinoplasty

for dorsal height (bump) management.

Revision rhinoplasty: Rhinoplasty performed to correct issues related to previous surgery. Also

known as secondary rhinoplasty if one surgery had been done before.

Rhinophyma: 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.

Rib cartilage: 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.

Rim incision: 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.

Rocker deformity: A high osteotomy will create a situation where the bones can not be

mobilized effectively, creating this deformity.

S

Saddle nose: The bridge of the nose is too low. This can be due to medical diseases, previous

rhinoplasty, trauma, and cocaine use.

Scroll area: 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.

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The red arrow shows the area of the scroll on both sides. This is an important support area for the tip.

Sesamoid Cartilages: 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.

Septum: The flat piece of bone and cartilage that separates the right side from the left side of

the nose.

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The septum is seen below in cross section:

Septal deviation. 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.

Septal extension graft: 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.

Septoplasty: Surgical repair and alteration of the septum.

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Septorhinoplasty: The combination of septoplasty and rhinoplasty. Shield graft: A graft that sits

on the tip of the nose and extends inferiorly. It provides tip projection and definition.

Spreader grafts: 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.

Soft triangle: 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.

Splints: 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.

Spurs: In reference to the septum, these are portions of the septum that jet out, or stick out.

They can cause nasal obstruction and even sinus issues.

Strut graft: In rhinoplasty, a graft which gives support and thickness by being placed underneath native cartilages.

Submucous resection: 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

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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).

Supratip area: The area just above the nasal tip, which is at the inferior part of the dorsum.

Symba concha cartilage: 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.

T

Tip: the high point of the lobule. Also synonymous with “lobule.”

Tip-defining points: 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.

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Tip projection: 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.

Tip rotation: 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.

Trans-columellar incision: 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.

Transfixion incision: 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.

Turbinates: 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.

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An endoscopic view from inside the nose, right in front of the inferior turbinate.

U

Upper lateral cartilages: 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.

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The arrows show the two paired Upper Lateral Cartilages.

V

Vestibular stenosis: 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.

Vibrissae: Nasal hairs.

W

Weir incision: Incisions at the alar base used to narrow the nostrils.