Surgicalanatomy Ofthenose: Robert M. Oneal,, Richard J. Beil

Surgical Anatomy
of the Nose
Robert M. Oneal, MD, Richard J. Beil, MD*
KEYWORDS
Nasal anatomy Rhinoplasty Anatomic nasal analysis
Assessing the external nose requires an under- the anterior to the posterior nostril apices and
standing of the anatomic components that intersects with the vertical facial plane. It deter-
contribute to its normal topographic features. mines the amount of cephalic rotation of the tip.
Structures that influence the external appearance In an esthetically pleasing nose, the columella
include the skin, which varies in thickness, and projects as a gentle curve below the alar margin
the underlying bony/cartilaginous skeletal frame- as seen on lateral view. In the non-Caucasian
work. Because skin thickness is greatest at areas nose, however, a common variation is for the ala
of skeletal narrowness, the external appearance to overhang the columella posteriorly.4 The colu-
of the nose from the frontal view is one of a soft, mella and infratip lobule projection are influenced
gentle curve emanating from the medial brows by the configuration of the medial and middle
and extending to the tip-defining points (dorsal crura. Because of the thin, adherent skin, asym-
esthetic line) (Fig. 1). The lobule can be defined metries or prominences in these structures are
as an area including the tip of the nose and easily visible in external configuration. In addition,
bounded by a line connecting the upper edge of projections of the caudal edge of the septum can
the nostrils, the supratip breakpoint, and the ante- produce a prominence of the columella also.
rior half of the lateral alar wall. The lobule is subdi- On base view (Fig. 3), the flaring of the caudal
vided into the tip, supratip, and infratip lobule. On edges of the medial and middle crura is noted.
lateral view, one should be aware of the marked The degree of flare plus the lateral curve of the
differences in the thickness of the soft tissue medial crural footplates determine the width of
(Fig. 2). the columella and infratip lobule. Columellar devi-
The internal structure most frequently respon- ations and asymmetries are frequently caused by
sible for the prominence of the lateral tip-defining deflections in the caudal septum. Medially, the
point or pronasalae is the cephalic edge of the relationship should be noted of the anterior nasal
domal segment of the middle crus. On lateral spine to the depressor septi muscle, which is
view, the tip of the nose is the apex of the lobule paired and inserts into the medial crural foot
and ideally the most defined element on the plates. Laterally, the alar part of the nasalis muscle
profile.1–3 In non-Caucasian, however, the tip should be noted.
tends to lack definition.4 The infratip lobule is
between the tip and the apex of the nostrils. The
SOFT-TISSUE COVERING OF THE NOSE
configuration of the infratip lobule depends on
Skin
the shape, size, and angulation of the medial and
middle crura of the alar cartilage (see Fig. 2). The Skin thickness is one of the most important
supratip lobule lies between the pronasalae and features to assess preoperatively in planning
the supratip breakpoint. The nasolabial angle is rhinoplasty. The skin tends to be thinner and
plasticsurgery.theclinics.com
defined as the angle formed by a line drawn from more mobile in the upper half of the nose and
This article is adapted from Oneal RM, Beil Jr RJ, Schlesinger J. Surgical anatomy of the nose. Clin Plast Surg
1996;23(2):195–222.
Department of Surgery, University of Michigan, Center for Plastic and Reconstructive Surgery, St Joseph Mercy
Hospital, 5333 McAuley Drive, Suite 5001, PO Box 994, Ann Arbor, Michigan, MI 48106, USA
* Corresponding author.
E-mail address: rjbeil@earthlink.net (R.J. Beil).
Clin Plastic Surg 37 (2010) 191–211

doi:10.1016/j.cps.2009.12.011
0094-1298/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
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192 Oneal & Beil
Fig. 3. Basal view of nose. (Courtesy of Jaye Schlesinger,

Ann Arbor, MI.)
the underlying framework and the natural esthetic

Fig. 1. Frontal view of nose. (Courtesy of Jaye Schle- lines normally visible, particularly in the non-
singer, Ann Arbor, MI.) Caucasian nose, which may have a larger subcu-
taneous dense fibrofatty layer than the Caucasian
nose.4 Some of the nasal changes seen with aging
thicker and more adherent distally. In dissections (ie, tip droop, nasal lengthening) may be caused by
reported by Lessard and Daniel,5 average skin changes in skin character.6 The skin is usually
thickness was noted to be greatest at the naso- thinner along the alar margin and in the columella,
frontal groove (1.25 mm) and least at the rhinion where the configuration of the alar cartilages may
(0.6 mm). There are usually more sebaceous be visualized through a thin skin cover. The skin-
glands in the lower half of the nose, causing an oili- to-skin approximations in the soft triangle area at
ness and thickness in the skin that may limit topo- the nostril apex makes it extremely vulnerable to
graphic definition, sometimes obscuring entirely notching and irregularities due to scarring when
intranasal incisions violate this delicate area.
Subcutaneous Layer
The soft tissue intervening between the skin and
the osteocartilaginous skeleton is made up of
four layers.5 They are the superficial fatty pannicu-
lus, the fibromuscular layer, the deep fatty layer
and the periosteum or perichondrium. The fibro-
muscular layer includes the nasal subcutaneous
muscular aponeurotic system (SMAS). The nasal
SMAS is a continuation of the superficial muscular
aponeurotic system, which covers the entire face,
interconnecting the facial musculature, the galeal-
frontalis layer, and the platysma. Ignorance of the
importance of this level or inadvertent surgical or
traumatic division of the superficial muscular
aponeurotic system (SMAS) leads to its bilateral
retraction. This retraction exposes the deeper
skeletal components to possible adherence
through scar tissue to the superficial fatty layer,
which is directly connected to the dermis.7,8 The
major superficial blood vessels and motor nerves
Fig. 2. Right lateral view of nose. Note the distance of
the lateral crus from the skin edge of the nostril. (Data run within the deep fatty layer.9 Just beneath it
from Daniel RK. Discussion of Constantian, MB. Two and superficial to the periosteum and perichon-
essential elements for planning tip surg. Plast Reconstr drium is the proper plane of dissection, similar to
Surg 2004;114:1582. Courtesy of Jaye Schlesinger, Ann the areolar layer beneath the galea aponeurotica
Arbor, MI.) in the scalp.
Surgical Anatomy of the Nose 193
and (8) the compressor narium minor. An in-depth

discussion of these muscles can be found in arti-
cles by Griesman10 and Letourneau and Danie1.9
All the muscles are innervated by the zygomatico-
temporal division of the facial nerve.
EXTERNAL BLOOD SUPPLY

The superficial arterial supply to the external struc-
tures of the nose is derived from the internal
carotid artery (through the ophthalmic) and
external carotid artery (through the facial and
internal maxillary) (Fig. 5).12,13 The lateral surface
of the caudal nose is supplied by the lateral nasal
branch from the angular artery, which is the contin-
uation of the facial artery. This branch anasto-
Fig. 4. Nasal muscles of facial expression. (Courtesy of moses with its pair from the opposite side across
Jaye Schlesinger, Ann Arbor, MI.) the dorsum of the nose. Herbert14 referred to the
angular artery as an alar branch of the superior
labial artery. He noted that it passed deep in the
Muscles groove between the ala and the cheek and lay
buried in the levator labii superioris alaeque nasi
Griesman10,11 subdivided the nasal muscles into muscle.14 It tended to follow closely the margin
four groups. Letourneau and Daniel9 substantiated of the pyriform aperture. Sequentially it gives off
these findings in 30 fresh cadaver dissections between 7 and 12 short branches, which perforate
(Fig. 4). The elevator muscles, which shorten the the enveloping muscle and enter the subdermal
nose and dilate the nostrils, include (1) the proce- plexus of the nostril and cheek.14 These branches
rus, (2) the levator labii superioris alaeque nasi, provide a rich axial blood supply to subcutaneous
and (3) the anomalous nasi. The depressor based cheek and nasolabial flaps and the nasalis
muscles, which lengthen the nose and dilate the myocutaneous flap.15,16
nostrils, include (4) the alar portion of the nasalis An external branch of the ophthalmic artery, the
muscle (dilator naris posterior) and (5) the dorsal nasal artery, perforates the orbital septum
depressor septi. The minor dilator muscle is the above the medial canthal ligament and runs down-
(6) dilator naris anterior. The compressor muscles, ward on the side of the nose to anastomose with
which lengthen the nose and narrow the nostrils, the lateral nasal branch of the angular artery. It
include (7) the transverse portion of the nasalis gives off a branch to the lacrimal sac. All of these
vessels, which vary in size, are supplemented by
twigs laterally from branches of the infraorbital
artery. The dorsal nasal artery, which also can
have communications with the supratrochlear
and infraorbital arteries, forms an axial arterial
network for the dorsal skin as described by
Marchak and Toth.17 Injection studies quoted in
their article show the rich anastomotic blood
supply to the lateral skin of the nose, allowing
elevation of this entire soft-tissue envelope on
a narrow vascular pedicle.
Branches of the superior labial artery supply the
nostril sill and the base of the columella. Consis-
tently a substantial branch ascends in the colu-
mella just superficial to the medial crura (see
Fig. 5). The columellar artery, which is often bifur-
cated, is cut with a transcolumellar incision used in
the open rhinoplasty approach.18 The branches of
the external nasal branch of the anterior ethmoidal
Fig. 5. Arterial supply of the external nose. (Courtesy artery along with the angular artery in the ala also
of Jaye Schlesinger, Ann Arbor, MI.) contribute to the arterial supply to the nasal tip.
194 Oneal & Beil
incisions. Instead, the dissection should be main-

tained directly on the surface of the cartilage
(deep to the fibromuscular layer and extension of
the periosteum [SMAS]).10 Sensibility to the soft
tissues on the side of the lower half of the nose is
supplied through the infraorbital branches of the
maxillary nerve, which also supplies portions of
the columella and the lateral vestibule. Thus, an in-
fraorbital block is important when relying on local
anesthesia during rhinoplasty.
CAUDAL THIRD OF THE NOSE

The lower third, or base, of the nose is made up of
the lobule, columella, nostril floors, vestibules, alar
bases, and alar side walls. It contains the paired
alar cartilages and accessory cartilages and
fibrous fatty connective tissue (see Figs. 1–3).
Alar Cartilage Morphology

Fig. 6. Sensory nerve supply of the external nose. The traditional concept of alar cartilage
(Courtesy of Jaye Schlesinger, Ann Arbor, MI.) morphology was that of medial and lateral crura
connected by an anatomic domal segment. To
The level of these vessels should be considered in clarify the understanding of the surgical anatomy
open rhinoplasty to minimize compromise of the of the nasal tip, Sheen and Sheen3 introduced
circulation to the nasal tip and columellar skin. It the concept of a middle crus, with its inferior limit
is also important to maintain dissection just super- at the columellar lobule junction and its superior
ficial to the lateral crura of the alar cartilage to limit at the junction of the medial extent of the
avoid injuring these lateral vessels. For the same lateral crus (Figs. 7–9). Daniel’s20 observations
reason, when performing open rhinoplasty, alar place the domal segment in the most superior
base excisions should always be limited to skin aspect of the middle crus. After Sheen’s original
and superficial subcutaneous tissue.19 observation, the middle crus has also been
The venous drainage of the external nose has referred to as the intermediate crus.19,21 The
the same-named veins, which accompany the concept of a distinct and independent middle or
arteries. These veins drain via the facial vein and intermediate crus has been challenged by another
the pterygoid plexus and through the ophthalmic study, in which the term body or intercrural
veins into the cavernous sinus. segment was applied.22 It is the authors’ opinion,
however, that this structure is more than a con-
necting link between the medial and lateral crura.
EXTERNAL SENSORY NERVE SUPPLY
Sensibility to the external nose is mediated through
branches of the ophthalmic and maxillary divisions
of the fifth cranial nerve (Fig. 6). Sensibility to the
skin of the nose at the radix, the rhinion, and the
cephalic portion of the nasal side walls is supplied
by twigs from the supratrochlear and infratrochlear
branches of the ophthalmic nerve. The external
nasal branch of the anterior ethmoidal nerve, which
emerges between the nasal bone and the upper
lateral cartilage, accompanying the same-named
artery, supplies the skin over the dorsum of the
distal nose down to and including the tip of the
nose. Injury to this nerve explains tip numbness
commonly noted after rhinoplasty, as this branch
is vulnerable during intercartilage or cartilage-split-
ting incisions. To minimize the chance of injury to Fig. 7. Paired alar cartilages: frontal view. (Courtesy
this nerve, it is best to avoid deep endonasal of Jaye Schlesinger, Ann Arbor, MI.)
Fig. 8. Paired alar cartilages: lateral view. (Courtesy of

Jaye Schlesinger, Ann Arbor, MI.)
Fig. 10. Alar cartilage: right lateral view of angles of
rotation. a, angle of cephalic rotation; b, columellar-
lobular angle; c, angle of tip rotation. (Courtesy of
Its complex and variable structure is so important Jaye Schlesinger, Ann Arbor, MI.)
to the configuration of the nasal lobule that it
deserves separate description and consideration.
In this discussion, each alar cartilage is divided angle of cephalic rotation, as noted on lateral
into 3 components: the medial, middle, and lateral view (Fig. 10), and the angle of footplate diver-
crura. gence, as noted on base view (see Fig. 9C). The
effect of the configuration of the medial crus
Medial crus produced by these angles greatly influences the
The medial crus consists of two components: the shape and prominence of the flared portion of
footplate segment and the columellar segment. In the base of the columella (see Fig. 3). The foot-
most patients, angulation occurs in 2 planes: the plate segment of the columella is influenced not
only by its intrinsic shape but also by the posterior
caudal edge of the cartilaginous septum, and by
the amount of soft tissue in the base of the
columella.
The columellar segment begins at the upper limit
of the footplate segment and ends at the colu-
mellar lobule junction (columellar breakpoint),
where it joins the middle crus. The length of the
columellar segment varies. Elongated nostrils are
due in part to vertically long columellar segments.
Natvig and colleagues described three common
anatomic variations of the medial crus in a cadaver
study that were confirmed by others (Fig. 11).5 The
most common type is an asymmetric parallel
(75%) (Fig. 12). The other two types, the flared
symmetric and the straight symmetric, occur
about equally (12.5%).20 Although the skin is thin
Fig. 9. Paired alar cartilages: basal view shows angles
and the subcutaneous tissue is almost nonexistent
of divergence and angle of domal definition. a, angle laterally, the intervening soft tissue between the
of domal definition; b, angle of domal divergence; c, columellar segments of the medial crus frequently
angle of footplate divergence. (Courtesy of Jaye camouflages any asymmetries. In contrast, the
Schlesinger, Ann Arbor, MI.) absence of sufficient intervening soft tissue
196 Oneal & Beil
Fig. 11. Paired alar cartilages:

basal view shows variations in
shape of the medial crus and
lobular segment of the middle
crus. (A) Asymmetric parallel. (B)
Flared symmetric. (C) Straight
symmetric. (Courtesy of Jaye
Schlesinger, Ann Arbor, MI.)
creates a bifid appearance of the columella. When junction of the columellar segment of the medial
performing an open rhinoplasty, it is important to crus and the lobular segment of the middle crus.
elevate with the columellar skin flap at a depth to Acute angulations can produce an unattractive
include all the intervening soft tissue. If this is not protrusion. The amount of protrusion of the colu-
done, the inadvertent postoperative result could mella (caudal projection) depends not only on the
be an unplanned bifidity in the columella. When re- horizontal width of the columellar segment but
positioning the columellar segments or resuturing also on the width of the membranous septum
them after separation to expose the caudal and the amount of protrusion of the caudal edge
septum in open rhinoplasty, it is important to retain of the septal cartilage. Likewise, upward retraction
the natural flare of the caudal edges by placing any depends on a deficiency of the same factors but
fixation sutures only at the cephalic borders. most often is caused by retraction of the caudal
From the lateral view, the most convex portion septum because of trauma or congenital deformity
of the columellar lobular curve is termed the colu- or iatrogenically because of overresection of the
mella breakpoint (see Fig. 10). Its configuration is edge of the caudal septum or failure to leave an
determined intrinsically by the shape of the adequate caudal septal strut during submucous
resection of the septum.
Middle (intermediate) crus

The middle crus is made up of the lobular segment
and the domal segment. The lobular segment of
the middle crus tends to be the most variable
and have the least correlation between the actual
internal structural configuration and the external
appearance. Its superficial expression is camou-
flaged by the thicker, overlying soft-tissue
envelope.
The lobular segment tends to have the same
variable configuration as described by Natvig
and colleagues for the medial crus. Their descrip-
tion did not include the middle crus as a separate
anatomic unit. Daniel and Letourneau, in
describing their observations from open rhino-
plasty, noted that in almost all cases the cephalic
edges of the lobular segment were in close
approximation but that the caudal edges diverged
(Fig. 13). Their length, configuration, and angula-
tion determine the shape, height, and protrusion
of the infratip lobule.
The domal segment is usually short and also
frequently the most thin, delicate, and narrow
portion of the entire alar cartilage arch. In contrast
Fig. 12. Operative view of the medial and middle to Sheen’s earlier description, Daniel has
crura during open rhinoplasty. Note the flared described a medial genu at its connection with
symmetric configuration, the flare of caudal borders, the lobular segment and a lateral genu at its junc-
and the domal segment. tion with the lateral crus.3,5 The domal segment
intruding into the soft triangle, where postopera-

tive scarring may produce deformity in this deli-
cate skin. The cephalic edges of the paired
domal segments are frequently in close approxi-
mation or have minimal separation (Fig. 15).19,20
The approximation of the domal segments also
may extend to include the adjacent cephalic
edge of the lateral crus. The cephalic edge usually
slopes posteriorly from the high point of the domal
segment in the normal esthetic nose to contribute
to the supratip breakpoint (see Fig. 15). The paired
domal defining points characteristically decrease
at the most anterior projecting point along the
domal segments. These defining points can be
narrowed using sutures.25
The medial and middle crura are also tightly
bound together by transverse fibrous connective
tissue. The most anterior thickening is termed the
interdomal ligament (Fig. 16A). These fibers fuse
with the more cephalic transverse fibers between
the cephalic edges of the lateral crura and to verti-
cally oriented fibers connected to the overlying
Fig. 13. Fresh cadaver dissection: a topdown view dermis, termed the dermocartilaginous ligament
from the forehead. Note the flared caudal edges of by Pitanguy (see Fig. 16B).26 There is strong
the middle crura, the closed approximation of the evidence to support the idea that the fibrous tissue
cephalic edge of the middle crus, and the domal connections between the full length of the medial
segment symmetry (arrows). and middle crura create a single function or unit
of these paired structures (J Tebbets, personal
communication, 1990).27 Thus this paired struc-
can vary in configuration (Fig. 14). It may be ture can be considered one leg of a tripod, with
concave, which is the least common. With the the lateral crura (and their extensions) being the
convex medial and lateral genu, this configuration other 2 legs (Fig. 17).28,29
produces a double-dome effect. It also can be The external expression of the domal segment
smooth, which gives the tip of the nose a wide, depends on 3 factors: (1) its specific angulation,
boxy configuration.5 Varying degrees of convexity (2) its position relative to the opposite domal
of the domal segment produce a more esthetic segment as determined by the divergence of the
tip.20,23 The concave caudal edge of the domal dome-defining points, and (3) the thickness of
segment frequently has a notched configuration the overlying soft tissue (Fig. 17). The subcuta-
(the domal notch), which is largely responsible neous fat is thickest in the supratip area, and the
for the facet of the soft triangle. The soft triangle soft-tissue thickness over the tip of the nose varies
is at the apex of the nostril, where dermis is in considerably from patient to patient. A bifid tip is
direct contact with dermis containing no inter- caused by a deficiency of intervening soft tissue
vening subcutaneous tissue.24 Because the between the domal segments and thin skin as
caudal edge of the domal segment is so irregular much as it is caused by the amount of divergence
and the cartilage itself is so delicate, great care between the dome-defining points.
must be taken in making infracartilaginous inci- The supratip breakpoint is important esthetically
sions to avoid injuring the cartilage edge or because it defines the cephalic limit of the nasal tip
Fig. 14. Variations in domal

configurations. (A) Convex domal
segment configuration. (B) Boxy
broad with minimal convexity. (C)
Double-dome, concave dome
segment. (Courtesy of Jaye Schle-
singer, Ann Arbor, MI.)
198 Oneal & Beil
to 10 to 12 mm in thick-skinned noses to create

an adequate supratip.
Surgical techniques to create a satisfactory
supratip breakpoint have been described using
suturing of the medial aspect of the lateral crura
to narrow and elongate the tip of the nose, and
lowering the dorsal surface of the caudal septal
cartilage. This technique leaves an iatrogenic
tissue void, which has a propensity to fill in with
scar tissue and can be one of the causes leading
to a supratip fullness or ‘‘pollybeak deformity’’.25
An alternative is direct suture sculpturing, thereby
emphasizing the alar cartilage projection to create
an esthetically pleasing supratip break with
minimal cartilage excision and potentially less
‘‘dead space’’ and possibly a more predictable
result (J Tebbets, personal communication,
1990).16,30
Fig. 15. Note the supratip slope of the right alar carti- Lateral crus
lage and the scroll area of the lateral crus. (Courtesy The lateral crus is the largest component of the
of Jaye Schlesinger, Ann Arbor, MI.) nasal lobule and plays a major role in defining
the shape of the anterior superior portion of the
alar side wall. Medially the lateral crus is directly
and the inferior limit of the nasal dorsum. It is contiguous with the domal segment of the middle
created in part by the difference between the crus and laterally with the first of a chain of acces-
projection of the dome-defining points and the sory cartilages that abut the pyriform process.6,31
height of the anterior septal angle (Fig. 18). Equally Caudally its free edge may be flat or it may be
important is the degree of posterior slope of the curved posteriorly to varying degrees. The caudal
lateral crus immediately adjacent to the convex edge parallels and provides support for only the
domal segment of the middle crus.20,23 The most anterior one-half of the alar rim.7,31 Thus, any
common relationship between the anterior septal excessive excision of the medial half of the lateral
angle and the nasal tip is where the distal portion crus can potentially contribute to weakening of
of the caudal septum does not have much influ- support of the anterior alar rim. As it progresses
ence on the position of the clinical domes; the laterally the caudal edge turns cephalically away
domes are as much as 8 to 10 mm caudal to and from the alar rim. Thus a marginal (infracartilagi-
3 to 6 mm anterior to the anterior septal angle. nous) incision does not follow the rim of the ala,
The latter differential constitutes the supratip except medially, but ascends cephalically
break. This distance may have to be exaggerated following the edge of the cartilage.23
Fig. 16. Fresh cadaver dissection. (A) Basal view shows the interdomal condensation of fibrous connective tissue
between the medial and middle crura. (B) Right oblique view shows the dermocartilaginous ligament (From the
dermis to the domal segment of the middle crus).
Fig. 17. Tripod concept of nasal tip cartilages. (Cour-

tesy of Jaye Schlesinger, Ann Arbor, MI.)
Usually the lateral crus is at its widest just medial

to where the caudal border takes its cephalic turn (S
Stahl, personal communication, 1990). The longitu-
dinal axis of the lateral crus (from dome point to Fig. 18. Fresh cadaver dissection. (A) Right lateral
lateral point) is more vertical than indicated in view: the domal segment (right alar cartilage) projects
classic texts and may be close to 45 .5,14 On frontal (3 mm) above the anterior septal angle. (B) Right
view this axis is directed toward the pupil. A more lateral view: the soft tissue and alar cartilage of the
exaggerated cephalic positioning of the alar carti- right side of the alar base (lower one-third of the
lage produces what Sheen describes as a malposi- nose) have been removed. The left-side medial and
tioned or ‘‘parenthesis’’ tip.3,32,33 middle crura are in anatomic position. Note the rela-
Zelnick and Gingrass34 described several varia- tionship of the medial crus to the caudal septum
tions of shape of the lateral crus in a report of and the relationship of the domal segment to the
anterior septal angle.
preserved cadaver dissections (Fig. 19). In types
C and D, the lateral crus adjacent to the domal
segment is concave. This variation is favorable in
achieving a more convex dome, possibly requiring people there is some degree of overlap of these
only minimal modification of the lateral crus if cartilages, which may enhance the function of
combined with the creation of a more acute angle the internal nasal valve.10 The degree of this curva-
of domal definition.20 As noted by Zelnick and ture determines in part the flare and fullness (bul-
Gingrass, however, because of the camouflaging bousness) of the lateral lobule. If resection of
effect of the overlying soft tissues, in many cases either cartilage edge is contemplated, the under-
it would be impossible to appreciate these varia- lying mucosa should be preserved carefully and
tions without direct exposure of the alar cartilages. the cartilage excision should be minimized to
Dion and colleagues31 observed side-to-side avoid unpredictable, undesirable late changes.35
asymmetry in lateral crus shape in more than half More details of this junction were described
of their 31 cadaver specimens. after microscopic study. The presence of a variable
The junction of the cephalic edge of the lateral number of small sesamoid cartilages was noted.
crus and the caudal edge of the upper lateral carti- The cartilage pieces were interconnected by
lage is known as the scroll area. An early study on a dense, fibrous connective tissue contiguous
the configuration of the caudal edge of the upper with the superficial and deep perichondrium of
lateral cartilage showed some degree of lateral the upper lateral cartilage and the lateral crus.
(downward) curling. Conversely, the slope of the The configuration of this junction was likened to
adjacent cephalic edge of the lateral crus is usually reptile skin or armor as it is characterized by
a convex curve downward (Fig. 20). In most closely inherent multiple plates of cartilage with
200 Oneal & Beil
Fig. 19. Variations of form of the lateral crus of the alar cartilage. (A) Smooth convex. (B) Convex medial, concave
lateral. (C) Concave medial, convex lateral. (D) Concave medial, convex central, concave lateral. (E) Smooth
concave. (Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
flexibility but little or no extensibility.6 Because of and lateral crus; and laterally a chain of acces-
the frequent overlap, the interspersed sesamoids, sory cartilages. The most posterior accessory
and the nondistensibility, the intercartilaginous cartilage is attached to the anterior nasal spine
incision is rarely that but probably almost always through fibrous connections in the nostril floor.
an intracartilaginous incision.6,36,37 These laterally placed cartilages contained
The intrinsic shape and form of the alar carti- within a distinct structural formation are acces-
laginous arch depends entirely on its inherent sory in contrast to the highly variable sesamoid
form and resiliency. LePesteur and Firmin cartilage found between the upper lateral carti-
showed that the paired alar arches are also lage and the lateral crus. The lateral accessory
a part of 2 cartilaginous rings, one for each nos- cartilage configuration may vary, from multiple
tril (Fig. 21). Each ring consists of the following to one or two larger pieces.7,38
components: the medial crus embracing the In the non-Caucasian nose, the medial and
caudal septum; the septum firmly set on the lateral crura are frequently shorter and the carti-
anterior nasal spine; the continuity of middle lage structures comparatively weak, affording
dense fibrofatty connective tissue. Griesman10 re-

ported on variations in configuration and offered
a classification of the junction of the alar bases
with the cheek, which forms the alar cheek groove.
The variations in configuration are the following
(Fig. 22):
1. Cheeked junction: the alar side wall is relatively
straight and the foot, or base, is only slightly
curved medially.
2. Labial junction: the foot (base) turns medially
and joins the columella in the middle of the nos-
tril floor.
3. Columellar junction: the alar base turns across
the nostril floor in a tubular configuration and
continues across the nostril floor in a broad
sweep. The size and shape of the tube vary
considerably in addition to the location of its
attachment to the skin of the base of the
columella.
Fig. 20. Nasal skeleton: frontal view. Note the cut- The shape of the nasal base is considered the
away section of the right upper lateral cartilage and most pleasing when it has the form of an equilat-
the lateral crus of the right alar cartilage and the eral triangle with the ratio of the columellar length
scroll junction of the upper lateral cartilage and to the height of the infratip lobule approximately
lateral crus (interlocked configuration). (Courtesy of
2:1 (see Fig. 3). In Caucasians, attractive nostrils
Jaye Schlesinger, Ann Arbor, MI.)
normally have a teardrop shape. Nostril configura-
tions vary considerably according to racial and
less support.4 Even in some Caucasian noses with ethnic types, as described by Farkas.38–42
thick skin and soft tissue, the cartilages are thin,
providing less support than normal.1 Vestibule
The vestibule of the lower third of the nose is the
THE NOSTRIL cavity just inside the external nares bounded
The nostril is composed of the alar base and the medially by the mobile septum and columella
vestibule. There is wide variation in the shape and laterally by the alar side wall with a protruding
and size of the external naris. fold of skin with hair (vibrissae) under the lateral
crus. Inferiorly, it is bordered by the skin overlying
the alveolar process of the maxilla.43 Cephalic to
Alar Bases
that is the inferior edge of the pyriform ridge, which
The shape and resiliency of the nostril and the demarcates the junction of the vestibule with the
posterior half of the alar side walls depend on floor of the nasal cavity. The vestibule forms part
Fig. 21. (A) Lateral view of

nose-view from right side.
Note cartilage ring consisting
of alar cartilage, accessory
cartilages, caudal septa1 carti-
lage, and their fibrous inter-
connections. The dotted line
shows the level of the cross-
sectioned view. (B) Nasal valve
area. (Courtesy of Jaye Schle-
singer, Ann Arbor, MI.)
202 Oneal & Beil
Fig. 22. Variations in alar base:

nostril floor configuration. (A)
Cheek type. (B) Labial type.
(C) Tube type. (Courtesy of
Jaye Schlesinger, Ann Arbor,
MI.)
of a valve mechanism for inspired air.44 As from the caudal septum. The amount of separation
described by Cottle,45–47 the vibrissae together and flare from the septum varies, as does the
with the vestibule provide a series of baffles, or amount of projection of the caudal end of
resistors, to the stream of air, slowing down the the septum, which can project 1 cm beyond the
currents of air and directing them backward into caudal edge of the upper lateral cartilage (see
the nasal cavity for warming and moisturizing. Fig. 20).50 The lateral border of the upper lateral
cartilage frequently terminates at the level of the
THE CARTILAGINOUS VAULT nasal bone lateral suture line. The fetal orientation
of the cartilages extending beneath the piriform
The upper (cephalic) cartilaginous vault is made up and the nasal bones, however, is maintained at
of the paired upper lateral nasal cartilages and the birth, and this anatomic variation needs to be re-
dorsal cartilaginous septum. Early studies sug- spected when performing nasal surgery in young
gested that the cephalic one-third of the vault children.51 The lateral configuration of the upper
was a unified structure.48 McKinney and lateral cartilage tends to be more rectangular
colleagues49 showed that actually the entire than triangular and does not, as is commonly
cephalic two-thirds of the vault is a single cartilag- believed, rest on the pyriform process (see
inous unit (Fig. 23). Inferiorly, there is gradual Fig. 21). This lateral space is termed the external
separation of the upper lateral cartilages from the lateral triangle. It is bordered by the lateral edge
septum to a level just above the septal angle. of the upper lateral cartilage, lateral prolongation
Embryologically, a single cartilaginous nasal of the lateral crus, and the edge of the pyriform
capsule is present by 4 months.48 During develop- fossa. It is lined by mucosa and covered by the
ment, as chondrification proceeds, fibrous tissue transverse portion of the nasalis muscle. It also
ingrowth produces separation of the upper lateral may contain one or more small sesamoid carti-
cartilage from the pyriform process laterally and lages, and it functions as a bellows during
Fig. 23. Cross-sectional views of

the nasal skeleton showing the
osseous and upper cartilaginous
vault. (A) Bony vault caudal to
nasofrontal suture (near radix).
(B) Bony vault, just cephalic to
intercanthal line. (C) Junction
of bony and cartilaginous vault.
Note the overlap of nasal bones
over the cephalic edge of the
upper lateral cartilage and the
T configuration of the nasal
septum continuous structure
with the paired upper lateral
cartilages. (D) Middle third of
upper cartilaginous vault. Note
Y configuration of the nasal
septum and the persistent struc-
tural continuity of the nasal
septum and the upper lateral
cartilage. (E) Caudal upper
cartilaginous vault. Note that
the nasal septum and the upper lateral cartilages are separate structures at this level. (Courtesy of Jaye Schlesinger,
Ann Arbor, MI.)
respiration.6,46 There is no lateral skeletal support development and racial influences.24,50 The high
for the upper lateral cartilage; its support comes angular nose with a prominent dorsum tends to
only from attachments to the nasal bones and have a more prominent caudal septal cartilage
septum. than the nose with a low fat dorsum.55 Occasion-
There is a common perichondrial lining on the ally the septal border of the distal septal cartilage
undersurface of the upper lateral cartilages and may be definitively felt at the anterior septal angle
the septum (Fig. 24). During traditional rhinoplasty and may present almost subcutaneously between
techniques, whenever the dorsum is lowered, the the caudal ends of the upper lateral cartilages and
apex of the cartilaginous vault is often interrupted medial lateral crus. Most commonly, however, the
depending on the amount of cartilage closely approximated medial aspects of the lateral
removed.30,52 The upper lateral cartilages are crura are superimposed.20,56
thus separated from the septum through their Lateral deviations of the caudal dorsal septum
length and totally depend on their connection can ‘‘artificially’’ produce asymmetries in the posi-
with nasal bones for their support.45,50 If the muco- tion of the domal segments similar to the
perichondrial lining between the septum and the secondary effect of caudal deflections of the
upper lateral cartilage is divided further, instability septal cartilage or the medial crus. These external
is created. By creating submucosal tunnels and influences on tip position should be carefully docu-
performing an extra mucosal rhinoplasty, the mented preoperatively by careful clinical
integrity of the mucoperichondrial layer can be examination.
maintained beneath these structures (see
Fig. 24).9,50,53 Caudally, where the upper lateral THE BONY VAULT
cartilage diverges from the septum, the mucoper-
ichondrium contains a fibrous aponeurosis that The bony vault consists of the paired nasal bones
lends support to this area of the internal valve; it and the paired ascending processes of the
should be protected by gentle and judicious maxilla.57 The vault is generally pyramidal in
dissection. As it approaches its caudal end, the shape; however, the cephalic portion of the bones
upper lateral cartilage ideally forms an angle of flare outwardly as they approach the nasofrontal
10 to 15 with the septum (see Fig. 21). This is suture (see Fig. 23). The most narrow part of the
the area of the internal nasal valve, which requires bony pyramid is at the intercanthal line, which
flexible patency for a normal airway.3,35,46,54 connects the attachments of the medial canthal
There are many variations in configuration and tendons at the anterior crest of the lacrimal bone
position of the anterior septal angle because of (see Fig. 1).10 The nasal bones are thicker and
denser above the level of the medial canthus.58
The nasofrontal suture line averages 10.7 mm
cephalic to the intercanthal line.5 The nasal bones
average 25 mm in length, although there may be
considerable variation. Thus, the bony vault is
divided approximately in half at the intercanthal
level (Fig. 25). One variation described by Sheen
is of short nasal bones.3 Preoperative recognition
is important because standard osteotomies in
such patients may lead to excessive postoperative
collapse of the bony and cartilaginous vault. Nasal
bones also tend to be shorter and smaller and the
bony pyramid is widened in the non-Caucasian
nose.4
At the cephalic end of the nasal dorsum, the
soft-tissue nasion, or sellion, is the deepest portion
of the curve between the glabella and the nasal
dorsum (nasofrontal groove or curve) (see
Fig. 25).10 This is generally at a level approximately
between the supratarsal fold and the upper lid
Fig. 24. Caudal upper cartilaginous vault. The dark
black line on the left represents the continuous muco- margin with the eye open and approximately 9 to
perichondrial layer in its normal configuration. The 14 mm anterior to the corneal projection.59 This
submucosal tunnel on the right is the approach to area is referred to as the radix. The thin caudal
the nasal skeleton. (Courtesy of Jaye Schlesinger, edge of these 2 bones and the adjacent thin ante-
Ann Arbor, MI.) rior ridge of the premaxilla, continuous with the
204 Oneal & Beil
surrounding structures, which also provide addi-

tional orientation for structures anterior and poste-
rior to the CT scan cuts.
The nasal vestibule is lined with squamous
epithelium that contains numerous thick stiff
vibrissae. The limen nasi is consistently at the
junction of the skin with the nasal mucosa. This
mucosa has a highly specialized function in respi-
ration and should be preserved carefully when
possible. Superiorly, the lining consists of olfactory
mucous membrane, which has a yellowish hue.
Bony Septum
Fig. 25. Lateral view of the bony skeleton and over- The perpendicular plate of the ethmoid forms the
lying soft tissue from the right side. Note the relation- upper third of the bony septum and is continuous
ship of the sellion (nasion) to the nasofrontal suture above with the frontal bone and the cribriform
line and the level of the intercanthal line. The inter- plate. Anteriorly, it articulates with the inward
canthal line splits the dorsal (anterior) length of the projection of the nasal bones in the midline,
nasal bone approximately in half. (Courtesy of Jaye caudally with the septal cartilage, and inferiorly
Schlesinger, Ann Arbor, MI.) with the vomer (see Figs. 26 and 27). The degree
anterior nasal spine, make up the pyriform of contact between ethmoid and vomer depends
aperture. on how much septal cartilage is interposed
Caudal to the intercanthal line, under the midline between them. The level of the junction of the
of the fused nasal bones, there is an inward curved perpendicular plate with the septal cartilage at
bony spine that articulates with the superior edge the dorsal keystone area varies with the amount
of the perpendicular plate of the ethmoid. This of distal nasal bone overlap of the upper lateral
spine is also just cephalic to where the dense cartilage, but can be 1 cm or more cephalic to
fibrous tissue connects the overlapped cephalic the caudal end of the nasal bone. Along its anterior
edges of the upper lateral cartilages. These carti- junction with the septal cartilage, the ethmoid is
lages are, in turn, fused to the cartilaginous nasal sometimes grooved, making its disarticulation
septum, which articulates solidly with the perpen- from the septal cartilage difficult during septo-
dicular plate of the ethmoids (Fig. 26). This plasty. In some patients it may be easier to incise
confluent area of 4 solid structural elements is through the cartilage 2 to 3 mm anterior to this
called the keystone area (Fig. 27).24,36,50, This junction to separate the two structures.
area provides critical support for the nasal dorsum The vomer is shaped like the keel of a boat and
in the middle third of the nose. If the bony and extends anteriorly and inferiorly from the sphenoid
cartilaginous dorsum is lowered and the side walls superiorly to the nasal crest of the palatine bones
separated in the midline, then the integrity of both and maxilla, where it joins the premaxillary wings
the perpendicular plate of the ethmoid and the of the maxilla (see Figs. 26 and 27). Anteriorly
dorsal-cartilaginous septum is essential to support the vomer and premaxillary wings embryologically
the nasal dorsum once osteotomies are per- are paired bones that fuse to form a groove for
formed. To maintain this support, these midline insertion of the inferior edge of the quadrilateral
bony and cartilaginous structures must be septal cartilage. Caudally, the most projecting
preserved, or if mobilization is required during part of the premaxilla is the anterior nasal spine,
reconstruction of the septum, they must be recon- which is the most caudal attachment at the inferior
stituted carefully. edge of the septal cartilage. In the non-Caucasian
nose, the anterior nasal spine may be undevel-
oped or even totally absent.4 The bony groove
INTERNAL ANATOMY OF THE NOSE that supports the septal cartilage is most promi-
Nasal Cavities nent caudally in the premaxilla and gradually
becomes more flattened as it progresses posteri-
The normal spatial relationships of the nasal cavi-
orly along the vomer.
ties with surrounding structures in the skull are
illustrated by a series of coronal computed tomog-
Cartilaginous Septum
raphy (CT) scans (see Fig. 26). The location of
these sections is depicted in relation to the sagittal The septal cartilage is a flat plate of cartilage of
view of the nasal septum lateral wall and irregular quadrilateral shape and varying size (see
Fig. 26. (A) Location of coronal CT sections projected on sagittal view of the cranium. (B) Level of the anterior
maxilla and frontal sinus. Note the groove in the premaxillary crest and the groove in the perpendicular plate
of the ethmoid. (C) Level of the anterior aspect of the maxillary sinus and posterior frontal sinus. Note the
cephalic septa1 cartilage extension between the vomer posteriorly and the perpendicular plate of the ethmoid
anteriorly. (D) Level of the midseptum. Note the following: the crista galli above the roof of the nasal cavity;
the nasal crest of the maxilla; the middle and inferior turbinates and meatuses; and the ethrnoid cells between
the lateral wall of the nose and the medial wall of the orbit. (E) Posterior septum. Note the nasal crest of the
palatine bone or floor of the nose and the superior turbinate with the lateral ethmoid interposed next to the
medial orbital wall.
206 Oneal & Beil
Fig. 27. Lateral view of the left side of the nasal septum. The left lateral wall of the nose has been removed.
(Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
Fig. 27). Embryologically, it develops as a single

unit along with the cephalic two-thirds of the upper
lateral cartilages.48,49 It articulates with the
perpendicular plate of the ethmoid and the fused
portions of the vomer and premaxillary wings. Its
shape depends in part on the length and angula-
tion of the cephalic extension between the vomer
and perpendicular plate of the ethmoid. The quad-
rilateral cartilage provides support and form of the
nasal dorsum from the cartilaginous bony junction
(rhinion) to just cephalic to the lobule in the supra-
tip area. The anterior septal angle is at the junction
of the dorsal and caudal septum. The other two
caudal angles are the intermediate and posterior
(Fig. 28).
There are some critical aspects about the
tongue-and-groove articulation between the
quadrilateral septal cartilage and the premaxilla
and vomer (Fig. 29).36 Although some periosteal
fibers are continuous with the ipsilateral perichon-
drial fibers, many pass around the superior articu-
lated edge of the bone to become continuous with Fig. 28. (A) Lateral view of nose from right side. The
soft tissue has been removed. Note the 3 angles of
the opposite periosteum or cross to become
the caudal septum and the anterior nasal spine. (B)
continuous with the opposite perichondrial fibers. Fresh cadaver dissection: view from right side with
The perichondrium has a similar crossed configu- right nasal wall removed. Note the 3 angles of the
ration around the inferior edge of the quadrilateral caudal septum, the anterior nasal spine, and the posi-
cartilage. There are fibrous connections within the tion of the left medial and middle crus. (Courtesy of
groove that allow mobility of the cartilaginous Jaye Schlesinger, Ann Arbor, MI.)
Fig. 29. (A) Cross-sectional diagram depicting the joint between the septal cartilage and premaxilla. (B) Common
posttraumatic configuration of this junction. (Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
septum in this bony groove, permitting slight rota- The turbinates can cause interference with visuali-
tion laterally when the cartilage is compressed, zation and manipulation during intranasal examina-
reducing the danger of fracture. The sum effect tion and usually require vasoconstriction to allow
is a joint with intricate interweaving of periosteum adequate intranasal examination preoperatively.
and perichondrium that makes a continuous mu- Vasoconstriction also facilitates visualization of
coperichondrial dissection difficult. the posterior reaches of the nasal cavities during
surgical procedures. The inferior turbinates often
become compensatorily enlarged on the side
Lateral Wall of the Nasal Cavity
opposite septal deviations. There is crucial juxta-
The lateral wall of the nasal cavity is a specialized position of the caudal end of the inferior turbinate
area (Fig. 30). It contains the 3 turbinates: superior, within the narrow flow-limiting segment of the nasal
middle, and inferior. They are scrolls of bone valve area (see Fig. 21).60 Consequently, alter-
covered by mucosa containing a plexus of large ations of their size and position are required
veins, which can become markedly engorged. frequently during operations for nasal airway
Fig. 30. Right lateral wall of the nasal cavity viewed from left side with left nasal wall and septum removed. The
palate is sectioned in the midline. (Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
208 Oneal & Beil
Fig. 31. Right lateral wall of the nasal cavity (same view as in Fig. 30), showing the sensory nerve supply of the
lateral nasal wall. (Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
obstruction. Inferior to each turbinate are the supe- approximately 1 cm behind the pyriform opening.
rior, middle, and inferior meatuses, respectively. There can be temporary interference with drainage
Openings from the various paranasal sinuses of these adjacent structures because of intranasal
open into these meatuses and the nasolacrimal swelling, which may explain the increase in tearing
duct, which drains into the inferior meatus and sinus stuffiness seen after rhinoplasty.
Fig. 32. Left side of the nasal septum with left lateral wall of nose removed (same view as in Fig. 27), showing the
sensory nerve supply to the nasal septum. (Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
Fig. 33. Right lateral wall of the nasal cavity (same view as in Fig. 30), showing the arterial blood supply to the
right lateral nasal wall. (Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
Fig. 34. Left side of the nasal septum with the left lateral wall of the nose removed (same view as in Fig. 32),
showing the arterial blood supply to the left side of the nasal septum. Kesselbach’s plexus is shown in the dotted
circle. (Courtesy of Jaye Schlesinger, Ann Arbor, MI.)
210 Oneal & Beil
The Nerves, Blood Supply, and Lymphatics pharynx and middle ear to pass into the retrophar-
of the Inside of the Nose yngeal nodes.12,63
Figs. 31 to 34 clearly depict the nerves and
arteries of the inner nose. They should be studied SUMMARY
carefully. Special mention of only a few facts
Knowing the details of nasal anatomy is essential
needs to be made. Little’s area on the anterior
when undertaking rhinoplasty surgery. Careful
septum is one of these (see Fig. 34). This is an
study of these details makes for a more confident,
area of vascular confluence of the superficial
prepared practitioner.
terminal branches of the anterior ethmoidal, sphe-
nopalatine, and superior labial arteries.12,29,61 This
is called Kesselbach’s plexus (see Fig. 34). REFERENCES
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Surgical Anatomy

Clin Plastic Surg 37 (2010) 191–211

Fig. 3. Basal view of nose. (Courtesy of Jaye Schlesinger,

the underlying framework and the natural esthetic

and (8) the compressor narium minor. An in-depth

EXTERNAL BLOOD SUPPLY

incisions. Instead, the dissection should be main-

CAUDAL THIRD OF THE NOSE

Alar Cartilage Morphology

Fig. 8. Paired alar cartilages: lateral view. (Courtesy of

Fig. 11. Paired alar cartilages:

Middle (intermediate) crus

intruding into the soft triangle, where postopera-

Fig. 14. Variations in domal

to 10 to 12 mm in thick-skinned noses to create

Fig. 17. Tripod concept of nasal tip cartilages. (Cour-

Usually the lateral crus is at its widest just medial

dense fibrofatty connective tissue. Griesman10 re-

Fig. 21. (A) Lateral view of

Fig. 22. Variations in alar base:

Fig. 23. Cross-sectional views of

surrounding structures, which also provide addi-

Fig. 27). Embryologically, it develops as a single

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