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Anatomy, Physiology, and General Concepts in Nasal Reconstruction

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Anatomy, Physiology, and General Concepts in Nasal Reconstruction Anatomy, Physiology, and General Concepts in Nasal Reconstruction Jason D. Bloom, MDa, Marcelo B. Antunes, MDb, Daniel G. Becker, MDb,* KEYWORDS Nasal reconstruction Nasal anatomy Skin physiology Wound healing Facial lines ANATOMY, PHYSIOLOGY, AND GENERAL originally determined the nasal subunits when CONCEPTS IN NASAL RECONSTRUCTION described by Gonzalez-Ulloa and colleagues.2 The thickest area is the caudal portion of the nose, Nasal reconstruction has made great strides in the on the nasal tip and ala, with its skin rich in seba- last 50 years. Nasal reconstructive surgeons have ceous glands. This nasal skin progressively gets gotten away from the idea of “filling the hole” and thinner until it reaches the rhinion, where it is the now have multiple options, which enable them to thinnest,3 and again as it transitions from the tip to achieve an aesthetically pleasing nose and good the columella and the alar rim.4,5 functional results.1 As the central and often the most noticeable feature of the face, the nose is Soft-tissue envelope also one of the most difficult to reconstruct. Nasal The soft-tissue envelope is composed of 4 layers: reconstruction requires a thorough understanding the superficial fatty layer, the fibromuscular of this complex, 3-dimensional structural and layer, the deep fatty layer, and the perichondrial/ topographic anatomy. Also, key to this type of periosteal layer.4 The superficial fatty layer is inti- surgery is the relationship of the nose to the mately connected to the dermis. Immediately surrounding tissues of the face and how these deep to this layer is the fibromuscular layer. This tissues can be used for a reconstruction that is construction is called the nasal superficial muscu- cosmetically normal for the patient and enables loaponeurotic system (SMAS) and is in continuity them to breathe properly. with the rest of the SMAS overlying the face. The The first step in nasal reconstructive surgery is mimetic muscles of the nose are within this layer. an understanding of the nasal anatomy. The facial The next layer is the deep fatty layer, which plastic surgeon must understand the intimate rela- encases the neurovascular system, supplying the tionships between the underlying nasal support skin-soft-tissue envelope.6 Between this layer structures, the cover of the external skin, the func- and the perichondrium/periosteum lies the avas- tion of the nasal lining, and the unique aspects of cular plane that is used to deglove the nose during the location and contours of the nose. rhinoplasty. As mentioned previously, part of the soft-tissue Nasal Anatomy envelope is composed of a muscular layer. The Skin mimetic muscles of the nose are usually divided The skin thickness varies depending on the different into 4 groups.6,7 The elevator muscles shorten locations of the nose. In fact, this variation is what the nose and dilate the nostrils. They are the a Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, New York University Langone Medical Center, 550 First Avenue, NBV Suite 5E5, New York, NY 10016, USA b Department of OtorhinolaryngologyeHead and Neck Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 5 Silverstein, Philadelphia, PA 19104, USA * Corresponding author. Becker Nose and Sinus Center, 400 Medical Center Drive, Suite B, Sewell, NJ 08080. E-mail address: [email protected] Facial Plast Surg Clin N Am 19 (2011) 1e11 doi:10.1016/j.fsc.2010.10.001 1064-7406/11/$ e see front matter Ó 2011 Elsevier Inc. All rights reserved. facialplastic.theclinics.com 2 Bloom et al procerus, levator labii superioris alaeque nasi and and the superior labial artery. The former passes anomalous nasi. The depressor muscles, which in a deep groove between the nasal alae and the lengthen the nose and dilate the nostrils, consist cheek, deep to the levator labii-superioris alaeque of the alar nasalis and depressor septi nasi. The nasi muscle, and gives off the lateral nasal branch, compressor muscles lengthen the nose and which provides the blood supply to the lateral narrow the nostrils. They are the transverse nasalis portion of the caudal nose. The angular artery and compressor narium minor. Finally, the minor then continues, following the rim of the pyriform dilator muscle, the dilator naris anterior, widens aperture, giving off about 7 to 14 branches that the nostrils. perforate through the soft-tissue envelope to supply the nasal skin.9 The superior labial artery Lining courses medially to the columella, where it gives The nasal vestibule is lined by a strip of thin skin off septal branches to supply the anterior portion (stratified squamous keratinized epithelium). This of the nasal septal mucosa, and it terminates as epithelium loses its keratinizing nature and transi- the columellar artery, which runs between the tions into the nasal mucosa (pseudostratified medial crus of the lower lateral cartilage (LLC) and columnar ciliated epithelium) as it moves further is frequently transected during the transcolumellar into the nose. This epithelium, called the respira- approach for an open rhinoplasty. The infraorbital tory epithelium, lines the sinonasal cavity with the artery arises from the infraorbital foramen with the exception of the area covered by the olfactory infraorbital nerve and supplements the blood epithelium. The nasal mucosa has a rich vascular supply with branches that give rise to the lateral supply, which makes it an attractive option for nasal artery and the dorsal nasal artery. flaps in reconstructing the inner lining of full- The internal carotid system also gives rise to an thickness nasal defects.8 extensive vascular network that supplies the nose. The ophthalmic artery has both ocular and orbital Blood supply branches. One of the orbital branches is the ante- The blood supply to the nose comes from rior ethmoidal artery, which provides the blood branches of both the external carotid artery supply for the anterosuperior portion of the nasal (through the facial artery and the infraorbital artery) cavity. After running in the skull base between and internal carotid artery (through the ophthalmic the frontal sinus and the anterior ethmoid sinuses, and anterior ethmoidal artery) (Fig. 1).4 it emerges between the cephalic edge of the upper In the external carotid artery system, the facial lateral cartilage (ULC) and the caudal edge of the artery has 2 terminal branches, the angular artery nasal bone, providing part of the blood supply to Fig. 1. Blood supply to the external nose. (From Jewett BS. Anatomic considerations. In: Baker SR, Naficy S. Principles of nasal reconstruction. St Louis (MO): Mosby; 2002. p. 19; with permission.) General Concepts in Nasal Reconstruction 3 the nasal tip, along with the lateral nasal artery. vestibule. The nasopalatine branch enters the The ophthalmic artery finally gives rise to 2 nose through the incisive foramen and innervates terminal branches: the frontal artery and the dorsal the nasal septal mucosa. nasal artery. The latter pierces the orbital septum and exits the orbit just superiorly to the medial canthal ligament and runs down to anastomose Bone and cartilaginous framework with the lateral nasal artery, creating a rich, axial The bony framework is a pyramidal structure that arterial network. consists of the paired nasal bones and the ascending process of the maxilla on either side. Sensory nerve supply The cephalic portion articulates with the frontal The skin overlying the nose is innervated by the bone superiorly and caudally, forming the cranial portion of the pyriform aperture (Fig. 3). The nasal ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve (Fig. 2). The cutaneous branches bones are thicker superiorly and progressively 10 of the ophthalmic nerve are the supratrochlear, the become thinner until their free edge inferiorly. infratrochlear, and the external nasal nerves. The The nasal bones are, on average, 25 mm, but their supratrochlear branch exits at the supraorbital length can vary significantly. They fuse at the foramen, and the infratrochlear branch exits the midline and give an internal projection that orbit just superior to the medial canthus. They supports the perpendicular plate of the ethmoid provide sensory supply to the skin of the nasion, bone. Inferiorly, the nasal bones articulate with radix, and rhinion and the cephalic portion of the the overlapped cephalic portion of the ULC, which lateral nasal sidewall. The external nasal branch are fused medially with the cartilage of the nasal comes from the anterior ethmoid nerve and septum. This area of confluence between the nasal emerges between the ULC and the nasal bone, bones, perpendicular plate of the ethmoid bone, accompanied by the anterior ethmoidal artery. ULCs, and cartilage of the nasal septum is con- This branch innervates the skin of the caudal nasal nected by a dense fibrous tissue and is called 11,12 dorsum and nasal tip. the “keystone area.” This region provides crit- The branches of the maxillary nerve are the in- ical support to the midvault of the nose. fraorbital nerve and the nasopalatine nerve. The infraorbital branch courses on the roof of the maxillary sinus and exits the cranium at the infraor- bital foramen. It innervates the skin of the caudal portion of the lateral nasal sidewall, ala, and nasal Fig. 2. The sensory nervous innervation to the Fig. 3. (A, B) The bony and cartilaginous framework external nose. (From Jewett BS. Anatomic consider- of the nasal skeleton. (From Jewett BS. Anatomic ations. In: Baker SR, Naficy S. Principles of nasal recon- considerations. In: Baker SR, Naficy S. Principles of struction. St Louis (MO): Mosby; 2002. p. 19; with nasal reconstruction. St Louis (MO): Mosby; 2002. p. permission.) 19; with permission.) 4 Bloom et al The upper cartilaginous vault is made by the external and internal nasal valves. The resistance ULCs and the fused cartilaginous nasal septum.
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