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Rhinopedia by Dr 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. 1 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. 2 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. 3 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. 4 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. 5 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.
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