Defining the Parameters of Nasal Tip Anatomy

Correspondence: Dr Jacono, The New York Center for A Facial Plastic and Laser Surgery, 440 Northern Blvd, Great Neck, NY 11021 ([email protected]). Author Contributions: Study concept and design: Jacono. Acquisition of data: Parikh and Jacono. Analysis and interpretation of data: Parikh and Jacono. Drafting of the manuscript: Parikh and Jacono. Critical revision of the manuscript for important intellectual content: Parikh. Sta- tistical analysis: Parikh and Jacono. Administrative, tech- nical, and material support: Parikh and Jacono. Study supervision: Jacono. Financial Disclosure: None reported.

1. Rogers BO. History of the development of aesthetic surgery. In: Regnault P, Daniel RK, eds. Aesthetic Plastic Surgery. Boston, MA: Little Brown & Co; 1984. 2. Skoog TG. The Aging Face: Plastic Surgery: New Methods and Refinements. Philadelphia, PA: WB Saunders Co; 1974:300-330. B 3. Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86(1): 53-63. 4. Rees TD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg. 1984;73(6):911-915. 5. Mosely LH, Finseth F. Cigarette smoking: impairment of digital blood flow and wound healing in the hand. Hand. 1977;9(2):97-101. 6. Grover R, Jones BM, Waterhouse N. The prevention of haematoma follow- ing rhytidectomy: a review of 1078 consecutive facelifts. Br J Plast Surg. 2001; 54(6):481-486. 7. Riefkohl R, Wolfe JA, Cox EB, McCarty KSJ Jr. Association between cuta- neous occlusive vascular disease, cigarette smoking, and skin slough after rhytidectomy. Plast Reconstr Surg. 1986;77(4):592-595. 8. Schuster RH, Gamble WB, Hamra ST, Manson PN. A comparison of flap vascular anatomy in three rhytidectomy techniques. Plast Reconstr Surg. 1995; 95(4):683-690. 9. Whetzel TP, Mathes SJ. The arterial supply of the face lift flap. Plast Recon- str Surg. 1997;100(2):480-488. 10. Schaverien MV, Pessa JE, Saint-Cyr M, Rohrich RJ. The arterial and venous anatomies of the lateral face lift flap and the SMAS. Plast Reconstr Surg. 2009; 123(5):1581-1587.

Figure 2. Photographs demonstrating relocation of the deep-plane entry point. Preoperative (A) and postoperative (B) views. The area marked represents the subcutaneous pocket. Note the limited subcutaneous pocket The C-Ring Complex: Defining in the postoperative photograph. the Parameters of Nasal Tip Anatomy niques were a separate subcutaneous and sub-SMAS dissection, a composite (deep-plane) rhytidectomy, and a he human nose arises from the frontonasal promi- subperiosteal face-lift. The results showed that the sepa- nence during the 4th to 10th weeks of gesta- rate subcutaneous and sub-SMAS dissection interrupts T tion. Migration of neural crest cells into these soft the rich continuous anastomotic network between all tissues gives rise to the olfactory placodes. Invagination these vessels. Arterial continuity is best maintained with of the central placode epithelium within the proliferat- the composite lift and the subperiosteal face-lift.8 The most ing mesenchymal tissue allows for the development of significant arterial contribution of the face-lift flap is from the nasal pits and the medial and lateral nasal promi- the transverse facial artery perforator.9 This perforator nences. In time, these prominences fuse to form the as- has a constant anatomic location at 3.1-cm lateral and sociated soft, muscular, and cartilaginous tissues of the 3.7-cm inferior to the lateral canthus. This vessel is not paired external nares. The lateral prominence gives rise disturbed in a deep-plane face-lift.10 to the lateral nasal wall and ala while the medial prominence develops into the nasal septum, columella, and na- Sachin S. Parikh, MD sal tip.1 Each of the lower nasal cartilages is formed within Andrew A. Jacono, MD a C-shaped fusion of these embryonic prominences. Considerable attention has been given to the archi- Author Affiliations: The New York Center for Facial Plas- tecture and surgical management of the lower lateral tic and Laser Surgery, Great Neck, New York (Drs Parikh cartilages. The current medical literature is replete with and Jacono); Division of Facial Plastic and Reconstruc- discussions involving nasal tip rotation, projection, and tive Surgery, North Shore University Hospital, Long Is- soft-tissue alteration and refinement. Unfortunately, there land Jewish Medical Center, New Hyde Park, New York is limited integration of nasal embryology and anatomic (Drs Parikh and Jacono); and Departments of Otolaryn- studies involving the tissues of the nasal base. In our sur- gology–Head and Neck Surgery, Divisions of Facial Plas- gical experience we have noted significant, posterior ex- tic and Reconstructive Surgery, The New York Eye and tensions of the lateral crus of the lower lateral nasal car- Ear Infirmary and Albert Einstein College of Medicine, tilages that may be of considerable importance in the New York (Dr Jacono). treatment of the nasal base.

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Figure 1. Lateral nasal dissection. A, Extension of the lateral cartilage(s). B, Complete removal of the same cartilage complex.

A B

Figure 2. Lower lateral nasal dissection. A, Dissection of the lateral cartilages. B, Soft-tissue attachments extending the base of the medial crura. Methods. Twelve cadaveric nasal dissections were per- remained a constant. The robustness of the posterolat- formed in specimens without traumatic, surgical, or posi- eral extension of cartilage beyond the traditional tional distortion of the nose. Dissections were performed boundaries of the lateral crus varied considerably. Car- in a layered fashion with removal of external tissues, in se- tilage in the posterolateral region was found to be either quential fashion, analogous to that of an archeological ex- a continuous ribbon, a series of multiple hinged units, cavation. Isolation of 24 lower lateral cartilages was per- or segmented units aligned in a fashion similar to a formed in 10 male and 2 female specimens. Eleven of 12 string of pearls. The cartilage(s) varied in size, curva- specimens appeared to be of Caucasian descent while the ture, and number. Variations in lateral crural dimen- 12th specimen was of African descent. sions and configuration were appreciated as well.

Results. In all 12 specimens there was notable exten- Comment. The shape of the lower nose is determined sion of cartilage lateral to the lateral crus of the lower by the lower nasal cartilages, ligamentous attachments, lateral nasal cartilage. In all specimens the lateral carti- and surrounding soft tissues. Various discussions have lage(s) extended toward the piriform aperture, diverged highlighted the inherent framework of the nasal tip. The inferiorly, and extended anteromedially toward the tripod concept by Anderson2 describes the medial crura columella and anterior nasal spine to form a near- as a single, anterior leg of a tripod with the remaining complete circle. The appearance of these findings two legs represented by the lateral crura. Adamson et al3 directly resembled a C-ring configuration (Figure 1). refined this concept with the development of the M- Soft-tissue attachments extending from the distal tip of arch model. Instead of representing forces in a linear ar- the ring complex toward the base of the medial crura rangement, the M-arch model defines the surgical and were found to invest in either the soft-tissue plane dor- anatomic considerations of the medial, intermediate, and sal to the depressor septi nasi muscle or along the lateral crura in an arch configuration.3 Both concepts de- fibrous attachments to the nasal spine (Figure 2). fine the nasal tip as an interrelated system in which al- Notable variations in cartilage quantity and unity were terations to any one specific region has a notable effect observed, but the cartilaginous ring configuration on all others.

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Figure 3. Configurations observed. A, Solid strip or ribbon of cartilage. B, Multiple hinged cartilage units. C, Series of cartilages aligned similar to a string of pearls.

In our anatomic and clinical investigations we have The extent to which the cartilages beyond the hinge re- observed, with considerable variability, the cartilages that gion contributes to the functional shape and appearance extend beyond what Anderson2 described as the hinge of the nose is speculative but not without merit. The de- region, or the posterolateral point of the lower lateral car- stabilization of the lateral crura or hinge region is well de- tilage. The configurations observed include a solid strip scribed in its potential to compromise the nasal airway with of cartilage, multiple hinged cartilage units, and a series resultant in-flaring of the soft tissues.8 Furthermore, when of cartilages aligned similarly to a string of pearls performing a lateral crural steal or repositioning of cephali- (Figure 3). In the circumstance of multiple cartilage cally oriented lower lateral cartilages one is confronted with units, the cartilages were commonly aligned in tandem the considerations of dividing, strengthening, and reposi- and connected by overlying perichondrium.4 Classi- tioning the cartilages of the lower nose.9,10 We submit that cally described as the accessory cartilages,5 these carti- the interrelated nature of these individual surgical maneu- lages appear along the planes of their embryonic origin vers is associated with the common embryologic origins and create a shape analogous to that of a C-ring. The car- of the cartilages and soft tissues comprising the cartilagi- tilaginous ring, which also includes the medial, inter- nous ring complex. The current discussion builds on the mediate, and lateral crura, is enveloped by perichon- conceptual principles of the tripod theory and the M-arch drium and invested with multiple soft-tissue and muscular model while integrating embryologic relations of known attachments.6 These attachments impart various forces anatomy as well as their biologic variability. along the ring and ultimately influence the static and dy- Of course, there are limitations in our ongoing inves- namic shape of the nasal base. There is considerable bio- tigation. Owing to the limited number of specimens, spe- logical variation in the quantity of cartilage, its inherent cific characteristics could not be identified for various eth- resilience, and the overall general configuration. Each of nic groups. A larger sample population would probably these parameters ultimately defines nasal tip projection, reveal greater variations of the C-ring complex than those length, width, and rotation. currently presented. What interrelations between nasal Knowledge of the various nasal cartilage configura- width and protrusion are present? Are there implica- tions, the underlying forces, and their clinical appear- tions with regard to nasal flare? These questions and many ance can allow the rhinoplasty surgeon to identify the others are beyond the scope of this pilot study, but we anatomic considerations of surgical significance. Ex- feel the C-ring concept may prove as a useful tool in the tremes in the orientation of a single C-ring can range from conceptualization of interconnected forces as well as the a nearly horizontal orientation, as observed in a cleft lip surgical maneuvers necessary in nasal base surgery. nasal deformity, to a sagittal position, in which the cartilages are aligned parallel to the nasal septum as seen in James M. Ridgway, MD a parentheses deformity.7 Orientation of the lower nasal Craig S. Murakami, MD cartilages should be evaluated bilaterally and can be en- visioned as two rings with the medial crura represent- Author Affiliations: Larrabee Center for Facial Plastic Sur- ing a relatively stable, central hinge. From this central gery (Dr Ridgway) and Facial Plastic Surgery, Virginia hinge one can appreciate the various degrees of diver- Mason Medical Center (Dr Murakami), Seattle, Wash- gence between the rings. ington.

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©2011 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Correspondence: Dr Ridgway, Department of Otolaryn- 2. Anderson JR. A reasoned approach to nasal base surgery. Arch Otolaryngol. 1984;110(6):349-358. gology–Head and Neck Surgery, The Larrabee Center for 3. Adamson PA, Litner JA, Dahiya R. The M-Arch model: a new concept of na- Facial Plastic Surgery, 600 Broadway, Ste 280, Seattle, WA sal tip dynamics. Arch Facial Plast Surg. 2006;8(1):16-25. 98122 ([email protected]). 4. Daniel RK. The nasal tip: anatomy and aesthetics. Plast Reconstr Surg. 1992; 89(2):216-224. Author Contributions: Study concept and design: Ridg- 5. Gunter JP. Anatomical observations of the lower lateral cartilages. Arch way and Murakami. Acquisition of data: Ridgway. Analy- Otolaryngol. 1969;89(4):599-601. sis and interpretation of data: Ridgway. Drafting of the manu- 6. Zelnik J, Gingrass RP. Anatomy of the alar cartilage. Plast Reconstr Surg. 1979; 64(5):650-653. script: Ridgway. Critical revision of the manuscript for 7. Hamilton GS III. Correction of sagittally malpositioned lateral crura. Ear Nose important intellectual content: Ridgway and Murakami. Throat J. 2009;88(6):961-962. 8. Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical Study supervision: Murakami. applications in rhinoplasty. Plast Reconstr Surg. 1997;99(4):943-955. Financial Disclosure: None reported. 9. Foda HM, Kridel RW. Lateral crural steal and lateral crural overlay: an ob- jective evaluation. Arch Otolaryngol Head Neck Surg. 1999;125(12):1365- 1. Sadler TW. Head and neck embryology. In: Sadler TW, ed. Langman’s Medi- 1370. cal Embryology. 6th ed. Baltimore, MD: Williams & Wilkins; 1990:313- 10. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg. 320. 2006;8(3):156-185.

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