---
title: "Surgical Anatomy of the Nose for Rhinoplasty"
description: "ENT notes on the surgical anatomy of the nose for Rhinoplasty."
source: "The ENT Resident"
author: "Dr. Mausumi Das"
canonical_url: "https://www.theentresident.com/ent-notes-lectures/surgical-anatomy-nose-rhinoplasty"
categories: ["Rhinology"]
video: "https://www.youtube.com/watch?v=C7s-wFhpYzc"
image: "https://media.theentresident.com/og-images/surgical-anatomy-nose-rhinoplasty.png"
---

# Surgical Anatomy of the Nose for Rhinoplasty

ENT notes on the surgical anatomy of the nose for Rhinoplasty. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=C7s-wFhpYzc

## 👃 Surgical Anatomy of the Nose for Rhinoplasty

A sound knowledge of the surgical anatomy of the external nose is essential before learning rhinoplasty.

This post covers:

- Parts of the external nose
- Bony pyramid and articulations of the nasal bone
- Surface landmarks of the bony vault
- Upper cartilaginous vault, keystone area and related triangles
- Lower cartilaginous vault, lobule and columella
- Tripod concept and types of dome
- Soft tissue covering, muscles, blood supply and nerve supply
- Anatomy of the septum and nasal valves

---

### 📋 Parts of the External Nose

The external nose is anatomically divided into three parts:

1️⃣ **Bony pyramid**

2️⃣ **Upper cartilaginous vault**

3️⃣ **Lower cartilaginous vault**

---

### 🦴 Bony Pyramid

#### Structures Forming the Bony Pyramid

1- Paired **nasal bones**

2- **Frontal process of the maxilla** (on both sides)

3- **Nasal part of the frontal bone**

⭐ All **osteotomies** in rhinoplasty are performed on the **nasal bone**.

> What are the articulations of the Nasal Bone?

---

### 📍 Surface Landmarks of the Bony Vault

| Landmark | Definition |
| --- | --- |
| **Glabella** | Most prominent smooth area in the midline of the forehead, at the level of the supraorbital ridges |
| **Nasion** | Midpoint of the bony junction where the two nasal bones meet the frontal bone, corresponding to the frontonasal suture |
| **Rhinion** | Lower end of the suture formed between the two nasal bones |

> What is Radix Nasi?

> What is Dorsum Nasi?

> What is the Nasal Bridge?

> What is the Nasofrontal Angle? What is it's normal value?

---

#### ⚠️ Applied Importance of the Bony Vault

**Anatomical Variations of the Nasal Bones**

* Symmetrical or asymmetrical
* **Agenesis** of one or both nasal bones
* Markedly large nasal bones

**Lateral Osteotomy**

❌ Lateral osteotomy should **not extend up to the upper thickened end of the nasal bone at the level of the nasion**.

⭐ At this level, the bone is thickest and **cannot be compressed further**.

---

### 🔺 Upper Cartilaginous Vault

#### Structures Forming the Upper Cartilaginous Vault

1- **Upper lateral cartilages** on both sides (major portion)

2- A part of the **cartilaginous septum**

⭐ Both have the **same embryological origin**, are enclosed in a **common perichondrial sheath**, and constitute a **single cartilaginous unit**.

> What is the Keystone Area? What is its clinical importance?

---

#### Relations of the Upper Lateral Cartilage

**1- Lateral**

* The upper lateral cartilages fall **just short of the piriform edge of the maxilla**
* The intervening gap is filled with **dense fibrous tissue**

> What is the Empty Triangle of the nose?

**2- Superior**

* The upper margins (cephalic borders) are united under the lower ends of the **nasal bone and frontal process of the maxilla** by connective tissue
* The upper lateral cartilage extends about **1 cm above the lower edge of the nasal bone**
* There is **fusion of the perichondrium and periosteum** at this level

⭐ This firm connection allows **transmission of the motion of the nasal bone to the upper lateral cartilage**.

**3- Inferior**

* The caudal edge of the upper lateral cartilage is **rolled outwards and upwards**, forming a **scroll**
* The scroll contributes to **widening of the dorsal area and the lateral wall**

⚠️ Prominent scrolls may need to be **excised**, as they can produce a **Polly beak deformity**.

> What is Pollybeak deformity?

> What is Anterior Septal Angle?

> What is Posterior Septal Angle?

> What is Weak Triangle of Converse? What is it's clinical significance?

---

### 🔻 Lower Cartilaginous Vault

#### Structures Forming the Lower Cartilaginous Vault

1- **Lower lateral cartilages (Alar cartilages)** - one on each side

2- **Sesamoid cartilages**

---

#### Parts of the Lower Lateral Cartilage

The lower lateral cartilage is a **single piece of cartilage on each side**, with three parts:

**1- Medial Crus**

* Lies immediately **under the skin of the columella**
* The two medial crura join in the midline, attached to each other by **fibrous tissue**
* Attached to the lower end of the septum by the **membranous septum**

**2- Dome**

* The **meeting point of the medial crus and lateral crus**
* Contributes to the formation of the **lobule and the tip of the nose**

**3- Lateral Crus**

* About **1 mm** in thickness
* Its upper edge also forms a **scroll**, overlapping the lower edge of the upper lateral cartilage

> What is the Soft Triangle in the nose? What is it's clinical significance?

---

#### Lobule

#### Formed By

* **Lateral crura** of the lower lateral cartilage
* **Dome** of the lower lateral cartilage

#### Tip

* Formed by the **two domes**
* The **most anterior part of the lobule**

> What are the boundaries of the Lobule?

#### ⭐ Mobility of the Lobule

The lower cartilaginous part is a **separate part of the nose**, with no connection to other structures except an **aponeurosis** formed by the continuity of the fibrous envelope investing the upper and lower lateral cartilages.

👉 Therefore, the lobule is **freely mobile** upwards, downwards and from side to side.

---

#### Columella

#### 🔍 What is it?

The structure extending **between the lip and the tip of the nose**.

#### Formed By

* The **two medial crura** with intervening areolar tissue
* Covered with a thin layer of skin

⭐ Its shape depends on the **size and contour of the medial crura**.

#### Parts of the Columella

1- Upper lobular part

2- Middle narrow part

3- Wider lower (basal) part

> What is the effect of length of Medial Crura on the size and shape of nose?

> What is the normal angle Between the Medial Crura?

---

### 🔺 Tripod Concept (Anderson, 1969)

Anderson compared the **lower lateral cartilage to a tripod**, consisting of:

* One relatively **long leg** - the **lateral crura**
* One **short leg** - the **medial crura**

#### Structures Supporting the Tripod

1- Part of the **upper lateral cartilage**

2- Part of the **caudal border of the septal cartilage**

3- **Soft tissue at the base of the columella**

4- **Membranous septum**

> What is the Applied Importance of Tripod Concept given by Anderson?

> What are the Types of Dome given by Bernstein?

> Define Anatomical Dome. 

> Define Surgical Dome. 

> Define Clinical Dome.
---

### 🧴 Soft Tissue Covering

The nasal skin is **not uniform** throughout.

| Site | Thickness of Skin |
| --- | --- |
| Nasion | Thickest |
| Rhinion | Thin |
| Supratip area (above the tip) | Thickens again |

* Skin over the **lower part** of the nose is **thicker and more firmly attached** to the cartilages
* Skin over the **nasal bone and upper lateral cartilage** is **mobile**
* Skin of the **alar region** has abundant **sebaceous glands**

---

### 💪 Muscles of the Nose

**1- Procerus**

| Feature | Detail |
| --- | --- |
| Origin | Upper part of the upper lateral cartilage and the nasal bone |
| Insertion | Skin of the root of the nose |

**2- Compressor Naris (Transverse part of Nasalis)**

| Feature | Detail |
| --- | --- |
| Origin | Maxilla on each side |
| Insertion | Dorsum of the nose in its lower part, into the aponeurosis |

**3- Dilator Naris (Alar part of Nasalis)**

| Feature | Detail |
| --- | --- |
| Origin | Maxilla, over the lateral incisor tooth region |
| Insertion | Lateral part of the crus |

**4- Depressor Septi**

| Feature | Detail |
| --- | --- |
| Origin | Incisive fossa of the maxilla |
| Insertion | Caudal end of the septum and part of the alar base |

> Which muscle is sectioned when a **transfixion incision** is given in rhinoplasty?

---

### 🩸 Blood Supply of the External Nose

⭐ The arteries and veins of the external nose lie **superficially in the soft tissue**.

#### Arteries

**Branches of the Facial Artery**

* Angular artery → **Lateral nasal artery**
* Superior labial artery → **Columellar branch** and **Septal branch**

**Branches of the Ophthalmic Artery**

* **Dorsal nasal artery**
* Anterior ethmoidal artery → **External nasal branch**

**Infraorbital Artery**

#### Veins

* Angular veins
* Ophthalmic veins

#### ⚠️ Applied Importance

While mobilizing the soft tissue after the opening incisions, the **plane of dissection must be close to the bony and cartilaginous framework**.

👉 This avoids injury to the muscles and superficial vessels, which can cause:

* Unnecessary bleeding
* Button-holing of the skin

---

### 🧠 Sensory Nerve Supply of the External Nose

Supplied primarily by the **ophthalmic and maxillary divisions of the trigeminal nerve (5th cranial nerve)**.

| Nerve | Area Supplied |
| --- | --- |
| Supratrochlear nerve (Ophthalmic) | Skin of the nasal root, nasal bridge and upper part of the side wall |
| Infratrochlear nerve (Ophthalmic) | Skin of the nasal root, nasal bridge and upper part of the side wall |
| Infraorbital nerve (Maxillary) | Remaining part of the nasal side wall |
| External nasal nerve (Branch of anterior ethmoidal nerve) | Skin over the dorsum and nasal tip |
| Terminal filaments of the palatine nerve | Skin at the base of the columella |

⭐ The **external nasal nerve** exits between the **nasal bone and the upper lateral cartilage**.

⭐ Knowledge of the nerve supply is important for **pre-operative infiltration**.

---

### 🧱 Anatomy of the Nasal Septum

#### Parts of the Septum

1- **Columellar septum**

2- **Membranous septum**

3- **Septum proper** - osseous and cartilaginous parts

#### Cartilaginous Part

* **Septal cartilage**

#### Bony Part

**Major Contribution**

* Perpendicular plate of the ethmoid
* Vomer

**Minor Contribution**

* Crest of the nasal bone
* Nasal spine of the frontal bone
* Anterior nasal spine of the maxilla
* Crest of the maxilla
* Crest of the palatine bone
* Rostrum of the sphenoid

> What is the detailed anatomy of the nasal septum?

> What are the boundaries of the External Nasal Valve?

> What are the boundaries of the Internal Nasal Valve?

> What is the anatomy of the internal nose?

---

### ⭐ Exam Pearls

- Bony pyramid → **Nasal bones, frontal process of maxilla, nasal part of frontal bone**
- Nasal bone is **thick above and thin below**
- Lateral osteotomy should **not** extend up to the level of the **nasion**
- Weakening of the keystone area → **Saddle nose deformity**
- Prominent scroll → **Polly beak deformity**
- Tip of the nose is formed by the **two domes**
- Tripod concept → **Anderson, 1969**
- Types of dome → **Bernstein, 1974**
- Nasal skin is thickest at the **nasion** and thin at the **rhinion**
- Internal nasal valve → **Least cross-sectional area** of the nose

---

## About This Note

This free ENT note on Surgical Anatomy of the Nose for Rhinoplasty was written by Dr. Mausumi Das and is paired with a corresponding video lecture.

Canonical page of this note: https://www.theentresident.com/ent-notes-lectures/surgical-anatomy-nose-rhinoplasty

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