The nose consists of an underlying skeleton of cartilage, (lower two thirds) and bone (upper third) covered by a skin-soft tissue envelope (SSTE). The size and shape of the underlying supportive structures determine the external appearance of the nose, which is also influenced by the thickness of the SSTE.

A dorsal hump is usually due to a combination of prominence of the nasal bones and the upper lateral cartilages.  Hump reduction is commonly part of the rhinoplasty operation. This results in an “open roof” which is corrected by a  lateral osteotomy with infracture to “close” the roof. This manoeuvre helps to smooth the nasal dorsum and narrow the bridge (link to glossary) of the nose. Osteotomies can also be used to help correct the twisted nose.

Nose before hump reduction		Nose after hump reduction

The Tip

The shape of the tip of the nose is determined by the size, shape and consistency of the underlying lower lateral cartilages and the support of the intervening nasal septum. The lower lateral cartilages are paired curved structures that consist of a medial, intermediate and lateral crurae.

Anatomy of Lower Lateral Cartilages

Excessive size of the lateral crurae result in broadness of the nasal tip. This prominence is often corrected by performing a cephalic trim to narrow the tip and at times dome excision to deproject the tip.

Cephalic trim

Weakness of the medical crurae and deficiency of the underlying nasal septum can result from ageing changes, previous trauma or nasal surgery (Septoplasty). This can lead to a “droopy tip” which is rotated downwards and deprojection of the tip. Correction of this deformity usually involves suture techniques to strengthen the tip often with the assistance of a columellar strut of septal cartilage.

Columellar Strut

Bifidity of the tip is the result of divergence of the domes of the lower lateral cartilages and can be corrected by suture techniques.

Divergent domes		Sutured tips

The Septum

This is the midline supportive structure of the nose that lies between the paired nasal bones and the upper part of the nose and upper and lower lateral cartilages below.  Like the side walls of the nose it consists of bone postero-superiorly and cartilage anteriorly.

Diagram of nasal septum

Often rhinoplasty surgery will also involve surgery to the septum (septorhinoplasty) to straighten deviations resulting from trauma or a twist in the septum due to an acquired deformity during growth of the nose.  The back of the septum is reduced in hump reduction but may also be strengthened by augmentation rhinoplasty to correct a saddle nose deformity, the so called “boxers nose”. 

Functional rhinoplasty addresses breathing problems that result from septal deviation as well as the external appearance of the nose.  Twisting of the septum often results in crookedness of the external nose and correction of this may be necessary in these patients.

The Skin

The thickness of the skin is a crucial factor in assessing patients for rhinoplasty.  While thick skin helps disguise any irregularity of the underlying nasal skeleton after rhinoplasty it also limits the definition and refinement of the nasal dorsum and tip that can be realistically achieved with surgery. 

Thin skin permits improved definition and refinement but may make even minor irregularities of the underlying skeleton of the nose visible after rhinoplasty.  Often this becomes apparent only months after surgery.  This is very difficult to correct. 

Your surgeon should discuss the limitations that your skin may place on the results of planned surgery.