Rhinoplasty
Rhinoplasty (, nose + , to shape), commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle  between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty. In closed rhinoplasty and open rhinoplasty surgeries – a plastic surgeon, an otolaryngologist (ear, nose, and throat specialist), or an oral and maxillofacial surgeon (jaw, face, and neck specialist), creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the soft tissues from the nasal framework, altering them as required for form and function, suturing the incisions, using tissue glue and  applying either a package or a stent, or both, to immobilize the altered nose to ensure the proper healing of the surgical incision. History. Treatments for the plastic repair of a broken nose are first mentioned in the Edwin Smith Papyrus, a transcription of text dated to the Old Kingdom from 3000 to 2500 BCE. The "Ebers Papyrus" ( 1550 BC), an Ancient Egyptian medical papyrus, describes rhinoplasty as the plastic surgical operation for reconstructing a nose destroyed by rhinectomy. Such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time and culture. Rhinoplasty techniques are  described in the ancient Indian text "Sushruta samhita" by Sushruta, where a nose is reconstructed by using a flap of skin from the cheek. During the Roman Empire (27 BC – 476 AD) the encyclopaedist Aulus Cornelius Celsus ( 25 BC – 50 AD) published the 8-tome "De Medicina" (On Medicine, 14 AD), which described plastic surgery techniques and procedures for the correction and the reconstruction of the nose and other body parts. At the Byzantine Roman court of the Emperor Julian the Apostate (331–363 AD), the royal physician Oribasius ( 320–400 AD) published the 70-volume "Synagogue Medicae" (Medical Compilations, 4th century  AD), which described facial-defect reconstructions that featured loose sutures that permitted a surgical wound to heal without distorting the facial flesh; how to clean the bone exposed in a wound; debridement, how to remove damaged tissue to forestall infection and so accelerate healing of the wound; and how to use autologous skin flaps to repair damaged cheeks, eyebrows, lips, and nose, to restore the patient's normal visage. In Italy, Gasparo Tagliacozzi (1546–1599), professor of surgery and anatomy at the University of Bologna, published "Curtorum Chirurgia Per Insitionem" (The Surgery of Defects by Implantations, 1597), a technico–procedural manual  for the surgical repair and reconstruction of facial wounds in soldiers. The illustrations featured a re-attachment rhinoplasty using a biceps muscle pedicle flap; the graft attached at 3-weeks post-procedure; which, at 2-weeks post-attachment, the surgeon then shaped into a nose. In Great Britain, Joseph Constantine Carpue (1764–1846) published the descriptions of two rhinoplasties: the reconstruction of a battle-wounded nose, and the repair of an arsenic-damaged nose. (cf. Carpue's operation). In Germany, rhinoplastic technique was refined by surgeons such as the Berlin University professor of surgery Karl Ferdinand von Gräfe (1787–1840), who published  Rhinoplastik (Rebuilding the Nose, 1818) wherein he described 55 historical plastic surgery procedures, and his technically innovative free-graft nasal reconstruction (with a tissue-flap harvested from the patient's arm), and surgical approaches to eyelid, cleft lip, and cleft palate corrections. Dr. von Gräfe's protégé, the medical and surgical polymath Johann Friedrich Dieffenbach (1794–1847), who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published "Die Operative Chirurgie" (Operative Surgery, 1845), which became a foundational medical and plastic surgical text (see strabismus, torticollis). Moreover, the Prussian Jacques Joseph (1865–1934) published "Nasenplastik und sonstige  Gesichtsplastik" (Rhinoplasty and other Facial Plastic Surgeries, 1928), which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions. In the United States, in 1887, the otolaryngologist John Orlando Roe (1848–1915) performed the first modern endonasal rhinoplasty (closed rhinoplasty) and about his management of saddle nose deformities. In the early 20th century, Freer, in 1902, and Killian, in 1904, pioneered the submucous resection septoplasty (SMR) procedure for correcting a deviated septum; they raised mucoperichondrial tissue flaps, and resected the cartilaginous and bony septum (including the vomer bone and the perpendicular plate of the ethmoid bone), maintaining septal support  with a 1.0-cm margin at the dorsum and a 1.0-cm margin at the caudad, for which innovations the technique became the foundational, standard septoplastic procedure. In 1921, A. Rethi introduced the open rhinoplasty approach featuring an incision to the nasal septum to facilitate modifying the tip of the nose. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1947, Maurice H. Cottle (1898–1981) endonasally resolved a septal deviation with a minimalist hemitransfixion incision, which conserved the septum; thus, he advocated for the practical primacy of  the closed rhinoplasty approach. In 1957, A. Sercer advocated the "decortication of the nose" ("Dekortication des Nase") technique which featured a columellar-incision open rhinoplasty that allowed greater access to the nasal cavity and to the nasal septum. The endonasal rhinoplasty was the usual approach to nose surgery until the 1970s, when Padovan presented his technical refinements, advocating the open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the later 1970s, and by Jack P. Gunter in the 1990s. Goodman impelled technical and procedural progress and popularized the open rhinoplasty approach. In 1987, Gunter reported the technical effectiveness  of the open rhinoplasty approach for performing a secondary rhinoplasty; his improved techniques advanced the management of a failed nose surgery. Anatomy of the human nose. The structures of the nose. For plastic surgical correction, the structural anatomy of the nose comprises: A. the nasal soft tissues; B. the aesthetic subunits and segments; C. the blood supply arteries and veins; D. the nasal lymphatic system; E. the facial and nasal nerves; F. the nasal bone; and G. the nasal cartilages. B. Aesthetics of the nose – nasal subunits and nasal segments. To plan, map, and execute the surgical correction of a  nasal defect or deformity, the structure of the external nose is divided into nine aesthetic nasal subunits, and six aesthetic nasal segments, which provide the plastic surgeon with the measures for determining the size, extent, and topographic locale of the nasal defect or deformity. The surgical nose as nine "aesthetic nasal subunits". In turn, the nine aesthetic nasal subunits are configured as six aesthetic nasal segments; each segment comprehends a nasal area greater than that comprehended by a nasal subunit. The surgical nose as six "aesthetic nasal segments". Using the co-ordinates of the subunits and segments to determine the  topographic location of the defect on the nose, the plastic surgeon plans, maps, and executes a rhinoplasty procedure. The unitary division of the nasal topography permits minimal, but precise, cutting, and maximal corrective-tissue coverage, to produce a functional nose of proportionate size, contour, and appearance for the patient. Hence, if more than 50 percent of an aesthetic subunit is lost (damaged, defective, destroyed) the surgeon replaces the entire aesthetic segment, usually with a regional tissue graft, harvested from either the face or the head, or with a tissue graft harvested from elsewhere on the patient's body. C. Nasal  blood supply – arteries and veins. Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant blood. The principal arterial blood-vessel supply to the nose is two-fold: (i) branches from the internal carotid artery, the branch of the anterior ethmoidal artery, the branch of the posterior ethmoidal artery, which derive from the ophthalmic artery; (ii) branches from the external carotid artery, the sphenopalatine artery, the greater palatine artery, the superior labial artery, and the angular artery. The external nose is supplied with blood by the facial artery, which becomes the angular  artery that courses over the superomedial aspect of the nose. The sellar region (sella turcica, "Turkish chair") and the dorsal region of the nose are supplied with blood by branches of the internal maxillary artery (infraorbital artery) and the ophthalmic arteries that derive from the internal common carotid artery system. Internally, the lateral nasal wall is supplied with blood by the sphenopalatine artery (from behind and below) and by the anterior ethmoid artery and the posterior ethmoid artery (from above and behind). The nasal septum also is supplied with blood by the sphenopalatine artery, and by the anterior and posterior  ethmoid arteries, with the additional circulatory contributions of the superior labial artery and of the greater palatine artery. These three vascular supplies to the internal nose converge in the Kiesselbach plexus (the Little area), which is a region in the anteroinferior-third of the nasal septum, (in front and below). Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the cavernous sinus, which makes possible the potential intracranial spreading of a bacterial infection  of the nose. Hence, because of such an abundant nasal blood supply, tobacco smoking does therapeutically compromise post-operative healing. D. Lymphatic system of the nose. The pertinent nasal lymphatic system arises from the superficial mucosa, and drains posteriorly to the retropharyngeal nodes (in back), and anteriorly (in front), either to the upper deep cervical nodes (in the neck), or to the submandibular glands (in the lower jaw), or into both the nodes and the glands of the neck and the jaw. E. Nerves of the nose. The sensations registered by the human nose derive from the first two branches  of cranial nerve V, the trigeminal nerve. The nerve listings indicate the respective innervation (sensory distribution) of the trigeminal nerve branches within the nose, the face, and the upper jaw (maxilla). The maxillary division innervation. The supply of parasympathetic nerves to the face and the upper jaw (maxilla) derives from the greater superficial petrosal (GSP) branch of cranial nerve VII, the facial nerve. The GSP nerve joins the deep petrosal nerve (of the sympathetic nervous system), derived from the carotid plexus, to form the vidian nerve (in the vidian canal) that traverses the pterygopalatine ganglion (an autonomic ganglion of the  maxillary nerve), wherein only the parasympathetic nerves form synapses, which serve the lacrimal gland and the glands of the nose and of the palate, via the (upper jaw) maxillary division of cranial nerve V, the trigeminal nerve. F. Bony anatomy of the nose. In the upper portion of the nose, the paired nasal bones attach to the frontal bone. Above and to the side (superolaterally), the paired nasal bones connect to the lacrimal bones, and below and to the side (inferolaterally), they attach to the ascending processes of the maxilla (upper jaw). Above and to the back (posterosuperiorly), the bony  nasal septum is composed of the perpendicular plate of the ethmoid bone. The vomer bone lies below and to the back (posteroinferiorly), and partially forms the choanal opening into the nasopharynx, (the upper portion of the pharynx that is continuous with the nasal passages). The floor of the nose comprises the premaxilla bone and the palatine bone, the roof of the mouth. The nasal septum is composed of the quadrangular cartilage, the vomer bone (the perpendicular plate of the ethmoid bone), aspects of the premaxilla, and the palatine bones. Each lateral nasal wall contains three pairs of turbinates (nasal conchae ), which are small, thin, shell-form bones: (i) the superior concha, (ii) the middle concha, and (iii) the inferior concha, which are the bony framework of the turbinates. Lateral to the turbinates is the medial wall of the maxillary sinus. Inferior to the nasal conchae (turbinates) is the meatus space, with names that correspond to the turbinates, e.g. superior turbinate, superior meatus, et alii. The internal roof of the nose is composed by the horizontal, perforated cribriform plate (of the ethmoid bone) through which pass sensory filaments of the olfactory nerve (cranial nerve I); finally, below and behind (posteroinferior) the  cribriform plate, sloping down at an angle, is the bony face of the sphenoid sinus. G. The cartilaginous pyramid of the nose. The cartilaginous septum ("septum nasi") extends from the nasal bones in the midline (above) to the bony septum in the midline (posteriorly), then down along the bony floor. The septum is quadrangular; the upper half is flanked by two triangular-to-trapezoidal cartilages: the upper lateral-cartilages, which are fused to the dorsal septum in the midline, and laterally attached, with loose ligaments, to the bony margin of the pyriform (pear-shaped) aperture, while the inferior ends of  the upper lateral-cartilages are free (unattached). The internal area (angle), formed by the septum and upper lateral-cartilage, constitutes the internal valve of the nose; the sesamoid cartilages are adjacent to the upper lateral-cartilages in the fibroareolar connective tissue. Beneath the upper lateral-cartilages lay the lower lateral-cartilages; the paired lower lateral-cartilages swing outwards, from medial attachments, to the caudal septum in the midline (the medial crura) to an intermediate crus (shank) area. Finally, the lower lateral-cartilages flare outwards, above and to the side (superolaterally), as the lateral crura; these cartilages are mobile, unlike the  upper lateral cartilages. Furthermore, some persons present anatomical evidence of nasal scrolling—i.e., an outward curving of the lower borders of the upper lateral-cartilages, and an inward curving of the cephalic borders of the alar cartilages. The external nose. External nasal anatomy. The form of the nasal subunits—the dorsum, the sidewalls, the lobule, the soft triangles, the alae, and the columella—are configured differently, according to the race and the ethnic group of the patient, thus the nasal physiognomies denominated as: African, platyrrhine (flat, wide nose); Asiatic, subplatyrrhine (low, wide nose); Caucasian, leptorrhine (narrow nose); and Hispanic, paraleptorrhine  (narrow-sided nose). The respective external valve of each nose is variably dependent upon the size, shape, and strength of the lower lateral cartilage. Internal nasal anatomy. In the midline of the nose, the septum is a composite (osseo-cartilaginous) structure that divides the nose into two similar halves. The lateral nasal wall and the paranasal sinuses, the superior concha, the middle concha, and the inferior concha, form the corresponding passages, the superior meatus, the middle meatus, and the inferior meatus, on the lateral nasal wall. The superior meatus is the drainage area for the posterior ethmoid bone cells and  the sphenoid sinus; the middle meatus provides drainage for the anterior ethmoid sinuses and for the maxillary and frontal sinuses; and the inferior meatus provides drainage for the nasolacrimal duct. The internal nasal valve comprises the area bounded by the upper lateral-cartilage, the septum, the nasal floor, and the anterior head of the inferior turbinate. In the narrow (leptorrhine) nose, this is the narrowest portion of the nasal airway. Generally, this area requires an angle greater than 15 degrees for unobstructed breathing; for the correction of such narrowness, the width of the nasal valve can be increased with spreader  grafts and flaring sutures. Nasal analysis. The surgical management of nasal defects and deformities divides the nose into six anatomic subunits: (i) the dorsum, (ii) the sidewalls (paired), (iii) the hemilobules (paired), (iv) the soft triangles (paired), (v) the alae (paired), and (vi) the columella. Surgical correction and reconstruction comprehend the entire anatomic subunit affected by the defect (wound) or deformity, thus, the entire subunit is corrected, especially when the resection (cutting) of the defect encompasses more than 50 percent of the subunit. Aesthetically, the nose—from the nasion (the midpoint of the nasofrontal junction) to the columella-labial junction —ideally occupies one-third of the vertical dimension of the person's face; and, from ala to ala, it ideally should occupy one-fifth of the horizontal dimension of the person's face. The nasofrontal angle, between the frontal bone and the nasion usually is 120 degrees; the nasofrontal angle is more acute in the male face than in the female face. The nasofacial angle, the slope of the nose relative to the plane of the face, is approximately 30–40 degrees. The nasolabial angle, the slope between the columella and the philtrum, is approximately 90–95 degrees in the male face , and approximately 100–105 degrees in the female face. Therefore, when observing the nose in profile, the normal show of the columella (the height of the visible nasal aperture) is 2 mm; and the dorsum should be rectilinear (straight). When observed from below (worm's-eye view), the alar base configures an isosceles triangle, with its apex at the infra-tip lobule, immediately beneath the tip of the nose. The facially proportionate projection of the nasal tip (the distance of the nose's tip from the face) is determined with the Goode Method, wherein the projection of the nasal tip should be  55–60 percent of the distance between the nasion (nasofrontal junction) and the tip-defining point. A columellar double break might be present, marking the transition between the intermediate crus of the lower-lateral cartilage and the medial crus. The Goode Method determines the extension of the nose from the facial surface by comprehending the distance from the alar groove to the tip of the nose, and then relating that measurement (of nasal-tip projection) to the length of the nasal dorsum. The nasal projection measurement is obtained by delineating a right triangle with lines parting from the nasion (nasofrontal juncture ) to the alar–facial–groove. Then, a second, perpendicular delineation, that traverses the tip-defining point, establishes the ratio of projection of the nasal tip; hence, the range of 0.55:1 to 0.60:1, is the ideal nasal-tip-to-nasal-length projection. 3D simulations and planning can be used to communicate the patients existing deformities, and plan or propose the desired approach. 3-dimensional cameras allow photographic capture, inspection, analysis, and modification to understand the existing nasal anatomy, and communicate a potential result to the patient. Patient characteristics. To determine the patient's suitability for undergoing a rhinoplasty procedure, the surgeon  clinically evaluates them with a complete medical history (anamnesis) to determine their physical and psychological health. The prospective patient must explain to the physician–surgeon the functional and aesthetic nasal problems that they suffer. The surgeon asks about the ailments' symptoms and their duration, past surgical interventions, allergies, drugs use and drugs abuse (prescription and commercial medications), and a general medical history. Furthermore, additional to physical suitability is psychological suitability—the patient's psychological motive for undergoing nose surgery is critical to the surgeon's pre-operative evaluation of the patient. The complete physical examination of the rhinoplasty patient determines  if he or she is physically fit to undergo and tolerate the physiologic stresses of nose surgery. The examination comprehends every existing physical problem, and a consultation with an anaesthesiologist, if warranted by the patient's medical data. Specific facial and nasal evaluations record the patient's skin-type, existing surgical scars, and the symmetry and asymmetry of the aesthetic nasal subunits. The external and internal nasal examination concentrates upon the anatomic thirds of the nose—upper section, middle section, lower section—specifically noting their structures; the measures of the nasal angles (at which the external nose projects from the  face); and the physical characteristics of the naso-facial bony and soft tissues. The internal examination evaluates the condition of the nasal septum, the internal and external nasal valves, the turbinates, and the nasal lining, paying special attention to the structure and the form of the nasal dorsum and the tip of the nose. Furthermore, when warranted, specific tests—the mirror test, vasoconstriction examinations, and the Cottle maneuver—are included to the pre-operative evaluation of the prospective rhinoplasty patient. Established by Maurice H. Cottle (1898–1981), the Cottle maneuver is a principal diagnostic technique for detecting an internal nasal-valve  disorder; whilst the patient gently inspires, the surgeon laterally pulls the patient's cheek, thereby simulating the widening of the cross-sectional area of the corresponding internal nasal valve. If the maneuver notably facilitates the patient's inspiration, that result is a positive Cottle sign—which generally indicates an airflow-correction to be surgically effected with an installed spreader-graft. Said correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. Nonetheless, the Cottle maneuver occasionally yields a false-positive Cottle sign, usually observed in the patient afflicted with alar collapse, and in the patient  with a scarred nasal-valve region. Surgical rhinoplasty. There is limited evidence that a single dose of corticosteriods decreases oedema and bleeding first two days post operation but the difference is not maintained after this. Swelling and edema can take at least 1-year to diminish. Certain adjuncts, including fat grafting may help quicken the time to edema and bruising resolution. Open rhinoplasty versus closed rhinoplasty. The plastic surgical correction of congenital and acquired abnormalities of the nose restores functional and aesthetic properties by the surgeon's manipulations of the nasal skin, the subcutaneous (underlying) cartilage-and-bone support framework , and the mucous membrane lining. Technically, the plastic surgeon's incisional approach classifies the nasal surgery either as an open rhinoplasty or as a closed rhinoplasty procedure. In open rhinoplasty, the surgeon makes a small, irregular incision to the columella, the fleshy, exterior-end of the nasal septum; this columellar incision is additional to the usual set of incisions for a nasal correction. In closed rhinoplasty, the surgeon performs every procedural incision endonasally (exclusively within the nose), and does not cut the columella. Procedural differences. Except for the columellar incision, the technical and procedural approaches of open rhinoplasty and of  closed rhinoplasty are similar; yet closed rhinoplasty procedure features: The "ethnic nose". The open rhinoplasty approach affords the plastic surgeon advantages of ease in securing grafts (skin, cartilage, bone) and, most importantly, in securing the nasal cartilage properly, and so better to make the appropriate assessment and remedy. This procedural aspect can be especially difficult in revision surgery, and in rhinoplastic corrections of the thick-skinned "ethnic nose" of the person of color. The study, "Ethnic Rhinoplasty: a Universal Preoperative Classification System for the Nasal Tip" (2009), reports that a nasal-tip classification system, based upon skin thickness, has been  proposed to aid the surgeon in determining if an open rhinoplasty or a closed rhinoplasty can best correct the defect or deformity afflicting the patient's nose. Cause. Cause, the open and closed approaches to rhinoplastic correction resolve: (i) nasal pathologies (diseases intrinsic and diseases extrinsic to the nose); (ii) an unsatisfactory aesthetic appearance (disproportion); (iii) a failed primary rhinoplasty; (iv) an obstructed airway; and (v) congenital nose defects and deformities. Ultrasonic rhinoplasty. Recently, ultrasonic rhinoplasty which was introduced by Massimo Robiony in 2004 has become an alternative to traditional rhinoplasty. Ultrasonic rhinoplasty uses piezoelectric instruments to reshape atraumatically nasal  bones, also known as rhinosculpture. Ultrasonic rhinoplasty uses piezoelectric instruments (scrapers rasps, saws) that affect only the bones and the stiff cartilages through ultrasonic vibrations, as the instruments used in dental surgery. The use of piezoelectric instruments requires a more extended approach than the isial one, allowing to visualize the whole bony vault, to reshape it with rhinosculpture or to mobilize and stabilize bones after controlled osteotomies. Surgical procedure. A rhinoplastic correction can be performed on a person who is under sedation, under general anaesthesia, or under local anaesthesia; initially, a local anaesthetic mixture of lidocaine and epinephrine is injected  to numb the area, and temporarily reduce vascularity, thereby limiting any bleeding. Generally, the plastic surgeon first separates the nasal skin and the soft tissues from the osseo-cartilagenous nasal framework, and then reshapes them, sutures the incisions, and applies either an external or an internal stent, and tape, to immobilize the newly reconstructed nose, and so facilitate the healing of the surgical cuts. Occasionally, the surgeon uses either an autologous cartilage graft or a bone graft, or both, in order to strengthen or to alter the nasal . The autologous grafts usually are harvested from the nasal septum, but, if  it has insufficient cartilage (as can occur in a revision rhinoplasty), then either a costal cartilage graft (from the rib cage) or an auricular cartilage graft (concha from the ear) is harvested from the patient's body. When the rhinoplasty requires a bone graft, it is harvested from either the cranium, the hips, or the rib cage; moreover, when neither type of autologous graft is available, a synthetic graft (nasal implant) is used to augment the nasal bridge. The main types of grafts to support and reposition the nasal tip (or the central/medial limb of the tripod) are either  columellar strut, or the septal extension graft. Both are useful and effective, but the septal extension graft (SEG) is shown to impart greater control, and less changes over time. Photographic records. For the benefit of the patient and the physician–surgeon, a photographic history of the entire rhinoplastic procedure is established; beginning at the pre-operative consultation, continuing during the surgical operation procedures, and concluding with the post-operative outcome. To record the "before-and-after" physiognomies of the nose and the face of the patient, the specific visual perspectives required are photographs of the nose viewed from the anteroposterior  (front-to-back) perspective; the lateral view (profiles), the worm's-eye view (from below), the bird's-eye view (overhead), and three-quarter-profile views. Types of rhinoplasty – primary and secondary. In plastic surgical praxis, the term primary rhinoplasty denotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The term secondary rhinoplasty denotes the revision of a failed rhinoplasty, an occurrence in 5–20 per cent of rhinoplasty operations, hence a revision rhinoplasty. The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of a functional breathing deficit from an over aggressive rhinoplasty, asymmetry, deviated or  crooked nose, areas of collapses, hanging columella, pinched tip, scooped nose and more. Although most revision rhinoplasty procedures are "open approach", such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from the ear (auricular cartilage graft) or from the rib cage (costal cartilage graft). Results Can be good if performed by an experienced practitioner. As in all plastic surgery procedures, there can be some unpredictability, and biologic systems can heal in different ways . Nasal reconstruction. In reconstructive rhinoplasty, the defects and deformities that the plastic surgeon encounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose; congenital defect, trauma (blunt, penetrating, blast), autoimmune disorder, cancer, intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). When cartilage is disrupted, suturing for re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the  normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial) nose prostheses, because of the reduced incidence of histologic rejection and medical complications. Surgical anatomy for nasal reconstruction. The human nose is a sensory organ that is structurally composed of three types of tissue: (i) an osseo-cartilaginous support framework (nasal skeleton), (ii) a mucous  membrane lining, and (iii) an external skin. The anatomic topography of the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose into nasal subunits: (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures. Therefore , the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three anatomic layers: The technical principles for the surgical reconstruction of a nose derive from the essential operative principles of plastic surgery: that the  applied procedure and yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of the mucosa; cartilage battens to brace against tissue contraction and depression (topographic collapse); axial skin flaps designed from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting of bone, cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the  reconstructed nasal subunit is not a nose proper, but a collagen-glued collage—of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments of ear cartilage—which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose. In nasal reconstruction, the plastic surgeon's ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patient's "normal nose", as perceived at conversational distance (c. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach , which requires that the surgeon balance the patient's required rhinoplasty, with the patient's aesthetic ideal (body image). In the context of surgically reconstructing the patient's physiognomy, the "normal nose" is the three-dimensional (3-D) template for replacing the missing of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials—such as bone, cartilage, and flaps of skin and of tissue. In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral ) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the "normal nose" and from photographs of the patient before he or she suffered the nasal damage. Principles of rhinoplastic reconstruction. The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining with mucosa, cartilage with cartilage, bone with bone, and skin with skin that best match the native skin  color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notable scarring propensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude. The most effective nasal reconstruction for repairing a defect  (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in the topographic transition between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose with skin flaps. Nonetheless, in the final stage of nasal reconstruction—replicating the "normal nose" anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars , and render them (more) inconspicuous. Reasons for reconstruction. Reconstruction rhinoplasty is indicated for the correction of defects and deformities caused by: Surgical techniques. The effectiveness of a rhinoplastic reconstruction of the external nose derives from the contents of the surgeon's armamentarium of skin-flap techniques applicable to correcting defects of the nasal skin and of the mucosal lining; some management techniques are the bilobed flap, the nasolabial flap, the paramedian forehead flap, and the septal mucosal flap. The design of the bilobed flap derives from the creation of two adjacent random transposition flaps (lobes). In its original design, the  leading flap is applied to cover the defect, and the second flap, is emplaced where the skin flexes more, and fills the donor-site wound (from where the first flap was harvested), which then is closed primarily, with sutures. The first flap is oriented geometrically, at 90 degrees from the long axis of the wound (defect), and the second flap is oriented 180 degrees from the axis of the wound. Although effective, the bilobed flap technique did create troublesome "dog ears" of excess flesh that required trimming and it also produced a broad skin-donor area that was difficult to  confine to the nose. In 1989, J. A. Zitelli modified the bilobed flap technique by: (a) orienting the leading flap at 45 degrees from the long axis of the wound; and (b) orienting the second flap at 90 degrees from the axis of the wound. Said orientations and emplacements eliminated the excess-flesh "dog ears", and thus required a smaller area of donor skin; resultantly, the broad-based, bilobed flap is less prone to the "trap door" and the "pin cushion" deformities common to skin-flap transposition procedure. The design of the bilobed flap co-ordinates its lobes with the  long axis of the nasal defect (wound); each lobe of the flap is emplaced at a 45-degree angle to the axis. The two lobes of the bilobed flap rotate along an arc, of which all points are equidistant from the apex of the nasal defect. In the 19th century, the surgical techniques of J.F. Dieffenbach (1792–1847) popularized the nasolabial flap for nasal reconstruction, for which it remains a foundational nose surgery procedure. The nasolabial flap can be either superiorly based or inferiorly based; of which the superiorly based flap is the more practical rhinoplastic application, because it has a  more versatile arc of rotation, and the donor-site scar is inconspicuous. Depending upon how the defect lay upon the nose, the flap pedicle-base can be incorporated either solely to the nasal reconstruction, or it can be divided into a second stage procedure. The blood supply for the flap pedicle are the transverse branches of the contralateral angular artery (the facial artery terminus parallel to the nose), and by a confluence of blood vessels from the angular artery and from the supraorbital artery in the medial canthus, (the angles formed by the meeting of the upper and lower eyelids ). Therefore, the incisions for harvesting the nasolabial flap do not continue superiorly beyond the medial canthal tendon. The nasolabial flap is a random flap that is emplaced with the proximal (near) portion resting upon the lateral wall of the nose, and the distal (far) portion resting upon the cheek, which contains the main angular artery, and so is perfused with retrograde arterial flow. The pedicle of the nasolabial flap rests upon the lateral nasal wall, and is transposed a maximum of 60 degrees, in order to avoid the "bridge effect" of a flap emplaced across the nasofacial angle. The paramedian  forehead flap is the premier autologous skin graft for the reconstruction of a nose, by replacing any of the aesthetic nasal subunits, especially regarding the problems of different tissue thickness and skin color. The forehead flap is an axial skin flap based upon the supraorbital artery (an ophthalmic artery branch) and the supratrochlear artery (an ophthalmic artery terminus), which can be thinned to the subdermal plexus in order to enhance the functional and aesthetic outcome of the nose. Restricted length is a practical application limit of the paramedian forehead flap, especially when the patient has a low frontal hairline. In  such a patient, a small portion of scalp skin can be included to the flap, but it does have a different skin texture and does continue growing hair; such mismatching is avoided with the transverse emplacement of the flap along the hairline; yet that portion of the skin flap is random, and so risks a greater incidence of necrosis. The paramedian forehead flap has two disadvantages, one operational and one aesthetic: Operationally, the reconstruction of a nose with a paramedian forehead flap is a two-stage surgical procedure, which might a problem for the patient whose health (surgical suitability) includes  significant, secondary medical risks. Nonetheless, the second stage of the nasal reconstruction can be performed with the patient under local anaesthesia. Aesthetically, although the flap donor-site scar heals well, it is noticeable, and thus difficult to conceal, especially in men. The surgeon designs the paramedian forehead flap from a custom-fabricated three-dimensional metal foil template derived from the measures of the nasal defect to be corrected. Using an ultrasonic scanner, the flap-pedicle is centre-aligned upon the Doppler signal of the supraorbital artery. Afterwards, the distal one-half of the flap is dissected and thinned to the  subdermal plexus. The septal mucosal tissue flap is the indicated technique for correcting defects of the distal half of the nose, and for correcting almost every type of large defect of the mucosal lining of the nose. The septal mucosal tissue flap, which is an anteriorly based pedicle-graft supplied with blood by the septal branch of the superior labial artery. To perform such a nasal correction, the entire septal mucoperichondrium can be harvested. The surgeon cuts the anteriorly based septal mucosal tissue-flap as widely as possible, and then releases it with a low, posterior back-cut; but only  as required to allow the rotation of the tissue-flap into the nasal wound. A technical variant of the septal mucosal flap technique is the trap-door flap, which is used to reconstruct one side of the upper half of the nasal lining. It is emplaced in the contralateral nasal cavity, as a superiorly based septal mucosal flap of rectangular shape, like that of a "trap-door". This septomucosal flap variant is a random flap with its pedicle based at the junction of the septum and the lateral nasal skeleton. The surgeon elevates the flap of septal mucosa to the  roof of the nasal septum, and then traverses it into the contralateral (opposite) nasal cavity through a slit made by removing a small, narrow portion of the dorsal roof of the septum. Afterwards, the septomucosal flap is stretched across the wound in the mucosal lining of the lateral nose. Surgical management. The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) reconstruction; and (iv) total nasal reconstruction. A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary  intention closure, with sutures. Based upon the locale of the wound, the surgeon has two options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10 mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed. In the event, larger nasal wounds (defects) do successfully heal by secondary intention , but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is  a small wound directly upon the nasal tip. Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient's ear is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient's neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and  sebaceous glands, thus is unlike the oily skin of the nose. The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue morbidity. The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural histologic tendency for such skin grafts to contract , which might distort the shape of the corrected nose. Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately  and in combination. The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of wound contracture; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is aesthetically hidden by the shadows of the nasal dorsum and of the supraorbital rim, thereby obscuring any  differences in the quality of the color and of the texture of the replacement skin (epithelium). Healing by secondary intention (re-epithelialisation) occurs even when the wound extends to the nasal bone. Although the rate of healing depends upon the patient's wound-healing capacity, nasal wounds measuring up to 10 mm in diameter usually heal in at 4-weeks post-operative. Nonetheless, one potential, but rare, complication of this nasal correction approach is the formation of a medial canthal web, which can be corrected with two opposing Z-plasties, technique which relieves the disfiguring tensions exerted by the scar  tissue's contracture, its shape, and location on the nose. The size of the nasal defect (wound) occurred, in either the dorsum or the lateral wall, or both, determines the reconstructive skin-flap technique applicable to the corresponding aesthetic nasal subunits. The width of the human nasal-tip ranges 20–30 mm; the average width of the nasal tip, measured between the two alar lobules, is approximately 25 mm. The appropriate surgical management of an alar lobule defect depends upon the dimensions (length, width, depth) of the wound. Anatomically, the nasal skin and the underlying soft tissues of the alar lobule  form a semi-rigid aesthetic subunit that forms the graceful curve of the alar rim, and provides unobstructed airflow through the nostrils, the "anterior nares". The reconstruction rhinoplasty of an extensive defect or of a total nasal defect is an extension of the plastic surgical principles applied to resolving the loss of a regional aesthetic subunit. The skin layers are replaced with a paramedian forehead flap, but, if forehead skin is unavailable, the alternative corrections include the Washio retroauricular-temporal flap and the Tagliacozzi flap. The nasal skeleton is replaced with a rib-graft nasal dorsum and lateral nasal wall ; septal cartilage grafts and conchal cartilage grafts are applied to correct defects of the nasal tip and of the alar lobules. The nasal lining of the distal two-thirds of the nose can be covered with anteriorly based septal mucosal flaps; however, if bilateral septal-flaps are used, the septal cartilage does become devascularized, possibly from iatrogenic septal perforation. Furthermore, if the nasal defect is beyond the wound-correction scope of a septal mucosal flap, the alternative techniques are either an inferiorly based pericranial-flap (harvested from the frontal bone) or a free flap of temporoparietal fascia (harvested from the  head), either of which can be lined with free grafts of mucosa to achieve the nasal reconstruction. Corrections of defect and deformity. Illustration 1: The surgeon cuts the excessively wide bones of the upper nasal dorsum (violet) with an osteotome (bone chisel), then detaches, corrects, and relocates them inwards, to a position, between the ocular orbits (red), that narrows the width of the nasal dorsum. Illustration 2: The surgeon chisels two cuts (incisions) to the nasal bones, each incision begins at the nasal cavity. The first incision begins at the yellow dot and extends upwards, along the green arrow, until  meeting the zig-zag line (red). The second incision begins at the blue dot and extends upwards, along the black arrow, until meeting the zig-zag line (red). Once cut and loosened from the face, the nasal bone pieces are corrected, then pushed inwards and re-set, thus narrowing the nose. The rhinoplasty patient returns home after surgery, to rest, and allow the nasal cartilage and bone tissues to heal the effects of having been forcefully cut. Assisted with prescribed medications—antibiotics, analgesics, steroids—to alleviate pain and aid wound healing, the patient convalesces for about 1-week, and can  go outdoors. Post-operatively, external sutures are removed at 4–5 days; the external cast is removed at 1-week; the stents are removed within 4–14 days; and the "panda eyes" periorbital bruising heal at 2-weeks. If an alar base reduction is performed conjunctively within the Rhinoplasty, these sutures need to be removed within 7–10 days post operatively. Throughout the first year post-operative, in the course of the rhinoplastic wounds healing, the tissues will shift moderately as they settle into being a new nose. Risks. Rhinoplasty is safe, yet complications can arise; post-operative bleeding is uncommon, but usually  resolves without treatment. Infection is rare, but, when it does occur, it might progress to become an abscess requiring the surgical drainage of the pus, whilst the patient is under general anaesthesia. Adhesions, scars that obstruct the airways can form a bridge across the nasal cavity, from the septum to the turbinates, and require surgical removal. If too much of the osseo-cartilaginous framework is removed, the consequent weakening can cause the external nasal skin to become shapeless, resulting in a "polly beak" deformity, resembling the beak of a parrot. Likewise, if the septum is unsupported, the bridge of the  nose can sink, resulting in a "saddle nose" deformity. The tip of the nose can be over-rotated, causing the nostrils to be too visible, resulting in a porcine nose. If the cartilages of the nose tip are over-resected, it can cause a pinched-tip nose. If the columella is incorrectly cut, variable-degree numbness might result, which requires a months-long resolution. Furthermore, in the course of the rhinoplasty, the surgeon might accidentally perforate the septum (septal perforation), which later can cause chronic nose bleeding, crusting of nasal fluids, difficult breathing, and whistling breathing. A turbinectomy may result  in empty nose syndrome. Non-surgical rhinoplasty. Non-surgical rhinoplasty is a medical procedure in which injectable fillers, such as collagen or hyaluronic acid, are used to alter and shape a person's nose without invasive surgery. The procedure fills in depressed areas on the nose, lifting the angle of the tip or smoothing the appearance of bumps on the bridge. The procedure does not alter nose size, though it can be used to correct some functional birth defects. Originally developed at the turn of the twenty-first century, early attempts used biologically harmful soft-tissue fillers such as paraffin  wax and silicone. After 2000, physicians minimally invasive techniques using modern fillers.