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Rhinoplasty — anatomy, airway and complications
Good rhinoplasty changes shape without harming breathing: the internal nasal valve is the narrowest point of the airway, and every dorsal or septal reduction must preserve its support — a septal "L-strut" at least 10 mm wide dorsally and caudally, and spreader grafts when needed.
Why it matters in the exam
The internal valve is the angle between the septum and the upper lateral cartilage (about 10 to 15 degrees), and it accounts for most of the airflow resistance; the Cottle test (pulling the cheek laterally) improves breathing when the valve is narrow. The external valve is the alar rim, supported by an alar batten graft. The main tip support mechanisms: the size and strength of the lower lateral cartilages, the medial crura's attachment to the caudal septum, and the attachment of the upper to the lower lateral cartilage (scroll). In "component" dorsal hump reduction the upper lateral cartilages are separated from the septum, the septum is reduced stepwise, the bone is rasped, and the "open roof" is closed with osteotomies; when the upper lateral cartilages collapse an inverted-V deformity forms — prevented with spreader grafts or spreader flaps.
Complications: pollybeak — supratip fullness from over-reduction of tip support, a high residual septum or scar; saddle nose — from over-reduction of the septum or an abscess after septal haematoma; "open roof" — missing osteotomy; and the "rocker" deformity — an osteotomy that runs up into the thick frontal bone. A septal haematoma after trauma or surgery needs immediate drainage, because the cartilage is fed by the perichondrium and its necrosis leads to saddle nose. In the open approach the columellar artery is cut, and the tip skin depends on the lateral nasal artery — so it is not divided in the alar incision. "Filler rhinoplasty" with hyaluronic acid is dangerous: injection into a dorsal nasal vessel can cause blindness via the ophthalmic artery; sudden blanching or pain — stop immediately and give hyaluronidase.
Key points
- Internal valve — the narrowest; Cottle.
- L-strut of at least 10 mm.
- Spreader — prevents inverted V and widens the valve.
- Septal haematoma — immediate drainage.
- Nasal filler — risk of blindness; hyaluronidase.
Summary table
| Structure or condition | Feature | Action or prevention |
|---|---|---|
| Internal nasal valve | Angle 10 to 15 degrees; the narrowest point | Spreader grafts |
| Septal L-strut | At least 10 mm dorsally and caudally | Prevents saddle nose |
| Pollybeak | Supratip fullness | Preserve tip support and reduce the septum appropriately |
| Septal haematoma | Bluish swelling of the septum | Immediate drainage |
| Hyaluronic acid nasal filler | Risk of vascular occlusion and blindness | Slow, superficial injection; hyaluronidase for occlusion |
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Sources
- AAO-HNS Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty, 2017 — Assessment and counselling
- Plastic Surgery (Neligan), 5th edition (2023) — Open rhinoplasty; Nasal airway
- Rohrich and colleagues, component dorsal hump reduction, 2004 — Stepwise technique
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.