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2 Nose, Nasal Sinuses, and Face

Applied Anatomy and Physiology

■ Basic Anatomy

■ External Nose

The supporting structure of the nose consists ofbone, cartilage, and connective tissue. Figure 2.1shows the most important elements. The bonysuperior part of the nasal pyramid is often broken

in typical fractures of the nasal bones, but it mayalso be fractured in injuries to the central part of theface. The cartilaginous inferior portion is less at risk,at least in mild blunt trauma, because of its elasticstructure, but it is endangered in stab wounds,lacerations, and gunshot injuries. The shape, posi-tion, and properties of the bone and cartilage of thenose have a considerable influence on the shapeand esthetic harmony of the face (see p. 212) andon the function of the nasal cavity.

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Fig. 2.1 The nasal skeleton.1, Glabella; 2, nasal bone;3, lateral nasal cartilage;4, cartilaginous nasal septum;5, alar cartilage with lateral (a)and medial crus (b); 6, nasalvalve between the cranial alarand caudal lateral cartilages.R, Rhinion. The bony portionof the nose is completely rigid.The flexible cartilaginous por-tion begins at the rhinion. Thedistal caudal lateral cartilagescan move like the wings of abutterfly, whereas the alarcartilages move more like thewings of a bird. The nasal sep-tum is the center of stability.

aus: Behrbohm u. a., Ear, Nose, and Throat Diseases (ISBN 9783136712030) © 2009 Georg Thieme Verlag KG

The following blood vessels in the external noseare of practical importance:● Facial artery and its branches.● Dorsal nasal artery, arising from the ophthalmic

artery.

Profuse hemorrhage can arise from these vesselswhen the central part of the face is injured.

The angular vein is also clinically important.Thrombophlebitis arising from a furuncle of theupper lip or the nose can spread via the ophthalmicvein to the cavernous sinus, causing a cavernoussinus thrombosis (see p. 189 and Fig. 2.2).

The external nose derives its sensory nerve sup-ply from the first and second branches of the tri-geminal nerve (see Fig. 2.15a, b). The muscles de-rive their motor nerve supply from the facial nerve.

■ Nasal Cavity

The interior of the nose is divided by the nasalseptum into two cavities,which are usually unequalin size. Each side may be divided into the nasalvestibule and the nasal cavity proper (Fig. 2.3a, b).The nasal vestibule is covered by epidermis con-taining hairs (vibrissae) and sebaceous glands. Thelatter are the site of origin of a nasal furuncle, whichcan thus only develop in the nasal cavity in thevestibule.

The medial wall of the nasal vestibule encloses the sup-porting structure of the anterior part of the cartilaginousseptum and the membranous septum—i. e., the columella.The roof of the vestibule is formed by the bird wing–shaped

lower lateral or alar cartilage, the medial crus of whichextends into the columella and the lateral crus of whichsupports the external wall of the vestibule (Figs. 2.1, 2.3a,b). The alar cartilage determines the shape of the nasal tipand the nasal apertures. Correcting this area is often animportant part of rhinoplasty.

Applied Anatomy and Physiology 117

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Fig. 2.2 Important vascular relationships in the face.1, Sitefor ligation of the angular vein; 2, facial artery; 3, facial vein;4, common carotid artery; 5, internal jugular vein; 6, pter-ygoid plexus; 7, sigmoid sinus; 8, inferior sagittal sinus;9, superior sagittal sinus; 10, cavernous sinus; 11a, superiorpetrosal sinus; 11b, inferior petrosal sinus.

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Fig. 2.3a, b a Section throughthe anterior nose, showing thevestibule and the limen nasi. Thedashed line in b shows the sec-tional plane of a. The limen nasi islocated at the junction of the pinkand red areas.b Medial nasal wall. 1, Bony nasalbridge; 2, nasal septum;3, upper lateral nasal cartilage;4, nasal cavity; 5, alar cartilage;6, nasal vestibule; 7, nasal ala;8, nasal columella with medialcrus of the cartilaginous ala;9, filaments of the olfactorynerve; 10, olfactory bulb;11, palatine bone; 12, perpendic-ular plate of the ethmoid;13, vomer; 14, pharyngeal eusta-chian tube ostium.


The internal nasal valve or limen nasi is a veryimportant structure from the physiologic point ofview. It lies at the junction of the vestibule and thenasal cavity. It is formed by a prominence of theanterior edge of the upper lateral or triangular car-tilage on the lateral wall of the nose (Fig. 2.3a). Theinternal nasal valve is normally the narrowest pointin the entire cross-section of the nasal cavity, mak-ing it an important factor in nasal respiration (see p.135).

The nasal cavity extends from the internal nasalvalve to the choana. The structure of the floor androof of the nose, the medial wall, and the nasalseptum is shown in Fig. 2.3a, b.

The outline of the lateral wall of the nasal cavityis more complex than that of the medial wall. Itcontains several structures that are important inthe functioning of the nose and nasal cavity (Fig.2.4):● Three nasal turbinates (superior, middle, and

inferior)● Drainage of the paranasal sinuses (frontal sinus

and maxillary sinus through the hiatus semilu-naris in the middle meatus, located between theinferior and middle turbinate; the sphenoid si-nus has an ostium of its own in the sphenoeth-moidal recess)

● Opening of the nasolacrimal duct into the infe-rior meatus

The superior, middle, and inferior meatus are lo-cated inferior to the three turbinates (Fig. 2.4); theparanasal sinuses and the nasolacrimal duct openinto them. These openings are of diagnostic andtherapeutic importance.● The inferiormeatus, located between the floor of

thenose and the insertion of the lower turbinate,lacks a sinus ostium, but contains the opening ofthe nasolacrimal duct ≈ 3 cm posterior to theexternal nasal opening and 3 mm posterior tothe head of the inferior turbinate (Fig. 2.4).

● The middle meatus, between the inferior andmiddle turbinate, is of clinical importance be-cause the frontal recess, the anterior ethmoidcells, and the maxillary antrum open into it(Fig. 2.4).

● The superior meatus, between the middle andsuperior turbinate, contains the opening for theposterior ethmoid cells. The sphenoid ostium islocated on the anterior wall of the sphenoid si-nus, at the level of the superior meatus (Fig. 2.4).

118 2 Nose, Nasal Sinuses, and Face

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Fig. 2.4 Lateral nasal wall. I,Superior meatus; II, middlemeatus; III, inferior meatus.1, Nasal vestibule; 2, opening ofthe nasolacrimal duct; 3, originof the inferior turbinate;4, semilunar hiatus; 5, insertionof the middle turbinate;6, sphenoid sinus; 7, insertion ofthe superior turbinate; 8, frontalsinus. a, Drainage of the antralcavity; b, drainage of the frontalsinus; c, drainage of the anteriorethmoid cells; d, drainage of theposterior ethmoid cells;e, drainage of the sphenoidsinus; f, area of infundibulum(dotted area).


The nasal cavity is lined by two types of epithelium: respira-tory and olfactory (Figs. 2.5a–d, 2.6a, b). Respiratory epithe-lium coats the entire airway and its projections and exten-sions (e. g., the paranasal sinuses and the middle ear), fromthe nasal introitus to the bronchi. It shows morphologicvariation in different parts of the respiratory tract. Figure2.5c, d shows the structure of the respiratory epithelium of

the nasal cavity. The epithelium is columnar-ciliated withgoblet cells and a layer of mixed glands, a fairly well demar-cated lymphoid cell zone and well developed venous caver-nous spaces in the turbinates and around the ostia (Fig.2.5a).

The olfactory mucosa, innervated by fibers of the olfac-tory nerve, covers the area of the olfactory cleft, the cribri-

Applied Anatomy and Physiology 119

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Fig. 2.5a–d a Frontal sectionthrough the nasal cavity. Thenasal mucosa is constricted onthe left side and normal on theright.b Respiratory mucosa. 1, Middleturbinate; 2, antrum with os-tium; 3, nasal septum; 4, inferiorturbinate; 5, layer of mucus;6, respiratory epithelium withcilia; 7, goblet cells; 8, mucosalglands.c Sagittal section through thenose with the septum reflectedsuperiorly. 1, Olfactory region;2, middle turbinate; 3, inferiorturbinate.d 1, Scent molecules dock ontoreceptors; 2, bipolar nerve cells;3, olfactory bulb with 4, glo-merulus (microcenter) and5, mitral cells.

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Fig. 2.6a, b a 1, Scent mole-cules, 2, scent receptors. Eacholfactory cell bears only a singletype of receptor. There are 350types of receptor in humans. Areceptor can recognize up to100 structurally similar mole-cules in a scent category.b Scent molecules only fit onespecific receptor. They trigger abiochemical reaction and a sub-sequent electrical signal, whichis transmitted to the olfactorycenter in the brain.


form plate, part of the superior turbinate, and the part of theseptum lying opposite it. The structure is shown in Fig. 2.5 d,and its topographic extent in Fig. 2.5c. Bowman glandsoccur specifically in this area. They produce a lipo-lipid se-cretion that covers the olfactory region and aids in olfactoryperception due to the enzymes it contains. It is entirelydissimilar to the secretion of the glands of the respiratoryepithelium.

■ Paranasal Sinuses

The paranasal sinuses are pneumatized cavities inthe bone adjacent to the nose (Fig. 2.7a, b).

Ostiomeatal ComplexThe ostiomeatal complex is a functional entity inthe anterior ethmoid complex that represents thefinal common pathway for drainage and ventilationof the frontal, maxillary, and anterior ethmoid cells(see Fig. 2.9). Anyor all cells, clefts, and ostia, aswell

2 Nose, Nasal Sinuses, and Face120

Fig. 2.7a, b The paranasal si-nuses.a Arrangement of the paranasalsinuses in the facial skeleton.b The mucosal surface of theparanasal sinuses is substantiallylarger than that of the nose. Thearrows indicate the mucociliarytransportation of secretions outof the sinuses to the nose.a, Frontal sinus; b, ethmoid cellsystem; c, maxillary sinus;d, sphenoid sinus.

Fig. 2.8 Anatomy of the ethmoid bone. 1, Labyrinth;2, perpendicular lamina; 3, ethmoidal bulla; 4, crista galli.

as their dependent sinuses, can become diseased,contributing to the symptoms and pathophysiologyof sinusitis.

Ethmoidal LabyrinthThe central structure in this system of pneumatizedcavities is the ethmoid bone. The anterior ethmoid isthe morphologic connection and secretion channelbetween the nose and the frontal and maxillarysinuses. The tight spaces and clefts normally ensureventilation and drainage of the sinus mucosa. Theanterior ethmoid is central to the pathogenesis ofacute, recurrent, and chronic inflammations of thefrontal and maxillary sinuses, since ≈ 90% of alldiseases of the frontal and maxillary sinuses beginhere.

The central part of the ethmoid bone is T-shaped.In the median plane, the crista galli projects into theanterior fossa (Fig. 2.8). The falx cerebri inserts here.The perpendicular plate (lamina perpendicularis)abuts anteriorly onto the septal cartilage and dor-sally onto the vomer. The paired ethmoidal labyrinthis situated between the nose and orbit. It consists of10 to 15 pneumatized cells lined with respiratoryepithelium. The volumevaries individually; roughly,it is the size of amatchbox standing on its short side.

The lamina cribrosa passes into the ethmoidalnotch (incisura ethmoidalis) of the frontal bone.The olfactory nerves extend from the olfactory rimto the olfactory bulb.

The ethmoid air cells are differentiated into anterior andposterior groups. They are derived from an embryonicpaired anlage that coalesces in the first year of life to forma single ethmoid cell. There are communications between allof the ethmoid cells on one side. There are often alsocommon ostia for the anterior ethmoid complex in the


Complications. These include CSF fistula, recurrentlate meningitis, early or late brain abscess, osteo-myelitis of the flat bones of the skull (see p. 190),and formation ofmucoceles or pyoceles (see p.184).

Other Possible Injuries to the Facial SkeletonInjury to the facial nerve. See page 112.

Injuries to the lacrimal system (Fig. 2.113). Theseare quite commonly combined with injuries to thesinuses and the middle of the face. If possible, theyshould be repaired in the same session as the in-juries to the sinuses and face. If this is not possible,or is not successful, stenosis or complete obstruc-tion of the lacrimal sac or nasolacrimal duct mayoccur (see Fig. 2.113), requiring correction (dacryo-cystorhinostomy; see Fig. 2.113) either by an oph-thalmic or rhinologic surgeon.

Injuries to the mandible and temporomandibularjoint. These injuries aremanaged byamaxillofacialsurgeon, who is also responsible for restoring cor-rect occlusion.

The main symptoms of mandibular fractures in-clude swelling of the lower part of the face, abnor-mal movement or deformity of the mandible,

anomalies of occlusion, pain on movement, com-pression or torsion of the mandible, and possiblytrismus.

Immediate first aid measures should be under-taken for comminuted fractures, particularly frac-tures of the chin with extensive soft-tissue injury.The patient should be intubated, or a tracheotomyshould be performed, due to the danger of respira-tory obstruction. Profuse bleeding should be ar-rested, if necessary with a pressure dressing. Soft-tissue defects or scars are dealt with in the usualway using plastic surgery reconstructive proce-dures.

■ Congenital Anomalies and Deformitiesof the Nose

■ Congenital Anomalies of the Nose

Development of the embryonic face involves nineprocesses. Due to the complexity of these processes,congenital anomalies are relatively common,although many of them are only slight. Anomaliesincompatible with life—e. g., arhinia—are extremelyrare.

Cleft Face and NoseOblique facial clefts, even in a rudimentary form, arerare, as are transverse facial clefts, in which theangle of the mouth is located near the tragus, caus-ing macrostomia.

Median clefts are more common, but are usuallyonly rudimentary. They range in extent from hyper-telorism, with or without a true median facial cleftand with or without meningoencephalocele, to dognose, proboscis, or even double nose.

Treatment. Plastic surgery.

Cleft Lip, Jaw, and PalateThese anomalies are relatively common, affecting1% of Caucasians.

Treatment. Reconstructive surgery, occasionally instages, and orthodontic and prosthetic procedures.In addition, speech therapy may be needed. Treat-ment planning is described on page 281.

Cleft lip and palate present the rhinologist withseveral problems: firstly, anomalies of the externalnose, such as a flattened nasal ala, and anomalies


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Fig. 2.113 The eye and nose. 1, Lacrimal gland; 2, lacrimalsac with lacrimal ducts; 3, nasal cavity; 4, site for dacryocys-torhinostomy; 5, antral cavity.


within the nose, such as dislocation of the septum;secondly, speech disorders, such as rhinolaliaaperta of varying degrees of severity; and thirdly,abnormalities of tubal aeration which are regularlypresent, causing seromucotympanum or chronicotitis media.

Nasal Fistulas, Nasal Cysts, Dermoid Cysts, andGliomasMedian nasal fistulas, from which a cloudy secretion maydrain, usually end blindly at the level of the glabella or inthe ethmoidal–septum region. This is also true of congenitalnasal cysts, which develop at the same site, but also mayarise in the nasal vestibule or nasal septum.

Dermoid cysts aremore common. They often contain hairand accessory structures, such as ectodermal inclusions,which lie above, below, or within the frontal bone.

Gliomas are tumors of the frontal region or the root ofthe nose in the midline; they consist of solid glial tissue.

All of these anomalies must be removed surgically.

MeningoencephaloceleDural and brain herniations (hernias and celes)maybe found in the nose, where they are easily mis-taken for nasal polyps. They may also be locatedextranasally and be related to the frontal bone,ethmoid, or nasal septum. The causes are incom-plete closure of the neuropore during the thirdweek of embryonic development, and trauma(Fig. 2.114a, b). Meningoencephaloceles and glio-mas can often be removed and the defect can nowa-days be repaired endoscopically.

Diagnosis. MRI with contrast medium and CT.

Treatment. Surgical removal, closure of the dura,and osteoplastic correction of any existing hyper-telorism, if required.

Stenosis and Atresia of the NostrilsThese are usually congenital, but may also be ac-quired—e. g., due to trauma or destructive infec-tions.

Treatment. Plastic surgery.

Choanal AtresiaThis is a bony or membranous occlusion of theposterior nasal opening, and may be bilateral. Girlsare more often affected than boys. Hereditary fac-tors have been demonstrated. The disorder is usu-ally congenital, but it may also be acquired due totrauma. Incomplete atresia (stenosis) also occurs.

Clinical Features. Newborn babies with bilateralchoanal atresia present with intermittent cyanosis,especially during feeding. Other symptoms includechronic purulent nasal discharge, inability tobreathe through thenoseor to sneeze, and anosmia.

!Note: Bilateral atresia in the newborn is a life-threaten-ing condition. As the infant is unable to breathe satisfac-torily through the mouth due to the relatively high posi-tion of the larynx, it has to rely on nasal respiration duringfeeding. This poses a risk, in bilateral atresia at least, ofasphyxia, cyanosis, atelectasis of the lungs, or aspirationpneumonia. Spontaneous feeding is difficult or impossi-ble.

Clinical Aspects of Diseases of the Nose, Sinuses, and Face 211

Fig. 2.114a, b Post-traumatic meningoence-phalocele following fronto-basal fracture with a largefrontal bone defect.a Caudal displacement ofthe eyeball.b Bony defect in the ante-rior base of the skull.


Diagnosis. The most reliable and simple test is tohold a cold metal spatula just beneath the nose andlook for misting. Further tests include probing thenose with a smooth catheter and endoscopy of thenose and nasopharynx.

Differential diagnosis. This includes any disordersthat cause nasal obstruction, especially polyps, for-eign bodies, encephalocele, and tumors.

Treatment. When bilateral atresia has been recog-nized, the airway obstruction can be relieved byinserting an oropharyngeal airway until surgicalcorrection can be arranged. Transpalatal surgeryhas now been largely superseded by dilation underdirect vision of the posterior choana using a 120°endoscope in the pharynx.

In unilateral atresia, surgical correction can bedeferred to a later date.

■ Disorders of Shape of the External Nose

Anomalies of the shape of the external nose oftenrequire rhinoplasty, both for esthetic reasons andbecause of impaired function.

Anomalies of the shape of the nose may be due to thecartilaginous or bony parts of the internal or external noseskeleton being too large or too small, or being improperlypositioned in relation to each other or to surrounding struc-tures. Analysis of the deformities is based on certain param-eters, as illustrated in Figs. 2.115 and 2.116, on standard-ized photographs. Certain angles in the facial contour alsohave to be taken into account.

Fundamentals of RhinoplastyRhinoplasty has two purposes:1. It should restore a normal shape to the nose, so

that it harmonizes with the rest of the face.2. The function of the nose and nasal sinuses with

regard to respiration, olfaction, etc., should bemaintained, improved, and returned to normal.

This dual character of modern nasal surgery oftenrequires correction of both the outside and inside ofthe nose—i. e., septorhinoplasty. These operationsmust be performed by a suitably trained rhinolo-gist.


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Fig. 2.115a, b Facial proportions and symmetry.a Lines dividing the face into vertical thirds (Leonardo daVinci).b Lines dividing the face into horizontal fifths (Powell andHumphreys). Right half of face, features of symmetry: es-thetic eyebrow-tip line, facial midline, nasal tip rhomboid.Left half of face, major causes of asymmetry: asymmetricaleyebrow-tip line, hypoplasia of maxilla, midface or mandible(usually with a crooked mouth), slanted nasal base (cleft lipand palate, asymmetry of specific structural elements suchas the upper lateral or alar cartilage).

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Fig. 2.116 Geometric points and lines used in profile anal-ysis.


A distinction is made between corrective and reconstruc-tive operations. In corrective rhinoplasty, and particularly forcorrection of the supporting framework of the nose, all ofthe surgical steps are performed from inside the nose, with-out an external incision (Fig. 2.117).The principal steps in rhinoplasty are:● An incision in the nasal vestibule or at the medial colu-

mella.● Elevation of the soft tissue covering the nasal skeleton.● Exposure, mobilization, and correction of all skeletal

elements.● Union of the mobilized and corrected skeletal parts to

form a pleasing nasal framework and a functionally com-petent nasal cavity.

● Fixation of the mobilized, corrected skeletal elements inthe required position.

Anomalies of the cartilaginous part of the nose in-clude anomalies of the shape of the base of thenose—e. g., a hanging nasal tip, or a tip that is tooflat or too wide, cleft, too long, or too short; nasalalae that are flaccid, too arched, or asymmetrical; anasal columella that projects too much, is too re-tracted, too thick, too short, or too bent. The entirenose may also be too long or too short.

Anomalies of the bony part of the nose includeanomalies of the shape of the bridge of thenose—e. g., hump nose, saddle nose, twisted nose,broad nose, or narrow nose; of the root of the nose;and of the nasal septum. The bony and cartilaginousparts of the nose usually need to be corrected to-gether.

Approaches. Three approaches have proved valuable forrhinoplasty:● The splitting approach (Fig. 2.118).● The delivery approach (Fig. 2.119).● The open approach (Fig. 2.120).

Which approach is used depends on the specific morpho-logic problems. Other decisive factors are types of skin andconnective tissue. Thick skin predisposes to healing prob-lems, whereas thin skin limits the selection of surgical tech-niques—e. g., using tip or shield grafts that might remainvisible through the skin.

Reconstructive rhinoplasty deals with partialloss of the soft tissue, of the skeleton of the nose,or total loss of the nose, and reconstruction of acomplete nose. Local or distant flaps are used, de-pending on the type and extent of the defect (see p.217).

Hump NoseThis is due to an excess of the bony or cartilaginousnasal skeleton. Usually, it does not cause anymarked functional disturbance.

Treatment. Rhinoplasty is performed, with re-moval of the hump and narrowing of the nasalbridge. The principles of the procedure are shownin Figs. 2.121a,b and 2.122.

Clinical Aspects of Diseases of the Nose, Sinuses, and Face 213

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Fig. 2.117a–f Different nasaltypes.a Hump nose.b Overprojecting nose, func-tional tension nose.c Drooping nasal tip.d Saddle nose.e Short nose.f Deviated nose.

Fig. 2.118 The splittingapproach for cranial volumereduction of the alar carti-lage.


Saddle NoseThe term “saddle nose” denotes a multifactorialcondition that is associated with destabilization ordestruction of the bony or cartilaginous structuresof the nose. Osseous forms of saddle nose are nowa-days rare and usually result from dysplasia of thenasal bones or from nasal midfacial trauma.

Cartilaginous saddle nose is a more frequent concern forrhinologists. The central problem in this condition is theserious structural compromise caused by a loss of anteriorseptal cartilage between the rhinion (keystone area) andwhat is known as the septal pedestal at the level of thepremaxilla and the anterior nasal spine.

Pathomechanism. The septal cartilage is partly or com-pletely absent due to trauma, an incorrectly executed sep-toplasty, a septal abscess, or an infection; the condition mayalso be congenital.

There is considerable functional disturbance due toballooning—i. e., expansion of the nasal valve caused bycollapse of the ala (Figs. 2.123a, b and 2.124a–c).

Clinical Features. The profile of the nose is typical.The patient may also report nasal obstruction dueto absence of support for the nasal valve and in-troitus.

Treatment. A reconstructive procedure is neededfor surgical treatment of a saddle nose. Rhinoplastyis performed, with implantation of several strutsand implants to restore the cartilaginous frame-work of the nose, particularly the important centralstructure of the anterior nasal septum.

Deviated NoseThe cartilaginous and bony nasal skeleton and nasalseptum are most often involved here. The cause isusually trauma, but a deviant nose may be congen-


Fig. 2.119 The deliveryapproach for shaping thenasal tip.

Fig. 2.120 The openapproach for correction ofdifficult asymmetries ofthe tip and nasal dor-sum.

Direction forresection of bone

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Direction forresection of cartilage

Fig. 2.121a, b a A young woman with dorsal hump, over-projecting nasal tip, recessed chin, and effaced nasolabialangle.b The appearance 3 years after septorhinoplasty. The dor-sum has been lowered and projection decreased, the chinappears normal, and the upper lip and nasolabial angle arerelaxed.

Fig. 2.122 The principle of nasal hump correction. 1, Bonyresection; 2, cartilaginous resection; 3, shaping of the nasaltip; 4, correction of the anterior nasal septum.


thieme: ear, nose, and throat diseases · the middle meatus, between the inferior and middle...

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