Understanding Rhinoplasty Part II: The Middle Nose

When looking at someone’s nose, the middle part, just above the tip and going up to the nasal bone area, is sometimes overlooked in terms of its importance to shape and breathing. The upper nasal bone area draws attention as either having a bump or being in line. The tip perhaps garners the most attention- whether it is wide or narrow, thick or thin, upturned or downturned, pointy or boxy. Maybe the middle third of the nose is “less glamorous”, but in the operating room, it takes plenty of attention from plastic surgeons.

This part of the nose is supported by two cartilage structures, the septum and the upper lateral cartilages, and they are vital for supporting the nose to keep airflow open. Sports injuries and other accidents frequently affect this area causing a curve in shape to one side. This is called a deviated septum. From the front view, patients often have a curved or off-center appearance. The side that the septal cartilage ( another word for the septum) is often blocked with limited air flow. The other side of the nose can appear open, but while breathing in, there is less support for the skin of the nose and it can be suctioned inward, causing a block on that side as well. Correcting this during surgery will improve breathing as well as help straighten the appearance of the nose from the front view.

Fixing only the internal part is called “septoplasty surgery” and does not change the shape of the outer nose much. Sometimes surgeons call this surgery “SMR”, standing for “submucous resection”, meaning that the surgeon lifts off the mucous membrane soft tissues off of the septum to allow removal of the deviated portion.

The surgeon ust preserve at least 10 cm of healthy cartilage on the bottom of the septum and across the bridge of the nose to keep enough support for the shape and health of the nose. This is called an “L-Strut”. Removing the deviated portion of the septum and preserving enough to keep the nose strong and functioning requires skill and special instruments. There can be significant bleeding when this is not done properly, and that is why your surgeon has trained for so many years.

Fixing a curved nose shape is very difficult and it sometimes is not possible in one operation to get ideal, long lasting correction. Even when the nose is not curved from the front view, our rhinoplasty surgeon often has to operate on the middle third of the nose. When taking down a bony bump, the cartilage usually is also protruding outward. This cartilage is gently trimmed until it is the same height as the new reduced bone height. The upper lateral cartilages on the side often have to be trimmed as well. If a person has a very thin or narrow middle nose area with breathing blockage, then this area can be supported with additional cartilage to make sure the nose says straight and the airway is open. This additional cartilage support is added in the form of “spreader grafts”, which are rough matchstick size strips of cartilage that are carefully sewn to each side of the septum to add support, widen a narrow nose, or straighten a deviated nose.

This part of surgery may not be as attention getting or glamourous like changing the bump or tip, but it sure is essential for making your nose function normally.The hardest part of doing septal surgery is the difficulty with seeing all the structures and having angles to suture and cut cartilage properly. It takes patience and years of practice!

If you would like to learn more about rhinoplasty surgery with Dr. Suzman, please reach out to us on instagram (suzmanplasticsurgery)

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We hope we have added to your understanding of the complexities of rhinoplasty surgery.

Dr. Suzman is a leading plastic surgeon in New York and a member of the American Society of Plastic Surgeons. The focus of his practice is on reconstructive and cosmetic surgery of the nose, face, breast, and body. He is widely known for his work in rhinoplasty and nasal injury correction. He has offices in both Westchester County, NY and Greenwich, CT and serves patients from around the world.