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The anatomy of the nose

A nose is three stacked vaults sitting on one central wall: bone at the top, paired cartilages in the middle, two curved cartilages at the tip, and the septum holding all of it up from inside. Every rhinoplasty manoeuvre changes one of those structures, the ligaments that tie them together, or the skin envelope over them. Almost every complication in this literature is what happens when one is removed without being replaced.

The structures that decide the operation

Four things a surgeon reads before choosing a technique.

The three vaults, and the joint between them

The upper third is the bony vault: the paired nasal bones with the maxillary processes beside them. The middle third is the upper lateral cartilages. The lower third is the paired lower lateral (alar) cartilages, each with a medial and a lateral crus. Where the bone overlaps the cartilage is the keystone area, measured in cadavers at about 8.9 mm long and 4.9 mm wide, with the overlap of bone over cartilage varying between people. StatPearls puts it plainly: preserving that junction is critical to support, which is why an entire modern technique family is defined by leaving it alone.

Rests on: StatPearls, Rhinoplasty · Palhazi et al., the osseocartilaginous vault · and preservation rhinoplasty.

The septum, which is both the wall and the quarry

The septum divides the airway and holds the nose up, and it is the first source of graft cartilage. What can be taken is limited by what must be left: an L-shaped strut 10 to 15 mm wide along the dorsal and caudal margins. CT of 116 adults quantifies the rest, a mean of 461.5 mm² of harvestable cartilage, significantly less in women, rising to 992.0 mm² if the bony septum is included. That is the number behind every graft plan, and the reason a second operation reaches for the ear or the rib.

Rests on: StatPearls · Nguyen et al., septal donor site on CT · and cartilage grafts.

Two valves, and the narrowest point in the airway

The internal valve is the angle where the upper lateral cartilage meets the septum, with the head of the inferior turbinate beside it. The external valve is the nostril itself, bounded by the lower lateral cartilages, the columella and the nasal sill. The internal valve is the narrowest part of the whole airway, which is why removing a hump without rebuilding the roof narrows breathing as well as the middle third.

Rests on: StatPearls · Rohrich et al., component dorsal hump reduction · and the septum and the airway.

The tip has three supports, and surgery divides at least one of them

StatPearls lists them: the size, shape and resilience of the lower lateral cartilages; their attachment to the upper lateral cartilages at the scroll; and their attachment to the caudal septum. Almost every tip technique weakens one of those and then replaces it, which is why a graft fixed to the septum holds projection where a floating strut loses it. The cartilages themselves have now been measured: 40 cadaveric lower lateral cartilages flattened, photographed and turned into templates for rebuilding one from rib.

Rests on: StatPearls · Kiranantawat and Pakawatkul, cadaveric cartilage templates · and nasal tip.

Part by part

Each structure, what it does, and what happens when it is changed.

The bony vault

Two nasal bones, thicker in men at every measured point, and asymmetric in 35.2% of primary patients, with the deviated side thicker than the other. Narrowed or straightened with osteotomies, typically medial and lateral in a high-low-high configuration. Cut badly, it narrows the airway; cut well, it closes the roof left by a hump reduction.

Rests on: Kim et al., the bony vault on CT · StatPearls · and the dorsum and the hump.

The upper lateral cartilages and the middle vault

The roof of the middle third, attached under the nasal bones and to the septum. Removing a hump separates them from the septum and leaves an open roof; unsupported, they collapse inward months later as the inverted-V deformity. The structural answer is a spreader graft, ideally straight septal cartilage 1 to 2 mm wide and 3 to 4 mm high, or the cartilage folded inward as an autospreader. The preservation answer is not to open the roof at all.

Rests on: StatPearls · Sheen, the spreader graft · Rohrich et al..

The lower lateral cartilages

Two curved cartilages, each with a medial crus in the columella and a lateral crus in the nostril rim, meeting at the domes. They set the shape of the tip and hold the sidewall open. Over-resected, they buckle, pinch and retract; repositioned and reinforced, they support both appearance and breathing. The modern literature is unanimous about the direction: preserve and reposition rather than excise.

Rests on: StatPearls · Tanvar and Basu, lateral crura classification · and nasal tip.

The ligaments and the soft-tissue envelope

The scroll ligaments tie the upper and lower lateral cartilages; Pitanguy's midline ligament runs from the dorsum down to the tip. Cadaver dissection shows the Pitanguy ligament tethers the tip and is displaced by open dissection, so it may need release and reconstruction. Over all of it lies the skin envelope: thick and sebaceous skin hides definition, thin skin shows every graft edge, and previously operated skin has a reduced blood supply.

Rests on: Lisiecki et al., the Pitanguy ligament in cadavers · Kosins and Obagi, measuring the envelope.

The blood supply, and why it limits everything

The nasal skin is fed by branches of the facial and ophthalmic systems, and previous surgery, smoking, age and injected filler all reduce what remains. It is the reason skin compromise concentrates in revision patients, the reason filler in an operated nose carries a higher necrosis risk, and the reason a columellar closure under tension can fail.

Rests on: the revision literature · Robati et al., necrosis after previous rhinoplasty · Toriumi, columellar necrosis.

When the nose is finished growing

StatPearls puts the usual threshold at about 15 in girls and 17 in boys, with the caveat that a nose operated earlier for obstruction or trauma does not appear to stop growing when cartilage-sparing technique is used.

Rests on: StatPearls · and the growing nose and the ageing nose.

Frequently asked questions

The questions people search, answered from the cadaver and CT measurements.

What does a rhinoplasty actually change?

One of three stacked vaults, the ligaments that tie them together, or the skin over them. The upper third is bone, the middle third is the upper lateral cartilages, and the lower third is the paired lower lateral cartilages that make the tip. Almost every complication in this literature is what happens when one of them is removed without being replaced.

Rests on: Palhazi et al., the osseocartilaginous vault · StatPearls.

What is the septum, and why does every operation involve it?

It divides the airway and holds the nose up, and it is the first source of graft cartilage. What can be taken is limited by what must be left: an L-shaped strut 10 to 15 mm wide along the dorsal and caudal margins. CT of 116 adults puts the harvestable cartilage at a mean of 461.5 mm², significantly less in women, rising to 992.0 mm² if the bony septum is included.

Rests on: the septum measurements.

What is the keystone area?

Where the nasal bone, the upper lateral cartilage and the septum meet, measured in cadavers at about 8.9 mm long and 4.9 mm wide. Preserving that junction is critical to support, which is why a whole modern technique family is defined by leaving it alone.

Rests on: Palhazi et al. · preservation rhinoplasty.

Why does skin thickness keep coming up?

The skin and soft tissue envelope, the fat, muscle and ligaments over the framework, decides how much of the work underneath shows. Thick skin hides refinement and holds swelling longer; thin skin shows every edge.

Rests on: the skin and soft tissue envelope section.

The terms, defined

The anatomical words used in every operative note.

  • Bony vault: the paired nasal bones and adjacent maxillary processes; the upper third. [36594157]
  • Middle vault: the upper lateral cartilages and the septum between them; the middle third and the roof over the internal valve. [15457053]
  • Lower lateral (alar) cartilages: the paired tip cartilages, each with a medial and a lateral crus meeting at the dome. [41294316]
  • Keystone area: where nasal bone, upper lateral cartilage and septum meet; about 8.9 × 4.9 mm in cadavers, and the structure preservation techniques leave intact. [25805276]
  • Quadrangular cartilage: the main plate of septal cartilage; the first graft source. [42303768]
  • L-strut: the 10 to 15 mm dorsal and caudal septal margins that must be left to keep the nose standing. StatPearls
  • Internal nasal valve: the angle between septum and upper lateral cartilage; the narrowest point of the airway.
  • External nasal valve: the nostril and its rim, bounded by the lower lateral cartilages, columella and sill.
  • Scroll: where the upper and lower lateral cartilages curl into each other; one of the three tip supports and a standard endonasal access point. StatPearls
  • Pitanguy's midline ligament: the band from the dorsum to the tip through the soft-tissue envelope. [39026387]
  • Dorsal aesthetic lines: the paired highlight lines running from the brows to the tip; the visible output of the middle vault's width. [41369038]
  • Columella: the strip of skin and cartilage between the nostrils; where the open approach's incision goes.
  • Nasal sill: the floor of the nostril where it meets the lip. [39572464]
  • Skin–soft tissue envelope (SSTE): skin, fat, muscle and ligaments over the framework; the tissue that decides how much of the work underneath shows. [27965218]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should examine and record about the framework before operating on it.

Rests on: the clinical practice guideline · the plain language summary.

What is not settled

  • Measurements come from small cadaver sets and single-centre CT series, mostly Asian or Caucasian. Population differences are real and thinly mapped: quadrangular cartilage area differs measurably between the two groups compared on file. [38599617, 42303768]
  • There is no non-invasive way to measure skin thickness in routine practice; the published methods are a pinch test and ultrasound in a 75-patient series. [27965218]
  • Asymmetry is the norm rather than the exception, a third of bony vaults, and no outcome study tests whether planning each side separately changes the result. [36594157]
  • The keystone measurements come from cadaver dissection. No series tests whether leaving that junction joined holds support better over years than separating and rebuilding it. [25805276]
  • The lower lateral cartilage templates were traced from flattened cadaveric specimens. Whether a cartilage rebuilt to a template behaves like the original in a living nose is untested. [41294316]

Written by rhinoplasty.cc from the sources linked above, 2026-09-09.

Who publishes on anatomy and nasal analysis

Ranked surgeons with papers under this topic in the archive, most first.

Rod J. Rohrich (14) · Sam P. Most (11) · Dean M. Toriumi (6) · Jason Roostaeian (6) · Samuel Lin (6) · Bardia Amirlak (4) · Brian J. Wong (4) · Michael Lee (4) · Steven Pearlman (4) · Bahman Guyuron (3)

The literature: Anatomy and nasal analysis, 325 papers. Video: Technique and teaching, 232 videos. Every technique.