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Background: Reshaping the nose can be achieved following 3 main concepts: preservation and reshaping of normal anatomy, resection of nasal deformities, reconstruction of nasal framework. Time, experience and nasal anatomic knowledge are keys to understand nasal biomechanics., Objectives: To describe how experience and morphodynamic anatomy lead to a new concept of sequential primary rhinoplasty, resulting in reducing revision rhinoplasties., Methods: Through 36 years' experience in different rhinoplasty procedures, 25 years in personal anatomic studies of the nose and reviewing the last 15 years including 600 patients who underwent new concepts in primary rhinoplasty out of 1200 patients operated during this period, the author analyzes how nasal anatomic layers, surgical approaches, and morphological effect of the time interact to modify the aesthetic results according to current rhinoplasty concepts., Results: Nasal bony cartilaginous vaults biomechanics understanding leads to consider the K‑area as a flexible joint which can be reshaped without resection of the nasal vaults. The role of the subdorsal septum is highlighted as the main anatomic structure which can be safely resected in rhinoplasty, and which allows to respect the natural anatomy, the nasal valves and the dorsal aesthetic lines. Description of nasal compartments divided by the "T" ligament leads to rethink the incisions and approaches of the nose: the interseptal-columellar and extended infracartilaginous incisions allow to protect nasal ligaments and to perform a deep plane undermining. Protection of the anatomic layers allows quick recovery, nasal function improvement and long-lasting results., Conclusion: The goal to reduce the rate of revision rhinoplasty and to improve the natural results can be achieved, considering the concept of sequential primary rhinoplasty. Nasal soft tissues are protected as far as possible. The current rhinoplasty concepts are not antagonist but appear as an intraoperative succession of alternative techniques from anatomy and function preservation to reconstruction of the nasal framework.

Currently, most rhinoplasty surgeons focus their analysis and operative techniques on the upper nasal base, with its alar cartilages. They tend to minimize the lower nasal base, composed of the columellar base, nostril sills, and alar lobules. The requisite operative techniques are often considered ancillary techniques. In this article, the authors describe anatomical composition of the columellar base, nostril sill, and alar lobule; discuss the presence of a distinct lower nasal base; and reevaluate the nasal musculature and the nasal superficial muscular aponeurotic system in an anatomical cadaver model. They also discuss the results of both a detailed literature review (for articles related to the levator labii superioris alaeque nasalis, orbicularis oris, depressor septi nasalis, myrtiformis, and dilator naris) and the results of their own dissection of 45 fresh cadavers.

Objectives: To discuss overprojected nasal tips, to overview treatment options, and to introduce a new method of nasal tip modification., Patients and Methods: A retrospective study was conduced on 29 patients who underwent rhinoplasty where the domes crossover technique was employed. Patients were stratified into 3 groups: 18 patients presented with homogeneous overdevelopment of the LLC (nasal tip over projection type 1), 5 patients with predominant over development of the lobular portion of the LLC (nasal tip overprojection type 2), 6 patients with a true Pinocchio-type nose and a predominant overdevelopment of the columellar portion of the LLC (nasal tip overprojection type 3). Before and after photographs were compared to evaluate nasal tip characteristics. Analysis of results was performed by the use of 3 measurements: Goode's ratio, nasofacial angle and lobule-to-columella ratio., Results: Final nasal tip projection, rotation, volume and shape were satisfactory in all cases. No complication was observed during the follow-up period., Conclusion: This new method of nasal tip modification presents the advantage of preserving natural domes, being quick and allowing the achievement of desirable nasal tip projection, rotation, volume and shape. Moreover according to the alar ring concept, the crossover technique preserves the continuity of the inferior cartilaginous arch and gives an excellent support to nasal tip.

Objectives: To analyze the nasal superficial arterial vasculature and to compare these anatomic findings with the results of ultrasonography Doppler investigations to evaluate nasal blood flow in physiological and pathologic conditions., Methods: We performed 40 ultrasonography Doppler investigations in patient volunteers, 20 facial anatomic dissections in fresh cadavers, and a review of the literature on nasal blood supply. In cadavers, facial arteries were dissected to analyze nasal arterial supply., Results: When the facial artery, the ophthalmic artery, or both were compressed on 1 side in volunteers, blood flow inversion was proved by ultrasonography Doppler investigation at the level of the nasal area. These results confirm anatomic findings that demonstrate a polygonal system., Conclusions: A schema of nasal blood supply as a polygonal system connecting the external and internal carotid systems is proposed. This facilitates our understanding of anatomic variations, physiological and pathologic modifications of blood flow, and nasal reconstructions with local flaps and medical rhinoplasties using filler injections.

Objective: To give a unifying description of nasal muscles and ligaments corresponding to anatomical and surgical findings such as the dermocartilaginous ligament described by Pintanguy in 2001., Methods: In 30 fresh cadavers of white individuals, nasal dissections were performed, divided into 3 different approaches: from radix to nasal tip, from nasal tip to radix, and from midline to lateral. The anatomical and surgical planes of dissection were followed to isolate the nasal superficial musculoaponeurotic system (SMAS). Correlations between the nasal SMAS and the nasal framework were noticed. In 9 specimens, the left nasal wall was resected for histologic examination., Results: The nasal SMAS consists of a unique layer, and it divides at the level of the nasal valve into deep and superficial layers. Each layer has medial and lateral components. The dermocartilaginous ligament corresponds to the deep medial expansion. Both the deep and the superficial medial expansions correspond to the lowering ligaments of the nasal tip; the cephalic rotation of the nasal tip is allowed by their cut. The histological examination showed that the deep lateral expansion is composed of fat., Conclusions: This description of the nasal SMAS explains the relationship between the nasal muscles and ligaments, including the dermocartilaginous ligament described by Pitanguy. Furthermore, it is helpful to surgeons during rhinoplasty.

Objective: The authors developed an original and simple method of evaluation of the aesthetic lines of the nose adapted to the harmony of the face., Method: Initially based on their experience, the authors propose an evaluation of the nose in 2 stages and 5 sequencies based on the construction of single circuit lines according to various incidences. They checked thereafter the validity of this method on the operative project and on the appreciation of the results of the rhinoplasties., Results: Controlled on several types of faces, the method suggested by the authors proved to be reliable, simple, reproducible., Conclusion: The authors proposed a method of evaluation of the aesthetic lines of the nose integrated to the harmony of the face. This method relies on the construction, in 5 stages, of single circuit lines not requiring any particular material. The artistic method of evaluation of the nose proposed by the authors is very simple. Rapid and immediately usable, it makes it possible to schedule a rhinoplasty in a few minutes. The evaluation of the aesthetic results of the rhinoplasties is also very simple and reproducible. It has moreover the merit to propose a model of teaching making it possible to the rhinoplastician to criticize his results and thus to progress in its technical training and its operational indications.

Objectives: To highlight the morphodynamic anatomical mechanisms that influence the results of rhinoplasty. To present the technical modalities of nasal dorsum preservation rhinoplasties. To determine the optimized respective surgical indications of the two main techniques of rhinoplasty: interruption rhinoplasty versus conservative rhinoplasty., Materials and Methods: Based on anatomical dissections and initial morphodynamic studies carried out on 100 anatomical specimens, a prospective study of a continuous series of 400 patients operated of primary reduction rhinoplasty or septo-rhinoplasty by one of authors (YS) has been undertaken over a period of ten years (1995-2005) in order to optimize the surgical management of the nasal hump. The studied parameters were: (1) surgical safety, (2) quality of early and late aesthetic result, (3) quality of the functional result, (4) ease of the technical realization of a possible secondary rhinoplasty. The other selected criteria were function of the different nasal hump morphotypes and the expressed wishes of the patients., Results: The anatomical and morphodynamic studies made it possible to better understand the role of the "M" double-arch shape of the nose and the role of the cartilaginous buttresses not only as a function but also the anatomy and the aesthetics of the nose. It is necessary to preserve or repair the arche structures of the septo-triangular and alo-columellar sub-units. The conservative technique, whose results appear much more natural aesthetically, functionally satisfactory and durable over the long term, must be favoured in particular in man and in cases presenting a risk of collapse of the nasal valve., Conclusion: The rhinoplastician must be able to propose, according to the patient's wishes and in view of the results of the morphological analysis, the most adapted procedure according to his own surgical training but by supporting conservation of the osteo-cartilaginous vault whenever possible.

A good anatomical knowledge is a pre-requisite to all surgeries. In rhinoplasty, where many steps are performed without visual control and are only guided by palpation, anatomy must be mastered. Based on classical static anatomy and dynamic surgical modifications of the nose, this study analyses anatomical and surgical correlation and reports their technical implications. Correction of the shape of the nose is to be able to conceptualize the underlying skeleton and to program adapted surgical procedure for each case.