Nasal Osteotomies in Asian Patients: Surface Aesthetics, Anatomy, and Technical Considerations

Adapted from the work of Jae-Yong Jeong, MD, PhD; Taek-Kyun Kim, MD, PhD; Inhoe Ku, MD; and Bakhtiyor Najmiddinov, MD, PhD. This study assessed the relationship between silicone implant hardness and tissue response, demonstrating that softer implants are associated with reduced inflammatory and fibrotic reactions. These findings highlight implant hardness as a key determinant of biocompatibility and long-term surgical outcomes in rhinoplasty.

Background While osteotomy is commonly performed in rhinoplasty, its principles are often difficult for less experienced surgeons to fully understand. The goal of this article is to clarify nasal osteotomy in Asian patients by exploring nasal anatomy, surface aesthetics, and their direct relationship to surgical execution. Surface Aesthetics for Nasal Osteotomies

Dorsal Width (DW) and Basal Width (BW)

Dorsal width (DW) refers to the distance between the two DALs. Ideally, this width should match the width of the nasal tip or the distance between the philtral columns. The dorsal width is not uniform—it is widest near the nasal root, narrowest in the mid-bridge, and widens again toward the tip.

Basal width (BW) is commonly thought of as the width of the nasal base, but in Asian noses this can be misleading due to thicker skin and soft tissue. A more accurate way to assess BW is by measuring the distance between the two LALs.

Because the LALs are not parallel, the basal width changes along the length of the nose. It can be evaluated at two main levels: near the inner corners of the eyes and lower down at the level of the nasal base. Externally, the end of the LAL corresponds to the supra-alar groove.

Fig. 1 Dorsal aesthetic line (DAL) and lateral aesthetic line (LAL). (A) Graphical illustration of DAL and LAL. DALs start from supraorbital ridges superiorly and run medially along the glabellar area, eventually meeting at the level of medial canthal ligaments before subsequently diverging at the keystone area and finally, end up at the tip-defining points. The LAL lies on the nasofacial groove and demonstrates the transition line between the facial surface and lateral nasal polygons in surface aesthetics. (B) Topography of DAL and LAL on patient’s nose. Vertically, the LAL starts from supratarsal sulcus (upper white dotted line) and after passing the medial commissure, it lies on the nasofacial groove. Caudally, the LAL extends down to the level of the supra-alar groove (lower white dotted line). Red line represents DAL, green line represents LAL, and the yellow dot indicates the location of the medial commissure.

Anatomical Considerations for Nasal Osteotomies

Nasal Bone and Pyriform Aperture

The bony vault of the nose consists of the nasal bones and the frontal process of the maxilla, which together form the pyriform aperture. The medial border is created by the premaxilla and maxilla, whose fusion forms the anterior nasal spine.

When planning osteotomies, the three-dimensional shape of the lateral nasal wall must be considered, as it varies between individuals and often between sides, influenced by sex, ethnicity, and environmental factors.

Nasomaxillary Transition Zone (NMTZ) The frontal process of the maxilla creates a transition between the lateral nasal wall and the cheek, known as the nasomaxillary transition zone (NMTZ), which extends from the medial canthus to the pyriform aperture. Although its shape varies among individuals, the NMTZ serves as a safe zone for lateral osteotomy and plays a key role in shaping the lateral aesthetic line (LAL). Webster’s Triangle There is ongoing debate about whether osteotomy-related bony medialization affects postoperative airway function. Although excessive medialization, internal valve narrowing, or a low osteotomy line may theoretically compromise the airway, clinical experience suggests this risk is low—particularly in Asian patients, likely due to a wider internal nasal valve. Overall, lateral osteotomy appears to have minimal impact on airway patency when performed appropriately.

Lacrimal Drainage System A key concern during osteotomy is potential injury to the lacrimal drainage system. However, when lateral osteotomy is performed within the nasomaxillary transition zone (NMTZ), lacrimal injury is uncommon due to natural bony protection and lower resistance in this area. Postoperative tearing is usually temporary and related to edema rather than true lacrimal damage. Properly performed osteotomies also improve nasal contour by enhancing the lateral aesthetic line (LAL).

Fig. 2 Relationship between osteotomy and upper lateral cartilage (ULC). ULC tends to move toward medial side with lateral osteotomy, because of overlapping between nasal bone and cartilage. It may cause potential narrowing of internal nasal valve due to hinge motion of osteotomized bone causing medial movement of ULC concomitantly. (A) Cadaver demonstration shows potential narrowing of internal nasal valve after osteotomy. (B) Illustration of the relationship between osteotomy and ULC. Relationship between Osteotomies and Surface Aesthetics

• Nasal osteotomies aim to improve DAL, LAL, dorsal width (DW), and basal width (BW).

• Lateral osteotomy mainly reduces BW and affects the LAL, with limited effect on DAL or DW.

• Medial + lateral osteotomies are needed to effectively narrow a wide DW and control the DAL.

• The medial osteotomy starting point determines final dorsal width.

• Medial outfracture and septoplasty help correct bony deviation and straighten the DAL.

• Osteotomies enhance three-dimensional contour by deepening the NMTZ.

• A paramedian oblique medial osteotomy preserves the keystone area and improves stability.

Kinetics of Medial and Lateral Osteotomy Lateral osteotomy modifies the lateral aesthetic line (LAL) by reshaping the nasomaxillary transition zone (NMTZ), a thin area along the frontal process of the maxilla. Because this zone has minimal bony thickness, lateral osteotomy should follow an ascending line from the pyriform aperture for optimal control.

Maximal medialization is achieved by performing medial osteotomy before lateral osteotomy. Percutaneous lateral osteotomy allows more direct and controlled medial bone movement, and a continuous fracture pattern provides better stability and predictability, particularly in Asian noses.

Fig. 3 More deepening of the nasofacial groove was achieved by osteotomy, creating three-dimensional effect. Photos of a 26-year-old patient after osteotomies. (A) Preoperative view. (B) Postoperative view. Differences According to the Fracture Levels Classical medial osteotomy can cause rocker deformity, with outward flaring of the upper edge and inward collapse of the lower edge. Excessive medialization or high lateral osteotomy may result in a staircase deformity, which can be corrected with a double-level osteotomy—also useful for asymmetric lateral wall convexity.

Lateral osteotomies are classified as high or low relative to the NMTZ. A low-to-low pattern, guided by preoperative CT, is now preferred to reduce lacrimal and airway risks, especially in Asian noses. Technical Tips for Successful Osteotomy

• Medial osteotomy: Typically uses a 3–6 mm osteotome; piezo devices may reduce control after fracture.

• Mucosal preservation is essential, especially with implants.

• Follow the natural bony cleavage plane to achieve predictable narrowing and smooth contours.

• Use small (≤3 mm) osteotomes to reduce mucosal injury and bleeding.

• When combining medial and lateral osteotomies, leave a ≥2 mm gap between cephalic ends for stability.

• Gentle, precise mallet use is essential; percutaneous lateral osteotomy has a longer learning curve and higher risk with repeated passes.

Conclusion Nasal osteotomy is a complex but essential component of Asian rhinoplasty. Understanding the relationship between surface aesthetics, nasal anatomy, and osteotomy techniques—including dorsal and lateral aesthetic lines and nasal width—is critical to achieving consistent and predictable outcomes.

Reference:

1. Jeong, J. Y., Kim, T. K., & Ku, I. (2024). Nasal osteotomies revisited in Asians: Surface aesthetics, anatomical, and technical considerations. Archives of Plastic Surgery, 51(2), 2–13. https://www.thieme-connect.com/products/ejournals/pdf/10.1055/a-2201-8219.pdf

   Adapted from the authors’ original work. All patients provided written informed consent for publication and image use.

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