Management of the middle nasal third in revision rhinoplasty

The middle nasal third is often the source of both aesthetic and functional problems with primary rhinoplasty. Weakness of the middle nasal vault can occur from overresection of the upper lateral cartilages or cartilaginous nasal septum, malposition of the upper lateral cartilages, or from secondary scarring from the primary rhinoplasty. These functional and aesthetic problems can be avoided by maintaining an adequate infrastructure to the middle nasal vault. If secondary problems occur in the middle nasal third, precise anatomic reconstruction can be performed in the form of cartilage grafting and/or suture reconstitution. This reconstruction requires an in-depth knowledge of the functional nasal anatomy and the ability to re-create the infrastructure so that it withstands the forces of scarring and wound contraction. This article outlines the anatomy of the middle third of the nose, the conditions that cause secondary middle-third problems, and the surgical management of these deformities.