Rhinoplasty

Rhinoplasty

Contents


Introduction to Rhinoplasty


Rhinoplasty, or nasal re-shaping, is a procedure to change the appearance of the nose. The nose is the centerpiece of the face and subtle changes may have a dramatic impact. Every face looks best with a natural-looking nose that is properly proportioned to it. After surgery, your nose should look like one you could have been born with. 

There are a number of ways to alter the bridge, tip, and nostrils. Most consider rhinoplasty to be the most technically difficult of plastic surgery procedures due to the complicated anatomy and potential effects on breathing. Any change to the external appearance of the nose (e.g. making the nose smaller, narrower, straighter, etc.) may make your airway smaller. We take this into account and make the necessary internal improvements to your airway. The last thing we want is an attractive nose that doesn’t work well! Fear not, as facial plastic surgeons are not only trained in cosmetic rhinoplasty but also nasal airway surgery.

The usual candidates for this procedure are patients who 1) have always felt that their noses do not fit their faces (a disconnect between one's inner and outer identity), 2) have suffered trauma that has caused their nose to appear different or abnormal, or 3) have noticed changes to the shape or smoothness of their noses as they have aged.

Approaches & Techniques


Open Rhinoplasty

Open rhinoplasty, aka external rhinoplasty, is a type of nose re-shaping surgery that involves one small external incision located between the nostrils on the underside of the nose (the remaining incisions are hidden inside the nose). This allows the tip of the nose to be opened to gain full view and access to the underlying structures of the nose. This technique allows the most accurate and precise modifications of the nose. This is especially useful in revision cases or when major nasal tip modifications are required.

Endonasal ("Closed") Rhinoplasty

Endonasal rhinoplasty, aka “incisionless” rhinoplasty, is a type of nose re-shaping surgery that involves only incisions hidden inside the nose. This allows a shorter procedure and speedier recovery, but less visualization for complex maneuvers as compared to the open rhinoplasty. This procedure is useful for minor modifications to the bridge and tip of the nose.

Tip Rhinoplasty

Tip rhinoplasty is a type of nose re-shaping surgery that only involves the nasal tip and may or may not involve an external incision. The nasal tip may be positioned closer or farther from the face, or may be turned up or down. We often couple this procedure with nasal airway surgery, when required or desired.

Revision Rhinoplasty

Revision rhinoplasty, aka secondary rhinoplasty, is arguably the most difficult operation performed in plastic surgery. It involves re-shaping a nose that has already undergone previous surgery to achieve a more desired result. Usually it is performed a year or more after the previous procedure to allow proper healing. The extent of revision may vary – in some, it may be a small modification to the nostril or tip, while in others, major bridge or tip work may be necessary. The degree of surgery dictates the type and extent of incisions required. With major revisions, we often need cartilage grafts from the septum, ears, or rib to accomplish our goals.

Planning Your Procedure


The Consultation

During the consultation, we really want to get to know you and understand your concerns. We will review with you the changes you would like to make and their potential impact on your breathing and your life. We will also review your medical history and the history of your current concerns. We will examine your nose, both externally and internally.

A very essential part of the process will be taking your photograph and reviewing digitally-altered images of your nose to establish common goals for surgery and to make sure it looks natural. These alterations are kept realistic by always considering what surgical maneuver would be performed for a given change. Dr. Patel brings these pictures into the operating room to assist him in surgery.

After the consultation there is a second visit prior to surgery called a "preop". At this visit we will go into much greater detail about how to best prepare for the coming surgery. We offer a wealth of information about optimizing your recovery, ensuring proper healing, resuming normal activities, and avoiding complications.

Duration of Surgery

A primary rhinoplasty averages 3 to 4 hours. A tip/minor rhinoplasty can take as little as an hour while a difficult revision requiring harvesting of rib or ear cartilage grafts may take up to 6 hours. This is usually an outpatient procedure.

Anesthesia Options

For tip or nostril work only, there is an option to have the procedure performed in the office under local anesthesia. If bridge work is required, our standard protocol is general anesthesia at a surgery center. 

Incisions

The external incision for an open rhinoplasty is located on the columella (between the nostrils on the underside of the nose). The remainder of the incisions are located inside the nose. There are several techniques  used to make the incision heal well. First, the incision is shaped like a “W” instead of a straight line, as the human eye sees straight lines better than curved or jagged ones. Second, it is placed far back on the base of the nose, which allows better camouflage. Third, unlike most, we take the time to place deep, dissolvable sutures that keep the closure strong for many months. In the vast majority of patients, the incision heals well and will not be seen by the casual observer. The rare visible scar is easily correctable in the office.

How It's Done

We can improve the slope and definition of the bridge by sculpting the underlying bone and cartilage. The bridge may be lowered (e.g. for a hump), raised, narrowed, and widened.

We can improve tip position and definition by sculpting the underlying nasal cartilage and soft tissue. The tip may be raised, lowered, projected more, or projected less.

We can improve the position, width, and flare of the nostrils by sculpting the soft tissue of the ala. Generally, this is done to narrow the nostrils and reduce flaring.

Recovery

Typical at-home recovery time is 1 week. Immediately after surgery, most patients will have light packing in the nose that is removed the following day. All also wear a protective splint on the nose upon which glasses may be worn. A mustache dressing is taped over the upper lip to passively collect any nasal drainage and is usually required for 24-48 hours. In most cases, there are stitches located between the nostrils. The splint and all visible stitches are removed after 5-7 days.

Pain

The first night after surgery, you will feel a dull ache around your nose that we will instruct you how to treat and minimize. Everyday thereafter, any discomfort will reduce significantly. Most patients are bothered by postoperative nasal congestion more so than pain. This congestion takes a few weeks to clear up but we will instruct you how to reduce it.

Swelling & Bruising

Swelling and bruising are normal parts of surgery that often go hand-in-hand. Most of it will subside within the first week. Most bruising may be concealed with cover-up as it gradually fades. The tip rhinoplasty is associated with far less swelling and bruising than a traditional rhinoplasty. For a primary procedure, 90% of the swelling subsides by 6 weeks after surgery, and the remaining 10% slowly diminishes over a year. For revision surgery, 90% takes 3 months, and the remainder up to two years. Eventually all swelling and bruising will go away.

Nasal Packing

We use a very light packing the first night after surgery for most patients. It is of great benefit because it reduces the risk of any serious nose bleeds and helps keep swelling down inside the nose. The packs are not painful and are easily removed the day after surgery.

Nasal Congestion

Your nose will be congested after surgery. The swelling on the outside is also present on the inside. Also, the nose produces more drainage for a short time after surgery. These are all temporary. You may improve your breathing during this time with oral decongestants and non-medicated saline sprays.

Open vs. Closed Rhinoplasty

For patients who want major modifications to the tip or bridge of the nose, or those who need placement of complex grafts, an open rhinoplasty will be the better choice. The endonasal or “incisionless” option is better for patients who mostly want minor bridge and tip work. We will guide you on this decision.

Special Topics


Nasal Anatomy 101

The external nose is made up of a bridge, tip, and ala: 

The bridge is formed by hard bone on the upper half and softer cartilage on the lower half. The lower half of the bridge also houses the nasal valve area, which is critical for nasal breathing. The nasal septum runs right down the middle of the entire bridge and often dictates straightness of your nose. On profile, we prefer the bridge to be relatively straight from top to bottom. In females, a light inward slope is often desirable. In men, a slight outward slope may look attractive. From the front, the bridge should be straight and project forward to a gently rounded apex. The width of the bridge should resemble an hourglass from top to bottom.

The tip is formed by two arched cartilages with one common leg, resembling a three-legged stool. The upper legs extend above the nostrils, while the lower, common leg spans the columella (the fleshy part between the nostrils). There is a wide variety in their width, height, curvature, and overall shape. With a refined nasal tip, these cartilages have a strong bend in the arched region and the tripod legs are straight and strong.

The ala is the fleshy part that houses the nostrils. There is no cartilage in this region. The floor of the nostril opening between the ala and columella is called the nasal sill. Nostril show is influenced by the position of the nasal tip, position of the columella (fleshy part between the nostrils), and arch of the nostrils. Ideally, the nasal tip should be project straight out from the face, the columella should hang down a little lower than the nostrils, and the nostril margins should have a gentle arch.

Hump On The Bridge

A hump or bump on the bridge of the nose is probably the most common feature altered with rhinoplasty. The hump may be a familial trait or caused by trauma. Even as we age, it seems like we ‘grow’ a hump due to loss of nasal tip support. This is such a common phenomenon, that we often associate a hump with an aged appearance. As a result, removing a hump will often make one appear younger. 

A hump may involve all or part of the bridge. During surgery, the bone and cartilage of the hump are carefully removed. The skill in hump removal is making sure the bone and cartilage blend into one another so that the bridge looks smooth from top to bottom. After the hump is removed, the sides of the nose are pushed inward to narrow the new bridge. It is often assumed that the process of removing or moving the nasal bone is forceful, however, we actually perform this in a finessed and controlled manner. Finally, the width of the nasal valve area is checked. A narrow nasal valve not only makes breathing more difficult, it may create a visible indentation that looks like an upside-down ‘V’. If narrow, the nasal valve area is widened with cartilage grafts from the nasal septum, creating a smooth flow from the top to bottom of the nose.

Low Bridge Or Saddle Nose

A saddle nose has a bridge that appears low or indented on profile and wide and undefined from the front. It may be congenital, an ethnic variation, or occur as a result of trauma or previous surgery in which the bridge was reduced too much. Commonly, we see a saddle nose in the presence of a large nasal septal perforation inside the nose. 

With a saddle nose, insufficient cartilage and bone gives the nasal bridge a flattened or indented appearance. When the nasal valve area is affected, there is often trouble breathing. Cartilage grafts are placed to widen the nasal valve area and create a larger airway. In cases of nasal septal collapse, the nasal tip falls up and into the nose creating a flattened and upturned appearance. Cartilage grafts are used to extend and rotate it to a more natural position.

The cartilage grafts that are used must be strong. For this reason, we prefer rib cartilage. Not only is it firm, it may be sculpted to resemble normal structure (e.g. the nasal bridge). We prefer to use your own rib cartilage, but another option is to use donor rib cartilage from the deceased who have donated their bodies for medical use. The donor rib has been treated to remove all microbes and cells. Once the treated rib cartilage is put into your nose, your own cells occupy it and it becomes a part of you. 

Crooked Nose

A crooked nose may be quite noticeable and impede breathing. It may prevent you from wearing eyeglasses or sunglasses properly. A crooked septum inside the nose may cause breathing problems on one or both sides. Trauma is often the cause of a crooked nose, though it is possible to have one since birth. 

Deviations in the nasal septum or nasal bones often cause the entire nose to bend to one side. These bends can affect breathing by blocking airflow, especially at the nasal valve region. They may also block sinus drainage. The nose may bend to one side only or in multiple directions creating a C- or S-shaped nose. 

During surgery the structures of the nose are "released" from one another to reduce tension. Cartilage that is bent or deviated has “memory” and resists straightening. Methods of scoring, shaving, flattening, splinting, or removing cartilage is necessary to cause bends to unbend. The key is to strengthen, not weaken, structural supports for the nose – otherwise the nose may collapse over time. The nasal bones often need to be re-positioned into a straighter, more symmetric position. It is often assumed this process is forceful, however, we actually perform it in a finessed and controlled manner. Cartilage grafts from the nasal septum are often used to splint and straighten the bridge of the nose. The released structures are put back together in a more symmetric fashion. Strength may be added to the nasal tip with additional cartilage grafts.

Large, Wide Nose

A wide nose may appear unattractive on some faces but not others, especially depending on one’s ethnicity. A nose that is wide may make the face appear narrower or make the eyes appear closely set. Wideness in the tip and nostrils, may make the bridge look too narrow, and vice versa. The goal is to make the nose more balanced top to bottom, and better proportioned to the size of the face. 

A nose may look wide in the bridge, tip, nostrils, or in combination. This lower bridge may appear pinched compared to a wide upper bridge and create an indentation resembling an upside-down ‘V’. The nasal tip may appear wide or bulbous due to large or overly curved nasal tip cartilages. Flaring of the nostrils may cause them to look wide. Thick nasal skin may contribute to increased nasal width, especially near the nasal tip where it may be its thickest. 

For the wide nasal bridge, the nasal bones may be narrowed. If a bridge is low or indented, a cartilage graft augmenting the bridge will create a narrower-appearing bridge. If the nasal valve region is narrow, cartilage grafts may be used to make the nose look more uniform in width. For the wide nasal tip, the nasal tip cartilages may be trimmed and sutured tighter to form a more defined tip. Sometimes, cartilage grafts from the nasal septum are used to stretch or splint the nasal tip to create narrowing. For wide or flared nostrils, please see the section on Wide Nostrils.

Pinched Nose

The pinched nose appears too narrow and may compromise breathing. Unfortunately, this may be a by-product of previous aggressive rhinoplasty. A nose that is narrow may make the face appear wider or make the eyes appear widely set. Narrowness solely in the tip and nostrils, may make the bridge look too wide, and vice versa. The goal is to make the nose more balanced top to bottom, and better proportioned to the size of the face. 

The pinched portion may be at the nasal valve region, located just below the bony bridge, and may appear as an upside-down ‘V’. Another site of pinching may be at the nostrils and/or nasal tip. This may appear as a deepening of the crease above the nostril and lead to airway collapse with forceful inspiration. A weak nostril rim may also contribute to airway collapse. 

The goal for correction is to strengthen the nose and re-create structure.. In the case of a narrow nasal valve, cartilage grafts are placed to widen this region. When the nostrils and nasal tip are pinched, cartilage grafts are used to fill-in the contour from the nasal tip to the nostril crease. For a weak nostril rim, a cartilage graft is precisely placed directly into the rim to add strength and support.

Short, Upturned Nose

With an upturned nasal tip, the nostril openings are much too visible from the front and the nose may appear under-projected from the side. The nose may look too short overall. One may have been born with an upturned nose or acquired it from trauma or a large septal perforation. 

During surgery, the nasal tip may be pushed downward by using cartilage grafts the extend the septum and tip complex to a lower position. A cartilage graft secured on the nasal tip may also lower the apparent position of the tip and add more projection.

Long, Droopy Nose

A downturned, or droopy, nasal tip may make a face look prematurely aged or emotionally upset. The nose may look too long overall. This may be congenital or due to aging. We believe that with aging, the ligaments supporting these cartilages weaken and the tip cartilages begin to sag and point downward. 

During surgery, the nasal tip may be tilted upward with a variety of methods. One we commonly use is to shorten the upper legs of the tip cartilages to tip them upward. If the columella also hangs downward, we may tuck it up into the nose (see section on Too Much Nostril Show).

Overprojected Tip

A nose that sticks out too far may draw unwanted attention. Often one is either born with this type of nose or acquires it from previous surgery. The over-projected nasal tip may have stretched-thin skin with too visible underlying cartilages. Also, the nostrils may appear long and thin from the bottom view, and may collapse with forceful inspiration. Over-projection may result from previous surgery due to improper placement of a nasal tip cartilage graft. An overly reduced nasal bridge may also make the nasal tip appear over-projected. In this case, the problem is not with the tip cartilage, but with the height of the bridge. 

During surgery, the nasal tip may be pushed closer to the face with a variety of methods. One we commonly use is to shorten the upper and lower legs of the tip cartilages to bring them back. An improperly placed nasal tip graft may be re-positioned or removed and any over-reduction of the bridge may be corrected with a rib cartilage graft. This graft may come from the patient or a donor (see section on The Low Bridge). Nostril flaring is usually increased if the tip of the nose is de-projected, and this must be accounted for (see section on Wide Nostrils).

Underprojected Tip

When the nasal tip does not project adequately from the face, it may appear flat on profile and broad or bulbous from the front. Often one is either born with this type of nose or may acquire it from previous surgery, trauma, or aging that has led to loss of ligamentous tip support.

During surgery, the nasal tip may projected farther from the face in a variety of ways. One common method we use is to place a cartilage nasal tip graft that projects farther than the tip cartilages.

Bumpy Nose

A bumpy nasal tip may appear irregular, asymmetric, and draw attention away from the eyes. This bumpiness often results from asymmetries and irregularities in the underlying cartilage and bone and may be congenital or acquired through injury or previous surgery. 

With a smooth nose, the bony and cartilaginous structures tend to feel smooth, seamless, and symmetric. A step-off or asymmetric shift from side to side bumpy appearance in the overlying skin. Sometimes, if the tip cartilages are spaced too far apart an indentation forms at the tip of the nose. During surgery, the nasal cartilage is shaped to make them more symmetric and smooth. Sometimes cartilage grafts from the nasal septum are used to splint cartilage that is curved or bumpy. Suture techniques are also used to make the cartilages more symmetric.

Bulbous Nose

A bulbous nasal tip makes the tip of the nose look balloon-like. It often distracts from the rest of the nose and is a source of unwanted attention. In most cases, individuals are born with a bulbous tip.

With a bulbous tip, the cartilages are often too wide and convex, creating a ballooning effect which pushes out on the nasal skin.  During surgery, the width of the nasal tip cartilage is trimmed. This reduces the tip size and convexity. Next, the arch of each tip cartilage is tightened into a sharper bend and the two arches are bound together. This also lessens tip width and convexity. If the ballooning effect still persists, cartilage grafts are placed liked splints to straighten the tip cartilages.

Wide & Flared Nostrils

The nostrils may appear wide, especially when compared to a narrow nasal bridge or tip. This creates a perceptual imbalance. One is typically born with wide nostrils, and average nostril width varies between races. Wider nostrils may also result from previous nose surgery due to loss of nasal tip projection. 

Nostril flare is outward bending of the nostril beyond its attachment point to the cheek. Nostril flaring increases when the nasal tip is pushed closer to the face, and must be accounted for when correcting an over-projected nose. Nostril-reducing procedures address both nostril flaring and nasal sill width. It is important to maintain enough nostril size to maintain proper breathing. 

For nostril flaring, the position of the nasal tip is assessed and corrected first. Adding projection to an under-projected nasal tip will, in itself, reduce nostril flaring. In cases where the nasal tip is adequately- or over-projected, nostril tissue is removed at the nostril crease. In those with wide nasal sills, tissue is removed from the sill region. These maneuvers create a more triangular appearance to the base, and the incisions are concealed in natural creases.

Too Much Nostril Show

Overly visible nostril openings as seen from the front or profile is generally not desired and may be a source of insecurity. This may be congenital or from previous surgery or trauma. The nostril openings become more visible if the tip is upturned, the columella hangs downward, or the nostrils are arched upward. 

For a hanging columella, we trim and tighten the hanging components, thereby tucking the columella upward into the nose. For an overly arched nostril, the nasal tip cartilages may be manipulated or cartilage grafts may be used to further drive the nostril margins downward. Cartilage grafts may also be placed into the rims of the nostrils to help straighten them from an overly arched configuration. In cases where scarred skin prevents downward movement of the nostril, ear cartilage grafts are used to extend the tight skin and cartilage that are pulling up on the nostril. Regarding an upturned nasal tip, please see section on the Upturned Nose.

Too Little Nostril Show

Though not obvious at first glance, not being able to see much of the nostril openings as seen from the front or profile may make the nostrils appear low-hanging (or hooded) or the nasal tip droopy. This may be congenital or from previous surgery or trauma. 

The nostril openings become less visible if the tip is downturned, the columella retracts upward, or the nostrils are hooded. Hooded nostrils may be a normal ethnic variation and is often just due to increased nostril tissue. For a retracted columella, through incisions inside the nose, we can place a cartilage graft that will push the columella downward. Nostril hooding is treated by removal of excess nostril tissue. Regarding a downturned nasal tip, please see section on the Droopy Nasal Tip.
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