Procedures::Face
Rhinoplasty
This is one of the most interesting and challenging plastic surgery procedures. The procedure has gone through an evolution during the last thirty years. It takes experience and again artistry to get a great result, but one has to be mindful that the results change over the years and a nose that looks great in six months after surgery could look less perfect five years later. The respect for the structures of the nose, especially the tip cartilage, is very important for long term results to be acceptable. These are facts that the patients are not aware of, but everyone should know.
I divide the nose into an upper part which is bony and a lower part which is made of cartilage. The bone forms an arch that makes the nasal bridge. Below this area, the upper lateral cartilages form a cartilaginous arch that is a continuation of the bony arch. The shape of the tip is determined by the lower lateral cartilages that are a pair, shaped like an inverted U.
Tip rhinoplasty is often done with an open approach called open rhinoplasty. The shape of the tip is also influenced by the thickness of the skin. The thicker the skin, the less one sees the shape of the cartilages. In a wide boxy tip, the inverted U is wider and needs to be narrowed. Years ago, this cartilage was weakened or divided, so that it would get narrower. The results were unpredictable and often led to deformities that everyone sees in older people with old rhinoplasties. Today, I use an open approach to modify the tip by a combination of sutures, conservative resection and grafting. This allows me to have better control of the way things heal and scar.
Many times, the tip cartilages are asymmetric. In those cases, the open approach allows better control and exposure to symmetrize the tip through sutures and grafting. The scar from the open approach heals well and is usually non-visible. It goes across the columella from one nostril to the other, usually in a step fashion.
The inside of the nose is divided by a bony and cartilaginous structure called the septum. On each side of the septum, there are two pairs of curved structures called the turbinates. The role of these turbinates is to humidify and warm the air and like radiators. When the septum is deviated and the turbinates are enlarged, it is difficult to breathe through the nose and the patients instead breathe through their mouth. Mouth breathing is not physiologic and makes the airways dry and irritated.
To treat the problem, the deviation of the septum needs to be corrected and the turbinates reduced. In many patients, especially if they had a previous rhinoplasty, their lower lateral cartilages are collapsed against the septum. This blocks the airway as they breathe in. I will place a cartilage graft called the spreader graft to open this area and not only help the breathing, but to improve the pinching of this area above the tip.
When I see a patient for a rhinoplasty consultation or as most often call it a “Nose Job”, after a careful history and examination, I go over all these issues with them. Then I will do a computer imaging to show them what I have in mind and what my aesthetic goal or endpoint is. This is the best way to know if my plans correspond to what the patient has in mind, and if they are in full agreement with my plan. The typical rhinoplasty requires the dorsum (hump) to be reduced, the nasal bones to be brought together to recreate the arch after the hump removal, and some degree of work on the tip. If the tip is even close to adequate in shape, we would try not to change it. The best results in the long run are when the tip has not been modified. I only work on the tip if it is absolutely needed or if it requires a very conservative refinement. The tip work is required when it is asymmetric, too wide or projecting too far.
When the hump is removed and the nasal bones are moved together, one has to make sure that the lower half of the nose has internal support (spreader grafts). When the cartilaginous arch of the nasal dorsum is interrupted by hump removal, the upper lateral cartilages can collapse toward the septum and make the lower part of the nose too narrow. This not only would look bad, but will create difficulty breathing by creating a valve effect to obstruct the airway when the patient breathes in. Grafts are made out of a piece of the septal cartilage that has to be carefully harvested, cut and measured. Then the cartilages are placed between the upper lateral and the septum to prevent collapsing and the internal valve problem. These are called the spreader grafts.
After the rhinoplasty, there will be a splint over the nasal bridge taped to the cheeks and the forehead. This will remain in place for a week. If the nasal bones are moved, there could be some bruising by the eyelids. When surgery is done inside the nose, for example, on the septum, I would leave a plastic tube in each nostril for twenty-four hours while the packing is in place to allow the patient to breathe. The results are visible when the splint is removed. Ninety-five percent of the swelling is gone within a month, but that last 5 percent could take months or years. That is why the long term results could be different than what one could see in six months.
