DiscoverBeauty :: Rhinoplasty Nose Job Surgery Nasal| DiscoverBeauty

Learning Suite Article   < Back to Learning Suite

Procedure: Rhinoplasty

Author: David W. Kim, MD FACS

Author: Patrick Byrne, MD FACS

Learn how your nose is surgically altered during rhinoplasty, a cosmetic nasal surgery. There are structured approaches to this medical procedure which impact your nasal anatomy.

Rhinoplasty

Rhinoplasty (Cosmetic Nasal Surgery)

 

Rhinoplasty is an operation in which the shape of the nose is changed in order to create improvements in appearance and/or function.  Because the nose sits in the center of one’s face, cosmetic rhinoplasty can make a significant impact in improving one’s overall appearance.  It is widely acknowledged that rhinoplasty is the most difficult of all the surgeries performed in facial plastic surgery because of the complex three-dimensional anatomy of the nose.

During rhinoplasty, work is done predominantly on the cartilage and bone of the nose—the structures which create the nose’s shape.  Incisions are made on the skin inside of the nostrils and/or across the columella (the narrow bridge of skin between the nostrils).  There are numerous concerns which prompt individuals to seek rhinoplasty and there are a wide range of possibilities in terms of final appearance. 

 

Anatomy and Approaches to Rhinoplasty?

 

The nasal bones form the structural component of the upper third of the nose while cartilage represents that of the rest of the nose below.  Too much cartilage in the middle portion of the nose (represented by the upper lateral cartilage)  and/or prominent nasal bones may contribute to a hump or bump along the bridge.  The lower lateral cartilages form the lower 1/3 of the nose.  These paired cartilages create the shape and position of the tip of the nose.  The nasal septum is the wall between the two nostrils which extends along the length of the nasal passages.  The septum is made of cartilage in its front half and bone in its back half.  A skin covering, which varies in thickness from person to person, covers the entire nasal framework.   A moist layer of skin (the mucosal layer) covers the nasal septum and other internal nasal structures.

 

Because changing the shape of the nose is achieved  by altering the nasal framework (bone and cartilage), incisions must be made either on the external skin or internal lining to gain access. 

 

Endonasal Rhinoplasty

 

Endonasal rhinoplasty refers to surgery accomplished solely through hidden internal incisions within the nostrils.  The advantages of this approach include: lack of a visible scar, shorter surgical time, and less swelling and bleeding.  The disadvantages include limited exposure for the surgeon, limited ability to create large changes, and difficulty in  re-stabilizing structures within the nose that are weakened during surgery. 

 

Open Rhinoplasty

 

Open or external rhinoplasty combines many of the same internal incisions as endonasal rhinoplasty with an additional external “trans-columellar” incision which is placed across the narrow bridge of skin between the nostrils.  The advantages of this approach are the open exposure, greater ability for precision, and general wider array of rhinoplasty techniques available to the surgeon.   The disadvantages are the external scar, the lengthier surgery, and more prolonged swelling. 

 

Relevant Anatomy

Your nose is separated into right and left sides by a midline partition called the nasal septum. It is usually pretty straight, and is a very important source of support to the bridge and tip of the nose. If it is crooked – a deviated septum – it can obstruct the breathing on one or both sides of the nose. The tip of the nose has a pair of cartilage – the lower lateral cartilages – that determines its shape and size.  Just above the nasal tip is the midvault of the nose, where two more pieces of cartilages (the upper lateral cartilages) reside. The upper third of the nose is the part that is made of bone.  These five cartilage structures and two bones determine what your nose looks like and how it functions. Overlying the cartilage and bone is a layer of skin and soft tissue. This is referred to as the “skin soft tissue envelope”. Some patients have a very thin skin soft tissue envelope, others have a very thick one, and most are somewhere in between. This is important because the thickness of the skin soft tissue envelope determines not only what your nose looks like now, but also which techniques should be chosen to achieve the best potential outcome. 

 

Consider for example the patient with very thin skin and soft tissue. Because the skin soft tissue envelope is thin, it is possible to make the nose more refined and smaller. This is because when changes are made to the underlying framework (cartilage and bone) of the nose, the thin skin soft tissue envelope tends to heal tightly down to this framework. In addition, it is easy to see the newly created shape through that thin envelope. The down side to a very thin envelope is that it easily shows every tiny irregularity.

 

Keep in mind that rhinoplasty is an art, and the medium the surgeon has to work with is not up to his or her choosing. One can only use the materials that the patient has that make up his or her own nose. If the surgeon could choose the material, he or she would invariably choose a substance like clay that can be molded into any desired shape. None would choose to use cartilage and bone – inherently awkward materials to work with, with a limited ability to alter accurately. Yet that is what is available. As such, the surgeon reshapes the cartilage and bone as well as possible, but inevitably there are imperfections. In the thin-skinned patient, these imperfections are likely to become visible. The wise surgeon, therefore, pays considerable attention to maneuvers that will camouflage any underlying imperfections. There are multiple such techniques available to the surgeon, such as the use of crushed cartilage or fascia (connective tissue) to conceal imperfections under the skin.

 

Contrast this with the patient with a very thick skin soft tissue envelope. In these patients, one cannot simply reduce the size of the nasal tip and expect the envelope to contract down tightly and reveal the beautiful changes underneath.  Because the skin is so thick, it never will assume the shape of the underlying cartilage and bone. The result will likely be a shapeless, amorphous tip that appears neither smaller nor more refined. In these patients, a very different approach is necessary.  Instead of reducing the size of the underlying cartilage framework, the surgeon needs to increase the projection of the tip in order to force the thicker envelope of skin and soft tissue to reveal the improved contours that are created. Thus while the surgeon may not be able to create a smaller nose in the thick skinned patient, hopefully he or she will still accomplish the goal of a more refined nose by creating a more favorable shape.

 

How is the Procedure Performed?

 

Anesthesia

Rhinoplasties are usually performed under general anesthesia, in which the patient is completely asleep, or sedation. Occasionally, more limited procedures may be done under local anesthesia alone. This is not common.

 

Incisions and Approaches

Rhinoplasties may be performed through an  “endonasal” (also referred to as “closed”) approach in which the incisions are all made on the inside of the nose. Alternatively, they may be performed “open” in which the internal incisions are connected by an additional incision across the skin between the two nostrils (the columella).  Though some patients express concern over the potential visibility of the scar using the open approach, in reality, over 99% of such patients cannot notice the incision. Whether or not your surgeon performs rhinoplasty “open” or “closed” is therefore largely irrelevant. What is important is how skilled the surgeon is, and if he or she respects the structural integrity of the nose

 

The “Structure” Approach to Rhinoplasty

Traditionally, rhinoplasty techniques have involved the removal of cartilage and bone. These “reductive” techniques include splitting and removing of cartilage to produce refinement of the nose. In the past 20 years, there has been a trend away from such reductive techniques toward a more “structural” approach. In this strategy, surgeons try to limit removal of cartilage. Attempts are made to preserve the structural integrity of the nose, including the midvault and tip. This change in philosophy occurred because it was recognized that many patients who underwent rhinoplasty with traditional techniques would ultimately (sometimes many years later) be left with unnatural appearing noses, pinched nasal tips, narrow noses and difficulty breathing.

 

Many proponents of the “structural approach” to rhinoplasty (including the author of this article) find that the ‘open’ approach allows the surgeon to perform the important maneuvers of rhinoplasty with a degree of precision and control that traditional ‘closed’ approaches do not.

 

Maneuvers in Rhinoplasty

The patient and the surgeon determine together during the process of consultation the desired changes. Ideally, this is done in a very systematic fashion with quite a bit of dialogue. The desired changes then determine the maneuvers performed.

 

Nasal Tip

The nasal tip may be altered in its projection (decreased, increased), rotation (decreased, increased) and width.  These alterations are performed on the cartilage framework of the nose.

 

Midvault

The midvault is narrowed if it is too wide. If the midvault is asymmetric or narrow it can be corrected with cartilage grafts, such as “spreader grafts”. These are pieces of cartilage (usually taken from the septum inside the nose) that are placed in a way to create the desired width, correct twists, and/or support the airway to assist with optimal breathing.

 

Bridge

Most patients want a bump reduced. This is usually a matter of removing cartilage (and some bone). Some patients need the bridge raised. This is done with cartilage grafts, which can be obtained from inside the nose, from behind the ear, or from the chest wall.  Some surgeons use artificial materials for this type of augmentation.

 

Nostrils

Some people want their nostrils reduced in size. This usually is done by an “alar base reduction.” To be more specific, some people need the width of the nostrils reduced, while others need the “flare” (outward curvature) of the nostrils reduced but have an appropriate width. Others have too much width and flare. These maneuvers do require incisions on the outside of the nose, in the crease of the nostril. While these incisions heal very well, they are in a location that is potentially conspicuous. So, this is a decision to be carefully considered in terms of the risk / benefit ratio.

 

Osteotomies

This refers to breaking the nasal bones in order to reposition, narrow or straighten them.  This is a common maneuver, and is the main reason there is usually some bruising around the eyes after a rhinoplasty.

 

Who is a Candidate for Rhinoplasty?

Rhinoplasty is performed in almost any age group, although rarely in children under the age of 16. It is preferable to wait until the nose and face is fully grown before performing a rhinoplasty. It is most commonly performed on people between 18 and 50.  It is usually performed either under general anesthesia or sedation in an operating room. So the patient must be healthy enough to undergo a surgical procedure.

 

There are a variety of reasons that people seek rhinoplasty. Most commonly, they just don’t like the way their nose looks, and have always been troubled by one or more features. Often the nose appears too large, “droops”, or has a prominent bump. Others seek treatment after an injury, or when they develop trouble breathing through the nose.

 

What Happens Before Surgery?

 

A pre-operative consultation is typically conducted during which the surgeon will examine the patient and then discuss goals and options for surgery.  Pre-operative photographs will be taken which may aid the surgeon during surgery.  Some surgeons will use modification morphing software program to demonstrate the possible changes which could be made during surgery.  This process may be helpful in allowing the surgeon and patient reach mutual goals for surgery.

 

Experienced surgeons will understand the limitations of rhinoplasty and be able to help the patient formulate realistic expectations.  In general, there is only a certain degree of change which is possible after nasal surgery. Rhinoplasty may be performed with the patient under general anesthesia or awake with sedation and local anesthetic. 

 

What are the Limitations of Rhinoplasty?

 

The nose is not a lump of clay which can be molded into any form or a block of wood which can be carved into any shape.  The structures on which the surgeon works are bone and cartilage, materials which are inherently awkward to manipulate.  The possible outcomes following surgery are determined largely by the anatomy and orientation of the original nose.  In essence, changes to the nose can only go so far.  There are two concepts which explain this.

 

First, the bone and cartilage in the nose are there for a reason: to provide strength and support to the nose.  Over-aggressive alteration of these structures weakens the stability of the nose and may lead to collapse, pinching, or breathing problems.  Also, the bone and cartilage have memory and may have a tendency to shift back to the original position and shape.  Second, the stiffness and thickness of the skin and soft tissue envelope of the nose limits the degree to which the size of the nose can be changed.  In patients with thicker, more oily skin, the changes in form created in the cartilage and bone may not be easily seen through the thick skin envelope, particularly when the nose bas been reduced in size significantly.

 

What Happens During Surgery?

 

The first step in rhinoplasty is to make incisions in the skin or nasal lining inside the nostrils in order to gain access to the framework (bone and cartilage) of the nose.  As discussed above, an endonasal approach or open approach may be used. Once access to the framework of the nose is achieved, the bulk of the work is done.

 

Literally hundreds of rhinoplasty maneuvers have been described in the extensive rhinoplasty literature.  The maneuvers may be grouped into three major categories.  In reality a combination of maneuvers taken from all of these groups are used in many rhinoplasty surgeries.

 

  • Augmentation:  Maneuvers to add volume to the nose.  Added volume may be cartilage taken from other parts of the nose or body, other soft tissue, or artificial material.  Examples: elevating a low nasal bridge, adding tissue to the tip of the nose to make it more prominent, covering an irregularity with a thin tissue graft that acts as camouflage.

  • Narrowing the nose bones: If the bridge has been lowered by shaving the cartilage and bone, then often the nose bones need to be narrowed so that the bridge does not look wide and flat. This maneuver, called an osteotomy, is achieved by using an instrument to make fine cuts in the side of the nose bone on both sides. This is often what people refer to when they say that the nose is “broken” during surgery. In actuality, the narrowing is controlled and precise.

 

If cartilage grafts will be needed for surgery, toward the beginning of the case, the surgeon may harvest the cartilage from the nasal septum, behind the ear, or from a rib in the chest.  Using one’s own cartilage instead of artificial material may increase operative time and cause some discomfort at the harvest site but is associated with reduction in the likelihood of infection.

 

There are a wide variety of problems for which patients seek rhinoplasty.  The techniques necessary for correction will vary depending on the nature of the problem, the goals of the patient, and the individual nasal anatomy.  Some of the more commonly treated areas and techniques used for correction include (but are not limited to):

 

PROBLEM

 

Treatment

 

Bump or hump on bridge of the nose

 

Remove cartilage or bone

 

Crooked nose

 

Reposition nasal bones and straighten or reconstruct nasal septum

 

Bridge too wide

 

Narrow nasal bones

 

Bridge too flat

 

Add cartilage or implant over the bridge

 

Visible angles or ridges of nasal bones

 

Rasp and smooth edges of nasal bones

 

Nasal tip too wide or irregular

 

Re-orient nasal tip cartilages into a better (triangular) orientation

 

Nostrils too flared or wide

 

Remove a wedge of nostril tissue and narrow nostril opening

 

Nose too long

 

Reposition nasal tip cartilages upward

 

Nose too short

 

Reposition nasal tip cartilages downward

 

Nasal tip asymmetric

 

Separate the lower lateral cartilages from one another and re-position

 

Nasal tip pinched

 

Re-build the nasal tip complex or add cartilage grafts

 

Nasal breathing obstruction

 

Correct septal deviation, turbinate enlargement, or nasal collapse

 

 

 

Very tiny sutures are used to close the incision at the base of the nose.  All of the sutures inside the nose are absorbable and will fall out on their own.  Tape and a thin plastic cast are placed on the nose at the end of surgery and there may be thin plastic stents on either side of the nasal septum inside the nose. 

 

What Happens after Surgery?

 

After surgery patients may be given a prescription for pain medication, antibiotics, and ointment for the incisions.  The pain medications should be used on an as-needed basis and the antibiotics and ointment are taken regularly for about one week.  Soon after, the pain will subside, but a feeling of mild pressure inside the nose may persist for a few days.  It will be more difficult to breath through the nose for the first week until the swelling inside the nose subsides and any internal packing or splints (if used) are removed.  Bruising around the eyes may occur if work on the nasal bones is required.  If it occurs, bruising is typically mild and will resolve in 1-2 weeks.

Recovery

Pain is usually minimal after rhinoplasty. The nose is swollen however and the swelling is significant for the first few days. Most patients take one week off from school or work. By that time, typically the patient has little to no bruising or swelling and can resume work or school without any concerns regarding their appearance. After 3 to 4 weeks, most patients are happy with the appearance. Ultimately, however, all of the swelling takes about one year to fully resolve.

 

Summary

Rhinoplasty is really one of the most remarkable operations in plastic surgery. It is elegant and sophisticated, and can have profoundly positive effects on the individual patient. It is typically considered one of the most difficult operations to perform. For this reason, it is best performed by someone with focused expertise and experience.

 

References

  1. New concepts in nasal tip contouring. Toriumi D. Arch Facial Plast Surg. 2006 May-June;8(3):156-85

  2. Frequently used grafts in rhinoplasty: nomenclature and analysis. Gunter JP, Landecker A, Cochran CS. Plast Reconstr Surg. 2006 jul;118(1):14e-29e.

  3. The underprojecting nasal tip: an endonasal approach. Pastorek N, Ham J. Facial Plastic Surg Clin North Am. 2004 Feb;12(1):93-106.

 

Rhinoplasty- Revision

Revision Rhinoplasty

Rhinoplasty is viewed by many to be the most difficult operation in plastic surgery.  Thus it is no surprise that rhinoplasty has one of the highest revision and complication rates of any operation.  Because revision rhinoplasty seeks to correct problems created by previous rhinoplasty, the surgeon and patient must have a clear understanding of the nature of the complications created from the original operation.  Due to the vast breadth of approaches, techniques, and philosophies used in primary surgery, a broad range of problems for which one may seek revision surgery exist. 

 

Patients who seek revision rhinoplasty may present with any number of cosmetic complaints and nasal breathing difficulties.  Small asymmetries or irregularities may occur as the result of minor errors of technique.  These problems are relatively straightforward and more easily corrected than more serious problems.  Large asymmetries, functional obstruction, and gross deformities are more likely to result from errors of judgment.

 

Pre-operative Evaluation

It is crucial that the patient and surgeon discuss in detail the problems that led to the patient’s visit.  Previous operative notes, rhinoplasty diagrams, and preoperative and postoperative photographs may help in determining the nature and time­-course of the problems.  Photographs may also reveal which problems resulted from surgery and which problems predated the original surgery.  A thorough physical examination inspecting the state of the soft tissue covering and skin, the nasal cartilages, bones, and internal structures of the nose is critical.  Based on all of this information, the patient and physician should prioritize goals and gauge how reasonable and achievable these requests are. As with primary rhinoplasty, the use of photography and computer assisted imaging may be of great help in the discussion of cosmetic goals.  Each specific problem should be discussed with regard to possible cause and prospects for repair.

 

In many cases, revision rhinoplasty patients suffer from some functional nasal breathing problems caused by previous surgery.  Pinching or collapse of the external nose during breathing suggests that reductive surgery has led to narrowing and/or weakening of those structures in the nose which maintains breathing.   These include the nasal septum, bones, and cartilages of the nasal tip and bridge.  Inspection inside the nose with a small endoscope may be helpful in determining the nature of the breathing problem.  

 

Understandably, revision rhinoplasty patients have already undergone a period of disappointment regarding the appearance and/or function of their nose.  They may have invested considerable energy and effort in considering revision surgery. This makes it all the more important that the surgeon instils realistic outcome expectations. Patients should understand that the greater the degree of baseline damage, the more limited will be the possibilities for improvement. In many situations it is not possible for the surgeon to fully understand the extent of damage in the nose until exposure is gained during surgery.  As such, it is not always possible for the surgeon to outline every detail of surgery and expected outcome pre-operatively.  As with all cosmetic procedures, surgery should not be performed unless common expectations can be generally reached between patient and surgeon.

 

What are the Risks?

The main complications of revision rhinoplasty are the same as in primary rhinoplasty. However, the risks of these complications occurring may be higher, depending on the severity of the problems being addressed.  In particular, if there has been damage, thinning, or infection of the skin and soft tissue covering of the nose, there will be a higher risk of skin injury during revision rhinoplasty.  Such injuries can lead to visible scar formation, pigmentation of the skin, or contour irregularities, especially at the tip and base of the nose.

 

What are the types of Problems Revision Rhinoplasty Can Correct?

In essence, revision rhinoplasty seeks to correct problems caused by previous rhinoplasty.  These problems may be classified into several groups related to the type of complication which occurred during the original surgery.  The following table describes these groups of problems, providing examples of the technical mistakes and resultant deformities.  In many cases, more than one type of complication exists within a given revision rhinoplasty nose.

 


 

 

 

 

 

Malpositioned implant

 

  •  

      Malpositioned cartilage graft
  •  

    1.  

      1.  

 

  •  

  • (e.g. persistent dorsal hump, twisted nose, asymmetric middle vault, and various tip deformities)

Failure to restabilize structures which have been weakened during surgery

Failure to stabilize nasal base

 

  •  

    1.  

  •  

    1.  

      1.  

 

 

Short nose, up-turned nose, retracted columella

  •  

    Nasal tip cartilages

    1.  

      Nostril base

Tip irregularity, tip collapse, nasal obstruction

Scooped dorsum, ski-sloped nose, nasal obstruction

Overly narrow nostrils, slit-like nostrils, nasal obstruction

 

  •  

  •  

 

How is the Surgery Done?

Most surgeons will use an open or external approach during revision rhinoplasty.  This is because the complexity of revision cases generally requires the additional exposure and visualization provided by this approach.  For the correction of isolated minor problems, an endonasal approach may be possible.  Once exposure is achieved, the specific maneuvers used depend on the type of problems needing correction.  Common problems requiring revision surgery are outlined below.

 

Irregularity of the nasal bridge.  Most commonly, this problem arises after contour irregularities are created along the bony and/or cartilaginous dorsum.  Such problems may be addressed through rasping of the bone or shaving of the dorsal cartilage.  If there are areas of deficiency due to over-excessive reduction, augmentation grafting with cartilage or soft tissue grafts may be of benefit. 

 

Polybeak (rounded tip)A polybeak refers to an abnormality seen on the profile view in which the tip of the nose is less projected (sticks out less) than the bridge above it.  This causes a rounded appearance to the tip with an associated lack of definition.  One cause of this problem is the failure to adequately reduce an overly high bridge.  In such noses, the profile view of the bridge looks outwardly curved, or convex.  The overall “hook” shape of the nose can be corrected if the bridge is reduced and/or the nasal tip is brought forward further.  When done correctly, this will result in a bridge which appears straight or slightly concave (inwardly curved).  If these maneuvers do not fully correct the problem, an outward curvature (convexity) may persist after surgery.  Because this deformity is caused by inadequate previous reduction of the bridge and tip cartilages, this type of problem is called a “cartilaginous polybeak”.  Correction during revision surgery requires either further reduction of the bridge or elevation/projection of the nasal tip.

 

Another type of polybeak deformity is caused by excessive excision of the cartilage of the nasal bridge, particularly in patients with thick, stiff skin.  In this situation, the skin is unable to redrape tightly down onto the cartilage infrastructure which has been aggressively reduced (lowered).  A gap then results between the stiff skin envelope and the cartilage.  This void eventually fills with scar tissue, resulting in the so called “soft-tissue polybeak”.  Correction of this problem is difficult and requires primarily elevating and repositioning the nasal tip structures into a more projected position to stretch into the thickened soft tissue envelope.  This restores the normal relationship between the tip of the nose and the bridge above it so the profile will look straighter. 

 

Pinching of the nasal bridgeThe middle one-third of the nose is created by the two mirror-image “upper lateral” cartilages and the nasal septum between them.   The septum forms the vertical structural wall that supports the nasal bridge.  Each upper lateral cartilage (ULC) is connected to the top edge of the septum along the bridge and slopes down toward the face—one for the right side and one for the left side.  The cross-section of this structure looks like a triangle with its apex at the bridge.  Separation of the ULCs from the septum often occurs in rhinoplasty, most often as the result of reducing the nasal bridge in the middle one-third of the nose.  In effect, this removes the top of the triangular structure created by the ULCs and the septum, causing separation of these structures where they were previously connected.   Unless the connection between the ULCs and septum is recreated (done surgically through placement of cartilage “spreader” grafts and sutures), the ULCs will collapse inward progressively over time.  This will lead to pinching of the bridge and internal nasal airflow obstruction.  Sometimes only one side will collapse, resulting in an asymmetrically pinched middle one-third.  Correction of these problems requires placement of spreader grafts stabilized between the top edge of the septum and ULCs.  Asymmetries in this region may be addressed by utilizing spreader grafts which are appropriately varying in width.

 

Weakness of the side walls of the nasal tip causing pinching and nasal collapse.  Some of the most common complaints of the secondary rhinoplasty patient are those related to weak, unsupported nasal tip side walls.  This complication creates a pinched appearance to the tip and may create nasal obstruction.  Aggressive reduction or narrowing techniques of the tip during initial rhinoplasty are likely to create these problems.  Patients with thin skin and narrow noses are particularly at risk to develop such complications.

The degree of collapse may vary in severity and typically requires structural cartilage grafting.  These grafts can be curved cartilaginous supports placed into the area of maximal side wall weakness.  Through the external approach, the grafts are placed into tight pockets which overlap and extend the normal cartilages of the nasal tip and side walls, the lower lateral cartilages (LLC). 

 

Nostril pinching and retraction.  Reduction or narrowing of the tip cartilages may also cause weakness and deformity along the edge of the nostrils as well as nasal airway obstruction problems.  Over-elevation of the nasal tip may cause excessive nostril show.  Contracture from previous reduction of the lower lateral cartilage may also be evident from the base view of the nose as nostril pinching.  Correction of the problems may be accomplished by placement of thin cartilage grafts (alar rim grafts) which may restore support and create a stronger triangular nasal base.  These grafts are long, narrow cartilaginous segments which are placed into precise pockets along the nostril rim.  Severe cases of nostril retraction may require the use of composite grafts containing both cartilage and skin in order to push down the elevated nostril.  These grafts may be taken from the inner bowl of the external ear.

 

Nasal tip.  Some of the most noticeable nasal deformities caused by rhinoplasty occur in the nasal tip.  Tip deformities come in all forms and may result from any of the classes of surgical errors described above.  The external rhinoplasty approach in revision of the nasal tip allows for unparalleled ability to correct asymmetries.  Asymmetry of the tip may result from problems of unequal excision, suture modification, or cartilage grafting.  Subtle discrepancies may not become evident for several months until the edema resolves.  Cartilage irregularities, or “bossae”, may form as the result of knuckling or angulation of the lower lateral cartilage and tip grafts as the skin envelope contracts after primary surgery.  Patients with thin skin and strong cartilage are particularly susceptible to this problem.  Conservative cartilage trimming, re-doing suture techniques, and/or placement of camouflaging grafts may correct such problems.

 

The pinched nasal tip results from excessive narrowing of the tip cartilages.  The narrowness of the tip may be further complicated by tip side-wall collapse and nostril rim pinching.  This unnatural, operated appearance is a sure sign of prior surgery.  Restoring a natural tip appearance may require reconstruction of the entire tip cartilage system with grafts which rebuild the entire complex.

 

Over-shortened nose.  A short nose deformity is most frequently due to upward malposition of the tip cartilages.  This may be the result of poor judgment in the degree of tip elevation created by the surgeon. In other cases, destabilization of the nasal tip cartilage in combination with upward scar contracture creates this unwanted result.  

 

Correction of this deformity may require repositioning of the tip cartilage structures into a lower position.  This may be accomplished by pulling the tip cartilages downward, effectively lengthening the nose.  Typically, the two lower lateral tip cartilages are freed from each other and repositioned downward through suture fixation onto a stable anchor in the center of the base of the nose.  This anchor may be the edge of the septum if it is long enough.  In other cases, a strong midline cartilage graft may be used to secure the cartilages.  Other cartilage grafts may be placed above the nasal tip in order to push the tip structures downward. 

 

Droopy tip.  Maintaining tip position during rhinoplasty depends on restoring any loss of tip support which occurs during surgery.  A variety of surgical maneuvers to the nasal tip and surrounding areas during primary rhinoplasty can significantly compromise nasal tip support.  This may lead to gradual loss of tip support, a hanging tip, an overly acute angle between the nose and upper lip, and an underprojected, long nose with a rounded polybeak deformity.  During revision surgery, tip position and support may be restored through the use of cartilage grafts which may build strength and size to the tip.

 

Alar nostril base.  One of the most difficult rhinoplasty complications to correct is the overly narrowed nostril alar base.  Alar base reduction during primary surgery should be performed conservatively with the aim of achieving 60 to 70% of an idealized reduction at the time of primary surgery.  Unfortunately, excessive or asymmetric reduction is a common mistake during primary rhinoplasty.  Composite grafts of skin and cartilage harvested from the ear work well to correct such deformities.  These grafts are inserted into incisions placed at the areas of maximal narrowing.  Such grafts are useful also to correct scarred nostril narrowing from previous surgery (Fig. 6).

 

Skin injury.  When the skin has been significantly damaged, the revision rhinoplasty surgeon must be exceedingly cautious in manipulating the skin-soft tissue envelope. This problem is often caused by an infected or extruding implant.  In such situations, the implant should be removed, the infection controlled with antibiotics, the damaged skin envelope allowed to recover, and the contour restored with replacement cartilage grafting. If there is any doubt regarding the integrity of the skin, surgery should be delayed to allow full recovery.  Blue discoloration or multiple broken blood vessels signify damage and added risk for skin complications.  In the worst cases where the soft tissue envelope has already been severely compromised, one should consider staged preliminary repair of the skin prior to any structural nasal surgery.

 

Conclusion

Revision rhinoplasty poses some of the most difficult challenges of facial plastic surgery.  The ability to correct these problems is limited by the integrity of the existing structures, the availability of grafting material, and the severity of the individual deformities.  In many cases, revision rhinoplasty becomes an operation of reconstruction more than of simple refinement. 

 

The examples cited represent only a fraction of the multitude of potential problems during revision surgery. In some cases, the cause of the problem may not become clear until surgery.  In the face of compromised nasal structures, scarred soft tissue, and a lack of cartilage grafting material, the revision surgeon must be prepared for the worst of scenarios.  Even more than in primary rhinoplasty, this requires meticulous attention to detail in pre-operative analysis.  Thoughtful planning based on this analysis as well as a thorough understanding of the problems often encountered in revision rhinoplasty will maximize the chance of a favorable outcome.

 

 

Rhinoplasty- Functional

Functional Rhinoplasty

In essence, rhinoplasty is an operation in which the shape of the nose is changed in order to create some desired improvement.  In many cases, the goal is cosmetic.  However, surgery can also be performed with the goal of creating improvement in nasal airflow—a procedure commonly known as functional rhinoplasty.  In truth, there are a number of procedures which may help to correct nasal obstruction.  Functional rhinoplasty refers to an operation in which a combination of these surgical procedures is performed with the goal of nasal airflow improvement.  In some cases, both cosmetic and functional improvements are made in the same operations.  These procedures may be termed “hybrid”, “dual” or “blended” rhinoplasty.  In some situations, the same surgical technique will simultaneously improve both breathing and appearance, particularly in the cases of revision rhinoplasty when the structural integrity of the nose was previously weakened.

 

Anatomy of Nasal Obstruction

The two nasal passages are separated into a left and right side by the nasal septum, a partition of cartilage and bone that starts just inside of the nostrils and extends back deep inside the nose.  The septum is covered with the same pink mucous membrane that lines the rest of the internal nose.   Though the septum is a thin structure, only 1-2 mm wide, it can cause obstruction when it does not sit straight in the center of the nose.  It may be bent, slanted, curved, or fractured, causing partial blockage of one or both nasal passages.

 

The turbinates are structures attached to the outer walls of the nasal passages made of thin bone covered with mucous membranes.  The inferior turbinates are the bulkiest of the turbinates and serve to filter, warm and humidify the air that passes through the nose.  The turbinates are the structures that swell and cause obstruction when one has a cold or allergies.  When the turbinates are too large or are positioned too closely to the septum, they can contribute to the obstruction.

 

The nasal bones form the upper third of the nose.  When they are severely displaced and are shifted from their normal position, they can cause narrowing of the nasal passages, creating obstruction.  This collapse of bone can be caused by trauma (broken nose) or may be a genetic or developmental problem. 

 

The cartilage portion of the nose can also be collapsed or pinched, also creating an obstruction to airflow inside the nose.  The area between the septum and the cartilage side-wall of the nose is commonly called the nasal valve area because it is a region where airflow may meet the most resistance as it passes through the nose.  Nasal valve collapse can be seen in some individuals as visible pinching of the sidewall of the nose with inspiration through the nose.  In severe cases, the nose may completely collapse on one or both sides.

 

Surgical Steps

Septoplasty refers to the procedure in which the septum is straightened in order to increase the passage of air in the nose.  Through an incision through the mucous membrane of the septum, the cartilage and bone of the septum is accessed.  The cartilage and bone may then be removed or repositioned to straighten the overall structure.  Often the surgeon will use the cartilage that was removed as building material in order to make other desired changes during the rhinoplasty.  In such cases, the cartilage is carved into the desired shape and transferred into another area of the nose.

 

Like the septum, the inferior turbinates may be reduced, repositioned, or partially removed to create more space within the nose and increase airflow.  Removing too much can lead to over-dryness inside the nose, prompting many surgeons to be conservative with this procedure.

 

If collapsed or deviated, the nasal bones may be repositioned through the placement of precise cuts in the bone, called osteotomies.  These cuts are made with delicate sharp instruments which allow for controlled, targeted movement of the bones into a more favorable position.

 

Nasal valve problems are generally treated by adding cartilage to weak areas of the nose.  These cartilage “grafts” add support, strength, and width to the regions that collapse with inspiration.  Serving a similar function as the commercially available Breathe-Rite strips, these grafts can significantly improve airflow for the collapsing nose.

 

Rhinoplasty

Rhinoplasty

(Cosmetic Nasal Surgery)

Plastic surgery of the nose – rhinoplasty – is performed to improve the appearance of the nose. It may be performed in conjunction with procedures to improve the breathing, or to correct injuries that occurred as the result of trauma. It is a fascinating, exciting, and challenging procedure, often referred to as the most technically sophisticated of all plastic surgery procedures. What is truly unique about rhinoplasty is the fact that no two noses – and thus no two rhinoplasties – are ever exactly alike. Every patient has his/her own unique characteristics – the size, shape, and consistency of the cartilage, the thickness and quality of the skin and soft tissue, and more.

 

The rhinoplasty procedure has changed dramatically in the past decade or two. This change is associated with different expectations of the modern rhinoplasty patient. Today, patients seeking rhinoplasty tend to be very sophisticated, do not want to look “operated on”, and desire a very “natural” look. They do not want the pinched tip, and “ski slope” appearance that in previous generations was considered acceptable.

 

This article will provide you with the information to be knowledgeable about rhinoplasty.  It will discuss nasal anatomy, surgical principles, and the techniques used in modern rhinoplasty. It will address primary rhinoplasty – that is, when the patient has not had a previous nasal operation.

 

Who is a Candidate for Rhinoplasty?

Rhinoplasty is performed in almost any age group, although rarely in children under the age of 16. It is preferable to wait until the nose and face is fully grown before performing a rhinoplasty. It is most commonly performed on people between 18 and 50.  It is usually performed either under general anesthesia or sedation in an operating room. So the patient must be healthy enough to undergo a surgical procedure.

 

There are a variety of reasons that people seek rhinoplasty. Most commonly, they just don’t like the way their nose looks, and have always been troubled by one or more features. Often the nose appears too large, “droops”, or has a prominent bump. Others seek treatment after an injury, or when they develop trouble breathing through the nose.

 

Relevant Anatomy

Your nose is separated into right and left sides by a midline partition called the nasal septum. It is usually pretty straight, and is a very important source of support to the bridge and tip of the nose. If it is crooked – a deviated septum – it can obstruct the breathing on one or both sides of the nose. The tip of the nose has a pair of cartilage – the lower lateral cartilages – that determines its shape and size.  Just above the nasal tip is the midvault of the nose, where two more pieces of cartilages (the upper lateral cartilages) reside. The upper third of the nose is the part that is made of bone.  These five cartilage structures and two bones determine what your nose looks like and how it functions. Overlying the cartilage and bone is a layer of skin and soft tissue. This is referred to as the “skin soft tissue envelope”. Some patients have a very thin skin soft tissue envelope, others have a very thick one, and most are somewhere in between. This is important because the thickness of the skin soft tissue envelope determines not only what your nose looks like now, but also which techniques should be chosen to achieve the best potential outcome. 

 

Consider for example the patient with very thin skin and soft tissue. Because the skin soft tissue envelope is thin, it is possible to make the nose more refined and smaller. This is because when changes are made to the underlying framework (cartilage and bone) of the nose, the thin skin soft tissue envelope tends to heal tightly down to this framework. In addition, it is easy to see the newly created shape through that thin envelope. The down side to a very thin envelope is that it easily shows every tiny irregularity.

 

Keep in mind that rhinoplasty is an art, and the medium the surgeon has to work with is not up to his or her choosing. One can only use the materials that the patient has that make up his or her own nose. If the surgeon could choose the material, he or she would invariably choose a substance like clay that can be molded into any desired shape. None would choose to use cartilage and bone – inherently awkward materials to work with, with a limited ability to alter accurately. Yet that is what is available. As such, the surgeon reshapes the cartilage and bone as well as possible, but inevitably there are imperfections. In the thin-skinned patient, these imperfections are likely to become visible. The wise surgeon, therefore, pays considerable attention to maneuvers that will camouflage any underlying imperfections. There are multiple such techniques available to the surgeon, such as the use of crushed cartilage or fascia (connective tissue) to conceal imperfections under the skin.

 

Contrast this with the patient with a very thick skin soft tissue envelope. In these patients, one cannot simply reduce the size of the nasal tip and expect the envelope to contract down tightly and reveal the beautiful changes underneath.  Because the skin is so thick, it never will assume the shape of the underlying cartilage and bone. The result will likely be a shapeless, amorphous tip that appears neither smaller nor more refined. In these patients, a very different approach is necessary.  Instead of reducing the size of the underlying cartilage framework, the surgeon needs to increase the projection of the tip in order to force the thicker envelope of skin and soft tissue to reveal the improved contours that are created. Thus while the surgeon may not be able to create a smaller nose in the thick skinned patient, hopefully he or she will still accomplish the goal of a more refined nose by creating a more favorable shape.

 

How is the Procedure Performed?

 

Anesthesia

Rhinoplasties are usually performed under general anesthesia, in which the patient is completely asleep, or sedation. Occasionally, more limited procedures may be done under local anesthesia alone. This is not common.

 

Incisions and Approaches

Rhinoplasties may be performed through an  “endonasal” (also referred to as “closed”) approach in which the incisions are all made on the inside of the nose. Alternatively, they may be performed “open” in which the internal incisions are connected by an additional incision across the skin between the two nostrils (the columella).  Though some patients express concern over the potential visibility of the scar using the open approach, in reality, over 99% of such patients cannot notice the incision. Whether or not your surgeon performs rhinoplasty “open” or “closed” is therefore largely irrelevant. What is important is how skilled the surgeon is, and if he or she respects the structural integrity of the nose

 

The “Structure” Approach to Rhinoplasty

Traditionally, rhinoplasty techniques have involved the removal of cartilage and bone. These “reductive” techniques include splitting and removing of cartilage to produce refinement of the nose. In the past 20 years, there has been a trend away from such reductive techniques toward a more “structural” approach. In this strategy, surgeons try to limit removal of cartilage. Attempts are made to preserve the structural integrity of the nose, including the midvault and tip. This change in philosophy occurred because it was recognized that many patients who underwent rhinoplasty with traditional techniques would ultimately (sometimes many years later) be left with unnatural appearing noses, pinched nasal tips, narrow noses and difficulty breathing.

 

Many proponents of the “structural approach” to rhinoplasty (including the author of this article) find that the ‘open’ approach allows the surgeon to perform the important maneuvers of rhinoplasty with a degree of precision and control that traditional ‘closed’ approaches do not.

 

Maneuvers in Rhinoplasty

The patient and the surgeon determine together during the process of consultation the desired changes. Ideally, this is done in a very systematic fashion with quite a bit of dialogue. The desired changes then determine the maneuvers performed.

 

Nasal Tip

The nasal tip may be altered in its projection (decreased, increased), rotation (decreased, increased) and width.  These alterations are performed on the cartilage framework of the nose.

 

Midvault

The midvault is narrowed if it is too wide. If the midvault is asymmetric or narrow it can be corrected with cartilage grafts, such as “spreader grafts”. These are pieces of cartilage (usually taken from the septum inside the nose) that are placed in a way to create the desired width, correct twists, and/or support the airway to assist with optimal breathing.

 

Bridge

Most patients want a bump reduced. This is usually a matter of removing cartilage (and some bone). Some patients need the bridge raised. This is done with cartilage grafts, which can be obtained from inside the nose, from behind the ear, or from the chest wall.  Some surgeons use artificial materials for this type of augmentation.

 

Nostrils

Some people want their nostrils reduced in size. This usually is done by an “alar base reduction.” To be more specific, some people need the width of the nostrils reduced, while others need the “flare” (outward curvature) of the nostrils reduced but have an appropriate width. Others have too much width and flare. These maneuvers do require incisions on the outside of the nose, in the crease of the nostril. While these incisions heal very well, they are in a location that is potentially conspicuous. So, this is a decision to be carefully considered in terms of the risk / benefit ratio.

 

Osteotomies

This refers to breaking the nasal bones in order to reposition, narrow or straighten them.  This is a common maneuver, and is the main reason there is usually some bruising around the eyes after a rhinoplasty.

 

Recovery

Pain is usually minimal after rhinoplasty. The nose is swollen however and the swelling is significant for the first few days. Most patients take one week off from school or work. By that time, typically the patient has little to no bruising or swelling and can resume work or school without any concerns regarding their appearance. After 3 to 4 weeks, most patients are happy with the appearance. Ultimately, however, all of the swelling takes about one year to fully resolve.

 

Summary

Rhinoplasty is really one of the most remarkable operations in plastic surgery. It is elegant and sophisticated, and can have profoundly positive effects on the individual patient. It is typically considered one of the most difficult operations to perform. For this reason, it is best performed by someone with focused expertise and experience.

 

References

  1. New concepts in nasal tip contouring. Toriumi D. Arch Facial Plast Surg. 2006 May-June;8(3):156-85

  2. Frequently used grafts in rhinoplasty: nomenclature and analysis. Gunter JP, Landecker A, Cochran CS. Plast Reconstr Surg. 2006 jul;118(1):14e-29e.

  3. The underprojecting nasal tip: an endonasal approach. Pastorek N, Ham J. Facial Plastic Surg Clin North Am. 2004 Feb;12(1):93-106.