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Category: Rhinoplasty Surgery

De-Rotation of the Nasal Tip

As a surgeon who does many nasal revisions, I am often asked to correct an overly rotated nose: the so-called “pig’s nose or snout”. It generally results from an over-resection of cartilage at the end of the nasal septum (wall separating the two nasal chambers), but can result from other inappropriate maneuvers, as well.

Depending on the degree of over-rotation, as well as the amount of associated nostril retraction, there are several methods of correcting this. Since the nasal tip and adjacent nostrils are intimately connected, we can use a cartilage graft placed at the end of the septum to push the entire lower third of the nose down. This “septal extension graft” essentially replaces what was removed in an earlier surgery. Also, because the graft has to be lined with mucous membrane, a moderate amount of freeing up of the internal lining has to be performed to allow for this advancement.

The accompanying “before & after” photos show one such example using a septal extension graft to de-rotate a nose.

Finally, other lesser procedures can be employed for less severe cases. A cartilage tip graft can be placed below the nasal tip, to give the illusion of de-rotation . And a composite graft composed of cartilage and skin can be placed within the nostril to selectively de-rotate that.

Post-operative Nasal Irregularities

Dr. PincusIn rare instances, an irregularity will develop under the skin following a very successful rhinoplasty.  It usually becomes apparent days or weeks after the procedure as the swelling subsides. In some instances, it is bony in nature and may present as a spicule of bone, resulting from the irritated periosteum (lining over the bridge) or a larger area of bone, if there is a shifting or displacement of the reconstructed bony bridge. The treatment for this may be a simple procedure under local anesthesia in a treatment room or a more involved procedure in an operating room.  For a small spicule of bone, the area can be anesthetized locally and a tiny incision made in the club of the eyebrow. Through this incision a narrow chisel can be used to reduce the bony prominence…usually with one or two taps of the mallet. Unfortunately, if the bony irregularity is much larger in nature, a return to the operating room is usually necessary. In this case, rasping or even chiseling is needed and usually takes only a few minutes to accomplish.

If the irregularity noted under the skin is cartilaginous in nature from shifting of a graft or repositioning of the cartilaginous dorsum, an initial attempt at correction can be via a transcutaneous needle. In this case, the area is anesthetized and a small gauge needle is placed through the skin to fracture and progressively crush the cartilage. But, as with the larger bony deformity, if the cartilaginous deformity is large or unaffected by the transcutaneous approach, an intra-operative approach to trim it would be required.

Open versus Closed Rhinoplasty

The difference between an “open” versus a “closed” rhinoplasty is a small (transcolumellar) incision between the nostrils. This incision, when connected to the traditional intranasal incisions within each nostril, allows the skin to be elevated off the underlying framework. This “opens” up the surgical field which has certain benefits, especially when operating on a nose that has been injured or operated on previously. In both of these cases, dissection through scar tissue is easier, evaluating causes of asymmetry is easier, placement of grafts is easier and performing certain suture techniques is easier. I have not seen an increase in swelling or post-operative recovery time with the open technique. And the resultant transcolumellar scar is generally imperceptible over time. On the other hand, unless special care is taken to avoid disrupting the attachments of the tip to the septum, nasal tip support has to be re-instated which lengthens operative time. Additionally, there are special cases where an open rhinoplasty is also useful. These involve procedures where the tip has to be significantly reconstructed or repositioned. Though many of these manipulations can  be accomplished  using the “closed” technique by an experienced surgeon, they are more easily and more predictably performed  using an “open” approach. Furthermore, in the “closed” technique all of the access routes to the bone and cartilage are through intranasal incisions. Because of this, placement of any synthetic implant could be problematic due to the risk of extrusion.

Though I’ve outlined many advantages of the “open” versus “closed” technique, I should state that in a fairly straightforward, primary rhinoplasty, the closed technique is perfectly satisfasctory, predictable and probably most often employed.

Common Misconceptions regarding Nasal Surgery

Nasal Surgery

One of the biggest misconceptions is that just about any nose that you desire can be accomplished with the right surgeon. While it is true that experience, technical expertise and aesthetic judgment  vary among surgeons, there are certain limiting factors that no surgeon can overcome. Chief among these is thickness and quality of the skin. The thicker the skin, the less likely it is that it will re-drape  to a smaller, more angular framework. Various techniques such as cross-hatching the dermis, injecting with steroids and other medications such as 5-FU, prolonged casting or nightly taping and the use of Accutane to diminish the oil glands in the skin have been used with variable success. Additionally, as one ages there is a loss of elasticity in the skin making it harder to shrink-wrap down onto a reshaped  bony-cartilaginous framework. Since the skin over the upper one half of the nose is thinner with less oil glands, it is more capable of conforming than the skin over the lower half. Additionally, since the lower half skin will shrink to the smallest volume for its surface area, which is a sphere, we tend to see a rounded lower half of the nose if too much bone and cartilage has been removed for the skin to adapt. This is called the “pollybeak” deformity.

Another misconception is that breaking the nose makes the operation more painful with a longer recovery period. In actuality, nasal surgery is usually painless or minimally painful in the post-operative period, whether or not breaking of the bones was necessary. And it’s been my experience that recovery time is unchanged in either case. Furthermore, I have seen people bruise without bone breaking and no bruising in some patients who required it. It seems more related to capillary fragility, hormonal balance and/or medications or herbal products that they were taking.

Another misconception is that there are some things that can’t be corrected on the nose, such as nostril asymmetries and their  facial attachments . Since wide variation exists between surgeons regarding experience and abilities, it is wise to go to several surgeons if you are told that something can’t be done. It might just mean that this particular surgeon can’t do it!

Another misconception is that you will have no idea what your nose will look like until six to twelve months have passed. While it is true that swelling and settling can take weeks or months to resolve, it has been my experience that you should have a rough idea of what your nose will look like in the immediate post-operative period.  Obviously, there are many variables that play into this, such as skin thickness, techniques used, post-operative care, etc.

Another misconception is that  very “difficult” noses require two operations. While it is true that minor revisions or “tweaking” a result may be warranted in 5%-10% of the time, most of the time all that is needed can be accomplished in one operation.

A final misconception is that a surgeon who performs rhinoplasty can also perform revision rhinoplasty or reconstructive rhinoplasty. In actuality, it’s usually just the reverse. In revision rhinoplasty, the surgeon is trying to establish an aesthetic result in a nose that was operated on with a poor outcome. Like the first  surgeon, he is trying to achieve a nose that is better than it was initially…that is, taking a normal nose and making it “better than normal”. However, in this case there is additional internal scarring, misplaced or absent tissue, shrinkage of internal lining and maybe external scarring as well. In reconstructive rhinoplasty, the surgeon is trying to establish a normal appearing nose from one that is less than normal, from a cancer procedure or trauma. The techniques used may require skin flaps or grafts as well as cartilage or bone from several sources. The internal arrangement of these components may have no resemblance to what normal nasal anatomy is. However, the goal is to establish a nose that looks relatively normal and functions well.


Minimal Rhinoplasty Photos Beverly Hills

In a previous blog posting (10 Sep 2011) I discussed the “minimal rhinoplasty”. I would like to present the “before & after” results, several years later, of one such case. In this instance, a cartilage graft was placed to fill out a depression over the left side of the tip, and the right nasal wall was brought in to create better symmetry. One will note that the essential appearance of the nose is unchanged, but that it looks better.


Nasal Implants

Though many rhinoplasties are of the “reductive” variety, with the object being to make the nose smaller, occasionally an “augmentative” rhinoplasty is the procedure of choice. This may be necessary in certain ethnic groups, such as Asian and African, or for nasal revisions, if too much tissue has been removed during the initial surgery. The best material to use for this is the patient’s own cartilage. This is usually harvested from the nasal septum, the ear or from a rib. However, if cartilage is unavailable at these sites or if the patient refuses this additional surgery, then an implant may be necessary. Implants are synthetic materials that may or may not bond with the patient’s own tissue. The use of cadaver homograft cartilage is another option which I generally avoid because of its brittleness, lack of true incorporation at the recipient site and the possibility of resorption. Among the synthetic materials in use, we have silastic, Medpor (high-density porous polyethylene) and Gore-Tex (expanded-polytetrafluoroethylene). All have been used to augment the nasal bridge.

Silastic implants are usually pre-formed, though can be trimmed, and form a capsule of scar tissue around themselves. Because of this, they are never truly incorporated into the tissue. Consequently, you can move it side to side manually and, occasionally, it will break through the overlying tissue. I never use this implant material.

Medpor comes in various shapes and sizes, is somewhat firm, and can be carved or trimmed. It can be placed over the bridge or in areas to create lateral nasal support or even tip support, as long as there is soft tissue and cartilage covering it. There is a minimal amount of tissue ingrowth which tends to fix it in place.

Gore-Tex is a very popular implant, which also allows for a slight amount of tissue ingrowth enabling it to be fixed and stabilized. It comes in several thicknesses, is easily trimmed and is quite malleable. It makes for an excellent dorsal implant. However, as with any foreign material, there is a slight chance of infection. Also, Gore-Tex has to be fixed securely because it has a tendency to change shape or even allow for the formation of fluid under it.

The American Academy of Facial Plastic and Reconstructive Surgery

Recent statistics released by The American Academy of Facial Plastic and Reconstructive Surgery show that in 2011 the 3 most commonly performed facial procedures were rhinoplasty, eyelid surgery and Botox Cosmetic. And it is no surprise to me that this should be the case.

Rhinoplasty is one of the most transformational procedures that I do. It can make someone who has been unattractive their whole life more appealing, and it can even make a person look younger by elevating their tip. Eyelid surgery is relatively easy to perform with minimal downtime and does wonders for making someone look more relaxed, less “burned-out” and even younger. Finally, Botox Cosmetic is one of the “lunchtime” procedures, which is easy and quick to perform, relatively inexpensive and produces dramatic results in the right patient. In addition to smoothing out wrinkles of the forehead, between the eyebrows and around the eyes, it can raise downturned corners of the mouth and lessen the prominence of early neck bands.

Increasing Nasal Tip Projection

The ideal nasal profile has a tip that is slightly higher than the rest of the bridge. In many instances, this requires raising the tip to this level. To accomplish this, there are several techniques that can be employed. The first involves narrowing each of the two tip cartilages and then sewing them together. Because each cartilage forms an arch under the tip skin, narrowing them with sutures causes them to elongate upwards (Fig. A).  Another popular way of increasing tip projection involves placing a cartilage tip graft over the underlying tip cartilages (Fig. B). This has the added benefit of creating more angularity to the nasal tip, which is especially useful with thick skin. Finally, the third most common way of increasing tip projection is by placing a fixed strut of cartilage anchored to the septum to which the tip cartilages can be sutured in a more projected fashion (Fig. C). Though each of these techniques work to accomplish an increase in tip projection, the choice of which one to use depends on many factors such as the need to improve tip definition or the desire to improve the proportional relationship between the length of the nostril to the length of the tissue in front of it (the lobule).

Nostril Re-shaping in Beverly Hills

Being a surgeon who sees many rhinoplasty patients, I am frequently asked if nostrils can be re-shaped. Many of these patients have been told that what they want is either impossible, unpredictable or very difficult to accomplish. However, it has been my experience that this is generally not the case. In fact, most nostril shapes can be improved or made to look more aesthetically pleasing—even if numerous attempts at improvement have been unsuccessful in the past.

The margin of the nostril can be raised or lowered and the attachment to the cheek can be brought in, out or even lowered. Additionally, the thickness of the wall can be narrowed. Finally, it is not unusually for several of these maneuvers to be performed at the same time.

When lowering the nostril rim, we can rotate some of the internal lining downward, if the correction is small. For larger deformities, we usually need to add a composite graft of skin and cartilage, from an inconspicuous part of the ear, to act as a “spacer”.

Raising the nostril rim is quite easy and just involves an internal resection of skin with internal and upward rotation of the hanging external skin.

Narrowing a wide nostril can be accomplished in several ways. Skin from the nostril or floor of the nose can be excised, “cinching sutures” can be placed to pull the nostrils in or  nostrils can be released from the underlying bony attachments to allow them to contract inward.

Widening a narrow nostril can be effected with the use of a graft from the opposite nostril, an advancement flap from the floor of the nose or rotation of a flap just outside the nose, for severe cases.

Finally, a thickened nostril wall can be thinned by excising an elliptical slice out from between the internal lining and external skin covering.


The Nasal Overkill

Being a facial plastic surgeon who specializes in nasal surgery, I have been somewhat dismayed by the relatively recent increase in cosmetic as well as reconstructive procedures that are much more extensive than they need to be. This is not to say that the results aren’t acceptable or that it is being performed by inexperienced surgeons. However, one must always consider the associated morbidity or “collateral damage” that these procedures produce. When we consider cosmetic nasal surgery, especially revisional following prior poorly executed rhinoplasty, I am seeing many patients who come for second opinions because they were told they need a “rib graft”. While a rib graft may get the job done, it results in another operative site on the chest with its associated scarring, pain  and risk of lung collapse. It is my procedure of “last choice” when there are no other alternatives such as nasal septal cartilage, ear cartilage or occasionally synthetic implants. And, to this date, I have never been disappointed in a result from the use of these materials in patients who were told that they needed a rib graft.

Regarding reconstructive nasal surgery following trauma or cancer surgery, I have seen a huge increase in the use of forehead flaps. These require an unsightly flap of tissue from the forehead attached to the nose for a period of three weeks, a second or more additional surgeries and resultant forehead scarring (which is usually acceptable). Once again, there are usually many alternatives like local flaps, skin grafts or composite (skin plus cartilage) grafts. Obviously, the main object of cancer surgery is complete removal of disease. However, it is still important to “factor in” the post-operative morbidity and, at least, to consider these other alternatives.