By far, the most challenging aspect of rhinoplasty surgery is in the nasal tip. As the nasal tip is probably the greatest variable in appearance amongst individuals and one of the most defining parts of the nose, precision in nasal tip changes during rhinoplasty is of critical importance. Therefore, good access to provide adequate visualization and workability of the nasal tip cartilages is key.
Rhinoplasty, by its history, has been traditionally done through a closed or endonasal delivery technique. By this approach, the nasal tip cartilages are delivered without using a skin incision at the columella. In the ‘right’ nose, I personally prefer this technique as it is simple, produces consistent results, and has a low rate of the need for revisional surgery. It also offers the bonus of less prolonged swelling of the nasal tip after rhinoplasty. Good patients are those that have fairly thin nasal skin, strong stiffer cartilages, and have never had rhinoplasty surgery before. The only problem with the closed approach to rhinoplasty is that it requires more finesse in delivering and suturing the cartilages than an open approach.
Open structure rhinoplasty, where the entire nasal tip is widely exposed, is done by making a incision across the columella (skin between the nostrils) and lifting the skin off of the nasal tip. With such exposure, manipulation of the nasal tip cartilages is much easier and symmetry between the sides better appreciated. For this reason, open rhinoplasty is the most common way rhinoplasty surgery is done today and, in most surgeon’s hands, produces more reliable results. It certainly is the way to go in revisional rhinoplasty (of the tip area) and in primary rhinoplasty where the patient has thick skin, nasal tip asymmetries, or weak cartilages. The fear over a columellar scar is largely unfounded as they heal nearly imperceptably. The biggest problem with gloving the nasal skin through an open approach is that some patients will have some prolonged swelling of the nasal tip, particularly those with really thick skin.
The debate between open vs. closed rhinoplasty isn’t really a debate anymore. It is more about what type of nose does a patient have and the plastic surgeon’s experience with each rhinoplasty technique.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
One of the most frequently confusing issues for patients is the cost of rhinoplasty. Rhinoplasty, external nose reshaping, which is frequently a cosmetic procedure (although not always) is often confused with Functional Nasal Airway Surgery whose onjective is to improve breathing and is often covered by medical insurance.
Th confusion comes in as many patients believe that if they have a breathing problem with their nose that they then can get their reshaping rhinoplasty done under insurance reimbursement. This belief is both inaccurate and fraudulent. Medical insurance may pay for functional nasal airway surgery such as septoplasty, turbinate reduction and repair of nasal vestibular stenosis with cartilage grafts. All of these procedures aim to provide a functional improvement by making one breathe through their nose better. None of these procedures will make any significant difference in the outward appearance of your nose As soon as any procedure is done to change the appearance of your nose, such as hump reduction or tip lifting or narrowing, this enters the realm of a cosmetic rhinoplasty which has no impact on breathing improvement. The only time that any external changes to the nose is covered by medical insurance is if the abnormal appearance of the nose is due to a birth defect (such as cleft lip or palate or other craniofacial deformity) or an accident. (if it is due to an accident, this event must be documented with medical records that substantiate the injury…just saying it happened won’t cut it)
One of the frequent motivations for nasal breathing surgery is to have the nose reshaped at the same time. This is perfectly understandable, achieve two goals at the same time and is commonly done. The rub comes in from a money standpoint. Some patients believe, however, that ‘once you are there doing one thing, you can just the other thing…how does insurance know what you are doing?’ Trust me, they do. The hospital/surgery center knows and I know. It is fraudulent to have your medical insurance carrier ‘pay’ for the cosmetic portion of your nose surgery. In today’s world, the hospital or surgery center knows what is going on in any nose procedure and will ask for payment up front. Any responsible plastic surgeon will as well.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Rhinoplasty, nose-shaping surgery, is one of the most common plastic surgery procedures of the face. It can have a dramatic effect on one’s facial appearance due to the prominent position of the nose on the face. While rhinoplasty surgery has been performed for over 100 years, modern rhinoplasty techniques create noses that are more natural and can hold their shape over time.
Historically, rhinoplasty surgery was associated with after surgery appearances which were ‘overdone’. This type of reductive rhinoplasty produced noses that were short with up-turned tips(pugnose appearance) and with low bridges. Even if the nose did not appear this way immediately after surgery, this appearance developed months or years later. This nasal appearance was the result of removing too much of the natural structures of the nose. Taking the bridge of the nose down too low (bone and cartilage) or shortening the tip of the nose excessively (all cartilage), while immediately looking good, weakens the support of the nasal framework. Over time, as scar forms and tissues heal and contract, the nose gradually ‘falls’ and assumes an unnatural appearance. It may look too small, too upturned, or too narow and pinched at the tip.
The importance of maintaining as much of the support of the nose is better appreciated today. The nose is like a house, the framework must be maintained to keep the roofline intact. Contemporary rhinoplasty is more of a rearrangement of the framework structures with only small removals of cartilage or bone. In this way, the nasal dorsum (line along the bridge to the tip) remains smooth but at a good height, the end of the nose is lifted but not too high, and and the nasal tip is narrowed but is not made into a single point.
Besides less cartilage and bone removal, the natural rhinoplasty makes use of adding support through cartilage grafts as necessary. Supporting the nasal tip through columellar strut grafts, small hand-carved grafts for better tip definition, spreader cartilage grafts to the middle vault to improve breathing, and adding height at the very top of the nose where it joins the forehead (radix) with small crushed cartilage grafts are some of the ways to help build and strengthen the framework of the nose. These cartilage grafts are usually acquired from the septum of the nose (which may be simultaneously straightened) or from the back of the ear.
Natural rhinoplasty techniques are a combination of preserving critical nasal tissues, skillfully rearranging the different zones of the nose, and the three-dimensional eye to visualize how to get to the final nasal result. It is usually best done through an ‘open approach’ with a resultant indetectable scar across the columella. (strip of skin between the nostrils) Natural noses fit each patient’s face more proportionately and never have that ‘operated’ appearance. While tedious to perform, I find the long-term results rewarding and the need for secondary revisional surgery reduced.
Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
