*required fields
You are currently browsing the archives for the rhinoplasty category.
Archive for the 'rhinoplasty' Category
There are numerous ethnic noses (Asian and African-American) that are characterized by having a low and wide nasal bridge. Such low nasal bridges are almost always associated with a tip of the nose that has poor definition and is wider and flatter. Rhinoplasty in this nose type requires the bridge and dorsal line to be built up higher. The choice in nasal augmentation is always between that of synthetic materials and one’s own bone or cartilage.
While I always prefer and use rib cartilage for significant nasal augmentation, some patients understandably do not want to have that done. This is particularly true in the patient who walks in for a cosmetic rhinoplasty without any prior nasal surgery. As a result, the use of synthetic implants, particularly composed of silicone, is the most commonly used nasal augmentation material around the world.
Synthetic nasal implants do have, however, a recognized history of problems such as infection, mobility, and even extrusion. This has led to the belief that all synthetic materials should be avoided in the nose. The extremely large experience in Asia with synthetic rhinoplasty, however, would indicate that this is not completely accurate.
Greater success in nasal dorsal augmentation with an implant is to place it, not just under the skin, but under the periosteum on the nasal bones. Elevating this periosteum can be difficult but is important particularly when the implant needs to be placed high on the nasal bones, which is usually needed in men. The significance of subperiosteal placement is that it will help prevent implant mobility and hide the edges of the implant better.
When it comes to nasal implants, what are our options today? The choices come to down material types (silicone vs Medpor primarily) and either a dorsal implant or an extended dorsocolumellar implant style. There are advocates for both material compositions and neither one is necessarily superior over the other. My preference is currently for a silicone-based material because of one factor…its ease of revision. Medpor gets a lot of tissue ingrowth which is biologically favorable. However, should it be necessary to revise it, it is a bear to get out. This translates into a fair amount of tissue disruption to remove it. Since the long-term potential for revisional rhinoplasty surgery is not rare with implants, I lean towards what would be easiest and least destructive to remove.
From a nasal style standpoint, I have concerns with an L-strut shaped implant. This implant comes down along the entire bridge of the nose, over or through the tip , and down to the base of the columella. (after turning 90 degrees at the tip) While it helps give the tip of the nose definition, it does so by putting point pressure in a fairly small area. This may make the nose tip too pointy and unnatural looking. (even a thin nose tip is round and not naturally pointy) With such pressure on the tip of the nose over time, it can become thin, get red, and ultimately develop extrusion. I have seen this more than once. The other problem with an L-strut is the potential for it becoming twisted and making the nose crooked. This can occur from simple scar contracture over time or from even slight trauma to the nose.
For these reasons, it makes more sense to me to keep an implant relegated to a dorsal style only. This places pressure over a much broader area of skin, lessening the risk of long-term tissue thinning problems. (provided it is not oversized) Once can usually find enough natural cartilage for tip and columellar grafting and support. It is the long dorsum where the implant provides its primary benefit of enough volume without a graft harvest Mobility and visibility problems can be improved with subperiosteal placement over the nasal bones as previously discussed. Modern dorsal nasal implants use a ‘saddle’ over the dorsal area for better fixation.
Some ethnic rhinoplasties need substantial dorsal augmentation as a foundation for its aesthetic success. When rib harvesting is not an option, a properly sized and placed nasal implant can have good long-term results.
Dr. Barry Eppley
Indianapolis, Indiana
Background: The evolution of rhinoplasty surgery over the past twenty years has leaned heavily towards a cartilage preservation approach. Focus has been more on cartilage reshaping and less on cartilage removal. As a result, the once common over-reduced or ’ski-slope’ nose is now a rare finding rather than a common one. When an over-reduced nose presents, the concept of nasal lengthening or expansion is needed for secondary revision.
This is a case of a 56 year-old female who came in having had three prior rhinoplasty procedures. Her primary rhinoplasty appeared to have been for reduction of a hump and narrowing and shortening of the nasal tip. Apparently the primary rhinoplasty created a reverse problem, that of a saddle nose deformity and a retracted shortened tip with excessive nostril exposure. Her original surgeon performed two subsequent revisions, using septal and both ear cartilages for donor sites during the two procedures. While improvement was clearly obtained, she was still unhappy with the shortened tip and nostril exposure. Her original surgeon informed her that she had no more cartilage to give and she sought other opinions.
Her fourth rhinoplasty, (third revision), used the 11th free floating rib for a cartilage source. Grafts were placed as septal extenders between the caudal end of the septum and the medial footplates, extension grafts from the end of the upper lateral cartilages to the underside of the domes, a columellar strut, and an onlay tip graft was done. All these were done to drive the tip out and down and provide more tip definition. Extensions were also placed on the caudal side of the lower alar cartilages to try and lessen the nostril show/retraction.
Any effort to improve nasal tip retraction requires cartilage expansion. Even if her ear and septal grafts had not been taken, I may still have used rib cartilage. You never want to limit what the operation can achieve by the amount of graft you have to work with. Successful nasal lengthening is largely a function of the amount and construct of the cartilage grafts. As understandably unappealing as the thought of rib harvesting is, it always will provide the most graft material.
The two undesired aspects of rib harvesting, pain and scar, can be controlled by surgical technique. Injecting with a long-acting local anesthetic keeps the discomfort at bay at least for the first 24 hours after surgery. Waking up with severe rib pain can be avoided. The incision for rib graft harvesting can be kept quite small. The skin slides freely over the ribcage so there is no need to make a long incision.
At one month after surgery, she was pleased with the improvement and felt that she had finally reached a nose shape which made her feel comfortable and not self-conscious. Her rib discomfort had largely gone away except for an occasional twinge when she twisted or rotated her body significantly. Both her nose and rib scars were very acceptable to her.
Case Highlights:
- The success of revisional rhinoplasty is often dependent on adequate cartilage grafts. Recovery from prior rhinoplasty procedures in the over-reduced nose requires cartilage restoration for soft tissue expansion and lengthening.
- Cartilage graft harvesting from the rib always provides an adequate amount of cartilage. While there is more discomfort from the harvest site, its use should always be considered when septal and ear grafts have been previously harvested. The scar is usually cosmetically acceptable.
- The need for a second or third rhinoplasty revision is rare and can be overcome with a commitment to full exposure and cartilage grafting.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Indianapolis, Indiana
It is a common perception that our noses get bigger as we get older. I have been asked that very question many times in my Indianapolis plastic surgery practice. This perception is based on the belief that cartilage continues to grow even though our bones have long stopped growing. (in fact, our facial bones are getting smaller in size and volume as we age)
So what accounts for larger noses in older folk? Plastic surgeons feel that this is largely a phenomenon that occurs at the nasal tip. Rather than getting longer by growth, it is a function of the tip of the nose dropping or getting droopier. The lower alar cartilages, which make up the tip, or dome, of the nose lose support and begin to fall slightly. When the tip of the nose falls, it makes the nose look longer as the distance from the top of the nose (radix) to the very tip does lengthen. This, one’s nose does get longer with age but not because it is growing.
This condition is known as senile nasal tip ptosis. It can be improved or corrected by standard rhinoplasty surgery techniques. Through different rhinoplasty techniques, the tip structures can be predictably altered from just a little to a lot. (nose being shortened and rotated upward) For just a little nose tip uplift, shortening of the caudal septum and lower alar cartilage suturing can be done through a closed intranasal approach. More significant changes require an open approach where angulated caudal septal reduction, cartilage graft strengthening of the medial footplates, trimming of the cephalic margins of the lower alar cartilages, and footplate to septal suturing can be easily done.
Another nasal maneuver, although very uncommon, is a nasal skin lift. Excess skin can also cause the nasal tip to drop, particularly in thick-skinned individuals. For a minor tip lift, a horizontal ellipse of skin at the junction of the nose and forehead (glabella) can be done. This is like a facelift for the nose. Such a simple ‘rhino’ technique can be done in the office under local anesthesia.
While all of these rhinoplasty maneuvers sound complicated, they are not. Nasal tip surgery is a one hour outpatient procedure than can even be performed comfortably under IV sedation or general anesthesia. All sutures are dissolveable and only flesh-colored tapes are used for the tip. There should be no facial swelling and virtually no pain. Bruising and facial swelling only occurs in more complete rhinoplasty surgery where the bones are broken and moved. This is not part of an isolated tip rhinoplasty.
One of the side benefits of a tip-lifting rhinoplasty is that many patients will breathe better. Rotating the tip upward opens up the internal nasal valve. It is like a surgical ‘cottle manuever’, a physical movement of the nostrils upward and outward which will let in more air with inspiration.
For older patient with a nose that is getting longer (sagging tip) reversing this sign of aging is a simple cartilage restructuring of the nasal tip. Some call this procedure a ’senile or senior rhinoplasty’, I would more accurately refer to it as a ‘noselift’.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis, Indiana
Changing the shape of the nose through rhinoplasty surgery continues to be increasingly popular amongst African-Americans. The most common reasons sought for nasal improvement are lack of tip definition, wide nostrils, flat bridge of the nose and breathing problems. The consistent theme is that the nose is broad and lacks a well-defined bridge and tip. The nose simply does not fit well with the overall shape of their face.
Every African-American is sensitized to the ‘Michael Jackson look’ and that, of course, is not the goal. In any non-Caucasian rhinoplasty, everyone knows that the goal is to maintain ethnicity. Moderate shape improvement is always better tolerated than an unnatural look which comes from trying to make the rhinoplasty do ‘too much’. The thick skin, short nasal bones, and broad tips of the African-American nose require special handling and an appreciation that you can’t and shouldn’t try and make a thick broad nose into a thin delicately shaped one.
There are three basic considerations in the African-American rhinoplasty that is incorportated in most procedures. Building up the nasal bridge, narrowing the tip with improved projection, and reshaping the nostrils are the three primary maneuvers. All of these must be done with the elast amount of external scars. This raises the question of whether the open ( external) vs. closed (endonasal) approach is used for exposing the nasal cartilages and bones. The fundamental difference between the two is the placement of an incision across the columella. While there can be debates between the two given the higher incidence of keloids and shorter thicker columellas in African-Americans, meticulous closure techniques can make that distinction largely irrelevant. The most important issue is which one allows you the best opportunity to do the most precise recontouring.
The skin in every rhinoplasty patient is more than just an obstacle in the way of the surgery. How the skin reacts as it heals long after the surgery is a key factor in how definition of the nasal tip is or is not seen. The thickness of African-American skin on the tip of the nose means it usually must be thinned but supported as it contracts during healing. Debulking of fat underneath the skin, leaving just a thin layer on the underside of the dermis, is needed to improve definition. But the widely spaced tip cartilages must be supported by cartilage grafts to the columella and tip to give the thinned tip skin a stable structure to heal and contract on for better shape and definition.
Next to tip refinement, definition of the dorsum is the most requested nasal change in this ethnic group. How to do that is controversial. The simplest and very effective method is to use an implant which is usually made from silicone. This builds up the dorsal line quickly and significantly. Because of infection and long-term risks of extrusion, however, the use of one’s own tissue is preferred by many. Your own cartilage has no rejection or significant infection risks but such grafts are less effective in building up the bridge and does require a donor harvest. Typically, this tissue is taken from the septum or the ear but this is often not enough for a real visible bridge change. The use of a rib graft gets around that issue.
The short and wide nasal bones can be narrowed but that must be done carefully. And it always needs to be done with bridge augmentation to get the overall look of a more narrow and refined upper third of the nose.
Nostril narrowing is a key maneuver. It can be done through skin removal in the alar crease or from inside the nostril sill. More effective nostril changes comes from the external incision approach but such scars for me are to be avoided. Keeping the scar inside the nostril may not make as much of a change but the potential scar issues are less and more easily improveable should they turn out to be a problem.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis, Indiana
Reconstruction of certain nasal deformities requires significant structural support. Despite the ease of use of synthetic implants, the use of cartilage is associated with minimal risk of severe implant problems such as infection or extrusion. In the very visible nose, this is a huge advantage. Infections and extrusions in the nose from foreign materials may end up destroying or distorting skin or internal lining, problems from which creating a normal looking nose may not be possible.
Adequate cartilage is the key to recovery from many rhinoplasty problems. The nasal septum and the ears can usually suffice. But problems such as saddle nose deformity, short nose problems, large nasal defects from tumor resections and multiply operated and scarred noses may require more than cartilage sites above the neck can provide. The final cartilage harvest stop is the ribs.
Use of a rib graft in rhinoplasty is also known as costal cartilage grafting. It requires a small incision on the chest wall based on the rib number which is to be used. Many plastic surgeons use the fifth or sixth rib for rhinoplasty but my preference is for lower level rib harvesting. Having substantial experience in microtia ear reconstruction, harvesting the free floater 9th rib and portions of ribs 7 and 8 is easier and provides plentiful options of shape and configurations. A small subcostal incision can be moved around to provide good visibiity and the underlying rectus muscle is split vertically for access rather than transecting it.
One of the major concerns about rib harvesting is the risk of pneumothorax as the lung pleura is close by underneath. But at the level of the 7th ribs and lower, the lower apex of the lung is higher so this is not going to happen. In over 65 cases of rib harvest at this chest wall level, the pleura has never been violated. It becomes evident at the level of the 7th and most certainly at the 6th rib.
But many cases of using rib graft material in the nose do not require a full-thickness graft harvest. A split-thickness graft can be easily and quickly harvested, sparing the bottom side of the rib. This can be very useful for smaller straight grafts of the columella, middle vault spreader grafts, and septal extension grafts. Doral augmentation grafts must usually be 3 to 4 cms. long.
One known risk of using rib grafts is warping. This has been an historic concern. With time, rib segments can change shape and warp. This is particularly prone to occur if one tries to shape a curved piece into a straight graft. It is far better to harvest enough of a segment that you do not have to try and change its natural shape.
It has been a belief that beyond a certain age, rib sites become calcified and largely unusable. While there is no question that at the age of roughly 50 and older, ribs do become harder to work with and have isolated areas of partial calcification, one can always find enough cartilage to use. I have done rib grafts up to age 65 and adequate cartilage has always been found. There is a flip side to a partially calcified rib, it largely resists warping and will not usually change shape anytime after surgery.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis Indiana
Being a teenager is tough, but it can be a lot tougher if you don’t like your nose. While most teens deal with their physical imperfections with acne medication and trendy clothes, a nose that is too big can not be easily camouflagued. Unfortunately, being ridiculed for a big nose is not uncommon. With today’s social networking sites, such as Facebook and My Space, social ridicule can even extend to that of internet bullying.
As a result, a growing number of teenage Americans are opting for rhinoplasty surgery. Nose reshaping continues to be the most common cosmetic surgical procedure performed on teenagers in America…and maybe even around the world.
Undoubtably, our culture and perpetual media exposure has an influence on fragile teen self-images. Between TV shows, pop music icons, and the wider awareness and acceptance of plastic surgery, teens can be motivated to seek out physical changes. At least once a week, I receive inquiries on my blog from teens that identify themselves as being under 18 and there may be many more that do not reveal their real age. Several years ago teen inquiries were relatively non-existant.
At what age should rhinoplasty be performed in teens? Traditional plastic surgery thought is that the minimum age to undergo nose reshaping is 14 or 15 years for girls and 15 to 16 for boys. The concept is that one doesn’t want to operate too early on a nose that still has a lot of growing to do. While this traditional approach is sound, there are other factors that can alter these surgical time frames. What nasal problem is being corrected? How extensive is the surgery? Are there associated breathing problems? How much growing does the teen have yet to do? My experience operating on many cleft nose deformities at early teenage years, because of their severity, has shown me that the fear of growth restriction after early rhinoplasty is more perception than reality.
Teenage rhinoplasty is often touted as being easier to do (because of more flexible and malleable tissues) as well as easier to recover from after surgery. While this sounds appealing and even seemingly correct, there is little truth to those espoused benefits. The reason to reshape a nose during one’s teenage years is primarily for self-image and emotional benefits. Whatever healing or recovery benefits that exist between age 16 or 35, for example, are so negligible that it is irrelevant.
The most common teenage nose problem is that it is perceived that it is too big or out of proportion. Some part of the nose may be excessive, whether it is a prominent hump or a tip of the nose that is too fat. As a result, many teen age rhinoplasties are ‘reductive’ in nature. The aim of the procedure is to reduce its size and enhance the shape of the nose. This is commonly done by reshaping the existing cartilage and bone on the nose and, if needed, use the excess cartilage from the nasal septum to help support the reshaping efforts. There is no need for every using foreign material in the young nose and rarely are cartilage grafts needed from other parts of the body.
Because of the young age of teenagers, they have a long time for any healing deformities of the nose to appear. For this reason, it is important to not overdo the surgery or perform an overly aggressive rhinoplasty. Keeping good support to the nose is important. If too much cartilage or bone support is removed as a teenager, the need for secondary rhinoplasty as adults may develop if difficulty breathing, nasal deformities, and other problems develop due to the collapse of the nose.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Indianapolis, Indiana
Rhinoplasty and Health Insurance - How To Avoid Paying Through The Nose
Author: barryeppley
Rhinoplasty surgery, in the purest sense of the term, implies changes to the external or visible parts of the nose. Since the appearance of the nose does not necessarily affect how it functions, your insurance will not cover any of the rhinoplasty procedure if the goal is to achieve an improved looking nose. For instance, your insurance will deny coverage if your primary reason for surgery is improving a nose that is unattractive, too large or crooked.
But there are circumstances where insurance will provide coverage of a nasal procedure. Notice that I did not use the term rhinoplasty. As soon as you use that term, you are talking about changes to the outside of the nose which we know is not covered…unless the source of the problem is from a birth defect, traumatic injury, or from tumor removal. To define those further, birth defect usually means cleft lip and palate or some other craniofacial deformity where the nose has not developed normally. Traumatic injury means a documented history of nasal fracture, that is relatively recent (not 20 years ago or when you were a child) and there are medical records to substantiate that it actually happened. Tumor excision almost always means some type of skin cancer where a portion of the skin on the nose has been removed All of these external nose needs will constitute a reconstructive rhinoplasty procedure and there is not usually battle to get it approved. (most of the time)
Your insurance will not only cover for these reconstructive issues but they will also cover for breathing difficulties of the nose. A deviated septum is the classic case but there are other internal structures of the nose that can be obstructive, most notably the turbinate bones. Difficulty breathing can also cause headaches and contribute to sleep apnea. All of these are medical issues because they dysfunctional. Many times, the physician’s examination alone is sufficient to provide adequate documentation but other tests may eventually be required including nasometry, CT scans, or sleep studies. One key area that your medical insurance looks for is…what non-surgical treatments have been tried ( and failed) to prove that surgery is necessay. (and the last resort) This usually means a trial course of steroids or other nasal swelling treatment strategies.
Documentation is key for your insurance company to consider that such symptoms exist. Regardless of whether the medical necessity reason is a structural problem due to a birth defect or trauma or a long-standing breathing problem, a pre-determination letter must first be sent from your plastic surgeon. One must then wait until you receive a written response from the insurance company before ever proceeding to surgery. If you do not see it in writing, do not assume that it is going to be covered.
Do not let the urgency of your or your surgeon’s schedule override written confirmation of medical coverage. This is a common mistake. It is much better to know the financial facts up front (and then pay if you have to) than try and sort it out later when you are receiving bills and late notices from a variety of providers because it has been denied due to a lack of the required pre-determination. Remember, once you have it done without a pre-determination, the insurance company is not really under any obligation to pay after the fact. (even if it would have been initially qualified) Paying medical charges that are accrued at the rate of insurance billings are a lot higher than those charged for on a cosmetic fee basis. Let the insurance and pre-determination process run its course…or otherwise you may find yourself really paying through the nose.
http://www.eppleyplasticsurgery.com
Indianapolis Indiana
A good looking nose is about balance of its many nasal parts, particularly the three thirds of the nose. One of these, the upper third, also known as the bridge is a frequent source of dissatisfaction. When it is overgrown or too high, a hump or bump on the nose results. In rhinoplasty terms this is referred to as a high dorsum. When the dorsum is high relative to the rest of the nose, the dorsal line (line from the bridge of the nose to the tip) is curved rather than not straight. This creates an unpleasing profile and makes the nose look too big.
When a nasal hump deformity is combined with a plunging tip, a hooked nose results. In profile, the nose is convex with a nasolabial angle that is less than 90 degrees. This type of nasal shape can also be called a witch’s nose. The hooked nose can also create the appearance that one’s chin is short. (pseudo microgenia) This becomes particularly magnified when the chin is actually horizontally short in projection.
A hump reduction (dorsal management)is an integral part of rhinoplasty correction in the hook nose. The hump is a combination of bone and cartilage as the hump occurs where the bone of the nose stops and the cartilage of the nose begins. This may seem like a trivial anatomic point but reducing this area involves removing both. Taking the hump down lowers the dorsal line and often requires osteotomies (breaking the nasal bones) to close down the open roof deformity which frequently results.
While it is natural to assume that the hump reduction is the major maneuver in the treatment of a hooked nose, but it is not. In some cases, it may not even be the most significant part of the rhinoplasty operation. Correction of the plunging tip is often more important. Raising and shortening the tip of the nose can make any hump look smaller as the lower end of the dorsal line is shortened and becomes closer to the line of the hump. While hump reduction may not be eliminated, the amount of reduction may be less than one may think. Without this consideration, it is possible to reduce the hump too much resulting in a saddle nose deformity long-term and possible impairment of one’s breathing.
There are also small rhinoplasty techniques that can help both the hump and tip changes. Adding a cartilage graft to the radix (upper part of the hump) as well as at the base of the nose (opening up the nasolabial angle) helps further refine and enhance smaller, less often appreciated, deficiencies in the hook nose.
Like all rhinoplasties, consideration of adequate chin projection is important. This is particularly so in the hook nose which is larger and disproportionate to the rest of the face. This is not an illusion. Even in those that may only be slightly so, chin augmentation (usually by an implant) can make a dramatic facial profile difference as it makes the nose appear less large.
Hooked nose correction involves a variety of nose and chin changes. Hump reduction alone is inadequate and must be combined with top rotation and shortening and crushed cartilage augmentation to the radix and anterior nasal spine areas. Chin augmentation completes the correction and at least 5 to 7mms of increase is needed in most cases.
http://www.eppleyplasticsurgery.com
Indianapolis Indiana
“ My nose is too wide…My nose is big and troll-like nose… My nose is thick and bulbous…I have a nose with a boxy tip”
Many patients seeking rhinoplasty have what they commonly describe as a wide, boxy, or bulbous tip of the nose. What they really want is to have it look more refined through it being narrowed. If the tip is the main nasal deformity, then it can be improved through a tip rhinoplasty.
In understanding the boxy nose, one has to understand its anatomy or anatomic derangement. In short, the problem is an enlargement or broadening of the tip of the nose. When the cartilages of the tip of the nose are enlarged, they will give the nose a boxy or broad appearance. This is especially true if the upper part of the nose is shaped well and does not need surgical alteration. When looking from below, the boxy nasal tip appears square whereas the more appealing nasal tip appears triangular.
To get more specific, the boxy nasal tip can present in three varieties, all based on how the two lower alar cartilages come together. One variation is that there is an increased intercrural angle of divergence but with a normal dome width. Another variation is that the dome is wide but with a normal intercrural angle of divergence. The last variation has both an increased intercrural angle of divergence and a wide dome width. These different types of boxy tips are usually not seen until they are exposed in surgery.
The rhinoplasty techniques to change the boxy nose are all based on manipulated the cartilages that make up the dome. In the past, these techniques have all involved reducing the size of the cartilages. Tip narrowing was historically done by thinning of the upper edge of the lower alar cartilage. Known as a ‘cephalic trim’, this maneuver is helpful but if it is overdone it can result in weak alar cartilages and collapse when breathing in. The cephalic trim today is done more conservatively to prevent creating a weak lateral alar cartilage and in recognition that it is not the most important maneuver is narrowing the tip.
A more predictable way to narrow the shape of the tip is by using suture techniques. Drawing the tip cartilages together with sutures can change their shape. The tip cartilages can be narrowed individually, known as a single dome plication or they can be done together known as double dome plication. There are plastic surgeon advocates for either approach. The great thing about suture plication is that you can change their shape without being destructive. And they are reversible doing surgery should one not like the shape it is making.
Such suture techniques can produce a dramatic change in the shape of the tip. But the patient needs to be aware of the signficance of the overlying skin. The skin poses two considerations. Does one need to do an open or a closed rhinoplasty for the boxy tip? Given the complexities of the cartilage confluences that make up the boxy tip, an open rhinoplasty will produce more consistent and complete tip shaping due to the increased exposure. Secondly, despite that the dome cartilages are newly narrowed, a thick skin covering may help obscure some of that benefit. The swelling that occurs in thick skin can help maintain some of the boxy shape for some time after surgery. While swelling does eventually go away, it may take much longer than an anxious patient would prefer. In my Indianapolis plastic surgery practice, I advise patients to wait a minimum of three and more ideally six months before judging the final result.
The boxy tip can be dramatically changed by modern rhinoplasty surgery. Since the tip of the nose is the most variably shaped element of the nose amongst different people, changing it to a more pleasing shape can really make a big facial difference.
http://www.eppleyplasticsurgery.com
Indianapolis
1. How will my nose look after a rhinoplasty?
One of the most important considerations about having a rhinoplasty is to end up with a ‘new’ nose that makes you happy. While no surgery can absolutely be guaranteed as to how it will look, there should be a good understanding between the you and your plastic surgeon as to what your goals are. This is why computer imaging is so important before surgery. It serves as a method of communication so that what you would like and what is possible can be meshed into an image of a likely outcome.
As a plastic surgeon, we can reasonably predict what each patient will say bothers them about their nose. Whether it is a nasal hump, a wide tip, a downturned nose or a nose that is off center, we can quickly see what makes one’s nose out of proportion. The pupose of computer imaging is to make sure what we see is the same as you see. And it also allows us to know how to modify the changes we might do (e.g., more hump reduction, too much tip narrowing, tip up too high or still too low) so that it meets your needs better.
2. Does rhinoplasty leave scars?
Rhinoplasty can be done two ways, open and closed. While there may be some debate and advocates for either approach, most rhinoplasties today are done through an open approach. This does leave a small horizontal scar on the strip of skin between the nostrils. (columella) The remainder of the incisions are hidden inside the nose just like a traditional closed technique.
While the open approach does result in a scar, it almost always heals so well that it is virtually impossible to find when the scar matures. In some patients, you can only see that scar if you are within 10 cms or less. And it requires one to be looking from below the tip of the nose…a very unnatural viewpoint.
3. Will rhinoplasty improve the breathing through my nose?
Nose surgery can be done to change the external appearance of the nose (aesthetic rhinoplasty) or to improve obstructed breathing through the nose. (functional rhinoplasty or septorhinoplasty) Often both are done together.
Functional nasal surgery, however, is done completely inside the nose and works on those structures that contribute to air flow. This includes the septum (straightening a deviation), turbinates (reduction or partial resection) and manipulation of the internal nasal valve. (cartilage grafting for expansion)
It is important to realize that doing the two together has many benefits. Straightening a deviated septum can help straighten a crooked nose and is a good source for cartilage grafts. Turbinate reductions help open up an airway that may be adverseloy affected by some of the external changes. Expanding the middle vault with grafts can make a pinched-looking nose wider and make the dorsal lines more symmetric.
4. Will insurance pay for my rhinoplasty?
While we all would like health insurance to cover all of our medical needs, rhinoplasty is not usually one of them. Expenses related to improve breathing are almost always covered within the limits of your policy, any external changes to the appearance of the nose however are not. There are certain exceptions to that exclusion if there is a documented medical reason for how the nose is deformed. Birth defects (e.g., cleft lip and palate) and traumatic injuries (e.g., fractures)are the two main examples. I emphasize the word ‘documented’ as just saying that it occurred is not sufficient.
5. What can be done if I am unhappy with how my nose looks after surgery?
For most rhinoplasties, the biggest risk or complication is that of an undesired appearance outcome. This is usually not a large cosmetic problem but more like an irregularity, a dip or deviation, or some location of asymmetry of the bridge, tip, or mostrils. As a plastic surgeon, we are very sensitive to how even a minor ‘problem’ is of a big concern to a patient, particularly when it is on their nose.
When one sees something on their nose after surgery that displeases them, one should first be patient. The nose is unique in that the skin continues to change on the nose for months after surgery, sometimes even up to a year. What may be there to day, could be gone or even more apparent months from now. Secondary or revisional surgery is not usually done for at least six months from the initial surgery. The primary reason is that we want to operate on a ‘stable target’, not a nasal feature that is in a state of evolution. Also, it is important that the stiffness of the nose tissues has had time to settle down and become softer again. Revisional surgery done too early is highly prone to fail.
The risk of the need for revisional rhinoplasty surgery is not rare. Because of the many different types of nose problems and types of surgery needed, no one can give a reliable estimate that applies to any specific patient. In my Indianapolis plastic surgery practice, I use the estimate of a 10% risk…a not insignificant number.
6. What type of anesthesia is used for rhinoplasty surgery?
Surgery of the nose has a history of being done under local or IV sedation in many practices. While some plastic surgeons still do so, one should never compromise the ‘fear’ of anesthesia vs a good outcome. Comfort of the patient and the ability to manage any bleeding that may occur during surgery is best done under general anesthesia. Many older patients can recall having their nose done when they could hear or feel their ‘bones being broken.’
Today’s anesthesia techniques and drugs are so good, I see no reason to use anything less than a general anesthetic for almost all cases.
7. I have heard that rhinoplasty is a difficult surgery to do, why is that so?
While the nose is a small structure in comparison to the rest of the face, there is a lot of complex anatomy packed in there. Contrast the nose to the chin, for example, which is much larger. The chin has only two pieces of important anatomy (solid piece of bone and soft tissues) while the nose has three bone and six pieces of cartilage covered by a very thin layer of skin. The interrelationship of how this anatomy comes together, what changes occur by altering parts of it, and how it responds to healing and scar contracture make rhinoplasty less predictable than almost any other facial surgery that we do.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis