Almost anyone in the world is aware of the recent tragedy in Norway with the mass killings of an incomprehensible number of Norwegian teens and young adults. The murderer Anders Breivik appears to have acted alone, driven by his white supremacist and anti-Muslin views. What has caught my attention as a plastic surgeon, however, is comments that have been written about his facial appearance.

According to the head of Norway’s intelligence agency, it is believed that he had undergone plastic surgery in the past to look more “Aryan.” The agency’s head has stated that “You do not have that Aryan look naturally in Norway”…”Hitler would have had him on posters. He has the perfect, classic Aryan face. He must have had a facelift.”

While I am not an expert on Norwegian facial structure, I do know that he would not have had a facelift to change his facial appearance. That is not what a facelift does. A facelift is what I call ‘anti-aging facial surgery’, where one is trying to return to one’s prior appearance. This does not change your face but rather makes it look rejuvenated and less tired like it did 10 or 15 years ago. But you still look like you, just a better you.

Rather he would have undergone ‘structural facial surgery’, where the foundational components of the face are altered. That can and often does change one’s appearance. Foundational facial procedures are done at the bone or cartilage level, not just the skin and soft tissues. This includes plastic surgery procedures such as rhinoplasty and facial bone augmentations. (forehead, brow, cheek, chins and jaw angles) According to reports, he supposedly underwent nose and chin surgery at age 21. This would make more sense as these can change the structure of the face and definitely can make one more Aryan in facial appearance, particularly if certain elements of the face are already there.

This raises the question of what is an Aryan facial appearance and why does it look so? The word Aryan, at least as it was perceived and used in Nazi Germany, specifically refers to being white, blond-haired and blue-eyed. But there is not necessarily a specific set or arrangement of facial features that are ascribed to an Aryan face. People talk about it and one would know if they saw it but may not be able to describe the details of it.  But what it undoubtably refers to is a strong and well-chiseled face. For a male this would be highlighted by well-defined facial bony prominences of the brows, cheeks, chin and jaw angles. The nose would have a strong and high dorsal line with a balanced ratio between the three nasal thirds.

The concept of an Aryan face continues to exist today but it is better known as the ‘Male Model Face’. Most young male models in any advertisement today almost all have this type of facial appearance. Whether they have it by genetics, plastic surgery or the use of good lighting and/or Photoshop, the strong and desireable male face has these consistent features.

Plastic surgery techniques today can help many men undergo these type of structural facial changes. Rhinoplasty, anatomical cheek implants, square chin implants, vertical lengthening jaw angle implants and occasionally select fat removal below the cheeks and in the neck can create a face that has more well-defined angles and is more masculine in appearance. For some men, this ‘Male Model Surgery’ can be very effective provided they don’t have a lot of facial fat and not an overly round face.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Rhinoplasty is a unique plastic surgery, not in how it changes the shape of the nose, but on its potential impact on a patient’s psyche. Rhinoplasty has long been associated with patients who obsess over apparently very small nose issues and frequently request and pursue multiple revisional surgeries from different plastic surgeons. While changes in one’s face or body can evoke a variety of patient reactions, rhinoplasty disproportionately causes a greater amount of obsessive or perfectionist reactions.

Known as body dysmorphic disorder (BDD), this is a condition in which one has an unnatural and often unreasonable preoccupation with defects in appearance. Most of the time these defects are slight to even imaginary. Some patients with the disorder complain about body parts that most people would consider to be normal. Given that the outcome of a rhinoplasty involves a lot of different and interrelated parts to create the overall look, it is no surprise that BDD occurs most commonly with this plastic surgery operation.

In the August issue of Plastic and Reconstructive Surgery, a study out of Belgium reports that a significant number of people who complain about the size or shape of their noses show signs of this mental condition. This study was based on more than 200 patients who were evaluated for rhinoplasty over a nearly 1 ½ year period. During the initial consultation, the patients were given a psychological questionnaire to assess their potential symptoms of body dysmorphic disorder. They found that over 40% of patients had symptoms of BDD that were seeking to have cosmetic changes in their nose. Conversely, only a handful (2%) of patients seeking correction of a breathing problem exhibited symptoms of the disorder. Collectively, one-third of the studied rhinoplasty patients had signs of BDD.

This study shows a surprisingly higher number of BDD symptoms in rhinoplasty patients than previously thought. Previous studies have shown that about 10 percent of patients seeking plastic surgery suffer from the condition. But there is the influence of the makeup of the questionnaire and the study and culture of the patient population being evaluated. It is also relevant that these were primary rhinoplasty patients. Patients seeking revisional rhinoplasty may or may not have a higher incidence of BDD.

When evaluating a patient for rhinoplasty, it is important to remember that they are there because they are dissatisfied with the appearance of their nose. This does not automatically make them abnormal or have BDD. I would say that the vast majority of rhinoplasty patients I see have very visible and understandable reasons for why they don’t like the shape of their nose. What can not be known in most consultations is how much the appearance of their nose disrupts the rest of their lives. Even a big deformity of the nose if it disrupts the major functions of their life is not a healthy psychological sign.

But it is very hard to pick up BDD symptoms in a primary rhinoplasty consultation. That discovery all too often is not made until afterwards. But despite this study’s findings, my own practice experiences do not show the potential numbers of rhinoplasty patients with BDD that are remotely that high. While I have never done a consultation questionnaire, the percent of rhinoplasty patients unhappy with their results is a ‘hard’ test after the fact…and a hard one to miss.

The risk of rhinoplasty and subsequent unhappiness in a patient with BDD escalates considerably in revisional surgery, particularly when you did not do the primary surgery. A knowingly unhappy patient upfront has a very diminished ability to be happy afterward. Fortunately, these patients are easier to pick up than primary rhinoplasty patients with BDD. They describe in great detail the anguish of their prior surgerie(s), how it has disturbed their everyday life, and have pictures or drawings as to what is wrong or what needs to be done. They spend a great deal of time with a mirror in their hand pointing out the flaws of the prior surgery during the consultation. This does not mean that a good surgical outcome can not be obtained, but the percentage of doing so drops precipitously.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

One of the very common reasons that a patient wants to change their nose is for the reduction of hump or bump. Known as dorsal reduction, it is one of the most common maneuvers in all of rhinoplasty. Contrary to the perception of many patients, a hump reduction is not just about taking down and smoothing bone. Rather a hump, even the smallest one, is a combination of bone and cartilage. That is because the hump area is really where the cartilage of the middle third of the nose (middle vault) meets the bone of the upper third of the nose. (nasal bones)

While a hump reduction seems like it would be a simple rhinoplasty maneuver, it is not. The skin is very thin over this area (the thinnest on the nose) and it is not uncommon to have unhappy patients who can feel and even see irregularities and unevenness after surgery across this area. Worse complications can also occur including collapse or separation of the cranial end of the upper lateral cartilages resulting in middle vault collapse (evidenced by a pinched appearance of the middle third of the nose) with internal nasal valve obstruction and breathing difficulties.

Maintaining straight and symmetric dorsal lines as well as good internal airway function is as important as the amount of nasal hump reduction in rhinoplasty. Many techniques have been described as to how to take down a nasal hump but the one I have found most successful is the component dorsal hump reduction technique. It is a series of five graduated steps including initial separation of the upper lateral cartilages from the septum, dorsal septal reduction, dorsal bony reduction with a rasp, external skin palpation and finally osteotomies or spreader grafts if needed. Why this approach works well is that the bone and cartilages of the hump are treated separately and sequentially, unlike the radical hump reductions of the past.

The determination of the success of any hump reduction technique in rhinoplasty is the preservation or restoration of the dorsal aesthetic lines. In the July issue of Plastic and Reconstructive Surgery, a study was reported that looked at this aspect of rhinoplasty. One hundred primary rhinoplasty patients from a single plastic surgeon was assessed by digital image analysis one year after their surgery. Dorsal line symmetry and nose width were assessed and compared before and after surgery. The study showed significant improvements in both dorsal line symmetry and nasal width lines. Almost all of the patients had harmonious dorsal lines after surgery.

Dorsal reduction using the components technique demonstrates a very reliable method for preserving or obtaining the aesthetic dorsal lines and significantly reducing the risk of middle vault collapse. This has proven to me to be the safest hump reduction method in rhinoplasty with fewer postoperative problems such as dorsal irregularities. Rasping of the nasal bones is a slower method of bony hump reduction than an osteotome in surgery but allows for a smoother result in my hands. This excellent study proves it with a careful digital computer analysis.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background: Rhinoplasty is a structure-changing operation that draws considerable attention to the patient’s midface. Most rhinoplasties today are done through an open approach which requires a small horizontal incision in the middle of the columella. This scar heals very well due to the superb blood supply surrounding the columella with inflow from the septal mucosa and the skin at the base of the nose and upper lip.

A subnasal lip lift is a skin-reducing procedure that shortens the upper lip and creates more of a central lip pout. This is done by removing skin in an irregular wavy pattern under the nose so that the final scar is at the groove of the union of the base of the nose and the upper lip. The incision runs from one side of the nostril, across the base of the columella, to the side of the opposite nostril. When well placed and executed, this scar also heals well and inconspicuously.

When doing a rhinoplasty, patients will often focus on other potential facial changes as well. This is the result of surgical opportunity and convenience. It is not infrequent that lip augmentation is one of those combined procedures. Adding volume to the upper lip or even doing a lip (vermilion) advancement can easily and safely be done at the time of a rhinoplasty. Considering a subnasal lip lift with a rhinoplasty, however, places two incisions very close to each other and the blood supply to the skin between the two incisions must be considered.

Case Study: A 26 year-old female wanted reshaping done to her nose as well as a lip enhancement procedure. She was bothered by her thin upper lip. She had previously had injectable fillers but was unhappy with the lip look that it created. She wanted the lip lift by shortening the upper lip skin. She did not want, however, a scar along the skin and vermilion junction (vermilion advancement) and felt a lip lift (bullhorn lip lift) was a better procedure.

While she ideally and understandably wanted a rhinoplasty and subnasal lip lift done together, the risks of skin necrosis between the two incisions was not worth the risk in my opinion. Her open rhinoplasty was then done alone with an uncomplicated and successful outcome.

Four months later, a subnasal lip lift was performed in the office under local anesthesia. At its central portion, 6mms of vertical skin length was removed from the base of the nose and the central lip lifted. After three months, the scar was virtually undetectable and there was minimal relapse of any of the central lip pout.

While a rhinoplasty and subnasal lip lift can be performed at the same time…doesn’t mean it should. I suspect that the skin between the two incisions would not be affected in most patients. However should there be a skin necrosis problem, it is a difficult area to reconstruct well. Given that it is a procedure that can be performed in the office, a delay between the two procedures is the safest approach.

Case Highlights:

1) Rhinoplasty and lip lifts are midfacial procedures that are close in proximity and have incisions that are separated only by millimeters.

2) Because of the surgical opportunity provided by a rhinoplasty, it is very tempting and desired by the patient to perform both during the same procedure. The risk of skin necrosis between the two incisions should make one very cautious to do so.

3) To prevent any incision healing problems, an open rhinoplasty should be performed first. This can then be followed by a subnasal lip lift three or six months later.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Changing the appearance and improving the function of the nose through rhinoplasty surgery is sought by many patients. Having the opportunity to get rid of that hump, narrow and lift the tip, straighten the nose and overall make the nose more proportionate can improve the look of one’s entire face. Coupled with improving the breathing through one’s nose, should that also be a problem, provides a functional benefit as well.

While the outcome of a rhinoplasty can be very exciting, it is surgery and with that comes a recovery period. While often stated as being two or three weeks for a rhinoplasty recovery period, what happens in an actual patient is quite different than what is written in a brochure or on a website. Because it is a surgery that affects the most prominent part of one’s face, the recovery period after nasal surgery will always be much longer than most patients anticipate. Recovery from rhinoplasty must be thought of as having both a cosmetic and functional component that occurs in four stages.

The first stage of rhinoplasty recovery is up to a week after surgery and is largely a functionally restrictive period. It is during this period that splints and tapes will be on the nose and it is obvious one has had surgery. This is the ‘social reclusion’ stage for most patients. Few patients want to go in public or go to work with this external marker present. Whatever pain one will have is during this phase although rhinoplasty is not commonly very painful. It is uncomfortable with the splint in place for sure and, when combined with congestion and nasal stuffiness (if septal and turbinate work has been done), is a week one wants to get over quickly. If nasal osteotomies (breaking the bones) are done, bruising may appear under the eyes but often will not appear for several days. The nose does not get swollen (because of the splint) but the surrounding face might in the cheeks and down to the jowls.

The second stage of rhinoplasty recovery is between one and three weeks after surgery. After one week, the nasal splint and tapes are removed as well as any internal splints. The nose is also cleaned of any clots if possible. That is a breath of fresh air for every patient, no pun intended. If bruising has occurred it will still be present and will take up to the end of stage two to go away completely for most patients. This is not the end of the functional recovery as further improvements in breathing will occur but it is the beginning of the cosmetic recovery. Removing the splint is not a ‘TV moment’, meaning the final result is not going to appear. The nose will be swollen and distorted and often will look worse than before surgery. This is normal. The thicker one’s skin is and the more work that has been done leads to a lot of swelling. This swelling will not go away in the next two weeks. It will improve but even at three weeks after surgery less than 50% of the swelling will be gone. Most patients understand this but it is still hard when it is one’s own nose.

The third stage of rhinoplasty recovery is between three weeks and three months. It is a completely cosmetic recovery at this point as the swelling gradually goes down. While many patients want to look critically and note many ‘flaws’ in the result, what is seen now is still not the final result. While the biggest parts of swelling have subsided in the first couple months after surgery, many finer nasal issues such as the size of the tip or shape of the nostrils still needs more time. But during this phase the general change in nose shape should be apparent even if it needs more time for further refinement. This is the hardest phase as one’s patience is growing thin but just remember how far you have come sicne stage two. But no matter how it looks, even if it is not what one anticipated, the thought of revisional rhinoplasty will never be entertained at this time. All plastic surgeons will advise patience.

The fourth and final stage of rhinoplasty recovery is between three months and one year after surgery. Subtle changes continue to take place. Something that looked not quite at three months may have completely gone away by six or nine months after the surgery. Conversely, an asymmetry or bump may appear at six months after surgery that was not apparent at three or four months after surgery. Revisional surgery, if needed, may be entertained at the end of this stage.

In conclusion, recovery from rhinoplasty surgery is a long process and the final result may take up to a year to fully appreciate.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Rhinoplasty is always stated to be about achieving a better balance or match of the shape of the nose to the rest of the face. That certainly sounds like a good goal but what does it exactly mean? As a plastic surgeon, this refers to changing or creating specific angles, measurements and lines of various nasal structures. Patients however are more interested in its overall appearance and, most importantly, a natural-looking result.

The most critical concept in creating a natural, pleasing, and long lasting rhinoplasty result is to create a nose that has good support. Preserved or rearranged bone and cartilage keeps the shape of the nose stable with strong outlines. Conversely, an unnatural or obviously ‘surgical nose’ lacks support and has an overall look of collapse and retraction. We have all seen these unnatural noses that are way too small, have a scooped out bridge, is pinched at the tip, are bent or twisted or have nostrils that pulled too far upward. These are some of the most common problems that occur with first time rhinoplasty surgery that are almost always caused by a weakening of the nose and therefore loss of support. Many of these unnatural rhinoplasty are not obvious right after surgery and often occur over the course of a few years following the surgery.

One of the well known signs of an unnatural rhinoplasty is a bridge that is too low. When a line between the top of the nose down to the tip is not straight and dips inward, this is known as a saddle nose deformity. Too aggressive removal of a hump composed of bone and cartilage is the cause. Weakening or loss of the internal support of the septum can also contribute to this same problem. Rhinoplasties of  old were famous for having a scooped-out appearance to the nose…not to mention the eventual breathing difficulties. A straight dorsal line signifies good nasal support.

Two features of the nasal tip are dead giveaways for having an overdone rhinoplasty…the tip of the nose that is lifted up too high or tilted back too far and the tip of the nose that is too narrow or pointy. This is synonymous with loss of septal or lower alar cartilage support. Nostril deformities and asymmetries are common with each tip deformity. When the tip is too high, too much nostril exposure is seen. When the nasal tip is too narrow or a ‘unitip’, the nostrils often get a pinched look as its sidewalls bend inward. Interestingly, these tip deformities are more common today with the open approach which allows more extensive manipulation…sometimes too much.

Natural  rhinoplasty is mostly about rearranging nasal structures rather than simply removing them. In this way, the nasal dorsal line remains straight but at a good height, the end of the nose is lifted if needed but not too high, and the tip of the nose 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. Supporting the tip of the nose through columellar strut grafts, using small hand-carved grafts to improve tip shape, spreader cratilage grafts in the middle of the nose to open up breathing, and actually increasing the height and line of the nose through onlay or radix grafts are some of the methods by which the nose can be builtup and strengthened. These cartilage grafts are usually acquired from the septum of the nose (which may be simultaneously straightened) or from the back of the ear. Use of these maneuvers during a primary rhinoplasty will lessen the chance of the need for revisional surgery later.

What makes a rhinoplasty natural, for the most part, is to avoid the ‘operated’ appearance. Such appearances are from aggressive rhinoplasty maneuvers. While every patient wants a perfect result, most would choose a less noticeable more conservative result as an alternative if need be.  

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The correction of the crooked nose is one of the most challenging deformities in rhinoplasty surgery. It is difficult because it requires improvement of two nasal problems; a functional breathing problem and an aesthetically asymmetric appearance. The goals of this type of rhinoplasty is the creation of a rigid and straight nose that has an increased patency in internal nasal airflow.

The crooked nose is caused by a variety of derangements in the internal structures of the nose, dominated by the shape of the internal septum on the external appearance of the nose. They can be classified into five main types of nasal deviations. The most common is the caudal septal deviation also known as a septal tilt. This is obvious externally by looking at the shift in the nostrils. The anteroposterior C-shaped deviation is also common and is observed to have an external nasal deviation which is on the opposite side of the internal deviation. The others include an anteroposterior s-shaped and cephalocaudal c- and s-shaped nasoseptal devations. The diagnosis of these various septal deformities can be made primarily by visual speculum assessment and finger palpation. (which I find particularly useful)

Successful correction of deviated noses almost always requires an open rhinoplasty approach. This is the only way to truly see and release all deviated structures. All mucoperichondrial attachments must be released , meaning the upper lateral cartilages and the septum must be completely separated. Often such release can bring a near straightening of the septum. Then any deviated structures are removed which can include portions of the septum, the maxillary crest, vomer bone and the perpendicular plate.

The septum is then straightened and supported with spreader and batten grafts as well as using ethmoid bone grafts if necessary. The creation of a rigid and straight L-strut construct is critical. In very severe deviations, it may be necessary to completely remove the septum (extracorporeal resection) and fashion a straight L-strut ouside before re-inserting it. Once septal support is re-established, osteotomies of the nasal bone is performed followed by reduction of the size of the inferior turbinates.

While every step is critical in correction of the deviated nose, the fabrication of a straight and stable septal L-strut in the midline is paramount. Because of the natural memory of cartilage, if the septum is not stented by grafts there will be relapse and recurrent deviation. The reconstructed and stabilized septum is finally secured to the anerior nasal spine. Between the upper lateral cartilages and the anterior nasal spine, these are the only two fixation points.

After closure, it is critical to use some form of internal nasal support or packing. I am not a usual fan of nasal packing after most less complicated rhinoplasties and almost always use quilting sutures. But the extent of the mucosal dissection and cartilage grafting requires good compression of the mucosa against the septum to prevent internal adhesions and obstructive scarring. Some plastic surgeons prefer actual packing but I like to use Doyle plastic splints sutured in and removed a week later.

Correction of the deviated is one of the most difficult problems in rhinoplasty and has an historic high rate of either relapse or some residual nasal deviation. With this more aggressive cartilage resection and grafting approach, straighter noses after surgery are more likely to result with better long-term corrections.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Narrowing wide or flared nostrils can be a beneficial addition to some rhinoplasty procedures. This concept dates back to the name that is still used to describe it today, Weir wedges, from way back in 1892 when it was first described. At that time, the use of external alar wedge excisions was used to correct an unattractive alar flare. It was not until 1931 when narrowing of the alar base by using internal excisions from the nostril base and vestibular floor was first described. Its obvious benefit was to avoid the external scar that results from the traditional Wier wedge excision.

In assessing nasal base width, it is important to distinguish the width of the alar base and the degree of alar flare. The width of the alar base is the distance measured from one alar crease to the other, which ideally should equal the intercanthal distance. The alar flare is the degree of alar convexity above the alar crease.

An undesired wide nasal base can be due to wide nostrils, excessive alar flaring, or a combination of both. In wide nostrils, internal excisions from the nostril floor will result in narrowing of the nostrils and a true decrease in the width of the nasal base. In cases of excessive alar flare, external alar excisions will result in a decrease in alar flare but with no true decrease in the width of the alar base. Finally, in cases of a wide alar base associated with excessive flaring, effective nasal base narrowing can only be achieved by combining an internal vestibular floor excision with an external alar wedge excision.

A scarless technique for alar narrowing also exists which is the use of cinching sutures to pull the ala together from under the base of the nose.  The major advantage of the cinching suture technique is that no external incisions are needed. However, many limitations are associated with the use of this technique for wide noses with excessive flaring because it may lead to bunching of the floor of the nostrils and excessive rounding of the alae. It can, however, be combined with excisions from the vestibular floor or the alar lobule to prevent some of these problems. It is a technique that I have found very useful in LeFort osteotomies at the time of closure but is of more limited use for ideal nostril narrowing.

Alar base narrowing is performed as the final step in rhinoplasty. This is because any narrowing of the nasal tip or any change in tip projection will have a direct effect on the alar base shape. Only after the closure of all rhinoplasty incisions can the amount of alar base narrowing be judged properly. It usually can be known before surgery that it will be a useful step in the rhinoplasty procedure.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana   

Rhinoplasty is a well known operation that has a long history of changing the external shape of the nose. Non-surgical rhinoplasty is a more recent concept which can make some small changes to the nose through the use of injectable fillers. Small dorsal humps can be camouflaged by adding volume to the upper end of the dorsum.

In the spirit of the non-surgical rhinoplasty along comes a device offering similar promises. Known as the Nose Huggie, this is an external slimming device designed to decrease the size of a nose. It is a clip which is applied to the outer nose. To achieve results, it is to be applied to the bottom part of the nose for 15 minutes per day and results are purported to appear in several weeks up to a month after its use. While the manufacturer clearly states that it will not give the same results as a surgical rhinoplasty, it does state that it has been successful in changing the appearance of the nose for thousands of users.

This nasal compressive device purports to work by cartilage reshaping. Stating that cartilage is a flexible and malleable tissue, it can be gradually changed to a desired shape with appropriate pressure. To show how ’easily’ cartilage can be reshaped, they use the illustration of using your hand to push your nose back and forth and up and down with the resultant realization of how easily it can be moved. Applying pressure to flexible cartilage is how the Nose Huggie is supposed to correct the nose’s appearance. Further proof of concept comes in comparing it to the use of nose and ear expansion devices in African cultures

While the Nose Huggie is a cute device, the science behind how it is supposed to work is quite flawed. Cartilage is flexible because it is not stiff like bone, but this flexibility is cartilage bending not deforming or changing its inherent shape. Cartilage may resorb under continuous pressure but it will not change its shape. It most certainly won’t change its inherent genetic shape with low pressures of just a few minutes a day. Your nasal tip can be easily moved in three dimensions because the lower alar cartilages are only connected to the septum and upper lateral cartilages by fibrous tissue allowing it to be suspended but not rigidly fixed. This allows the nasal tip to be like a bumper on a car, able to withstand some impacts without permanent injury.

As a plastic surgeon do I think the Nose Huggie really works….no. But it is harmless to use it and it poses no risk of injury to the nose. What I do like about it, however, is that it may be useful for post-rhinoplasty surgery swelling. One of the common problems after rhinoplasty, particularly in thicker-skinned and certain ethnic noses, is prolonged edema of the skin particularly in the tip area. Intermittent application of the Nose Huggie may help get rid of this swelling faster and in a more controlled fashion than continuous taping or steroid injections. That may be its most useful role in changing the shape of the nose.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana  

The concept of a non-surgical rhinoplasty or nosejob has emerged with the popularity and widespread use of injectable fillers. For select nasal defects, most commonly to camouflage a small nasal hump, fillers are introduced by needle through the skin to get an immediate result. While it is not permanent, the use of longer lasting fillers can get results from this type of ‘rhinoplasty’ that may last six months or longer. The most common fillers used for this injectable rhinoplasty is that of Radiesse, although any filler composition may be used.

The appeal of this needle approach is that it is not surgery and gets an immediate effect with no recovery. But it is not permanent and the cost to maintain the result over time will eventually exceed that of a surgical rhinoplasty.

There is, however, an alternative to this injectable rhinoplasty that can be permanent and involves no synthetic materials. It is more than an office injectable treatment but short of doing a more formal open rhinoplasty. Using your own cartilage, small nasal defects can be treated by injection.

Diced cartilage is a well known method of cartilage grafting to the nose. Solid pieces of cartilage are cut into very small pieces, wrapped in surgicell or fascia, and then inserted as a flexible sausage-like graft. It is easily moldeable, even after surgery, and the cartilage is quickly revascularized and ingrown by native tissues. It has a near 100% percent volume survival.

A modification of diced cartilage nasal grafting is to convert it into an injectable technique. For small cartilage-deficient defects in the nose, it is not necessary to wrap it in a sleeve for introduction. The size of the pocket controls where the graft stays. It is introduced through an endonasal approach as opposed to a percutaneous needle method.

A septal cartilage graft is diced into very small pieces (1 x 1mm) or even smaller and then placed into a 1cc syringe for introduction. The size of the defect is measured by laying the syringe along side the defect and doing a volumetric assessment by pulling back on the plunger. The open end of the syringe is cut flush and then packed with the diced cartilage up to the measured pullback of the plunger. Small quantities of cartilage of .1 to .2cc can easily be delivered.

Through an intercartilagenous incision inside the nose, a narrow pocket for the pathway of the syringe is made up to the location of the defect. The graft is then injected and molded externally. It is then externally taped for up to a week until the graft is completely adherent and immoveable.

Even smaller quantities of diced cartilage (less than .05 to .1cc) can be injected through a smaller introducer. Using a 7 French suction catheter, the end can similarly be packed and then extruded once into position by the stylet that is usually used to clean it.

This injectable rhinoplasty technique for diced cartilage is especially effective for dorsal augmentation. It can be used to primarily augment above a small hump or correct any irregularities from dorsal osteotomies or fractures.

The key to success with injectable cartilage rhinoplasty is a precise tunneling technique and pocket control. It is important to keep the graft confined to the exact area of the cartilage deficiency.

This method of injectable rhinoplasty using one’s own cartilage may be a better long-term choice than the repetitive use of injectable fillers for small nasal defects.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana