Rhinoplasty surgery can create changes in many aspects of the nasal anatomy. Most of those changes are typically focused on the bone and cartilage that makes up all of the internal and underlying support of the shape of the nose. The one exception to ‘framework’ modification is that of changing the shape of the nostrils.
Nostril shape change or alarplasty is most commonly done to alter the width of the nose. Known as nostril narrowing, the width of the nostrils can be narrowed by two basic techniques. It can be done by either removing skin from the nasal sill inside the nostrils or carrying the nostril skin excision around the sides of the nostrils for a more dramatic nostril shape change. The latter is usually done as part of many ethnic rhinoplasties.
But the position of the base of the nostrils can be changed in another dimension as well. They can also be lowered to a more inferior position as well. This is done by removing a crescent of skin which brings the nasal base lower when closed. Usually up to 4 to 5mms of lowering can be achieved.
Alar base lowering can be done for a variety of reasons. These can include too high an alar position after deprojection of the nasal tip, alar retraction due to scarring or contracture from prior nasal base or upper lip procedures, congenital deformities such as cleft lip and palate and combined with alar width reduction to affect a 3D alar base change.
Bruising after certain elective facial procedures is very common and expected. While well tolerated by patients, given that they have no choice, any reduction of its extent and duration would be appreciated. Rhinoplasty is one of those facial procedures that is well known to cause considerable bruising when osteotomies (breaking of the nasal bones) are done as part of the nasal reshaping. It creates the classic ‘raccoon eyes’ as the blood released by the cut nasal bones tracks along the lower eyelids/cheek tissue junction.
In the May 2016 issue of the Annals of Plastic Surgery, a paper was published entitled ‘Perioperative Arnica Montana for Reduction of Ecchymosis in Rhinoplasty Surgery’. In this paper thirteen patients who had rhinoplasty surgery with nasal bone osteotomies were prospectively randomized to receive either oral perioperative Arnica Montanaor a placebo in a double-blinded fashion. Ecchymosis (bruising) was measured in digital photographs at three after surgery time points as well as its extent based on color assessment. Nine patients taking Arnica Montana had less bruising on days 2, 7 and 10 by 16%, 33% and 20% respectively compared to the control patients.
The authors conclude that Arnica Montana seems to accelerate postoperative healing, with quicker resolution of the extent and the intensity of ecchymosis after osteotomies in rhinoplasty surgery, which may dramatically affect patient satisfaction.
Arnica Montana, a homeopathic remedy as an extract of a flower, is given routinuely before and after many types of plastic surgery. It is particularly used in facial surgery where the very visible appearance and prolongation of facial bruising is the most distressing to patients. Arnica Montana is widely used because it has no known adverse effects and that it is believed to create reduced bruising. But there is limited clinical evidence of its effectiveness. This study adds support to its continued clinical use.
How does Arnica Montana potentially work in reducing and clearing bruising? The active ingredients of Arnica are sesquiterpene lactones, such as helenalin and 11,13- dihydrohelenaline and chamissonolid. These two sesquiterpene lactones have been shown to inhibit collagen-induced platelet aggregation and thromboxane formation. By having an effect on platelet aggregation, less bruising theoretcically occurs and clot/bruisinhg may be cleared faster.
Aging affects all facial tissues to some degree including the nose. The effects of time on the nose occurs at the nasal tip where the cartilages are help up by ligaments to the cartilage structures of the middle value. The effects of age on the nasal tip are that some increased droop can occur as the ligaments weaken or stretch. This makes the tip go down slightly and the nasolabial angle lessens.
The typical treatment for a drooping nasal tip, at any age, is to lift and support the lower alar cartilages in a more upward position. This could involve trimming of the upper edge of the cartilage, suture suspension or a combination of both. This us usually done from below through an open rhinoplasty approach.
In older patients with nasal tips that droop or in older patients that have been through a rhinoplasty and do not want any further open rhinoplasty surgery, an alternative approach would be a ‘nasal lift’. Like anti-aging procedures on the face this involves the use of skin excision at a distant location to create its effect. No cartilage manipulation is done.
Using a horizontal skin excision at the bridge of the nose (frontonasal angle), the tip of the nose is lifted from the upper nasal tissue closure. Because the tip is at some distance from where the lift is created, the amount of nasal tip elevation would be slight. (1 to 2mms)
While the removal of nasal skin and the creation of a fine line scar in the upper nose may seem ‘radical’, it really is not. The location of a fine line scar is at the frontonasal junction which is a natural skin line when one lifts their nose or squints. Many older patients already have a fine line skin wrinkle there already.
A nasal lift is a very uncommon procedure that would only be for a very specific type of nose patient. One must be older, have an established frontonasal crease and desire only a minor amount of nasal tip rotation.
Primary or secondary correction of nasal bridge deformities is now well known to be corrected by injectable fillers. The use of hyaluronic acid-based (HA) injectable fillers provides a quick and very directed approach to a wide variety of nasal contour deformities. While effective, no HA filler to the nose provides a permanent contour correction in the vast majority of patients.
I have run across a handful of patients that stated they had gotten one HA injection to the nose years ago and the result was sustained. But it is hard to know whether this is merely cosmetic accommodation or was indeed a ‘permanent’ result. I suspect that of the nasal contour issue was significant, such a permanent result would not have been seen. I know from injecting a lot of dorsal hump patients with HA fillers to camouflage it (placing filler above the hump to create a straight dorsal line) that such filler volumes are not sustained in the nose.
An alternative and permanent options for larger primary or secondary dorsal line defects is that of a diced cartilage graft injection. This is a concept that, while injected, must be differentiated from that of HA filler injections. This is where cartilage grafts from either the septum, ear or rib are processed to make them injectable. This is done by cutting (dicing) them into small 1 x 1mm cubes (or smaller) and placing them into an open barrel 1ml syringe.
Through an intranasal (intercartilaginous) incision, a tunnel is made on the dorsum up onto the upper dorsal defect area. (frontonasal junction, radix, nasal sidewall) The syringe is introduced and the compressed cartilage grafts are injected in the desired amount and shaped externally. The grafted area is taped to hold the desired shape for 7 to 10 days.
While many diced cartilage are traditionally wrapped in surgical or fascia, there is a role in smaller nasal dorsal defects for direct injection of the cartilage. The small nasal tunnel and confinement of the syringe allow the cartilage particles to be precisely delivered.
Background: Depressions along the dorsal line or bridge of the nose can be caused by a wide variety of reasons. Trauma, congenital deformities and adverse outcomes from a prior rhinoplasty can create dorsal line irregularities and indentations. The use of cartilage grafts for their correction would be a standard approach.
Cartilage grafts can be obtained for either the septum, ear or rib donor sites. The septum is always the first choice because it is a straight piece of cartilage and can offer a fair amount of graft material. But this donor site is often depleted from prior harvesting. The ear is the second choice but it is not ideal for the dorsal line because it is curved graft with low volume. The rib provides an unlimited amount of cartilage but leaves a subcostal scar from its harvest and is prone to warping and edge visibility.
The shape inadequacies of rib cartilage can be gotten around by using a technique known as ‘diced cartilage grafting’. In this technique the rib cartilage is cut into small pieces and placed in a variety of containment wraps. Once the particulated cartilage graft is placed, it can be digitally molded into the desired dorsal line shape.
Case Study: This 45 year-old female had a rhinoplasty done several years before which left her with multiple aesthetic nasal shape concerns. Most prominently there was a depression from the tip backwards up to the middle portion of the dorsum. The left nostril and nostril rim was also collapsed and she had trouble breathing in and out of the left nostril.
Under general anesthesia, a portion of the left #9 rib (3 cms) was harvested through a small subcostal incision. The rib graft was diced into 1 x 1mm cubes which were compressed into a syringe. Surgical collagen mesh was wrapped around the syringe and the diced cartilage injected into it creating a diced cartilage ‘sausage’ graft. Through an open rhinoplasty, a left spreader graft was placed in the middle vault as well as a left alar rim graft. The diced rib cartilage graft was then cut to the length needed and the graft placed along the dorsal defect.
Her after surgery results showed improvement in the dorsal line of her nose as well as the shape of the left nostril. She could breathe a lot better through the left side of her nose.
Rib grafts to the nose provide all the volume any rhinoplasty procedure would need, particularly for dorsal augmentation. Its main disadvantage of graft warping can be eliminated by the creating a diced cartilage graft. Different surgeons use containment wraps from surgical mesh, fascia and thin allogeneic dermis. I have used all of these diced rib graft rhinoplasty methods but have not seen any major differences in outcomes between them.
1) Dorsal depressions of the nose can be treated by a variety of materials and cartilage grafts.
2) Larger dorsal deformities with other nasal reconstructive needs requires a bigger cartilage graft than one may think.
3) A diced rib graft rhinoplasty provides both ample augmentation volume and avoids any risks of warping or graft irregularities.
Significant augmentative rhinoplasty of the dorsum usually poses a choice between a synthetic implant and a rib cartilage graft. When choosing a rib cartilage graft, the options are to use it as a carved solid graft or to dice it and assemble it as a moldable wrapped cartilage graft. Introduced back in 1989, a finally diced cartilage graft became known as a ‘Turkish Delight’ because of its conceptual introduction by Turkish plastic surgeon.
The original technique description was to dice the cartilage graft into 0.5 to 1mm cubes and then wrap it with resorbable Surgicel collagen mesh. This original rhinoplasty grafting technique has been modified over the years by others using the patient’s own fascia instead of Surgical and moistening the small cartilage cubes with PRP. (platelet rich plasma)
In the February 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘ Long-Term Results and Refinement of the Turkish Delight Technique for Primary and Secondary Rhinoplasty: 25 Years of Experience’. The original developer of this rhinoplasty cartilage grafting technique summarized his experience with it in close to 10,000 patients over a 25 year period. The patients reviewed were anywhere from 4 to 25 years out from their initial surgery. Both primary (7700) and secondary (2300) rhinoplasties had the cartilage grafting technique used. They report very low complication rates with its use including less than 1% incidences of prolonged swelling, overcorrection and resorption. They reported no infections or graft show over the short or long term followup.
Particulating a cartilage graft for nasal implantation into small particles predictably eliminates the issue of graft visibility. The controversial aspect of the diced cartilage graft technique is the material used to contain. Surgicel is the original mesh wrap and is well known as a resorbable hemostatic material. It is made of an oxidized cellulose polymer (polyanhydroglucuronic acid) derived from plant fibers. It works by absorbing fluids which causes platelet plug formation to stop bleeding. The plant cellulose breaks down once it becomes wet and this results in a more acidic pH around it, giving it in contact with moisture which lowers the pH (more acidic). This gives Surgicel a bacteriostatic property. The cellulose material is rapidly eliminated, initially by absorption of the sugar acid uronic acid within the first day after implantation, and then days later by macrophage digestion of the fibrous residue.
Some controversy exists about whether to use Surgicel or the patient’s fascia to contain the diced cartilage graft for placement into the nose. The author stands by his contention based on his experience that Surgicel does not induce cartilage graft resorption. It does, in fact, create a the smooth enveloping fibrocartilaginous layer under the skin that prevents graft visibility.
This paper supports the contention that wrapped diced cartilage grafting has revolutionized the approach to dorsal augmentation in rhinoplasty. In my experience this become really significant in larger rib grafts where warping and cartilage outlien show are not uncommon.
Background: Many anti-aging facial procedures are done in middle aged patients or older. Whether it be a facelift or blepharoplasties, it take some aging to need these procedures to help turn back the clock. But when it comes to rhinoplasty, it is usually the opposite. This facial restructuring procedure is often done in younger patients between their teen years and up to middle age. Because it changes the structure of a facial feature, it is usually done in younger patients for improved self-esteem and social acceptance.
But just because one doesn’t have a rhinoplasty done when they were younger does not mean they may have not liked their nose. For many older patients that have always disliked their nose, it is often an issue of opportunity and even economics. Older rhinoplasty patients may be motivated by a desire to improve their breathing but, for cosmetic purposes alone, it may just have not been possible until they were much older.
Older rhinoplasty patients may also have discovered that their nose has gotten bigger or longer. The old phrase ‘getting longer in the tooth’ applies to the nose as well. With age the nasal tip cartilages can weaken and the tip becomes more droopy. This can become really magnified in a nose which naturally has always had a bit of nasal droop. (more acute nasolabial angle)
Case Study: This 79 year-old woman of German descent had a nose with a large hump and a long and protruding tip. She had always wanted a nose job but never had the opportunity.
Under general anesthesia, she had an open rhinoplasty done. The large nasal hump was reduced of bone and cartilage. The height of the septum was reduced and the tall upper lateral cartilages were folded into spreader grafts. The end of the septum was shortened and the nasal tip cartilages shortened and rotated upward. Alar rim grafts were also done.
Her postoperative results at two years after surgery showed a good change in her nasal shape. Her nose was smaller and better proportioned but maintained good support and she had no breathing problems.
One can have an elective rhinoplasty at an older age as long as they are in good health. Her result proves that it is never to late to correct a facial feature that one may have always disliked.
Rhinoplasty can be safely done even up to 80 years of age
Reshaping of a large protruding nose can be done through bone and cartilage reduction while still maintaining structural support.
3. A true senior rhinoplasty (in the 70s and 80s) is rare but proves it is never too late to correct a lifelong aesthetic facial concern.
Background: Rhinoplasty is one of the most common facial plastic surgery procedures performed. It is also the dominant facial reshaping procedure that has been performed for over a century. Historically and up to the present day removal of a hump or a lowering of the bridge of the nose is one of the most common patient requests for the procedure.
A straight line of the nose in profile, also known as a straight dorsal line, is a desired aesthetic feature of a nose. The major portion of the dorsal line is in the upper half of the nose and is comprised of the union of the lower edges of the paired nasal bones and the septum and upper end of the paired upper lateral cartilages. When the septum overgrows underneath the union of the nasal bones and upper lateral cartilages raises up creating varying degrees of a prominent nasal hump.
Reduction of a prominent nasal hump is one of the most commonly understood techniques in rhinoplasty. By removing the high portions of the nasal septum and the ends of the nasal bones, a flat plateau is created. Re-establishment of a narrow roof or dorsal line is created by collapsing the nasal bones inward. This is done by the classic cutting or breaking of the nasal bones at different levels so that they move inward.
Case Study: This 26 year female had always disliked her nose with the most dissatisfied area being that of the prominent hump. She also did not like the tip of her nose which she felt was thick and bulbous. Computer imaging done before surgery showed what type of result was realistically possible. Her request was to have a dorsal line that was a but dipped as opposed to a perfectly straight dorsal line.
Under general anesthesia and through an open rhinoplasty, her nasal hump through septal cartilage and nasal bone removal was done. Medial and low lateral osteotomies were done to close the open roof which were also rasped smooth. Her septum was straightened and a grafts harvested and used as spreader grafts between the septum and the upper lateral cartilages. The tip cartilages were reduced/shortened and reshaped for a more narrow and uplifted tip.
The success of many rhinoplasty surgeries hinges on how well a nasal hump is reduced. At the least most patients want a straight dorsal line with no evidence of any residual hump. Men almost always prefer a high straight dorsal line while some women want may want a slight concavity to it. With dorsal hump reduction the nasal tip becomes even more prominent and often needs to be reduced and reshaped as well.
One of the most common requests by patients considering rhinoplasty is removal of a prominent hump on the bridge of the nose.
Hump reduction in a rhinoplasty is a combination of bone and cartilage reduction.
While many patients think that all they need is a reduction of the hump, rarely would this be the only maneuver needed in their rhinoplasty.
Background: The shape of the nasal tip is primarily affected by its anatomic composition. The size, thickness and length of the lower alar cartilages create the major shape of the lower third of the nose. Combined with the thickness of the nasal skin over these cartilages the shape of the nasal tip is defined.
The nose is a fairly stable structure throughout one’s life being located in the very center of the face. Supported by bone and cartilage, the composition of the nose is more hard tissue than soft tissue. The rest of the face around the nose undergoes well known aging changes but the nose is less affected. But that does not mean that it does not age at all.
Numerous people feel that their nose has become ‘bigger’ as they have gotten older. Just as teeth can age as known by the historic phrase ‘long in the tooth’ (due to soft tissue gingival recession), the nose can have its own unique set of age-related changes.
Case Study: This 60 year old female has always felt she had a long nose and had wanted a rhinoplasty for some time. As she had gotten older she felt her nose has gotten longer and wider.
Under general anesthesia she has an open rhinoplasty. Her lower alar cartilages and caudal septum were shortened and the tip reshaped. She had no work done on the upper half of her nose to change her dorsal height and nasal bony width.
Her one year results show descreased nasal tip length and slight upward nasal tip rotation. Her nasal tip was also less wide.
As people age the nose does actually become a bit longer and and the nasal tip may develop more of a droop. This is a well known phenomenon due to weakening of the nasal tip ligaments where the cartilaginous tip complex can ‘slide’ slightly off of the upper lateral cartilages and bone. This can take a nose tip that is already long and heavy to become more so. Rhinoplasty surgery can have a nose aging reversal effect with tip deprojection surgery.
1) The overprojecting nose that is accentuated by aging is one where the lower alar cartilages are long, creating a nasal tip that sticks out too far and may droop down.
2) Rhinoplasty for the overprojecting aging nose shortens the lower alar cartilages and brings the tip back and up. (deprojection)
3) Surgical manipulation of the lower alar cartilages also allows the width of the nasal tip to be narrowed as well.
Background: The wide variety of nose shapes that exist around the world have been attempted to be classified by multiple approaches. One type of nasal shape classification, known as leptorrhine, mesorrhine and platyrrhine, are based on the nasal indices. The nasal index is the ratio of the widest part of the nose to its length multiplied by 100. If the nasal index falls under 70, the nose is said to be leptorrhine. (narrow-nosed) If it is over 85 the nose is said to be platyrrhine. (broad-nosed) In between lies the mesorrhine nose shape. There are known relationships between geography, climate, body weight and nose shape as expressed by the nasal index.
Facial shapes and the noses that lie within are influenced by geography. Europeans, for example, have long and more narrow faces with a wide variety of nose shapes. Nasal shapes among Europeans is most commonly mesorrhine but this changes by region such as the Mediterranean and Western Europe being more leptorrhine while Eastern Europeans and the Balkan region more commonly having platyrrhine nasal form.
Ethnic rhinoplasty is usually defined as that of non-Caucasians. (mesorrhine or platyrrhine nose shapes) Often these noses are accompanied by thick or thicker overlying skin usually of a more sebaceous quality. The nose may often be long and droopy with a dorsal convexity. Getting good nose refinement in the tip area can be challenging with the droopy tip having a thick and fatty skin quality to it.
Case Study: This 20 year old female of Czech family origin had always wanted a rhinoplasty to reshape her nose and make it more thin and shapely. She had a wide and droopy nasal tip with thick skin. Her profile showed no hump or dorsal convexity but an overprojecting and under rotated nasal tip with long lower alar cartilages and very thick skin.
Under general anesthesia, she had an open rhinoplasty performed focusing on nasal tip reduction/reshaping with small dorsal reduction and narrowing osteotomies. Her postoperative course was marked by blunt trauma to the tip of the nose resulting in extreme swelling. It became apparent that once the swelling went down that the tip reshaping had become undone. After waiting one year a secondary tip rhinoplasty was done to recreate the original internal rhinoplasty effort.
Eastern European or Slavic rhinoplasty is aimed to correct the drooping tip, which is often covered with thick skin, and put it into better alignment and size with the rest of the nose. The thick nasal skin, as it is in any rhinoplasty, is a controlling factor in both the recovery process and in the final result.
1) Ethnic rhinoplasty in the Eastern European nose often deals with broad and drooping nasal tips with thick skin.
2) Getting good nasal tip definition by narrowing and derotation are key rhinoplasty manuevers in the Eastern European nose.
3) If secondary rhinoplasty is needed in the Slavic Rhinoplasty six to twelve months should pass before doing so.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.