Background: There are a wide variety of reasons why people seek out a primary or initial rhinoplasty. Since patients don’t usually know the names of the nasal anatomy or the terminology of the rhinoplasty surgeon, they have to describe their concerns in layman’s terms. Concerns such as a ‘big hump’, ‘fat tip’, or ‘bulbous nose’ are just a few of the most common. Thes descriptions alone makes it easy for the plastic surgeon to almost immediately identify as to the anatomic derangement and a general idea as to what needs to be done.
When prospective patients use the more broad term ‘big nose’ that can imply a variety of structural deformities. For some patients the entire nose is just very big with thick overlying skin. In others only a certain part of the nose is big, usually the tip, and it is out of proportion to the rest of the nose or the face. In many cases, but not all, the overlying nasal skin of the ‘big nose’ is thick…an issue relevant to how successful a rhinoplasty result can be.
Many so-called ‘big noses’ involve a wide and overprojecting nasal tip. The lower alar cartilages have a wide interdomal gap and they are elongated in the cephalic-caudal direction. In addition each dome itself is wide and is the lower alar cartilages elongated. As part of having a long nasal tip the underlying septum is also overgrown or too long.
Case Study: This 50 year-old female had always been bothered by her ‘big nose’. She had wanted a nosejob decades ago but was afraid that her nose would end up being packed and that she would have a lot of pain after surgery from having her nose ‘broken’. These concerns kept her from having the procedure hen she was younger. Now that her children were all grown she decided to do something for herself and do the one thing she had always dreamed about doing.
Under general anesthesia, an open rhinoplasty approach was used. The lower alar artilages were shortened 5mm through a lipsett technique, a cephalic trim was done of 6mms and the tip reshaped over and around a columellar strut graft. The caudal end of the septum wa shortened as well as a septal height reduction done after separating and then reattaching the upper alar cartilages. Some rasping was done on the distal end of the nasal bones as well. She was taped and splinted and the end of the procedure.
While she did develop some bruising under the eyes (from the rasping), she never had an ounce of pain after the procedure. She never took a single pain pill. Her tapes and plint were removed one week after surgery and she had the expected, but not excessive) amount of tip swelling. (moderately thick nasal skin) At one month after the procedure, although she had a way to go for all swelling to resolve, she already had a much better shape and size to her nose.
Changing a ‘big nose’ into a truly smaller one is rarely possible due to how much the enveloping skin sleeve can shrink down. But the ‘big nose’ can be altered to give a much better shape and proportion which makes it seem smaller and more pleasing in appearance. Much of that has to do with changing the lower third alar cartilages in size and how they relate to each other.
Case Highlights:
1) Complaints of a big nose often revolve around the size of the nasal tip being wide and long.
2) Tip reshaping is a main element of the big nose rhinoplasty but the structures above the nasal tip must often be modified as well.
3) The amount of structural changes needed to reshape a big nose requires an open rhinoplasty approach.
Dr. Barry Eppley
Indianapolis, Indiana