Specific Types of Rhinoplasty in Virginia, Washington D.C. and Maryland.
Types of Rhinoplasty
Alar base reduction or nostril narrowing is one of the most over abused procedures in rhinoplasty. Too often rhinoplasty patients end up with unnecessary nostril reduction.
Alar base reduction is performed to narrow the skin portion of the nasal base. From the base view, the triangular nasal shape is made up of several anatomic components: anterior nasal spine, caudal septum, the 2 lower lateral cartilages and the skin of the nostrils.
If the nostrils are too wide then they may be reduced. There are 2 sections of the nostrils that need to be evaluated and possibly reduced. The alar side wall and the alar sil. One or both of these segments may need reduction. Alar base reduction is always the very last step of a rhinoplasty. After everything has been completed (bridge work, osteotomies, tip work, etc) then the nostrils and ala are evaluated again to see if they still look too wide or not. If not then they should be left alone to avoid the alar base reduction scars. If they still look too wide then very careful and precise alar base reduction should be performed meticulously. Complete symmetry is impossible to guarantee but the measurement and reduction of the two sides should be as symmetric as possible.
Some times alar reduction is all that is needed to create a nice and balanced nose if the other parts are just fine. Other times, alar base reduction can be used to correct asymmetric nostrils that were that way as result of previous rhinoplasty or just hereditary.
The worse case scenario is over aggressive alar base reduction resulting in vestibular stenosis and breathing obstruction. Correction of such bad complications of poorly performed nostril reduction involves the use of auricular composite grafts of skin and cartilage from the ears to open up the narrow nostrils. These are very complex cases where function takes precedence over aesthetics so its best to avoid creating bad nose job results like this.
Alar base reduction may also be necessary when the nostrils are notched or retracted either genetically or as result of previous rhinoplasty. Auricular composite grafts of skin and cartilage from the ears are placed inside the nostril to “push down” the notched or retracted ala and then alar reduction is performed to “pull in” the nostrils. This is a very complex maneuver and should be left to experienced Rhinoplasty Specialist Surgeons.
Non-Surgical Rhinoplasty Virginia
“Non-Surgical Rhinoplasty” was not a medical procedure until just a few years ago. Essentially the Non-Surgical Rhinoplasty is a procedure where various fillers are injected into the nose in order to create a better contour to the nose without surgery. This procedure was coined and even trademarked and heavily promoted by Dermatologists and non-rhinoplasty-surgeons like Dr. Alexander Rivkin as the Non-Surgical Nose Job TM.
While the procedure does have a role and some merit, it is over used and abused by patients and doctors. In reality, it is a fine procedure but only when performed in the properly selected patient population.
The ideal candidates are:
- Patients who would benefit from cartilage onlay grafts to the dorsum, in a normal surgical Rhinoplasty. In such cases, “safe” fillers can be used in the office with little down time instead of placing cartilage grafts along the bridge of the nose.
- Patients who after a Rhinoplasty develop a slight indentation on the nose. Safe fillers can be used instead of a minor revision or while waiting until a minor revision.
- Asian patients who seek a higher bridge, depending on the tip position.
- Patients who realize the non-surgical nose job is not a replacement for a true Rhinoplasty.
There are significant limitations to the non-surgical nose job:
- Only safe Hyaluronic Acid fillers like Juvederm or Restylane should be used
- Artefill, Radiesse, Silicone and other longer lasting fillers should be avoided as they can result in severe irreversible scarring, granuloma reactions and hard to treat infections.
- Only small amount of safe fillers should be injected
- The nasal tip should generally be avoided
- Computer imaging should be done to show the patient what a non-surgical Rhinoplasty can achieve.
- For informed consent and full disclosure, patients should also be informed as to what a true Rhinoplasty can achieve. This means that the best person to perform a non-surgical Rhinoplasty is a Rhinoplasty Surgeon or at the very least a Plastic Surgeon rather than a nurse injector, Dermatologist, etc.
With the proper patient selection, education and expectation, nice results can be achieved with a non-surgical nose job. But ideal patient selection, as well as thorough education regarding realistic results and limitations is the responsibility of the ethical surgeon.
Typically, a non-surgical Rhinoplasty costs fractions of what a true surgical Rhinoplasty costs. There are always risks of infection or allergic reaction but when Juvederm or Restylane are used, the most common risk is a minor bruise. The down-time is practically none to perhaps a few days in case of a bruise.
Crooked & Twisted Nose Virginia
CROOKED & TWISTED NOSE RHINOPLASTY (Washington DC, Virginia & Chevy Chase Maryland)
Some say, “The essence of beauty is symmetry.” But in reality, symmetry is more an aspired ideal than a realized actuality. In fact, symmetric human faces are extremely rare. Over 85% of people have significant facial asymmetry. That is the norm. The eyes are almost never at the same level. The cheekbones are usually not at the same height or width. The mid part of the forehead does not often line up with the mid portion of the lips.
And the nose is not perfectly symmetric from side to side. These are all widespread norms of the human visage. It is extremely rare to find a very symmetric nose. How could the nose, a midline anatomic structure, be perfectly symmetric when the two sides of the face are almost never perfectly even? “If you were to build a house on uneven grounds, most certainly the house would be tilted.”
Classic anatomic studies have taken one side of the face, copied it, then flipped and used it to create a mirror image for the other side, and vice versa. Consistently, these two resultant faces, made from each left and right halves, have shown to be very different indeed. These studies highlight the significant, normal asymmetries of the human face, where the left half and the right half vary greatly. But these same studies have also shown that the asymmetric original face is often aesthetically more pleasing to the human eye than the perfectly symmetric left- or right-based versions.
So asymmetry is a part of the human face and a reality. A perfectly symmetric nose on an asymmetric face would not look right. It all has the blend and it all has to fit. A face can be asymmetric, yet balanced, harmonious and attractive. In fact, some of the most famous and attractive celebrities have extremely asymmetric faces (Tom Cruise, Shannen Doherty, Keira Knightley, etc). When the nose is awkwardly twisted, tilted, or crooked, it may draw excess attention to itself, relative to the rest of the face, creating an aesthetic problem.
Anatomic reasons for a crooked nose or a twisted nose or a C-shaped nose are:
- Asymmetric nasal septum (deviated septum)
- Asymmetric nasal bones
- Asymmetric middle vault cartilages (Upper Lateral Cartilages)
- Asymmetric tip cartilages (Lower Lateral Cartilages)
- Asymmetric alar rim length (nostrils)
- Significantly asymmetric facial bones
Clinical reasons for a crooked nose or a twisted nose or a C-shaped nose are:
- Congenital / Developmental
- Trauma
- Poorly performed previous Rhinoplasty
- Poorly healed previous Rhinoplasty
Lets briefly discuss healing after a Rhinoplasty and why healing forces may create asymmetries:
- Some surgeons prefer to create very strong and prominent post Rhinoplasty noses, using lots of rib cartilage to place 10 to 20 grafts in the nose. Such strong and wide noses withstand the healing forces and scar tissue contracture better than average. But most patients do not like having a larger, wider, stronger nose after a Rhinoplasty. Most patients will not want to wait 3-5 years for the rib cartilage to melt and mold before their nose looks aesthetically acceptable. Most patients prefer aesthetic, beautiful, natural and refined noses. Most patients want to see immediate improvements after a Rhinoplasty and be able to enjoy their new nose even the week after a Rhinoplasty. If a post Rhinoplasty nose looks significantly better as early as 7 to 10 days after a Rhinoplasty, patients will enjoy and witness the rest of the refinement and healing over the following 1 to 3 years. But patients should not have to wait for 3 years to start enjoying their new nose after a Rhinoplasty. However, there is a trade off and each patient has to make a decision between wanting a “cuter” nose or a stronger nose that withstands scar tissue forces. Either is fine as long as the patient is fully informed, and an active part of the decision making.
- To understand scar tissue after a Rhinoplasty lets use an analogy in carpentry: Imagine you hire a carpenter to shave down the wooden legs of your dining room table, to create a more refined shape. The newly refined table would look great, forever, if it weren’t for weight exerted on the tabletop. The problem will be if someone comes along and sits on the new more slender looking dining room table. At that point, the smaller, sleeker wooden legs may not be able to withstand this new weight and will buckle or break. If the table is analogous to the nose, then the weight on the newly modified table is scar tissue after a Rhinoplasty. Scar tissue is what changes the nose after a Rhinoplasty. Scar tissue is inevitable. It will occur. And it will change the results of the Rhinoplasty from week, to month to year to decade. But good a-traumatic technique can minimize scar tissue. Good technique also involves good judgment in creating a more refined nose but also one that can decently withstand the healing forces of scar tissue contracture after a Rhinoplasty. Scar tissue forms after any surgery but with the nose, it is especially important. Scar tissue forming deep inside the abdomen after bowel surgery is not visible (although it can create its own specific set of problems). But scar tissue on the 3-dimensional nose can distort things while the nose heals. Stronger, larger, thicker noses with more cartilage and thicker skin, will withstand the twisting forces of scar tissue. There will always be scar tissue but stronger noses will not be influenced as much. However, scar tissue should never scar or deter a realistic patient from undergoing a Rhinoplasty. As long as a patient understands that a Rhinoplasty Specialist Surgeon can improve the nose significantly, then slight changes to the nose as it heals, over the life of the patient, should not matter. Perfection is an ideal but not a reality. Significant improvement is the actual goal of Rhinoplasty. The nose should not become worse but rather it should be greatly improved after a Rhinoplasty. In experienced, skillful and artistic surgical hands, this is very possible. Realistic patients should take comfort in this fact. But more importantly, a patient who accepts nothing less than “perfection” or demands “100% symmetry,” is not a candidate for elective Rhinoplasty.
✓ Scar tissue is the enemy after a Rhinoplasty
✓ A non operated nose does not have scar tissue acting upon it
✓ A post Rhinoplasty nose has scar tissue forces acting upon it for months and years.
✓ Scar tissue is inevitable
✓ Scar tissue takes 2-3 years or even longer to mold and mature
✓ Scar tissue contracts and shrinks as it matures. These forces can pull the nose from side to side.
✓ A post Rhinoplasty nose is often smaller, weaker and more susceptible to forces exerted by scar tissue and healing.
Rhinoplasty techniques for correction of a crooked nose or a twisted nose or a C-shaped nose are:
- Septoplasty to correct a deviated septum. The inside and outside of the nose are intimately connected. When one is deviated, it often “pulls” the other with it and vice versa. Correction of a deviated septum occasionally requires correction of a deviated external nose. Correction of a deviated external nose often requires correction of a deformed septum.
- Osteotomies to correct asymmetric nasal bones. Asymmetric osteotomies are often needed: Double osteotomies on the longer nasal bone.
- Correction of asymmetric Upper Lateral Cartilages or dorsal septum using spreader grafts.
- Correction of asymmetric Lower Lateral Cartilages with proper grafting and suture tip techniques.
- Alar augmentation, reduction or support to correct asymmetric alar rim length (nostrils).
- Surgery to correct or augment significantly asymmetric facial bones
Cartilage sources for grafting are septal cartilage, ear cartilage and rib cartilage.
Droopy Tip Virginia
The position and shape of the nasal tip is determined by 3 factors:
- Skin:
* Thick vs Thin skin - Intrinsic Nasal Tip:
* Shape and size of the Lower Lateral Cartilages (LLC) - Extrinsic Nasal Tip Position:
* Size and shape of Caudal and Dorsam Septum at the Anterior Septal Angle.
* Size of Anterior Nasal Spine - Support mechanisms
- Dynamic ptosis (droopy tip when smiling)
These factors contribute to the shape and character of the nasal tip.
Skin is the blanket that covers the bone and cartilages of the nose. The skin on the tip can be thin and reveal the shape of the Lower Lateral Cartilages or the nasal tip skin can be thick and completely hide the shape of the underlying cartilages. Ideally the nasal tip skin is medium thickness but “ideal” is rare and a skilled rhinoplasty specialist surgeon can and should work with the individual’s anatomy to create a pleasing and appealing nose.
The actual shape and size of the Lower Lateral Cartilages (LLC) determine a large part of the shape of the nasal tip. These cartilages are often modified through various rhinoplasty techniques and maneuvers to create a more cosmetic nose tip. However, these cartilages themselves sit on top of the underlying foundation of the nose: Septum and anterior nasal spine. Occasionally an unattractive tip may be due to the underlying septal framework and not the actual tip cartilages themselves. This is easy to miss by the novice plastic surgeon. Diagnosis of the nasal problem is the most crucial initial aspect of any nasal reshaping surgery.
The nasal tip needs to have proper structural integrity and support. A nose tip that is too pliable and easily “squishy” will droop more when smiling and will droop more over time as the patient gets older. Support can be added with sutures or grafts. Columellar strut grafts are very commonly used to support the nasal tip.
Dynamic ptosis or drooping of the nasal tip when speaking or smiling is commonly due to a weak tip support &/or strong septal muscles (depressor septi muscle ) pulling the nasal tip down in motion. Botox can temporarily relieve the action of the septal muscles and prevent dynamic ptosis (drooping) or the muscle can be cut surgically and then the tip supported with grafts to prevent the nose tip from dropping down.
Feminization vs. Masculinization Virginia
While this may seem to be a very important topic carrying with it potential underlying psychological issues, sexual identity issues and body dysmorphic issues, it is also a very simple concept at some levels. For example, a very petite and attractive female patient with a large and masculine nose will want to undergo a feminization reductive Rhinoplasty to create a nose that fits her face and stature better. There is nothing unusual about this scenario. A very tall and muscular male patient with a small, upturned nose may want to balance his face by undergoing an augmentative masculinization Rhinoplasty. He may have been born with his current nose or more likely it may have been the result of a botched nose job by another plastic surgeon.
Yet there are patients who want to completely change their faces, noses and even identity. Some patients desire concurrent eyelid surgery, eyebrow surgery, facial implants, orthognathic maxillo-facial surgery, lip surgery, etc. While an older patient desiring a facelift and a concurrent Rhinoplasty does not raise any suspicions, a younger patient desiring Rhinoplasty and a series of facial altering cosmetic surgeries should raise some questions. Questions do not necessarily mean this patient is not a candidate for elective facial plastic surgery but questions must be asked and satisfactorily answered before proceeding.
While Rhinoplasty is very common amongst gay and lesbian patients and the evaluation is not any different than heterosexual patient seeking Rhinoplasty, Transgender patients do require much deeper evaluation and psychological screening prior to proceeding for elective Rhinoplasty. Even the most cautious, safe and ethical Facial Plastic Surgeon like Dr. Naderi only gets to see and know his Rhinoplasty patients during several consultations, while each patient’s family, friends, primary care doctors and psychiatrists will undoubtedly “know” the patient better and their input is invaluable.
Male Rhinoplasty Virginia
Hump Removal (Dorsal Bump) Virginia
Dorsal hump reduction or nasal bump (hump) removal is perhaps the most common type of nose job. The hump or bump on the nose bridge is often made up of a combination of extra high nasal bone in the upper third of the nose as well as extra high nasal cartilage in the middle third of the nose (middle vault). There is usually also an extra high dorsal septum contributing to the nasal dorsal hump or bump. The case of the dorsal hump must be evaluated and the individual components must be addressed – often individually. Too often a plastic surgeon will take a chisel and remove either too much bone or too little middle vault cartilage or too much septum and end up with either a scooped out (ski slopped) nasal bridge profile or alternatively not take enough and end up with a different shaped or just a smaller version of the initial dorsal hump.
Another common mistake plastic surgeons make is creating a “Polly Beak” by removing too much nasal bone and not removing enough middle vault or supra tip cartilage. The facts are that even something “as simple as” “just removing a bump on the nose” can be done properly or poorly. We see patients who come in for Revision Rhinoplasty consultation who have gone elsewhere and had a plastic surgeon completely miss the mark and end up ruining “a simple hump removal.” The reality is nothing is simple when it comes to rhinoplasty ad rhinoplasty is the most complex of all plastic surgery procedures. But when an experienced and skillful rhinoplasty specialist surgeon carries out a rhinoplasty, patients usually end up with the highest chance of a successful nose job outcome.
Finally, many patients assume that trauma to their nose during childhood, such as getting hit to the nose by their 8 year old brother’s toys, cause their nose hump. In fact, the vast majority of nose humps are genetic and due to the natural growth of the external nose and septum. Situations where trauma creates a dorsal hump are when the middle vault and tip get hit so hard that they collapse and result in the appearance of a bony dorsal hump. Proper diagnosis is required because the proper correction involves addition support to the nose tip and middle vault and not simply taking down what appears to be extra nasal bone. If not diagnosed and treated properly, this type of nose job can result in a more dramatic saddle nose with lack of bridge definition.
Long Nose Virginia
The primary goal of cosmetic Rhinoplasty is always to bring balance and harmony to the face. This is accomplished by reducing attention to the nose and redirecting it to the beauty of the eyes and lips. As such, the nose has to fit the face. It cannot be too long, too short, too wide or too narrow. It must be just right.
A long nose is a nose that is simply too long for the face. This is always relative to the patient’s sex, age, height, facial size and proportions. For example, occasionally a nose is best left “too long” in order to balance and offset a forehead that is too long, or a chin than is too strong. Creating an “ideal nose” in such situations would direct undue attention to the less-than-ideal forehead or chin.
A long nose can be too long in the vertical dimension (superior-inferior or cephalic-caudal), &/or it can also be too long in the horizontal dimension (anterior-posterior). Typically on profile view, the nasal starting point for white (Caucasian) patients is usually at the level of the “superior eyelid crease.” For African American and Hispanic patients, the nasal starting point is usually at the level of the pupils. The length of the nose in the vertical dimension is essentially equal to 1/3rd of the length of the face or slightly less. The length of the nose in the horizontal dimension is known as its “projection.” Projection of the nose should be roughly equal to the length of the upper lip. We have discussed these proportions in other chapters of this Online Textbook of Rhinoplasty.
{It is important to note that as Rhinoplasty Surgeons, whenever we are reviewing and discussing Facial or Nasal Analysis, we have to use proper photographs. Proper photographs are taken with an SLR camera (digital or film) using a 105mm lens. A Single Reflex Lens camera with a 105mm Macro lens creates the least photographic distortion and artifact. Essentially the photograph is as true to life as possible. Significant distortions are seen with point-and-shoot cameras, and cell phone cameras, such as the ones often submitted online using the iPhone. For a Rhinoplasty Surgeon to be able to make proper measurements and analyze the nose, the subject’s face must be in a standardized position. The Frankfort Horizontal Line (a line drawn from the upper edge of the ear canal to the lower orbital rim) must be parallel to the floor.}
Once the Rhinoplasty Surgeon has made the diagnosis of a “long nose,” the proper surgical techniques must be employed to create a beautiful but natural looking nose. These Rhinoplasty maneuvers should be used meticulously and incrementally, from least invasive to more aggressive until the desired results have been achieved.
Having a frank discussion between the Plastic Surgeon and the patient is very important. Similar to how there is only so much a short nose can be safely lengthened, there is only so much a long nose can be safely shortened as well. Often the rate-limiting factor is the skin and soft tissue envelope. If the nose is made significantly smaller or shorter, there may be “too much” skin left over. While most of the time, after a Rhinoplasty, nasal skin “shrink wraps nicely over the newly modified cartilage and bone framework, too much skin will not. These rare, but important Rhinoplasty cases create situations, where the inability of the skin to drape and shrink-wrap over the nasal framework, leaves a space between the skin and deeper cartilages. This space is initially occupied with fluid (edema or swelling) after the Rhinoplasty. But over a matter of weeks and months, this edema fluid is replaced with scar tissue. This problem is most often seen in Rhinoplasty patients with very thick and stiff skin. Thick skin is much less likely to simply drape and shrink-wrap over the deeper cartilages and bones of the nose. In many situations, serial monthly conservative steroid injections may be necessary to “melt” this scar tissue and allow the skin to settle over and adhere to the nasal framework. However, in cases where the nasal cartilages and bones where made significantly smaller (too small), the skin may be unable to adhere properly, creating less than desired results. Experienced Rhinoplasty Surgeons must not make such mistakes. More importantly, Rhinoplasty Surgeons must educate their patients during the Cosmetic Rhinoplasty consultation, using computer imaging, about such pitfalls and limitations. This way, each Rhinoplasty patient will be able to visualize the limits of Rhinoplasty prior to surgery. In certain cases the nose simply cannot be made that much smaller or shorter, just like in other cases, it cannot be built up greater than a certain length or size. There are limits and being realistic is crucial in achieving excellent Rhinoplasty results and having happy Rhinoplasty patients. In all cases, an experienced Plastic Surgeon should be able to significantly improve the nose and deliver very nice Rhinoplasty results.