Specific Types of Rhinoplasty in Virginia 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:

1. Skin:
   * Thick vs Thin skin
2. Intrinsic Nasal Tip:
   * Shape and size of the Lower Lateral Cartilages (LLC)
3. Extrinsic Nasal Tip Position:
   * Size and shape of Caudal and Dorsam Septum at the Anterior Septal Angle.
   * Size of Anterior Nasal Spine
4. Support mechanisms
5. 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

Men have always been interested in Rhinoplasty and male patients make up a significant portion of the nose job seeking population. Most men desire simply a better nose and want a natural looking improved nose. Most men do have a healthy attitude towards male Rhinoplasty and have proper realistic expectations. However, there are some men who should not be offered Rhinoplasty due to their psychological characteristics and predisposition. Some Plastic Surgeons have gone as far as refusing to operate on any and all male Rhinoplasty patients in order to avoid operating on this small but troubling segment of the nose job seeking population.

For all men, computer imaging is crucial. Men are not used to drastic changes of their facial appearance. Unlike female patients who may be comfortable with makeovers resulting in changes in hairdo, hair color, makeup, even eye color with variations of contact lenses – male patients usually have not had such experiences and do not tolerate such changes easily. Some men may be unable to “identify” with their new face as result of their new nose even if the nose job is perfectly successful. Hence, computer imaging is very important to get men prepared and not surprise the male Rhinoplasty patient after cast removal.

Body Dysmorphic Disorder (BDD) is not confined to women and can afflict male Rhinoplasty patients as well. More specifically, there have been scientific papers published about the SIMON (Single Immature Male Over-expectant Narcissistic) patient. This acronym is self explanatory and such patients become obsessed with their noses and are rarely satisfied post Rhinoplasty.

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.

Pinched Tip Virginia

One of the tell tale signs of a poorly performed nose job is a “pinched tip.” Although a few patients still desire the pointy, pinched tips of the past, the vast majority of patients seeking Rhinoplasty these days prefer aesthetic, but natural looking nasal tips.

Before we discuss how to correct a pinched tip, with a Revision Rhinoplasty, we need to discuss a few initial facts:

QUESTIONS:

1. What affects the shape of the nasal tip?
2. What changes can be made to the nasal tip during Rhinoplasty, in order to achieve a beautiful, but natural looking tip, and avoid a pinched tip?
3. What wrong surgical maneuvers result in a pinched tip?
4. How does a Rhinoplasty Specialist Surgeon correct a pinched tip during Revision Rhinoplasty?

ANSWERS:

1. Shape of the nasal tip is largely determined by:

• Shape and size of the two adjacent Lower Lateral Cartilages (LLC)
• Nose skin & soft tissue thickness, and character
• Underlying Caudal septum and Anterior Septal Angle
• Alar skin thickness and integrity

2. There are infinite types and shapes to the nasal tip. No two tips look exactly alike. Even with two very similar looking tips, the surgical maneuvers, required during Rhinoplasty, may be quite different. Some Nasal tips can be characterizes into:

• Bulbous
• Boxy
• Trapezoidal
• Asymmetric
• Pointy
• Amorphous
• “Meaty”

For example, lets take a large or full nose tip, and discuss some of the various methods to refine it, during Tip Rhinoplasty. This is a very broad topic and an entire textbook can be easily dedicated just to Tip Rhinoplasty, but we shall cover this complex and comprehensive topic in a brief manner here:

One of the most popular techniques for de-bulking and reducing nose tip fullness during Rhinoplasty is the “Cephalic Trim” maneuver. This technique involves reducing the width of the Lower Lateral Cartilages (LLC) at the most crucial point relating to tip fullness. The Rhinoplasty Surgeon will meticulously trim the top (i.e. cephalic) portion of each LLC and leave behind no less than 6 to 8mm of width. What is removed creates a more refined tip. What remains supports the tip and ala.

Cephalic trims of the LLC’s can be done through an Open Rhinoplasty, or Closed Rhinoplasty. Furthermore, either of the two sub-categories of Closed Rhinoplasty can be used to carry out this maneuver: Closed Delivery Rhinoplasty & Closed Non-delivery Rhinoplasty.

In the Open Rhinoplasty, the skin is pulled back, off of the tip, and the cephalic trim is carried out. Sutures can also be placed at the domes to bend and shape the remaining LLC segment into a more favorable shape. Sutures can create the desired curvature and symmetry. In Closed Delivery Rhinoplasty, each of the LLC’s are “delivered” through the nostrils, in essence partially protruding for the surgeon to visualize and carry out the maneuver. Again, domal sutures can be placed after the cephalic trim to bend and shape these cartilages. In a Closed Non-delivery Rhinoplasty, each of the LLC’s are trimmed “in place,” from underneath. This technique does not allow for placement of dome sutures, therefore the Closed Non-delivery Rhinoplasty is ideal for the tip that has nice overall symmetry and shape but is just too wide and would benefit from de-bulking, with the cephalic trim maneuver.

3. The Lower Lateral Cartilages are the framework of the nasal tip. Removing too much cartilage during Rhinoplasty will weaken this framework. Skin draped over this framework can somewhat support itself if thick enough.

“The enemy in Rhinoplasty is scar tissue.” It is unavoidable. Scar tissue forms with every, and all surgeries. Some of it is the glue that holds things together. But excess amounts can distort the results of a nice Rhinoplasty. Scar tissue molds and matures over a two to three year period of time. During this period, the pulling and pushing forces of the scar tissue can create distortions of the nose. It is extremely important for the Rhinoplasty Surgeon to have built a nice strong framework for the nose, that can withstand and counteract these scar tissue healing forces. A nose that has been too aggressively reduced may look good on the operating table, or even at 3 months out from surgery. But almost always, it will look distorted and asymmetric several years later, necessitating a Revision Rhinoplasty.

Some of the older techniques in Rhinoplasty, still used by older Plastic Surgeons, as well as their students, included aggressive resection of the Lower Lateral Cartilages. As we discussed before, the skin is an important part of the equation. Aggressive tip cartilage reduction in patients with thin skin always results in pinched and fake looking nose tips. Breathing problems can also occur. On the other hand, thicker skin, in some patients, can “stand on its own” and not collapse or get pinched as easily as thin skin. However, aggressive cartilage reduction, during Rhinoplasty, in patients with thick skin also has its own problems. The space where cartilage was removed, in thick skinned patients, fills with scar tissue. This results in even less definition of the nasal tip, resulting in an amorphous blob rather than a refined tip.

4. In both the thin and thick skinned patients, with over aggressively reduced Lower Lateral Cartilages, the correction of a pinched tip, during Revision Rhinoplasty involves adding and replacing cartilage in the tip. The proper balance has to be restored. The framework has to be re-established. Occasionally this can achieved by a skilled Rhinoplasty Specialist Surgeon through a Closed Revision Rhinoplasty. Precisely shaped cartilages can be placed into precisely shaped “pockets” to provide support. This is common for the nostril margin using alar rim grafts, or soft tissue facet grafts. Grafts can also be placed further away from the nostril margin to support the ala such as alar batten grafts. With more distorted and asymmetric pinched tips, especially in patients with thin skin, Open Revision Rhinoplasty with total lobular reconstruction is necessary. Fascia grafts may also be needed to add slight thickness to the skin to help camouflage cartilage or suture edges during healing.

In summary, beautiful and natural nasal tips are not pinched. Support is key to achieving a non-pinched nasal tip during Rhinoplasty. Support is important in prevention of a pinched tip during Primary Rhinoplasty. Addition of support is an integral part of surgical planning and execution during Revision Rhinoplasty, in correction of a pinched tip.

Augmentative & Reductive Rhinoplasty Virginia

Rhinoplasty or Nasal Reshaping is not simply a matter of removing cartilage and bone. This was the mistake of the Plastic Surgeons doing Rhinoplasty 20 or 30 years ago, and unfortunately still repeated by some Cosmetic Surgeons today. Rhinoplasty may involve removal of cartilage, bone or nostril skin but may also involve addition of cartilage, bone or fascia. Many times, a Rhinoplasty Specialist will rearrange cartilage during Rhinoplasty or reshape cartilage, using sutures.

However, you can group some nose jobs into #Reductive Rhinoplasty# where the size of the nose needs to be reduced overall. Or a nose job can be classified as an #Augmentative Rhinoplasty# if the size of the nose needs to be increased overall. For example, many Middle Eastern, Jewish, and Mediterranean patients undergo Reductive Rhinoplasty while some Asian patients undergo Augmentative Rhinoplasty.

Saddle Nose Virginia

Saddle nose is usually a collapsed and flattened nose. Often it refers to the middle section of the nose but it can affect the tip and the upper third as well. Most times, there is a lack of underlying septal cartilage support at the dorsal septum. Boxers and professional fighters with multiple nasal fractures commonly present with a saddle nose deformity. Sometimes a true saddle nose deformity will look like a nose with a dorsal hump to the novice plastic surgeon. There is a clear distinction and this must be determined prior to the rhinoplasty surgery.

Correction of the saddle nose involves addition of cosmetic cartilage grafts such as dorsal only grafts taken from the cartilage of the septum or ears or ribs. Correction of the saddle nose may also involve addition of structural cartilage grafts such as spreader grafts, caudal septal extension grafts, columellar strut grafts,etc.

Short Nose Virginia

The definition of a “short nose” is one that is proportionately short for the patient’s face and stature. A nose that is 3cm in length may look cute on a 5 foot tall 17 year old female’s face, but it will almost certainly not look right on a 6 foot tall 50 year old male’s face.

Although a “short nose” does not always occur concurrently with an excessively “upturned nose”, it often does. Moreover, while many short noses are hereditary, often they are sign of an over-aggressive previous Rhinoplasty, by a Plastic Surgeon with poor judgment.

Whether the short nose is due to genetics or a poorly performed previous Rhinoplasty, the correction involves the same stepwise algorithm:

1. Diagnose the problem
   1. Is it a Primary or Revision Rhinoplasty
   2. How short is the nose?
   3. Is the nose also too upturned (over rotated)?
   4. Does the nose look short from front and profile views?
      1. If the patient likes her nasal length from the profile view but wants a longer nose from the front view, this unrealistic expectation must be addressed and demonstrated, using computer imaging during the consultation, by the Rhinoplasty Surgeon.
   5. Are the alar margins retracted as well?
   6. Is there too much “nostril show?”
   7. What is the condition of the nasal septum?
      1. Has the septum been operated on before
      2. Is there a septal perforation?
         1. If so, what part of the septum has a hole?
         2. How large is the hole?
   8. Assess availability of adequate nasal skin envelope
      1. It is useless if the Rhinoplasty Surgeon builds up the cartilage and bone properly, but is unable to drape the skin over the newly built-up framework – without tension.
   9. Assess the Rhinoplasty patient’s aesthetic taste and see what she/he likes
      1. The Rhinoplasty Specialist Surgeon must use computer imaging to discuss his recommendations and abilities, while prioritizing the patient’s desires and goals.
         1. The patient may want a longer nose than is surgically possible and this discussion needs to be taken before any surgery. Computer imaging is a crucial part of this discussion so the patient can see what is realistic surgically.
         2. The surgeon’s aesthetic taste or recommendations may not be the same as the patient’s and these issues must be addressed before any surgery so that compromises and changes can be made or so that another unsatisfactory surgery can be avoided
   10. The Rhinoplasty Surgeon must assess the availability of sources of cartilage and discuss these with the patient
       1. Cartilage from Septum
       2. Cartilage from ears
       3. Cartilage from patient’s own ribs (Costal Cartilage)
       4. Cartilage from Cadaver (Frozen or Irradiated Rib Cartilage)
2. Plan the surgery
   1. Plan the timing of Rhinoplasty (applies to Revision Rhinoplasty)
      1. Sometimes it is better to wait longer for Revision Rhinoplasty so the skin relaxes and scar tissue softens up
      2. Sometimes it is not good to wait too long as the skin will “shrink-wrap” further, and will be more difficult to stretch out over a more built up nasal framework.
   2. Open Rhinoplasty or Closed Rhinoplasty?
   3. Rhinoplasty technique for achieving length?
      1. Release of scar tissue &/or previous permanent sutures to allow the tip position to drop down 1-2mm
      2. Single, double or triple layer tip grafts to lengthen nose during Rhinoplasty
      3. D.A.R.T. to lengthen nose (use of two large and long spreader grafts attached to a strong columellar strut graft, to create a cantilever and lengthen nose by pushing the tip downwards)
      4. Caudal Septum extension graft to build up the “foundation” of the nose.
         1. Often combined with total tip reconstruction
            1. Tip grafts
            2. Alar strut grafts
            3. Lateral Crus (LLC) repositioning technique
            4. Composite auricular (ear) cartilage grafts
      5. Para-median Forehead Flap nasal reconstruction
         1. Used in Revision Rhinoplasty cases where the nasal tip skin is severely inadequate due to multiple previous Rhinoplasties and skin “shrink-wrapping.”
            1. This aggressive Revision Rhinoplasty technique may have been necessary in a case such as Michael Jackson to build up his nose and create a stronger, more natural and masculine nose.

Figure 1: Normal septum anatomy

Figure 2: Short nose due to caudal septum resection

Figure 3: Caudal septum extension graft

Tip Rhinoplasty Virginia

Changes to the nasal tip are often part of a “complete” Rhinoplasty. As result of a Rhinoplasty, the various parts of the nose (tip, nostrils, bridge, etc…) must all fit each other, and fit the face, of each patient. However, each patient’s face, nose, and needs are unique. Some patients have nearly perfect nasal tips and only need modification of the nasal bridge. Others have nearly perfect bridges and only need refinement of the tip. A few may only need alar reduction (nostril narrowing). While some need reshaping of the entire nose, and all of its parts. There is no “standard” or “one-size-fits-all” Rhinoplasty. Each nose is unique. And each Rhinoplasty should be based on the patient’s needs, goals, age, sex, race, facial features, as well as the Plastic Surgeon’s professional and artistic recommendations. Computer imaging is what merges all these components into the finalized Rhinoplasty surgical outline.

During a complete “top to bottom” Rhinoplasty, some Plastic Surgeons choose to first correct the nasal tip position and shape, and then match the rest of the nose to the new tip. Other Plastic Surgeons leave the reshaping of the nasal tip for the end after the bridge and dorsum have been modified. Regardless of approach, the end result must be a nose with all of its components in perfect harmony with each other and the rest of the face.

It is well known and accepted by most types of surgeons, and all Plastic Surgeons, that Rhinoplasty is amongst the most complex of all surgical procedures. There is no comparison between the technical complexity of procedures such as Liposuction, Breast Augmentation, Brow lift, and Rhinoplasty. Hence why a handful of Cosmetic Surgeons have dedicated their training and practice to Rhinoplasty near exclusively. Some surgeons have gone as far as boldly stating that Rhinoplasty is the most complex surgical procedure. Much of the reason behind such statements is the complexity of nasal tip Rhinoplasty. Reasonable and ethical Plastic Surgeons in support of this fact point out:

• The complex three dimensional aspect of Rhinoplasty:
  • Changes to one facial view, result in changes to other views and vice versa. The Rhinoplasty surgeon must be able to visualize, predict, and plan for these interdependent changes
• Rhinoplasty is an operation of millimeters or fractions thereof. There is no room for sloppiness or errors. Every surgical move must be meticulous and intentional.
• Rhinoplasty results change after one week, to one month, to one year, to ten years after surgery, and the Rhinoplasty surgeon has to build a nose that will look better than the initial nose, for the life of the patient.
• Dynamic and continually changing forces between the skin, cartilage, bone, and scar tissue, affect the results of Rhinoplasty
• The results of Rhinoplasty sit on the middle of a patient’s face for the world to see. A bad nose job cannot be hidden by makeup or clothing.
• Slight variations in surgical technique influence the result of the surgery.
• A significant portion of highly trained and experience Board Certified Plastic Surgeons choose not to perform any Rhinoplasty or offer it in their practice, due to these factors; and instead refer patients to specialized Rhinoplasty surgeons.

Understanding and mastering the Rhinoplasty of the nasal tip is crucial for the Plastic Surgeon. Creating beautiful yet natural looking nasal tips is what patients desire. Pinched or fake nasal tips are unappealing and a thing of the past. Unfortunately, poor Rhinoplasty technique or over aggressive surgical resection by prominent experienced Plastic Surgeons today still result in such undesirable asymmetric or “pinched tips.”

Sometimes a Rhinoplasty surgeon may employ an open Rhinoplasty technique and spend hours creating a beautiful tip through the use of sutures, grafts, excisions and rearrangements of cartilage. Other times, a Rhinoplasty surgeon may use a closed Rhinoplasty technique and spend only minutes creating a beautiful nasal tip. The approach and the surgery depends on the starting point, the native symmetry or asymmetry of the patient’s tip, skin thickness, etc. The end point should be a natural, balanced tip with lack of any obvious signs of a Rhinoplasty.

Pic 1: Nasal Tip made up of the two Lower Lateral Cartilages

Pic 2: Nasal Tip forming a symmetric isosceles triangle

Pic 3: Lower Lateral Cartilages positioned slightly ahead (anterior) of the Upper Lateral Cartilages.

Upturned Nose Virginia

Position of the nasal tip and the shape of the nasal bridge are intimately related aesthetically.
For example: a hump or bump on a nose can look completely different depending on changes to the nose tip:

• Moving the tip back towards the face (de-projecting the tip), to make it less protruding, will make a hump look larger.
• Moving the tip forward (adding projection to the nose tip), to make the tip protrude more from the face, will make a hump look smaller or even disappear.
• Moving the tip up (rotating the nose tip) to make the tip more up-turned, may make a hump look smaller often times.
• Moving the tip downward (de-rotating the nasal tip) to make the tip less up-turned, may make a hump look larger.

There are two approaches to performing a Rhinoplasty during the surgery. I am not referring to Closed or Open approaches, which are techniques used to make the changes. By approach here I am referring to an aesthetic eye and a stepwise approach to creation of the changes to the nose during Rhinoplasty.

• The tip position can be set or changed to the ideal shape and position first. Then the bridge and the rest of the nose can be changed to match the tip.
• The bridge height and shape can be set or changed to the ideal height and position and shape first. Then the tip can be changed to match the bridge.

So what should the ideal tip position be?

• • Two factors determine the ideal tip position:
    • Projection
    • Rotation
  • Although there are many methods of calculating the ideal projection of the nose tip, classically one of 3 methods below are used by most Rhinoplasty Specialists:
    • Goode method sets the tip projection as 55-60% of the nasal bridge

• • • Crumley method equates the nose to a 3:4:5 triangle using the relationship between projection to vertical length to dorsal length.

• • • Simons method relates the projection of the nasal tip to the length of the upper lip with an ideal 1:1 relationship.

But in reality none of these methods should be used alone. The nose has to fit the entire face, and even the body, and “look” of the patient. The fact is that other factors affect the projection of the nose:

• Chin position:
  • Stronger, more protruding chins warrant maintaining or creating a somewhat over projected nasal tip, in order not to throw off the harmony and balance of the face. An “ideal tip projection” based on the 3 above methods, will draw too much attention to the chin of a patient with a strong chin.
  • Weak or retro-positioned chins will make the tip appear over projected even if it is not. It is important to recognize this fact before surgery to either plan for a chin implant at the time of surgery or to avoid de-projecting the tip position too much. The tip position should not be compromised in order to match a smaller chin.
  • Forehead slope, Radix depth, & Glabellar prominence:
    • Foreheads that are sloped back will make the nose appear to be over projected
    • Prominent Glabellar prominence (brow ridge) as well as the depth of the radix also affect appearance of the nasal projection. A strong brow ridge or a deep radix can make the tip appear under projected.
  • Mid-face position:
    • A midface or maxilla that is positioned too far forward in relation to the upper face (forehead) and lower face (jaw), will make the nose appear over projected.
  • Height, sex, age and “look” of the patient:
    • Taller patients, male patients, older patients and more “exotic” patients often times look better with slightly over projected noses.

So what should the ideal tip rotation be?

• • Rotation or how up-turned a nose is (also called the naso-labial angle) has to be measured and then adjusted if necessary. The calculation is as follows:
    • The angle is the junction of a line drawn along the slope of the upper lip, and a line drawn through the nostril. Many Plastic Surgeons use the columella erroneously instead of the line through the nostril.
    • In men the naso-labial angle should be about 90-95 degrees
    • In women the naso-labial angle should be about 95-120 degrees
      • The taller the patient, the less rotated the nose should be
      • The shorter the patient, the more rotated the nose can be
      • A 120-degree naso-labial angle does not necessarily equal an “up turned” or “miss piggy” nose. Poor positioning and relationship between the tip, infra-tip lobule, columella, septum, and nostrils is what creates a “miss piggy nose.”

The upturned looking nose (referred to as a “miss piggy nose”) can be a result of a “short nose” or an “over rotated nose.” Often times though, this visually unappealing look of an upturned nose is the result of a short and an over rotated tip as well as other factors.

There are lots of patients who are born with upturned noses. Many Asians, some African Americans, some Latinos, and some Caucasians have naturally upturned or over rotated noses. These patients can undergo correction of this aesthetic issue with a properly planned primary Rhinoplasty.

However, the vast majority of patients with an upturned nose, are ones seeking a Revision Rhinoplasty after over aggressive, over reductive prior Rhinoplasty. The creation of an upturned nose is often times a simple task. In young patients and ones with thin skin, the rotation of the nose can be accomplished in a matter of seconds by any Plastic Surgeon. But the correction of this “error in judgment” of the previous Plastic Surgeon, involves much more skill, and effort by the Rhinoplasty Surgeon, and much higher emotional and financial burden on the patient.

The correction of an upturned or over-rotated nose depends on the degree of correction necessary. Single or double or even triple layer tip grafts can accomplish lesser corrections. Greater correction may be accomplished by the D.A.R.T. method. This method described by Dr. Dyer, uses structural spreader grafts, attached to a structural columellar strut graft, to create a cantilever, to “push” the tip down. More significant corrections often times require addition of length and support to the Caudal Septum. This may be necessary in order to lengthen the foundation of the nose first using a Caudal Septal Extension Graft. Then the tip, dorsum and rest of the nose can be “built around” this stronger, longer foundation. Sometimes, the limiting factor in de-rotation or lengthening of the nose, by the Rhinoplasty Surgeon, during a Revision (but even in some primary Rhinoplasties such as in Asian patients) is the stretch-ability of the skin envelope. The Rhinoplasty Surgeon can create a great cartilage and bony framework, but if there is not enough skin to drape over the structure, in a tension-free manner, significant problems can arise – such as horrific tip necrosis.

• In summary, the skilled Rhinoplasty Specialist Surgeon can determine the proper nasal tip position in Primary Rhinoplasty or in Revision Rhinoplasty cases. The execution of various techniques requires the utmost skill as well as a good source of cartilage (be it septum, ear or rib).

Wide Nose Virginia

Proper nasal width should be assessed in relationship to nasal length and the rest of the face. Over and over again we come back to the notion that “the nose must fit” the face. Whether Caucasian (white), African American, Asian, Hispanic, or Middle Eastern – after a good Rhinoplasty, the nose has to fit the face. Classically the face can be holistically analyzed by assessing the “facial fifths” and “facial thirds” as seen below in figure 1. Essentially the “ideal face” can be divided into five equal vertical columns and three equal horizontal rows. However, there are significant variations in facial proportions amongst different races and ethnicities. Furthermore, most people do not have an ideal face. In fact about 85% of the general population has significant facial asymmetry. With the exception of the chin, the various facial features are not easily or safely modifiable. The height and slope of the forehead cannot be changed easily. Changing the position of the maxilla or mid-face requires major maxillofacial surgery, etc. So while the face cannot be easily modified to fit the nose, the nose can be shaped to “fit” the rest of the face in order to give it balance and harmony.

Figure 1: Facial Fifths and Thirds

The width of the nose is assessed on the frontal view as well as the base view. On the front view, classically the ideal nose should have two “brow-tip aesthetic lines.” Some Rhinoplasty surgeons call these the “brow-dome aesthetic lines.” In white as well as ethnic patients, these lines start from each eyebrow head and extend along the side of the nose down towards each “tip defining point.” Ideally these lines start narrow and progressively and smoothly diverge from each other as they reach the tip. In figure 2 below, you can see that a wide nasal tip (before Rhinoplasty on left side) created an unfavorable set of brow-tip aesthetic lines. A painless closed Rhinoplasty through a non-delivery approach, which took about 15 minutes to perform and 3 days to recover from, resulted in a much improved set of brow-tip aesthetic lines. The post Rhinoplasty results, on right side, demonstrate much smoother aesthic contour from the eyebrows to the nasal tip, and less distraction from the beauty of the eyes.

Figure 2: Brow-Tip Aesthetic Lines before (left) and after (right) Closed Rhinoplasty

A wide nose can be due to any of the following:

• Wide nasal bones
• Wide middle vault cartilages
  • Wide Upper Lateral Cartilages
  • Wide dorsal septum
• Wide nasal tip
  • Wide Lower Lateral Cartilages
  • Thick skin
• Wide nostrils (ala)
• “Relative illusion of width” due to inadequate length of the nose

Occasionally the nose may have a near perfect shape but be wide from top to bottom requiring a stepwise approach during Rhinoplasty. The goal in such situations is to proportionately refine the nose from top to bottom while maintaining is essential balance and shape.

However, most commonly, the wide nose has certain wide areas that are not in harmony with the rest of the nose.It is extremely important for the skillful Rhinoplasty Surgeon to first diagnose the issue and determine if the wide appearing part of the nose is truly due to excess width or due to an adjacent, proportionately, extra-narrow area. This is often seen in patients who think, or have been told by other Plastic Surgeons, that they have a wide nasal tip and need tip narrowing, while all along their tip was perfectly fine, but the middle vault was too narrow. The disproportionately narrow middle vault (pinched Upper Lateral Cartilages) makes the tip appear to be wider than it actually is. Clearly, in such cases, spreader grafts or onlay cartilage grafts to the middle vault is the proper approach rather than nasal tip narrowing maneuvers, which will make the nose even more unbalanced and pinched or fake in appearance. These are plans and decisions that should be made by the experienced Rhinoplasty Surgeon during the initial consultation. Proper diagnosis and skillful execution separate the Rhinoplasty Specialist from the average Plastic Surgeon.