Rhinoplasty is plastic surgery that is performed to improve the appearance and function of the nose. Cosmetic reasons for desiring a rhinoplasty commonly include a nose that has a hump, is too large, is too small, is crooked, or has a drooping tip. From a functional standpoint, rhinoplasty can improve breathing by treating collapse or narrowing of the inside of the nose.
In patients with nasal obstruction, a septoplasty may be indicated if there is deviation of the septum. The septum is the structure that separates the left nostril and right nostril. Straightening a crooked septum not only improves breathing through the nose, but can also potentially help with snoring and sleep apnea. Another cause for nasal obstruction is large turbinates (e.g. inferior turbinate hypertrophy). The turbinates are structures inside the nose that warm and moisturize air. If these structures are abnormally large and are causing obstruction, a turbinate reduction can be helpful.
Rhinoplasty is one of the most challenging procedures in plastic surgery. The difference of even a single millimeter can significantly affect the appearance and functionality of the nose. Furthermore, some changes after a rhinoplasty may not become evident for months or years later. Scar tissue formation, contracture, and collapse can progressively worsen with time. Revision rhinoplasty is performed when the primary rhinoplasty did not turn out well, either because of poor cosmetic outcome and/or difficulty with breathing. It is imperative that rhinoplasty is performed by a well trained surgeon who recognizes the complexities of the nose. The techniques performed should be customized for each patient, while considering the effects on both appearance and breathing.
The following cases are presented to help better illustrate the basics and intricacies of rhinoplasty, as well as to highlight my techniques and principles.
The case presented in this section involves a gentleman who presented with concern of nasal obstruction and an over-rotated (upturned) nose. The over-rotation of his nose was associated with excess nostril exposure and tenting of his upper lip.
I performed a rhinoplasty with septoplasty to treat his nasal obstruction and to improve the appearance of his nose. From a cosmetic standpoint, a major goal was to decrease the rotation and projection of the tip of his nose. In order to precisely set the tip at the appropriate position, a caudal septal extension graft was used. This graft was created using cartilage from his septum that had been harvested during the septoplasty. The caudal septal extension graft is placed to support and position the tip, and help prevent the tip from moving over time. The height of the bridge of the nose (dorsum) was also reduced to match the new height of the tip. This was performed very meticulously to maintain his original straight dorsal profile. Attention was also placed on improving the contour at the junction of the lip and nose. In order to accomplish this, the skin at the bottom of the nose (columella) was recruited downwards, creating a more refined lip-nose junction. This also reduced the pull on the upper lip, which improved closure of his lips. The combination of all these techniques and attention to minor details resulted in substantial overall refinement and a natural appearance.
This case involves a female who initially underwent two rhinoplasty surgeries with another surgeon. During her most recent operation, the surgeon used cartilage grafts from her ear. However, she continued to have severe deformity of her nose and developed worsening breathing problems.
I performed revision rhinoplasty using rib cartilage to reconstruct her nose. As with all my patients, meticulous planning was performed before the procedure. Traditional morphs were created to demonstrate the anticipated appearance of the nose after the procedure, and morph ‘blueprints’ were designed to illustrate the exact changes needed. The main challenge of this case involved significant lengthening of her nose and providing appropriate structural support.
Rib cartilage was used to create various grafts in order to support and lengthen the nose. The foundation of the nose was reconstructed with a flying buttress graft. A diced cartilage fascia (DCF) graft was then placed along the dorsum of the nose to improve the dorsal profile. Rim grafts were placed to help support the nostril rim.
The green marking illustrates the amount of lengthening that was planned. The red marking illustrates the amount of reduction that was planned.
(Airway Enhancement & Subtle Changes)
This case involves a female who underwent rhinoplasty and septoplasty by another surgeon one year prior to her consultation with me. She stated that the goal during the first surgery was to remove a hump and to improve her breathing. However, after the rhinoplasty, her breathing worsened.
On exam, the front part of the septum was deviated to the left. She also had collapse of the side of her nose. The combination of these problems resulted in a very narrow airway (refer to Base View Photographs). From a cosmetic perspective, she had poor contour of her nose and retraction of the alar rim (refer to Profile View Photographs). Alar rim retraction is a condition in which the nostril rim is elevated (pulled upward), which leads to exaggerated nostril exposure. Alar rim retraction is a common complication of rhinoplasty and can occur because of excessive cartilage resection and/or improper cartilage positioning.
I performed a revision rhinoplasty and septoplasty in order to fully straighten the deviated septum, treat the collapse and retraction, and to improve the contour of her nose.
The front part of the septum is a relatively difficult region of the septum to straighten and requires specialized skill to properly manage. I had to separate the septum from its attachment at the front of the nose, straighten the cartilage using various maneuvers, and then re-secure the septum in a more appropriate position. The alar retraction was corrected using articulated rim grafts created from her own cartilage. Unlike conventional rim grafts, articulated rim grafts require significantly more skill to use, but are much more effective in pulling the rim down and preventing future retraction.
Base View Photographs
The severe obstruction within the left nostril (right side of picture) was significantly improved after the septum was straightened and the collapse of the side of the nose was treated. The red markings in the lower set of photographs highlight the opening of her nasal airway.
Profile View Photographs
After the procedure, several minor cosmetic improvements were achieved. Nostril exposure was reduced as a result of correction of the alar retraction and the contour of the nose was improved. The red markings in the lower set of photographs highlight the amount of nostril exposure.
This case involves a female who was trampled by horse and injured her nose approximately a decade before presenting to me for rhinoplasty surgery. Her main concern was nasal obstruction that was so severe that it forced her to breathe through her mouth. In addition to wanting to improve her breathing, she desired to straighten her nose while maintaining her natural appearance.
I performed a functional rhinoplasty with septoplasty using an external (open) approach. The external approach provides optimal visualization and access to the structures of the nose. This enables the ability to perform advanced techniques that are not otherwise possible using a closed (endonasal) approach. The small incision created at the bottom of the nose for the external approach is typically imperceptible when sutured meticulously.
An important step in the case was to straighten the septum. This involved releasing a significant amount of scar tissue that had formed due to the trauma. The fractured and deviated cartilage at the center of the septum was removed, and the remainder of the cartilage was repositioned in a more straight position. A sufficient amount of cartilage was maintained at the septum to ensure adequate support of the nose. The portion of the cartilage that was removed from the septum was then used a caudal septal extension graft in order to provide support for the tip of the nose. The remaining structural elements of the nose was then able to be aligned based on the straight and strong foundation.
Frontal View Photographs
After rhinoplasty and septoplasty, the nose is straighter and very natural in appearance. The dotted line in the bottom photographs illustrates the curvature of the nose.