Since the nose is the most prominent facial feature, the fact that a large number of people living in Cherry Hill, New Jersey seek alteration of the nose is not surprising. Even small abnormalities of the nose can lead to major issues with a patient’s self appearance.
Rhinoplasty (“Nose Job”) is among the most challenging of all facial plastic surgery techniques, while its effects can provide some of the most gratifying results for the patient.
It is one of the most elegant procedures performed, requiring expert surgical skills and artistic sense. Countless techniques have been developed to creatively alter the size, shape, and function of the nose. Board certified cosmetic surgeons use a thorough knowledge of nasal anatomy and normal facial aesthetics to choose the techniques best suited to each particular nose. Each patient’s nose provides a unique and different set of challenges. Careful preoperative nasal and facial analysis is imperative, allowing these highly trained doctors to customize a surgical plan which will fulfill your goals.
Dr. Anthony Corrado Discusses Rhinoplasty
The objective is to create a natural appearing nose which is in total harmony with the rest of the face. Having realistic expectations of postoperative results as well as the recovery period is vitally important for the patient.
Rhinoplasty surgery must strike a balance between nasal aesthetic form and nasal function. Many failed rhinoplasties are performed where the surgeons do not respect the functional aspects of the nose. In these cases nasal collapse and difficulty breathing are very common.
Dr. Corrados article on Rhinoplasty
Rhinoplasty Surgery Facts
Surgical Goals: To surgically refine the size, shape, and contours of the nose to produce a more aesthetically pleasing nose which is in harmony with the rest of the facial features. To produce a functional nose in which breathing is not compromised.
The Procedure: Internal and external rhinoplasty approaches are utilized. After careful and precise preoperative evaluation Dr. Anthony Corrado will decide which approach is best for the you. The nasal dorsum (“bridge”) is sculpted and the nasal tip is refined. All sutures that are placed dissolve and DO NOT need to be removed. Dr. Anthony Corrado DOES NOT place packing in the nose. He uses nasal splints inside the nose that have air channels allowing the patient to be able to breath after surgery. A small cast will be placed over the nose to protect it and allow it to heal in the immediate post operative period. Other procedures such as Chin Augmentation or Neck Liposuction may be performed to complement the procedure.
Anesthesia: General anesthesia.
Length of Time: The amount of time varies based upon what types of refinements are necessary. Procedure times can range from 1-4 hours depending on the complexity of the case. Revision rhinoplasty cases usually require more operative time than primary rhinoplasties. All procedures are performed at a fully accredited outpatient surgery center.
After the Procedure: All patients are sent home the night after surgery, and are given a set of post procedure instructions to follow. The patient will follow up the next day for a post procedure check, and again on the 5th post procedure day.
Recovery: Most patients can return to work in a week, although all individual patient recovery time is variable. Patients are asked to refrain from physical exertion for a period of two weeks. Swelling and bruising are all variable depending on the patient, although most is resolved within 1-2 weeks.
What is the difference between an Open vs Closed Rhinoplasty?
The difference between both procedures involves the small difference between the types of incisions used to gain access to the nose. In Open Rhinoplasty a small skin incision is made on the nasal columella. The columella is the cartilage containing structure which is covered with skin that sits between both nostrils. This is the only difference between the two procedures. All other incisions in both the Open and Closed techniques are well hidden inside the nose. It should be noted that the incision in the Open approach heals very nicely without any evidence of visible scarring.
What are the advantages of the Open vs Closed Rhinoplasty?
I find that the advantages of the Open approach are that this technique gives the surgeon much better visualization and exposure of the structures of the nose which are being operated on. The open approach allows direct visualization of the nasal dorsum, allowing precise removal of dorsal humps. It also provides a clear view of the nasal tip cartilage. With this improved view of the cartilage, meticulous modifications of the nasal tip can be made. Excess cartilage can be shaved, while sutures and grafts can be precisely placed. I feel that all Revision Rhinoplasty should be performed with an Open approach, because in these cases the anatomy is distorted and precise modifications need to be made to allow the nose to regain a normal cosmetic appearance and functional status.
Are Open vs Closed Rhinoplasty Surgeons Better?
I do not feel that the use of a specific rhinoplasty technique makes someone a better surgeon. What makes someone a good rhinoplasty surgeon is excellent training, surgical experience and expertise, and great surgical results. I suggest patients pick a surgeon based on these qualifications as opposed to what technique they use.
What is an Inverted “V” Incision?
An Inverted “V” incision is the type of incision placed on the columella to gain access to the nose in Open Rhinoplasty. The incision is placed low on the columella and is in the shape of an upside down “V”. This incision heals exceptionally well and rarely results in any visible scarring if closed carefully.
What type of anesthesia is used for Rhinoplasty?
In my practice all rhinoplasty surgery is performed under general anesthesia. I feel that this is the safest and most effective type of anesthesia for the procedure. IV sedation is used by some, but I feel that this type of anesthesia does not protect one’s airway from secretions such as blood which may drip down the back of the throat during surgery. These secretions can then trigger the gag reflex in the airway and cause a possible respiratory emergency. I prefer general anesthesia because the airway is never a risk, allowing me to perform my surgery without complication. I do not find that patients have any difference in the length of recovery when comparing both types of anesthesia.
How long is the recovery from rhinoplasty?
Typically, it takes about 7-10 days for a majority of the acute swelling and bruising to subside. We have patients sleep elevated, and ask that they apply ice as directed to speed up the resolution of swelling. The splint placed on the outside of the nose is removed in 7 days. Most patients are off pain medications 7 days after surgery and can return to work by 10 days after the procedure. Patients are instructed to refrain from strenuous activity for 2-3 weeks after surgery. The nose will still be swollen after 7-10 days, with a majority of the swelling resolving over the course of the next 6 months. Subtle swelling after rhinoplasty is not fully resolved for up to a year after the surgery. Healing from this type of procedure will also take up to a year.
Why do we wear splint on the nose after rhinoplasty?
A splint is placed on bridge of the nose for a period of seven days after surgery. The skin under the splint is also covered with special tape. The tape and splint combination help to provide protection, stability, and limit swelling in the immediate postoperative period. Typically, the splint and tape are removed after 7 days. After splint removal the nose is typically taped for another week to further limit swelling along the dorsum and tip.
Why do surgeons “break” the nasal bones during rhinoplasty?
The word break is such a violent term and doesn’t give a true picture of what is actually done in surgery. The surgeon makes osteotomies, precise cuts along the nasal bones, allowing the surgeon to reposition the nasal bones.
Will I have stitches that need to be removed after rhinoplasty?
No. All the sutures that are placed both outside and inside your nose are dissolvable. You will just have to keep them most with antibiotic ointment during the first 7-10 days after surgery to allow all incisions to heal well.
Can I have my deviated septum fixed during my rhinoplasty surgery?
Correction of a deviated septum is routinely completed during rhinoplasty surgery. Many patients that present for cosmetic nasal improvements also have functional nasal complaints associated with difficulty breathing. Many of these patients breathing problems are corrected by straightening their nasal septum and opening their nasal airway. The deviated portions of septal cartilage that are removed can also be used for grafting in the rhinoplasty portion of the procedure.
If I had prior surgery to correct a deviated septum, where will my surgeon get cartilage from for grafting during my rhinoplasty?
A key step in a surgeon’s preoperative evaluation for rhinoplasty is to assess the need for possible cartilage graft use in surgery. If the surgeon feels that they might need cartilage, the septum is carefully examined to assess the amount of cartilage available. If septal cartilage is not available, a small amount of conchal cartilage is taken from the ear. Conchal cartilage is taken from the ear via an inconspicuous incision in the crease behind the ear. No deformities of the ear will result after surgery. If a patient has had multiple rhinoplasties, and septal or ear cartilage is not available, rib cartilage must be harvested.
What are osteotomies used for?
Osteotomies are precise surgical cuts made in the nasal bones allowing the surgeon to reposition the nasal bones to a more aesthetically appealing position. Osteotomies are used to correct a twisted nose due to nasal bone malposition, narrow the width of the nose to give it a more slender appearance, and to help close the “open roof” along the nasal bridge after a hump is removed.
What is an “open roof” in rhinoplasty?
The nasal bones align like a peaked roof on a house. The peak of the roof is represented by the top of the nasal bridge. At this peak, the nasal bones meet to form the nasal bridge. The sides of the roof gently slope off the peak as do the nasal bones extend from the nasal bridge to the face. When a large hump is removed from the top of the nasal bridge, the “peak” of the roof is removed. This leaves a space between the nasal bones, resulting in a flat or concave deformity along the bridge, the open roof deformity. In order to reposition the nasal bones, placing them back together to recreate the “peak” of the roof, osteotomies are used. Once the nasal bones are freely mobile after osteotomies, they are be realigned, closing the open roof deformity.
What is an Inverted “V” Deformity?
The inverted-V deformity is a complication which can sometimes arise after rhinoplasty surgery. When looking at the patient from a frontal view an upside down V-shaped shadow is cast along the middle third of the nose. This unfavorable cosmetic complication usually results from separation of the upper lateral cartilage attachments from the dorsal septum and the caudal margin of the nasal bones, resulting in collapse of the middle nasal vault. This complication can arise if an inexperienced surgeon removes a large hump along the nasal dorsum, and does not resupport the upper lateral cartilage to prevent collapse of these structures. Collapse of the upper lateral cartilage can also result in functional complication involving nasal breathing. Breathing is obstructed because of narrowing of the internal nasal valve, the narrowest section of the nasal airway. The internal nasal valve represents the airway space between the upper lateral cartilage and the septum. Being the narrowest segment of the airway, small changes in the support structures of the airway can lead to noticeable breathing difficulty. A revision rhinoplasty is needed to correct the cosmetic and functional complications of this condition.
How are Internal Valve Collapse, Middle Vault Collapse, and an Inverted “V” deformity corrected?
All of the above complications result from collapse of the upper lateral cartilage due mostly likely to unidentified separation of the cartilage attachments from the nasal septum and nasal bones during prior rhinoplasty surgery. Commonly, revision rhinoplasty is needed to correct these problems. The use of spreader grafts is typically needed to help resupport the cartilage and open the internal nasal valve. Spreader grafts are small rectangular shaped cartilage grafts made from cartilage taken from nasal septum, ear, or rib if need be. They are placed between the nasal septum and upper lateral cartilage, and help to increase the width of the internal valve. They are they sutured to the septum and upper lateral cartilage, supporting the upper lateral cartilage, and preventing further collapse.
Can an overly “scooped out” bridge from prior surgery be fixed?
Yes. Many patients come to my office with complaints of an overly “scooped out” or “ski slope” appearance to the bridge of their nose after prior rhinoplasty surgery. This complication is usually caused by over reduction of a nasal hump. The nasal bridge should have a smooth appearance in a male, and a gently concave natural appearance in a female. The bridge should not be overly sloped, a dead giveaway for prior rhinoplasty surgery, and an aesthetically unappealing look. The results of rhinoplasty should be natural, and patient results should not “scream out” that they had a surery. Subtle and natural results are the best results when it comes to rhinoplasty. This problem is commonly fixed by rebuilding the nasal bridge, and thereby increasing its height to a more natural level. This is commonly done with grafts. The most popular graft that I use in my practice is made up of diced cartilage and fascia (DCF). This graft is very versatile and can be used to fix a variety of complications. It can also be modeled in the immediate postoperative period, allowing small modifications to be made. For larger defects, rib cartilage is harvested and used to provide added bulk and support. It is commonly covered with a DCF to hide the sharp edges of the rib graft, allowing a smoother appearance for the nasal dorsum.
What does it mean to have a bulbous tip?
A bulbous nasal tip refers to an overly rounded tip which lacks tip definition. The tip is usually overly full and gives the nose a bottom heavy appearance. Patients complain of having “a ball at the end of my nose”, a fat nose, or a full nose. The bulbous tip destroys the balance and harmony of the nose. Instead of the tip blending in with the rest of the nasal structures in perfect balance, the bulbous tip directs an observer’s attention to it. The bulbous tip is the first aspect of the nose which is seen. A bulbous tip is a result of the cartilage framework making up the nasal tip or skin covering the tip. Most commonly the lower lateral cartilage which make up the nasal tip are the cause of the bulbous appearance. These cartilage are usually excessively wide and rounded resulting in tip fullness. The nasal skin thickness can also play a role in tip fullness. Patients with thick skin, or excess soft tissue and fat under the skin, many times lack tip definition resulting in a bulbous appearance as well.
How do you correct a bulbous tip?
Treatment for a bulbous tip first involves diagnosis of the cause. After careful examination by an experienced rhinoplasty surgeon, the underlying problem should be discovered. It can be caused by excessively wide lower lateral cartilage, thick nasal skin, or a combination of both.
Treatment of Lower Lateral Cartilage
- Trimming of the Upper Lateral Cartilage(Cephalic Trim)- The lower lateral cartilage is trimmed along their cephalic (top) border to reduce cartilage width. Care is taken to leave sufficient cartilage behind for tip support preventing tip collapse.
- Suture Reshaping- Sutures are placed along the lower lateral cartilage at precise points. These sutures help to narrow, unify, reshape, and reorient the cartilage to provide better tip definition.
- Cartilage Grafting- Using cartilage harvested from the nasal septum, ear, or rib; small grafts are shaped and placed on top of the lower lateral cartilage in the tip region to provide added definition to the tip.
It is not uncommon that a combination of the above techniques is utilized in surgery to gain the desired results in surgery.
Treatment of Thick Nasal Skin
- Careful removal of any excess soft tissue under the dermis is carried out to thin the skin/soft tissue covering over the tip cartilage. Care is taken not to violate the dermis and cause compromise of the viability of the skin.
- Cartilage Grafting- Using cartilage harvested from the nasal septum, ear, or rib; small grafts are shaped and placed on top of the lower lateral cartilage in the tip region to provide added definition to the tip. These grafts help to provide further shape and definition to the cartilage framework beneath the tip skin.
What is a “Polly Beak” Deformity of the Nasal Tip And What causes It?
A “Polly Beak” deformity usually results from prior rhinoplasty surgery, specifically surgery directed at removing a large dorsal hump. A dorsal hump consists of excess bone and cartilage along the nasal dorsum. A pollybeak deformity occurs when a dorsal hump is not fully removed in the supratip area. The supratip region corresponds to the area just above the tip of the nose along the nasal dorsum. Excess cartilage along the dorsum not removed in prior rhinoplasty results in fullness in the supratip area causing this region of the nose to appear overly convex in shape without a break between the tip and nasal bridge. This lack of a supratip break results in the nose resembling the beak of a parrot on profile view. Other causes of supratip fullness, and subsequent “Pollybeak Deformity” are excess scar tissue, and overresection of the nasal bones.
How is a “Polly Beak” deformity treated?
If the deformity is caused by excess cartilage remaining in the supratip area, revision rhinoplasty is necessary to surgically remove the excess cartilage. If scar tissue is causing the fullness, serial steroid injections can be attempted, and if failed surgical correction with revision rhinoplasty will be necessary. If over resection of the nasal bones causes excessive lowering of the dorsal height above the supratip area, augmentation grafting is necessary to build up the dorsum. This is routinely done in my practice with diced cartilage and fascia grafts (DCF).