• Board Certified
    Philadelphia Facial Plastic Surgeon

1919 Greentree Road Suite C  | 
Cherry Hill  |  New Jersey 08003

Rhinoplasty in Philadelphia

An individual’s facial appearance is one of the most important factors in creating a first impression. Since the nose is the most prominent facial feature it plays a key role in facial appearance. Balance and proportion are the keys to facial beauty and when a nose is disproportionately large or out of proportion compared to other facial features, the delicate balance which creates facial beauty is disturbed. Even small abnormalities of the nose can lead to major issues with a patient’s self image. A rhinoplasty (“Nose Job”) is one of the most elegant facial cosmetic procedures that Dr. Anthony Corrado, a board certified facial plastic surgeon, performs in Cherry Hill, NJ. A large number of people living in the South Jersey and the Philadelphia Metropolitan area, seek cosmetic nasal surgery for alteration of the nose. Dr. Corrado strives to provide his patients some of the best rhinoplasty Philadelphia and the Delaware Valley has to offer.

Should I Get A Nose Job?

A Good Candidate For Rhinoplasty May Have…

  • An overly large nose.
  • A nasal tip that droops, protrudes or is bulbous.
  • An overly small or “pinched” nose.
  • A “hump” on the nasal bridge.
  • A wide nose.
  • A crooked nose.
  • A nose that has been broken.
  • Problems breathing due to irregularities of the internal nose structure.

Schedule Your Rhinoplasty Consultation

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. Choosing your rhinoplasty surgeon “For You” is one of the keys in achieving your surgical goals.

Trust Your Face to a Specialist

  • For his entire career, Dr. Corrado has solely focused on cosmetic surgery of the nose and face.
  • He is double board certified in both Facial Plastic Surgery, as well as Otolaryngology (Ear, Nose, and Throat Surgery), which gives him great skill and expertise in performing both cosmetic and functional nasal surgery.
  • Dr. Corrado has trained with leaders in the field of rhinoplasty surgery in both Newport Beach and Beverly Hills, CA.
  • He has lectured at national symposia, and published articles in the medical literature on rhinoplasty.
  • His practice philosophy hinges on patient safety and natural results.

“It is my pleasure to share with you my thoughts on Dr. Anthony Corrado. I have scrubbed with him in surgery many times during his cosmetic surgery fellowship with us. Anthony is a gifted surgeon with a keen aesthetic eye. He also has the skills and experience to achieve great results for his patients. The natural and easy rapport he develops with his patients creates a perfect environment for making their dreams a reality.”

– Dr. Drew Ordon co-host of the CBS television’s “The Doctors”

Dr. Corrado believes that every patient’s nose is unique requiring an individualized approach towards every rhinoplasty. Each patient exhibits differences in nasal anatomy and structure. The qualities of the nasal skin, cartilage, and bone will all create different challenges which require a personalized surgical plan. The “cookie cutter” approach is never used and corners are never cut. Dr. Corrado strives for natural-looking results without the tell-tale signs of “overdone” nasal surgery. Although it may have been easy to pick out patients who had “nose jobs” in the past, modern belief in rhinoplasty is to create a nose strikes a natural balance with the rest of the face. Dr. Corrado strives to create a naturally beautiful result so that others will think you were just “lucky” to be born with such a great nose. Don’t worry your secret is safe! 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. Corrado believes in not only providing the best cosmetic result for his patients, but also delivering a nose which functions the same if not better than prior to surgery.

A rhinoplasty consultation will allow you to meet face to face with Dr. Corrado to determine if rhinoplasty surgery is right for you. Patients will discuss their aesthetic goals and motivation to undergo cosmetic nasal surgery. A patient’s past medical and surgical history will then be reviewed. A detailed examination of the nose will then be performed to evaluate for cosmetic, as well as functional nasal issues. Each patient’s nose provides a unique and different set of challenges. Careful preoperative nasal and facial analysis is imperative, allowing Dr. Corrado to customize a surgical plan which will fulfill your goals. He will use a thorough knowledge of nasal anatomy and normal facial aesthetics to choose the procedures best suited to each particular nose. Computer imaging will be used to visual possible results and to discuss realistic expectations. Dr. Corrado then will discuss countless techniques which have been developed to creatively alter the size, shape, and function of your nose. Finally, a cosmetic consultant will discuss other factors related to surgery including scheduling, cost, financing options, and recovery.

What are the benefits of rhinoplasty surgery?

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.

How is rhinoplasty surgery performed?

The nasal dorsum (“bridge”) is sculpted and the nasal tip is refined. Any functional issues causing nasal obstruction are also addressed. A small cast will be placed over the nose to protect it and allow it to heal in the immediate postoperative period. Other procedures such as Chin Augmentation or Neck Liposuction may be performed to complement the procedure.

What type of local anesthesia is used for a rhinoplasty?

General anesthesia is generally used for nose jobs in Philadelphia and the South Jersey area.  This type of anesthesia allows the procedure to be performed very safely because this method of anesthesia prevents blood and mucus from entering the airway.  General anesthesia also allows the patient to be fully asleep so there is no concern for being aware of their surrounding, feeling discomfort, or remembering their surgery.  All anesthesia is performed in a fully accredited outpatient surgery center by board certified anesthesiologists and anesthetists.

How long is rhinoplasty surgery?

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.

 

What is initial nose job recovery time?

All patients are sent home after surgery with a responsible adult and are given a set of post instructions to follow. A prescription for a mild pain medication will be given to allow for patients to recovery without discomfort. The patient will follow up the next day in our office for a post procedure visit.  The patient will then return to the office one week later.  At this visit any non-absorbable sutures, as well as the intranasal splints and the external cast will be removed. Although swelling will be present, patients are able to see noticeable changes in the appearance of their nose.

How long does it take to recover from rhinoplasty?

After the initial one-week recovery, there will be a long term recovery period after rhinoplasty in New Jersey.  Most patients can return to work in a week after the external case is removed, although all individual patient recovery time is variable. Patients are asked to refrain from physical exertion for a period of three weeks. Bruising is variable depending on the patient, although most is resolved within 1-2 weeks. Most of the extensive swelling is resolved in the next several months after surgery, although subtle changes in nasal shape will be seen over the course of a year as the nose completely heals.

VIEW TABLE OF CONTENTS

Types of Rhinoplasty

What are the different types of Rhinoplasty?

Primary rhinoplasty refers to the initial surgery a patient undergoes to achieve cosmetic or functional change for their nose.

Revision rhinoplasty refers to any rhinoplasty performed after a primary rhinoplasty to correct issues, both functional or cosmetic, that have resulted from the primary surgery.

Tip Rhinoplasty refers to a rhinoplasty which solely is performed to improve the appearance of the tip.

Functional Rhinoplasty refers to a procedure performed to improve nasal function. Functional rhinoplasty typically involves correction of the nasal septal deviation, nasal valve collapse and possible inferior turbinate hypertrophy.

Nasal Anatomy

What major structures make up the nose?

The nasal framework is made up of both bone and cartilage. The upper one third of the nose is made up of the nasal bones and boney nasal septum. The lower two thirds of the nose is made up of the upper lateral cartilage, cartilaginous septum and paired alar (“tip”) cartilage. The boney and cartilaginous structures are sculpted during rhinoplasty surgery to achieve the desired cosmetic result. Care is taken maintain the structural integrity of both the boney and cartilaginous elements of the nose to ensure appropriate nasal support following surgery.

Fig 1: Nasal Anatomy

Rhinoplasty Approaches

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.

Fig 2: Intraoperative view of an open rhinoplasty surgery.

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.

Rhinoplasty Incisions

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 Incisions are used in Closed Rhinoplasty?

In a closed rhinoplasty, the incisions are placed entirely inside the nose. The incisions are placed along the inner portion of the nostril rim, as well as the septum.

Fig 3: Rhinoplasty incision placement- The dotted red lines represent the sites of incisions for both open and closed rhinoplasty.

Will I have stitches that need to be removed after rhinoplasty?

Yes. Any sutures that are present externally are typically not absorbable and will need to be removed at one week after surgery. All the sutures that are placed inside your nose are dissolvable and will not require removal. You will just have to keep all incisions moist with antibiotic ointment during the first 7-10 days after surgery to allow all incisions to heal well.

Rhinoplasty Anesthesia

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 at 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.

Rhinoplasty Recovery

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.

rhinoplasty recovery new jersey

Fig 4: Image depicts the external nasal cast (splint) and nasal taping used following rhinoplasty surgery.

Surgery of the Nasal Dorsum (Bridge of the Nose)

The nasal dorsum, otherwise known as “the bridge” of the nose, makes up the upper 2/3 of the nose. The upper half of the nasal dorsum is made up of the nasal bones. The nasal bones are paired structures which come together to form the bony nasal vault. The lower half of the nasal dorsum is cartilaginous, consisting of the dorsal septum and upper lateral cartilage.

Common Complaints Related to the Nasal Dorsum

  • The Dorsal Hump
  • The Crooked Nose
  • The Wide Nose
Common Patient Questions:

Will my surgeon “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.

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.

rhinoplasty process new jersey

Fig 5: Image depicts sites of bone cuts for nasal osteotomies and the resultant narrowing of the nasal dorsum.

The Dorsal Hump

Excessive dorsal convexity, dorsal height, or fullness of “the bridge” can lead to the appearance of a dorsal hump. A dorsal hump refers to the appearance of a bump on “the bridge”. A dorsal hump can significantly detract from the appearance of the nose, specifically when evaluating one’s profile. A dorsal hump can be composed of bone, cartilage or a combination of both.

the dorsal hump

Fig 6: Image displays the presence of a dorsal hump and ideal dorsal contour following hump reduction.

Treatment of A Dorsal Hump

Treatment of a dorsal hump involves removal of excessive bone or cartilage to reduce the dorsal height and create a smooth appearance to “the bridge” to improve the nasal profile. Nasal profile appearance is typically based on patient preference which is discussed with patients prior to surgery. A straight dorsal contour is typically desired by most male patients, while females typically request a straight or slightly concave contour. An overly aggressive hump reduction leading to a “scooped” or “ski slope” type appearance can cause the nose to appear very unnatural and “overdone”. While this type of look was popular in the past, it is typically frowned upon by the modern rhinoplasty surgeon.

Fig 7: Anatomic representation of a dorsal hump and the resulting smooth dorsum after hump reduction. The upper portion of the dorsal hump is composed of bone and the lower portion is composed of cartilage.

Fig 8: This patient underwent rhinoplasty for dorsal hump reduction to improve her profile. Note the resulting smooth character of the nasal dorsum after surgery.

The bony and cartilaginous components in dorsal hump reduction are addressed separately. The bony hump is typically “filed down” with specialized surgical files, otherwise known as nasal rasps. The cartilaginous hump is usually reduced with special dorsal scissors or meticulously shaved with a scalpel blade. Following large dorsal hump removal, an “open roof” deformity is typically present which will need to be addressed.

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.

The Crooked Nose

The ‘crooked nose’, otherwise known as a misaligned nose, an asymmetric nose, a shifted nose, a twisted nose or broken nose, refers to a nose that appears “off center” or deviates from midline. Deviation or distortion of the bony or cartilaginous components of the dorsum can lead to a nose appearing crooked.  Nasal trauma is one of the most common causes of a crooked nose.  Abnormalties of the nasal bones, nasal septum, as well as the nasal cartilage can result in a crooked appearance. 

Fig 9: This patient underwent rhinoplasty to correct the crooked appearance of her nose. The nose deviated to the patient’s right prior to surgery, and this was very evident by the positioning of the nasal tip to the right of the midline of the upper lip. Note the marked improvement in nasal symmetry after surgery and the positioning of the tip directly over the midline of the upper lip.

Asymmetry of the nasal bones can be corrected with nasal osteotomies.  Nasal osteotomies are precise cuts which are made at the nasal bones, allowing for nasal bone mobility.  Once the nasal bones are mobile, they are then repositioned in a more symmetric fashion, allowing the nose to achieve a straighter appearance.  Abnormal curvature of the dorsal septum can also lead to a crooked appearance.  Septoplasty techniques as well as spreader grafts can be utilized to achieve a straighter appearance.  Caudal septal deviation can also lead to a crooked or “twisted” appearance of the nasal tip.  Many times this can be corrected with a “swinging door” technique, where the caudal septum is repositioned at the anterior nasal spine, which is the anatomically correct position for the caudal septum.  In severe cases septal replacement grafts can also be utilized for septal reconstruction.        

Can an overly “scooped out” bridge from prior surgery or Saddle Nose Deformity be fixed?

Yes. Many patients come to my office with complaints of a “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 surgery. 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).  The graft is made up of finely diced cartilage wrapped in deep temporalis fascia. 

diced cartilage fascia graft

Fig 10: A. The diced cartilage fascia graft (DCF) being constructed. The syringe is being used to injected finely diced cartilage into the fascia sheath. B. The diagram shows positioning of the DCF (in red) on the nasal dorsum.

 

This graft is very versatile and can be used to fix a variety of complications. It can also be molded 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.

The Wide Nose

What is Wide Nose Rhinoplasty?

Correction of the ‘Wide Nose’ typically refers to treatment of an overly wide nasal dorsum (“bridge of nose”).  The superior third of the nose consists of the bony nasal pyramid which is made up of the paired nasal bones.  Overly wide nasal bones can result in a nose that appears abnormally wide for a patient’s face.   Lateral nasal bone convexity can also lead to an overly wide appearing nose.  The nasal “dorsal lines”, as well as the bony base width (“x point”) govern dorsal width.  The “dorsal lines” refer to the parallel profile lines which correspond to the width of the philtral columns and tip defining points.  The bony base width refers to the maximal base width of the nasal bones at their point of attachment to the facial bones. 

wide nose rhinoplasty

Fig 11: Diagram Depicts Aesthetic Surface Landmarks and Measurements:
Red: Philtral Columns
Green: Tip Defining Points
Blue: Dorsal Aesthetic Lines
Yellow: Bony Base Width

Nasal osteotomies can be performed to reposition the nasal bones to narrow the bony dorsum and correct lateral nasal bone convexity.  Many times several types of osteotomies are used to treat the wide nose including medial, intermediate, and lateral osteotomies.

Functional Nasal Surgery-Correction of Nasal Obstruction

Nasal Septal Deviation

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.

nasal septal deviation

Fig 12: Images illustrate normal and deviated septal anatomy.

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.

Turbinate Hypertrophy

What is turbinate hypertrophy?

The nasal turbinates are structures located inside the nose, along the outer wall of the nasal cavities. They are composed of bone and and soft tissue.  Their primary function is to regulate airflow, and to warm and humidify the air we breathe in.  There are three sets of turbinates known as the inferior, middle and superior turbinates.  The inferior turbinates are located in the lowest position in the nasal cavity, just inside the nostril.  The inferior turbinates can sometimes be excessively large or swollen; a condition termed turbinate hypertrophy.  This enlargement can be due to swelling of the soft tissue covering of the turbinate, known as the mucosa.  The inner framework of the turbinate which is composed of bone can also be enlarged.  Enlargement or Hypertrophy of the turbinates is a common cause of nasal obstruction. 

enlarged inferior turbinate

Fig 13: Image illustrates normal and enlarged (hypertrophic) inferior turbinate anatomy.

How is turbinate hypertrophy treated?

Turbinate hypertrophy is initially treated medically with intranasal steroid or antihistamine sprays, oral steroids, oral decongestants or oral antihistamines.  When medical therapy fails to treat the problem surgery can be performed to reduce the size of the turbinate to relieve nasal obstruction.  Turbinate reduction refers to surgery that is directed at shrinking the soft tissue and/or bony components of the turbinates to alleviate nasal blockage.    

Nasal Valve Collapse

What is Nasal Valve Collapse?

Nasal Valve Collapse is a common cause of nasal obstruction.  Nasal valve collapse results from dynamic inward collapse of the lateral nasal wall with inspiration.

Lateral nasal wall

Fig 14: Image depicts the lateral nasal wall a key structure involved in nasal valve collapse.

This condition typically results from a lack of adequate cartilage support.  Inspiration through the nostrils results in negative pressure inside the nasal cavity.  When the lateral nasal wall lacks the appropriate cartilage support, the sidewall is unable to withstand the negative pressure in the nasal cavity, resulting in collapse. 

lateral wall collapse

Fig 15: Image illustrates normal positioning of the lateral nasal wall (left) and dynamic inward collapse of the lateral wall in cases of nasal valve collapse(right).

Nasal valve collapse can occur at two levels in the nose: the internal and external valve. 

nasal valve collapse

Fig 16: Image illustrates the two main sites of nasal valve collapse: Zone 1: Internal Nasal Valve, Zone 2: External Nasal Valve.

What Causes Nasal Valve Collapse?

  • Prior rhinoplasty surgery due to excessive removal of cartilage.
  • Aging
  • Nasal Trauma
  • Iatrogenic Causes
  • Congenital Deformity

How is Nasal Valve Collapse Diagnosed?

  • The physician will discuss your symptoms of nasal obstruction, including the severity, as well as any factors which alleviate or exacerbate your symptoms.
  • The physician will take a thorough medical history including discussing any prior nasal surgery, chronic nasal or sinus disease or history of nasal trauma.
  • A thorough nasal exam and possible nasal endoscopy will also be performed to evaluate your nose.
  • A Cottle Maneuver or Modified Cottle Maneuver are helpful in determining if you suffer from nasal valve collapse. It is also helpful in determining the level of collapse. 

How is Nasal Valve Collapse Treated?

There are many treatment options for nasal valve collapse. Non-Invasive options such as nasal breathing strips provide temporary relief of symptoms.  Surgical treatment provides permanent alleviation of symptoms.  Surgical treatment typically involves the use of cartilage grafts, which are placed in the nose to improve support of the internal and external nasal valves.  Spreader grafts and batten grafts are used to treat internal and external valve collapse, respectively.  New bioabsorbable implants such as the Spirox Latera implant, have shown to help many patients suffering from nasal valve collapse. The Spirox Latera implant offers a more minimally invasive option to treat nasal valve collapse compared to traditional surgery. 

Fig 17

Tip Refinement Techniques

The Bulbous Tip

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.

Fig 18: This patient underwent rhinoplasty to correct an overly bulbous tip. Tip refinement techniques were used to create a more delicate tip which was in better proportion with the face.

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 Lower 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.
cephalic trim

Fig 19: Image depicts the “Cephalic Trim” technique used for tip refinement. The area outlined in red is the region of the lower lateral cartilage which is surgically removed, when in excess, to refine a bulbous nasal tip.

  • 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.
suture reshaping

Fig 20: Positioning of the domal stabilization suture (red) in relationship to bilateral intradomal sutures (blue).

suture reshaping

Fig 21: A, B.  Placement of tip refinement sutures in open rhinoplasty

  • 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.
tip refinement grafts

Fig 22: Examples of Common Tip Refinement Grafts: A. “Peck” Onlay Graft B. Shield Graft.

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.

The “Droopy” Ptotic Tip

What is a “Droopy” Nasal Tip?

A common patient complaint is a ptotic nasal tip, otherwise known as a droopy tip or hooked nose.  The tip of the nose typically points downward, and the appearance is commonly worsened with smiling.  Patients seeking ptotic tip rhinoplasty desire a more upturned or rotated position for their nasal tip.  Females typically desire a more upturned or upwardly rotated nose compared to males. 

What causes a “Droopy” Ptotic Tip?

Aging is a common cause of the droopy nasal tip.  As we age the support structures of the nose weaken, leading to downward descent of the type.  Trauma can also result in a ptotic nasal tip if the support structures of the nose are injured.  Some patients noses may point downward naturally, without a definitive cause.  Patients that complain of a plunging tip when smiling may suffer from muscle tightness.  The depressor septi muscle runs between the base of the nose and upper lip.  In cases of facial animation when smiling, overactivity of the muscle, can lead to abnormal sagging of the tip. 

What is “Droopy” Ptotic Tip Rhinoplasty?

Many techniques are used to improve a ptotic nasal tip.  In all cases the goal is to rotate the tip upwards into a more aesthetically pleasing position.  In cases of depressor septi muscle overactivity, the muscle fibers can be divided, resulting in less downward traction on the nasal tip especially when smiling.  In cases of caudal septal excess, the caudal septum can be shaved which helps to shorten the septum, resulting in upward tip rotation.  In cases of poor nasal tip support, cartilage grafts can be placed to provide more tip strength.  The most common graft for this need is called the columellar strut graft.  Cartilage is typically harvested from the septum, ear or rib to create the graft.  It is placed in a precise pocket created between the medial crura and secured in place to provide strength and support for the nasal tip.

droopy ptotic tip rhinoplasty

Fig 23: A Columellar Strut Graft (Yellow) positioned between the medial crura to provide improved tip support.

Tip suture techniques can also be utilized to achieve improved tip rotation and projection.  The “Tongue in Groove” technique is very useful for this purpose.  In this technique, the medial crura are advanced onto the caudal septum and are positioned to create a more upturned tip.

Fig 24: This patient underwent rhinoplasty for correct a long nose with ptotic tip. Note the resulting upward rotation of the nose and shortening of the length of the nose to a more aesthetically pleasing proportion.

The Overprojected Tip

What is an over projected nose?

Tip projection refers to how far the nose protrudes (“sticks out”) from the face.  Tip projection is typically most noticeable on a side view or profile photo.  An overly projected tip is commonly referred to as a “Long Nose”.  In cases of excessive tip projection is it also sometimes referred to as a “Pinocchio Nose”.

What causes tip overprojection?

Causes of tip overprojection commonly involve elongation of the alar cartilage which can be caused by excessively long medial crura, lateral crura or a combination of both.  Injury or iatrogenic causes such as prior nasal surgery can also result in this nasal deformity.  A high nasal septum, referred to as a Tension Septum, can also lead to the appearance of an overly long nose.

How is tip overprojection corrected?

Tip Deprojection refers to reducing the protrusion of the nose by bring the tip closer to the face.  The most important factor is diagnosis of the cause of tip overprojection.  A skilled rhinoplasty specialist will be able to determine if your nose is overly long for your face.  Several surgical techniques which modify the nasal tip cartilage can be used to achieve tip deprojection.  These include dome truncation, as well as medial and lateral crural overlay.  An overly high septum can also be lowered to reduce protrusion of the tip.   

Fig 25: This patient underwent rhinoplasty for correction of an over projected tip which she felt “stuck out” too far from the face. Note the resulting de-projection of the tip with positioning of the tip closer to the face creating better profile balance.

Alar Base Reduction

Rhinoplasty for Wide Nostrils

The alar base refers to the bottom of the nose at the base of the nostrils.  Nostril width, shape, proportion and flare are common cosmetic concerns from rhinoplasty patients.  Patients who seek alar base reduction commonly complain of “wide nostrils”.  The alar base is considered “wide” when the interalar distance exceeds the intercanthal distance.

alar base reduction for wide nostrils

Fig 26: This image depicts analysis of alar base width. Alar base width is considered excessive when interalar distance (red) exceeds the intercanthal distance (yellow).

How Do You Correct Wide Nostrils?

Careful examination by an experienced facial plastic surgeon is required to determine the cause of a wide alar base.  Two common issues leading to the wide alar base are excessive nostril flare and overly wide nostrils.   Nostril flare refers to an overly “rounded” appearance to the nostril rim.  Excessive nostril sill width refers to an overly wide nostril “opening”.  To techniques are commonly used for alar base reduction

Weir “Wedge” Incisions

This technique involves the removal of a small wedge of tissue at the edge of the nostril, where the nostril meets the face.  This technique is commonly used to treat nostril flaring.  The incisions are placed in the natural crease at the base of the nostril which is know as the alar facial groove.

Nostril Sill Excision

This technique involves removal a small amount of tissue at the nostril sill (“base of the nostril”) to reduce the width of the nostril. 

nostril sill excision

Fig 27: This image illustrates reduction of wide, flared nostrils with Weir Wedge Resection.

Common Complications Requiring Revision Rhinoplasty

What is a “Polly Beak” Deformity?

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 formation at the supratip, overresection of the nasal bones, as well as a loss of tip support?

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, along with taping of the nose to apply compression at the supratip.  If conservative therapy fails surgical correction with revision rhinoplasty will be necessary to remove the excess scar tissue.   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).  Lastly, the loss of tip support can be treated with cartilage grafts.  A columellar strut graft is typically used to reestablish the appropriate tip support and projection. 

What is a “Pig Nose” Deformity?

The “Pig Nose” Deformity commonly refers to an overly short or upturned nose.  This is a complication from prior rhinoplasty surgery, where the tip was overly rotated in the upward direction.  This is typically a result of excessive removal of cartilage particularly at the caudal septum, which is at the bottom portion of the nose between the nostrils.  Excessive scar tissue formation after rhinoplasty can also results in tip retraction. 

How is a “Pig Nose” Deformity Corrected?

The main goal in correcting this type of deformity is to lengthen the nose and “turn down” the tip.  This is typically accomplished with revision rhinoplasty utilizing both septal extension grafts and extended spreader grafts.  Septal extension grafts are inserted at the end of the short septum to increase the length of the septum and overall length of the nose. Septal extension grafts typically require a very rigid piece of cartilage to be effective.  Costal cartilage, otherwise known as rib cartilage, is commonly used for this maneuver.  Extended spreader grafts are also used to further lengthen the nose and provide support.    

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 support 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 support 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.

What is a Saddle Nose Deformity?

A saddle nose deformity is characterized by a collapse of the nasal dorsum with decreased dorsal height.  They are seen after rhinoplasty surgery when there is over aggressive cartilage removal with dorsal hump reduction.  Over resection of the cartilaginous septum leading to inadequate L-strut support can also result in this deformity.  Minor saddle nose deformities that do not result in structural weakness of the nose can be corrected with dorsal grafts.  My particular graft of choice is the diced cartilage fascia graft (DCF).  For moderate to severe saddle nose deformities with structural compromise, extensive cartilage grafting is needed to rebuild the nasal framework.  This typically involves use of costal cartilage (rib cartilage) due to its increased strength.  DCF grafts would also be used for cosmetic enhancement once the nasal framework is rebuilt. 

What is the cause of an overly “Pinched” Tip?

An overly pinched tip after rhinoplasty is typically a result of over resection of the lateral crura.  This can also lead to nasal obstruction with collapse of the nostrils on inspiration due to structural weakness at the external nasal valve.  An experienced rhinoplasty surgeon will typically maintain at least a 6-8mm thick strip of lateral crura to ensure appropriate support for cosmetic and functional purposes.  Cartilage grafts are usually required to enhance the strength of the lateral crura.  Alar batten grafts, as well as lateral crural strut grafts, are typically used to treat this deformity.  Lateral crural malposition can also lead to an overly “Pinched” Tip.  This occurs when the caudal (lower) border of the lateral crura is positioned significantly inferior to the cephalic (upper) boarder.  Lateral crural repositioning with lateral crural strut grafts can correct his complication.   

What is an “open roof” deformity?

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 Alar Retraction?

Alar retraction refers to significant upward ascent of the alar rim leading to alar columellar disproportion.  This can be caused by over aggressive resection of the lateral crura during cephalic trimming.  It can also result from lateral crural malposition.  Minor cases of alar retraction can be treated with alar rim grafts which help to move the alar rim in a lower position.  Lateral crural strut grafts can be used to correct lateral crural malposition.  In more severe cases of alar retraction composite grafts consisting of conchal cartilage and skin may be needed to reposition the alar rim, as well as provide lining inside the nose. 

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