Nasal surgery, or Rhinoplasty in New York City, has evolved over the years from a “cookie cutter, one-type fits all” procedure to now individualizing the surgery to provide a natural result while also maintaining or improving breathing for most patients. This may mean removing a bump on the nose or refining the tip shape in some patients. There are some patients that have a “flat and wide” nose that may need narrowing of the nose, or even raising of the profile of the nose. Some patient’s surgery is more involved than others, and if there are breathing issues this adds to the surgical time. The surgical procedure usually takes between one and two hours with a recuperation of one to two weeks. More difficult rhinoplasties requiring extensive septal work or secondary rhinoplasties for complicated revisions will often take longer. Dr. Wallach, a Manhattan NY Plastic Surgeon, has presented at national meetings and published papers on rhinoplasty in peer-reviewed journals.
- Alar Base Reduction
- Airway Obstruction or Breathing Difficulties
- Ethnic Rhinoplasty
- Graft Options
- Open vs. Closed Approach
- Suturing Techniques
- Tip Refinement
Alar Base Reduction
Alar base reduction surgery is often requested in patients that have a wide nasal base and complain of flaring nostrils. A general guideline to evaluating the nostrils and nasal base is to compare their relationship to a line drawn longitudinally from each medial canthus (the inner portion of the eye). There are several different types of alar base reduction procedures that excise various portions of the alar rim to reduce flare of the nostril and/or the nasal width, and they are chosen based upon the given anatomy and patient goals. These procedures can be done at the same time as the rhinoplasty, but also can be done under local anesthesia at a later time.
“As an expert in the field of plastic surgery, one of the most rewarding aspects of my career has been listening to my patients stories about how having plastic surgery has changed their lives.”
Airway Obstruction or Breathing Difficulties
Many, but not all causes of airway obstruction or breathing difficulties can be treated surgically. The most common causes of airway obstruction include: septal deviation, internal valve collapse, external valve collapse, turbinate hypertrophy, nasal polyps, and adenoids. However, there are also other causes of airway obstruction, and these are not always easy to correct. This includes allergic rhinitis, chronic sinusitis, infectious disorders like the flu, and emotional and stress induced causes. The ones listed below can be treated by Dr. Wallach during standard rhinoplasty surgery for his New York City patients. Treatment of the these causes, while often improving airway flow, do not always succeed because of the other potential causes described above.
External Valve Collapse
This refers to the nostril valve or the external and internal structures around the nasal rim, including the columella, the lower lateral cartilage(LLC), and the nasal floor. This valve collapses with inspiration and is usually due to weak LLC either genetically, from trauma, or from previous rhinoplasty surgery. Usually, providing better support to the LLC will improve this condition. This can be accomplished with cartilage grafts sutured to the LLC or columella.
Internal Valve Collapse
The internal nasal valve is made up of the area in the middle third of the nose, consisting mainly of the upper lateral cartilage (ULC), the nasal sidewall, the septum, and the inferior turbinate. Collapse can be seen in the middle third of the nose with deep inspiration. Treatment of the collapse can be accomplished by placing a cartilage graft, commonly known as a spreader graft, between the septum and ULC. An alternative is to fold in a portion of the ULC as a graft to increase the angle between the ULC and septum.
Curvature of the septum can cause airway obstruction. Treatment of the septal deviation can be done using suture techniques, scoring of the cartilage, reinforcement of the cartilage with grafts, and/or removal of a portion of the deviated cartilage as in a submucous resection (SMR). Commonly, a SMR procedure will provide cartilage graft material for use in other areas such as for spreader grafts, batten grafts to straighten the septum, alar cartilage grafts for support of the nasal rim, and as tip grafts, to name a few.
The turbinates are a series of structures that are out pouchings within the nose that work like alternating humidifiers of the respired air. The ones that often give the most trouble are the inferior turbinates. The turbinates are made of bone and overlying mucosa. One or both of these structures may be enlarged and cause airway obstruction. Treatment consists of removal of the enlarged component. Sometimes, segments of the inferior turbinate bone and mucosa are resected during rhinoplasty to improve airflow. Out-fracturing the turbinate is occasionally performed. Treatment is dependent upon the exact pathology.
Dr. Wallach does not like this phrase because it is often used to describe select ethnic groups that undergo rhinoplasty. Dr. Wallach practices in New York City and his patients are from all different ethnicities and commonly of mixed ethnicities. He feels that every patient is so ethnically different that in reality, everyone has their own version of an “ethnic rhinoplasty” in some shape or form. The goal for his patients is to maintain their ethnic identity and yet give them a natural result.
To achieve certain results for the tip, for nasal deviations, for breathing difficulties, for dorsal onlay grafting, or for nasal support, to name a few, graft material may be necessary. This can be obtained from a variety of sources both autologous (your own tissue) and non-autologous (synthetic or cadaver).
Autologous Graft Choices
Since these are harvested directly from the patient, they tend to have better take than non-autologous grafts, and in general are better to use. There is a lower risk of infection and extrusion.
Ear cartilage is a popular choice to provide grafting material. It can be harvested from an incision behind the ear, and it is often harvested from the conchal bowl leaving little to no ear deformity. It is good for tip grafting and sometimes as a spreader graft. It does not have the same structural support as a septal or rib cartilage graft.
Rib cartilage is harvested from the chest wall. A small incision on the chest is used to obtain the graft, and in women it is often harvested through a small incision under the breast fold. This usually provides the largest amount of graft material. It is commonly used when a significantly large dorsal augmentation is required for flat noses particularly in African American, Asian, Mestizo, Hispanic, and Latin American noses. It can be used for most other grafting requirements as well. The main drawback is the scar and the discomfort that can develop from the harvest procedure.
Septal cartilage is often the first choice of graft material because the septum is very commonly exposed during the rhinoplasty, and often treated, as well, for deviations during rhinoplasty. It is an excellent source of cartilage and can be molded for almost any use. There are no additional external incisions to harvest the graft.
Temporalis fascia is found in the lateral forehead region within the hairline. Fascia is the white connective tissue layer that is soft and covers the muscle in many different areas of the body. The incision used to harvest this particular fascia is within the hairline. It is often used for camouflage purposes when the overlying skin is very thin, so that underlying structures are not as noticeable. It is also for dorsal onlay procedures when diced cartilage is used for a nasal augmentation. The fascia is wrapped around the cartilage in what has been called a “Turkish Delight.”
Non-Autologous Graft Choices
Are either synthetic or derived from human tissue. They are used frequently but the better choice is autologous cartilage grafts.
Acellular Dermal Matrix (ADM)
ADM’s are derived from dermis or skin elements that are treated to remove all antigenic material. They are from either human or porcine tissue. They are used in a similar fashion to fascia. They are good for camouflage purposes to cover the framework structures under a thin skin envelope.
Irradiated Homograft Costal Cartilage (IHCC)
This is rib cartilage and is harvested from a human cadaver and treated so that all antigenicity and any microorganisms are removed. This is used as a cartilage graft like those in the autologous cartilage graft descriptions. It is an excellent product that eliminates the harvest of the patient’s own rib cartilage, thus avoiding the incision and discomfort associated with the rib harvest. It is commonly used when multiple cartilage grafts are needed, when there are not enough donor site grafts available from the septum or ear, or when the patient does not want their own rib to be harvested. There have been several studies in the medical literature showing the long-term use and efficacy of this product.
Gore-Tex, Porex, and Silicone are all types of synthetic grafts that are available for nasal augmentation. Since they are synthetic and they do not become incorporated into the adjoining tissue, they have a higher incidence of infection and extrusion. Dr. Wallach does not usually use these products for nasal grafting, and prefers the autologous tissue grafts when available.
Open vs. Closed Approach
Traditionally, the closed approach was the most common surgical incision technique used to gain access to the underlying nasal framework during surgery. This usually employed various incisions internally and could include incisions between the upper and lower lateral cartilages, at the inferior border of the lower lateral cartilages, or within the border of the lower lateral cartilages. Commonly, this was combined with a transfixion incision (along the lower border of the septum). The closed approach can be used in many instances, and for some surgeons this is the only approach that they use. Interestingly, many surgeons have moved away from this approach and have used an open approach more frequently. The open approach employs some or all of these previously described incisions, but includes a small incision on the skin of the columella. The columella is the area between the two nostrils. The incision added is only about 0.5 -1 cm in length but it gives so much more exposure to the surgeon. Since the columella incision is in the shadow of the nose, when looking at someone straight on, the columella incision is often well hidden. The best analogy to using a closed approach is like working on a car engine with your hands under the hood and not looking directly at what you are fixing, and the open approach is like working on the car engine with the hood open, and you can see everything that you are working on. Most surgeons feel that with this better exposure, more precise and accurate work can be done. Dr. Wallach prefers this technique for most of his New York rhinoplasty patients. Learn more about Open vs Closed Rhinoplasty.
Rhinoplasty surgeons perform osteotomies, or precise bony cuts so that the nasal bones can be moved. If a dorsal nasal hump is shaved down to reduce it, commonly the dorsum becomes flat and osteotomies are required to move the bones inward and restore the natural nasal pyramid. This can be done with several different types of bone cuts: low-to high, low-to-low, medial oblique, or even double-level cuts. In many circumstances, the nasal pyramid is narrowed after the osteotomies. In some cases especially after trauma, the bones sometimes need to be out-fractured to restore nasal width.
Rhinoplasty surgery has evolved over the years. As described above, as our knowledge of the nose has improved and results have been scrutinized, techniques have improved from a “cookie cutter” “one size fits all” approach to a more individualized, meticulously carried out procedure to provide aesthetic improvement, but yet maintain nasal function. The days of removing structural support to make the cute “button nose” and leave the patient a “nasal cripple,” unable to breathe properly have disappeared. With this in mind, conservation of inherent structural support is keenly observed. As such, suturing techniques (stitching internally) have evolved to modify structural shape, such as the tip. In addition, suturing techniques and careful dissection of vital internal structures have evolved to help minimize scarring and contracture in an attempt to maintain good vital function.
Many patients desire improvement in the nasal tip. Sometimes the tips are “boxy,” bulbous, rounded, clefted, have a parenthesis shape, or are just amorphic. These deformities can be related to the underlying anatomical structures that create the tip. The lower lateral nasal cartilages contribute to the tip appearance, and often have to be modified with partial excision as well as with suturing techniques to create the desired shape. Sometimes cartilage grafts are used to improve tip projection as well, and are secured to the cartilage in the columella region. The overlying skin envelope also contributes to the overall shape. In patients with very thick, oily skin, these underlying structures may not be as well defined as in someone with very thin skin. The thicker skin and soft tissue envelope tend to blunt the underlying structures and hide them, therefore, thinning the subcutaneous tissue a bit may improve the tip definition.
If you would like more information about Manhattan Plastic Surgeon Dr. Wallach and his success with New York City Rhinoplasty procedures, we hope that you will not hesitate to contact our Manhattan office at (212) 257-3263 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.
Rhinoplasty (Nose Job) Frequently Asked Questions
It was very common 20 or 30 years ago for patients to have similar rhinoplasty results, typically with an over resected nasal dorsum that left a “scooped out” appearance and an over resected nasal tip which left a “pinched” look. The nose often did not “fit” the face properly and left a very “plastic looking” nose, sometimes with breathing difficulties. Today, most surgeons perform a rhinoplasty that will improve the appearance of the nose but just as importantly maintain adequate function.
This is a question that is asked often. Most patients want to maintain their ethnic look but often with “softer” features. Some patients just want a bump on their nose softened or removed, some want a flat nose to be raised, and still others desire slightly narrower noses. A natural result maintaining a patient’s ethnic features is all possible by using subtle maneuvers to achieve surgical goals.
Many patients who present for rhinoplasty complain that their nose is too big and they want a bump removed. The bones are gently shaven down to soften the bump. In doing so, the normal pyramidal shape of the dorsum of the nose sometimes becomes flat. In order to restore this pyramid shape, the bones have to slide inward from both sides. This is achieved by precisely cutting the bones and realigning them to recreate this pyramid.
A bump on the dorsum of the nose is often due to both bone and cartilage growth. Rasping or shaving the bone down and then delicately trimming the cartilage is how a dorsal hump is usually removed. Because shaving the dorsum will often create a flat appearance or an open roof, lateral osteotomies, or precise cuts in the bones on the side of the nose will allow the open roof to close.
Increased nasal width can be at any level. If it is in the upper one-third then this can be due to the wide bones. Osteotomies of the bones or precise cuts in the bone can narrow this region. In the middle one-third, or middle vault, the upper lateral cartilages can be trimmed to narrow this region. Osteotomies treating the upper one-third will often help to narrow the middle one-third as well. For the lower one-third, this often includes the nasal base, and various alar base reduction procedures can be performed to narrow this region.
A crooked nose can be due to curvature of the nasal bones and/or the septal cartilage. Treatment may require a submucous resection (SMR) of the curved component of septal cartilage, and possibly osteotomites of the bones to straighten it. A good nasal exam pre-op will facilitate making the appropriate surgical plan. Sometimes cartilage grafts are used and/or sutures are used to straighten the septal cartilage as well.
A septoplasty is a procedure to straighten the nose. This can consist of removing a small portion of the septum called a submucous resection (SMR) or even placing sutures or scoring the cartilage to straighten it. Sometimes internal splints are placed temporarily to support the correction.
The letters, SMR, stand for submucous resection. This refers to the removal of a portion of the septal cartilage to improve curvature or it is used to harvest cartilage for graft material.
An alar base reduction is sometimes referred to as a Weir excision depending upon the technique. An alar base reduction can be performed to treat flare of the nostrils, and/or width of the nasal base. Small crescents of tissue can be taken out along the nasal vestibular floor, along the crease of the nostril sill rim, or used in a combination of both.
Flaring nostrils can be treated with an alar base resection usually along the nostril sill. Fine sutures are used to repair this treated region. The sutures are usually removed within one week after surgery.
A flat dorsum can be augmented with autologous tissue or non-autologus tissue. Autologous tissue (tissue from one’s own body) includes cartilage grafts that can be harvested from the septum, the ear, or the rib. If the nasal bridge is very flat, often rib graft is the best choice. Non-autologous tissue includes irradiated homograft costal cartilage (IHCC) which is cadaveric rib cartilage, or an implant like silicone or medpor. My preference is usually rib cartilage, followed by IHCC.
Diced cartilage is usually made from either septal or rib cartilage. This is literally chopped up cartilage that is then wrapped within a tube of either temporalis fascia or even Alloderm and then secured on the nasal dorsum and used for augmentation.
Commonly the dorsum is flat, the base is wide, and the tip often does not have enough projection. Cartilage grafts are used to provide dorsal height and can add tip support. A columella strut with tip grafts can improve the tip projection for many patients. A base excision treating alar flare or base width can be performed as well.
Commonly in this patient population, the nose is flat and wide. A dorsal onlay cartilage graft is a good option to augment the dorsal profile. Modifications of the alar base can be performed using various techniques to narrow the base or treat nostril flare.
Thick skin can minimize the risk of seeing irregularities in the nasal tip or other structures after rhinoplasty. However, tip definition may be difficult to achieve for some when the tissues are very thick. Sometimes cartilage grafts are beneficial and occasionally skin flap thinning may be performed.
A tip plasty is a procedure performed on the nasal tip to refine it. It is often requested by patients who are unhappy with a boxy or bulbous tip. This is not as involved as a standard rhinoplasty because no bony or cartilaginous septal work is done on the dorsum. The recovery is often a bit easier, and bruising is not as significant as in a standard rhinoplasty. This can be performed using an open or a closed approach.
Columella show is sometimes misconstrued by the patient. This is because of the delicate relationship between the alar rim and the columella. Sometimes the columella show is due to a retracted alar rim which can result from weak alar rims or over aggressive excision of alar cartilage during a rhinoplasty. A hanging columella is one in which the columella is pushed down and “shows” more than normal. Treatment of columella show due to alar retraction can be performed using alar grafts to strengthen the alar rim cartilages. Sometimes if there is severe retraction, a composite graft of cartilage and skin can be placed internally to lower the alar rim. If there is a hanging columella, this is often due to a prominent caudal septum pushing the columella downward. Treatment of a hanging columella can be as simple as trimming the caudal septum.
Nasal cartilage grafts are obtained most commonly from the septum. Performing an SMR (submucous resection) to harvest septal cartilage is common. Other sources of cartilage include the ear and the rib.
A rib graft is harvested when a large piece of cartilage is required for dorsal augmentation or septal cartilage is not available. Usually septal cartilage will not provide adequate augmentation in these cases.
When the nose is flat and dorsal augmentation is requested, options for augmenting the nose include use of autologous tissue (the patient’s own) such as the septal cartilage, ear cartilage or rib cartilage. Non-autologous sources include silicone or medpor implants. Another great option, in my opinion, is irradiated homograft costal cartilage which is a cadaveric rib cartilage graft.
An open rhinoplasty is one technique used for performing a rhinoplasty. It uses the same incisions as a closed rhinoplasty but also incorporates a small incision across the columella skin. This additional one centimeter incision allows the soft tissue envelope over the tip and dorsum to be raised so that the surgeon can directly visualize the underlying cartilaginous and bony structures while performing a rhinoplasty.
A closed rhinoplasty is a technique employing incisions internally in the nasal vestibule to provide access for performing a rhinoplasty. This can include either an inter or intra-cartilaginous incision as well as a septal or transfixion incision.