Posted on April 13, 2011 in Revision Rhinoplasty, Rhinoplasty, Septal Reconstruction, Septoplasty
I wanted to post a plastic surgery blog entry focusing on rhinoplasty imaging as it relates to achieving realistic results in nose reshaping. This particular San Diego rhinoplasty patient had suffered trauma to the nose when he was actually stepped on after falling to the ground. As you can see on his frontal rhinoplasty view, he had severe trauma to the bridge of his nose with collapse. You can see his frontal view looks ‘washed out’ – meaning, he has very poor shadowing on both sides of his bridge. In addition, you can appreciate that his nose was collapsed asymmetrically, or differently on both sides.
Imaging in Rhinoplasty
We consulted with him in our San Diego office regarding reconstructive rhinoplasty surgery, which included a discussion of cadaveric rib cartilage grafting. Using a computer imaging program, we provided him with a visual idea of what his nose might look like following nasal reshaping surgery. Below are his preoperative rhinoplasty photos and the corresponding imaged view of what his nose might look like after nose reshaping. This imaging represented rebuilding his bridge back up and repositioning his nasal bones to their original orientation. On his side view you can see just how much his bridge was collapsed. With the computer imaging program, we were able to demonstrate visually how rebuilding his bridge back up might look following rhinoplasty.
Computer Images From Rhinoplasty Consultation
Actual nose preoperatively on left side, computer imaged/enhanced photo on right showing possible changes with planned rhinoplasty or nose job surgery.
Reconstructive Rhinoplasty With Rib Grafting
I ended up taking this patient to surgery and performed a complex open reconstructive septorhinoplasty. As part of the nasal reshaping process, I also performed a cadaveric rib grafting procedure. This was needed to rebuild his bridge height and restore and more normal looking nose.
Actual Rhinoplasty Before And After Photos
Here are his before and after rhinoplasty (nose job) photos. As you can see, we have now restored a more symmetric frontal view of his nose with improved shadowing. His nose no longer looks flattened across the front. On his profile view, rhinoplasty has provided restoration of a masculine profile view through elevation of his bridge height. Also compare his true post-rhinoplasty result with the computer imaged rhinoplasty photos shown above. As you can see, his actual rhinoplasty results are better than what we imaged in his rhinoplasty consultation before surgery. This is, in fact, my goal with all rhinoplasty patients. My personal approach to the rhinoplasty consultation involves ‘under-imaging’ and ‘over-delivering’ in terms of the nasal reshaping process. I would much prefer to show you computer images that are sufficiently enhanced to make you satisfied as a rhinoplasty patient, yet realistic and achievable. If you are content with the surgical goals using a computer image that is under enhanced, you should then be even happier when the actual rhinoplasty results surpass the anticipated imaging. This particular San Diego rhinoplasty patient is a prime example of our routine use of computer imaging in nasal reshaping surgery.
To see this San Diego rhinoplasty patient’s complete photo series, use this link here to our online rhinoplasty gallery.
Posted on January 21, 2011 in Ethnic Rhinoplasty, Rhinoplasty, Septal Reconstruction, Septoplasty
Wanted to post a quick blog entry on cosmetic reshaping of the crooked ethnic nose. Correcting a crooked nose deformity is arguably one of the most difficult and challenging types of cosmetic rhinoplasty, or nose reshaping, procedures. This young rhinoplasty patient from San Diego presented to my office with a notable crooked nose. As you can see, her nose alignment is shifted to her right side. Like her, most rhinoplasty patients are bothered by the fact that the crooked nose draws unwanted attention to the mid portion of the face and can be quite distracting. Her goal was simply to have a nose that was in proper alignment with her other facial features and one that was smaller. We performed an open cosmetic septorhinoplasty to reshape her nose. This included reshaping her nasal bridge and repositioning her nasal bones. I also performed some tip work to reduce the overall size of her tip and bring it to a more midline position. As you can see from her before and after rhinoplasty photos, she has a nice improvement with better alignment of her nose. The nose also looks smaller, yet not too small for her face. She also has improved tip position and shape. Overall, she now has a much softer, more feminine look that is appropriate for her face.
Before and After Rhinoplasty
Posted on January 13, 2011 in Rhinoplasty, Septoplasty, Spreader Graft
This particular patient was a great example of how we utilize spreader grafting technique as part of a nasal reshaping process. This pleasant male patient presented with difficulty breathing through his nose as well as cosmetic concerns regarding the appearance of his nose. On nasal examination he was found to have a fairly complex nose in terms of anatomical problems. As you can see in the photo diagrams below, his nasal bridge was fairly displaced but in a somewhat unique fashion. The upper portion of his bridge was collapsed inward (as shown by the blue arrow) on his right side and pushed out on his left side (as shown by the upper end of the white line). The lower portion of his nose was more displaced to his right side. The end result was a nose that looked as if it ran obliquely across the middle of his face. In addition, he had a slight bump on his bridge immediately above a depression involving the left side of his bridge. The curvilinear blue line in the diagram below follows the outline of his nose as seen on this oblique view highlighting just how misaligned his nasal bridge really was preoperatively. Although this is not the most dramatic crooked nose deformity that you might have seen, this particular nose encompassed a number of fairly complicated deformities that needed to be addressed concurrently.
The Rhinoplasty Repair
We were able to perform a combined functional and cosmetic rhinoplasty procedure using an open rhinoplasty approach. As part of the corrective process in reshaping his nose, we reduced the upper portion of his bridge where the bump was present. We also performed osteotomies to fracture the nasal bones and reposition them. However, this only resulted in correction of the upper 1/3 of his nasal bridge. At the same time, we had to place a spreader graft on his left side in order to rebuild the middle vault region where he was noted to have an obvious depression on the oblique view referenced above. Not only did this spreader graft help elevate and widen his nose in this area (see his oblique after photo showing a nice straight nasal outline), it also helped improve his nasal function. Coincident with these rhinoplasty maneuvers we reduced his right tip volume to give him a more symmetric frontal view. Combined, these various rhinoplasty techniques made for a fairly challenging and complex nasal reshaping process. Fortunately, we were able to provide him a nice overall improvement in nasal shape and function. We did end up performing a secondary refinement procedure to give him even more improvement with the end result shown below in the photo series. One can appreciate the new nasal shape as one that is a clear improvement over his preoperative nose. In addition, he still looks quite natural while maintaining a nice masculine overall appearance.
Posted on January 3, 2011 in Septal Reconstruction, Septoplasty
We are proud to announce that we have added a new page to our San Diego Rhinoplasty Tutorial focusing on septal reconstruction, or septoplasty. Here is the link to the new septoplasty tutorial page. We hope this provides some assistance to those patients out there who are considering septoplasty surgery for difficulty breathing through the nose.
Posted on December 23, 2010 in Facial Plastic Surgery, Rhinoplasty, Septoplasty
One of the main differences between my practice and other plastic surgeons’ practices is that I have additional advanced specialty training in reconstructive work related to the nose. This more commonly involves patients that need a plastic and reconstructive surgeon for functional, or medically indicated, work that needs to be done. This is commonly referred to as a reconstructive septorhinoplasty. This reconstructive septorhinoplasty patient from San Diego was recently seen in our office and was thought to be a good example of how we integrate reconstructive nose work with cosmetic reshaping of the nose. He presented primarily with complaints of difficulty breathing thru his nose. On preoperative examination he was noted to have asymmetry of his nose where the base was different from one side to the other. On frontal view of his nose you can see how it is canted off to his right side and his nostrils are different from left to right. From underneath his nose, you can easily appreciate how his left nasal airway is nearly completely blocked. This was from deviation of his septum, which happens to be a common cause of nasal obstruction. He elected to undergo surgery to help improve his nasal airway function while also providing him more symmetry. His surgery was performed with use of cadaveric costal, or rib, cartilage grafting. This was used in order to have sufficiently strong and plentiful material to reconstruct the nose. A caudal strut graft was used to stabilize the tip while providing more symmetry. In addition, a long strut graft was used along the left side of his bridge to stabilize his dorsal support and contour. Internally, a formal septoplasty was performed to straighten out the deviated septum and improve the internal nasal airway. The end result can be seen in the before and after photos below. Notice how on his frontal view his nose is now much more symmetric and fits his face more appropriately in terms of balance. From below, you can see how his nostrils are now much more even. In addition, his septum is now much straighter. The end result for this reconstructive septorhinoplasty patient is a nose that is more symmetrically shaped for his face and one that is much more efficient when it comes to breathing.
Posted on October 21, 2010 in Ethnic Rhinoplasty, Revision Rhinoplasty, Rhinoplasty, Septoplasty
I recently saw one of my postoperative revision rhinoplasty patients in follow-up and it reminded me of several discussions that have taken place online regarding a hanging columella. This particular patient had prior rhinoplasty surgery by another plastic surgeon. One of her remaining concerns following surgery was the position and shape of her columella. The columella refers to the column of soft tissue and cartilage that divides the two nostrils. In her particular case, it was simply too heavy and brought unwanted attention to this area of her nose. Many people with this particular problem inquire whether or not this type of revision rhinoplasty can be done under local anesthesia. The answer is – yes. Over the years I have performed many revision rhinoplasty procedures for this exact indication and have successfully done this under local anesthesia or local anesthesia with very light sedation.
This particular patient here had hers done in under 45 minutes using a closed approach. This means that there were no external incisions made on the nose. An incision was made on each side of the columella to allow adequate exposure of the underlying anatomy. I then tucked up the cartilage and soft tissue with permanent sutures. The end result of this type of revision rhinoplasty was a subtle yet noticeable improvement in her tip and columella. Her nose now looks much softer overall and she is quite happy with the change.
To see other photos from her revision rhinoplasty, use this link here: http://www.drhilinski.com/gallery/revision-rhinoplasty/patient-39#content
Posted on March 4, 2010 in Facial Plastic Surgery, Septoplasty
Many patients inquire about septoplasty for nasal obstruction, or difficulty breathing through the nose, and ask whether I perform suture technique to straighten the septum. The answer to this is ‘no’ in terms of my primary surgical technique for septoplasty. The reason for this is that the cartilage of the septum has what we call ‘memory’, which means that it has a tendency to go back to its original shape if given the opportunity. Conservative methods of straightening the septum like just suturing the cartilage are highly prone to failure because the cartilage memory overrides the suture tension. The end result is that the cartilage bends back to its original crooked shape. In order to effectively straighten a deviated septum, the surgeon normally has to cut the cartilage at the very least to permanently reshape it. By cutting the septum in strategic locations one can completely erase the memory issue and provide a long-term improvement.
Posted on October 22, 2009 in Rhinoplasty, Septoplasty
One of the most common fears following rhinoplasty and/or septoplasty is the possibility that the surgeon is going to pack the nose. This means the surgeon places gauze or similar material inside the nasal passages to put internal pressure on the tissues. This is done to minimize chances of bleeding as well as to promote stable healing of the internal lining (called the mucosa). Unfortunately, nasal packing after rhinoplasty/septoplasty is extremely uncomfortable. Not only is packing painful, it also inhibits patients from breathing thru the nose during the early recovery period. Because these issues can be so anxiety provoking for some patients, I stopped packing noses on a regular basis nearly 6 years ago. Instead, I use an absorbable suture to stabilize the internal tissues that also helps minimize bleeding. Doing this also allows patients to have at least some degree of breathing thru their nose in the early recovery period. If I do place anything in the nose after surgery, it might be a small piece of absorbable gel-like material that dissolves with use of salt water spray in the nose. Either way, I avoid having to pack the nose in the traditional manner, leaving my patients with a much more comfortable recovery.
