Rhinoplasty (Nose Job)
Individualized Nose Surgery Brings Balance to the Face in the Philadelphia Area
As the central feature of the face, the nose has important aesthetic significance. It helps frame the face and establishes the subtle lines, curves, and shadowing of our mid-facial region. That is why so many patients come to Dr. Kevin Cross for rhinoplasty (commonly known as a "nose job") in the Philadelphia area.
Rhinoplasty surgery must be done well to look natural and balanced. Advances in closed and open rhinoplasty techniques, tissue elevation and structural molding approaches, and incision-less rhinoplasty options are methods Dr. Cross is pioneering for patients who are interested in a nose job to maximize results and minimize recovery.
What Sets Rhinoplasty Procedures Apart from Other Surgeries?
Since the nose projects off of the face, there are more ways a nose can look out of balance than other, flatter features. Due to its added dimension of projection, the nose can look too deviated, too long or short, too thick or thin, or too downturned or upturned. It can have too much of a hump or be too sloped. The tip can look too bulbous or be too pinched.
With the significant number of ways a nose can look out of balance, it is not surprising that rhinoplasty is one of the most commonly performed procedures in plastic surgery in the United States. In fact, it is one of the oldest procedures ever documented, with evidence of rhinoplasty surgeries having been performed in Ancient Egypt more than 5,000 years ago, and in Ancient India 3,000 years ago.
Currently, more than 200,000 nose jobs are performed in the United States each year—and rhinoplasty is not just a procedure for the young. A significant number of patients seek rhinoplasty procedures for age-related changes to the nose. As the ligaments weaken over time, the nose itself can become longer, more bulbous, and even start to drift to one side or the other. In Dr. Kevin Cross's practice, a surprising 30 percent of his rhinoplasty patients are older than 40.
Nose jobs require more finesse than many other procedures. The margin for error is low in rhinoplasty surgery, since every nuance of the nose is there for the world to see and mere millimeter shifts or alterations can make a noticeable visual difference. Using the techniques described below, Dr. Cross has been able to reduce rhinoplasty revision rates in his practice to a fraction of the national average.
Rhinoplasty Basics: Nose Anatomy
There are two main components to the appearance of the nose: the tip and the dorsum. Not every nose job involves both parts of the nose, but any rhinoplasty surgery needs to take their relationship into account in order to create the most balanced, proportionate, and harmonious look possible.
The Nasal Tip
Tip shape is defined by cartilages positioned under the skin of the tip of the nose, known as the lower lateral (or "alar") cartilages.
The cartilages start where the central base of the nose meets the lip, and they arch out and up from there, giving them the appearance of bird wings in flight. The size, strength, and position of these cartilages determine the appearance of the tip.
The dorsum is comprised of the long portion of the nose that runs from just above the tip, up to where the nose meets the forehead in an area known as the nasion. The shape and appearance of the upper dorsum is determined by the nasal bones, which can be felt as the solid portion of the nose when you move your fingers down from the nasion. As your fingers move farther down, the hard nasal bones under the skin will transition to softer, compressible cartilages. These cartilages are called the upper lateral cartilages. They determine the appearance of the mid-portion of the nose. Running down the center of the nose, like a supporting wall in architecture, is the septum. The septum runs vertically down from the nasion, under the nasal bones, and down to the tip. It divides the two sides of the nose into separate chambers and can be felt with its soft lining on either side by putting your fingers into your nose and feeling the hard wall separating the two nostrils.
What Are the Various Nose Surgery Types and Techniques?
A nose job typically involves one or more of three general strategies:
- Managing the dorsum to correct humps, slopes, and deviations.
- Tip procedures to correct the position, deviation, and appearance of this region.
- Functional procedures to correct breathing problems and nasal obstruction.
Dr. Cross often combines elements of two or three of these into a single rhinoplasty procedure to achieve optimal results. Most of the work can be done from inside the nose. In many rhinoplasty patients, both cosmetic and functional results can be achieved without any external incisions. In some cases, however, a small incision at the base of the nose, on the nostril-separating tissue known as the columella, allows for optimal precision.
*Results May Vary
Before & After Photo Gallery
See for yourself the patient transformations that can be achieved by Dr. Cross and his team.
Managing the Dorsum
Humps and bumps of the nose are treated by lowering the position of the nasal bones, the upper lateral cartilages, and the upper septum. A combination of trimming and shaving in this area allows for gradual reductions that can be seen at the time of the rhinoplasty procedure. Dr. Cross emphasizes that precision is paramount. Over-reduction should never be allowed.
Patients often ask if the bones of the nose have to be "broken" during a nose job. When the amount of reduction of the hump is significant, or if the dorsum of the nose is not straight because the bones are out of alignment, moving the bones will allow them to result in proper positioning and in relation to each other and the rest of the nose. They are not "broken" in a traditional sense. Rather, Dr. Cross bends and molds them during rhinoplasty surgery in a way that allows them to be moved and then remain in their new position.
Managing the Tip
Dr. Cross manages the tip position, size, and appearance by making alterations to the lower lateral cartilages during rhinoplasty surgery. These cartilages are divided into three areas: medial, middle, and lateral. Shortening or lengthening the medial component adjusts the degree of elevation of the tip, while doing the same to the lateral component adjusts the rotation of the tip.
A tip that is too bulbous or boxy is fixed by altering the width and shape of the middle and lateral components. Unlike past rhinoplasty techniques, which used cartilage removal to make changes to the appearance of the nose, Dr. Cross performs most of these changes by reshaping the cartilage using sutures. Bending and molding cartilage, instead of removing cartilage, allows for more predictable results with stronger cartilage that stands the test of time and allows the results to hold their appearance indefinitely.
Difficulty with breathing through the nose generally results from one or a combination of three issues:
A deviated nasal septum will narrow the airway and restrict air flow by bulging into one or both nasal passages. Deviated septums are corrected during rhinoplasty surgery by a combination of reshaping, reinforcing, and—when necessary—removing excess cartilage.
Inferior turbinates are natural outpouchings present in each nostril. They are responsible for humidifying air as it passes through the nostrils and also help to filter out particles in the air. When these outpouchings become enlarged, they can also obstruct the flow of air. Enlarged turbinates can be reduced during rhinoplasty surgery by shrinking the lining of the turbinate or by moving them back, out of the airway.
Finally, nostrils are kept open during each in-breath by the strength and shape of the nasal cartilages. If these cartilages are naturally insufficient to support the nostrils, or if they have been weakened by prior surgery that removed too much tissue, the nostrils will collapse inward during each inhalation, making it more difficult to breathe. Weak or poorly shaped cartilages can be strengthened by suturing techniques or reinforced by adding strong septal cartilage to areas of cartilage collapse during rhinoplasty surgery.
What Is Revision Rhinoplasty?
Dr. Cross performs a large number of revision surgeries, which alter the results of a prior nose job. One of the most common reasons for a revision rhinoplasty is that a prior surgeon tried to achieve more than was possible without making a small incision on the columella. When it is necessary to use, this incision will heal in a way that is essentially imperceptible, as seen in this patient with the incision pictured close up at two weeks after the nose job and then two months after the nose job.
Preparing for Your Rhinoplasty Procedure
After listening to a patient's goals and desires, Dr. Cross gives every patient a full aesthetic and functional nasal exam, as well as a gentle look at the anatomy inside of the nose using a fiber-optic light. He then discusses a nose surgery plan, illustrating any corrective goals with the Vectra three-dimensional imaging system. This approach allows rhinoplasty patients to see their own nose, the changes that are planned, and how these changes will look in relation to the rest of the features of the face.
Finally, Dr. Cross shows before-and-after pictures of patients with similar anatomic features who had similar goals, so that prospective patients can get comfortable with how rhinoplasty results look in real life. As shown in this example, the after result of a specific rhinoplasty surgery can very accurately be predicted by the Vectra imaging.
Vectra Simulated Results
*Results May Vary
If More Cartilage Is Needed, Where Does It Come From?
Infrequently, aesthetic and breathing improvements require additional cartilage, beyond what excess cartilage the nose can provide. This is most commonly the case when Dr. Cross performs a revision rhinoplasty. Most revision rhinoplasty procedures do not require extra material to work with, but when massive amounts of structural cartilage were removed or damaged during a previous procedure, it is sometimes necessary to replace this cartilage.
In these rhinoplasty cases, cartilage can be obtained by using excess cartilage that is found in the back bowl region of the ear, or by taking a cartilaginous portion of one or more rib. When harvesting ear cartilage, the incision is placed behind the ear where it is not noticeable. Rib cartilage is acquired through a small incision that is placed in the underfold of the chest in men or in the inframammary fold in women.
Some rhinoplasty surgeons try shortcuts as substitutes for obtaining cartilage, including silicone implants, plastic inserts, and rib cartilage from cadavers. Dr. Cross feels that these options come with too many risks and dangers. Use of silicone and plastic can lead to infections, foreign body reactions, and skin erosion, and cartilage from cadavers is dead tissue that has been processed and altered. Over time, it is prone to be dissolved and replaced with excessive scar tissue. The use of a patient's own natural tissue, when possible, is always the best option when needed for rhinoplasty, and the incisions that are necessary to obtain the required cartilage typically heal imperceptibly when performed correctly.
Most rhinoplasty procedures take between one to two hours. Patients wake up after their procedure with a splint on the nose. The splint acts very much like an ace wrap to help minimize swelling. Dr. Cross rarely—if ever—uses packing in the nose. The splint comes off five to seven days after the rhinoplasty procedure. If sutures are used at the base of the nose, they are removed at this time as well.
Recovery after a rhinoplasty procedure by Dr. Cross is typically less involved than is common. Dr. Cross has all patients decontaminate their nose with an antibiotic solution prior to rhinoplasty surgery. This helps to reduce swelling after the procedure.
Additionally, rather than cutting through areas of the nose that do not need to be worked on in order to get to the areas that do need work, Dr. Cross lifts up the tissues that do not need adjustment, performs the necessary work underneath, then gently lays the overlying tissue back. This approach to rhinoplasty further reduces trauma to the nose, decreasing bruising and swelling. It also translates into less postoperative pain.
Patients will feel some achy throbbing shortly after their rhinoplasty procedure, but true pain is infrequent and lasts only a short period of time. In a survey of 250 of Dr. Cross's nose job patients, only 5 percent took prescription pain medicine for more than just the first night after their surgery. Almost all patients take nothing more than Tylenol starting the day after the rhinoplasty procedure.
During the first and second office visits after rhinoplasty surgery, ultrasound and sometimes lasers are used to reduce swelling and bruising more quickly. Patients can start exercising in five to seven days, but need to avoid activities that have high potential for nose injury for three weeks. While rhinoplasty recovery times vary, and the end result takes months to materialize, patients can generally start interacting socially within 10 days—and sometimes sooner—without anyone knowing they've had a nose job.
Facial Procedures Beyond Rhinoplasty
A well-balanced face has features that work in harmony, with no particular element standing out in particular as too large or too small. Other plastic surgery options to create ideal facial contours at Cross Plastic Surgery include ear surgery and chin and cheek implants.