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 midfacial region. Since the nose projects off of the face, there are more ways that a nose can look out of balance than other, flatter features of the face. With its added dimension of projection, the nose can look too deviated to one side or the other, too long or short, too thick or thin, too down turned or upturned, have too much of a hump, or be too sloped. The tip can look too bulbous or be too pinched. With the large number of ways that a nose can look out of balance, it is not surprising that rhinoplasty procedures are one of the most commonly performed procedures in plastic surgery. In fact, it is one of the oldest procedures ever documented, with evidence of rhinoplasties having been performed in Ancient Egypt over 5000 years ago, and in Ancient India 3000 years ago. Currently, over 200,000 nose shaping procedures are performed in the United States each year and it 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 of the nose weaken over time, the nose can become longer, more bulbous, and even start to drift to one side or the other. In Dr. Cross’s practice, a surprising 30% of his rhinoplasty patients are over the age of 40.
There are two main components to the appearance of the nose: the tip and the dorsum. Tip shape is defined by cartilages that are positioned under the skin of the tip of the nose, known as the alar cartilages (shown in figure 1***). The cartilages start where the central base of the nose meets the lip and arch out and up. They have the appearance of bird wings in flight. The size, strength, and position of these cartilages determine the appearance of the tip. The dorsum of the nose is comprised of the long portion of the nose that runs from the just above the tip up to where the nose meets the forehead, 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 that you can feel when you move your fingers down from the nasion. As your fingers move further down, the hard nasal bones under the skin will transition to softer, compressible cartilages. These cartilages are called the upper lateral cartilages, and determine the appearance of the midportion of the nose (figure 2). Running down the center of the nose, like a supporting wall in architecture, is the septum. The septum runs vertically 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 (figure 3***).
Nose shaping surgery:
Surgery of the nose typically falls into three general components: 1. Managing the dorsum to correct humps, slopes, and deviations, 2. Tip procedures to correct the position, deviation, and appearance of this region, 3. Functional procedures to correct breathing problems and nasal obstruction. Often, elements of two or three of these are combined at the time of a single procedure to achieve the optimal results. Most of the work that is performed on the nose can be done from inside the nose. In many 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 is used to allow for optimal precision. Dr. Cross performs a large number of revision surgeries. One of the most common reasons for a revision is that a prior surgeon tried to achieve more than was possible without this small incision. When it is necessary to use, the incision will heal in a way that is essentially imperceptible (figure 4***). A result that is less than ideal, that results from trying to avoid this incision, will never look acceptable.
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 procedure. Precision with this part of the procedure is paramount. Over reduction should never be allowed.
Patients often ask if the bones of the nose have to be “broken” during a nose procedure. 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, they are bent in a way that allows them to remain in their new position.
Managing the Tip:
Tip position, size, and appearance is managed by making alterations to the lower lateral cartilages. These cartilages are divided into three components, 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 removal of cartilage to make changes to the appearance of the nose, most of these changes, when performed by Dr. Cross, are performed by reshaping the cartilage using sutures. Bending and molding cartilage, instead of removing cartilage, allows for more predictable results and ensures that the results will hold their appearance indefinitely.
Difficulty breathing out of 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. 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 too can obstruct the flow of air. Finally, nostrils are kept open during inspiration by the strength and shape of the cartilages of the nose. If the shape or strength are naturally not sufficient to support the nostrils, or if they have been weakened by prior surgery that removed too much of the cartilages, the nostrils will collapse in during inspiration, making it harder to breath. Deviated septums are corrected by a combination of reshaping, reinforcing, and when necessary, removal of redundant excess cartilage. Enlarged turbinates can by reduced by shrinking the lining of the turbinate or by moving them back, out of the airway. Lastly, weak or poorly shaped cartilages can be strengthened by suturing techniques, or reinforced by adding strong septal cartilage areas of cartilage collapse.
Ear and Rib Cartilage:
It is frequently the case that aesthetic and breathing improvements require addition of cartilage beyond what excess cartilage in the nose can provide. In these cases, extra 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.
Planning for a Procedure:
After listening to a patient’s goals and desires, every patient gets a full exam of the appearance and features of their nose, as well as a gentle look at the anatomy inside of the nose using a fiberoptic light. A plan is discussed, and these goals are then illustrated using a three dimensional imaging system called The Vectra System. This approach allows 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, before and after pictures of patients with similar anatomic features who had similar goals are shown so that patients can get comfortable with how real results look in real patients.
In Dr. Cross’s office, the recovery after a rhinoplasty procedure is typically less involved than is traditionally seen. Dr. Cross has all patients decontaminate their nose prior to the procedure with an antibiotic solution. 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, does the work underneath, then gently lays the overlying tissue back. This further reduces trauma to the nose, decreasing bruising, swelling, and pain. It also translates into less post-operative pain. Patients will feel some achy throbbing shortly after the procedure, but true pain is infrequent and lasts only a short period of time. In a survey of 250 of Dr. Cross’s rhinoplasty patients, only 5% took prescription pain medicine for more than just the first night. Almost all patients take nothing more than Tylenol by the day after the procedure.
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 keep swelling out of the nose. Nasal gauze is placed in the nose at the end of the case in 50% of patients. This packing slides out easily after 1 day. The splint comes off 5-7 days after the procedure. If sutures are used at the base of the nose, they are removed at this time as well. During the first and second office visits, ultrasound and sometimes lasers are used to reduce swelling and bruising more quickly. Patients can start exercising in 5-7 days, but need to avoid activities that are high risk for nose injury for three weeks. While recovery times vary, and the end result takes months materialize, patients generally can start interacting socially without anyone knowing they’ve had a procedure within 10 days, sometimes sooner.