The Art of Rhinoplasty

The size and shape of a nose is determined by the inherent size, shape, and consistency of an individual’s cartilage, bone, and overlying skin. While everyone has the same basic anatomical elements, the specific arrangement and contour of these elements varies greatly from person to person and is influenced by age, ethnicity, trauma, and other medical conditions. Rhinoplasty is the surgical art of re-shaping the nose. Primary rhinoplasty refers to the operation performed on a patient who has never undergone rhinoplasty in the past. First, inconspicuous incisions are made and the skin of the nose is lifted from its underlying bone and cartilage framework. Next, some of the bone and/or cartilage is removed or rearranged and the nasal support system is reconstituted, thus providing a newly shaped and structurally sound nose. The skin is then re-draped over the new frame and the incisions are closed. A soft packing material is usually placed inside the nose and removed the day after surgery. Small stitches and an external splint are usually removed one week after surgery. The majority of swelling, bruising, and discomfort is experienced during the first week following surgery, and most people return to school or work after this time period.

Our personal approach to primary rhinoplasty starts with an initial consultation during which we analyze the external contours of the nose as well as examine the internal structures that are crucial to nasal function. We exchange thoughts with our patients regarding their desires and our realistic expectations. In addition, we share our portfolio of work for inspection and discussion if necessary.

With regard to surgical approach, the merits of closed versus open rhinoplasty continue to be debated in the literature and consultation rooms throughout the world. Although we acknowledge that there is an appropriate place for both approaches and most of the decision comes down to personal preference, we feel strongly that the extensive dissection, detailed attention to symmetry, widespread use of grafting, and precise suture placement that we employ in almost every case could not be performed in any other manner other than the open approach. In addition, we feel that the internal incisions of the closed approach can lead to detrimental scar formation that has a negative effect on both nasal appearance and function. With regard to the incision of the open approach, we have demonstrated with a multitude of cases that with proper incision technique this will heal very well and be undetectable over time. Through the open approach we have exceptional exposure in order to properly assess the state of the nasal framework prior to manipulation and then proceed with alteration in any desirable manner. This allows the use of spreader grafts, lateral crural strut grafts, septal extension grafts, dorsal augmentation grafts, tip grafts, and alar rim grafts; many of which could not be correctly placed and secured through any other approach.

In our practice, primary rhinoplasty (as well as secondary rhinoplasty) is often performed in conjunction with functional nasal surgery such as nasal valve repair, septoplasty, turbinate reduction, or endoscopic sinus surgery. Through meticulous attention to detail and extreme patience, these operations can restore nasal function to normal while simultaneously creating a pleasing, natural, harmonious nasal appearance.

Secondary rhinoplasty (also referred to as revision rhinoplasty) is the operation performed on a patient who has undergone one or more rhinoplasties prior to the current procedure. Although it involves many of same considerations and techniques as primary rhinoplasty, it is in many ways very different than primary rhinoplasty. Secondary rhinoplasty is usually a more involved, lengthy operation that requires the surgeon to be able to react to a variety of unknowns, depending on what is encountered during surgery. This procedure frequently involves a very tedious dissection through scar tissue in order to elevate the skin and mucous membranes from the underlying cartilage and bone. It also frequently requires the use of additional structural material in order to rebuild the support system of the nose and create the necessary contour changes. In a primary rhinoplasty this structural material will usually be obtained by borrowing cartilage and / or bone from the septum. However, in most secondary rhinoplasties adequate septal cartilage and / or bone are rarely available. Alternative choices for structural material are the patient’s own ear cartilage, rib cartilage, or cranial bone; as well as cadaver rib cartilage or various artificial implant materials (i.e. silicone, gortex, Porex). Most of these choices have significant drawbacks and do not meet the criteria of a desirable implant material for secondary rhinoplasty.

A desirable implant material must be a low risk for infection or extrusion. It must be in abundant supply. It must be strong enough to maintain the necessary support and withstand the forces of scar contracture without changing shape or position. And it must possess the ability to be contoured in order to recreate the natural elements of the nose. Even when ear cartilage is taken from both ears this only yields a small amount of cartilage. In addition, ear cartilage is curved, thin, and soft. It works well for minimal cosmetic grafting, but never works well for grafting large areas or grafting that is required to maintain structural support. Cranial bone, on the other hand, offers more material to work with and is strong enough to maintain structural stability. However, it is difficult to contour, difficult to secure in various positions, and cannot mimic the natural feel and texture of nasal cartilage. All artificial implant materials are always a bad idea for nasal surgery. Over time, they have a high rate of infection and extrusion and often need to be removed. Therefore, the only materials which meet all of the criteria explained above are cadaveric rib cartilage and the patient’s own rib cartilage. We have found that when high quality cadaveric rib cartilage is utilized, it is safe, reliable, in abundant supply, delivers consistent results, and allows our patients to avoid an additional surgical site. Overall, secondary rhinoplasty with cadaveric rib cartilage allows for incredible transformations that many patients have thought or have been told are not possible.