A Closed rhinoplasty procedure can accomplish building up the nasal bridge. In many cases patients are born with a low bridge profile and would simply like to build up the height of the bridge for better facial aesthetics and balance. Other patients, have had an over-resection of the dorsal hump, and are left with a residual ski-slope deformity. In addition, some patients have received a traumatic injury to the nose and are left with a saddle nose deformity. When performing a revision rhinoplasty, it’s important to know how much cartilage as left on the inside of the nose for potential grafting purposes. A cartilage graft is the preferential way to build up patients own bridge line with their own natural tissues. If there is a cartilage-depleted nose, ear cartilage can be considered. In rare cases, rib cartilage may be needed. Once the nasal cartilage or ear cartilages have been harvested for potential grafting, they are then fashioned in the proper shape and inserted through a small incision along the bridge line of the nose. Most of the time the grafts are placed in a precise pocket, but they also can be sewn in place if needed. Alternatively, some patients require a significant amount of augmentation and they have no cartilage left on the inside of the nose and do not wish to have a rib cartilage taken out. For these patients, a Flowers Silastic nasal dorsal implant is used. These are also inserted in a small anatomical pocket along the bridge line. These implants are composed of Silastic, and can be custom carved when necessary. These implants are not the typical L- strut used in Asia. The L- strut implants can cause a lot of problems and many times have to be removed. In addition to building up the bridge of the nose, many patients require osteotomies placed in the nasal bones to narrow a pre-existing wide bridge line in addition to adding height to the bridge. This also helps to give added height to the bridge as well. Both medial and lateral osteotomies of the nasal bones are required to narrow them. It is also important to evaluate the status of the nasal tip to make sure it is in balance with the new and higher bridge line. Some patients require a reduction in the size of the tip with a conservative cartilage removal, while other patients require augmentation of the tip to of balance with the bridge. Tip cartilage grafting techniques are sometimes required to make sure the tip balances with the entire new bridge line. Dr. Portuese performs nasal surgery at The Seattle Facial Plastic Surgery Center, a state-of-the-art licensed and certified outpatient surgery center in Seattle Washington.
Dr William Portuese
1101 Madison St #1280,
Seattle, WA 98104
Closed Rhinoplasty to widen a narrow nose
Some patients are born with an unnaturally narrow nose and would like to have it cosmetically widened. Other patients are born with an “hourglass deformity” which means they have pinched or very narrowed upper lateral cartilages in the mid-portion of the nose. Typically these patients have wide nasal bones, a dorsal hump, and a wide tip. The inverted upper lateral cartilages appear concave and relatively speaking, can make the tip look more bulbous and the bridge look wider. To widen a narrow nose requires osteotomies placed in the nasal bones, which include both medial and lateral osteotomies. The medial osteotomies are placed at the junction between the upper lateral cartilage and the lower portion of the nasal bones. Instead of narrowing the nasal bones, they’re actually cantilevered out more widely, also known as reverse osteotomies. Cartilaginous spreader grafts are then inserted in the space where the medial osteotomies were placed to hold the nasal bones open in their new wider position. The cartilaginous spreader grafts can be harvested from the dorsal hump that’s been removed or from inside the nose from nasal septal cartilage. The spreader grafts are also placed in a sub-perichondrial and sub- periosteal pocket. It’s also important to make sure the tip of the nose balances with the new bridge line. In some patients the tip may need to be narrowed, and other patients, the tip needs to be widened. A conservative cartilage removal is required to narrow the tip, while cartilage-grafting techniques are required to widen it. Rhinoplasty is a very difficult endeavor, so is very important to choose a rhinoplasty specialist based on extensive experience performing osteotomies, spreader grafts, and advanced bone and cartilage work to create a natural appearance. Dr. Portuese performs all of his nasal surgery procedures at the Seattle Rhinoplasty Center, which is a state-of-the-art Medicare certified outpatient surgery center located in Seattle Washington
A rhinoplasty procedure can accomplish narrowing wide nasal bones with osteotomies. The osteotomies allow the entire bridge line composed of the wide nasal bones and the corresponding wide upper lateral cartilages to be narrowed from their pre-existing wider position. After performing medial and lateral osteotomies in the nasal bones, a cast is applied across the bridge of the nose and is usually left intact for one week. Anticipate 2 weeks of visible bruising and swelling from the procedure itself. The sutures placed on the inside of the nose with closed rhinoplasty are all dissolvable. It’s also important to make sure the tip of the nose balances with the new bridge line, so in many instances, some type of tip surgery may be required. To narrow the nasal tip requires a conservative cartilage removal or suture techniques called intra-domal or inter-domal sutures, which can narrow the nasal tip. It’s important that all of the components of the nose including the nasal bones, upper lateral cartilages, and the lower lateral cartilages of the nasal tip balance with themselves. To narrow wide nostrils requires an alar-plasty, which can be accomplished with an incision at the base of the nostril sill for very wide nostrils, or an internal incision if the amount of narrowing is minimal. To close the alar-plasty incision usually requires 2 types of sutures to hold the incision together underneath the skin with dissolvable sutures and a meticulous skin layered closure so that the incision heals inconspicuously.
Many nose job procedures require a dorsal hump reduction. The dorsal hump is composed of cartilage and bone and it must be shaved down in order to remove it successfully. The removing of the dorsal hump creates an open roof, and a flat-top nasal deformity which also has the appearance of a very wide nose. Osteotomies of the nasal bones are definitely required for each time the dorsal hump is removed. Osteotomies performed on the nasal bones allow closure of the open roof deformity to give a very balanced nose. It’s also important that the nose looks balanced from all angles, since it is a three-dimensional structure. Some patients also require small spreader grafts placed underneath a concave upper lateral cartilage once the dorsal hump has been removed. These grafts are placed through a small incision at the septal angle and inserted underneath the perichondrium and periosteum of the nasal septum to bolster and support the upper lateral cartilages and prevent them from falling inwards. Dr. Portuese performs closed rhinoplasty to accomplish narrowing a wide nose under general anesthesia by a board-certified physician anesthesiologist. The procedure is performed in a state of the art in a Medicare Certified, Outpatient Ambulatory Surgery Center. The center is also a licensed by the Department of Health in Washington State
There are many issues in the nose that can create an asymmetrical appearance to the nose. A nose job procedure, also known as a rhinoplasty can accomplish making the nose look more symmetrical. There are a variety of techniques available to accomplish making the nose look much more symmetrical than it already is. As a surgeon, it is very important to evaluate what is causing the structural asymmetries underneath the skin soft tissue envelope. A closed or open rhinoplasty procedure can address mild, moderate, or significant asymmetries. With a closed rhinoplasty approach, all incisions are placed on the inside of the nose and dissolvable sutures fall out in about a week. If the nasal bones themselves are asymmetric and crooked, medial and lateral osteotomies of them are required with an osteotome to set them straight and parallel. If the upper lateral cartilages are convex or concave, they need to be adjusted as well. A convex upper lateral cartilage can be shaved down. A concave upper lateral cartilage will make the nose looked twisted in the mid-portion of the nose, and this is corrected with a spreader graft placement. The nasal tip cartilages are often asymmetric and they need to be adjusted as well. The mild asymmetry is adjusted with shaving down a thick lower lateral cartilage of the nasal tip, while a cartilage graft is placed on the thinner nasal tip cartilage on the opposite side. When significant asymmetry exists in the nasal tip cartilages, a full delivery with suture techniques is required to make the lower lateral cartilages of the tip look symmetrical. Asymmetrical nostrils can also be adjusted with an alar-plasty, and a columellar-plasty. A deviated caudal septum can cause the columella to be twisted as well. Dr. William A. Portuese is the medical director and founder of the Seattle Rhinoplasty Center, a Medicare certified, Washington state licensed, outpatient surgery center located in Seattle Washington.