Rhinoplasty (nose job) Overview

Orange county rhinoplasty is dedicated to informing Orange County nose job prospects about nasal surgery. Nasal surgery is unique in that it must take into account both functional and aesthetic considerations.

Functional considerations involve assessing the quality of air flow through the two parallel nostrils. In essence each nostril posses a nasal tube that is lined by a mucosal membrane and which allows for air to be delivered from the outside air at the nares to the deep throat. The two tubes act in unison and provide for a smooth laminar flow of air. In fact, if one nasal tube is constricted, then not only does the flow through that tube get constricted but it effects the contralateral patent side. This is because the flows of air that are now non-uniform cannot merge together at the back of the throat resulting in turbulent flow. This turbulence actually causes irritation of the mucosal membranes that line the entire nasal passages causing inflammation and further global constriction.

Aesthetic Considerations

Aesthetic considerations involve assessing the specific region of the nose that is of concern. Aesthetic concerns can be further localized to the three regions of the nose that include the upper, middle, and lower nasal thirds. Each of these thirds has unique features that help guide the exact nose job maneuvers required to improve the nasal contour. Specifically, the upper third of the nose has a bony component infrastructure that requires being broken in a controlled manner, called osteotomies, to improve. The middle and lower third of the nose have a softer cartilaginous infrastructure that can be altered with careful incisions and bending with stitches. Localizing nasal contour aesthetics to these three components is also critical as it will guide whether closed or open rhinoplasty will be recommended.

Functional Rhinoplasty

Functional considerations that guide nasal surgery require a complete assessment of the nasal tunnel that extends from the nasal opening called the nares to the back of the throat where the two nasal tunnels converge. The nostril tube can be constricted by a deviated septum, at the nasal opening, called external nasal valve, at the middle nose, called the internal nasal valve, in the middle/back due to enlarged inferior turbinates, and throughout the entire tube if there is a crooked nose or saddle nose deformity.

External nasal valve collapse

The external nasal valve refers to the opening of the nose called the nares. There are three reasons why the external nasal valve can collapse and these include weakened lower lateral cartilages, a tip that is fatty, or a downturned nasal tip. Two paired lower lateral cartilages fusing at their centers create was we know as the tip. The medial components of the lower lateral cartilage form the central pillar that we refer to as the columella and support and define the tip position. The lateral aspect of the lower lateral cartilages fan out and help support the nares roof, and the nostril rim. If this lateral aspect of lower lateral cartilage is weak, then rim collapse can occur causing constriction of the nostril. To correct this problem, the cartilage needs reinforcement either with stitches or the addition of cartilage reinforcement. A fatty tip refers to a nasal tip that is chubby that possesses excess fat. Literally the weight of the fat in the tip can weigh down the nares and cause constriction of the nostril opening. The correction for this requires defatting the nasal tip. The final reason for a tight nares involves a nasal tip that is down turned or a tip that is too forward and usually associated with a prolonged nose. To correct this, the medial aspect of the lower lateral cartilages must be upturned or rotated back and reattached onto the nasal septum, the main central pillar infrastructure of the nose. This results in uprotation of the nasal tip, shortening of the nasal length, and opening of the external nasal valve.

Deviated septum

A deviated septum is the most common cause of functional breathing problems. This septal cartilage is the main, central pillar structure that keeps the nose supported. Unfortunately, the septum can become deviated either due to irregular growth congenitally or following trauma throughout your life. When the septal cartilage gets deviated it will lean onto one or the other nostril thus constricting one tube and thereby increasing the size of the other. This discrepancy in nasal tube sizes results in conversion of laminar or smooth flow to turbulent flow. This unfortunately results in inflammation of nasal mucosa that lines the nasal tubes. Inflammation of the nasal mucosa further constricts the tubes globally thereby hindering breathing. The treatment for a deviated septum involves removing the deviated portion of the septal cartilage thus bringing the pillar back to the middle and resetting the tube areas to equal measurements.

Internal nasal valve collapse

The internal nasal valve refers to a region inside the nasal tip at the junction of the lower and middle thirds. This area is a common constriction point and is defined by the angle created by the fusion point of the upper lateral cartilage and nasal septum. When the angle created by the upper lateral cartilage and dorsal septum is less than 15 degrees, then the internal nasal valve can become collapsed. A good test for internal nasal valve collapse is to have our patient breathe in deeply. If the sides of the middle of the nose get sucked down and prevent comfortable inspiration, then this is a sign of internal nasal valve collapse. There are two cures for this problem. First, you can add a piece of cartilage to the junction of the upper lateral cartilage and septum, called a dorsal spreader graft, which basically augments the angle discussed above and opens up the internal nasal valve. Another option is to support the nasal side wall with a cartilage graft, called a batten graft.

Enlarged inferior turbinates

Inferior turbinates are spongy bone outgrowths that extend from the maxillary bones on each of the nasal side walls and have functional purposes only. First, these turbinates circulate blood through them in order to warm up the air as you breathe in. This is so that you don’t get brain freeze if you live in colder climates. Another function of the turbinates is to grow and recede as needed to keep the two nostril tubes constant in size. Constant size of nostril tubes is to ensure smooth and laminar flow. For example, if you were to develop a septal deviation, such that the main central support structure of the nose leans to one side. The job of the inferior turbinates would be to grow into the contralateral side in an attempt to constrict the now larger tube. Although this compensatory reaction will avoid creation of turbulent air flow, it does have the net effect of now further constricting total air flow. To correct enlarged turbinates, the spongy bone underneath the nasal mucosa must be removed to push back the turbinate and reset nasal tube size to its normal aperture  

Crooked nose deformity

Crooked nose deformity results when there is mechanical trauma to the nose thus resulting in the entire nasal dorsum leaning over to one side or another. The typical scenario is of either being hit by a soft ball or a fist which cracks the nose to the contralateral side. So if you get hit from the right side, your nose will lean over to the left. This results in near complete constriction of the left side. The treatment for this injury in the early period, i.e. first week following injury, is to literally to push back the nose to the center and to keep it in place with an external splint for one week. If the crooked nose deformity has not been corrected in a timely fashion, then a formal closed rhinoplasty is required as described below.

Saddle nose deformity

Saddle nose deformity refers to the total collapse of the nasal dorsum. Think of the two nostril tubes as a mine and then imagine the mine collapsing! This is caused by an unstable nasal septum that literally collapses down. The correction for a saddle nose deformity requires a enblock costal cartilage graft that will serve as an I beam. This surgery is one the most complex in rhinoplasty surgery and requires an expert nasal surgeon. 

Aesthetic Rhinoplasty

Aesthetic rhinoplasty refers to nasal surgeries that are intended to improve the size and shape of the nose. When the changes of the nose desired are limited to the upper two third of the nose, then a closed rhinoplasty is recommended. Nasal concerns of the upper two third of the nose can involve a dorsal hump, a widened nasal bridge and base, supratip fullness. When the changes of the nose desired involve the lower third of the nose, or nasal tip, then an open rhinoplasty is required. If the tip shape, tip position, or length of the nose requires changing, then an open tip rhinoplasty is required. Of note, the open rhinoplasty can alter not only the lower third of the nose but also the upper two third concerns.

Closed rhinoplasty

A closed rhinoplasty utilizes two small incisions that are placed inside the nostril at the lower and middle third junction of the nose that allow access to all of the nasal soft tissues located above the incisions. As such, these two incision lines allow for dissection of the middle third of the nose that contain the cartilaginous structures of the nasal septum and the upper lateral cartilages as well as the upper nasal third made up of the nasal bones and medial aspect of the maxillary bones. The advantage of the closed rhinoplasty is that the incisions created are completely hidden and it minimizes area of surgical dissection. Completely hidden incision lines means that no one will know that you have had a nose job. Minimizing area of surgical dissection means that your surgery will take less time, cost less money, and heal quicker.

Eliminating the Dorsal Hump

The dorsal hump is the most common complaint of patients desiring a nose job. They will often complain that their nose looks like a Roman nose or that it is too prominent. This dorsal hump prominence is most noticeable on the profile view when photos are taken from the side. The dorsal hump involves both the upper third nasal bones and the middle third upper lateral and septal cartilage. The dorsal hump is eliminated first by isolating the prominent area of the nasal bone as well as the junction of the upper lateral cartilage and dorsal nasal septum that create an umbrella looking overhang. First the prominent portion at the top of the dorsal hump is rasped down thus lowering the bony roof. This maneuver does create an open roof of the nose which then needs to be closed by breaking the lower lateral legs of the maxillary and nasal bones, often referred to as osteotomies. Then, the prominence of the upper lateral cartilage and dorsal nasal hump incised and removed. These maneuvers will in essence eliminate the dorsal hump.

Widened nasal bridge and base

A widened nasal bride and base refer to the side walls of the nasal dorsum being too wide. They are made up of the nasal and medial maxillary bones of the upper third of the nose and the upper lateral cartilages of the middle third of the nose.  The nasal bridge refers to the upper aspect of the nasal side walls and the nasal base refers to the bottom of the nasal side walls. Both the nasal bridge and base can be narrowed in the upper third of the nose by completing osteotomies of the bones described above and pushing them in. The middle third nasal bridge can be narrowed by first releasing the upper lateral cartilages from the dorsal septum and then trimming the medial aspect of the upper lateral cartilages as needed.

Supratip fullness

Supratip fullness refers to the region located just above the nasal tip. It is the lowest area of the nose that can be accessed using the closed rhinoplasty incisions. Patients with supratip fullness will often complain that their nose looks like a parrot. This is because the supratip fullness can overpower the nasal tip. In order to improve supratip fullness, we can remove the junction of the upper lateral cartilage as it fuses to the lower lateral cartilage that is actually located in the lower nasal third. This junction is referred to as the scroll and will often be generous in fullness. 

Open rhinoplasty

Open rhinoplasty requires incisions in the front of the nose through the columella which are then extended into the nostril just above the nares opening. Although this incision is partially visible to an outside onlooker, the open rhinoplasty incision provides access to the entire nasal structures. This means that you can alter not only the lower third nasal tip region but also the middle and upper nasal thirds as well. The open rhinoplasty is advocated when major nasal alterations are required and/or when the nasal tip shape and position must be altered. Because the open rhinoplasty requires more aggressive dissection of nasal soft tissues, it does require several extra maneuvers to reinforce the nasal structures, longer operative times, and subsequently more expensive surgery. 

Bulbous Tip

A bulbous tip describes a tip that is wider and larger in shape. A bulbous tip is caused by enlarged or widely positioned lower lateral cartilages and/or a fatty tip. When the lower lateral cartilages are malpositioned or wider than normal, then trimming of cartilages and stitching of the lower lateral cartilages can be used to truncate and tighten the cartilages in order to tighten the nasal tip to a more aesthetically pleasing size and slape. When there is excess fat in the tip, then the fat can be removed as well using an open tip rhinoplasty.

Nasal tip malposition

When the nasal tip is malpositioned, it can be repositioned using an open rhinoplasty approach. If the tip is down turned which is often associated with a prolonged nasal length, the nasal tip cartilages, i.e. the lower lateral cartilages can be rotated up and nasal length shortened by sewing them back up to the septum. When nasal tip is rotated too high, such as in the pig nose, which is associated with an overly shortened nasal length, then the tip cartilages can be released and rotated down and extended down. This maneuver requires an extension graft that bridges between the septal cartilage and the lower lateral cartilages. 

Orange County Rhinoplasty Conclusion

In summary, nasal surgery is considered one of the more technical surgeries of plastic surgeries for several reasons. First, the nose is on the center of the face and thus under continuous scrutiny from onlookers especially if you live in or hip Orange County. Second, the nose possesses very intricate structures that are intimately interconnected. Finally, nasal surgery requires consideration of both aesthetics as well as functional considerations. Even when operating to improve aesthetic concerns, nasal surgeons must ensure that the nose is not functionally compromised. If you are considering rhinoplasty, you should choose a nasal surgeon who is a specialist who has significant experience. You can confirm your nasal surgeons expertise by reviewing his nose before and after photographs and reviews.