PART I — ANALYSIS
The best cosmetic nasal surgeons are adept at very detailed analysis of all aspects of the nose. The outside and the inside. For some patients, the evaluation of the inside is critical if there is a breathing, allergy sinus problem or all of the above. All this is about diagnosis. The right diagnosis leads automatically to the right procedure.
The external nose is comprised of areas and zones. Each may have imperfections that contribute to an overall unsatisfactory look. To help patients understand what we can – and cannot – do, at consultation, I analyze each portion of the nose that is unsatisfactory to the patient and relate what changes can be performed on that portion
Here is a list of the anatomical features of the nose that we most commonly are asked to correct:
- The bump.
- The entire nose is too wide.
- The nose juts out too far from the face.
- The bulbous tip.
- Unsightly nostrils.
- The nose-lip angle.
Remember, I mentioned that when the specialist examines the nose, he must understand the internal structure of the nose – inside and outside. The hidden interior architecture always has a bearing on the outside appearance. That internal partition, the septum, composed of both bone and cartilage, has a major influence. A crooked nose will almost always be accompanied by a crooked or deviated internal nasal septum. As a matter of fact, it is axiomatic in the world of nasal surgeons that, “As the septum goes, so goes the nose”. Even the lower (towards the lip) segment of the profile is a reflection of the height and strength of that septum.
That nasal septum runs a long course, from the front of the nose, where it sits behind the vertical partition that separates the nostrils, the columella (“little column”), to the back of the nasal cavity, where the upper throat begins.
A proper and thorough examination of the nose – breathing and sinus problems, allergies or not – should always include an evaluation of the internal septum and other key internal nasal passage structures called the turbinates. The turbinates, three in each nasal passage, are finger-like shelves attached to the lateral wall of the right and left nasal passages. Their function is to help moisturize, filter, and warm incoming air. The lower, or inferior, turbinate plays a major part in airflow volume. Enlargement of the turbinates takes up valuable nasal passage space and will diminish breathing. Typically, when turbinates are enlarged, allergy is the culprit. The doctor should also check for blockage of the openings to the sinuses, those air-filled chambers within the face bones. “Sinus sufferers” may learn that their problems begin within a blocked nose.
Had prior nasal surgery? “Inside”, “outside”, or both? The doctor will need to be particularly thorough with both the external and internal examination when the tissue has already been visited. Often some tissues are absent or still enlarged and misshapen, and all this has a bearing on what needs to be done.
PART II — WHAT DOES THE SURGEON DO AND HOW IS IT DONE?
Remember, no two patients require the same services. You should know – prior to surgery – what is on the surgeon’s “To-Do” list.
- The hump: The surgeon tunnels under the skin. Using delicate filing and shaving instruments, he shaves down the bump to a more satisfactory level. The “excess” skin is never removed; it naturally shrinks down to conform to the new architecture.
- The entire nose is too wide: If the entire nose is wider than you want it, you will have to face that unfairly castigated, but really not too bad, “breaking the nose”. But don’t worry, you’ll be asleep. You won’t know it is happening and you won’t feel it is happening. And it causes minimal discomfort after surgery. There is no other way to improve a wide nose. It takes the nasal surgery super-specialist only 90 seconds and “Bingo!” your nasal bones are closer friends. Less time than temporary, intricate makeup applications devised to make the nose look narrower. Plus, surgery is permanent.
- The nose juts out too far from the face: In Part I, I described what anatomical imperfections cause the nose to over-project, to be “too far forward”. It could be a combination of several factors; one or all may need correction. A prominent nasal spine is handily amputated; the owner of the nose won’t miss it. A too-high nasal septum is shaved down. If the tip of the nose rides in a too-tall position, the columella, mentioned previously, that separates the nostrils can also be shortened.
- The bulbous tip: That unattractive tip will be refined by using classic sculpture techniques to reshape and redefine the cartilage that comprises the tip, all with attention to symmetry and a natural look. Somewhat amazingly, all done “under the skin”. Just as with the bridge, the excess skin that once covered large, bulky tip cartilages will contract to envelope the smaller tip.
- The unsightly nostrils: Changing nostril size and shape is tricky. The surgical maneuvers that create a nicer tip will automatically effect the size and shape of the nostrils. For some patients, that is adequate to improve the nostril appearance; for others, it will be necessary to additionally remove a portion of the wings and/or the floor of the nostrils to achieve a satisfactory result, but that requires external incisions that could be somewhat visible.
- The nose-lip angle: The nose that sits close to the lip and that hangs down will be improved by removing a portion of excess internal support structures, such as the front portion of the nasal septum. This allows the nose to ride up and away from and to shorten the nose. This is done essentially at the expense of the lip. The same technique is used to sharpen the angle between the nose and the tip when there is a somewhat round and unfeminine transition between the nose and the lip.
- The nose that droops with smiling: A small but strong muscle that runs vertically from the internal upper lip to the hidden portion of the front of the nasal septum, appropriately called the “nose depressor”, can be released from the nasal attachments through an invisible incision. This is done by dissecting where the nose meets the lip as a continuation of the standard internal incisions.
All these procedures are done through hidden, inside-the-nose incisions, which are closed with dissolving stitches. External incisions, used for the “open rhinoplasty” are sometimes necessary but need not be used routinely.
A FEW WORDS ABOUT CROOKED NOSES. YOU NEED HELP BOTH INSIDE AND OUTSIDE
Whether from injury or just because Nature made you that way, your nose might be crooked. And, if it is, I’ll bet that you also have a breathing problem. Because a crooked nose on the outside is almost certain to be crooked on the inside.
If you have been told that the external nose can be straightened without tackling the crooked or deviated internal nasal septum, you need a second opinion. It is nearly impossible to cure a nose that is not straight unless you tackle the internal support structures that are driving the external appearance. Please also understand that it may be impossible, at least in one operation, to get that nose perfectly straight on the outside and/or inside. Often, the tissues were so severely damaged from one or more broken noses that perfection is unlikely. However, with today’s excellent filling injections — temporary or permanent— following surgery, as an office procedure, these fillers in minute amounts can be used to correct asymmetries that cause the crooked appearance.