Plastic Surgery Videos Texas

Dr. Buckingham:
Welcome to the Buckingham Center for Facial Plastic Surgery Rhinoplasty tutorial.

Rhinoplasty is one of the most challenging, as well as one of the most rewarding procedures to perform as a surgeon. It's extremely important when you're seeking out a rhinoplasty surgeon, to find someone who specializes in rhinoplasty and does many many of the procedures each year, as rhinoplasty is one of those procedures that has a high revision rate.

We do many rhinoplasties each year, including both primary and revision cases, and I think as we go through this rhinoplasty tutorial it will give you a good idea as to the level of intricacy that goes into analyzing a nose and therefore making the changes that are necessary to come up with a very satisfactory, if not excellent aesthetic, as well as functional outcome.

So what I'm going to try to do - and this is kind of 101 - but to go through looking at both a live patient photograph as well as a diagram of the underlying nasal anatomy and kind of go through it in a sequential fashion looking at first the frontal view and explaining the different pieces of anatomy that relate to how the nose looks on the outside and then we'll look at a lateral and a base view doing the same thing. Trying to keep it somewhat simple, but also interesting, so that you can learn about the different features on the outside and how those relate to the surgical procedures that take place to alter them.

So, here we have - and this is the actual diagram that we use for surgery to make different markings to show exactly what we've done during the procedure - and then this is a patient who I have done a cosmetic rhinoplasty on and I think that she has a very good outcome that can allow us to kind of use her nose as the aesthetic normal to compare to what we've done. So, when a patient comes in to us and we're looking at their frontal view, we're really looking at three pieces: we have the dorsum which consists of the boney dorsum, the cartilaginous dorsum and the tip. And that correlates over to here to this diagram - you can see the nasal bones, which are the grey part, here. And then this middle portion is the cartilaginous dorsum and the distal portion which is nasal tip cartilages. And so, what we're looking at when we see somebody is really what is the position of each of these structures.

We talk about the brow tip aesthetic line which is a nice curve line that flow from the brow down the side of the nose to the tip and it should make a nice gentle 'C' without interruption - as you can see that this persons nose does following her procedure. And really, that's looking at: Is the nose straight? Does the nose fall from the midline from the area between the brows to the top of the lip? Does it fall in a straight line? Does it have the right width from top to bottom? Is the top too wide or is it too narrow? Is the middle portion to wide or too narrow? And how does the tip relate? And so once we've looked at those features then we try and alter those individually to create a straight nose.

So, if the nasal bones are deviated to the right or the left, we do osteotomies, which means that we make a small fine cut into the bone in this region and up in the bone this region. So coming across we can mobilize each one of these nasal bones independently to move them left or right as needed in order to make the nose straight. Often times, the middle part of the nose is collapsed into somewhat of an hourglass shape which can have both a cosmetic, as well as a functional implication. And so often times, we'll harvest some of the septal cartilage. Which this picture in this diagram is actually showing the nose with the outer nostril cut and showing therefore the septum which is the part that divides the right and left half - the white part is cartilage and the blacker part or greyer part is bone - and so this area of cartilage is a great donor place where we could harvest this piece of cartilage and then we can place it.

So if this part of the nose is a little too narrow, we can cut little strips called spreader grafts, and place them between the upper lateral cartilage - which is this triangular cartilage - and this portion - which is the upper part of the septum - to widen that part of the nose and create any symmetry once again; creating a nice brow tip aesthetic line. And then of course the nasal tip, which is involved with these cartilages, which are called the lower lateral cartilages, and they're made up of three distinct segments: the inferior part which is medial crura, the middle part which is responsible for the nice dome highlights so you can see where flash hits the tip of the nose called the intermediate crura, and then the lateral crura which are really responsible for how the lateral aspect of the nose looks, how it flows into this portion which is called the alar, whether it has a nice triangular appearance, and they also relate to function whether the nostrils have enough support to breathe through. And so we can alter these cartilages by sometimes shaving a little portion of the upper part using sutures to narrow them both in the cartilage itself, as well as between the cartilage, known as dome sutures. So all of those things can take place on the frontal view to create, once again, a nice straight nose, gentle curve out to the tip, nice tip defining, nice symmetry of the tip.

The lateral view of the nose we talk about things like projection, which is the distance that the tip of the nose sits out away from the cheek. You can also talk about projection as it relates to the dorsum and we'll adjust these areas if they're too low as in somebody who may have had a previous rhinoplasty and too much taken off - but more often, we're talking about projection as it relates to the tip and then we're able to adjust the dorsum to fit in with that. We also talk about rotation, which is the angle that the upper lip forms with the tip of the nose, as well as the angle that the tip forms with the line of the face or the nasal facial angle. So basically, we're trying to balance those so that the tip sits up in the position that's aesthetically pleasing with the rest of the face. And there are defined measurements for this, which we use arbitrarily, but once you've done many rhinoplasties, you tend to look at it more aesthetically as to how it fits into the face and adjust the tip individually for each person.

We also look at how the dorsum. This part of the nose relates to the tip and ideally we want that dorsum to be just slightly below the tip - as it is in this woman - and that's my preference. There are certainly surgeons and patients who tend to try and make this more concave. My personal preference is that looks a little bit more like a rhinoplasty’s been performed and I'm really trying to create natural results, and so I tend to create a little stronger dorsum that's just a little bit concave in woman and basically straight in men. Now, if a patient has a particular preference that they'd like the dorsum to be a little bit more concave we can certainly arrange for that within limitations that we don't compromise the functional outcome of the surgery to achieve it. So, when we're adjusting the dorsum and tip - once again, the tip we're dealing with these cartilages: the lower lateral cartilages and how they relate to the nasal septum. Often times, we're able to just put those cartilages up on the nasal septum to either increase or decrease projection. Sometimes we have to add cartilage grafts from the back part of the septum to the front part of the septum, so that we can then position those cartilages in the proper position and then adjusting the dorsum.

Typically in a primary nose, involves reducing the bone and cartilage from the top of the nose, although occasionally, you end up adding to dorsum’s in primary noses, but that tends to be more common in people who've already had rhinoplasties and that have been over-resected, in which case we may have to harvest cartilage from either the septum, if it's still present, or perhaps from an ear - or even a rib - in order to get the quantity of cartilage necessary to augment the dorsum to give the nose a nice outcome. Additionally, on the lateral view, we'll look at how the columella, or this portion of the nose, relates to the alar margin, or here. And really we're looking to have between two and four millimeters of this nostril show. Any less than that and it looks like the columella is retracted behind the nostril. Any more than that and it looks unsightly as you get too much of this pink mucosa that shows underneath the alar margin and is unattractive. So, in this woman's particular case, you know we think she has a very nice dorsum, very nice tip projection, good columella show, good rotation, all those aspects that relate to that.

So, then the last view that we look at is the base view. And really from the base view, we're looking to achieve a very nice triangular configuration between the alar and the tip. You can take a very very narrow tip and it'll still look like a ball on the end of your nose if the alar come in here and so we're often times putting small cartilage grafts along the rim of the nose to create this nice triangular configuration to the way the nose appears here. We're also making sure that the nostrils are nice and oval and have a very symmetric shape from side to side and also times, dealing with the width of the columella and how it relates. So all of those aspects of the nose are altered to provide an aesthetically pleasing result.

So hopefully that gives you some insight. It certainly isn't the complex version of the anatomy that we look at when we're evaluating the nose, but I think from a patient perspective, that will give you a lot of insight into the anatomical components that contribute to the appearance of your nose and give you a little insight heading into a rhinoplasty consult about the things that might need to be changed in order to achieve the aesthetic or functional outcome you’re looking for.

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