Plastic Surgery: Rhinoplasty / Nose Job Information

What is a Rhinoplasty?

Rhinoplasty is a very common procedure which aims to change the appearance of the nose to make it more harmonious on the face. The surgery can thin, turn up, augment, shorten or lengthen, and essentially change the shape of the nose. Rhinoplasties are commonly called 'nose jobs'. It can involve rasping of the nasal bones to remove a bump, resecting the cartiledge to change it's projection, trimming the cartiledge to make it smaller and more defined and a whole myriad of procedures.

Most rhinoplasty procedures are done after the patient has stopped maturing on their face. This usually occurs at 16-17 in girls and a little later in boys. Rhinoplasty can be combined with a chin augmentation, which can help balance the look of both the nose and the chin. Sometimes a problem in one area creates a perceived problem in the other.

Common reasons for choosing a Rhinoplasty

Possibly everyone has a reason to dislike something about their nose. Whether or not that dissapointment is great enough for you to seek to change it is dependant on the individual. People looking to get rhinoplasty must remember that it is a cosmetic change only, it is also important to understand the limitations of the procedure - what can or can't be changed. There are realistic and irrational reasons for looking to change your nose.

Common complaints of people seeking rhinoplasty: too large, too flat, large bump or convex profile, too wide or fat, too thin, too long, too short, too pinched looking, scooped or concave profile (ski slope nose), hanging columella, functionality - difficulty breathing, crooked, asymettry (nostrils or general structure), bumps, a bifid tip - an indent down the center of the tip, scar tissue, damage from accidents, hooked nose, upturned nose, pointy, bulbuous, lack of definition

Common complaints or conditions of people who should not be seeking rhinoplasty: becoming more popular, life advancement, becoming more desirable, winning over someone, Body Dysmorphic Disorder (BDD) or any other self image disorder, low self esteem due to no visible cause, weak chin, weak jaw, weak or prominant upper jaw, pressure from third parties, career advancement

What your nose looks like on the inside

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The bone structure of the nose makes up the upper part of the nasal area. It consits of ideally symmetrical bones which form a pyramid shape. This is commonly known as the bridge. The dorsum is the flat surface at the front of the nose caused by the meeting of the nasal structures. The glabella is where the bridge joins the forehead.

The lower two thirds of the nose are made up of cartiledge structures. These consist of five large pieces, the septum, two lateral nasal cartiledges, and the two greater alar cartileges. There are also several smaller pieces of cartilege known as the lesser alar cartileges.

The septum is a piece of cartilege that runs down the center of your nose, it divides the nasal cavity in half. The front part of the septum (furthest from your face) is the thickest, it is the thickest where it joins the nasal bones.

The lateral cartilage is at about the half-way point down the nose. It is wide and flat, and has a triangular shape. The front part of the lateral cartilage is thicker, and the upper side of it is connected to the nasal bones, the lower part of it is conected with the greater alar cartilages.

The greater alar cartilages are small and thin, and flexible. They are situated at the lower part of the nose, and is folded back upon itself, forming the tip and forming the lower walls of the nose. The two are connected at the center, and as they spread out from the center they become flatter, narrower and more oval shaped.

The nostrils can be changed in a rhinoplasty as well, by excising sections from the floor of the nose or at the junction where the nose meets the cheek.

The ideal nose

There is no such thing as an ideal nose, an ideal nose is based upon the features of that person and what works for their face. A nose that may be attractive on one person may look out of place and actually detract from their good looks on another. Given that, time and time again people have searched for a formula to determine the perfect face.

Leonardo Da Vinci Facial Thirds

The width of the nose at the widest part of the base should be about the same distance as the distance between the eyes

The length of the upper lip should be twice the distance between the lower lip and the chin

A slight upwards rotation in the tip is better and more attractive

Yale Medical University

(a) The distance from the infraorbital rim to the base of the nose should be equal to the width of the nasal base (from the outside of each nostril to nostril) and ½ the distance of the middle third of the face (brow to the nasal base).

(b) The nasal length (radix to tip or RT) should equal the distance from the stomion to menton which equals 1.6 x TS (tip to stomion).

(c) Ideal tip projection (alar crease to the tip) equals 0.66 x ideal nasal length (RT).

(d) The line from the mid-glabellar area to the menton should bisect the nasal bridge, the nasal tip, and Cupids bow.

(e) The nasal dorsum should be outlined by two slightly curved divergent lines extending from the medial supraciliary ridges to the tip defining points. (f) The width of the bony base is approximately equal to 80% of the alar base.

(g) The width of the alar base is equal to the intercanthal distance or one eye width.

(h) The alar rims should have a slight outward flare in an inferior direction.

(i) Lines connecting the tip defining points, the supratip break area, and the columellar lobular angle form two equilateral triangles.

(j) A line outlining the alar rims and columella resembles a gull in gentle flight.

(k) With the eyes in frontal gaze, the nasofrontal angle lies at a level between the upper eyelashes and the supratarsal crease.

(l) The nasal dorsum, in women, lies approximately 2 mm behind and parallel to a line from just above the nasofrontal angle to the tip defining points. In men, the dorsum is slightly higher.

(m) 50-60% of the tip lies anterior to a vertical line drawn adjacent to the most projecting portion of a normally positioned upper lip.

(n) Tip projection equals alar base width.

(o) Tip rotation is determined by the degree of the nasolabial angle, measured as the angle between vertical and a line drawn through the most anterior and posterior edges of the nostrils (normal 95-100 degrees in women and 90-95 degrees in men) (nasolabial angle is not the same as columellar labial angle).

(p) The columellar-lobular angle is approximately 45 degrees.

(q) On a basal view, the outline of the nasal base forms an equilateral triangle; the lobular to nostril ratio is 1:2.

(r) The upper lip projects 2 mm more than the lower lip, and in women, the chin lies slightly posterior to the lower lip; slightly stronger in men. The distance from the mandibular angle to the menton is ½ the distance from the menton to the natural hairline (or trichion).

The procedure

- Open or closed

Surgeons performing rhinoplasty have a choice between two types of incision methods. An open or closed technique differes in the incision method, an open technique the surgeon will cut open the nose exposing the inner cartileges. A closed percedure is done with cuts, usually inside the nose. This operation is done wihout visual. What's more important is the skill level of the surgeon. Some surgeons prefer one method over another.

In an open rhinoplasty the cut is made across the base of the columella, the small wedge of flesh that creates and seperates your nostrils. The incision is usually made with either a "Z" or an inverted "V" cut, this help minimize the appearance of the scar. The scar that it leaves when healing is complete is usually very faint and eventually fades away on most people, sometimes there may be a faint pink line where the incision was made. In rarer circumstances a keloid scar can form, but this can be prevented or treated with post-operative care (Such as dermabrasion or kenalog injections)

- Nasal augmentation

Different shaped implant can be added onto the structure of the nose, increasing it's projection or width. There are a wide variety of materials to choose from, most doctors will use one particular material because they believe it to be superior. There are implants which can be harvested from your own body, and artificial implants to choose from.

Bone grafts are usually taken from the patients ribs. There is a small percentage of absorption when implanted, as well there is a longer time for recovery. An extra surgery is performed to extract the graft. There are possibilities of bone infection as well as excessive calcification. Rib grafts have been reported to warp and deform, as like any graft.

Cartilage grafts can be taken from the patients, either from their rib or ears. When taken from the ear a tiny sliver is extracted from the back of the ear, this is usually used in patients who have had too much cartilege removed. Rib cartilege is usually taken from the false floating ribs.

Silicone implants have been used for facial implanting since around 1956. They are hard, yet flexible depending on how they are manufactured. Alloderm is donor tissue, through treating the donor tissue is stripped until it is only a protein framework. It contains no human cells. It can last up to two years, and in some cases indefinetly. The product is expensive. It will not mimick the look of bone, but can be used for cartilege implanting and structure work. Polyethylene is a plastic which is porous, resembling coral. Scar tissue can heal into these pores securing the iplant. Gore-Tex is a biocompatable micro-porous material which allows tissue to grow into it. It is soft, flexible and strong. Gore-Tex is easily carved for further personalization to each patients face and needs. Medor/Porex is a light weight high density polyethylene. The implant material has a long history of medical use without any harmful effects. Because of it's porosity, it does have one downfall. If at a later date the implant has to be removed, the operation will become more difficult as it has fused.

- Ethnic rhinoplasty

As with any rhinoplasty the goal is to create something that will work harmoniously with the patients face. With an ethnic rhinoplasty it is important to retain and incorporate that persons ethnicity into the final nose. A good rhinoplasty will create a nose that does not stand out or attract attention. In most cases the patient wants more projection and definition in the nose bridge, as well as a narrowing of the nostrils.

Ethnic skin does have a higher chance of keloid scarring, which is the formation of excessive scar tissue. In pigmented skin, there is also the possibility of hypo or hyper pigmentation.

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