Firstly I think of the size of the nasal tip is it normal big or small. Then I think of the site of excess size, if present is it a vertical excess or a horizontal excess. Then to explain these two aspects further I think of the position of the lateral crus, is it malpositioned more vertically as in the perenthesis tip or is it excess horizontal width because the right and the left tip cartilages are widely spread or divergent. Thirdly I think of the shape of the tip cartilages to explain a problem with size and the site of the size problem. Are they excessively convex and if so where is the site of that convexity, which margins of the tip cartilages are involved the caudal or the cephalic margins and in which access or direction does the curl run. In summary I think of surface aesthetics in terms of size and shape of the tip and then try to see through the skin to explain and anticipate the size, site and shape of the tip cartilages themselves. This careful analysis then enables me to make an individual operation plan.
Latest
Thoughts on Open Approach Rhinoplasty
I’ve been thinking about why for difficult tips I favour the open approach. There are three main reasons for me. One is that it enables a very precise assessment of the shape of the tip cartilages and their relationship to each other. This is not a substitute for very careful analysis of the shape of the nose and the contour of the skin but I feel we can not truely understand what makes the nose the shape it is until we see the underlying cartilages. In closed approach bringing the cartilages down into the nostrils distorts them and makes it very difficult to really understand their true shape and relationships. It’s also true to say that after using a surgical technique sometimes during surgery the shape of the nose changes in a way we weren’t expecting and the open approach enables us to see and understand this directly and so correct it. Secondarily during surgery it enables accurate precise performance particularly fixing grafts into place. And thirdly I do believe that to get good definition and good shape into a nasal tip we often need to build a really strong structure in the cartilages that supports the overlying skin very well and introduces some tension into the tissues just as a really good framework on a tent keeps the material of the tent in the right shape and position. I don’t think this is as possible in the closed approach.
Of course not all nasal tips need an open approach and experience leads us to understand when the open approach is best and when the closed approach is best so it’s definately not a one operation fits all.
Reflections on Teaching and Training
I am off soon to lecture on the Milan Rhinoplasty Masterclass on strategies for treating the bulbous nasal tip and considerations in 3D for surgery to humps on the nasal bridge. Preparing for these meetings is hard work but very rewarding. One of the greatest benefits of a teaching commitment is that it forces one to reflect on ones own practice. This means carefully examining why one chooses certain surgical techniques and carefully assessing the results of these techniques. Reflection and an enquiring mind are part of the responsibility of a profession. I’m sure I’m a better surgeon for the time spent on teaching and training. The feedback one gets from young surgeons and from the audience also stimulates one to think and to constantly to try to improve.
Why see us?
We are not a clinic offering a range of cosmetic procedures. We are not a clinic providing free consultations with a view to advocating surgery and providing a standard rhinoplasty.
We want to understand you as an individual and what you are trying to achieve to move forward. We want to work with you and to help and advise you. Together we want to plan what is best for you and to provide you with a high quality experience. If rhinoplasty can not help you we will tell you so. When your nose is holding back your confidence and when rhinoplasty is right for you we will meticulously plan for the best result that we feel is possible for you.
We do not perform all the facial plastic surgery procedures. We specialise in rhinoplasty. We are committed through analysis of our own results and through the involvement that comes with teaching and training others, nationally and internationally to the continuous pursuit of excellence in rhinoplasty.
We want to work in partnership with patients who recognise our strengths and experience and our commitment to this very specialist surgical practice. We want to help patients who identify with our direction and values and who will find a relationship of mutual trust and respect rewarding. We do not have complete control over the final result but we do everything we can, through meticulous attention to detail at every stage, to minimise unpredictability and achieve the best possible result we can.
Ultimately we want our practice to be one that works with patients who hope to develop friendship with us and that provides a great experience which is rewarding and fulfilling for all of us.
Is rhinoplasty right for you?
If you want the assurance of complete control over the result of your rhinoplasty then rhinoplasty may not be for you. If you expect your surgeon to tell you he guarantees the result for you then we are not right for you. If you are a perfectionist hoping for fashion magazine perfection and nasal symmetry then rhinoplasty is unlikely to be right for you and may greatly disappoint you making you angry or unhappy. If you feel guilty about having rhinoplasty then rhinoplasty may not be for you. If you are hoping for improved self-confidence but are not expecting a new job or partner from your new nose then rhinoplasty may help you. If you are positive and plan to enjoy your journey to a new nasal shape, based on partnership with your surgeon then rhinoplasty may be for you.
European Academy of Facial Plastic Surgery Annual Meeting In Turkey
This was a great meeting full of international collegiate, spirit and friendship. It was great to catch up with all my colleagues and friends from Europe and the USA.
I gave a lecture on a diagnostic approach to surgery for the bulbous nasal tip which was the final presentation of many thoughts and reflections I’d had over the last few months on how to deal with this difficult problem. As with many aspects in rhinoplasty often we can correct one aspect of a nasal deformity with a surgical technique which then will carry a risk of creating another problem which we have to offset. In the bulbous nasal tip sutures can help narrow roundness in one area but increase pinching in another. This is why I think the lateral crural strut graft is so useful allowing us to create narrowing in one area and preventing pinching in another.
I also moderated a panel on the treatment of irregularities of the nasal bridge, was a panelist on a question and answer session for sutures in the nasal tip, I presented a video on sutures and grafts for the bulbous nasal tip.
In the next quarter I will be reflecting on nasal bridge bump or hump reduction and achieving the ideal profile in preparation for the Milan Rhinoplasty Masterclass which it’s my pleasure to have been invited to lecture on.
Modern Rhinoplasty
Lecturing and teaching both at home and abroad on rhinoplasty is a very rewarding part of my professioal life. I have just lectured on the use of rib cartilage for the saddle nose and the twisted nose in Geneva. Not only do I enjoy communicating my thoughts and ideas with others but I also find extremely stimulating the feedback and discussion I have with other invited members of these national and international panels. Putting together lectures and teaching videos also helps me reflect and crystallize my own thoughts as well as giving me the impetus to research the thoughts and ideas of others with whom I share rhinoplasty symposia and sessions. I particularly enjoy discussions and sharing ideasand surgical difficulties and solutions with my colleagues from Europe and America. Some of our most stimulating conversations are over a drink outside the lecture halls!
When I was training in rhinoplasty over 15 years ago much surgery was performed through a closed approach and favoured a philosophy of re-contouring the nose mainly through removal of tissue. Whilst very good results can be achieved for some noses using this approach I believe things have moved on since then and I have moved away from widespread application of closed surgery.
My travels to other surgeons and my time spent lecturing on panels with other surgeons from across the world since has led to me using the open approach for many of my rhinoplasties. I believe this does reflect a different philosophy and approach to surgery where structural grafts such as columella struts, spreader grafts, alar support grafts and lateral crural strut grafts along with stitches and sutures are used to reshape and support the nose. This minimises the amount of cartilage and bone that needs to be removed. I feel this leads to a more balanced nose which is more harmonious with the face in general terms and in which long term outcome may be more predictable and the affects of healing less left to chance than they might be when removal of nasal framework alone is relied on. A good, contemporary rhinoplasty result should look natural and not “done”.
My current practice reflects these thoughts and moves beyond what I experienced in my early years learning rhinoplasty. This contemporary approach to re-building the support framework of the nose and in severe cases using rib cartilage has I believe really advanced surgery particularly revision surgery for the over-reduced nose.
As I have discussed in my previous blog on wisdom in rhinoplasty though there is always a balance to be drawn between complex surgery to maximise the result and a desire to keep things simple so as to limit risk – a difficult equation.
Staying current and contemporary to me means travelling, visiting and lecturing, reflecting, listening and sharing thoughts and ideas with others who are also passionate about rhinoplasty. Amongst this quite small group of surgeons I have joined internationally, many have become great and valued friends.
Reflections on tip mal position
I performed a secondary rhinoplasty last week for a male with a bulbous tip and nasal nostril collapse and weakness. The nostril weakness was making breathing difficult during exercise.
At surgery although I noted he had particularly large tip cartilages they were positioned too far up the nose away from the nostril edges. This causes unnatural, bulbous curvature in the nasal tip and is associated with weak support to the nostril margins particularly when breathing in. I therefore used an open approach freed up the tip cartilages and swung them down to lie along the nostril rims. I strengthened them with struts of cartilage taken from the nasal septum. Rollin Daniel and I have discussed this technique before and recognise that it must not be considered lightly as a change in one part of the nasal tip cartilages can lead to abnormal changes in other areas which have to be counteracted with stitches and grafts. I saw Rollin use this technique in California 3 weeks ago which helped me think about my own technique more and it was good to have such a case to do when I returned home. I think the key is to fix the dome areas and the medial crura first before repositioning the lateral crura. After repositioning the lateral crura the infra tip lobule position must be reassessed as there is a tendency for the tip to rotate and turn up. This may need to be balanced with an infra tip lobule add on graft.
Rhinoplasty in the USA
I recently returned from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) meeting in Florida. It was great to catch up with international friends and to make new friendships. Those of us who have a particular interest in Rhinoplasty form strong bonds and friendships sharing experiences both high and low received from this most demanding of operations. There can be few if any other operations that can dominate a meeting programme in terms of hours dedicated to the subject than Rhinoplasty!
I lectured on surgery to de-project the nasal tip. My philosophy is to take a very analytical anatomical approach to diagnosing the problem and then a step wise graduated surgical approach to correction. I do think it’s important to be aware that there’s a limit to how much the skin will shrink to a smaller nose and therefore at times it’s better to maintain a little more projection than one might ideally want so that a slim nasal tip can be maintained from the front. Too much de-projection might lead to the nose looking bulbous from the front. This can be quite difficult to explain to patients at times.
I travelled from Miami to California for 5 days after the meeting. It was my great pleasure to be able to spend time in the operating theatre with Rollin Daniel in immaculate Newport Beach and Paul Nassif and Jay Calvert in Beverly Hills. Rollin has reflected on rhinoplasty as having essentially three levels of difficulty and complexity in the cases that present. As surgeons, those of us who look towards operating on the most difficult level 3 noses know we must really expand the envelope and push ourselves out of our comfort zones. It was therefore great for me to see colleagues I respect operate on revision cases, which are certainly level 3 and to swap ideas and thoughts.
I am sure that highly precise, accurate reconstruction of the nasal skeleton to restore support and contour to the nasal skin envelope is the right way to go and my experience leads me to feel now that often ear cartilage is inadequate for this reconstruction and that rib cartilage is the best way to proceed. I saw two very interesting rib cartilage cases with Rollin and Jay and saw Paul use injectable diced cartilage to finesse the nose.
Rhinoplasty is a very difficult operation and one has to be prepared to put huge effort in to get the best results out. This effort must extend into every aspect of surgical care from the analysis through the planning to the final actual surgery. It was interesting for me to see that we all share in common the need for unstinting energy and enthusiasm in focusing on attention to detail. This is important in all areas, including taking photographs during surgery and recording meticulously the surgical steps used to allow later reflection and comparison with the final result. We shared laughs too remembering it is also about enjoying the challenges of this great area of facial plastic surgery with great teams.
On my return I was also honoured to have been invited to give a lecture at the AAFPRS meeting in Chicago 2011. I will start preparing ideas now!
Teenage Rhinoplasty
Happiness for rhinoplasty patients is achieved when expectations are met, or even better when they are exceeded. It is therefore so important that patients have realistic expectations. This ideal state can only be reached if the surgeon understands what the patient wants and helps the patient understand what can be achieved for their nose, what the limitations are and what the risks are. Only then can the patient know what to expect and if it is what they are hoping for.
I think this is especially true for teenagers wanting rhinoplasty. The opportunity to have surgery may be a present, perhaps offered at the ideal time after leaving school and moving on to a first job or university and a new group of friends. Such an opportunity is associated with all the excitement that a gift can bring. Furthermore, expectations may be inflated due to pressure in the body conscious, beauty driven world of celebrities and media manipulation. A sense of entitlement may be present in some teenagers and there may be areas of emotional upset that the teenager thinks can be resolved by achieving a new nasal shape. Of course this may not be the case.
I think it is also true that teenagers may not appreciate that rhinoplasty is serious surgery and that the operation is considered probably the most difficult of all the cosmetic facial plastic surgery operations. I have seen many patients who rushed into rhinoplasty in their teens without researching the operation first and who later greatly regretted their rush into surgery and its results.
I also think that surgery should err on the side of conservatism in teenagers. Surgery should certainly not be performed before the age of 16 as the nose is likely to still be growing up until this age. Skin also tends to be thicker in teenagers so greater refinement of the nasal shape may occur with age anyway. It is important that surgery is predictable in the long run and so rhinoplasty should concentrate on reshaping and maintaining support rather than removing too much tissue in pursuit of a little nose that lacks balance and harmony. Good qualities in a nose should be recognised and maintained and a standard approach based solely on removing tissue should be avoided.
None of us can predict fashion change either. The small Barbie doll noses of the 1960’s are not considered fashionable now so again I think it is better to err on the side of conservative rather than radical surgery.
To compliment our rhinoplasty surgery I have put together a rhinoplasty discovery programme™. The components of this programme are all about providing patients, absolutely including teenagers, with all the information they need to understand what they want for their nose and what is possible. We also think it is extremely important that patients are fully informed of the risks of surgery. Only then are they able to make a decision with the help of their family and friends and with our honest advice and support as to whether they would like to proceed with surgery.
