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Rhinoplasty Technique and Variables Dallas


Rhinoplasty (“Nose job”) is most commonly performed today as an open rhinoplasty which includes an incision across the columella, the thin bridge of skin separating the nostrils. The rest of the incisions are inside the nose, allowing the skin to be precisely lifted off the bone and cartilage so the internal structures can be visualized and the nose more accurately reshaped. Most rhinoplasties are done to make a large nose smaller, smoother and in better proportion to the face.

In the most common rhinoplasty, the cartilages that shape and support the tip are sculpted then reshaped with sutures to control the width and position of the tip of the nose. The hump, if present, is “sanded down” with a rasp which is used like a nail file to reduce the prominence and correct the profile. There are two nasal bones that meet in the middle like the roof of a house and when they are “shaved down” with the rasp, often a gap results between them, similar to the roof of a house if the top foot or two was removed. In order to close that gap (“open roof”) the bone must usually be broken free from their rigid attachment to the adjacent facial bones. This allows them to be “pinched together”, closing the open roof and narrowing the nose. The nasal bones are broken free with a type of chisel called an osteotome.

The skin is placed back over the newly shaped bone and cartilage and a splint is applied after all of the incisions inside and out are closed with stitches. The splint protects the delicately repositioned bones while they heal. All of the internal stitches dissolve but any stitches in the exposed skin are idealy removed within six days to minimize visible scarring.

Variables And Realistic Expectations

There is a limit to how much smaller the new nose can be, based on its starting size. The skin “envelope” can only shrink within a certain range to fit the newly reduced bone and cartilage framework. If the nose is reduced in size excessively, the skin can “bunch up” and leave an unattractive fullness to the tip of the nose. Removing skin would require visible scars which can be very unfavorable. In addition, the tip cartilages can only be reduced and reshaped within certain limits since there is a minimum which must be left to adequately support the tip of the nose. Thus, in a sense, there is a certain non-negotiable degree to which the nose can be reduced in size. We try to demonstrate this using computer imaging to modify your nose and demonstrate realistic outcomes.

Certain aspects of the healing process vary from individual to individual and are not entirely in the control of the surgeon. When the bones heal back together they can thicken (called a bony “callus”) and result in slight bump which can show as a minor imperfection in a nose that is still beautiful. Also, scar tissue forms under the skin as part of the normal healing process that fuses the skin back to the reshaped bone and cartilage. If the individual forms thin, delicate scar, the nose will be slightly more refined and smaller. If the scar tissue is somewhat thicker (say the thickness of a slice of lunch meat instead of a tissue) the tip of the nose will be slightly rounder, fuller and less defined, although the nose is still typically nicely improved. Because of these physiologic variables, we like to use computer imaging to show a subtle range of outcomes that must be accepted to be a good candidate for rhinoplasty. If an individual is excessively picky with the computer imaging when realistic results are shown, they are usually not considered a good candidate for surgery since that type of patient has been shown by studies to be unhappy a very high percentage of the time even with an appropriate improvement in appearance.

We will always strive to demonstrate honestly what can and cannot be achieved and show a realistic range of outcomes as well as before and after pictures of our patients to help you decide if rhinoplasty is a good choice for you.

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