Rhinoplasty is one of the most complex, and most rewarding, procedures performed by Facial Plastic Surgeons
The nasal anatomy is three-dimensional with delicate convexities and concavities that form a sophisticated shape. The nose sits front and center on each of our faces, and thus to manipulate these soft angles and spatial relationships requires specialized surgical training and expertise.
Why is rhinoplasty so commonly performed by Facial Plastic Surgeons?
In essence, there are two main reasons: 1) to change the appearance of the nose, 2) to be able to breath better through the nose.
Patients often visit Dr. Markey’s clinic because they’d prefer to remove a bump on the front, or dorsum, of their nose. Others find their nose too large, or see the tip of the nose as sitting too low or too wide. Other patients have suffered traumatic accidents in the past and subsequently their nose appears crooked or points off to one side.
Still other patients tell Dr. Markey that one, or both, sides of the nose don’t allow enough air to pass. They find themselves breathing through their mouth, or even pushing their cheek to the side to stent open the front of the nose. Many have tried nasal sprays, nasal stents, nasal stickers and many other devices to help them sleep or exercise and nothing seems to work.
Oftentimes patients report difficulty breathing through their nose but would also prefer a change in their nasal shape.
For all these reasons and more, altering the shape of the nose is such a rewarding procedure to perform because it can make a world of difference for each patient undergoing rhinoplasty. What, specifically, is “rhinoplasty”? It is surgically altering the external cartilaginous and/or bony anatomy of the nose to result in the desired change in shape.
One main reason why performing the surgery requires such extensive experience is because the anatomy is so complex.
The nose starts at the shallow depression between between eyes and extends forward and downward to the nasal tip. The inside of the nose is divided by a cartilage and bony vertical wall called the nasal septum. Roughly, the top 1/3rd of the length of the nose is bony. If you place both of your index fingers around the upper part of your nose you’ll find its easy to feel where the bony portion of the nose ends and the cartilaginous portion of the nose begins. So the bottom 2/3rds of the nose are shaped by cartilage. The middle 1/3rd of the nose is shaped mostly by the upper lateral cartilages, with one on each side. These cartilage structures are attached to the nasal septum in the midline and help to give shape to the middle of the nose and prevent its collapse when you breath inward. Finally the lower 1/3rd of the nose, including the nasal tip, is formed largely by the lower lateral cartilages. These cartilages have a complicated shape – almost like two ram’s horns they start in the middle, extend outward and then gently curve backward and to the side. These essential cartilage structures provide the distinctive shape of the tip of the nose. Their firmness is important in preventing collapse of the nasal soft tissues during breathing.
These structures consisting of cartilage and bone, as well as the skin overlying these supports and the mucosa lining the inside of the nose, make up the complicated shape of the nose. This shape, in turn, determines how well the nose functions. If a patient has permanent trouble breathing through their nose oftentimes the shape that makes it up is to blame.
So, “rhinoplasty” then, is altering these shapes to improve a patient’s appearance or nasal function, or both depending on their preference. But what that means specifically may vary a great deal depending on each patient’s needs.
If the upper 1/3rd of the nose is deviated to one side or another, the nasal bones need to be adjusted. Many patients have suffered a nasal trauma, which may occur while playing sports, playing with their baby, or just slipping on a patch of ice. This injury can deviate the bones to one side or another, as well as causing black eyes and bloody noses. If one is seen quickly in Dr. Markey’s clinic, roughly the first 10-14 days, then he is able to carefully move the nasal bones back to the middle before they heal in the new deviated place. However, oftentimes a patient will visit Dr. Markey’s clinic weeks to months to years after a similar injury to report that the nose is off one side, or its difficult to breath through one side, or another concern. Still other patients note that the bony portion of the nose has always been deviated, or they feel the nose is too wide, or even too narrow.
Regardless of the specific complaint, Dr. Markey is able to adjust the positioning of the nasal bones to match the patient’s preference.
To reshape the upper 1/3rd of the nose, Dr. Markey places precise fracture lines on the nasal bones to efficiently move them to their desired position. With this, he is able to move a deviated nasal bone to the midline, narrow, widen, shorten, or lengthen the nasal bones to ensure the desired outcome.
Many patients will tell Dr. Markey that the middle 1/3rd of the nose, where the upper lateral cartilages and the cartilage nasal dorsum lie, is either deviated to one side, has a “bump” or “hump” so that is has a protruded “hooked” appearance when seen from the side in pictures, or sits too far back so that the nose appears flat or the shape of the nasal bones appears too prominent (the classic inverted-V deformity). Since this portion of the nose is supported by cartilage rather than bone, Dr. Markey employs different techniques than those used in the upper 1/3rd of the nose. He is able to borrow cartilage from the portion of the cartilaginous nasal septum found further back into the nose and use it to carefully reshape the middle 1/3rd of the nose. Cartilage grafts can be placed in between the upper lateral cartilages and the nasal dorsum or on top of the cartilages. Dr. Markey has extensive training in precisely removing the convex portion of the front of the nose that results in a nasal “hump”, or “bump”. The result is tailored to the desired goal of the patient. Many patients hope for a straight or even gentle “sloped” appearance of the nose when seen from the side.
Still others find that the mid-portion of the nose collapses inward when they take deep breaths through the nose. When this is the case, Dr. Markey is able to place thin cartilage grafts on the sides of the nose to act as a sort of Breathe-Right® strip and enable them to breath as they hoped.
The lower 1/3rd of the nose includes the tip of the nose, the nostrils, and the bit of skin between the nostrils called the columella.
Many patients visit Dr. Markey’s clinic because they hope to change the appearance of their nasal tip, which is largely shaped by the lower lateral cartilages.
Some feel as though the tip of their nose is too “boxy”, others find that it droops a bit too much, still others say that it doesn’t have much shape at all and the nose is too flat. Dr. Markey is able to partner with each patient and respond to their concerns individually.
To alter the shape of the tip of the nose, Dr. Markey uses one of two approaches: the “closed” approach, or the “open” approach. If only minor adjustments to the lower lateral cartilages are needed, then a closed approach may be the best choice. This involves making precise incisions only on the inside of the nostrils and adjusting the cartilage structures from the inside-out. These adjustments may take many forms. Dr. Markey uses advanced techniques with suture alone to adjust the position of the cartilage. Cartilage grafts, taken from either the septum within the nose or even the cartilage of the ear, are often placed around the nasal tip to perfect its shape. Certain portions of the cartilage that lend to an unwanted shape can also be excised and replaced in more favorable positions. The open approach is more commonly performed by modern Facial Plastic Surgeons. This involves making a well-hidden incision in the columella between the nostrils and gently lifting the skin to view the cartilage structure below. With this approach, Dr. Markey is able to clearly see the entirety of the nasal cartilages and make very precise adjustments to achieve the desired shape. He is also able to place thin cartilage grafts in well-studied anatomic pockets within the lower 1/3rd of the nose to enable the patient to breathe better through both nostrils.
So a “rhinoplasty”, may involve adjusting the shape and strengthening the support of one, a few, or all of these areas of the nose. Dr. Markey will take time to explain exactly what techniques will be used to partner together to get the best result.
Don’t hesitate to reach out Dr. Markey and his staff at the Ascentist Facial Plastic & Reconstructive Surgery Clinics of Kansas City with any questions regarding rhinoplasty.
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I was referred to Dr. Markey through my internist. My appointment was right on time. Dr. Markey is very personable and makes you feel at ease. He listens to your concerns and, in fact, found that I had cartridge growing in my left nostril that was inhibiting me from breathing correctly. We set up a date for same day surgery. His office team then helped me with scheduling. I messaged Dr. Markey with concerns and he responds right away. I am very glad I found him and would suggest his services to anyone needing a really terrific otolaryngologist. Thank you, Dr. Markey and Irene for being so terrific.
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