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| Dr. Joel Aronowitz |
Dr. Joel Aronowitz: “So our patient's asleep, the nose is anesthetized, I'm going to use this hook to give me retraction and here you can see the lower edge of the septum, the septum is rubbery because it's cartilage and then up higher it's bone so what I'm going to do is make an incision through the skin and connect that to an incision up above the lower cartilage but below the upper cartilage so there's a cartilage right here and then there's a bigger cartilage up here so I've made my incision between the two, and if you look carefully you can see that little white line, that little white is cartilage, is the upper lateral cartilage. I've introduced a slightly sharper scissor through that internal incision, you can see my scissor spreading, that's giving me access to the dorsum or the bridge of the nose and now when I put a retractor in I'll be able to see that whole top surface where the top surface is like the back of the nose is called the dorsum. Okay I'll take a right angle and a pick up. Now we're not doing anything at this stage except simply exposing the parts that we need to expose. I'll take a mosquito and in a moment I'll show you the bridge of the nose and the hump that's creating the problem. So you can see the white cartilage here and that's the hump right there, you can see it like a little little whale popping out of the ocean a little bit and what we're going to do is trim that for her so she has a straighter nose and does not look like her dad, at least not so much like her dad. We often hear that I'm having an open rhinoplasty or I'm having a closed rhinoplasty, what does that mean? It simply means that through this part of the nose, this is called the callumella, this is the philtrum and on either side of the philtrum this little dimple are the philtral columns but if I cut, here's my incision, if I make my incision straight across here either with a little chevron or straight cut or a little stepped cut then I can lift it up and see everything. That's an open rhinoplasty, that's necessary for complicated rhinoplasties especially patients had many previously and many surgeons have been trained to do an open rhinoplasty as the primary procedure. I think it's really not necessary to give the patient an additional scar here but it really doesn't show very much anyway typically.
Open versus closed rhinoplasty. I'm rasping the bridge of the nose similar to filing but a file is different than a rasp. If you look carefully at the blades of the rasp they just go in one direction so you're only cutting when you pull. When you're pushing nothing's happening. With a file you're cutting both ways. So now I've cut the bridge so that I can remove the hump and here's the piece of cartilage and that's what the you can so this is a the dorsum of the cartilage. So instead of using a hammer and chisel to break the sides of the nose so we can bring the edges together I'm using a saw. I'll show you what the saw looks like in a moment. I prefer it because I feel like I can make a cleaner cut. There's an electric version out now but the nose of the bone is pretty thin, a little thicker than eggshell is also pretty easy to cut if you have a good saw. I'm going to get it sawed enough I'll be able to just push with my thumb and fracture it. Did you hear that little crunch? So that was the the bone breaking sort of like that's the edges just falling in like that with my with my the pressure of my thumb and I can tell it's a nice clean cut and now we just need to do the same nice job on the opposite side. You can see the blades on that saw it's fairly sharp it's a double blade it's got two rows of teeth and they're pretty sharp which makes easy work of what I need to do here. So I'm going to introduce it to the little tunnel I just created if I can find it. There we go and I want to be high enough that I'm not in the pier duct area but low enough that I make a cut through the bone just where the at the base of the nasal bone. And that was the little fracture that you just heard and now we need to just hold pressure a couple of minutes so we control the bleeding in there and I seat the bone exactly where I want it.
Okay so hope you enjoyed that I want to recap a little bit about rhinoplasty a little bit about the anatomy of the nose a little bit about an approach to consultation from the surgeon's standpoint and also from the patient's standpoint and some pointers and then a little bit about secondary rhinoplasty and selecting a surgeon. So first off anatomy the nose is flat in the middle of the face we expect it to be symmetrical but if you think about it the right side and left side of the face are almost always different so the nose is going to have to bow one way or another to compensate for that and the two sides of the nose are rarely going to be exactly the same and many times the nose is not going to be right exactly in the midline as long as it appears to be in the midline that's fine. Many times asymmetries add a interesting element to facial appearance and even make somebody more attractive more interesting to look at. Remember we don't look at each other straight like this we look at each other a little obliquely in normal conversation and that covers all this asymmetry very well. As the surgeon when you're comparing the face when you're examining the nose you always want to point out these asymmetries of one thing that's a good guide is to look at the central incisors the space between the central incisors should be the middle line as right in the middle of the philtrum and carried up through the labella at the root of the nose so when we use those landmarks we can have some reference for how asymmetric the nose is. Next a little bit about an approach to rhinoplasty so in the consultation the surgeon should ask what you don't like about the nose. The surgeon shouldn't assume to know what you don't like about the nose because something that's a glaring to the surgeon may not have even been noticed by the patient so as the surgeon one should never volunteer imperfections in the surgeon's eyes one should always want to be receiving what the patient feels is unattractive or they don't like about the nose.
Obviously, we want to both question the functional aspect of the nose the airway and do a intranasal exam but we'll leave that for functional rhinoplasty or functional nasal surgery for another time and concentrate on the cosmetic aspect. So the key key point turning point here in the consultation is for the surgeon to figure out if this is going to be a reduction rhinoplasty or if something needs to be added to the nose. Most rhinoplasties are going to be reduction rhinoplasties except in many Asian patients who need the nasal bridge built up so if the nose requires building up or let's say there's asymmetry in one side of the nose then that's a good option. Maybe it wouldn't be a permanent solution but it would be a good option for the patient to see what surgery could accomplish and maybe the patient might not ever want surgery but be perfectly happy having a non-surgical rhinoplasty which is basically injecting fillers in the nose. I've done that many many times especially with patients that are a whether or not to pursue a rhinoplasty they're unhappy with their nose but they don't quite know why and a non-surgical rhinoplasty is a great very safe alternative that can substantially change the nose but not on a permanent basis. Next is the role of photography so nowadays there is really good um clinical photography and morphing software available.
Vectra is the unit that I use in the office but there are other devices that are available and the surgeon should be able to offer you morphing which means taking standard photographs and then doing changes on the computer show you what those changes look like the surgeon should always tell you no I can't that that's going to be the result obviously but that gives you a good mark to shoot for surgically and a point of discussion between you and the surgeon. The surgery typically should take anywhere from two hours to four hours and where cases it might take a little bit longer than four hours it's typically done under general anesthesia with an endotracheal tube so that the anesthesiologist or nurse anesthetist has positive control of the airway at all times just in case there's excessive bleeding or some other problem having an airway when the nose is being operated on is considered a good safety step by most practitioners. This sometimes gives you a little bit of a sore throat but it should give the patient confidence that the anesthesia is being done safely. The time that the surgeon requires really shouldn't be a big factor in your decision making but the experience of the surgeon and whether or not the surgeon is going to do the rhinoplasty open or closed should be a point of on your decision tree so an open rhinoplasty includes an incision through the callumella here this part of the nose is the callumella and then the rest of the incision is inside the nasal ala or inside the nostril and then the skin can be lifted up sort of like the hood of a car in order to do the work on the inside of the nose so if the surgeon is on the younger side probably under 40 I would say they will probably suggest an open rhinoplasty many surgeons who are a little older have trained in an era when a closed rhinoplasty was taught as a standard procedure and so an older surgeon may prefer a closed rhinoplasty and allow you to avoid this scar the experience of the rhinoplasty surgeon is a factor I do not think it is required or even optimal to see a surgeon who only does rhinoplasty it's a very limited scope of plastic surgery and many plastic surgeons are perfectly comfortable doing the first time around rhinoplasty especially if the nose is fairly uncomplicated and do a very nice job with low complication rate if you are having a second third or fourth rhinoplasty you should probably see three rhinoplasty surgeons people who do mostly rhinoplasty it's not exclusively for to select your surgeon should you see an ent versus a plastic surgeon I think there are plenty of ents who are capable of doing cosmetic rhinoplasty in general plastic surgeons are oriented more cosmetically from the get-go and less and less oriented toward the functional side of rhinoplasty but I think it really depends on the individual I do think that you should look for a board eligible or board certified plastic surgeon or ears nose and throat surgeon the facial plastic surgery certification is is not as meaningful as the certifications that require an actual residency or fellowship of a year or more and finally the post-op course so usually rhinoplasty will require a nasal fracture so the surgeon is going to make a cut in the bone this is kind of egg shell thickness bone here where the nasal bone attaches to the cheekbone and across the bridge of the nose so that these pieces can be pushed in together and fall together at the top otherwise when the surgeon takes the top off the roof is kind of flat like that and it'll be a very obvious contour along the top so you want to the surgeon wants to be able to allow those bones to fall together so that creates a natural appearance and that's why the fracture of the nasal bone is typically required even when you don't need to narrow the base of the nose very much or at all so that's going to cause some bruising that's going to cause some pain and cause some bleeding from the nostrils in the first hours post-operatively a splint is usually placed and that usually stays on for a week to 10 days and most people do not have more than one or two days discomfort require narcotics after that just feels like you have a little bit of a stuffy nose if packing is placed that's much less comfortable and that's a good question to ask your surgeon pre-operatively if you're going to require packing or not because the packing makes it so you can't breathe through the nose post-operatively creates a dry throat etc from having to breathe through your mouth and also is very uncomfortable the increased work of breathing through your mouth constantly also just gets exhausting after a while the other problem with packing is that it is very uncomfortable in many cases when the packing comes out so if you can avoid packing that's good you can't always avoid it problems in rhinoplasty excessive bleeding occurs in a small number of cases infection is rare asymmetry and cosmetic problems is probably the most common issue and that occurs anywhere from five percent to fifty percent i would say it just depends on the surgeon it depends on the patient i would say that rhinoplasty is one of those operations you want to have a really good rapport with your surgeon pre-operatively and kind of put each other through their paces if you will so that you know you have a good partner in dealing with problems after the fact if that should occur it's a rhinoplasty relationship a rhinoplasty patient doctor relationship can be strained because the healing takes months and the patient is very sensitive to small imperfections so you want to be sure that you're starting out with a surgeon that you are really comfortable with you have a lot of trust in so that if you do a problem if you do have a point of contention between you and the doctor you have a repository of trust and confidence that you can call on to get you through that tough patch.
So those are my thoughts recapping rhinoplasty i hope you enjoyed it it's a very interesting challenging and rewarding operation and if you're considering rhinoplasty i would encourage you to pursue it and especially while you're young under the age of 25 let's say and i get just go ahead and get it over with if you are not too sure and especially if you have a smaller nose or you have relatively small imperfections you should consider a non-surgical rhinoplasty as an option and see somebody who offers a non-surgical rhinoplasty which many doctors do nowadays which again is just injecting a filler material in the nose so that's my thoughts and meanwhile i will see you later from Aronowitz land bye bye now.”
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