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The Seattle Facelift Center™
William A. Portuese, M.D.
1101 Madison Street, #1280
Seattle, Washington 98104
Phone: 206.624.6200

The Sinuses


Nose Issues

BROKEN

Surgical Techniques

DORSAL SURGERY – SEPTOPLASTY WITHOUT SEPTAL BANKING

The area in red represents the septum. When the septum is crooked or deviated, it must be straightened to permit functional breathing. This also represents the area of cartilage and bone that is the internal portion of the nose, which can be used for dorsal augmentation to build up the bridge or sidewalls of the nose used in structural cartilage grafting for a rhinoplasty.

Normal Anatomy

Underneath the skin envelope of the nose, the upper portion of the nose consists of two paired nasal bones which form the solid bridge of the nose attached to the forehead. Below that are triangular cartilages called the upper lateral cartilages that attach to the nasal bones. Below that is the more flexible portion of the nose made up of the lower lateral tip cartilages which composes the shape and structure of the nasal tip. The nasal septum is composed of both septal cartilage in the front of the nose, and the top and bottom portions of the septum are composed of ethmoid bone and vomer bone.

 

 

Dorsal Surgery - Reduction

The area shaded in red shows the area of the bridge where a bump would be present. It is removed to further refine the dorsal aesthetic line or also known as a hump reduction in the nose.

 

 

Dorsal Surgery - Augmentation Dorsal Onlay Septal Cartilage

The green area represents an area of cartilage augmentation to build up the bridge when the bridge itself is too low or been previously resected or is ski-sloped and needs to be built back up. Typically the cartilage is harvested from the internal portion of the nasal septum or ear cartilage is also used. Occasionally patients require a synthetic implant to achieve the desired results.

 

 

Dorsal Surgery - Augmentation Radix Graft Crushed

The area in green represents a small cartilage graft that is placed at the top portion of the nasal dorsum called the radix. When the bridge of the nose has an area of depression, a graft is used to build up and lengthen the nasal bridge. Additionally this procedure augments the shallow takeoff root of the nose from the forehead.

 

 

Dorsal Surgery: Augmentation Lateral Nasal Wall Grafts Crushed

The green areas represent cartilage grafts that are placed over the nasal bone or upper lateral cartilage area to bolster the strength and augment the sidewalls of the nose during a rhinoplasty.

 

 

Tip Surgery - Claudal Septum Resection Slanted

The area in red shows the resection of cartilage that is done where there is a deviated septum and where the portion of the base of the nose is warped and blocking the airway. It is also done to trim off excess columellar show when the columella is hanging down too far below the nostril rim. This can be both cartilage and skin, it can be trimmed, and is frequently done during a rhinoplasty procedure.

 

 

Tip Surgery - Columellar Strut Floating With Sutures

On occasion when there is loss of tip projection or support in the tip, a cartilaginous columellar strut is fashioned from septal cartilage and positioned underneath the tip to give more projection and strength to the nasal tip.

 

 

Tip Surgery - Lateral Crural Cephalic Removal

The area in red shows the most common area of cartilage that is trimmed and removed to feminize, refine, and reshape a bulbous tip. This is a very common procedure during the tip component surgery of a rhinoplasty.

 

 

Tip Surgery: Tip Sutures Lateral Crural Spanning

The area in black across the nasal tip shows the area of the lower lateral tip cartilages that are sewn together to reduce a bulbous nose or a wide tip. These are sutures that are placed to refine and feminize a wide, flaring, boxy tip. Cephalic trim of the lower lateral cartilages can also be performed at the same time.

 

 

Tip Surgery: Tip Grafts Champagne Graft

The area in green shows small cartilage grafts placed in the tip to create further tip projection. This also helps with tip defining points and is sometimes used to give a better appearance to the tip.

 

 

Tip Surgery: Alar Base Resection Into Vestibule

The area in red shows the area of the skin of the nostrils that is removed and resected for wide, flaring nostrils. Sutures are placed in the natural crease and typically disappear after the incisions are well healed.

 

 

Osteotomies Medial and Lateral

The red lines represent the areas where the nasal bones are narrowed during rhinoplasty. This is when the nose is re-broken and reset narrower after it has been fractured or reduced in size to narrow the width of a wide nasal bridge.

Sinus Problem FAQ

Can rhinoplasty correct all defects?
The pictures indicate the issues needing to be addressed include a twist to the patient’s right side; it is wide and should be narrowed by surgery. A large convexity to the dorsum is present, and needs to be removed, and upon smiling a tip droop appears. Releasing the ligament that holds the upper lip to the tip will make it so smiling does not make the tip droop. Narrowing and straightening of the bones will need to be done once the cartilaginous bump is removed from the bridge.

When is closed rhinoplasty more complicated than open?
The nasal surgery operation is the same whether it is a closed or open procedure. The incision across the columella in the open approach is the only difference and it is not necessary in the closed approach. They are identical procedures

Can I count on the alar reduction to reduce nostril width?
Narrowing the base of the nose is done using an alar reduction or alar plasty, but will not thin the actual alar rim itself. Risk of scarring this fleshy skin part of the nostril prevents this reduction. The actual nostrils width of can be decreased by removing a small portion of skin from the nostrils attached to the floor of the nose.

If I do not like the alar base reduction is it reversible?
Alar base reduction is not reversible. Once performed, the procedure is permanent and it is not possible to enlarge it. It is possible to use skin grafts in this area however they will not look natural. Additionally, noticeable scarring can occur.

Do surgeons shave the sides of the nasal bone?
When having nasal surgery the corners and top of the nasal bones can be filed down, but filing the sidewalls is not common practice. Narrowing the sidewalls is done through osteotomies, breaking of the nasal bones to set them in a new natural position. The sidewalls will be more easily fractured and weakened if they are filed down too much.

I have a small piggish nose, is it possible to enlarge it?
The description is of a piggish nose is not tangible. Cartilage grafts make the tip wider and larger if that is your desire. Grafts from the ear, nose, or rib can make the bridge higher. These limited modifications can alter the nose. A limiting factor for your nose is that the skin envelope cannot be expanded.

What is the recommended sleeping position after rhinoplasty?
Keeping your head above their heart is recommended, simply to reduce swelling after nasal surgery; however it is only a suggestion and is not critical. If the cast is in place rolling over on a pillow will generally not make the nose crooked or dislodge it. Worrying about sleeping on three pillows versus two pillows is less significant than getting a good night of sleep.