Rhinoplasty surgery: techniques, anatomy, grafts
The operation in the surgeon's language: open and closed approaches, dorsal preservation, component hump reduction, rib and spreader grafts, revision, anatomy, recovery, cost and the psychology of patient selection. Each page cites the papers it rests on.
The anatomy of the nose
A nose is three stacked vaults sitting on one central wall: bone at the top, paired cartilages in the middle, two curved cartilages at the tip, and the septum h…
Open versus closed rhinoplasty
Open rhinoplasty adds one small incision across the columella, the strip of skin between the nostrils, so the skin can be lifted off and the whole framework see…
Rhinoplasty recovery
Recovery is one uncomfortable week, one strange month and one slow year: the splint is on for about a week, the bruising has usually gone by two, and the nose t…
Revision rhinoplasty
A second rhinoplasty is a different operation from the first: the cartilage that would have been used to rebuild is usually gone, the skin is scarred and less a…
What rhinoplasty costs
The number a surgeon publishes and the number you pay are rarely the same. The American Society of Plastic Surgeons puts the average surgeon's fee at $7,637 and…
The psychology of rhinoplasty
A nose is the one feature a person cannot look away from, and about one in three people who ask a surgeon to change theirs is carrying distress that the nose it…
Preservation rhinoplasty
Instead of cutting the hump off the top of the nose and rebuilding the roof underneath it, preservation rhinoplasty takes cartilage and bone out from below and …
Rib cartilage grafts
When there is not enough septum left to rebuild a nose, the surgeon takes cartilage from a rib, either the patient's own or one supplied by a tissue bank. That …
Blocked breathing after rhinoplasty
A nose that breathes worse after surgery than before it is the commonest functional complaint in revision practice, and it usually traces to one of three places…
The tip
- Technique
Tip rotation and projection
Rotation is the angle the tip sits at, projection is how far the tip stands out from the face. Both are set by the same frame of cartilage at the bottom of the nose, both are read off a prof…
Open - Technique
Tip sutures
A tip suture reshapes the cartilage of the nasal tip by pulling on it, with nothing cut away. Modern tip surgery is built on a short list of named stitches placed in combination, and where e…
Open - Technique
Tip support
Tip support is what stops the tip sinking back once the operation is over. It comes from the lower lateral cartilages, from their attachments to the septum and to each other, and every manoe…
Open - Technique
The bulbous tip
A bulbous tip is a tip that reads as wide and round from the front, with no clear light point. The width comes from the shape and position of the lower lateral cartilages, from the thickness…
Open - Technique
The drooping tip
A drooping tip points down, and in many patients it points further down on smiling. The resting position is set by the cartilage frame and the caudal septum, the movement on smiling is drive…
Open - Technique
Pinched tip and bossae
A pinched tip is a nose narrowed too far at the point, so the tip looks squeezed, the sidewall above the nostril falls in, and in thin skin the cut ends of the cartilage show through as two …
Open - Technique
The tongue-in-groove technique
The tongue-in-groove sets the two inner walls of the nostrils onto the front edge of the septum and sews them there. Tip height and tip angle are then fixed to the septum instead of being le…
Open - Technique
Lateral crural techniques
The lateral crus is the curved strip of cartilage that runs from the tip out towards the cheek, and it holds the side wall of the nose open while you breathe in. Modern tip surgery reshapes …
Open - Technique
Alar retraction
Alar retraction is a nostril rim that has pulled up, so too much of the nostril shows from the front and the profile reads notched between the rim and the columella. It follows loss or malpo…
Open - Technique
Revision of the nasal tip
Revising a tip means rebuilding the lower cartilages of a nose that has already been operated on, through scar, with less cartilage left and thicker skin over it. The tip is where most revis…
Open
Grafts and where they come from
- Technique
Spreader grafts
A spreader graft is a strip of cartilage set on edge in the gap between the septum and the upper lateral cartilage, one on each side, to hold the middle of the nose open. It is the most used…
Open - Technique
The butterfly graft
A butterfly graft is a single piece of ear cartilage laid across the middle of the nose, under the skin, so its natural spring holds the collapsed breathing valve open. It was described in 2…
Open - Technique
The columellar strut
A columellar strut is a short piece of cartilage stood on end between the two inner legs of the tip cartilage, in the column of skin between the nostrils, to hold the tip up. Measured a year…
Open - Technique
Alar rim grafts
An alar rim graft is a small strip of cartilage slid into a pocket along the edge of the nostril, where the nose has no cartilage of its own, to stop the rim curling up or falling in. In 90 …
Open - Technique
Crushed cartilage grafts
A crushed cartilage graft is a piece of the patient's own cartilage flattened in a metal crusher until it is soft, then laid under the skin to smooth a ridge, an edge or a dent. How hard it …
Open - Technique
Diced cartilage grafts
A diced cartilage graft is the patient's own cartilage cut into pieces about a millimetre across, packed into a sleeve or set in glue, and laid on the bridge of the nose to raise it or smoot…
Open - Technique
Ear cartilage grafts
Ear cartilage is taken from the bowl of the outer ear through an incision usually placed behind it, and used in the nose when the septum is gone or not enough. Across 372 harvests, 2.4% of p…
Open - Technique
Costal cartilage harvest
Taking rib cartilage means a second operation on the chest during the nose operation: an incision of about 2.4 cm, a length of cartilage cut from the sixth, seventh or eighth rib, and a woun…
Open - Technique
Irradiated rib grafts
An irradiated rib graft is donated human rib cartilage, sterilised with radiation at a tissue bank and carved to shape in the operating room, so nothing is cut from the patient's own chest. …
Open - Technique
The subalar graft
A subalar graft is a piece of cartilage placed under the base of the nostril, against the bone of the upper jaw, to build up a flat side of the face and bring a deviated tip back toward the …
Open - Technique
The tip onlay graft
A tip onlay graft is a piece of cartilage laid flat across the top of the tip cartilages, one layer or several, to add height and definition where the nose is short at the front. Measured on…
Open - Technique
Alloplastic implants
An alloplastic implant is a manufactured piece of silicone, expanded polytetrafluoroethylene or porous polyethylene, placed on the bridge of the nose to raise it without taking cartilage fro…
Open - Technique
Fat grafting in rhinoplasty
Fat drawn by liposuction from the belly or the flank is injected under the skin of the nose to add volume, cover a small irregularity and thicken a thin or scarred skin envelope. Across elev…
Open
The bridge and the nasal bones
- Technique
Dorsal hump reduction
The hump on a profile is not one thing: it is bone at the top, cartilage below it, and the joint where they meet. Taking it off in one pass with a rasp or an osteotome removes the roof of th…
Open - Technique
Nasal osteotomies
Cutting the nasal bones. An osteotomy is a controlled break in the bone of the upper third of the nose, made so the lateral walls can be moved inward, outward or straightened. It is the step…
Open - Technique
Piezo rhinoplasty
Cutting bone with sound. A piezoelectric handpiece vibrates a metal tip at ultrasonic frequency, which cuts mineralised bone but leaves soft tissue, cartilage and lining intact at the same s…
Open - Technique
Powered instrumentation
Motors instead of hands. A powered rhinoplasty uses a rotating burr, a reciprocating rasp, an oscillating micro saw or a suction shaver to remove and shape bone and soft tissue, in place of …
Open - Technique
Narrowing the bridge
A wide bridge with no hump. Some noses are straight in profile and too broad from the front, so the operation has to narrow the bridge without lowering it. That means moving or reshaping the…
Open - Technique
Open-roof deformity
Taking a hump off removes the roof of the nose along with it, leaving the cut edges of the two nasal bones facing the sky with a flat gap between them, the open roof. Closed at the same oper…
Open - Technique
Inverted-V deformity
An inverted-V is a visible shadow across the middle of the nose, shaped like an upside-down V, where the lower edge of the nasal bones stands proud of the cartilage that should have been sup…
Open - Technique
Polly-beak deformity
A polly-beak is fullness in the strip of nose just above the tip, so that in profile the bridge runs level or convex into the tip instead of dipping and then rising. The outline is a parrot'…
Open - Technique
Saddle nose deformity
A saddle nose is a bridge that has lost height in the middle, so the profile dips between the radix and the tip the way a saddle dips between its pommel and cantle. It happens when the septu…
Open - Technique
The deviated nose
A deviated nose is one whose axis leaves the midline of the face, at the bones, at the middle third, at the tip, or at all three. Surgeons rank it as the hardest nose to correct because the …
Open
The septum and breathing
- Technique
Septoplasty
Septoplasty straightens the wall of cartilage and bone between the two sides of the nose so that air moves through both sides instead of one. Two randomised trials now put it ahead of steroi…
Open - Technique
Turbinate surgery
Turbinate surgery shrinks the swollen shelf of tissue on the side wall of the nose so air can pass, and it is usually done at the same sitting as a septoplasty. The methods differ in how muc…
Open - Technique
The caudal septum
The caudal septum is the front edge of the septum, the part you can feel between your nostrils, and it holds the tip of the nose up. Bending here narrows the airway and tilts the nostrils, a…
Open - Technique
Extracorporeal septoplasty
Extracorporeal septoplasty takes the septum out of the nose, straightens it on the operating table and puts it back as a new L-shaped strut. It is the operation for the septum that cannot be…
Open - Technique
Septal perforation
A septal perforation is a hole through both linings and the cartilage or bone between them, and it whistles, crusts, bleeds and blocks. Most of them are made by a previous operation, and clo…
Open - Technique
Pediatric septoplasty
Septoplasty in a child straightens a septum that is still growing, and surgeons avoided it for decades because they believed it would stunt the face. The reviews written since do not find th…
Open - Technique
The internal nasal valve
The internal nasal valve is the narrow slot where the upper lateral cartilage meets the septum, about a centimetre and a third inside the nostril, and it is the tightest point in the whole a…
Open - Technique
The middle vault
The middle vault is the middle third of the nose, a roof made of the septum and the two upper lateral cartilages joined to it. Taking a hump off opens that roof, and how the surgeon closes i…
Open
Planning by anatomy
- Technique
Asian rhinoplasty
Rhinoplasty in Asian patients usually adds height and support rather than removing it, because the anatomy the papers describe is a low dorsum, a small and soft cartilage framework and a thi…
Open - Technique
African American rhinoplasty
The literature on rhinoplasty in patients of African descent measures a wide range of nasal shapes within the group and plans around three structural facts: a soft tissue envelope that is th…
Open - Technique
Latino rhinoplasty
The papers on Latino, Hispanic and mestizo rhinoplasty describe a nose whose supporting framework is slight and whose skin is thick, and they answer it by adding cartilage support rather tha…
Open - Technique
Middle Eastern rhinoplasty
The papers on Middle Eastern rhinoplasty describe a nose with a high radix, a wide and overprojecting dorsum, a droopy poorly defined tip and thick sebaceous skin, and they treat it as a red…
Open - Technique
Nasal analysis before surgery
Nasal analysis is the measured description of your nose and face that a surgeon makes before choosing what to do. It runs on standardised photographs, a defined set of landmarks, angles and …
Open - Technique
Cleft lip rhinoplasty
A cleft lip arrives with a nose built out of line: the nostril on the cleft side is flat and wide, the tip leans away from the midline, the septum bends, and the foot of the nostril sits low…
Open - Technique
Rhinoplasty in children
A child's nose is still growing, and the septum inside it is one of the structures the midface grows around, which is why nasal surgery before adulthood has been avoided for decades. The pub…
Open
Around the operation
- Technique
The consultation
The first rhinoplasty appointment is an examination of the nose and an examination of the reasons for wanting it changed, and the American Academy of Otolaryngology tells the surgeon to writ…
Open - Technique
Rhinoplasty photography
A rhinoplasty is planned, judged and defended on photographs, so the camera, the lighting and the distance are part of the operation. Change any of them and the nose in the picture changes w…
Open - Technique
Anesthesia for rhinoplasty
Most rhinoplasty is done asleep under general anesthesia, and the published complication rates for sedation and for local anesthesia are not worse. The choices that change the operation are …
Open - Technique
Complications of rhinoplasty
Large single-surgeon series report complications in roughly one rhinoplasty in eight and revision in roughly one in twenty-five, and most of what is counted is shape rather than harm. Infect…
Open - Technique
Long-term results
A rhinoplasty keeps changing after the first year. Swelling finishes resolving over about four years, the tip settles by an amount that depends on what was built to hold it, grafts thin or s…
Open - Technique
Steroids in septorhinoplasty
Surgeons give a corticosteroid around the time of a septorhinoplasty to hold down the swelling and bruising of the first days, and inject a steroid into the skin above the tip months later w…
Open - Technique
Alar base modification
Alar base modification narrows the nostrils and the base of the nose by cutting out a wedge of skin at the outside of the nostril, inside the nostril floor, or both. In 73 Asian patients who…
Open - Technique
Chin augmentation with rhinoplasty
A chin that sits behind the lip line makes the nose read as longer and more projected in profile, and moving the chin forward changes that without touching the nose. Of 108 consecutive patie…
Open - Technique
Injection rhinoplasty
Injection rhinoplasty changes the shape of the nose by adding gel under the skin, usually hyaluronic acid, in a few minutes and with no cutting. It adds volume and only adds volume, so it hi…
Open - Technique
Filler complications in the nose
Filler injected into the nose can enter an artery and stop the blood supply to skin or to the eye. This is rare, it is the reason the FDA advises against injecting the nose at all, and the s…
Open