Over-resection of the nasal dorsum and lower lateral cartilages can result in an over-rotated or upturned nose. The resulting piggy-look is quite unsightly. In these patients, the nasolabial angle is too obtuse and requires downward rotation to give a more natural look.
The techniques used to down rotate the nasal tip includes use of the extended spreader grafts or a septal extension graft onto which the lower lateral cartilages can be sutured onto in their new position. One limiting factor is the amount of skin laxity which will allow the additional length of the nose to be created without placing any undue tension in the skin. In the male patient the angle made by the nose against the upper lip (nasolabial angle) should be around 90 degrees whereas in a female this can be 95 – 105 degrees.
The term bulbous tip relates to the lower third of the nose being described as excessively round, bulging and/or fat. This is due to the large size of the lower lateral cartilages and exacerbated by thick nasal skin.
Improvement can be made by reshaping the lower lateral cartilages but care has to be taken to ensure excessive cartilage is not removed as this can result in weakness of the side walls (giving rise to secondary problems of nasal blockage) and scar tissue formation causing knuckles to occur (bossa formation).
A number of methods are used to improve the shape of the nasal tip. Such techniques include reducing size of the lower lateral cartilages and use of suture techniques to change the shape of these cartilages. Newer techniques include utilising thin strips of cartilage (lateral crural strut graft) which are placed underneath the curved lower lateral cartilages and by suturing the two together the excessive curvature of the bulbous tip can be refined. Please see before and after sections for examples.
One of the commonest complaints is the presence of a prominent dorsal hump. This is mainly seen on side or profile view. In previous generations, the fashion was for a small retrousse button nose with a very much lowered nasal dorsum.
Today, a straight or in men a very slightly convexed nose is preferred. Reduction of a dorsal hump will usually require fracturing in of the nasal bone so that the pyramidal shape of the nose can be regained usually resulting in a narrow appearance from frontal view. Large dorsal hump reduction involves associated reduction of the upper lateral cartilages and this necessitates the use of spreader grafts in order to avoid mid-vault collapse which is a recognised complication of rhinoplasty surgery (see Revision Rhinoplasty).
This can be a natural feature or secondary to injury. Usually after reduction of a nasal hump, the nasal bones need to be fractured in, which narrows the nose. A wide alar base seen most commonly in Afro-Caribbean patients can be improved by alar wedge resection.
Fracture of the nasal bones (osteotomies) is carried out using special sharp chisel like instruments called osteotomes. A common technique involves making 1 mm stab incisions on either side of the nose. Then a 2 mm osteotome is used to make a series of breaks along the sides of the nose rather like holes around a postage stamp. This allows a controlled break of the nasal bones. A new technique is the use of powered osteotomies. This utilises small saws and allows precise linear cuts to be made in the nasal bones.
In patient’s with weak nasal bones or those who have had previous trauma, the exact position of the fracture line is unpredictable and can result in floating pieces of nasal bones (comminutated fracture). Although the nasal cast applied over the nose at the end of the procedure helps to keep the pieces stable, subsequent healing can result in migration of the bone fragments giving an unsatisfactory result.
All fractured boned heal by initial formation of a material called callus. This then remodels to resume the normal shape but sometimes callus formation is excessive and/or the remodelling stage is inadequate so a prominence is noted in the post-operative result possibly requiring minor revision procedure. In rare instances a narrowed nose can result in nasal obstruction as the physical space in the nasal cavity is reduced.
Some patients have a prominent dorsal hump due to a large nasal septum and this result in a tension nose. Here, the nose often has a narrow appearance from the frontal view. Reduction of the dorsal hump and use of spreader grafts can result in a more balanced view.
Many patients have a narrow nose on frontal view but with a prominent dorsal hump. This is often described as a tension nose. In these instances reduction of the dorsal hump does not require fracturing of the nose as the newly widened appearance is desired. Ideally the width of then nose should equate to one fifth of the width of the whole face or equal to the width of the eye. A patient who has had too much tissue removed in the form of an alar wedge resection may require a revision procedure to widen this. This can be achieved by using a composite graft of a piece of cartilage and skin from the ear and inserted into the nostril to give it a wider appearance. Please see before and after examples.
Many patients have twisted noses but have never experienced any problems such that surgery is required. Indeed some celebrities are recognisable because of their twisted noses and examples include Stephen Fry, Cat Deeley and Daniel Day-Lewis.
The twisted nose is usually due to bony and/or cartilaginous deformities or indeed involving both structures. In some patients, twisting of the nose occurs after a previous operation due to asymmetric scar tissue formation and contraction, particularly affecting the nasal tip. Correction of a twisted nose is one of the most challenging aspects of rhinoplasty surgery. Rather like rebuilding a house, the foundations have to be corrected and only then can any subtle improvements be reliably assured. In some severely traumatised noses, surgical correction may need to be staged to get the optimum result over an 18 to 24 month period.
There is often inadequate good cartilage from the patient’s own nose available for the reconstructive process. Some new bio materials are used to assist the reconstructive process such as the relatively newly introduced biodegradable PDS foil onto which fragments of cartilage can be sutured. The fragments are then placed back onto the nose and healing occurs between the fragments but the biodegradable scaffold disintegrates over a period of time.
Such injuries can vary in complexity and may be associated with other injuries such as orbital rim fracture. Correction can be carried out within the first three weeks following the injury or in certain circumstances delayed by up to six months until all the inflammation has settled.
In certain circumstances a broken nose can be pushed back into its original shape at the time of injury before facial swelling occurs. This would obviously depend on the nature of the injury and the presence of a suitably qualified and experienced person in attendance. A common example is an injury during a rugby or football match where a broken nose can be clicked back into place by the Team Doctor. Following an injury the patient should be seen by a Doctor to exclude the possibility of a septal haematoma. The latter is a collection of blood within the layers of the septum and if left untreated can result in the loss of septal cartilage, abscess formation and subsequent saddle deformity of the nose. A septal haematoma requires immediate drainage under a short general anaesthetic.
If the nose is deviated after the swelling has reduced, the nose needs to be manipulated under anaesthetic. This requires admission to hospital as a day case, and the nose is pushed back into its original shape. The results are good but occasionally unsatisfactory and a formal Septorhinoplasty needs to be done 4-6 months later.
Occasionally the septum can be traumatised and fractured following an injury and during the manipulation procedure attempts can be made to manipulate the septum back into the middle. The results, however, are variable.
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My new nose has boosted my confidence level. I chose Mr Patel as I felt that he understood exactly what I wanted from the surgery, and more importantly as I had issues internally with my nose. The surgery went very well and I am extremely pleased with the results.
I would highly recommend Mr Patel He is a fantastic surgeon who levels your expectations and does everything in his power to ensure your operation is successful. He has a formidable reputation and cares about his patients. Since the surgery, my breathing is back to where it was when I was a child. My old nasal voice has now disappeared. Aesthetically my nose is a thousandfold better.
It's looks so natural that people don't even notice that I had an operation. Mr Patel was exactly the specialist I was looking for. On my first consultation, he examined me thoroughly, Mr Patel took his time to explain in detail what the problems were and what options I had, always considering the healthiest outcome. I had my operation and I have already noticed the difference in breathing, which gets better every day. I'm also very happy with my new nose.
After an unsatisfactory result from the first operation at another surgeon when I decided to seek a consultation with Mr Patel. His approaches including confident advice, which is backed by his knowledge and experiences, and detailed explanations about the procedures he was going to go through with the images of CT scan in front of me made me feel convinced of his method during the entire process. The outcome of the surgery was indeed a very satisfactory one.
I was happy with the first consultation as I felt I was in safe hands and as the Doctor explained exactly what was going to be done to me I felt I was making an educated decision. Despite the busy schedule Mr Patel was able to schedule the surgery one month later. The Surgery lasted 3 hours, already that evening I was sent home.
No problems breathing and I am very pleased with the result I was referred to Mr Patel through Bupa and could not have been happier with the experience. The consultations were very friendly and open and I was referred for surgery very quickly. The surgery was explained to me at length and I felt very confident with the process. Afterwards I received a detailed explanation of how it had gone, I recovered very quickly and the aftercare was very thorough. I have already recommended Mr Patel to my friends.
I have suffered from a deviated septum almost all my life. I have always suffered from trouble breathing through my nose, no sense of smell and snoring during sleep so I decided to seek medical advice and was referred to DR PATEL who comes highly recommended. The operation was a great success no bruising around my eyes I was in no pain or discomfort after the surgery. My aftercare has been excellent. I BREATH NORMALLY NOW. I am very pleased with the outcome. I would sincerely recommend Mr Patel.
I would sincerely recommend Mr Patel I consulted Mr Kalpesh Patel. From my first visit, Mr Patel answered all of my questions very clearly and I felt reassured that I was in “safe hands”. He understood my wishes and I felt confident in his abilities. On the day of the operation (a septorhinoplasty), I was impressed by the thoroughness of the procedures and the explanations that were given to me by both Mr Patel and the anaesthetist.
I choose Mr Patel because of his reputation (he was featured in best ENT article in Tatler magazine) and upon meeting his I trusted him, he put me at ease. The surgical experience was very comfortable and went well. I was back at work a week Monday after the operation. My nose is now perfect, back to the way it was before my traffic accident. Mr Patel really understood the situation and how to carefully return my nose to what it was before. The result was excellent, I couldn't be happier.