“My mission is to create natural results that show no signs of having had surgery. I do not aim for a particular “look”. My goal is to achieve the most attractive nose possible that is in harmony with the face. Every nose and every face is unique and so it is too simple to classify rhinoplasty into types. Every rhinoplasty I perform is unique to that patient. I do not believe in a “cookie-cutter”, one technique suits all, approach.”
Terms do appear in the media however and online and so it is helpful for you to understand them.
This only relates to the fact that incisions are placed inside the nostrils, not what changes are made to the nose.
This relates to the fact that the incisions are not only placed inside the nostrils on each side but are also joined together with a small incision across the columella, which is the skin between the nostrils.
Again it does not relate to what changes are made to the nose. I perform rhinoplasty using both approaches and which I choose depends on what changes are to be made to the nose. Generally speaking I prefer the open approach as I can see the structures of the nose better and can use more sophisticated techniques more precisely. I may use the closed approach if only small contour refinements are needed to nose. The closed rhinoplasty approach has been associated with traditional reduction rhinoplasty. The open approach is more associated with contemporary reconstructive rhinoplasty. This is also known as open structure rhinoplasty.
This is a very traditional approach that came about from early rhinoplasty teaching. It involves standard steps with removal of a bump from the bridge, shortening of the nose to turn the tip up and removal of cartilage from the tip to make it smaller as well as helping to turn it up.
The problem with this approach is that it treats all noses as the same and it relies on scarring to pull things into place. Healing and scarring is unpredictable. It may actually produce a droopy tip and If performed aggressively it will result in a very obvious surgical look with a ski slope bridge and a piggy, upturned nose with a pinched tip.
This reflects modern thinking. The aim is to preserve the structures of the nose rather than cutting them out and to reshape them and move them into the best cosmetic position.
This is achieved by building a new supporting framework, hidden inside the nose, particularly for the cartilages of the middle of the nose and the tip. The amount of cartilage and bone that needs to be removed is minimised and so predictability of the final result is improved. Great experience and specialisation is needed for this modern rhinoplasty approach. Depending on the nose, it can be complex. It may be necessary to take areas of the nose apart so that I can put them back together in a different way to create a more attractive and aesthetic shape.
This is rhinoplasty performed for patients who are not happy with their first or primary rhinoplasty. I have seen patients requesting rhinoplasty have had several previous operations.
These cases are sometimes called tertiary rhinoplasty and may have been referred to me by other surgeons. Secondary surgery is very often more difficult than primary. Usually too much has been removed at the primary rhinoplasty and scarring has caused buckling and twisting of the cartilages. If too much bone has been removed the bridge is scooped out. The soft tissues of the nose and the skin are stuck together and it can be very difficult to see and separate the bone and cartilage. Often new structures need to be made from ear or rib cartilage and it can be very difficult to match what nature gives us and to smoothly fit these new pieces onto the pieces left to work with.
This rhinoplasty is performed to remove a bump on the bridge. The bump is made of bone and cartilage. Unless the bump is very small the nasal bones need to be broken to bring the roof of the nose together.
This is called closing the roof of the nose. Hump reduction is a very common part of most primary rhinoplasty is. Modern rhinoplasty also reconstructs the middle part of the bridge where the bump was made of cartilage. This prevents the middle part pinching in and looking “done”.
This is not a specific type of rhinoplasty. It is a term that has been used when piezo technology is used during rhinoplasty. I have been a pioneer of using this technology for rhinoplasty.
Piezo physics are used to create vibrations in fine instrument tips which can be coated with diamonds. These tips are then used to rub away bone and to make cuts or fracture lines in bone. Bumps can be removed and bones can be moved. The advantages for me are that changes to bone are more controlled and precise than with traditional and bigger non-powered instruments such as rasps and chisels. Piezo technology also enables me to remove bone without injuring cartilage. The results of piezo rhinoplasty still depend most on the expense of the handholding this new instrument.
Patients seeing me for primary rhinoplasty often talk about the nasal tip. They might want to consider lifting a droopy tip. A droopy tip with a bump on the bridge will also cause a hooked nose.
Modern reconstructive rhinoplasty will use cartilage grafts hidden inside the nose to prop up and support a droopy tip. Lifting a tip can also make it look slimmer. Tip plasty may also relate to refining a bulbous tip. The anatomy of the cartilages of the tip is very complicated. Bulbous tip rhinoplasty might require not just reshaping round tip cartilages but also moving them into a more natural position to create more elegant tip contours. This is not simple surgery. Traditional, quick techniques that remove tip cartilage take little time, have a short recovery and early results can look promising. However with the scarring that occurs, over months and even years pinching and knuckling may appear creating a very unnatural, pointy tip. This is very difficult to improve with secondary tip rhinoplasty.
The alar base is the area where the bottom of the nostrils join the face and also curved into form the edge of the nostril floor. Alar base reduction rhinoplasty is performed to make the nostrils smaller.
Different techniques will be needed for different problems. All the techniques have in common removal of wedges of skin from this area. Where the skin is taken from is very important and depends on whether the problem is too wide a nostril floor or too round a nostril rim or both. It is essential that the problem is correctly diagnosed so the correct area of skin is removed. Badly performed alar base reduction can cause deformities that may not be correctable.
If too much cartilage is removed during septoplasty then support for the nasal bridge can be weakened and this can produce a saddle nose. Small saddles can be corrected with cartilage taken from the ear. I use this as finely diced cartilage placed in a pocket under the skin to plump up the dip. Bad saddles need complex reconstruction to rebuild the nasal framework and to re-support the tip. Rib cartilage is often needed. The nasal tip in these cases may be flat and droopy and need pushing forward or maybe piggy and need turning down. Turned up piggy nose correction is sometimes called short nose rhinoplasty.
A saddle nose has a dip in the bridge or a scooped out bridge in the side profile view. The profile is curved in like the saddle on a horse. A saddle nose can be caused by injury or by removing too much bone or cartilage from the bridge of the nose.
Some patients like the shape of the nose but not the size of the nose. They describe that the triangle of the nose is too big and that they have an over projected nasal tip. The nasal tip sticks out too far.
These are very difficult rhinoplasties as lowering the bridge alone will make the tip look even more over projected. Every part of the nose needs to be made smaller and all the pieces need to fit back together. There is a limit to how much the skin can shrink wrap and therefore a limit on how much the nose can be reduced. We do not have the equivalent of a tummy tuck for the nose. Bringing the tip back, closer to the face in the side view can make the tip look fatter and wider from the front.
Deviated nose rhinoplasty / twisted nose rhinoplasty
A deviated nose or a twisted nose may be due to deformities of the bones of the nose, the septum of the nose or both. These may be due to injury or you may have been one with them.
Twists and asymmetries of the nose may be associated with facial asymmetries. Asymmetries of the face may limit how straight the nose can be. Septorhinoplasty is surgery to both the nasal bones and the nasal septum and is a term for combined rhinoplasty and septoplasty, performed at the same time. The tip cartilages may also be twisted and have asymmetries that need correcting. Twisted noses can be very difficult to correct, especially if the is deformity of the septum is severe. The septum is the main foundation for the nose.
The nasal septum is the mid line partition on the inside of the nose. If it is bent, buckled or deviated across one or both nasal passages it will block the nose.
Septoplasty is performed to straighten the septum and to reposition it in the middle of the nose. This can be performed at the same time as cosmetic rhinoplasty and this is called septorhinoplasty. Cosmetic septorhinoplasty corrects a twisted nose when a deviated septum is also the cause of a nose that looks twisted.
I do not find this term helpful and do not use it. I do not think in the modern world there are particular types of noses that are specific to particular regions.
There may be a range of cosmetic nasal characteristics that are more common in some parts of the world than others. For example noses in the Oriental countries may be smaller with lower bridges than northern European noses but I do not believe there is one rhinoplasty that works for all Oriental patients and another rhinoplasty that works for all northern European patients. Listening to what the individual patient wants and very careful analysis to work out what is possible is much more important than knowing a patient’s ethnic background. It is important in every rhinoplasty patient to respect and appreciate their culture as this may influence their cosmetic choice. In every rhinoplasty patient their nose must be in harmony with their facial appearance and ethnicity. My aims are always to create natural -looking noses.
It has been said that rhinoplasty is easy to perform but that very difficult to achieve good results with. It has also been said that rhinoplasty is the most difficult of all the facial cosmetic operations.
Whilst modern rhinoplasty is complex, it makes sense to keep things simple when possible. For me this means being wise. I listen very carefully to my patients and take great note of what bothers them most. When asked for advice I may suggest that we concentrate only on what their main concern is and really get this right. I may recommend that a less important area that would require complex surgery with higher risk is left alone. Some of these rhinoplasties may be for already attractive noses that we are aiming to make beautiful. This finesse rhinoplasty is very demanding even though the changes are small. They must be spot on.
I think the risks of permanent fillers in the face, particularly the nose carry too much risk. Temporary fillers of hyaluronic acid can disguise a bump by plumping up the bridge, either side of the bump.
The injections need to be repeated approximately every year. Fillers in the nose carry risks of blocking arteries which can lead to bad scarring due to skin necrosis which is like frostbite. Blindness can also occur. These risks are higher in patients who have had secondary rhinoplasty. My preference is for surgical rhinoplasty.
If you are considering a cosmetic rhinoplasty or have any questions regarding the rhinoplasty procedure then get in touch with us on: 020 7118 3553 for our Harley Street clinic, or 01483 573 850 for our Guildford clinic.
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