Nasal Grafts in Rhinoplasty

"A woman undergoes the final step of her nasal grafts during rhinoplasty"Many a patient when going in for a first nose job or a revision rhinoplasty has asked about nasal grafts.

Because the nose is three-dimensional, it requires internal support in various areas. Some supports can come from synthetic materials like Silicone or Gortex. But, in most cases, your body’s own cartilage taken from the septum, (the thin wall separating your two nostrils) the ear or the ribs are best.

Structural grafts are used for support — as in a pinched tip – or when a bridge is too thin and affecting the patient’s breathing. Contour grafts help make the outside of the nose smoother or to change the shape of the nasal tip.

Cartilage donations are carefully shaped and almost always very small. The grafts replace weakened places in the nose or replaces cartilage that has been damaged or taken out in previous nasal surgeries. In other cases, cartilage donations can be used to build up a small nose or a nose that has a flattened bridge, something that is common to many ethnic rhinoplasties.

Other types of nasal grafts include:

  • Shield grafts: projects and defines the nasal tip
  • Spreader  “   : help make the nose wider, improve breathing and gets rid of a pinched nose look
  • Columellar strut: supports and straightens a nasal tip. Also used to increase projection, or how far a nose sticks out from the face
  • Alar rim graft: helps stop pinched nostrils and improves nostril shape
  • Dorsal onlay graft: repairs the scooped out nose or the nose in which too much tissue was removed in prior surgery

There are other cases  in which a nasal graft can’t help.

For instance, when a nose is severley twisted, a procedure known as Osteotomy is used; a nasal bone is shortened, lengthened or changed in alignment to the nasal pyramid so the nosse can be rebuilt to allow for healthy breathing and to be a more attractive, natural nose for that patient.

But any graft placement requires a Master Surgeon who has spent decades operating on noses and then watching how they heal over time to know what size graft is needed and where.

After Rhinoplasty: When to Call the Doc Back

"A handsome, friendly doctor takes a phone call in the clnic"

May I Help You?

After rhinoplasty, many patients have a situation in which they are not sure if they should phone their surgeon. They don’t want to be a pest and phone for nothing, but what if something serious is going on?

Our own personal policy is to give patients our home and cell phones with instructions to call anytime questions pop up after surgery. Better to make a call for nothing than take a chance!

If you’ve selected a board-certified cosmetic plastic surgeon, don’t worry. He or she has seen every post-surgical complication you can imagine, including some in which patients resumed their intimate lives too soon, raising their blood pressure too much and causing some otherwise unnecessary bleeding.

In cosmetic surgery, the usual, typical complications besides bleeding include:

  • Infections
  • A solid swelling of clotted blood just under the skin (medically, a Hematoma)
  • A small pool of watery blood right under the skin, medically known as a Seroma
  • Very, very rarely, an allergic response to anesthesia

The bleeding we mention above is not a spurting or gushing, but usually just a little trickle seeping under the bandages.

Virtually all plastic surgeons provide a handout sheet on signs to watch for after surgery. Be sure and read them all.

As for infections: that is the reason your surgeon wants to see the morning after surgery. Best to jump on infections ASAP. The red warning flag – and an excellent reason to call your surgeon — is red or sore skin near an incision.

Some face lift, neck lift or other patients may notice some numbness in the treatment area. That happens when minor nerve endings just under the skin are severed. But sensation returns to normal in several to four months.

For rhinoplasty, most of the motivation for patients phoning their surgeon is nose bleeds. We’ve complied a list of seven handy tips for handling post-rhinoplasty or internal nose surgery nosebleeds, if any.

Protective guards come off nose job patients in four to six days.

If you have had what nose surgeons call functional nose surgery, that is, surgery for a deviated septum or turbinate reduction surgery you will be back in the office four to six days to take out the Kotler Nasal Airway and the medication-laced tampon which helps your nose heal immensely.

It’s a painless, easy procedure.

Watch a video in which a Kotler Nasal Airway is removed from a patient’s nose.

Deviated Septum – Readers’ Top Questions

"A lovely woman tries to see her septum in a hand mirror"

Is My Septum Straight?

Many nose job patients are surprised to discover the very middle of their noses – the septum – can present problems in how your nose looks and how it passes air on to the lungs.

You may already know the septum, a thin wall of bone and cartilage, divides the two nostrils, sitting in the middle of the nose. But knock the septum one way or another a tad too much and you may problems like constant nasal congestion, frequent sinus trouble and more.

Q: What are the signs of a perforated septum?

A: Signs of a perforation, or hole, in the septum may be obstruction in the upper nose, scabs or bleeding. Hearing whistling while breathing is a sure sign of a septum hole. For only nasal congestion, try a nasal saline spray and bedroom vaporizer.

Q: What if I do have a hole in my septum?

A: You may not hear whistling from a small hole. But a medium-size perforation causes bleeding and crusting while larger holes can block the breathing channel through the nose.  When ignored, the bigger holes can lead to collapse of the nasal bridge, a condition known as saddle nose.

(Read more about saddle nose.)

Q: Can I push my deviated septum back on my own to where it should be?

A: Just after a fracture of the septum, you could, but it would hurt tremendously. Plus, the risk of bleeding and bruising are present. After a few days, the septum heals in its broken position, meaning you can’t move it back by any method except surgery. Whatever the case, if your ability to breathe and function well are important, let an experienced nasal surgeon handle new and old septum fractures. Surgery to restore a septum to the middle of the nose is known as septoplasty.

Q:  What causes a hole in the septum besides cocaine?

A: The typical causes of septum perforation include intranasal cocaine abuse (“snorting”), blows to the nose in contact sports, fistfights, past nasal surgery, including nose jobs (rhinoplasty) not done well, auto wrecks and other trauma. Some people are just born with bent, twisted or crooked septums. A hole in the septum is repaired with a small plug made of silicone during nose surgery.

If you suffer from allergies, a nasal spray or antihistamines may help. Plus, the surgical repair of a deviated septum may – or may not – improve snoring.

Q: What is deviated septum surgery?

A: Read about deviated septum surgery including what happens before, after and during surgery.

Rhinoplasty Revision: Top 5 Reasons to Choose BevHills

"A lighted Beverly Hills city sign is shown on a lawn at dusk"With America leading the world in the total number of first nose jobs – 242,000 in 2012, says the American Society of Plastic Surgeons (ASPS) – it follows that a fair number of those rhinoplasty procedures unfortunately result in unhappy patients.

Sometimes, Mother Nature is at fault and the nose doesn’t heal as expected. In some cases, the surgery was done by a young, unqualified or inexperienced surgeon. In other cases, the really difficult part of the surgery like – refinement of the nasal tip — is lackluster.

Whatever the reason, as many as one-fifth to one-quarter of first rhinoplasty patients start the process over, looking for a Master rhinoplasty surgeon to make the nose look attractive and fit the patient’s face and profile via a rhinoplasty revision.

But why come to Beverly Hills? Sure, it’s known as the globe’s Mecca for all cosmetic plastic surgery  procedures, but that must make it unaffordable, right? Not necessarily. A skill set exists in Beverly Hills not found in other U.S. locations.

So what are the top five reasons for journeying to Beverly Hills for a second rhinoplasty?

  1. Unhappy experiences with first nose jobs. Beverly Hills surgeons specialize in certain procedures – like revision rhinoplasty – and do the same few procedures for decades. Yet the costs of plastic surgery are affordable, thanks to competition among many, many specialists in one place.
  2. Unhappy nose job patients now know nose surgery is far more difficult and want surgeons who concentrate on the nose. You could do pre-surgery consultations in one Beverly Hills building for a week.
  3. Beverly Hills is a dedicated travel location, with a wide selection of hotels and even professional plastic surgery recovery hide-a-ways with nursing staff and rides to and from a surgeon’s office. (Learn more about cosmetic plastic surgery for patients in states other than California and abroad.)
  4. Beverly Hills is only 20 minutes away from the Los Angeles airport (LAX.) Some patients include the kids on the trip, making it a short vacation. After several days, virtually all patients are able to be out and about to world-class museums, hitting top spots like the Norton Simon Museum, world-class beaches, fine restaurants and top theaters offerings.
  5. Consider permanent, non-surgical rhinoplasty. While many cosmetic plastic surgeons offer the procedure, the vast majority use facial fillers that dissolve within about one year. But only in Beverly Hills can you often repair a botched nose job permanently without surgery.(Read more about permanent, non-surgical rhinoplasty.)

Nose Jobs – with Your Own Fat

"A syringe approaches the nose of a lovely womanA leading trend, non-surgical cosmetic surgery is huge in rejuvenation surgery, according to a new report released by the American Society of Plastic Surgeons (ASPS.)

With an incredible 5.7 million Botox treatments leading the way, annual statistics reveal that about 90 percent of all cosmetic surgery was minimally invasive cosmetic treatments like Juvederm for facial injectables.

Surely, cost is a driving force; while the price of an average invasive surgery runs well over several thousand dollars, many non-surgical procedures are closer to several hundred.

The second most performed cosmetic surgery in 2011 was nose reshaping. According to 1,286 RealSelf.com patient reviews, Rhinoplasty averages about $6,000 nationwide. But a non-surgical nose job – done via syringes only – is pegged at a U.S. average of seven hundred.

Eighty-one percent of surgical rhinoplasty patients checked the “worth it” box while 88 percent of 44 reviewers did the same for non-surgical rhinoplasty. One caveat: non-surgical rhinoplasty is only for depressions and other marks on the outside of the nose. (Continued below.)

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In the photo below and left, note the long, disfiguring groove on the patient’s left side of her nose. The right photo shows the results after permanent, non-surgical rhinoplasty. (Photo, Robert Kotler, M.D.)

"A lovely young woman tilts her head to show the results of nose surgery"

 

 

 

 

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Now, several plastic surgeons, writing in the professional journal, Plastic & Reconstructive Surgery report on a study of 59 patients who had surgery and nose reshaping by injecting the patient’s own fat cells. But 12 had only non-surgical rhinoplasty, injecting fat into nasal tips, bridges and bases. Some had fat injected into the forehead, making the nose look better by comparison.

(Read more about non-surgical rhinoplasty via fat grafting.)

Fat has been added to the face before. It starts with liposuction, filtration, preparation and then injection. But once injected, it is there to stay and cannot be removed. But the unknown item over time is that donated fat cells can grow.

If so, where does that leave balance and symmetry? What if only one side of the nose grows? Additionally, clinical experience has shown that fat “takes” better in the young. However, older people usually need the help.

All the while, we have permanent, non-surgical rhinoplasty with a 50-year record of safety and science that can do the same for a nose with marks, grooves or divots. (Read about the science of permanent injection rhinoplasty.)

A big plus for this option: it can also be tested before going permanent. Currently, we inject saline (sterilized salt water) into the marks on the nose for patients to see. The saline absorbs  back into the body shortly, but not before we take before and after photos.

Our patients take on permanent, non-surgical rhinoplasty? They love it with more requesting it.

Nose Job Surgery Day – Not a Time to talk $$

"A surgeon stuffs money into the pocket of his surgical gown"Yesterday, while performing nasal septoplasty and turbinate surgery, a discussion popped up with a circulating nurse about money, patients and the day of surgery.

(Quick aside: read what septoplasty is; learn more about turbinate reduction surgery.)

Where were we? Oh yeah, cash on the barrel head and a nasal surgery patient about to be put on the table. (Continued below.)

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The three panel picture below shows an actual before rhinoplasty & chin augmentation photo (left), the computer predicted picture (middle) and the actual after surgery result (right.) The nose surgery was done entirely within the nose. (Robert Kotler, MD, photo)

"A three-panel picture shows the patient before nose and chin surgery, then a computer predicted picture and then the actual after surgery picture"

 

 

 

 

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The nurse had worked at a surgery facility where the anesthesiologist and the surgery center staff collected all charges due from the patient on the same day as the surgery.

Having watched some 4,000 nasal surgery patients arrived for surgery, lo, these many decades, it struck us that the day of surgery is laden with enough anxiety and unsettling concerns for patients…without discussing finances.

When you’re about to be put asleep with your life’s vital functions put in the hands of others, why add to the worry and discuss money, fish around for a checkbook or a credit card, sign paperwork and otherwise pony up for surgery?

Could not a better time be found? Actually, we see that as being inconsiderate toward the patient.

Our cosmetic surgery practice — and do many others — hold these financial discussions and transactions well ahead of time over desks and in offices, not in an O.R.

On the day of surgery, the only matters being discussed should be the surgeon asking the plastic surgery patient if he or she has any questions or concerns before going into surgery.

We think our first obligation on the day of surgery is to relieve patient anxiety. For that reason, our patients receive a 10 milligram dose of Valium which is an excellent tranquilizer. The patient can take it with a little sip of water or let it dissolve under the tongue. Within twenty to thirty minutes, the cosmetic surgery patient is so relaxed he or she appears to have very few cares in the world.

And that’s the way it should be. The cares have shifted onto our shoulders while our attention is directed to making the patient comfortable before and after surgery. Of course, once the actual surgery starts, that job becomes the responsibility of the anesthesiologist.

Anybody’s day of surgery should be a time in which the only focus is on the patient’s well-being and the success of the surgery.

At that point, it’s not about dollars, billing or credit cards.

Rhinoplasty on the African-American Nose

"A smiling back woman crosses her arms while looking at the camera"Talk to any rhinoplasty surgeon about African-American nose jobs and you’ll quickly learn that black patients start a conversation about ethnic rhinoplasty surgery with what they don’t want. First off surgeons hear:  “Doctor, I do NOT want a Michael Jackson nose.” Black women might flag the nose of Latoya Jackson as a no-go.

And who could blame them? The goal for any rhinoplasty surgeon is a natural-looking nose that fits the face of its owner and blends with the profile. Additionally, all ethnic patients want to keep their basic racial characteristics. For ethnic rhinoplasty, one size does not fit all. (Continued below.)

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The lovely woman below, left, had a nose that was too wide for her otherwise flawless face. The nasal bones and all cartilage in the nose were narrowed while her nostrils were slimmed without visible scars. Three months after surgery, right, she has a nose that is proportional to her face. (Robert Kotler, MD photo.)

"A lovely black woman shows the result of ethnic rhinoplasty in before and after pictures"

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(Continued) While every nose is a unique case, many black men and women ask for:

  • Narrowing of the nasal bridge
  • Refinement of the tip
  • An alarplasty to narrow the nostrils

To do that, the rhinoplasty surgeon makes surgical adjustments to the tip of the nose, the bridge of the nose (nasal dorsum), the width of the nose and the base of the nose. All the while, the cosmetic plastic surgeon must keep in mind what happens to a nose over a year as it heals. That, in turn, requires many years’ experience following thousands of healing noses as they take their final shape.

Surgically reducing flared nostrils is done by removing a wedge or crescent- shaped section from both nostrils without leaving noticeable scars on the nose’s outside . Demanding? Absolutely. Pleasing for the patient if done correctly? Completely.

Nose reshaping requires a huge amount of surgeon artistic talent. Why? The human nose, a three-dimensional structure, must be balanced from front and side views. If all those elements –surgery, artistic balance, healing — weren’t demanding enough, the inside of the nose must function well to pass air to the lungs.

Other nasal structures must also be taken into account, too. The thickness of nose skin, the natural strength of the patient’s cartilage and bone must be judged.

Oh, one other thing: the experienced rhinoplasty surgeon, who uses a surgical method known as the closed technique, must do all this in a space that accommodates one human finger.

So, selecting a nasal surgeon with deep experience on ethnic noses is critical. You can do that by studying a surgeon’s before and after pictures while making sure he is board-certified in head and neck surgery, a specialty known as Otolargyngology.

Rhinoplasty & Nasal Surgery for Pitcher – for Free!

"Mets pitch Jon Niese is shown at bat before his nose job"

Before Rhinoplasty

When two Big League baseball players were chatting in a locker room in the summer of 2011, one heard his pal saying he would like to have a rhinoplasty along with correction of a deviated septum.

A septum is the thin wall of cartilage separating the nostrils. And we’re talking really thin – as in egg shell thin. Sometimes, people are:

  •    Born with a deviated septum
  •    Injured
  • Hit in the face with a baseball
  • Dive nose first into a base

Met pitcher and Lefty Jonathon Niese had his site set on a cosmetic rhinoplasty that included fixing his crooked septum. Trouble is, if the septum is bent out of shape that affects the breathing. And you know how it is with sports stars – they just gotta breath right.

But Niese seemed to be getting along O.K. and said he would get around to the nasal surgery someday. The cost of the rhinoplasty and septum repair would be about 10 grand, according to a New York plastic surgeon.

“Oh yeah” says Carlos Beltran. “What if it was already paid for? Would you do it then?”

“Of course,” says Niese.

So teammate Beltran pipes up right out of the blue and says to Niese: “Well then, go ahead and get the nose job. I’ll spring for it.” Beltran and Niese were with the Mets from 2008 to 2011.

And then a wrinkle crops up. Beltran gets traded to the St. Louis Cardinals.

Meanwhile, the New York papers get involved and report that Beltran recommended the plastic surgery, a supposition Beltran — who doesn’t know beans about cosmetic plastic surgery — denies.

Says Beltran, fully aware his pal is with another team: “I will have a check ready when the teams met.”

Niese had the nasal surgery in October, 2011, now notices a major league improvement in his breathing (as well as the appearance of his new nose, below!) and looks forward to receiving a  $10,000 check from Beltran who has announced his check is as good as his word.

Sometime after the national anthem is played on March 1, the two teams will face off during Spring training in Jupiter, Florida and Beltran will fork over the nose job money in person.

How’s that for a new high sportsmanship?

"Jon Niese is shown after his rhinoplasty"

After Rhinoplasty

 

Nose Surgery Can Mean Better CPAP Breathing

"Two medical professionals give a lovely young woman a nasal exam"

Nasal Exam

Regular readers of our blog posts already know a CPAP is a face mask and machine for people who snore, often due to problems inside the nose that block healthy breathing.

But, as a curious cosmetic plastic surgeon, we also scan forums and bulletin boards for news about CPAP (which stands for “continuous positive air pressure,” a fancy way of saying “forcing air into your lungs through your nose”.)

So we note some users have found that nasal surgery makes their CPAP work even better.

The basic start of all this is raw snoring….ear-splitting, freight train decibel, nocturnal snoring that makes the bedroom curtains flap in the breeze and can be heard downstairs, if not the next house.  Pity the sleep-robbed mates of snorers.

Snoring can have many causes but some of the most common are:

  • A deviated septum
  • Swollen turbinates, structures higher up in the nose

A septum is the thin wall of cartilage that separates your two nostrils. When bent, twisted or otherwise deformed, they can block the breathing channels in the nose.

Turbinates warm and humidify the air you breathe. But they often react to allergies and other conditions by swelling, again blocking healthy, quiet breathing.

Curious about the numbers of healthy and blocked breathers, The University of Washington’s Sleep Disorders Center studied 306 CPAP users for two years. They wanted to find why some did not wear the CPAP mask regularly. (Read more about nose surgery and CPAP use.)

After exams, 108 patients showed abnormal nasal exams and were also the same group who did not use the mask correctly, if at all. The study authors concluded patients with abnormal nasal exams had decreased CPAP use and tolerance.

Concluded the authors: why not treat nasal conditions before prescribing a CPAP?

Yet another study at the Stanford Sleep Disorders and Research Center in Palo Alto, California, found that turbinate treatments, when appropriate, appear to benefit nasal obstruction and ease the breathing of CPAP users.

But before you say “yes” to a CPAP, ask yourself if any medical professional has actually looked up into your nose to see and diagnose the state of your nose and if its internal architecture allows for easy, quiet breathing.

Perhaps that would be the best first step possible!

Nasal Surgery & CPAP Machines

"A bald man is shown sleeping in his CPAP mask"

CPAP User Sleeping

We recently traveled by air and were herded through airport security with some basic items piled into those cafeteria-like bus boy carts for passage through inspection, including:

  • Our shoes
  • Pants that drooped to our knees due to no belt
  • Our delicate, pricey laptop

We also noticed that quite a few men, who appeared over 50, had taken apart their CPAP (Continuous Positive Air Pressure) machines for inspection.

A CPAP is a small pump-like machine and face mask, used while sleeping. A CPAP forces air down the nose through a strap-on mask and into the lungs of a snoring person. Usually, a diagnosis of sleep apnea goes hand-in-hand.

Sleep apnea causes breathing to stop altogether and the person to wake momentarily.

Result? The CPAP puts plenty of oxygen into lungs and vital organs, allowing more rest. Bonus result: wives love the quiet that comes with no more snoring….once they get used to the whispering of the CPAP.

Thus, many who use CPAP machines have a blocked nose….. but don’t know it. The question is whether or not their blocked nose can be surgically repaired.

Many conditions may also cause snoring and sleep apnea, including:

  • A thick or short neck
  • An upper palate and or uvula (that worm-like extension that hangs down into the throat, above the back of the tongue) that needs reduction
  • An unrepaired broken nose
  • Deviated nasal septum, possibly from injury
  • Enlarged nasal turbinates, sometimes the result of nasal allergies

After having seen over 4,000 patients for nasal surgery, we’ve noticed that many structures inside the nose that can cause:

  • Snoring
  • Blocked sinuses with a head cold or allergy attack
  • Bonafide sinus infection, a serious condition,  requiring antibiotics and sometimes surgical intervention

One patient complained of loud snoring; when we looked into his nose and throat, we saw a huge uvula, hanging way down into the lower throat, swinging back and forth with each breath.

Result? Removing the uvula quelled the snoring. (Don’t worry, the uvula has no function; you can do nicely without it.)

Several key structures inside the nose need to be evaluated.

  • The septum, the thin, vertical wall separating the two nasal passages
  • The turbinates, shelf-like structures that warm, humidify and filter the incoming air.

If the septum has been broken and is crooked, it blocks incoming air.

The turbinates and nasal lining can swell due to cold viruses or allergies and contribute to reduced air flow through the nose.

A relatively short nasal procedure – done with or without cosmetic rhinoplasty – can:

  • Correct breathing
  • Stop the sleep apnea and
  • Remove the need for a CPAP

Major hint: if your nose looks bent or crooked on the outside, it is also probably crooked on the inside as well. And not likely to allow normal breathing.

Without having to lug around that CPAP machine, just imagine how nice it would be to have one hand free to hold up your drooping trousers while going through airport security!