Dr. Paul Nassif: Today we’re performing a revision ethnic rhinoplasty where we’re removing a silicone dorsal implant and reconstructing the patient’s nose with autologous cartilage. We’ll also be taking deep temporalis fascia, but our initial procedure today will be the removal of costal cartilage. We’re making a three centimeter incision on the right inframammary crease. We’re using a Bovie to divide the pec muscles and any intercostal muscles, and we’re just overriding the perichondrium of the rib. This is the boney part of the rib, and here’s the cartilaginous portion of the rib.

I’m making H incisions into the rib perichondrium, and they’re about a centimeter apart.

We use the Chamberlain elevator to dissect the perichondrium from the superior border of the rib.

This is a very important part of the procedure, because you want to start off in the right plane, and being in the right plane for rib harvest is, in my mind, the most important part of the procedure, because it prevents you from getting into pleura, into the chest. It just makes the whole dissection a lot easier.

Can I have the Woodson, please?

To me, I think the sharp end of the Woodson elevator is a great instrument to use to get in the right plane. Sometimes the caudal elevator or any freer of your choosing, but this is one of the portions of the procedure where you have to find what works best for each different surgeon. This is a Doyen retractor. I’m going to use this to hug underneath the rib, so the joiner is underneath the rib, in between the perichondrium, so we know we’re in a safe place, and I’m gently dissecting back and forth right up to the bony cartilaginous junction.

All right. Give me a 15 blade. I’m going to cut through the rib. This piece will be small, but I want to gently go and take the rib. From there, we get to take some of the other, the rib that’s attached. Okay, so this is the next rib right over here, and I’m gently using the Doyen to separate or to cut into the caudal border of actually into the rib. Can I have a 15 blade? I’m going to free up the superior border and start to cut some of the rib.

And we’re going to want to get positive pressure in a minute. We want to check. Do a Valsalva to make sure that there’s no air escaping. So we’re up to 30 centimeters of pressure, 20, 25, 30, 30 centimeters of water pressure. No leak. That’s great. That’s good news. We don’t want any sharp edges. If we do, we take a Rongeur and just gently shave off the edges. To prevent depressions in the contour along the chest, it’s very important to try and close the perichondrium of the rib. We’ll also spray some Marcaine in the area and PRP into the wound. The perichondrium of the rib will be closed first, either with 3.0 PDS or 3.0 monocryl. The next thing will be the pectro clavicular fascia, and we’ll also grab a little bite of the muscle, and we’ll also use 3.0 monocryl for this, followed by a subcutaneous layer of closure, then a dermal closure, and then we like using a 4.0 moncryl intradermal layer.

All right, next procedure is harvest the deep temporalis fascia. We make a two and a half centimeter incision and then bluntly dissect down to the deep temporalis fascia. We’ll hydrodissect in between the deep temporalis fascia and the deep temporalis muscle. We’ll score the fascia with a 15 blade, then harvest it bluntly. We want to make sure that we remove a significant portion of the fascia, since this will be used for dorsal augmentation. Finally, we close the incision with staples.

Previously, Jennifer had a closed rhinoplasty with placement of a silicone nasal implant, and we’re just being very gentle to remove the implant. The other thing that I do a little bit different is the standard columellar incision is more of a “W” rather than a “V.” One of our goals is to keep the skin flap as thick as possible, and we’re doing a minimal access open rhinoplasty where the marginal incision extends for approximately six to seven millimeters, and we’re going to see if this was a complete L-shaped silicone strut, which is what I feel it is. That will mean that once we take it out, there’ll be no support to the rest of the nose.

This pocket in the columellar is perfect, because I’m going to put plumping grafts in here. In addition, we’re going to use PDS plate and put a combined septal extension graft columellar strut. There is a small capsule on the implant. We’ll try to leave that in place. The good thing about the implant is that it’s stretched out the nasal skin, so when we put in our cartilage grafting and we structure the nose, we’ll already have sufficient length to reconstruct the nose.

Here is the L-shaped silicone implant. The pocket where the silicone implant was and the remaining capsule makes it easier for us to place our diced cartilage fascia burrito along the dorsum for dorsal augmentation. We want to dissect sharply the region where we’re going to place the septal extension and plumping grafts.

Jennifer has a deviated septum with a spur going to the left, obstructing approximately 80 percent of the airway, and the maximal apex of the spur is impinging on the inferior turbinate on the left. So we are going to have to do a septoplasty. We’re removing deviated septal bone now. Through the open rhinoplasty approach, we performed a septoplasty where we removed the bony septum, maxillary crest, and the vomer, which was creating the spur. In addition, there’s a small piece of cartilage along the floor that we removed. There is a compensatory hypertrophic turbinate on the right, since the septum was deviated to the left. We initially medialize the turbinates and then lateralize them, use the Ofrick in addition to the Boise elevator to lateralize and fracture the bones. Now, in this situation, we are going to do some bipolar cautery on the head of the right inferior turbinate. The only thing I don’t like about cauterization of the turbinates is the crust can last for weeks.

Usually the patients with dorsal implants come in for removal when either the implant is deviated or crooked or it’s about to extrude. In this situation, it was about to extrude, and the initial aspect of the reconstruction is replacement of the length of the nose with the septal extension graft. Here, we’re fixating the septal extension graft or PDS plate, and then end to end fixation to the nasal septum. This will lengthen the nose, give it more support, especially when we rebuild the tip and help re-support the nasal tip with the shield graft.

Usually when we’re performing ethnic rhinoplasty, we need a good amount of cartilage. This situation, we use rib and you see me here taking the remnants of rib cartilage and dicing it into finely diced pieces of cartilage. This will be placed into one cc syringes without the hub on, so we’ll initially use it for plumping grafts, and then we’ll use the remainder to make the dorsal augmentation dice cartilage fascia burrito graft. We use the fine diced cartilage for plumping grafts, and you can see that it’s going through the hub of the syringe, and then we’ll close the medial currab [sounds like 08:23] onto the septal extension graft. We use 5.0 PDS for inter and transdermal sutures for reconstruction of the nasal tip.

The most important part of the ethnic rhinoplasty in regards to tip work is the proper projection and counter rotation. Following the adequate length of the nose using the septal extension graft, we want to place the shield graft. Now if you’ll notice that there’s PDS plate on the back of the shield graft because part of this cartilage was slightly curved. And with that, we use the PDS plate to help strengthen the costal cartilage. We’re going to use multiple 5.0 PDS sutures to fixate the shield graft to the native tip, and we want to make sure that we have at least four to five millimeters of projection of the shield graft above the native domes.

To help nail the dorsum, we perform medial and lateral osteotomies on her taller lateral nasal bones. Here’s the deep temporalis fascia, and we’re going to place it around the implant, and we’re going to make and construct a burrito. We’ll put the fine diced cartilage through a one cc syringe. We’ll inject that into the burrito and then close the entire fascia burrito with 5.0 chromic. For the dorsal reconstruction, we’ll parachute percutaneously the burrito along the nasal dorsum. We’ll place three sutures along the nasal dorsum to help deliver and symmetrize and make sure the implant is straight. And here we are contouring the implant to make sure that it’s in appropriately. To camouflage any sharp edges around the shield graft, we’ll place deep temporalis fascia over the shield graft, and we’ll suture it in place. Meticulous closure of the columellar incision is mandatory, and the best way to do that is by placing a 5.0 PDS subcutaneous suture to prevent any tension along the moon, followed by multiple 6.0 prolene interrupted sutures with small bites of skin.

You want to make sure that the superior flap is inset by about one millimeter to the inferior flap so that, that will accommodate any of the superior flap edema. By performing this, we prevent any type of a step off in swelling along the superior flap. After looking at my profile, I just wanted a little bit more counter rotation and projection; therefore, I’m going to place a bruised onlay graft in the infra-tip lobule.

To prevent visibility of the lateral edges of the shield graft from shrink wrappage , we use these alar rim transition grafts which just about the lateral edge of the shield graft and continue along the edge of the rim. This will help prevent any step offs and give us a smooth transition on the entire alar.

For the final touches of the nose, I’ll use finely diced cartilage to camouflage any irregularities or increase augmentation. We carefully close the marginal incisions, and then I’ll add a little bit of finely diced cartilage along the infra-tip.

The rhinoplasty is complete, and now we’re going to perform alar based reduction. The final procedure is nasal sill incisions. She previously had weir [sounds like 11:45] incisions, and our goal here is to decrease the width of the nasal sills. We use an 11 blade to remove the diamond shape nasal sill incisions which are approximately three millimeters in width, and we’ll close the deep tissue with 5.0 monocryl, and then we’ll use a combination of 6.0 prolene and 6.0 fast gut along the nasal sills.

The surgery went exactly as planned, and I’m sure that Jennifer is going to be thrilled with the results. And here’s some of the postoperative photos which show the initial phase of healing, and these photos demonstrate before and four month following the surgery, which still show swelling of the nose as it’s healing.

The post Dr. Nassif Performs an Ethnic Rhinoplasty appeared first on Rhinoplasty Specialist.

Image courtesy of Modernmom.com

“I hate my nose and want my nose to be perfect, like Jessica Alba’s. Can I get that with a nose job?”

The myth of perfect beauty

Tolstoy wrote in Anna Karenina, “If you look for perfection, you’ll never be content.”

When it comes to the human face, beauty exists without perfect symmetry.  Every face and nose has asymmetries and imperfections, no matter how attractive.

When it comes to rhinoplasty, it’s important for both the patient and the surgeon to realize that it is a surgery of improvement, not of perfection.  For the patient, this is the key to having a successful outcome with surgery – having realistic, attainable expectations.  Can a nose that looks like Owen Wilson’s be turned into a nose that looks like Natalie Portman’s with rhinoplasty?  No.  Could it be made straighter and perhaps more attractive?  Yes.  Understanding the limitations of surgery is critical to having a great outcome.  That being said, the surgeon then assumes the responsibility for achieving the maximum possible result.

The Risks and Rewards of Rhinoplasty

For the surgeon, there is a crucial interplay between risk and reward during surgery.  In rhinoplasty this has very profound consequences, since by its very nature, healing is somewhat unpredictable.  Techniques that provide consistent, reproducible results often prove superior to others that may produce dramatic results at times, but utterly unsatisfactory ones during others.  One area this comes to play is the selection of graft materials for rhinoplasty.  Synthetic implants have become very popular because of their ease of use for the surgeon and their dramatic results.

However, they carry a risk of infection, migration, and extrusion (thinning out and even ulcerating through the skin) which is much higher than autologous grafts (tissue from your own body).  Dr. Nassif and Dr. Yoo exclusively use autologous grafts to provide their Beverly Hills rhinoplasty patients with the safest and long-lasting, beautiful outcomes.

Nose job before and after pictures of a Hispanic woman. Dr. Paul Nassif performed her rhinoplasty in his Beverly Hills office.

Should you a nose job?

Are you unhappy with the appearance of your nose?  Call today to set up a free consultation and find out if we can help.

The post Beverly Hills Nose Jobs and Perfection appeared first on Rhinoplasty Specialist.