Cosmetic Surgery Los Angeles

According to Dr. Nassif, sometimes, I will look at the nose and decide to use alar rim grafts in a primary rhinoplasty. This is because when I do nasal tip work, the nostrils will start to collapse in more after surgery.

I can look at the nose beforehand and tell that this might occur. The alar graft is used versus lateral crura strut grafts, especially in patients were there is vertically oriented lower lateral cartilage and where the tip cartilage is going in a more vertical direction.

In very select, simple, small cases, I will do a closed rhinoplasty. In most cases I will do an open rhinoplasty procedure.

When we do an open rhinoplasty, we are losing some of the natural support of the nose. Therefore, we have to reconstruct the nose so it won’t droop and the tip won’t drop in the future. So in many of my primary rhinoplasties, we add spreader grafts. I’d say about 90 percent of the time, I will put in a columellar strut to keep the nasal tip support up and projected.

That is what looks nice in a nose, when you can set the nasal tip projection so it looks supported. Then no one can complain that it has fallen after a couple of years. Often this is what happens with a patient looking to have a revision rhinoplaty. They will come in and say, “Well, it looked good for the first year. Then my nose started to collapse and fall.

A lot of patients will ask “Why do you need to make my tip bigger?” Or, some patients may come in with collapsed nostrils. They can’t breathe because they have had too much cartilage removed from the nasal tip. 

According to Dr. Nassif, even in situations when he removed a conservative amount of cartilage and leave the magic number of 7 mm of lower lateral crura, you still could have collapse of the cartilage. The patient will get these deep alar grooves in the nose.  What also occurs is a pinch in the airway, when we place binding sutures to make the tip smaller.

“With some patients, I notice that they have the pre operative signs of weak rims. Sometimes, when I look inside the airways after I put in dome binding sutures, I’ll notice that the lower lateral crura are impinging into the airway. So, I’ll reconstruct that area,” said Dr. Nassif. 

“I’ll take a piece of cartilage, most likely septo cartilage, and make it thin so that it will curve and give us a nice convex type of a graft. We will place that on the under surface or the posterior surface of the existing small remnants of lower lateral cartilage. This will prevent the cartilage from collapsing inwards. Hopefully, it also will prevent you from needing a secondary revision rhinoplasty in the future.”

According to Dr. Nassif, he is against placing a big septo cartilage dorsal onlay graft or even ear or rib cartilage along the whole dorsum. 

“The reason why I don’t use a large graft, especially with the rib cartilage, is that the cartilage will eventually warp even with soaking it in saline. I still have not seen that many good results from patients coming in that have had a dorsal rib graft in the whole or en bloc placed in the nasal dorsum.”

“There are a few doctors that do big septo cartilage dorsal only grafts across the country, but I can only think of one that does an excellent job of using this type of cartilage. In most other hands, I have seen the grafts warp. I have also seen them deviate. There can also be irregularities where septo cartilage can calcify, you just don’t want to put a large graft like this up in the nose.”

When rebuilding a nose during rhinoplasty or revision rhinoplasty it is sometimes necessary to use rib cartilage.

There are many reasons to use rib cartilage.  For example, if we have previously used ear cartilage or if we need composite grafts from the ears,.  A composite graft is where we are taking skin and cartilage in order to lower the nostrils because you can see inside the nose too much.

According to Dr. Nassif, “In rhinoplasty surgeries where rib cartilage is used, I’ll have a doctor come in to harvest rib cartilage while I am working on the nose.  So, as I am working on the nose, or possibly removing ear cartilage or fascia, another doctor is removing a piece of rib cartilage for me.”

“The rib cartilage is removed through a small incision which is minimally noticeable, but it does cause some discomfort after surgery.”

“When I receive the rib cartilage, I’ll soak it in saline for about a half an hour.  That way, if it is going to change shape, I’ll know.  Then, I’ll be able to use whatever piece of cartilage I have for reconstruction.  If the cartilage is curved, I’ll use it for the nasal tip. A piece of the middle aspect of the rib cartilage, which I know will be straight, is great for the middle vault of the nose.  The straight portion also is good for filling in the nasal dorsum if we are going to use the chopped cartilage, versus the columellar strut for the spreader grafts. This is why we need to use rib for these big procedures.”

Spreader grafts are often used in Rhinoplasty and Revision Rhinoplasty to add volume to the middle vault of the nose.

Spreader grafts are pieces of cartilage that lie in between the septum or the dorsal septum and what is the bridge of the nose that is made of cartilage.

When you take down a hump in the cartilaginous dorsum area and fracture the nasal bones, what happens quite frequently in the future – this is not something that happens in the short term we are talking a year, two years, three years - you get an inverted v deformity.

The Inverted V Deformity is where the upper level cartilages collapse inwards and you can see an upside down V in the middle part of the nose.

The placement of spreader grafts in the primary surgery versus in the secondary revision surgery helps replace or lateralize the upper lateral cartilages and give a little more volume and fullness to the middle vault of the nose.

Because that angle always decreases once you remove a hump.  The angle between the dorsal septum and the upper lateral cartilages, moves when you remove portions of both.  When you move the angle of that area, you are making it thinner.  And, thinner is not necessarily great in that area because what is going to happen is that you are going to have a thicker bony dorsum and it is going to pinch the middle and then be wider at the tip.

So it is called a wide, narrow, wide nose and it really should be a nice pyramid where the upper dorsum of the nose, where the bone is, is the thinnest, the middle vault is a little thicker and the nasal tip with the nostrils is the thickest.  That is the most aesthetic view of the nose.

There can be problems using cartilage from the ear in the case of making a columellar strut. The columellar strut sets up the whole base for the nasal tip.  

The strut is a piece of cartilage that lays in between the nasal tip cartilage and the media crura. It goes down toward the anterior nasal spine without touching it.

If the cartilage touches then it can move back and forth, or “Click,” over the nasal spine. You can actually hear the noise and feel it as it is clicking.  In order to avoid the clicking, we will put two pieces of ear cartilage back to back and stitch those together. This is not the preferred method, but it works if we don’t have any septo cartilage or rib cartilage available.

Before we do surgery, we need to determine how much cartilage a patient has available if cartilage grafts will be used to rebuild the nose. 

With our revision rhinoplasty patients, we also look to see if they have had an aggressive septoplasty to determine how much septo cartilage is left inside. We look to see if there is at least 10 to 15 mm of cartilage at the roof of the nose, called the anterior septum, and at the front of the nose where the columella is called the columella or caldul septum.

One of the first areas we’ll assess for cartilage harvesting is a patient’s ears. If the patient needs a complete nasal reconstruction without building up the dorsum or dorsal height, we can use cartilage from both ears, without having to go to rib cartilage. This is assuming that we have no septo cartilage. 

The incision for harvesting ear cartilage, in most scenarios, is behind the ear. The scar heals beautifully, and you do have a cotton bolster on both sides of the ear for the first week which can be a little uncomfortable.

Often, cartilage will be used when rebuilding a nose during rhinoplasty or revision rhinoplasty.

After removing the cartilage, it can be “bruised.” Bruised cartilage is taking a crimper, or what we can a cartilage morselizer, and just gently crushing the aspects of the cartilage. Now this may cause the cartilage to become, in simple words, a heap of scar tissue, but that is fine because we want volume to rebuild the nose.

Bruised cartilage can be used in the lower part of the nose in the case of a saddle nose deformity. The saddle nose deformity is where too much of the septum has been removed or from a large septum perforation. It is common to see this kind of deformity in boxers where there is a saddling right before the tip and below the boney dorsum. 

The lower part of the nose is an area where the skin is thicker and we can put some cartilage, especially ear cartilage, and cover it with fascia. We also use fascia for the dorsum area of the nose.