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Learning The Procedure

Presented by Dr. Philip Young MD of Seattle Rhinoplasty Expert and Aesthetic Facial Body Plastic Surgery:

We want you to learn all you can about your rhinoplasty procedure. Here on this Learning the Procedure page, we will go over the procedure from start to finish and this will give you a better idea about what Rhinoplasty is all about.

Transcolumellar incision open approach

In the picture above: the green wavy line is the inverted gull wing incision that is used commonly for the rhinoplasty incision's Open Approach. From this small incision, the whole nose can be exposed. The rest of the incisions are in the inside of the nostril. When this incision between the nostrils is not used, we call that the closed approach. With the closed approach, everything is done through the marginal incisions that are located on the inside that follow the inferior edge of the lower lateral cartilages (the lower lateral cartilages are defined and shown below). For the open approach, once this is completed this is the view below:

Open Rhinoplasty Approach

Below are the lower lateral cartilages outlined in blue. They are responsible for how the tips look and the appearance of the lower third of the nose. For ease of discussion and planning treatment, the nose is broken into thirds.

Open Rhinoplasty Lower Lateral Cartilages

Below is another picture of the open approach after the transcolumellar incision is opened and the incision is extended next to the margin of the nostrils (on the inside of the nostrils).

Open Approach Oblique View

Working on the Septum and Bridge: After the nose is opened, usually we like to find the septum and expose it through the open approach. In the above pictures, we find a path between the lower lateral cartilages labeled in blue above to find the septum. We expose the septum to prepare it allow us to first take down a Prominent Nasal Bridge. If you are not aware, a large part of your nasal hump is formed by the cartilage of the middle third of the nose. Exposing the septum allows the surgeon to take down the septum to lower the bridge. This is in the case of a Reduction Rhinoplasty where the person has a large bridge. In many Asian and African American noses, rhinoplasty entails raising the bridge and the principles of Augmentation Rhinoplasty. In this case, we still like to open up the septum so that we can harvest tissue for augmentation purposes. After the bridge is taken or if it is not taken down and we are just harvesting septal cartilage, we then take what we can for cartilage grafting later. Below is a picture of the open approach showing the side of the nose and the area outlined by the green where the Septal | Septum Harvest will take place in the midline septum.

Septum | Septal Harvest

The Function and Role of the Upper Laterals: With the reduction of the septum, the Upper Laterals may need to be reduced to allow the proper reduction. This part of the nose is responsible for the middle part of your nose. Reducing or shortening the height of the upper laterals can help narrow the middle part of the nose. The upper laterals and how they relate to the septum is important for the airway and in Functional Rhinoplasty. The upper lateral cartilages and they association with the septum at the portion next to the nostrils is called the Internal Nasal Valve. While the External Nasal Valve are the nostrils themselves. These anatomic points care responsible for 50% and 10% of the airway resistance of the entire respiratory tract. Talk about Important! How your surgeon treats this area is very important for your future breathing. The upper laterals are outlined in green below:

Upper Lateral Cartilages

Caudal Septum and Tip Refinement: After the hump reduction and septal harvest with the reduction of the upper laterals if needed, we then approach the tip. Sometimes related to the tip, there may be a need to change the Caudal Septum or the part of the septum related to the bottom of the nose and the area between the nostrils. By change the caudal septum, you can lengthen or shorten the nose. Also related to the caudal septum and the relation of this part of the anatomy to the apperance of the tip, you can alter the caudal septum to change the rotation or derotation of the tip. By taking the part of the caudal septum away from the face you are likely to Rotate the Tip upward. By reducing the part of the septum closer to the face, you are likely to Derotate the Tip. Reducing all of the septum will shorten the nose. Below is a picture showing you where the caudal and dorsal septum are located:

Caudal and Dorsal Septum of Nose

More on Refining the Tip. This is perhaps the most complicated part of the Rhinoplasty. The tip is made up of 3 parts: Medial, Middle (intermediate), and Lateral Crus or Crura of the Lower Lateral Cartilages. Below the Medial Crura is delineated by Blue. The Intermediate or Middle Crura is the Yellow portion. The Lateral Crura is in Green.

Medial, Middle, Lateral Crura

Below is a picture showing the location of the domal area of the tips and the connection between the lateral and middle crura:

Tip | Domal Area of Nose

The Transdomal Stitch: Shaping these segments will change the appearance of your tip. The connection of the lateral cartilage to the middle cartilage is where the domes of the tip are located. This is what makes a big part of where the tip is seen. This is where the light reflex is located and created. The bend that is inferior and lateral where these segments connect to each other determines how wide the tip is. Also, the width of the connection itself (the Domal Tip) within each side also contributes to the width of the tip. Sharpening the connection between lateral and medial helps to narrow the tip and it is created by the Transdomal Stitch. Below the blue shows where the Transdomal Stitch is placed. Although you can't see it, there are transdomal stitches in this picture already. They are clear and you can't see them. We use clear sutures in the real procedure. The transdomal stitch has created a sharper bend in the connection between the lateral and intermediate | middle crura (or the dome of the tip):

Transdomal Stitch

Below is yet another view of a transdomal stitch from front view:

Transdomal Stitch Front View

The Interdomal Stitch: while the transdomal stitches make the domes smaller and hence has an effect on the size of the tip, this is only half the story. The interdomal stitches bring these new sharper dome tips closer together and make the whole tip smaller. This stitch connects together the superior and medial part of the dome | domal tip area. Below is a picture of where the interdomal stitch is placed.

Interdomal Stitch Frontal View

Below is yet another view from the top of the interdomal stitch that is delineated in blue:

Interdomal Stitch View From Above

Tip Sutures: Below is a view of the tip after having the transdomal and interdomal stitches placed. The sutures are clear and you may not see them but you can see the effect they create. As you can see, the domes are more narrow, the connection of the lateral crus with the intermediate | middle crus is made sharper and smaller with the trandomal stitch. But this is just one half the story as we have alluded to. The domes may be more refined but they can still be more apart than we would like and the tip still large. The interdomal stitch brings them together and further narrows the tip. These two stitches are the most important tip refinement techinques for the rhinoplasty surgeon:

tip cartilage sutures