Current Trends and New Techniques in Rhinoplasty: An Expert Interview With Sherrell J. Aston, MD

Pippa Wysong


October 08, 2009

Editor's Note:

Rhinoplasties are increasingly popular procedures. A complex procedure, the rhinoplasty has in recent years seen changes of opinion in how this surgery should be performed, such as more attention to protecting or enhancing architectural integrity. Medscape's Pippa Wysong spoke to Sherrell J. Aston, MD, who offered his thoughts on the state of the art in rhinoplasty. Dr. Aston is Director and Chairman of the Department of Plastic Surgery at Manhattan Eye, Ear and Throat Hospital in New York, NY. He is also Professor of Plastic Surgery at the New York University School of Medicine, New York, NY, and is certified by the American Board of Surgery (ABS) and the American Board of Plastic Surgery (ABPS).

Medscape: Rhinoplasties are becoming more popular. Why is this, and who is having all of these rhinoplasties?

Dr. Aston: Most rhinoplasties are performed to change the cosmetic appearance of the nose. Most are performed in teenagers and young adults, but increasing numbers have been performed on people ranging from their 30s to their 60s. Breathing problems are frequently corrected during rhinoplasty.

Medscape: Are women still the main patient population for rhinoplasties?

Dr. Aston: Yes; however, about 15% of the noses in my practice belong to men. The incidence of men having rhinoplasties is a little higher than the incidence of men having facelifts. A large percentage of men who want rhinoplasties are in their late teens and early 20s. In men we perform rhinoplasties at a slightly older age than we do in women because a boy's face matures a little later.

Medscape: People might ask their surgeons whether it's possible to have a limited procedure, eg, take away the bump or change the tip. Is that realistic?

Dr. Aston: Only a small percentage of noses will look good with a limited procedure. The appearance of the nose depends on the relationship between all of the parts. If you change the tip, eg, make it smaller, it reduces some of the tip support and has the potential to make the profile look taller. On the other hand, if you just take a bump off the nose without touching the tip, it's possible that the tip will look bigger than it did before. When you alter one area, it influences the appearance of other areas of the nose.

Medscape: Are there any exceptions?

Dr. Aston: Yes; some patients have small bumps on their profiles (a thin tip with good projection), and you can just sand down the bump. Some noses have wide tips with good tip projection, and the patient's profile won't be reduced. A small number of patients don't need profile reductions or tip reductions, and you can do limited procedures. Today's rhinoplasty is more conservative than it was years ago.

Medscape: In what ways is rhinoplasty more conservative these days?

Dr. Aston: Today it's important to maintain architectural integrity because noses change over time. Twenty years after surgery, noses don't look the way they did 5 years after surgery. The skin sleeve of the nose eventually gets thinner. When I say skin, I'm including the fat layer and muscle overlying the cartilage and bones. Many rhinoplasties that were done 30-40 years ago and looked good a year after surgery, don't look as good today because less attention was paid to preserving architectural integrity.

Medscape: Preserving architectural integrity -- is that a state-of-the-art message?

Dr. Aston: Absolutely. State of the art is maintaining architectural integrity in both the bony and cartilaginous framework of the nose. In the patient lacking natural architectural integrity of the nose, we add it by borrowing cartilage from the septum, a rib, or possibly from the ear.

Medscape: What are some ways to preserve architecture? Does this commonly need to be done?

Dr. Aston: Yes, even in routine rhinoplasties. A spreader graft is often performed to maintain the dorsal lines of the nose. It maintains support for breathing in the midvault, gives an aesthetically pleasing contour line, and prevents a pinched look in the middle portion of the nose. We'll add strut grafts to the columella to maintain support of the tip and to give and maintain tip projection. Plus, we use various small cartilage grafts within the tip of the nose to give contour. The goal is to have the nose look normal, and function well.

Medscape: Is it possible to operate on the nose without leaving scars?

Dr. Aston: First, there are 2 basic types of rhinoplasties. One is closed or endonasal rhinoplasty. Incisions are made inside the nose to release the nose from its architectural framework, so one can work on the tip cartilage (the cartilage in the midvault of the nose), the nasal bones, and the septum. In my practice, a vast majority of rhinoplasties are performed with the closed technique. The second technique is open rhinoplasty, which requires an incision on the columella. The open rhinoplasty is indicated when the anatomy of the nose is more complex. It is also used in secondary rhinoplasties in which the procedure requires more direct exposure to the tip cartilage than you can get with a closed approach. You can obtain exposure to the nasal anatomy with either technique.

Medscape: Isn't open rhinoplasty more common than closed?

Dr. Aston: Probably, although closed is starting to regain ground. Although open rhinoplasty gives more direct exposure to the nasal anatomy, it leaves a visible scar. In most cases the scar heals well, but this is not always the case. In the past 20 years, the emphasis in plastic surgery residencies has been on open rhinoplasty, partly because you can see the anatomy more easily than with closed rhinoplasty. With closed rhinoplasty you need good 3-dimensional thinking to understand the anatomy and how the changes that you make will look afterward. Some noses have unusual anatomic situations that make open rhinoplasty the preferred technique. Personally, I think a lot of open rhinoplasties would be better if performed closed. Closed rhinoplasties take less time to heal. Open is more invasive and has more swelling.

Medscape: How do you make the tip of the nose look smaller?

Dr. Aston: Traditionally, making the tip smaller involved removing a portion of the tip cartilage. Today, a large number of tips are made smaller by removing very little of the tip cartilage -- sometimes none. Instead, you resculpt, reshape, and reposition the tip cartilage. For instance, if you have a broad bulbous tip, and the alar cartilages don't meet at the midline, you can remove small parts of the cartilages, but also change the angle of the tip cartilage so that the domes are made more acute. You can suture the domes of the 2 cartilages together to reposition them and make the tip smaller, which also makes the tip more triangular in shape and provides a more desired contour. Simply resecting cartilage in many tips won't do that. Many noses require cartilage grafts placed in the tip to support and project the tip. In some noses you actually make the nose look smaller by placing the grafts in such a way that it increases the tip projection, and supports the sidewalls. There are numerous options.

Medscape: What happens to the skin of the nose when you make the cartilaginous and bony framework smaller?

Dr. Aston: The skin of the nose contracts to conform to the bone and cartilage underneath. Removing skin has no place in routine cosmetic rhinoplasty. The scars would be unacceptable. You should leave the skin and let it shrink down. Skin type and thickness play a huge role in the final result.

Medscape: What's done to make breathing better with a rhinoplasty?

Dr. Aston: It depends on the etiology of the breathing problem. Repair of a deviated septum is common. If patients present with compromised valves, spreader grafts are used to maintain the internal valves of the nose. Sometimes internal valves could become compromised as part of the reduction rhinoplasty, but spreader grafts keep them open. Not infrequently, we alter the inferior turbinates to help open up the airway. Some noses need cartilage grafts to support the nasal tip and prevent the nostrils from collapsing.

Medscape: What does it mean to break the nose during rhinoplasty? Is it necessary?

Dr. Aston: It's necessary in probably 90% of rhinoplasties. When you lower the profile, you usually need to reduce the width of the base of the nose. A lateral osteotomy divides the ascending process of the maxilla on the sides of the nose so that you can adjust the base of the nose. If you lower the profile and don't narrow the sidewalls, then it will look too wide. Osteotomies can lead to bruising, but are much less traumatic than they were years ago.

Medscape: Do you have any general tips for physicians with regard to follow-up of rhinoplasty patients?

Dr. Aston: All noses take a minimum of 1 year for the swelling to go down. That doesn't mean that the nose doesn't look good 2 weeks after surgery, but refinements in the appearance occur over time. In patients with thicker skin it can take longer. It's important to convey this to patients.

Medscape: You've given everyone a lot to think about. Thanks for taking time to speak to Medscape.