Removing a dorsal hump involves more than you might think
Posted on February 26, 2010 in Rhinoplasty by Dr. Kim1 Comment »

One patient’s asks the question ….”I have an otherwise perfect nose, except for a huge dorsal hump that I developed after entering highschool. I am now 18 and looking to get a nose job.”

My answer….It is tempting to think that one can simply “chop off” a dorsal hump on the bridge of a nose. But there are several things that you must realize about this procedure.

1.  When you reduce a hump, you are lowering the height of the bridge of the nose.  Because the nose sits on your face like a triangular pyramid, lowering the bridge results in removing the narrowest part of the pyramid and you are left with a wider portion.  So there may be a tendency for your nose to appear wider on the front view after hump reduction.  The amount of widening depends on how thick your skin is, how much the bridge is narrowed, and how wide you were from the start.

2.  Once a hump is removed and the bridge is lowered, the skin must then drape down onto the reduced infrastructure.  For patients with thin skin and a small or medium hump, this is not a problem.  If you have thick skin, especially if a lot of reduction is done, the skin may not be able to drape cleanly onto the structures of the nose.  In these situation, the skin remains a bit raised above the bone and cartilage of the dorsum, and some outward fullness remains.  This is called a soft-tissue polybeak deformity.

3.  If the hump involves the cartilage part of the dorsum, removing it may lead to collapse of the cartilages that form the middle part of your nose.

So in summary there a lot of things to think about before going through a procedure like this.  Rhinoplasty is a complex operation with many variables and considerations, even for a change that you might think is simple.  the best thing to do is to do your homework and seek treatment from someone who has a lot of experience with rhinoplasty.

Don’t worry, your smile WILL come back…
Posted on February 19, 2010 in Rhinoplasty by Dr. KimNo Comments »

One patient asked the question, “When will my smile return to normal after my Rhinoplasty?

I am a post-op for Rhinoplasty.  I’ve been recovering pretty quickly and I haven’t been having any problems really, other than this:  I’ve noticed that after my surgery, my smile changed.  Now, whenever I smile, my top lip doesn’t go up as much as it use to and the top teeth barely show. My smile looks not only forced but very, very strange. Why is it like this, is it normal? If so, how long before my smile returns to normal?”

Dr. Kim answers… “After rhinoplasty, a few things can happen which can affect your smile.  If work was done at the base of your nose or at the bottom of the columella (skin bridge between the nostrils), swelling in the area can affect the lip and cause it to drop a bit temporarily.  As the swelling resolves, which can take months, the lip will return to normal position.  Sometime if extensive work is done in this area, the muscles responsible for pulling the uppper lip up are temporarily weakened, a condition which will also return to normal over months.  If the problem does not get better by one year’s time, you should be re-evaluated by your surgeon. ”

“In some cases, a surgeon may place material between your nostrils in order to provide more support to the tip of the nose.  Often this can be a cartailge graft which serves as a collumn to support the tip.  A rare complication is this graft slipping forward and down toward the lip.  Overall this is a very unusual situation, but if it does occur it can easily be corrected with a minor touch up procedure.”

“The other thing to keep in mind is that if the tip of the nose is brought up and elevated, it can make the upper lip appear longer.  It should not cause the lip to actually drop down and cover your teeth more, however.”

“Don’t worry, your smile will come back…”

Dr. Kim provides advice about osteotomies (cutting the nasal bones) during rhinoplasty
Posted on February 10, 2010 in Rhinoplasty by Dr. KimNo Comments »

Question by a patient:  The front profile of my nose has fatty bone, bulbous tip, and wide nostrils, but symmetrical and straight. The side profile of my nose has a very small hump, but also has a perfect shape.

I met 3 surgeons for consultation on Rhinoplasty for reducing width of bone and nostrils. Surgeon 1 listened to my needs, suggested closed surgery, cut/stitch cartilage near tip, rasp bone, and reduce nostril flare. Surgeon 2 suggested open surgery, and the rest same as above. Surgeon 3 suggested open surgery, increase tip definition, columella-show with graft, nostril width reduction, no flare reduction, osteotomy/fracture bone at the base on both sides to reduce width.

When is rasping not good enough? Why should Osteotomy be done? Where are the cut bones reattached at the base?

Answer by Dr. Kim: It can be confusing for a patient seeking rhinoplasty. So many methods and opinions exist which may vary surgeon to surgeon (as you discovered).  Sounds like your goals are: to narrow the bones, lower the hump on the bridge, refine the tip, and narrow the nostrils. These are common goals but the appropriate techniques to use would depend on certain features of your anatomy.  Without seeing pictures and having the luxury of a physical examination, it is tough to provide details about a plan.

However, one useful bit of information I can provide has to do with skin thickness.  Generally, rhinoplasty is an operation in which we change the form of the bone and cartilage of the nose. Once this is done, the skin then has to drape cleanly onto this altered infrastructure in order for there to be an overall positive change in appearance afterward. Before surgery, each nose has the exact right amount of skin for the infrastructure beneath, like a glove fitting a hand.

After surgery in which there is reduction, narrowing, or lowering of this infrastructure, there is too much skin.  If you have thin skin, the skin envelope can contract and shrink somewhat so that clean draping will occur.  If you have thick skin, however, the skin cannot shrink that much and you may end up with a permanent relative excess of skin. This may lead to thickening of the skin and an appearance of skin fullness or bulging,  sometimes called a polybeak deformity.  If you have thick skin and want to look narrower or more refined, it may require building up some areas of the nose so that the infrastructure pushes into the thick skin envelope to create a more narrow and refined appearance.

This issue with the skin thickness is just one of many considerations with regard to which techniques are best for any given rhinoplasty.  Though forums like this are helpful to provide information, they cannot replace a thorough evaluation with an experienced rhinoplasty surgeon so that all of these issues can be explored.