Many patients have a drooping tip for which they seek out a rhinoplasty to be able to lift their tip on a permanent basis. Most patients are simply born with a droopy tip, and it is usually not related to trauma. As a surgeon, it’s important to evaluate the nose anatomy to determine what is causing the droopy tip. Some patients have angulated nasal tip cartilages, which are pointing downwards which must be lifted up with a combination of suture techniques and conservative cartilage removal. Sometimes the lower lateral cartilages need to be sewn to the upper lateral cartilages to stabilize them. Cartilage grafts such as a columellar strut graft can accomplish lifting and supporting the nasal tip. Cartilage grafts are harvested from inside the nasal septum, are fashioned to the appropriate size and shape, and are inserted through a precise pocket to give structural support to the nose. It’s also important to make sure the new tip balances with the existing nasal bridge line so that the nose is not out of balance. A full rhinoplasty is usually required when lifting a droopy tip. Most patients who have a droopy tip also have a dorsal hump, so the dorsal hump must also be addressed by shaving it down as well. It is also important to evaluate the presence of the depressor septi ligament. If the depressor septi ligament is present in some individuals, it pulls the tip down with animation and smiling. Releasing of the depressor septi ligament prevents the tip from drooping with animation and talking. This also helps prevent the ligament from pulling the tip down in the postoperative period. The nasal tip cartilages also have to be addressed as far as narrowing or widening them, depending upon their pre-existing condition. Many droopy tips are also bulbous and lacked adequate tip support, therefore need to be lifted, supported and narrowed simultaneously. William A. Portuese, M.D. performs rhinoplasty to lift the droopy tip with a closed rhinoplasty approach. The procedure is performed under general anesthesia by a board-certified physician anesthesiologist in attendance throughout the entire procedure
A rhinoplasty procedure can accomplish narrowing wide nasal bones with osteotomies. The osteotomies allow the entire bridge line composed of the wide nasal bones and the corresponding wide upper lateral cartilages to be narrowed from their pre-existing wider position. After performing medial and lateral osteotomies in the nasal bones, a cast is applied across the bridge of the nose and is usually left intact for one week. Anticipate 2 weeks of visible bruising and swelling from the procedure itself. The sutures placed on the inside of the nose with closed rhinoplasty are all dissolvable. It’s also important to make sure the tip of the nose balances with the new bridge line, so in many instances, some type of tip surgery may be required. To narrow the nasal tip requires a conservative cartilage removal or suture techniques called intra-domal or inter-domal sutures, which can narrow the nasal tip. It’s important that all of the components of the nose including the nasal bones, upper lateral cartilages, and the lower lateral cartilages of the nasal tip balance with themselves. To narrow wide nostrils requires an alar-plasty, which can be accomplished with an incision at the base of the nostril sill for very wide nostrils, or an internal incision if the amount of narrowing is minimal. To close the alar-plasty incision usually requires 2 types of sutures to hold the incision together underneath the skin with dissolvable sutures and a meticulous skin layered closure so that the incision heals inconspicuously.
Many nose job procedures require a dorsal hump reduction. The dorsal hump is composed of cartilage and bone and it must be shaved down in order to remove it successfully. The removing of the dorsal hump creates an open roof, and a flat-top nasal deformity which also has the appearance of a very wide nose. Osteotomies of the nasal bones are definitely required for each time the dorsal hump is removed. Osteotomies performed on the nasal bones allow closure of the open roof deformity to give a very balanced nose. It’s also important that the nose looks balanced from all angles, since it is a three-dimensional structure. Some patients also require small spreader grafts placed underneath a concave upper lateral cartilage once the dorsal hump has been removed. These grafts are placed through a small incision at the septal angle and inserted underneath the perichondrium and periosteum of the nasal septum to bolster and support the upper lateral cartilages and prevent them from falling inwards. Dr. Portuese performs closed rhinoplasty to accomplish narrowing a wide nose under general anesthesia by a board-certified physician anesthesiologist. The procedure is performed in a state of the art in a Medicare Certified, Outpatient Ambulatory Surgery Center. The center is also a licensed by the Department of Health in Washington State