Rhinoplasty: Nose Reshaping In London

A nasal hump or bump defines the size and shape of the nose and may be elevated as a hump, or depressed as a consequence of collapse of the nose through trauma or over surgical resection.

The nasal hump of the nose is reduced in size by reduction of both the cartilage (lower two-thirds) and bones of the nose (upper one-third). In addition, other measures are required to maintain the natural pyramidal shape of the nose and prevent the nose from becoming too wide, this is why the bones are usually narrowed with osteotomies.

For some patients the bridge is also supported with the use of cartilage grafts as these support the nose long-term and maintain functional breathing, however care is required to avoid widening the nose. Other additional measures may also be required for patients with thin skin or thicker ethnic skin.

A more refined, elegant nasal tip is a common request from nose job patients. There are a few common factors that can create tip bulbosity. The shape of the nasal tip is made by the cartilage in the lower third of the nose. The cause of an enlarged or bulbous tip may be a result of enlarged cartilages, wide or convex shape or asymmetry. In addition, the thickness of the patient’s skin can also determine the width of the nasal tip. Patients with ethnic skin tend to have thicker skin that enlarges the size of the nasal tip.

Dr De Silva creates a more refined nasal tip by shaping and sculpting the lower lateral cartilages that are often too wide and asymmetrical. In addition, putting in special stitches (termed dome binding sutures) will also help shape the tip further by creating additional definition.

These dome binding sutures can be used to reshape and define the nasal tip. In patients with thicker skin, additional techniques may also be required including thinning the skin at the nasal tip and placing a cartilage graft underneath the cartilages called a lower lateral crural strut graft.
The lower lateral cartilages are shaped.

The key with refinement is to avoid over reduction of the lower lateral cartilages as this can sufficiently reduce the structure of the nose resulting in a pinched nasal tip or collapse on breathing. Dr De Silva takes care to measure the cartilages to ensure there is sufficient structural support of the tip to last for years to come.

A droopy nasal tip is defined as a tip that is low, commonly a patient with a low tip will have an appearance that the nose is too long, and often dips down further on smiling. Often when the patient looks in the mirror they will barely see their nostrils as the low tip hides them. The tip may naturally be droopy, can be inherited from parents, can also drop further with ageing or due to trauma.

Rhinoplasty can be used to reposition the tip in a more natural position by lifting the nasal tip. The pair of cartilages that make up the tip of the nose are shaped and sculpted, these are termed the lower lateral cartilages that are often too wide and asymmetrical. In addition, putting in special stitches (termed dome binding sutures) will also help shape the tip further by creating additional definition.

Care is required with this procedure as the tip should not be over lifted as this can result in a piggy-shaped nose in women, and a more feminine appearance in men. Artistry is required in ensuring the tip is lifted to a natural position. The natural position will depend on male or female sex, facial proportions, the height of the patient as well as ethnicity.

A long-over projected nose is described as a nose that comes out from the face too far, this is called over-projection.

Tip projection refers to how far forward the nose travels from the face and rhinoplasty can be used to treat a long nose by repositioning or trimming the tip cartilages.

To reduce the size of an over-projected nose requires shaving down the underlying bone and cartilage and repositioning the nasal tip further back towards the face

Dr De Silva feels it is important to consider the nose with the other facial characteristics, if you have a small chin it may create an illusion of a large nose when actually your chin is too small. For some patients combining a reduction in nose size with chin implant surgery will give the best possible result.

A crooked nose or an asymmetrical nose is one that turns either to the right or left sides.

Broadly speaking the nose can be separated into three parts: the top third, middle third and lower third. To straighten a nose requires evaluating and treating each of these three thirds to improve the appearance of the nose.

It is very difficult in rhinoplasty to completely straighten a crooked nose. The deviated cartilage and bone have a certain level of memory such that the nose wants to drift back towards its original shape, graft tissue can be used to help straighten the nose. Too much graft material in the nose can have a tendency to widen the nose so a balance is required in avoiding over widening the nose while improving its symmetry.

A narrower nose generally has a more elegant appearance in both women and men and across different ethnicities and cultures.

Narrowing the nose can generally refer to three main areas: narrowing the bridge of the nose, narrowing the tip of the nose and narrowing the nostrils.

Narrowing the bridge of the nose, termed osteotomies also known as breaking the nose. Narrowing the base of the nose, termed osteotomy, is required in most rhinoplasty surgeries to give the nose an improved shape and a narrower nasal bridge.

Dr De Silva utilises electrocautery to minimise bleeding and to make a pocket incision for the osteotome instrument to be used. The nasal bones that make up approximately the upper third of the nose are individually broken with special instruments that result in a controlled and planned break. The nasal bones are then brought together and pressure applied to minimise bleeding. Osteotomies can be performed through the skin or hidden within the inside of the nose, Dr De Silva prefers to use hidden incisions where possible as this avoids unnecessary scarring of the skin.

Narrowing of the nostrils that are indicated for some patients. This surgery requires both precision and delicacy to hide the incisions on the inside of the nostril and maintain adequate functional breathing through the nose.

Breathing through the nose is an important function of the nose and a nose job often narrows the airway passages that can reduce breathing. To improve the airways and maintain breathing, Dr De Silva frequently uses graft tissue to support the structure of the nose long-term.

Septoplasty is a common procedure that is combined with nose surgery. The septum is a cartilage plate that lies in the very centre of the nose (see the figure below), the septum is a wall of tissue that separates the right and left nostrils and airway. A deviated septum is commonly without symptoms, however if severe it may cause a crooked nose and difficulty in functional breathing, it is an important consideration in surgery to ensure that the breathing is not affected by the procedure.

In addition, the septal cartilage may be used for graft material which Dr De Silva uses for supporting the nose and enhancing the fine definition of the nasal tip. The septal deviation should be corrected during cosmetic nose surgery to give a good long-lasting and effective result. Dr De Silva performs septoplasty in 30% of cosmetic rhinoplasties.

What Does a Deviated Septum Look Like?

The CT imaging illustrates septal deviation. The green arrow shows a straight septum, this allows equal airflow in the right and left sides of the nose and normal breathing. The red arrow shows a deviated septum, this results in reduced flow to the side of the deviation by narrowing the airflow.
Septal deviation can vary substantially in severity, a severe deviation can cause near-complete obstruction of the airway.

A small chin can give the illusion of a large nose, by augmenting the chin at the same time during nose surgery can improve facial proportions and final result.

The figure below shows the normal position of the chin in relation to the lips. In a person with good facial proportions the lower lip is 1-2mm behind the upper lip and the chin is 1-2mm behind the lower lip. There are variations in facial harmony and balance based on genetics, gender and ethnicity.

The below figure shows the position of a recessed chin which is positioned (>5mm) behind a vertical green line drawn through the lips. With chin augmentation the chin is moved forward and the relative distance from the lips to the chin is reduced. Dr De Silva uses reference points on the face to evaluate proportions, however the artistry of chin augmentation also includes taking into account gender, ethnicity and chin shape into account with chin shaping.

There are two techniques for the insertion of a Chin Implant:

Surgery from the inside of the mouth (intra-oral), or Insertion of the Chin Implant from a small hidden incision under the chin (submental crease)

Dr De Silva performs both techniques. He tailors the surgery to the individual, his procedure of choice is insertion of the implant through the submental crease as this enables good access for the optimal position of the implant.

Intra-oral insertion of chin implants is associated with an increased chance of infection of the implant and a longer recovery period. Dr De Silva sculpts every chin implant to a person’s unique jaw line, every jaw line is different and requires a different 3-D enhancement to give the best result. Natural variation in the chin, jaw and neck skin, soft tissues and skeletal structure means that optimal proportions differ in all faces.

Particular importance is shaping the implant to soften the appearance of the chin and ensure a natural jawline (shown with hatching in the figure below). Dr De Silva is known for natural looking work and customisation of techniques that are in harmony with a person’s facial characteristics.