This was a question that I answered for someone that was worried about the common perception that when you get a rhinonplasty you have to “Break” the nose. This is how I answered rhinoplasty (Aesthetic Facial Plastic Surgeyr and Dr Young is in Bellevue Washington) does not need “breaking” of the nose but a controlled shaping of the nose to be effective.  It is all in the way that you say things I would say.  Breaking the nose sounds very uncontrolled and unrefined.  Rhinoplasty couldn’t be further from this.  This procedure is the most intricate and detailed that a plastic surgeon can do.  The nasal bones often have to be shaped to take on the new form.  And breaking is not accurately used to depict what is going on during the procedure in my opinion.  The shaping of the nasal bones does require separating the nasal bones from the surrounding facial bones.  This is done with fine osteotomes that are sometimes as small as one millimeter.  This separation is done in an extremely controlled fashion and not like what is done when you break your nose in an accident that commonly can occur in many situations. This is a video on Rhinoplasty, scroll down to view.

Thanks for reading, Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington

This is a question that I answered for a patient that had a hump, and a wider nose but felt that it has gotten worse as she aged. She wondered if a rhinoplasty could correct those elements in her nose.  This is how I answered her questions:

Your Nose can grow as you age and rhinoplasty (Aesthetic Facial Plastic Surgeyr and Dr Young is in Bellevue Washington) can correct this and other anatomical characterisitics.  When you age, your skin can enlarge over time which can create the appearance of a larger nose.  Also as you lose volume in your face, the nose can take on a larger role.  Also as ligaments in your nose loosen your nose has a tendency to lengthen further creating the illusion that your nose is getting longer.  Many of these elements can be corrected with a rhinoplasty.  The hump that you have will appear larger because your tip will descend as you age.  This descent also brings your nose closer to your face which makes it look wider. This is a video on Rhinoplasty., scroll down to view.

Thanks for reading, Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington

You should tailor your questions about rhinoplasty (Dr Young is in Bellevue Washington) based on your desires for the type of changes you are interested in.  If you were to ask questions about all aspects of rhinoplasty, you could be in for a long day / night so to speak.  Your questions should be really centered around your interests.  This will take also some research on how this procedure is performed, recovery, preparation etc.  You should go into the consult informed of the procedure as much as possible to facilitate the discussion about your particular concerns based on your anatomy.  Some common questions for your doctor though should be if he is board certified in this procedure, is he fellowship trained, how many rhinoplasties they have done, you should look at the before and afters of his procedure, you may consider asking for references from former patients as well.  You really should look over all of his credentials.  Where they studied can have a huge impact on their skills.

One thing to consider is that sometimes the number of rhinoplasties that a surgeon has done is not necessarily an indicator of how well the rhinoplasties are done. I used to know a surgeon who would always tell his patients that he has done over 3-4 thousand rhinoplasties.  Well that is great, but how many of those are done well.  Some surgeons stick with the same techniques and never get better.  You want to know that your surgeon is continually improving on his technique and constantly learning about new techniques and ways to improve older techniques.  This is more important, sometimes, than how many they have done.

You should find out if the surgeon does his rhinoplasties using open or closed techniques.  Closed techniques are based on older set of skills.  Although the recovery might be faster. These techniques, in my opinion, are much less accurate.  The main difference between closed and open techniques is that with the open technique there is an incision at the base of the nose in between the nostrils. Rhinoplasty link, the before and afters are further down, so you’ll have to scroll down to see it. As you can tell, you can barely see this incision. I totally prefer the open technique.

Another question you should ask your surgeon is how he performs his rhinoplasties and his techniques.  Does your surgeon do destructive maneuvers that lead to uncontrollable outcomes.  These destructive techniques are based on traditional and older techniques that many surgeons still use because they have not learned the newer less destructive techniques.  Nowadays, surgeons that are versed in more advanced up to date techniques tend to use sutures to affect the tip structures and shape them to the desired shape and size.    A surgeon that gives you a brief and easy to understand approach on how he would design and plan your rhinoplasty is probably better than someone that doesn’t.  I have some other blogs that describe how procedures are briefly done during a rhinoplasty. To also help, here is a video on Rhinoplasty.

Thanks for reading, Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery is located in Bellevue near Seattle, Washington

The type of anesthesia used during rhinoplasty depends on what is being done. If is a small change, you may use just local anesthesia.  Meaning, you will inject a local anesthetic, that is, you numbing fluid will be injected into the exact local area that you are working on.  Sometimes, regional anesthesia can help. That means that you inject a nerve where the region the nerve controls or innervates is numbed from the local numbing anesthesia to numb the region.  When the procedure that you are doing is more extensive, it could require local, regional anesthesia and then systemic anesthesia which is done throug either gases that are inhaled and anesthesia that are made from fluids that are injected into your veins to create a whole body anesthesia. I have done rhinoplasty under just local; with local and iv sedation; and local and general anesthesia.  I do most of my rhinoplasties under iv (intravenous) sedation, with local and regional anesthesia.  With Iv sedation, I get my patients very relaxed so that they don’t remember a thing after the procedure.  The less extensive the procedure, the less anesthesia.  The more extensive the more anesthesia you will need.  Also it depends on your tolerance as well.  If you are really afraid of needles, and the whole thing you will need more anesthesia compared to other people. Here is a video on rhinoplasty done under intravenous (iv, through your veins) sedation.

Thanks for reading, Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington

Rhinoplasty is the best way straighten a crooked nose. This procedure entails making an incision at the bottom of the nose and then exposing all of the elements of the nose that is creating the outward appearance.  Then manipulating each of these structures will then change the shape of the nose. For the crooked nose, you must change the structures by releasing the forces that are holding the nose in a crooked fashion and essentially weaken these structures then strengthening them in a straight position.  The question of what is it like is variable among patients, their personalities, their tolerance for pain, their genetics that affect their healing / tendency to bleed / tendency to swell, etc.  Generally the first week is the most challenging, then its the first month.  You get most of your healing in the first month.  Generally what I tell people is that you will get 60% of your healing the first 6 weeks, 80% at the first 6 months, and at 2 years the healing will be 89% of what you used to be.  So most of the improvement is within the first month. Here is a video showing a rhinoplasty and an explanation of the tip part of the rhinoplasty.

Thanks for reading, Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington

There are techniques in rhinoplasty that can be done to decrease the roundness of the nostril.  Usually it entails placing the cartilage as a graft along the rim of the nostril, above the nostril to push it down and sometimes grafts that have both cartilage and skin that are placed inside your nose to push the rim of your nostril. All of these techniques serve to push the rim of the notril down so that they are not rounded and retracted. As you can see below where the label lateral crus is located.  Most techniques entail placing the cartilage grafts above or below the lateral crus to push down the nostril margin or rim to correct the retraction and rounding of the nostril.

Rhinoplasty (Dr Phil Young MD, Bellevue WA) has gone through some changes during the last 30-40 years.  In the past, surgeons used to do destructive techniques by cutting the cartilage, morselizing, crushing, and placing many tip grafts.  What has been learned over the years is that these techniques tended to lead to unpredictable changes, knuckling, warping of the cartilage, nodule formation and poor results in general.  What is now done today are suturing techniques.  There are basically 5 sutures that surgeons can now do to really change the tip in most any way.  To understand these sutures you should look at the diagram below.  The key structures to know for the nasal tip are the lateral, middle and medial crura.  The lateral and medial crus are show in the diagram. What isn’t show and labeled is the middle crus / crura which is between the lateral and medial crura.  The first stitch that usually is done is the middle crural stitch that brings the middle crus and medial crus together and this is usually placed at the junction between these two crus (green stitch).  The next stitch is the medial crural sutures which brind the medial crura together.  Often times, another cartilage graft is placed in between the medial crura to add strength to the tip and the medial crural sutures incorporate this graft.   If the tip is still too wide and bulbous, you can then narrow the domes by doing the transdomal suture which pinches the lateral crura at the junction between the middle and lateral crura (pink color stitch).  This sutures helps to make the tips smaller.  If the tip is still too wide and the domes are still too far apart you can then do the interdomal sutures that brings the domes closer together on each side (red color stitch).  Sometimes, the lateral crura becomes bowed outwards from the transdomal sutures and then what is then required is the lateral crura stitch that cause the bow to become straighter (green color stitch).  The yellow colored loop in the diagram depicts the part of the lateral crura that is usually taken out or resected.  What should be left is 6-7mm of the lateral crura for adequate support and strength to prevent it from buckling and creating asymmetric tips, knobs, knuckles and buckling.  Part of this is explained in this video.

Thanks for reading,

Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington

I saw a patient recently that went to another doctor who had suggested to add tissue to the top of the bridge of the nose and also the bottom to camouflage the mild elevation in the middle of the nose.  She really didn’t want to do that and was only interested in refining the nasal tip.  In my opinion, everything looked really good with her nose except a moderate amount of tip bulbousity.  On my exam, I noticed that her elevation was more inferiorly near the tip.  I attributed this elevation to extra large tip cartilages.  In my opinion she only needed to refine the tip by excising the top part of the tip cartilages through rhinoplasty or nose reshaping.  In the picture below, the lateral crus is where I identified where her tip cartilages were enlarged.  They were so enlarged that it increased the size of the bridge in this area.  By refining the lateral crus, it would decrease the bridge in this area and would effectively cause a little desirable break just above the nasal tip that is beautiful when it is achieved.  I thought that her nose would be significantly masculinized if she were to get her nasal bridge in between her eyes elevated and enhanced.  It would be a wrong choice for her by this other surgeon.   The other surgeon wanted to narrow her nose as well.  On my exam, her nasal bridge was about the width of her irises which to me was ideal.  This was consistent with her ideals as well and was also consistent with my theory on facial beauty. You can read my theory here (Dr Young received the Sir Harold Delf Gillies Award for this theory by the American Academy of Facial Plastics and Reconstructive Surgery). Going to someone who has a good sense of aesthetics is probably one of the most important things about a surgeon.  You can have the best techniques but if you don’t have  blueprint how are expected to achieve the result without knowing the ideal or what is the best end result. The best techniques can lead to a bad result even if everything was done right.  That is why aesthetics is so important!

Thanks for reading, Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington

Ear and rib cartilage grafts usually are less than 10% of primary rhinoplasties (Dr Phil Young of Seattle / Bellevue WA).  Usually there is enough cartilage from the nasal septum to use for rhinoplasties.  This also depends on what kind of practice the surgeon has.  If they have a good reputation and a lot of experience, Secondary rhinoplasties or rhinoplasties that are the second time around are more common.  In this situation cartilage grafts from the ear and rib are more common and it varies for all surgeons.  It also depends on the ethnicities of the person.  Caucasians usually have more prominence of the nose and usually request making the nose smaller.  This requires taking cartilage out and in this instance the less cartilage is needed.  For other races, cartilage is usually more of a shortage and thus requires more grafts and in this case either foreign implants, or grafts from the rib or ear are taken.  Since taking rib is such an undertaking, patients usually opt for implants such as silicone, med por, and goretex are used.   Ear cartilage can be used but given its pliabilty and curvature it is less than optimal for many grafting needs and are more used for tip grafts and grafts for the cartilage that make up the tips.

Thanks for reading, Dr Young

Dr Young specializes in Facial Plastic and Reconstructive Surgery and is located in Bellevue near Seattle, Washington