Plastic Surgery Videos

Today's case is that of a 30-something year old Thai female who's had four previous rhinoplasty procedures. She currently has a silicone implant and actual injected silicone in her nose and she'd like more projection and a better look to the dorsum of the nose. In this segment I'm going ahead and reopening her previous columellar incision. When you revise previous rhinoplasties you have to be extra careful that you're not damaging the blood supply to the nasal tip. She had a tremendous amount of scar tissue in her nasal tip so I had to do the initial dissection with a 15 blade but I was able to eventually use my favorite Converse scissors to open up once the scar was debrided. We went ahead and removed excess scar on top of the lower lateral cartilages to define them more and allow for more of a finesse small tip. Here I am making the pocket for the rib graft construct. The pocket is between the middle courora of the lower lateral cartilages. With this rib graft construct I'm going to be able to create a more advanced projected tip to give her a more Westernized look to the nose. Here's what the rib construct looks like. It's made out of custom shaved pieces of cadaver rib graft. The graft is being put in place. It will be sutured in with re-absorbable sutures that will disappear in about six weeks. Scar in the area will hold the new tip projection over the long run and this patient should be quite happy with the outcome. I then go ahead and close the nasal tip with interrupted 6-0 PROLENE sutures. They are very small but they need to be removed in about a week and they leave minimal scarring. As with most Asian noses, this patient has very wide nasal bones. If it wasn't for the silicone implant, it would look like she had no center of her nose at all so what we want to do today is identify her right and left nasal bone positions and then we are going to surgically break them with something called a guarded osteotome and you'll see this here in the next few seconds of footage. Here I am injecting with local anesthetic with adrenalin in it. This makes the area comfortable after breaks and the adrenalin decreases blood loss in the area of the fracture point. Here I am carefully fracturing the nasal bones in a continuous pattern. I'm always palpating far up near the corner of the eye to make sure I'm not injuring important tear drainage structures and that I'm not going into the nose too deeply, which could potentially run the risk of brain injury. Now that I've finished fracturing both right and left nasal bones, just gentle pressure allows the nasal bones to be pushed towards the center, creating a more narrowed dorsum or bridge, and this is what she's going to be most happy with. Here I am making the final touches on nasal bone position and position for the nasal tip. I wanted to make sure that everything looked good both externally and with the palpation of the nasal tip cartilage graft that I put in. The cartilage graft is quite strong and should serve her for a long time quite nicely. Here's a picture of the patient from a profile view just before we started the case. Here's a picture of her right after I was finished. You can see that there is more tip projection and better shape of the dorsum. This is the patient one month after on the right hand side showing a better look to the nasal dorsum and better position of the tip. Two-quarters view shows better tip projection and better tip shape. The worms-eye view shows better shape of the nasal tip and much better even shape to the nostrils. Her nose now looks normal on profile and the patient is happy.