Sculpturing of the alar rim
Dr. Sam Rizk, selected as one of the world’s best rhinoplasty (nose job) surgeons by Tatler magazine, addresses the alar rims if they flare beyond a natural inner canthal vertical line or if they flare in the process of deprojecting the nose. Dr. Rizk has modified the Weir type incision of the alar rims to result in a natural curvature of the nostril. He does this by placing the lateral incision immediately in the crease and then curving to the floor of the nose. The amount removed medially is based on surgical judgement, depending on the airway and the amount of flare in the nostrils. The skin and soft tissue are then excised and the sutures are placed in an interrupted type fashion to achieve the best possible scar and closure. Additionally, Dr. Rizk does not remove vestibular skin intranasally during the nostril wedge excision. It seems logical that the vestibular skin should be excised intranasally to prevent a dog ear; however, this step should not be performed, since the excess skin helps prevent notching of the alar rim.
Sculpting of nasal tip using ONLAY GRAFTS or UMBRELLA GRAFT for AUGMENTATION of nasal tip projection
Nasal tip projection is one of the most important characteristics of an attractive nose. Dr. Sam Rizk, a ny rhinoplasty surgeon and double board certified facial plastic surgeon, states the the nasal tip should project gracefully from the line made by the nasal bridge with a slight break. If the nasal bridge line and the tip are confluent then the nose has a full, heavy, and thick appearance. The nasal tip projection is influenced by the tip support mechanisms of the nose such as strength of medial crura, septum, and the dome cartilages strength. Dr. Sam Rizk, an expert in ethnic rhinoplasty (Asian rhinoplasty, African American rhinoplasty, middle eastern rhinoplasty, latino or Hispanic rhinoplasty, or Caucasian rhinoplasty with thick skin), states that one of the most problematic features of the ethnic rhinoplasty which causes the bulbous nasal tip, is the poorly projecting nasal tip. In ethnic noses, the underprojected nasal tip results from weak tip support due to weak medial crura, soft and weak tip cartilages and thick skin. These features cause collapse of the nasal tip towards the face and creates the bulbous tip and the flaring nostrils. When the tip cartilages in ethnic rhinoplasty are too weak or thin then performing a reduction or cephalic trim will weaken them further and cause more collapse so in these noses it is imperative to use cartilage grafts to support the medial columellar support with a columellar strut as well as to project the dome with onlay tip grafts. In any event, Dr. Sam Rizk uses cartilage grafts frequently to define and project ethnic noses and he obtains these grafts from either the nasal septum, the ear or banked rib cartilage, especially in revision noses where not enough cartilage is present in the nose. Sometimes Dr. Sam Rizk will also use a medpor implant for support and definition. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant. In certain noses, sometimes a cephalic trim of the lateral crus of the lower lateral cartilages can be doubled on top of one another and used as an onlay tip graft as well.
The umbrella graft is used for more underprojected noses such as noses with loss of tip projection following rhinoplasty, loss of tip projection after loss of septal support, a severe plunging nasal tip, very thick skin tips, amorphous nasal tips, or congenital short nasal tip pyramid, and in patients with cleft lip deformities. The umbrella graft consists of a strut covered by a cap of cartilage which usually projects further anterior than the patient’s nasal tip dome. The strut can be made of preferably septal cartilage and needs to be placed between the medial crura and should not project below the caudal border of the medial crura except to fill a depression at the nasolabial angle. The strut does not usually increase nasal length unless it is positioned and intended to do this. The strut is sandwiched between the medial crura and gains their support. With this sandwich support, one a small anterior part of the strut stands alone above the medial crura. The strut is usually no longer than 3cm, but this varies according to the patient needs. The outer inferior part of the strut has to be shaved to contour to the infratip lobule angle. If the strut were to stand alone it would create a very sharp nasal tip and for this reason the strut is covered by an onlay tip graft or grafts of cartilage. This combination of cartilages produces the “umbrella effect”