The short nose: surgical approach

THE OPEN-EXTERNAL rhinoplasty is the best approach for the short nose in most but not all cases, according to Dr. Sam Rizk, a NYC nose job or rhinoplasty specialist. With the short nose, multiple nasal cartilage grafts will be used to lengthen the nose and wide release of tissue and undermining will be required to allow the skin to stretch and accommodate the new length. Dr. Rizk places an emphasis on this release of the skin-soft tissue envelope in order to close the transcolumellar incision without tension. Tension can create tissue necrosis and loss. To avoid this, a good release of the soft tissue-skin envelope, both superiorly and laterally is important.

A columellar inverted v incision is made. The purpose of using the inverted v incision is that in the event that there is a small notching on the side of the columella, it will not be seen from a profile view and the notch will camouflage well. Also a geometric closure is not visualized by our eye as well as a straight line closure. If there is a scar from a previous open rhinoplasty, the scar is simply excised before proceeding. It should be kept in mind that there is a tendency in a redo open approach for scar tissue thickening to occur deep to the columellar flap. This can potentially cause a retraction of the scar. Therefore, in reopening a nose, it is sometimes necessary to compensate for that potential problem by thinning out or shaving the tissue of the caudal edge of the medial crura where the columellar flap will be resting.

Elevating the flap is done by connecting the inverted v incision with a marginal incision, avoiding the soft triangle. This incision is made along the edge of the lower lateral cartilage. It is helpful to start the elevation of the dorsal flap from the vestibular aspect of the rim incision. Even in secondary or tertiary nose job surgery the soft tissue separates very easily here. Starting from the dome or from the columellar area is usually more difficult. In fact, after elevation of flap along the sides of the nose and the dome, the last area to be elevated should be the columella itself. The upper lateral cartilage is then released from its attachment to the dorsal septum. A spreader graft may be placed here to improve nasal middle vault collapse or to improve breathing by widening the internal nasal valve. The elevation of the mucoperichondrium usually is begun at the septal angle where the tissues are sometimes easier to free.

If the patient has had previous septal surgery, there is often an L-shaped septal strut. In the event that there is other work that needs to be done to the septum to straighten it, in addition to lengthening the nose, the bony septum itself is easiest to straighten by performing the so-called "closed septal osteotomy". This means inserting a very long and wide speculum that is often spread with some degree of force. Even spurs of the vomer often will yield to the forcibly expanding speculum. If cartilage is needed, Dr. Sam Rizk will harvest donor material from the central portion of the cartilaginous septum in those cases where there is enough to harvest for the rhinoplasty or nose job. If there is not sufficient septum cartilage, then auricular cartilage or banked rib cartilage grafts or nasal implants may be used. Now it is necessary to lengthen the nose to release the upper lateral cartilage from the lower lateral cartilage, which usually is foreshortened. Many patients have had previous surgery, and there may be a great deal of scar tissue here. As a general rule, Dr. Sam Rizk, a NY prominent rhinoplasty (New York nose job) expert, states that it is important to release more than is required to lengthen the nose, simply because there will invariably be some postoperative contraction, which will cause a small degree of shortening of the nose during the healing process.