In part one of this mini-series about rhinoplasty surgery, Dr. Guyuron explains the different types of rhinoplasty and how he approaches each variation.

Because it doesn’t make sense to create a nose that looks amazing but doesn’t function properly, Dr. Guyuron stresses the importance of a focus on function as much as aesthetics.

When treating injured noses, Dr. Guyuron takes extra care because rhinoplasty after trauma can be more complex. 

For those with “ethnic noses,” there are clear differences in the anatomy and shape. Dr. Guyuron explains how he helps his patients achieve results that match their face.

Although Dr. Guyuron rarely uses them for the nose, fillers can be used to temporarily make small refinements in the appearance of the nose. Find out what types of concerns fillers can safely camouflage and why this is an option he rarely recommends.

Read more about Cleveland rhinoplasty specialist Dr. Bahman Guyuron.

Learn more about revision rhinoplasty and rhinoplasty in Cleveland at the Zeeba Clinic.

Request a consultation with Cleveland plastic surgeon Dr. Bahman Guyuron


Announcer (00:01):
You are listening to Head On with your host, board certified plastic surgeon, Dr. Bahman. Guyuron

Dr. Guyuron (00:07):
Rhinoplasty is designed to improve the aesthetics and function of the nose, and that’s one of the things that’s actually emphasized to the other plastic surgeons when I speak about rhinoplasty that we really need to first detect the problem. Sometimes actually the patients don’t know that they have a breathing problems because they’re breathing through their mouths and they don’t know that actually the physiologic way is to breathe is through the nose and they’re not lying to us, they’re just used to it. So it is our obligation to detect when the patient is sitting across me, I’m watching how is their breathing actually, can they actually keep their lips closed for a period of time? So that’s the first step in helping these patients. I’m very focused on function and it doesn’t really make sense to create a nose that looks good but doesn’t function. So the goal is a combination of improving the shape, improving the function.

In fact, most of the time form translates to function, meaning when we make the nose to look right, it’s going to be functioning properly as well. But some of the issues are deep inside and you can’t even see them from the outside and we need to be able to fix those as well. There is some age guidelines for us in terms of when is the right time to do the surgery and those who are experienced usually do not do rhinoplasty on a male person, a boy earlier than age 14, and for a female age earlier than 13. But there are sort of loose guidelines and also the other end of the extreme, meaning older patients, as long as the health is good, we can do rhinoplasty at any age, but obviously as a certain age their skin becomes so thin and they also, health is so suboptimal that rhinoplasty is not a good choice.

But between those two limits, essentially we can do rhinoplasty on everybody. The type of rhinoplasty that the individuals can undergo varies from surgeon to surgeon. For example, some surgeons exclusively do closed rhinoplasty, meaning they don’t make a small incision in the column between in nostrils, there are surgeons that who do exclusively open rhinoplasty and most of us do almost exclusively open rhinoplasty, but to close rhinoplasty even within the closed and open rhinoplasty, there’s a category of preservation that has gained more recent popularity. Although it is not anything new, it is something that is over a hundred years old. The ultimate goal is to deliver the best result that every surgeon can deliver. Technical variations make some difference, but not really a major enough difference to be the reason for the patients to decide, okay, if you don’t do open rhinoplasty, I’m not going to have you to do the surgery.

If you are not doing preservation, I’m not going to do the surgery. But by you, they have to select this surgeon who has experience enough to deliver a good outcome regardless of what technique that person is going to use. But for many of us who do open rhinoplasty is about the precision, meaning control and being able to see what we are doing and setting the frame exactly the way we want. When you do a close rhinoplasty, you don’t have as much control and as much precision as we can exercise when we do a open rhinoplasty. But again, it is not to say that closed rhinoplasty is wrong as long as it’s being done by someone who’s experienced. If you are contemplating rhinoplasty and all of a sudden you have an accident and you break your nose, it would not be ideal to set everything on an urgent basis because sometimes the fracture in the bone is not in where you want to make the cut in the bone.

So it is commonly reasonable and the best choice is to initially set the bones in the right position that they belong to and wait a month, somewhere a month to a year to go back and then adjust everything to set it the way you want it. Unless it has ignored and somebody did not have opportunity to detect the fracture and we don’t know about it and then everything can be actually corrected at the same time, aesthetically and functionally related to the injury. There is some difference for the noses that have been damaged as a result of car accident, trauma or fight because the frame often is not in the right place, it makes the operation a little bit more difficult. Commonly the bones are not in the right place. Commonly the septum, the partition in the middle of nose that controls the shape of the nose and direction of the nose is not in the right place.

It makes the operation somewhat more complicated. But even on those noses, we often can get exactly what we want or very close to what we want. Ethnic noses, meaning African-American, Asian, middle Eastern, every one of them have a clear difference in the anatomy and also shape of the nose that requires understanding and correction properly. The African-American have often thicker noses. So are the individuals from South America and Asian noses often need to be built up rather than reduced. So we have to understand those nuances to be able to serve those patients better. And in fact, there is an expertise amongst us related to the ethnic nosis because again, they’re not exactly the same. Even anatomically inside the nose, African-American noses have available less cartilage to be used for some of the maneuvers that we need some cartilage for. So we need to be prepared for it.

When it comes to the word natural pertinent to the rhinoplasty, what most patients are referring to is a norm or beauty that is accepted by the majority without looking surgical. In fact, going back to early stages of my plastic surgery experience, I became very focused on what is going to produce natural noses. I’m a craniofacial surgeon by training, meaning we analyze every millimeter of the face in details to decide how the bones are functioning, what they need to do, what we need to do to eliminate the flaws. And that knowledge actually came to my head and over the years I developed a scientific way of analyzing the face, matching the nose to the face and creating proportionality. There are some faces that are larger and they need a larger nose to look natural. And those nose, a nose that may look perfect in one face is not going to look perfect on the other face.

It’s going to look unnatural, it’s going to look surgical and we can avoid that by adhering to certain beauty principles, angles, measurements. And we have actually, I published articles about it. It is in a rhinoplasty book that I have and I teach that to the residents and plastic surgeons as to how I conclude what is going to give that given patient a more natural look. And I’m not the only one that who got focused on others that I’ve been focused on, but it is crucial for us to analyze the face, entire face because the nose has to belong to the face and go with the face. And the advantage of doing this at this analysis that I can actually, I also share the pictures, life size pictures with the patients and show them what my plans are, what my aesthetic plans are, what are the alterations that I’m anticipating, and they have a good visual way of seeing what my goals are, my objectives are so they don’t wake up with a surprise after the surgery.

And also it helps me to understand what the patient’s desire. Have I ever declined a patient surgery because we are not on the same page? It extremely rarely, but it has happened. Within aesthetically policing range, there’s a slight latitude that still can give the patient a natural looking nose if we alter our plans minimally. But that is a small range and I want to make sure that with every patient I’m within that range of discussion. And it really gives the patients also more sense of comfort when they know that it is not about my personal taste, it’s about what is considered attractive looking for by majority of the individuals. Even within that range, we have to really take a lot of ethnic differences in consideration and we take care of that also. Yeah, approximately somewhere between five to 15% of the individuals undergo rhinoplasty require revision.

But I can tell you that the revision is merely the consequence of perfectionism of the surgeon and the patients. Meaning there are patients that they can actually accept some just minor asymmetries, minor flaws, but there are those who do not accept that. And the reverse is true also. There are surgeons like me actually, if the patient may tell me that she’s really happy, but I may look at the nose and see a tiny flaw here and there, I’m going to tell the patient, you know what? I can make the nose look slightly better with, but just to correct in that minor problem. So there are a variety of factors that actually also cause the revision for resulting revision in rhinoplasty and experience is probably the number one factor. Obviously those of us who have been doing this for a long, long time, I have been doing it for over four decades, I still see some flaws.

And the reason is we, as a physicians, know the patients can control the healing and sometimes healing can change the tissues. You form a little bit of a scar tissues that mars, the outline of the nose that we may want to correct that we do correct those. But also there are other insinuating factors and a lot of factors that actually come into play. If a primary rhinoplasty patient and I agree that there is some minor flaws in the nose, we schedule a revision surgery, I do not charge for the surgery. There’ll be a small anesthesia and smaller, I should say anesthesia and facility fee. That’s not true about the secondary rhinoplasty patients. And generally the steps that we go through during the surgery are really minor refinements. Often we don’t need a splint. I don’t often, we just some tapes commonly the patients recover a lot faster.

Commonly they don’t have to have those limitations in terms of the activities, meaning strenuous exercises for three weeks, usually just a week. And sometimes if it is minor, minor, minor enough, there’s really no limitation. They can go back to work the next day and resume all of their activities soon after the surgery. Some noses lend themselves to some alterations non-surgically to improve the shape of the nose. But in my view, there are very few that can do that. And I personally do not do that unless I’m buying time for some minor defect, some minor flaw in the nose until a year comes so I can do the major revision. It is not to say that it’s the wrong operation for patients who do not want to have surgery, that could be a possibility, but you cannot make a really wide tip narrower with adding volume there.

Fillers meaning these alterations are going to be done by the fillers. And when you add fillers, you’re adding volume. If the flaw or imperfection is deficiency, it can be camouflaged by a filler, but if it is excess, there’s no way that you can camouflage that by adding volume without making the nose larger than it should be. So again, there’s a possibility can be done but on certain patients and properly selected cases. And the reality is that the patients need to know that they have to keep doing that, meaning go back and have the fillers placed in their nose to achieve the same changes if it pleases them. However, the individuals are having fillers in their noses, they need to know that there are some serious potential complications and that is skin necrosis. And unfortunately I have had the opportunity to take care of some of those patients there who had the injection done by somebody else and they’re not really easy to take care of if one of the limitations that we have noses adjustment is necrosis of the skin, meaning skin dying. And that can come from injection of fillers. It does not happen often, but when it happens, it is very serious. So that complication has to be taken into consideration

Announcer (16:06):
Links to learn more about Dr. Guyuron and anything else mentioned on this podcast are available in the show notes. Head On is a production of The Axis.

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