Rhinoplasty Before & After Case 1
A septorhinoplasty and revision of her pharyngeal flap improved her breathing and refined her nasal tip, with no negative effects on her speech.
There’s nothing like being able to get a good night’s sleep!
Rhinoplasty Before & After Case 2
She is seen here early in her recovery, and can already breathe much more easily.
She also said we “gave her back her smile!” after revising the notch in her cleft lip.
Rhinoplasty Before & After Case 3
I performed a rhinoplasty to straighten a deviated septum, and used the removed cartilage from the septum to make grafts that helped to straighten and support the nasal passages.
We also chose to perform a genioplasty, moving the chin forward to balance his facial features.
Rhinoplasty Before & After Case 4
I performed an open rhinoplasty, with straightening of his septum and use of the septal cartilage along with ear cartilage to straighten and support his nose.
His breathing and symmetry is already much improved at 1 week after removal of his splints.
We also repaired a small notch in his lip, and performed fat grafting to his upper lip and a bone graft to his cheeks to improve his facial harmony and balance.
Rhinoplasty Before & After Case 5
The septum (or wall between the two nostrils) is deviated away from the cleft, and the cartilage on the cleft side is usually smaller and weaker.
Correction of the deviated septum, and use of the cartilage for grafts to buttress the airway, helped to improve his nasal symmetry and ease of breathing.
Rhinoplasty Before & After Case 6
I performed an open rhinoplasty to straighten her nose, including nasal osteotomies, dorsal hump reduction, and refinement of her nasal tip.
She returned at one week with a huge smile and amazement at how much better she can breathe! She is also pleased with a refined nasal contour that still harmonizes with her face.
Rhinoplasty Before & After Case 7
She came to us with difficulty breathing and severe deviation of her dorsum.
Bruising and swelling is expected early on, especially if the nasal bones need to be repositioned as was done here.
Her septum was straightened and reinforced with cartilage grafts that helped support her internal nasal valve.
I also filled in a small notch in her right alar rim with cartilage where the rim had been pulled up years ago from a skin cancer reconstruction.
I love paying attention to these finishing details to make the results as great as I can!
Call our office today if you have a crooked nose we can help straighten, and let you breathe through it again!
Rhinoplasty Before & After Case 8
We performed an open rhinoplasty using spreader grafts and nasal bone reduction to smooth her contour and help her breathe better than ever!
Here she is seen at 2 weeks after splint removal. Swelling will continue to come down with taping and time. We can’t wait to see her final results!
Rhinoplasty Before & After Case 9
This handsome man had severe nasal obstruction and nasal asymmetry, with collapse and less growth of the left side of his nose. He also had a notch of his upper lip with some irregular scar texture.
Open rhinoplasty was performed, with release of the old scar tissue, and multiple cartilage grafts from his septum used to support his collapsed nasal passages, and to fill in the deep depression at the left alar groove.
Removing the crooked septal cartilage also helped open up his nasal airway.
The lip was re-repaired, with removal of the irregular scar tissue and improved balance of the height and width of the skin, dry mucosa, and wet mucosa, along with the underlying muscle.
Each of these components must be addressed individually, as well as all together kept in balance.
His swelling will continue to improve for at least 9-12 months, though some patients report improvement even at 18-24 months. He is seen here at 4 months.
Rhinoplasty Before & After Case 10
This beautiful patient is thrilled after her cleft rhinoplasty!
She had the normal development we see with most cleft lip patients.
Her septum was pointing to the right — away from the cleft side — causing severe nasal obstruction.
She also had slumping and weakness of the cartilage and skin on the same side as her cleft lip.
We performed a closed technique (incisions all inside the nostrils), to straighten the septum.
Cartilage grafts from the removed septum were then used to straighten and support her nose.
She is seen here 1 month after her surgery, breathing better than ever! Swelling gradually improves over the next 6-12 months.
Rhinoplasty Before & After Case 11
First and foremost, he had difficulty breathing because of a deviated septum.
From the front you can see a slight deviation of the bridge of his nose extending to the tip. As it extended into his nasal passage, the deviation was more and more apparent, causing almost complete blockage of air movement on one side.
Correction of the deviated septum – and use of the septal cartilage grafts to the dorsum and cleft side of the ala – greatly improved his breathing.
He also has an improvement of his definition and symmetry, even at just 1 month after surgery with more improvement of his swelling still ahead of him.
Rhinoplasty Before & After Case 12
She also had some imbalance of her lip, with the height of the skin several millimeters shorter on the cleft side. This can be seen with very small imbalances magnified over years as a child grows. The scar tissue also usually does not grow as well as the surrounding skin, so even slight over-lengthening can still leave that side shorter over time.
Here, a cleft rhinoplasty and revision of the lip scar opened up her breathing tremendously. Her symmetry of the tip and wings of the nose is improved, with some upward rotation and tip support added.
Her lip was also revised, with a strong focus on not just the skin, but rebalancing the muscle height and direction of the muscle fibers.
As always, the scars will fade and flatten with time and care. She is seen here at 3 weeks after surgery.
Rhinoplasty Before & After Case 13
This athlete couldn’t breathe, with a history of a fractured and deviated septum, and a pharyngeal flap previously used to help speech for her cleft palate.
For patients with a history of a pharyngeal flap, these may actually be divided and revised after several years, usually with no change in speech and nasality, but with much improved breathing and speech.
In the same setting, her fractured septum was straightened, and cartilage grafts including spreader grafts and columellar grafts helped to let her breathe through her nose!
Her dorsum is now more regular, and her tip more refined and rotated up.
These are some of my favorite surgeries, tailoring surgeries to each person’s individual goals and needs, all while making sure they’re breathing like never before!
Rhinoplasty Before & After Case 14
I thought I had sleep apnea. My wife tells me my snoring went away… I’m just sleeping a lot better. Now I feel more rested and just breathing a lot better.
Slow process of trying to actually breathe correctly for the first time in my life, through my nose instead of through the mouth.
The smile says it all! Nearly 100% of our cleft patients have difficulty breathing.”
Factors include the septum deviating away from the cleft towards the nostrils from the asymmetric pull of the orbicularis muscle and other soft tissue attachments seen with most repairs historically. Further back, the septum follows the bone deviating and collapsing towards the cleft.
Other considerations are weak and collapsed cartilage in the middle and lower thirds of the nose, and compensatory inferior turbinate hypertrophy.
Structural rhinoplasty was performed via an open approach, with spreader grafts, lower lateral cartilage repair (with reorientation of his previous surgical repair), and septal extension graft. Turbinate outfracture and ablation is used adjunctively based on palpation and exam after correcting the deviated septum.
Rhinoplasty Before & After Case 15
Those surgeries included 2 free flap surgeries, but he still had a fair amount of asymmetry and tightness of the upper cheeks and soft tissue on the entire left side of his face.
He has since gone through two surgeries with us.
He is a full year since a dermal-fat graft to the cheek, and fat injections around the eye and cheek. The grafting has held up well, with no further fat grafting nor fillers since then.
More recently, a few weeks ago we performed a septorhinoplasty with cartilage and acellular dermal grafting, via a closed approach (no incision across the columella).
Some cartilage did come from his ear, and in the process that ear was intentionally set back to improve that ear symmetry despite the severely asymmetric bony base.
His breathing has improved as well, and he is happy with the improvements we’ve been able to make!
Rhinoplasty Before & After Case 16
Septoplasty and spreader grafts, with tensioning of the upper lateral cartilages over the grafts, helped his breathing. This is like having an internal Breathe Right strip people use for snoring and nasal collapse.
His contour and projection match his face well, with his dorsum straighter and tip projection increased.
An onlay alar graft and tip graft helped to soften his alar groove, and added to his tip support.
Finally, the fat graft to his upper lip acts as a permanent filler, balancing the thinner upper lip with the more full lower lip. I generally prefer using fat over dermal fillers, as I like giving the longest-lasting results with the fewest number of procedures. Plus, insurance will cover the fat graft procedure, and fillers are paid cash out of pocket.
Rhinoplasty Before & After Case 17
Not every patient requires a rib graft, or total deconstruction and reconstruction of the nose.
Here, we used a spreader graft on just the left side of the nose, columellar strut graft, and suture techniques to unite, reorient, and reconstruct the cartilage support.
Fat was also transferred to his upper lip to provide a little more fullness to balance with his lower lip.
We look forward to seeing him back again as the swelling continues to improve over the next 12-24 months.
Rhinoplasty Before & After Case 18
However, if nasal obstruction and symptoms are severe, nasal reconstruction before jaw surgery is sometimes done, knowing that a second surgery may be needed after the maxilla is moved forward.
Here, septal deviation and airway collapse led to nasal obstruction, sleep apnea, and difficulty with daily activities.
Also, her upper lip balance had room for improvement of the skin height, white roll continuity, muscle continuity for playing a brass instrument, and rolling in of the exposed wet mucosa (which otherwise cracks, bleeds, and is painful if chronically exposed).
The lip was fully taken down and re-repaired similar to a primary cleft lip repair.
Her nose reconstruction included septoplasty (reset, and resection of cartilage and bone), spreader grafts, columellar strut, tip and alar grafts, and dermal-fat graft.
She has made tremendous progress after 5 weeks, breathing well and excited to return to playing her instrument!
Rhinoplasty Before & After Case 19
She also hoped for improved nasal symmetry. We performed an open cleft rhinoplasty, including release of scar tissue and reconstruction with multiple cartilage grafts (spreader, septal extension, columellar strut, lateral crural strut, and tip grafts).
MTF cadaveric cartilage was used after discussion pros and cons of using her own rib versus donor cartilage.
She is seen here at just 4 weeks, so the swelling will still go down another 50%. Fat graft was also performed for the upper lip, to add more bulk to begin balancing that with the lower lip.
Jaw surgery will be performed in the future. Cleft rhinoplasty is usually performed after jaw surgery. However, in this case, her breathing obstruction was severe enough to warrant doing the nose portion sooner.
The alar base scarring and any further refinements may be done at the time of the jaw surgery.
Rhinoplasty Before & After Case 20
She has a history of previous surgery but had chronic problems breathing through her nose.
Closed septorhinoplasty (*no incision* across the columella) was done. Key maneuvers included septal resection, spreader and caudal septal extension grafts, and tip sutures.
This opened and strengthened her airway. She also had more dorsal support and definition.
Rhinoplasty Before & After Case 21
A gentle hump reduction and contouring of the dorsum can be done at the same time.
Here, preservation techniques to bring the nasal bones down, and component septal resection and spreader grafts, all work together for a natural result at just 1 month post-op.
Rhinoplasty Before & After Case 22
While correcting the deviated septum, we used that cartilage to make spreader grafts that support the airway further.
We also opted to bring his dorsum down, but kept it masculine and not too upturned.
His swelling is about half way down at this 1 month mark, but he’s already breathing well and liking his new contour.
Rhinoplasty Before & After Case 23
This patient communicates beautifully and expressively with her eyes and smile, but her nose was distracting and causing progressively worse breathing problems.
Anatomically, her septum and columella twisted to the left, and her lower lateral cartilage on the left with asymmetric amounts of lateral crural steal and medial crural excess.
After careful discussion about goals for breathing and symmetry, open approach rhinoplasty was performed, including septoplasty, spreader grafts, and tip reshaping.
She is swollen at this early 1 month mark, but already breathing better and getting compliments on her nasal remodeling.
We look forward to her definition and refinement showing through over the next 6-12 months!
Rhinoplasty Before & After Case 24
This patient had a previous trauma with reduction of the fractures done appropriately after her injury.
Unfortunately, over time the deviation and airway collapse continually worsened.
Open approach, structural rhinoplasty was required to build back up her framework, including extended spreader grafts that replaced her dorsal nasal bone entirely on one side where it was badly deformed.
The swelling has begun to come down at 1 month, and experience has shown that this continues to improve quite a bit over 12-18 months, and even beyond.
Rhinoplasty Before & After Case 25
Here, a deviated septum and narrow internal nasal valve were corrected with a septoplasty and spreader grafts, improving her nasal breathing.
The dorsal hump was brought down and smoothed as planned.
Under the hood, the turbinates are little humidifiers inside the nasal passages. These little outcroppings can be pushed out, and shrunk with RF energy to improve the airflow. Complete removal is not recommended except in some cleft or craniofacial rhinoplasties with severely narrowed anatomy.
She is seen here at 3.5 months post-op.
Rhinoplasty Before & After Case 26
A few things combine to create common complaints:
1) Inherently different/less growth potential
2) Asymmetric and/or abnormal attachments of muscles and ligaments
3) Bony asymmetries
4) Scar tissue
5) Abnormal blood and lymphatic flow
These inevitably lead to problems breathing, and often thick and scarred nasal envelopes that are difficult to restructure.
Here, septoplasty, multiple grafts (spreader, lateral crural strut, septal extension, and tip), all work together to provide a more symmetric and projected framework. The cartilage was a combination of his own septum and from MTF cadaveric rib. Other options include one’s own ear and/or rib cartilage.
He is seen here at 1 month, with swelling improving every day.
Rhinoplasty Before & After Case 27
Sometimes it may be due to underlying differences in bone structure – like in craniosynostosis, hemifacial microsomia, or a facial cleft.
Here, her nasal tip and nasal bones are subject to a subtle craniofacial “twist” from a history of craniosynostosis, even after previous cranial vault reconstruction. There is less projection of the left brow/orbit, and slight peaking of the skull base on that side.
This may also have contributed to the saddle nose seen with a dip in the mid-vault seen well from the oblique view.
Open approach rhinoplasty with structural reconstruction included spreader grafts, fixed columellar strut and septal reset, and nasal bone osteotomies. This lined up the upper, middle, and lower 1/3rds of her nose, and improved her breathing.
The nasal envelope will continue to smooth out as the skin and subcutaneous tissue adapts to the underlying structural support over time.