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THE SEATTLE FACIAL PLASTIC SURGERY CENTER
DR WILLIAM PORTUESE | 1101 MADISON ST #1280 SEATTLE, WASHINGTON 98104 | (206) 624-6200
Dr William Portuese - Board Certified Facial Plastic Surgeon in Seattle WA

Rhinoplasty Surgery – Nose Job

A Rhinoplasty, or ‘nose job,’ is a procedure to alter and change the shape of the nose. It is the most common procedure performed in our facial cosmetic surgery practice. The goal of Rhinoplasty is to give patients a very natural appearance with all of the components of the nose and face balanced with each other, and the entire new nose balanced with the patient’s facial features. There are many undesirable features of the nose that can be changed with a Rhinoplasty procedure. If a nose is too wide, it can be narrowed, a dorsal hump can be removed, a wide and boxy nasal tip can be refined , and a crooked nose – which may have been broken – can be narrowed. If there Is a functional breathing issue, it can also be addressed at the same time as a cosmetic Rhinoplasty procedure.

Before and After Rhinoplasty

Straightening a Nose

There are many issues contributing to a crooked nose; a deviated nasal septum, fractured and displaced nasal bones and a deviation of the septum creating a crooked nose in addition to a fracture of the septum off the maxillary crest and vomer. When an upper lateral cartilage has been fractured and dislocated off of the nasal bone itself, it can create a concave midportion of the nose. Treatment for this is usually a rhinoplasty which includes osteotomies placed in the nasal bones to straighten them back to their pre-injury state. A cartilaginous spreader graft, harvested from inside the nose, can accomplish straightening the midportion of the nose and building out the concave upper lateral cartilage. A tip-plasty is required on the nasal tip cartilages when they are asymmetrical and cartilage grafting or cartilage removal may be required. A Septoplasty is required for a fracture of the nasal septum and deviated septal cartilage itself. Any of these surgery components can be performed using the closed rhinoplasty approach under general anesthesia as an outpatient surgical procedure.

Reduction of the Bulbous Tip

The bulbous nasal tip is created from a combination of wide, divergent and thick nasal tip cartilages, known as the lower lateral cartilages of the nose. Suture techniques called inter-domal and intra-domal stitches are used to narrow the existing wide and boxy nasal tip cartilages. In addition to suture techniques to narrow the nasal tip cartilages, a conservative amount of cartilage is also removed to improve the nasal tip contour and maintain a natural outcome. These maneuvers can be performed with a closed rhinoplasty approach where all incisions are placed on the inside of the nose.

Narrowing a Wide Nose

A wide nose is usually present due to the congenital development of nasal bones. Wide and splayed nasal bones can also be present due to trauma and a nasal fracture. Narrowing the nasal bones requires medial and lateral osteotomies placed in the nasal bones themselves. This accomplishes the narrowing of the upper two thirds of the nose – the nasal bones and the corresponding upper lateral cartilages. A cast is placed over the bridge to hold the nasal bones in their narrower position.

Lifting a Droopy Nasal Tip

A droopy nasal tip is usually the result of downwardly pointing nasal tip cartilages. These cartilages can be lifted with a closed rhinoplasty procedure. The drooping tip can also be caused from a downward deviation of the caudal nasal septum as well. When the tip of the nose droops when smiling, “releasing” the depressor septi ligament is required. This prevents the tip of the nose from drooping dynamically when smiling. It is very important to lift the tip of the nose for both static and dynamic results when performing a rhinoplasty procedure.

Shaving Down the Dorsal Hump

A cosmetic Rhinoplasty to remove the dorsal hump is a very common reason for patients to choose a surgical rhinoplasty procedure. Most dorsal humps are composed of about two thirds cartilage and one third bone, but it can quite a variable based on individual anatomy. The dorsal hump must be shaved down in order to remove it. Once the dorsal hump has been removed, osteotomies placed in the nasal bones are required to close the open roof ( flat-top) nasal deformity that is created from the hump removal. The dorsal hump is the most common reason a patient will choose to have a nose job.

Breathing Difficulties Out of the Nose (Nasal Obstruction)

There are many issues that can cause breathing difficulties; Allergies – treated with nasal sprays, antihistamines and decongestants and turbinate hypertrophy – treated medically as well. When a medical therapy has failed, consideration for turbinate surgery may be made. Valve collapse and vestibular stenosis on the inside of the nose can be static or dynamic with inspiration, and are treated with spreader graft placement (from cartilage harvested from inside the nose) to bolster the nasal valve and upper lateral cartilage from falling inwards when breathing. A deviated septum blocking airflow is also a very common reason for nasal obstruction. This is treated with a surgical septoplasty procedure. Chronic sinusitis is caused from chronic sinus polyps located inside the sinuses and is treated with functional endoscopic sinus surgery.

Widening a Narrow Nose

Many patients are born with a very narrow and inverted upper lateral cartilages creating an hourglass appearance along with thin nasal bones. Reverse osteotomies and spreader graft placement are used to hold the nasal bones in the new open and wider position. These maneuvers are part of a closed rhinoplasty and are performed to widen a narrow nasal vault and narrow nose. A cast is applied across the nose for one week.

Rhinoplasty with a Chin Implant

A chin implant is performed in conjunction with a rhinoplasty when patients have an overly projecting nose in combination with an under projecting chin. The under-projection of the chin makes the nose look more prominent than it really is and placement of a chin implant can augment the chin further to give better facial balance and proportion, realized mostly from the side profile. Chin implants are manufactured in a large array of sizes, thickness and shape and the appropriate size is best determined at the time of the consultation and examination. Digital computer imaging is also helpful to understand what can be accomplished with both procedures to give better facial harmony and balance.

Reduction of the Hanging Columella

The hanging columella can be the result of previous rhinoplasty surgery, although many patients are born with excess skin and cartilage in that location. When there is excess skin and cartilage creating a “bottom heavy” look in the nose, a columella-plasty can be performed. This involves surgical removal of skin and cartilage on the inside of the nostrils along the nasal septum. This surgery, in addition to just simply tucking the columella inward can also help raise or lower the tip when necessary . Columella-plasty is usually an integral part of a closed rhinoplasty procedure.

reduction of the hanging columella

Revision rhinoplasty

Revision Rhinoplasty surgery is more difficult than a primary rhinoplasty due to the fact that there is scar tissue present and previous alterations to the normal anatomy. There are many reasons patients undergo a revision rhinoplasty; a residual dorsal hump, polybeak deformity, a hanging columella, twisted and asymmetric nasal bones or concavities somewhere in the nose which requires a cartilage graft.

Sports Related Injury and Rhinoplasty

Basketball, football and soccer tend to be the most common sports-related injuries to the nose. Male Rhinoplasty patients typically desire a stronger profile which keeps the nose masculine, yet refined while female patients may desire a subtle feminization.

Closed Rhinoplasty versus Open Rhinoplasty

In a Closed Rhinoplasty surgery all of the incisions are placed on the inside of the nose, with no visible external incisions. An Open Rhinoplasty means there is an incision across the columella of the nose to access the tip and the bridge and it is performed by lifting the entire nasal tip skin up off of the nasal tip cartilages. Dr. Portuese uses the closed technique to obtain natural and balanced results for his patients without the need for an external incision on the nose

Anesthesia for Rhinoplasty

Dr. Portuese performs all rhinoplasty procedures under general anesthesia by a board certified physician anesthesiologist. The procedure is performed in our Medicare certified outpatient surgery center adjacent to Swedish Medical Center in Seattle, Washington.

Postop Recovery

A cast is placed across the bridge of the nose during surgery which will stay on for one week. There is no painful packing placed on the inside of the nose, and all the incisions are internal with dissolvable stitches. It is important to understand that there will be 2 weeks of visible bruising and swelling and patients must refrain from any physical exercise during that time. Desired visible end results show around 3 months post op and a full year of healing is to be expected.


If you are considering rhinoplasty in Seattle WA contact Dr. William Portuese at 206-624-6200

Useful Links
Frequently Asked Questions
Nose Issue Information and Diagrams
Sinus Surgery Brochure
Patient’s Complete Guide to Rhinoplasty©

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Washington Ambulatory Surgery Center Association Washington State Medical Association American Academy of Facial Plastic and Reconstructive Surgery Real Self