Getting things started this morning with a
very beautiful rhinoplasty.
What you're gonna see that we're gonna have
to be doing for her is she's got a real hump
to her nose here; we definitely want to take
this down.
She also has a real bend to her nose.
The bend to her nose is totally blocking off
her airway and she's really struggling to
breathe out of the nose.
So we're going to make massive improvements
there as well.
Would like to refine the tip a little bit,
make that a little bit smaller and more petite.
And we also want to thin out the width of
the nose which is also wide for her otherwise
fine features.
So this central part of the nose is called
the columella.
We make an incision that's an inverted V to
break up the scar there so that it's very
hard to find long term.
You can see here is this white is cartilage
and these are called the lower lateral cartilages
and they meet down here in the middle of the
columella.
Actually inside the nostril and we actually
come in between the skin and the cartilage
here to help separate the skin from the underlying
structure of the nose.
So there are four basic parts to the structure
of the nose.
These are the lower lateral cartilages and
they're the first part of the structure of
the nose and they form a dome.
I like to compare them to the McDonald's golden
arches.
These cartilages are what gives the tip of
your nose shape.
The pointier and thinner they are the pointier
and thinner the tip of your nose will be.
This instrument is called the oferic and we'll
introduce this into the nose to help lift
the skin and fat up while we're dissecting.
So we're now separating the two domes or the
two lower lateral cartilages from each other
to help give us exposure.
The next critical structure in the nose; this
piece of cartilage here is called the nasal
septum.
Now we're gonna separate that septum from
our other critical structure the upper lateral
cartilages.
You see as the septum and then the upper lateral
cartilage on the side.
Alright, let's walk through that anatomy again.
You have your lower lateral cartilage, your
lower lateral cartilage, your septum, and
then you have your upper lateral cartilage
on this side, and your upper lateral cartilage
on this side.
You see this glistening white septal cartilage
showing all the way down to the bottom of
the nose.
Start taking down the hump of the nose and
we're gonna use that with this special instrument
called our angle septal scissors.
Cartilage we're removing to get rid of that
hump.
So we've taken out the cartilage portion of
the hump, but as you notice there's still
a hump right here.
That comes from the fourth critical structure
that makes up the nose; the bone.
We use this rasp now to take that boney hump
down.
Alright, now that we've taken down out the
boney and the cartilaginous hump, look at
that profile, beautiful.
Alright, we're gonna take out the piece of
septum from the middle that we're gonna use
to reshape the rest of the nose.
I'll highlight now the bend that's in her
septum from her previous breaks in her nose.
This is why her nose is not straight.
This is the piece of the cartilage that we
removed from the center of the nose.
We're now marking how we're gonna divide it
up so we can use it to make different structures.
What you see is we've created three separate
struts that we're gonna then use to restructure
the nose.
You can think of the nasal airway like a tepee
with the septum and the upper lateral cartilages
here.
This is called the internal nasal valve.
Someone is having decreased airflow through
this internal nasal valve, the fix for that
is to pop that valve open.
So we're gonna create these struts that will
open up the tepee and really open up the airflow
through here.
We saw in the last shot how the septum was
all bent and curled, we've put our first strut
here, securing it in place now look how nice
and straight it is.
Now I've added a second strut on the other
side.
These struts are so much thicker than the
septum and there's two of them, okay.
This is gonna ensure that this nose is rock
solid straight.
I talked about that tepee to breathe, this
is the outer leg of the tepee, the upper lateral
cartilages.
Having that strut in there that opens up that
internal nasal valve is really gonna improve
her breathing.
This strut now, this is called a columeller
strut.
Remember this little central piece here is
called the columella.
So this strut helps hold and support the tip
in its newly shaped position.
So we've put that strut here down the middle
and now we've done some suturing here to reshape
the tip to make it much more fine at the very
end.
Starting to close the incisions, but don't
worry there's still more action to come.
So we've closed the nose, totally reshaped
it, now the last thing left to do is she's
a little bit wide naturally through here.
The fix for that is gonna be to break her
nasal bones and bring them in.
Open the nasal bone from here all the way
to here which allows me with my finger to
push it in.
One thing you'll notice is that my fingers
are holding the nose with my left hand the
entire time.
And the reason is the very tip of my finger
is feeling the edge of this chisel to know
exactly where it is.
Since you obviously can't see what's happening,
this is where really having that connection
between your mind and the instruments is critical.
This is where having a really experienced
rhinoplasty surgeon makes all the difference
in the world.
We completed the breaks it really allows us
to narrow that bridge of the nose and thin
it out.
What a big difference.
Here we fixed the hump on the nose, we've
straightened it out, really opened up the
airways, it's a little bit more petite and
refined, and really thinned the side of it
for a fantastic result.
This is what we're gonna make the splint out
of.
And then we put pressure exactly where we
want the bones to heal.
You wear the splint for approximately a week.
