Seen as one of the biggest targets of complaints and discontent in plastic surgery offices, the nose plays a very important role in a person's appearance, mainly because it is part of the face's composition and occupies a prominent position in the centre. In addition, it is fundamental for the balance and harmony of the entire face, having a direct connection with the patient's self-esteem. A nose with an unsightly or disproportionate appearance ends up retaining all attention for you, in addition to causing discomfort and embarrassment.
Any improvement in the shape and size of the nose can have a great impact on the patient's self-image and confidence, bringing back the self-esteem that was previously lost.
Rhinoplasty, or nose job, poses some challenges to the plastic surgeon, either because of the diversity of techniques that can be used, or because of the anatomical differences of each patient, which requires specific planning for each case.
At the Zamarian Clinic, we offer exceptional Brazil rhinoplasty solutions that can be used to improve the appearance of any patient's nose whose nature has been negligent. Proven to be one of the most commonly performed facial aesthetic procedures, nose job surgery can reshape and resise the back, tip, and nostrils to create a better aesthetic appearance. In addition, it is possible to improve nasal breathing, correcting eventual deviation of the septum, hypertrophy of the turbinates and performing corrections in the internal and external nasal valve. In this way, we promote a complete treatment, both aesthetic and functional.
Londrina plastic surgeon Dr. Walter Zamarian Jr., specialised in the United States, under the guidance of the best nose surgeons in the world, in aesthetic and functional rhinoplasty. Not only does he have a keen aesthetic sense to allow for a beautiful and natural result, but he also has the skill and knowledge necessary to provide the maximum possible improvement in nose breathing. That's because it addresses the four pillars of nasal breathing during rhinoplasty: septum, turbinates, internal nasal valve and external nasal valve.
The nose has the following functions: breathing, humidifying and filtering the air, as a temperature regulator and protection, in addition to enabling the sense of smell. All these important functions of the nose must be taken into account by the plastic surgeon when performing an aesthetic rhinoplasty, so that this surgery does not interfere with any of the elements responsible for these functions. These elements are: the septum, turbinates and internal and external nasal valves, fundamental structures that directly influence the flow of air in the nose.
The nasal septum is a perpendicular structure, like a wall, which is composed of a cartilaginous part, called triangular cartilage, and a bony part, formed by the vomer and ethmoid bones, dividing the nose in half, in two nasal cavities, right and left. The air passes in a laminar fashion on each side of the septum. When it is desired to improve the function of the nose during aesthetic rhinoplasty, the septum must be evaluated in its entirety, as any deformity, deviating the septum, can alter the laminar flow of air and lead to a secondary increase in the turbinates. The surgery indicated in this case is septoplasty, which corrects the deviated septum. The good news is that plastic nose surgery can be combined with septoplasty to correct both aesthetic problems and functional problems of a nose, which we call rhinoseptoplasty. Dr. Walter Zamarian Jr. performs the aesthetic part of the rhinoseptoplasty, after his colleague Otorrino has improved the septum deviation and eventual hypertrophy (enlargement) of the turbinates.
The nasal turbinates are curved bone plates, as a lateral elevation of each wall of the nasal cavity, covered with mucosa, which stand out from the inner face of the ethmoid and protrude from the outside of the nasal cavities. They play an important role in the respiratory system, the immune system and the sense of smell in humans. There are two types of turbinates: the constant turbinates which comprise the lower, middle and upper turbinates and the inconstant turbinates which comprise Santorini's turbinate and Zuckerkandl's turbinate.
The lower turbinate is the largest turbinate among the three, being responsible for humidification, temperature and filtering of the air that enters through our nose. In addition, the lower turbinate has the greatest impact of resistance to the inflow of air into the nose, and can account for up to two-thirds of that resistance. The middle turbinate is the middle one, which protects the sinuses from coming into direct contact with the air stream. Finally, the superior turbinate is a smaller structure, which is connected to the middle turbinate by a nerve ending and is responsible for protecting the olfactory bulbs.
The mucous membranes, which cover the bony part of the turbinates, undergo a cycle of expansion and contraction mediated by the autonomic nervous system. Problems related to the turbinates are treatable during rhinoplasty, when it is also desired to improve respiratory function. Changes in the size of the nasal turbinates are known as turbinate hypertrophy and are very common in cases of bullous turbinate (swelling of the turbinate that can obstruct the sinuses), allergic rhinitis, and vasomotor (non-allergic) rhinitis. They can be treated in conjunction with rhinoplasty, by cauterizing the turbinates or removing them through turbinectomy surgery, also called turbinoplasty.
The nasal valve is an important regulator of airflow dynamics, and is divided into the internal nasal valve and the external nasal valve.
The internal nasal valve is the angle formed between the septum and the anterior border of the triangular cartilage. Its preservation, during nose surgery, is essential to avoid a sequel of collapse of the nose wings during inspiration. If the patient seeks a plastic surgeon with this complaint, the treatment performed may require a cartilage graft called "spreader graft".
The external nasal valve is located anterior to the internal nasal valve and is the vestibule that enters the nose. It may be obstructed by extrinsic factors (foreign bodies) or intrinsic factors (weakened alar cartilages due or not to previous plastic surgery of the nose, loss of vestibular skin or scar narrowing). There are several possible treatments for external nasal valve, which will depend on the case at hand.
The Brazil rhinoplasty performed by Dr. Zamarian involves reducing the nose in three dimensions, resulting in a natural and harmonious appearance with the face. Most of the time, when referring to a large nose, it is due to a high and long back. When the bridge of the nose is lowered, it becomes proportionately longer. It is for this reason that we almost always have to shorten it, also lifting the nasal tip.
The bulbous tip is one of the most frequent nose complaints in a plastic surgery office. Patients feel uncomfortable with the famous "potato nose" and want to see their nasal tip thinner and more delicate. To thin the nose, the partial removal of the alar cartilages is usually enough, always taking into account the thickness of the skin of each one, which can be a limiting factor in cases of nose with very thick skin. In some reserved cases, a complementary manoeuvre may be necessary to thin the nasal tip in closed rhinoplasty, which consists of the "bucket handle", also called "delivery". This manoeuvre aims to bring the knees closer to the alar cartilages to the centre, making their angle more acute and, as a consequence, further thinning the nasal tip.
The natural aesthetic of the nose dictates that the tip should have a higher projection than the nasal dorsum. When this does not occur, the nose is said to have a drooping tip, that is, lower than the back. This can be due to one of two (or both) reasons: very high back or very low tip, both of which can be corrected by surgery. In the case of a very high back, the treatment is lowering the back with a chisel and/or scraping. When the tip is too low, it can only be sutured higher after shortening of the caudal septum (more frequent), or supported with a cartilage stake in the columella.
Displacements are typically treated with dorsum lowering and fracture, along with septum repositioning if necessary. For cases of deviations involving the tip, Dr. Zamarian frees the septum from the columella and can also make relaxing incisions in the upper part of the caudal septum, on the concave side. Rhinoseptoplasty, performed together with a colleague, Otorrino, may often be necessary so that the septum can be rectified, allowing for an adequate treatment of the nasal deviation.
They can be closed by removing a segment on their lower and lateral sides, leaving the scars in excellent shape, and positioning them so that they are imperceptible. Uses, for this, a compass to measure the nostrils, so that the removal of the nostril segment is symmetrical and has a harmonious result.
Allergic rhinitis is a condition in which the nasal mucosa is hyperreactive, causing itching (itching), sneezing (sneezing), bad sense of smell, headache (headaches) and a runny nose. Rhinoplasty does not improve or worsen allergic rhinitis. This condition can improve by avoiding agents such as dust, fur, curtains, paints, insectisides and perfumes, or with local (topical) treatment with sodium cromoglycate or corticosteroid in spray, for example.
Whatever technique Dr. Zamarian for his rhinoplasty, he will perform according to the most modern tactics, learned by him in Brazil, with professor Ivo Pitanguy, and in the United States, with the biggest names in rhinoplasty in the world. Not only does he care about improving the aesthetics of your nose, he also takes care of every detail that can be addressed so that your breathing is the best it can be. He learned from Dr. Dean Toriumi of Chicago, the most renowned otolaryngologist who performs rhinoplasty, treats the turbinates, the inner nasal valve and the nostrils, in such a way that patients with difficult breathing can have the double benefit: of a beautiful result and of a function nose properly. Likewise, Dr. Ali Sajjadian from California relayed to Dr. Zamarian the modern techniques of nasal structuring in closed rhinoplasty, making its results evolve in a high degree. "I was already passionate about the results of closed rhinoplasty, according to Professor Pitanguy's principles. Now, with the structuring of the nose, both in closed and open rhinoplasty, in addition to obtaining aesthetically natural noses, the improvement in breathing greatly increases satisfaction of patients with the result."
Dr. Zamarian explains that structured rhinoplasty focuses not only on the aesthetic result, but also on improving breathing. In this way, in addition to lowering the back, narrowing the nose and raising and tuning the tip, other details are also performed, such as:
The internal nasal valve is an important part of the inside of the nose that helps regulate the passage of air. For this reason, the nose plastic surgery performed by Dr. Zamarian aims to reinforce the structure of the internal nasal valve with grafts called spreader graft. They consist of a strip of cartilage placed on each side along the bridge of the nose, running from the nasal bone to the tip. These grafts, in addition to serving to keep the nose aligned in the midline, serve to keep the internal nasal valve opening, improving breathing, especially in patients with weak lateral cartilages. Grafts can be taken from the septum, costal cartilages or, less frequently, from the ears. Dr. Zamarian has been dedicated to the functional part of the nose, and performs spreader graft in both closed and open rhinoplasty. The correct technique for placing a spreader graft by closed rhinoplasty is not so widespread in Brazil, and Dr. Zamarian went to acquire this knowledge in the United States, with Dr. Ali Sajjadian. This was a landmark given to her closed rhinoplasty results. Since then, the association of spreader graft with the treatment of the turbinates, when there is hypertrophy, has given nose plastic surgery patients a greater respiratory capacity. Many notice this improvement from the first week, even with the nose swollen inside.
Many patients looking for a rhinoplasty complain of a drooping tip and present columelolabial retraction. This means that support for the tip of the nose is lacking, and it is common in patients with weak or soft cartilage in the nose. To provide cutting-edge support and open the columelolabral angle, Dr. Walter Zamarian Jr. performs one of two procedures: septal extension graft in open rhinoplasty, or stake graft in the columella, in closed or open rhinoplasty. When the tissues of the nose are heavy and the need for support is great, Dr. Walter is for open rhinoplasty with septal extension graft. This graft consists of a segment of cartilage that is placed vertically, resting on the anterior nasal spine and slightly higher than the dorsum. It is attached inferiorly to the anterior nasal spine and superiorly between the two spreader graft cartilages. This graft can be wider at the base and narrower at the apex, performing an upward and backward rotation of the tip, helping to lift the tip when necessary. It can only be performed in an open rhinoplasty.
This graft is also used to help support the tip of the nose, and can be performed in both closed and open rhinoplasty. When the need to extend the septum does not exist, and the support of the tip can be performed in a less robust way, the stake graft in the columella, also called strut, can be performed. . During a closed rhinoplasty, Dr. Zamarian places the graft between the two alar cartilages, in the columella, through a vertical incision, in the columella, which practically does not leave very visible scars in the postoperative period. The graft is fixed in place using absorbable threads of PDS. In open rhinoplasty, this graft is placed under direct vision, also between the two alar cartilages and also helps to reinforce the structure of the tip, allowing for greater support and projection.
Radix is the nasal root, it is the part next to the glabella, the region that is between the eyebrows. Often, the nose bone in this part can be too low. This is very common in patients with an Indian nose, for example. That way, if the nose surgery were performed from that point on, the entire nose would be very low. To prevent this from happening, Dr. Zamarian performs a radix cartilage graft. With this, it raises the height of the nose at its root and the entire rhinoplasty can be performed from a higher point, when necessary. This graft is specially made with cut cartilage and very small pieces, which are placed inside a syringe. These little bits are then injected into the radix and modelled in place. It's like a filler with hyaluronic acid, but made with cartilage. After the healing process, this graft consolidates and becomes even harder than the cartilage, giving a very long-lasting result.
The graft mentioned above, for radix, can be performed along the entire dorsum of the nose. There are other ways to increase the height of the back, such as a rib cartilage graft or a cigar made with temporal fascia and chopped grafts, but these two have the drawback of eventually being able to move out of place or become a little palpable or apparent. For these reasons, Dr. Zamarian chose the radix minced cartilage graft, without temporal fascia, as the technique of choice to elevate the nasal dorsum.
During the decrease in the width of the tip, the upper (cephalic) segments of the two alar cartilages, which form the tip of the nose, are removed. This maneuver relaxes the tip and thins it out a bit. To thin it out a little more, stitches are given between the two cartilages, joining them and providing a more projected and thinner tip, with only the thickness of the skin being a limiting factor. To promote better definition of the tip of the nose. Dr. Zamarian uses one of these two cartilage segments, which were taken from the wings, and places it on the tip of the nose, horizontally. This brings the benefit of extra projection at the tip, in addition to smoothing any alar cartilage asymmetries that the person may have. In addition, you can control where the tip of the nose will have its greatest projection, making the tip as attractive as possible.
In both men and women, Dr. Zamarian recommends that rhinoplasty in Brazil should be performed from the age of 15, when the bone and cartilaginous structures of the nose and face are practically developed, avoiding the risk of failure in the development of the middle third of the face caused by the nose job. In addition, patients who decide to undergo rhinoplasty must be emotionally prepared to deal with the change in appearance that it may result in.
If your nose looks too big (rhinomegaly) or too small for your face, if you have a crooked or asymmetrical nose, if there is a rise or depression when viewed in profile (hump nose or saddle nose), if it is too wide when viewed from the front, if you have a bulbous tip, a black, arched nose, if the tip of your nose is droopy, too wide, or thick, or if your nostrils are too wide, with or without difficulty breathing through your nose, you are a good candidate to perform nose plastic surgery. It is important to remember that these cases selected above are just some of the possible treatments that rhinoplasty offers. If you don't fit into one of these situations, but feel uncomfortable with the appearance and function of your nose, schedule an appointment at our Plastic Surgery Clinic, in Londrina, and find out which treatments Dr. Zamarian can offer to improve your nose.
There are some basic factors that must be taken into account in order to obtain the best possible result in a nose job.
It is of paramount importance that the plastic surgeon performs a meticulous prior assessment of the patient's nose and face before surgery. The plastic surgeon needs to understand how the structure that will work, sculpt and model is found to improve its appearance and the patient's self-esteem. Dr. Zamarian, when analysing the patient's nose and face, is basically based, in addition to aesthetics, on mathematical proportions such as the thirds of the face and angles formed by the facial anatomy, which will allow for more accurate results of the proportions of the nose in relation to the face of a patient. each patient. Guided by his keen aesthetic sense, Dr. Zamarian begins to trace the route of the operative plan of his rhinoplasty.
As there are different approaches to a nose job, during the consultation, Dr. Zamarian explains what are the most viable possibilities for fixing the defects in question and what tactics can be used. In addition, after discussing the case with the patient, it outlines the operative plan that best provides the results for the specific case. It is important that the plastic surgeon correctly follows the previously stipulated operative plan so that the results are satisfactory for both him and the patient. The only exception to this is due to the occurrence of supervening causes that make it difficult for the plastic surgeon to follow the original surgical plan. Dr. Zamarian, always striving for the best results, takes the patient's entire operative plan with him to the operating room, along with standardised photos and the patient's file to resolve any possible doubts during the operative act.
During the nasofacial evaluation, carried out in the first consultation, the plastic surgeon will understand, from the patient's nasal anatomy, which manoeuvres will be necessary and what results will be possible. Unfortunately, if the anatomy is not favourable to the result dreamed of by the patient, the plastic surgeon cannot do anything in this case, as there are limits to making changes to the nose. Patients who arrive with a proposal far beyond what their structure allows should reflect on aesthetics confronting their own health and understand that not all nasal anatomy is favourable to the desired result. Therefore, it is the plastic surgeon who must show the limits, suggesting the maximum possibilities of modifications, being able to present alternatives to the very exaggerated results dreamed by patients. If this doesn't happen, the plastic surgeon can harm himself as well as put the patient's health at risk, causing the facial balance to be lost with the performance of a surgery without proper preparation.
During a rhinoplasty, it is not only the aesthetic factors that must be taken into account, as mentioned earlier. It is one of the most challenging plastic surgeries for the surgeon. A critical analysis must be done by the plastic surgeon so that he can tell the patient what will be the consequences of the modification he will make in the structure of his nose. That is, in addition to sticking to the aesthetic result of the nose, he should also be concerned with nasal functionality and health. It's like the cause and effect relationship: any change made during nose surgery will generate effects, which can be positive or negative. The positive effects involve the previous analysis, the operative plan and the favourable anatomy that, together, provide the good results.
One of the most important factors for the success of a surgery is due to the surgeon's experience and skill. Accordingly, Dr. Zamarian, cherishing for his good years in the field of aesthetic plastic surgery, is always updating himself, attending national and international congresses, as well as reading books and magazines about nose plastic surgery and other aesthetic and reparative surgeries. He accompanied the illustrious Professor Ivo Pitanguy in many of his surgeries during his three-year residency in Rio de Janeiro. He studied anatomy in depth and became an expert in facial analysis. All this made Dr. Walter Zamarian Jr. become one of the great names in nose plastic surgery in Brazil. Patients from all over the world come to learn a little more about his skills in sculpting and reshaping a nose. Schedule an appointment at the Zamarian Plastic Surgery Clinic and learn all the details of the aesthetic plastic surgery of the nose performed in Londrina, Paraná, Brazil.
In the past, you could only think of a cosmetic nose surgery. The function of the nose used to be, and is still today, the responsibility of an ORL specialist. Medicine is evolving, and both some ORLs are starting to perform cosmetic nose surgery, and plastic surgeons are treating the functional part. This has reinforced that the vision of nasal surgery should be as comprehensive as possible. No patient would certainly like to have a beautiful, functionless nose. For many years, Dr. Zamarian performed aesthetic rhinoplasty together with ORLs, which performed the functional part. However, due to the need to optimise the nasal cartilages to perform the necessary grafts, he underwent training in the United States to be able to offer his patients the same quality of functional result that he had been having with the aesthetic part. In this way, a single person makes the complete surgical plan, both aesthetic and functional, so that the approach to one aspect does not interfere with the other.
It is not just about unsightly congenital defects or defects resulting from trauma that are corrected by nose plastic surgery. Currently, what is in vogue is ethnic rhinoplasty, that is, one that involves different ethnicities, providing an even greater challenge to the surgeon: delving deeper into the anatomy and maintaining the patient's ethnic characteristics, correcting only the required. The patient's anatomy is at issue and is the most delicate part of rhinoplasty. Bringing equal results, like mass production of noses, is a thing of the past. The plastic surgeon tries to respect the peculiarities of each patient, because even those who want to correct details characteristic of their ethnicity, do not just want a reduced nose. They want results that allow them to know their original anatomy, in harmony. Therefore, some characteristics remain intact, allowing for an improvement in the nasal appearance.
Black and Indian noses that undergo rhinoplasty usually have a low back (or sealed), bulbous tip, open nostrils and the tip showing little support. To address these defects, Dr. Zamarian elevates the dorsum with the graft and fracture, thinning the tip with domus suture and removal of alar cartilages, defining the tip with an alar cartilage graft, and finishing the plastic with a septum cartilage graft in the columella to provide greater support to the tip. The Indian nose usually has a low radix, requiring small cartilage grafts to fill the depression. The Negroid nose, on the other hand, usually has a low back, which may require more cartilage for its graft.
Like the Negroid nose, the dorsum of the Asian nose needs to be elevated with a graft and fracture. We can shorten the nostrils a little, and improve the definition of the tip with the manoeuvres described. Sometimes, we use cartilage graft to define the tip and in the columella for support.
It is very characteristic of this ethnic group to have a large elevation of the back (hump) and a rounded and drooping tip. For correction, Dr. Zamarian performs manoeuvres that allow for the uniformity of the back, causing it to be lowered and the point raised, while the point is rotated (up). We thinned the tip by treating the alar cartilages, suturing the dome and performing an alar cartilage graft. The nose becomes more proportional to the patient's face.
Peculiarities such as a high back and hump and tip disproportionate to the size of the nasal structure make the characteristic Italian nose receive treatment similar to that of the Arab or Lebanese nose. Dr. Zamarian always respects the individual characteristics of each patient, maintaining the natural result, above all.
Patients who wish to undergo a rhinoplasty plastic surgery in Londrina undergo a thorough evaluation with Dr. Walter Zamarian Jr, who will explain the procedure, study the patient's facial structure based on mathematical formulas, thus being able to determine which areas of the nose will undergo greater changes in order to have the expected rhinoplasty result and if there will be any segment of the nose with expectations limited by several factors, such as, for example, the thickness of the nasal skin, the fragility of the bones of the nose, amongst others.
Briefly, we can mention here some parameters that the plastic surgeon takes as a basis to determine the points to be improved. They are mathematical parameters and proportions, so they help to measure what is visibly altered. It should be remembered that these parameters serve only as a guideline, and each nose has its particularities and measurements outside these parameters are totally acceptable, considering that there is harmony with the face, always reminding us of the ethnic differences that must also be taken into account.
In order to obtain predictable and more concrete results, the plastic surgeon divides the face in three, using four horizontal lines:
Divergences in these proportions may indicate maxillofacial alterations, such as vertical maxillary excess, known as "bird face" or maxillary hypoplasia. As it is the foundation of the nose, that is, where it is located, important changes in the maxilla must be treated before rhinoplasty.
In order to have a certain idea of what to do when the discomfort starts from the length of the nose, one must analyse whether the length of the nose is equivalent to the vertical distance between the oral commissures (angles of the mouth) and the lowest point of the chin, in a frontal view. In this way, Dr. Zamarian can confirm whether the length of the nose is proportionately unsightly or not for the surgery.
A straight vertical line is drawn that goes from the middle of the glabella (region between the eyebrows) to the chin, dividing the nasal dorsum, upper lip (with its Cupid's Bow) and incisors in the middle (so that it is parameter, the patient has a normal bite). Any nasal deviation from this line, called laterorhinia or "crooked nose", is likely to require an osteotomy (fracture of the nasal bone) and septoplasty.
The normal distance between the nasal wings is equivalent to the distance between the medial corners of the eyes (intercantal distance), or the width of the opening of an eye. If the distance between the nostrils is greater than the intercantal distance, the cause should be studied first. If the cause is a narrow intercantal distance, it is better to leave the wings of the nose slightly open, proportionately, than to surgically correct the distance between the eyes. If the nostrils are truly wide, closing the nostrils may be indicated.
The nasal tip is evaluated by drawing two triangles with their opposite bases, guided by the "supratip break" and by the columelolabial angle (formed between the lip and the outer septum, the columella). If these triangles are asymmetrical, it may be necessary to perform manoeuvres to modify the tip of the nose.
In addition to modifying asymmetrical tips, it may be necessary to thin the nasal tip, especially in patients with a bulbous nasal tip, the famous potato nose.
In the basal view of the nose, the nostrils and the base of the nose are evaluated, which must describe an equilateral triangle, with a ratio between the lobe and the nostril of 1:2. The nostril should be in a teardrop shape, with its major axis oriented slightly medial (from base to top).
This angle connects the glabella (space between the eyebrows) to the root of the nose, in a smooth curve, whose angle should be between 128 and 140 degrees, more specifically 134 degrees in women and 130 degrees in men.
In the side view of the nose, the tip projection should be equal to the width of the nostrils in a frontal view and 67 % of the length of the nose (from root to tip). Another way to evaluate the projection of the nasal tip is to know how much it is projected anteriorly to a perpendicular line to the most anterior point of the upper lip. This previous projection is normally equal to 50 to 60 % of the total tip projection.
The analysis of the dorsum starts by drawing a line parallel to it, which goes from the root of the nose to the tip. In women, the ideal position of the back is about two milimetres below this line and almost parallel to it. In men, the dorsum should be very close to this line, to avoid feminisation of the nose.
Usually, the tip is slightly more projected than the dorsum of the nose and the plastic surgeon can lower the dorsum, raise the tip, or perform these two techniques during surgery, in order to obtain the best result for each case.
It is the angle formed between the columella and a plumb line perpendicular to the natural horizontal plane of the face. This angle should be between 95 and 100 degrees for women and between 90 and 95 degrees for men.
Also known as sub-septum or mobile septum, the columella, the column of skin between the nostrils, can also be corrected. Basically, there are two unsightly defects of the nose that can involve the columella: the retracted columella and the hanging columella .
A retracted columella is one that is “hidden” due to lack of skin or cartilage in that region. The columella hanging, in turn, stands out for having excess skin and cartilage in that region, causing it to be protruding, that is, pedant, between the nostrils and both cases can be improved. How to know if the columella is pending? It is not always that the formulas go according to the patient. There are cases that only by visual evaluation, the plastic surgeon can detect the problem. Dr. Walter Zamarian Jr, in addition to performing a visual assessment, basically uses mathematical calculations to solve this rhinoplasty problem: according to the image, when A – B is greater than four milimetres, it means that the columella is altered.
Fortunately, both columella defects can be resolved. Dr. Walter Zamarian Jr uses cartilage removal or grafts to correct such problems.
The nasal dorsum is formed by the osteo-cartilaginous structure and the thickness of the skin that covers it. The skin that covers the entire nasal structure is not uniform in thickness, being thinner in its upper two thirds (root) and thicker at the tip. In addition, the upper part of the skin is more mobile and has fewer sebaceous glands than the part that covers the tip of the nose.
The skin of the nose covers everything that is performed below it during rhinoplasty, which is why Dr. Zamarian draws attention to this important detail: the thick-skinned nose shows less of the refinements made, and the thin fur shows the smallest details. Just as a thick blanket has a hard time showing what's underneath, a person with thick skin might have a hard time getting a very thin nasal tip.
Overall, patients with predominantly thinner nose skin will achieve the desired results faster and more pronounced when compared to patients who have predominantly thicker skin. These will have to wait a little longer for the results to reach complete healing.
In order for the plastic surgeon to know if there is support on the nasal tip, there is a simple test that allows you to see it immediately, which is done by simply squeezing the tip of the nose with your finger. If the nose sinks, it means it has little support, so it can be corrected. In these cases, Dr. Zamarian can conclude whether there is a need to lower the tip or not. If it remains in the same place, sinking a little, it is a sign that the tip of the nose is well supported, so there is no need to make changes to this element.
Dr. Zamarian contraindicates the use of certain medications before the surgery, as there are some medications that interfere with blood clotting, sedatives, anaesthesia and adrenaline, which must be suspended for a period of fifteen days before and after this cosmetic surgery. . Among them are:
Always tell your plastic surgeon about all medications you take, including natural ones.
Before performing nose plastic surgery, it is necessary to carry out some tests, so that Dr. Zamarian can assess the patient's health, including providing greater safety to the procedure. Tests that are usually ordered before rhinoplasty are performed include:
To perform rhinoplasty, whether primary or secondary, it is important for the plastic surgeon to know about the nasal breathing capacity of each patient before performing the nasal plastic surgery, as well as a history of trauma in the past, previous surgeries, rhinitis or sinusitis. Deviated septum and the nose as a whole are evaluated. Dr. Zamarian usually performs an examination of the inside of the nose, looking for synechiae, deviated septum or turbinate hypertrophy for a complete evaluation.
For a complete plastic surgery of the nose, which involves nasal osteotomy (bone fracture), grafts up to the tip treatment, general anaesthesia is indicated, because in these cases, only local anaesthesia is not satisfactory and safe for the patient. As for the cases where Dr. Zamarian indicates only the tip treatment, the procedure can be done with local anaesthesia and venous sedation only.
We use the term “general anaesthesia” to refer to the anaesthetic technique that promotes total unconsciousness (hypnosis) of the patient, pain relief (analgesia) and muscle relaxation. General anaesthesia makes it possible to perform any necessary manoeuvre during nose surgery. Local anaesthesia leaves the plastic surgeon a little limited, and this type of anaesthesia is not indicated when the patient must undergo an osteotomy, for example.
After anaesthetic induction, which is the period of transition from consciousness to the patient's unconscious state, the preparation of the nasal vestibules is necessary, at which time the plastic surgeon must trim the nasal vibrissae (nasal hairs) and perform the antisepsis on the inside and outside of the nose.
After preparing the vestibules for nose plastic surgery, approximately 20 ml of a solution with 1 % lidocaine and 1:80,000 adrenaline is injected to minimise bleeding during rhinoplasty, thus also preventing ecchymoses (purple ) and postoperative pain.
The areas of the nose where this solution is applied before rhinoplasty are: nasal dorsum, tip, anterior nasal spine, fracture line, alar mucosa and septum. Dr. Zamarian waits approximately 12 minutes for the full vasoconstrictor effect of adrenaline before starting the procedure.
To provide greater patient safety, our specialised anaesthesiologist monitors the entire surgery, from beginning to end, together with Dr. Zamarian. The presence of the anaesthesiologist during the surgery is essential to monitor the patient's pressure, pulse, temperature, breathing, degree of sedation, diuresis and hydration throughout the procedure.
After the anaesthesia was performed, Dr. Zamarian starts rhinoplasty, using the open or closed technique, with an incision in the columella, if open, or between the alar and triangular cartilages, if closed. In this way, it exposes the entire interior of the nose for dissection (back and tip).
He then performs a detachment of the nasal dorsum with scissors in the subcutaneous plane, with or without the aid of a detacher, just above the periosteum, taking care to keep the fat layer below the skin intact to avoid irregularities and retractions after rhinoplasty surgery. During the surgery, Dr. Zamarian uses some manoeuvres to make the changes foreseen in the surgical plan of rhinoplasty, among them: removal of the cephalic portion, lateralisation of the domus, interdomal suture, cartilaginous graft, etc. At this stage, it is possible to remove the excess cartilage that some patients have, either on the tip or on the nasal dorsum. Once the necessary detachment is done, the following areas can be remodelled:
When necessary, we treat the dorsum in order to correct the structures that are in excess or, as in some cases, missing, always respecting the internal structure and integrity of the mucous lining of the nasal dorsum.
What are the defects to be corrected on the back?
In the treatment of the back, the following are corrected: bony or cartilaginous hump, which is a kind of elevation on the back caused by excess bone or cartilage; the back with depressions or low back, also known as saddle nose, which, due to congenital defects or trauma, leaves the back deep and with little projection in certain places; the back that has the hump and depressions (saddle nose) combined; deviated septum, asymmetries, laterorhinias, etc.
In cases of bony or cartilaginous hump, the nasal dorsum is then lowered with diamond shavings or chisel. When there is a “saddle nose”, with a very low back, Dr. Zamarian uses augmentation with cartilage graft, harvested from the septum, ears or rib. It is at this stage of rhinoplasty that the fracture – nasal osteotomy – can be performed to correct deviated septum and also to leave the back with narrow and symmetrical laterorhinias. The osteotomy is performed internally by Dr. Zamarian, with the aid of a chisel and hammer, along the maxilla and lateral wall of the nasal bones, finishing the osteotomy with a squeezing manoeuvre with the fingers, bringing the walls of the nose to the centre. What should be taken into account for a rhinoplasty is that the bridge of the male nose is usually left straight, while the bridge of the female nose can either be straight or accept a gentle curve.
To improve the appearance of the unsightly tip of a nose during rhinoplasty, it is necessary for the plastic surgeon to take an accurate approach to obtain an adequate result, due to the delicacy involved in this part of the nose in nasal plastic surgery.
The nasal tip, a frequent subject of complaints by patients, is the most complex part of the nose and can have several unsightly defects, such as: bulbous or thick tip, high tip (very “upturned”), drooping tip, bifida (cartilages separated in half), amongst others. Fortunately, Dr. Zamarian manages to correct all these defects quickly and effectively, promoting great results.
Depending on the area in question, the skin surrounding the nasal tip has very variable characteristics. In addition, the nasal tip may have an important layer of subcutaneous cellular tissue, that is, fat, and it also has large amounts of sebaceous glands.
Therefore, after treating the bridge of the nose, the tip is gently detached by Dr. Zamarian with the aid of Fomon scissors that have their curved shape to help follow the nasal anatomy. During tip detachment in nose plastic surgery, Dr. Zamarian sections the dermocartilaginous ligament of Pitanguy. The tip can then be thinned with the removal of the upper third of the alar cartilages, present in the nasal tip, and may or may not be associated with a cartilaginous graft or other manoeuvres to improve the definition. One of the specialties of Dr. Zamarian is the technique known as the bucket handle, which allows a detailed sculpting of the nasal tip through a refinement of closed rhinoplasty.
The drooping tip can be elevated through manoeuvres, which include sectioning the Pitanguy dermocartilaginous ligament, removing the caudal septum and supporting the tip with a cartilage graft in the columella in noses that need it.
The angle formed between the columella, column, which supports the tip of the nose and the lip, called columelolabial angle, must be about 90 to 95 degrees in men and between 95 and 100 degrees in women, that is, the female nasal tip may be more upturned than male.
In facial dynamics, we must also assess the muscle that depresses the tip, called the tip depressor or also Pitanguy's dermocartilaginous ligament.
Professor Ivo Pitanguy, the internationally renowned plastic surgeon who passed on his techniques to Dr. Zamarian, described the dermocartilaginous ligament that runs along the nasal dorsum, descends through the tip and inserts into the anterior nasal spine. Its function is to lower the tip of the nose when the person speaks, which can be tested by asking someone to say the word "jellybean", for example. During rhinoplasty, both Professor Pitanguy and Dr. Zamarian, perform the section of Pitanguy's ligament to relax the tip, raising it discreetly, thus preventing it from continuing to lower during normal conversation.
The septum is the vertical and intermediate wall that separates the nasal passages. The septum can also be defective, like any other part of the nose, but it usually involves a functional problem. When Dr. Zamarian detects deviated septum, both bony and cartilaginous, interfering with nasal aesthetics and functionality, he corrects this deviated septum to establish an aligned aspect of the nose. Deviations that do not interfere with the aesthetics of rhinoplasty, only with the respiratory function, are also treated by him.
During the preoperative assessment, if hanging columella or retracted columella are detected, Dr. Zamarian very effectively corrects these defects by removing the excess cartilage or grafts, allowing the columella to become aesthetically proportional again.
Occasionally, the appearance of a nose can attract attention, not only because of the hump, drooping tip or deviations, but also because of the exaggerated opening in the nostrils. Nostrils that are too wide or protruding are often more common in Negroid and Asian noses. Dr. Zamarian can narrow the opening of the nostrils in a natural way that does not interfere with the function of nasal breathing. However, it is important to emphasize that, during the process of reducing the nostrils, even if the Brazil rhinoplasty is performed using the closed technique, an incision must be made at the bases of the nostrils. It is the only procedure that leaves a small external scar on the nose. Thanks to the good healing in this area and the minimal and discreet incision made by Dr. Zamarian, this manoeuvre is performed frequently, without harming the aesthetic results.
Nose grafts are used only when absolutely necessary. Cartilage graft donor areas include septum (fibrous, stiffer cartilage), ear cartilage (softer, hyaline cartilage) and very rarely costal cartilages (also fibrous). To increase the nasal dorsum, it may be necessary to graft hyaline cartilage in one or more layers, positioned along the dorsum, to increase its projection, especially in some Asian, Negroid or noses secondary to a previous rhinoplasty in which the dorsum was lowered. too much. The septal fibrous cartilage is great for providing tip support, when placed between the medial crosses, in the columella, especially indicated for noses without tip support and in negroid noses.
At the end of the surgery, Dr. Zamarian checks the passage of air through both nostrils. If there is any difficulty, he preferentially opts for turbinoplasty, which consists of mobilising the turbinates, dislocating them laterally, increasing the space for air passage. This manoeuvre is more physiological than the removal of the turbinates (turbinectomy), since the turbinates are important in humidifying the air. However, in cases of severe or refractory obstruction, he can perform a turbinectomy, performing a total or partial removal of the turbinates.
Finishing the rhinoplasty is performed with four Vicryl stitches (absorbable thread) 4-0: one on each internal nasal valve and another two between the columella and the septum, elevating the tip, as it later gives way a little throughout the first month.
The dressings are necessary so that they can immobilise the nasal structure, until scar tissue begins to form, in addition to keeping the sculpted structures in place, preventing the accumulation of blood between the skeleton and the skin, making compression so that the swelling decreases more quickly, help in the aesthetic molding of the result obtained and in breathing, etc. Dr. Zamarian uses a nasal plug or splint when necessary and immobilises the structure of the nose with Aquaplast. The dressings made will remain on the patient for a total of two weeks, the first week the dressing with Aquaplast will remain and from the second week onwards, when the Aquaplast is removed, Dr. Zamarian makes a micropore dressing, which remains for another week.
After suturing, a plug is then placed in each nostril, elevating the triangular cartilages so that there is a reduction in dead space and faster healing. The tampons are formed by gauze permeated with Nebacetin and are removed the next day, except when septoplasty is performed concomitantly. In the case of association of rhinoplasty with septoplasty to improve the functionality of the nose, the plug should remain for 48-72 hours, being removed soon afterwards.
In the past, a plaster bandage was used over the nose to immobilise it. To provide better patient comfort, Dr. Walter Zamarian Jr. Aquaplast is used, which is a dressing made of thermo- moldable plastic, which is shaped according to the patient's new nose. Aquaplast is removed in a week, at which time only a bandage made with skin-colored micropore is applied, which remains for another week, making a total of two weeks with bandages on the nose.
During the preoperative patient assessment by Dr. Zamarian, there are cases in which deviated septum and turbinate hypertrophy are detected. Deviated septum can occur, basically, for two reasons: congenital (present at birth) and acquired (generally after trauma). If the patient needs functional improvement with a nose job, in addition to the aesthetic improvement it provides, Dr. Zamarian performs rhinoseptoplasty, with treatment of the turbinates when necessary, where he himself performs the aesthetic and respiratory function. Therefore, rhinoplasty is not only performed for aesthetic but also functional improvement. There are several ways to correct a deviated septum, among them the simple removal of the deviated part of the septum, whether cartilaginous or bony, or also the removal of this segment, correction of its deviation with incisions and cartilage maceration and reinsertion into the nose. When the deviated segment is low and contains a spike, it is called a spur, and it can also be corrected during septoplasty. The turbinates can be treated with turbinoplasty, where the position of the turbinates is changed, or with turbinectomy, where they are removed.
Often, deviated septum is not the only villain that hinders respiratory function in patients who are candidates for nasal plastic surgery. The nose is made up of some turbinates, also known as turbines or shells, which are inserted into the side walls of the nose, which may be enlarged, making breathing difficult. During rhinoplasty, or rhinoseptoplasty, the combination of turbinoplasty or turbinectomy surgery may be necessary. Turbinoplasty modifies the position of the turbinates, increasing the passage of air. If the increase is very large, turbinectomy may be necessary, which consists of removing, in whole or in part, one or more turbinates. Most of the time, the turbinate that interferes with breathing is the lowest, lowest, which is also the largest.
During rhinoplasty with septoplasty and/or turbinectomy, it is usually necessary to place, in addition to the tampon, a nasal splint, which would be a small plastic or silicone plate , in each nostril. In addition to helping to support and fix the septum in the postoperative period, it prevents contact between bloody areas of the septum and the lateral wall of the nose, also preventing a condition called synechia. The synechia in the nose is a scar that forms a bridge between the septum and the lateral wall of the nose, after a surgery that involves septoplasty or turbinectomy where there was a bloody area (without epithelium) at the same height of the septum and the lateral wall of the nose. The synechia may have nasal obstruction or wheezing (whistling during nasal breathing) as symptoms. Its treatment can involve from a cross opening or total removal, then protecting with a nasal splint.
After the rhinoplasty was performed in Londrina, Dr. Zamarian makes some important recommendations that will greatly influence the final results:
In a week, we changed the Aquaplast dressing for a smaller, skin-coloured micropore dressing. On the fourteenth postoperative day, we remove the entire dressing and it is also at this time that any eventual purple ends up disappearing. However, the nose is still swollen and, when we took the photos, two months later, her recovery was about 85 %. The other 15 % of swelling takes up to a year to disappear completely.
Secondary is the plastic surgery of the nose in those who have already had a first rhinoplasty (which is called primary). Often, it is necessary to complete an incomplete fracture, lower the dorsum, increase the dorsum with cartilage grafts, correct an inverted "V" with "spreader graft", correct supratip, improve projection or tip definition with cartilage grafts or cartilage remodelling, correct superficial irregularities, improve scars from open rhinoplasty or nostril rotation, correct deviations, amongst others.
When performing secondary rhinoplasty, Dr. Zamarian will not use the same techniques as a primary rhinoplasty, or conventional rhinoplasty, as there will be the presence of fibrous scar tissue, changes that have arisen as a result of previous rhinoplasty (primary rhinoplasty) and, mainly, it must be taken into account that the nasal structure is already more fragile after having undergone possible osteotomies, grafts, scrapings, etc. performed in the first plastic nose surgery.
In order for the plastic surgeon to consider the possibility of revision of a rhinoplasty, the ideal is that the patient has waited a period of one year, counting from the date of the primary nose plastic surgery (first rhinoplasty), because this is the time required for full recovery from a rhinoplasty, so that the entire nasal structure is completely healed, recovered and with swelling at the end. Technically, secondary rhinoplasty is more complex as the plastic plastic surgeon will be dealing with distorted or even absent anatomy. Mainly due to swelling, it is not good for the plastic surgeon to perform secondary rhinoplasty within a year of primary rhinoplasty, as swelling is still present. The swelling between the nasal skeleton and the skin that covers it can cause the surgeon to lose the parameters of the original structure of the nose, being a high risk for the results, which can be in disagreement with what the patient wants. Therefore, Dr. Zamarian recommends waiting a year from the primary period before performing secondary rhinoplasty.
Dr. Zamarian explains that, in general, there are some prerequisites for the patient to undergo secondary plastic nose surgery, which are:
These are just some of the general prerequisites, that even if the patient is in compatible conditions according to the requirements, he must go through a previous consultation with the plastic surgeon, at which time he will evaluate the possible aesthetic defects and /or functional to diagnose which were the reasons for failure of the previous surgery. Dr. Zamarian makes a meticulous evaluation of all the problems and points of dissatisfaction that bother the patient, so that he can outline the surgical plan that, this time, will be much more complex than that of a primary nose job.
Considering that most cases of secondary rhinoplasty treatment that reach Dr. Zamarian involve patients with a lack of cartilage to produce a satisfactory nasal reconstruction, at the Zamarian Clinic, this procedure has as its basic repair technique the use of grafts. When dealing with primary rhinoplasty, cartilage collection is not usually a problem, since this material is found in large quantities in the cartilaginous septum and in both ears. “The preference is that septum cartilage is used, to make nose plastic surgery as less invasive as possible, however, septum cartilage collection is not always possible, as the patient may have operated on a deviated septum in the first surgery” , ponders Dr. Zamarian.
Furthermore, nothing prevents the plastic surgeon, in secondary rhinoplasty, from using the cartilage of the septum and ears when they are available and they will not weaken the nasal skeleton. “The cases of grafts vary a lot when we are dealing with rhinoplasty, especially secondary ones”, says Dr. Zamarian. Despite being quite complex, it is also very important that the plastic surgeon always aims at individuality, naturalness and compatibility with the patient's ethnicity when performing secondary rhinoplasty, as well as primary rhinoplasty.
Schedule your appointment for nose plastic surgery in Londrina. Dr. Walter Zamarian Jr. specializes in aesthetic and functional rhinoplasty, and can seek the best possible result for your case. Contact Zamarian Clinic now and speak to one of our receptionists, who will be happy to arrange your evaluation and ask some questions.
Cosmetic plastic surgeon in Brazil
Rua João Wyclif, 111, Sala 1702
Londrina - PR
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