You can have a beautiful and attractive nose, and still breathe better with rhinoplasty.

Natural Rhinoplasty

My greatest commitment is to a natural result. I want people to comment that you look different, more beautiful, that they ask if you did something to your hair - but do not realize it was a nose surgery. This is the type of result I seek in every rhinoplasty I perform.

Specialized in Aesthetic and Functional Rhinoplasty

I specialized in the United States, under the guidance of the best nose surgeons in the world, in aesthetic and functional rhinoplasty. I am not satisfied with just a beautiful nose: I want you to breathe better too. That’s why I address the four pillars of nasal breathing during rhinoplasty: septum, turbinates, internal nasal valve, and external nasal valve.

The Functions of the Nose

The nose is not just for appearance. It is responsible for breathing, humidifying and filtering the air, regulating temperature, and smell. All these functions need to be preserved during a rhinoplasty. That’s why I always take into account the septum, the turbinates, and the internal and external nasal valves - structures that directly influence airflow.

Nasal Septum

The nasal septum is a perpendicular structure, like a wall, composed of a cartilaginous part and a bony part (vomer and ethmoid bones). It divides the nose in half, into two nasal cavities. Air flows laminar from each side of the septum. Any deviation can alter this flow and cause enlargement of the turbinates. The indicated surgery to correct this is septoplasty. The good news is that I can combine septoplasty with rhinoplasty in the same surgery - what we call rhinoseptoplasty. This way, I take care of both aesthetics and respiratory function at the same time.

Turbinates or Nasal Turbines

The turbinates or nasal turbines are curved bony plates, like a lateral elevation of each wall of the nasal cavity, covered with mucosa, that protrude from the inner face of the ethmoid and bulge outward from 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 include the inferior, middle, and superior turbinates, and the variable turbinates which include the Santorini turbinate and the Zuckerkandl turbinate.

The inferior turbinate is the largest of the three, responsible for humidifying, temperature regulation, and filtering the air that enters through our nose. Additionally, the inferior turbinate has the greatest impact on resistance to airflow in the nose, potentially accounting for up to two-thirds of that resistance. The middle turbinate is the intermediate one, which protects the sinuses from direct contact with the airflow. Finally, the superior turbinate is a smaller structure, connected to the middle turbinate by nerve endings and is responsible for protecting the olfactory bulbs.

The mucous membranes that cover the turbinates undergo a cycle of expansion and contraction mediated by the autonomic nervous system. Size changes (hypertrophy) frequently occur in allergic rhinitis, vasomotor rhinitis, and in cases of bulbous turbinates. When necessary, I treat the turbinates during the rhinoplasty itself, either by turbinoplasty (repositioning) or turbinectomy (partial or total removal).

Internal and External Nasal Valves

The nasal valve is an important regulator of airflow dynamics and is divided into internal nasal valve and external nasal valve.

The internal nasal valve is the angle formed between the septum and the anterior margin of the triangular cartilage. Preserving this valve is essential to avoid collapse of the nasal wings during inspiration. When the patient arrives with this complaint, I use a cartilage graft called spreader graft to open the airway.

The external nasal valve is located at the entrance of the nose. It may be obstructed by weakened alar cartilages (sometimes due to previous surgery), loss of vestibular skin, or scar narrowing. Treatment depends on each case, and I evaluate the best approach during the consultation.

Types of Rhinoplasty

Closed Rhinoplasty

Technique developed by Joseph in the early 20th century, in which rhinoplasty is performed without external cuts. The entire surgery is done inside the nose. Although it still has specific indications, it has given way to open rhinoplasty, which allows for better visualization, more precise definition of the tip, and greater ability to structure the nose with cartilage grafts.

Open Rhinoplasty

In this technique, I make a small incision in the columella, which allows me to expose almost the entire nose. This enables a complete approach to everything that needs to be done. It has become increasingly widespread because it offers better results in most cases, especially when I use many cartilage grafts.

Aesthetic Rhinoplasty

Its goal is to improve the appearance of the nose, making it more attractive and harmonious with the face. Whenever possible, I associate the functional aspect in the same surgery.

Functional Rhinoplasty

Focuses on improving nasal breathing. I address the septum, turbinates, and internal and external nasal valves. In my practice, I rarely perform one without the other.

Reconstructive or Repair Rhinoplasty

In this surgery, I aim to give the most natural shape possible to the noses of people who were born with some deformity or who suffered trauma with loss of nasal structure.

Reducing Rhinoplasty

This is the oldest technique for nose surgery. In it, only bone and cartilage are removed to decrease the size of the nose. There is no reinforcement of the internal structure. Over time, the lack of support can cause problems: the tip may droop, the dorsum may bend, and breathing may worsen. Today, this isolated technique is rarely used by the best rhinoplasty specialists.

Structured Rhinoplasty

This is the most modern technique and the one I perform the most. Instead of just reducing, I reconstruct and reinforce the entire structure of the nose from within, using cartilage grafts from the patient’s own body. The cartilage can be taken from the nasal septum or, when necessary, from a rib. The result is more beautiful, more natural, and much more durable. Additionally, it allows for improved breathing at the same time. More than 90% of patients report high satisfaction with structured rhinoplasty, according to current medical literature.

Rib Cartilage Graft Rhinoplasty

In some cases, the cartilage from the septum is not enough for all the necessary grafts. This happens more in patients who have had previous nose surgeries or who need more extensive reconstructions. In these cases, I remove a small piece of cartilage from a rib. It is an abundant, strong material that allows me to create various types of grafts from a single piece.

Secondary or Revision Rhinoplasty

The first rhinoplasty a person has is called primary rhinoplasty. The second is secondary rhinoplasty. The third is tertiary rhinoplasty, and so on. In any case where there is a desire to improve something left by the primary rhinoplasty, it is a revision of rhinoplasty, or a revision rhinoplasty. Secondary, tertiary rhinoplasties, etc., excluding the primary, are all revision rhinoplasties.

Fractured Nose Rhinoplasty

This is a simpler rhinoplasty, where the goal is to restore the shape that the nose had before being broken by trauma. It does not aim to correct all aesthetic defects of the nose but seeks to improve deviations caused by the fracture.

My Technique: Structured Rhinoplasty

What sets my rhinoplasty apart is a dual aesthetic and functional approach. I do not simply reshape the nose for beauty; I simultaneously optimize nasal breathing. During my advanced training in the United States, I studied the four pillars of nasal airflow: the septum, the turbinates, the internal nasal valve, and the external nasal valve. In every rhinoplasty I perform at my clinic in Londrina, I evaluate and correct each of these pillars when needed, using techniques such as spreader grafts to widen the internal valve and turbinoplasty to reduce obstruction. This comprehensive methodology means my patients breathe better and look better after a single surgery, without needing a separate procedure with another specialist. With over twenty years of experience and more than eight thousand surgeries performed, I can confidently say that neglecting the functional aspect of the nose is the most common mistake in rhinoplasty worldwide, and one I am committed to avoiding.

Structured rhinoplasty is the technique I perform the most today. Instead of just reducing the nose, I reconstruct and reinforce the entire nasal structure from within, using cartilage grafts from the patient’s own body.

Think of the nose as a house. Reducing rhinoplasty (the old technique) removes walls and beams to decrease the house. It may work at first, but over time the structure weakens. Parts may give way. Structured rhinoplasty remodels the house from within. It places support beams in the right spots. The result? A more beautiful, stronger house that lasts for many years.

That’s why I structure every nose I operate on. My goal is for the result to look beautiful not just in the first month but for a lifetime.

Why Does Structured Rhinoplasty Yield Better Results?

The difference lies in the way the surgery is approached. The reducing technique removes tissue from the nose to decrease it. The problem is that, over the years, healing and aging can change the shape of the nose. Without support, the tip may droop, the dorsum may bend, and airflow may be compromised.

Structured rhinoplasty works differently. It reinforces the skeleton of the nose with cartilage grafts. These grafts act as pillars that keep the nose firm in the right position. Here are the advantages:

• More stable results over the years, without late deformities;
• More natural appearance, without the "operated nose" look;
• Significant improvement in nasal breathing;
• Lower chance of needing a second surgery;
• Can be performed from age 15, at any time of the year;
• It is individualized for the ethnicity and anatomy of each patient;
• Can be combined with other surgeries, such as mentoplasty (chin surgery) or facelift, improving facial profile;
• Does not require prolonged rest in the postoperative period.

Recent studies published in international scientific journals show that more than 90% of patients are satisfied with the results of structured rhinoplasty. The revision rate is much lower than with the reducing technique.

Where Does the Cartilage for the Grafts Come From?

The grafts used in structured rhinoplasty are made with cartilage from the patient’s own body. This is very important. Since the material comes from your body, there is no risk of rejection. The cartilage integrates naturally into the nose.

I primarily work with two sources:

Nasal Septum Cartilage

This is the first choice. The septum is the wall that divides the nose in half. It has enough cartilage to be harvested without compromising the support of the nose. It is the ideal material: straight, firm, and easy to sculpt into the necessary shapes. In most primary rhinoplasties (the first surgery), the septal cartilage is sufficient for all grafts.

Rib Cartilage

In some cases, the septal cartilage is not enough. This happens when:

• The patient has had previous nose surgery and the septum has already been used;
• There is a need for more extensive reconstruction;
• The nose requires a lot of support or dorsum augmentation;
• The cartilaginous septum is naturally small.

In these cases, I remove a small piece of cartilage from a rib. The collection is done through a small incision, which leaves a discreet scar. Rib cartilage is abundant, strong, and allows me to create various grafts from a single piece. The recovery of the donor area is quick. There may be slight discomfort in the rib area for a few days, but it is usually not significant.

The Grafts in Structured Rhinoplasty

Each nose is different. Therefore, I combine different types of grafts according to the needs of each patient. Here are the main ones:

Spreader Graft

This is one of the most important grafts in structured rhinoplasty. It consists of a thin strip of cartilage placed on each side of the nasal dorsum, between the septum and the upper lateral cartilages.

What it’s for:

• To keep the nose straight and aligned in the center of the face;
• To open the internal nasal valve, improving airflow;
• To avoid pinching of the dorsum, which gives the appearance of an operated nose;
• To reinforce the structure of the dorsum after lowering.

The grafts can be taken from the septum or from rib cartilage. I learned the technique for placing spreader grafts in both open and closed rhinoplasty in the United States, with Dr. Ali Sajjadian (California) and Dr. Dean Toriumi (Chicago). This closed technique is still not widely practiced in Brazil. Since I started associating the spreader graft with the treatment of the turbinates, my patients notice a significant improvement in breathing within the first week, even with the nose still swollen.

Septal Extension Graft

This graft provides firm support to the tip of the nose. It is a piece of cartilage positioned vertically, as an extension of the nasal septum. It is fixed at the anterior nasal spine (at the base) and between the spreader grafts (at the top).

What it’s for:

• To lift the tip of the nose durably;
• To give projection to the tip, ideal for those with a flat or unsupported nose;
• To open the angle between the nose and the lip, making the profile more harmonious;
• To keep the tip firm in place, without the risk of drooping over time.

It is especially indicated when the tissues of the nose are heavy or when the tip needs robust support. This graft is performed in open rhinoplasty.

Columellar Strut Graft

The columella is the part between the nostrils that supports the tip of the nose. The strut graft is a small rod of cartilage placed between the two tip cartilages, inside the columella. It is fixed with absorbable PDS sutures.

What it’s for:

• To provide light to moderate support to the tip;
• To subtly improve the projection of the tip;
• To reinforce the structure of the columella.

It is a more discreet option than the septal extension graft. It works well when the tip needs reinforcement but not maximum support. It can be done in both open and closed rhinoplasty.

Radix Cartilage Graft

The radix is the root of the nose, the highest part, near the eyebrows. In some patients, this area is too low. If rhinoplasty were performed from this height, the entire nose would be lowered.

To resolve this, I use small pieces of chopped cartilage, placed inside a syringe and injected into the radix. Then, I shape the material in place. It’s like a filler, but made with cartilage instead of hyaluronic acid. After healing, the graft consolidates and becomes even firmer than the original cartilage. The result is quite durable.

Dorsal Augmentation Graft

The same technique of chopped cartilage used in the radix can be applied along the entire nasal dorsum. It is a safe way to increase the height of the nose in patients with a low dorsum, such as in some African, Asian noses, or in cases of secondary rhinoplasty where the dorsum has been excessively lowered.

Ala Cartilage Graft at the Tip

When the tip needs more definition, I position a small cartilage graft at the tip, horizontally. This graft is made with cartilage taken from the patient’s own alar cartilages during the refinement of the tip. Nothing is wasted.

What it’s for:

• To project the tip forward, with more definition;
• To smooth asymmetries between the tip cartilages;
• To control where the point of greatest projection will be.

Closed or Open? I Perform Both

I master both techniques and choose the best one for each case.

In closed rhinoplasty, all incisions are made inside the nose. There are no external scars. Recovery tends to be a bit faster.

In open rhinoplasty, there is a small incision in the columella. This allows me to see the entire structure of the nose clearly. It is the preferred technique when the case requires many grafts or complex work on the tip.

In both techniques, I perform complete structuring of the nose. My training combines the teachings of Professor Ivo Pitanguy in Brazil with training alongside Drs. Dean Toriumi and Ali Sajjadian in the United States - world references in structured rhinoplasty. Each has contributed to the approach I practice today, uniting natural aesthetic results with the best possible respiratory function.

I structure all the noses I operate on. Previously, rhinoplasty was done only by removing. Today, I reconstruct. The nose looks more beautiful, breathes better, and the result lasts a lifetime.

Factors for Successful Rhinoplasty

There are some basic factors that I take into consideration to achieve the best possible result in each rhinoplasty.

Nasofacial Analysis

Before any rhinoplasty, I conduct a meticulous evaluation of the nose and face. I need to fully understand the structure I will be working on, sculpting, and shaping. Besides aesthetics, I base my work on mathematical proportions such as the thirds of the face and angles of facial anatomy. This allows me to predict more accurately how the nose will look in relation to each patient's face. From this analysis, I begin to outline the surgical plan for your rhinoplasty.

Surgical Plan

During the consultation, I explain which corrections are possible and which techniques I intend to use. After discussing the case with you, I outline the ideal surgical plan for your nose. I follow this plan rigorously during the surgery - the only exception is when something unexpected requires an adaptation at the moment. I take all the planning with me to the operating room, along with your standardized photos and complete file, to ensure maximum precision during the surgery.

Favorable Anatomy

During the first consultation, I can already perceive, from the anatomy of your nose, which maneuvers will be necessary and which results are possible. There are limits to what surgery can achieve, and I am always honest about that. If the anatomy does not favor the result you dream of, I prefer to explain the reality rather than promise something I cannot deliver. My role is to show the maximum possibilities for modification and, when necessary, present alternatives that respect your nasal structure and preserve your health.

Critical Analysis

Rhinoplasty is one of the most challenging surgeries in plastic surgery. It is not enough to think only about aesthetics: I need to critically analyze what each modification will cause to the structure and function of the nose. It is a cause-and-effect relationship. Each change generates consequences, which can be positive or negative. Good results come from the combination of detailed prior analysis, a well-drawn surgical plan, and favorable anatomy.

Experience and Skill of the Plastic Surgeon

The experience and skill of the surgeon are fundamental. Over more than twenty years, I have been constantly updating myself at national and international conferences. I completed my residency in plastic surgery with Professor Ivo Pitanguy in Rio de Janeiro, where I assisted him in hundreds of surgeries over three years. I studied anatomy in depth and specialized in facial analysis. As one of the best rhinoplasty surgeons in Brazil, I am a member of the SBCP (Brazilian Society of Plastic Surgery) and ASPS (American Society of Plastic Surgeons). I receive patients from various parts of Brazil and the world at my clinic in Londrina -- many through medical tourism for rhinoplasty in Brazil. If you want to know more about nose surgery in Brazil, schedule a consultation and we will have a detailed conversation about your case.

Comprehensive Approach to the Nose, Both Aesthetic and Functional

In the past, aesthetic nose surgery was separate from functional surgery. The plastic surgeon took care of the appearance and the ENT handled the breathing. For many years, I worked this way. But I realized that to perform the grafts in structured rhinoplasty, I needed to have total control over the septum and the cartilages. So I underwent training in the United States specifically to master the functional aspect. Today, I create the complete surgical plan - aesthetic and functional - so that one approach does not hinder the other. The result? A beautiful nose that also breathes very well.

Pre-operative

Nose Evaluation

During the consultation, I perform a thorough evaluation of your nose and face. I explain the procedure, study the facial structure based on mathematical proportions, and determine which areas will undergo the most significant changes. I also identify any limitations - such as skin thickness or bone fragility - that may influence the outcome.

Aesthetic Parameters of the Nose

I use some mathematical parameters and proportions to determine the points to be improved. They help me measure what is visibly altered. However, they serve only as guidance: each nose has its particularities, and measurements outside these parameters are entirely acceptable, as long as there is harmony with the face and respect for ethnic differences.

The Thirds of the Face

To achieve predictable results, I divide the face into three parts, using four horizontal lines:

• one tangent to the hairline (a variable and less important line);
• one line at the level of the eyebrows;
• another at the nasal base; and
• the last tangent to the chin.

Divergences in these proportions may indicate maxillofacial alterations, such as vertical excess of the maxilla, known as "bird face" or maxillary hypoplasia. Since this is the foundation of the nose, meaning where it is situated, significant alterations of the maxilla should be addressed before rhinoplasty.

Nose Length

To assess the length, I check if it is equivalent to the vertical distance between the corners of the mouth and the chin, in a frontal view. This confirms whether the nose is proportionally long or short for the face.

Nasal Deviations

I draw a straight vertical line from the middle of the glabella (between the eyebrows) to the chin, dividing the nasal dorsum and the lip in half. Any nasal deviation from this line - called laterorrhinia or "crooked nose" - will likely require osteotomy (fracture) and septoplasty.

Nostrils Base

The normal distance between the nasal wings is equivalent to the distance between the inner corners of the eyes (intercanthal distance). If the nostrils are wider, I first study the cause. If the distance between the eyes is narrow, I prefer to keep the nostrils proportional. But if the nostrils are truly wide, I may indicate closure.

Tip Shape

I assess the tip by drawing two triangles with opposite bases, guided by the supratip break and the columelolabial angle. If these triangles are asymmetric, I may need to modify the tip.

In addition to correcting asymmetries, I often need to refine the nasal tip, especially in patients with a bulbous tip - the famous "potato nose."

Basal View of the Nose

In the basal view, I evaluate the nostrils and the base of the nose, which should describe an equilateral triangle, with a ratio between the lobe and nostril of 1:2. The nostril should have a teardrop shape, with the longer axis slightly medial.

Frontonasal Angle

This angle connects the glabella (space between the eyebrows) to the root of the nose, in a smooth curve, with an angle between 128 and 140 degrees, more specifically 134 degrees in women and 130 degrees in men.

Tip Projection

In the lateral view, the projection of the tip should equal the width of the nostrils in the frontal view and correspond to 67% of the length of the nose (from the root to the tip). Another way to assess: the anterior projection, from the upper lip, should be 50 to 60% of the total projection of the tip.

Nasal Dorsum

I start by drawing a line from the root to the tip. In women, the ideal dorsum is about 2 mm below this line. In men, it should be very close to it, to avoid feminization.

Normally, the tip is slightly more projected than the dorsum. I can lower the dorsum, raise the tip, or do both in the same surgery to achieve the best result.

Columelolabial Angle

This 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 in women and should be between 90 and 95 degrees in men.

Columella

Also known as sub-septum or mobile septum, the columella, the column of skin between the nostrils, can also be a target for correction. Basically, there are two unaesthetic defects of the nose that may involve the columella: the retracted columella and the hanging columella.

The retracted columella is "hidden" due to a lack of skin or cartilage. The hanging columella, on the other hand, has excess skin and cartilage, protruding between the nostrils. How to know if it is hanging? Not all formulas apply. Often, I detect the problem visually, but I also use calculations: when A - B is greater than 4 mm, the columella is altered.

Fortunately, both defects can be resolved. I use removal or cartilage grafts to correct these issues.

Evaluation of Skin Thickness of the Nose

The nasal dorsum is formed by the osteocartilaginous structure and the skin that covers it. This skin does not have uniform thickness: it is thinner in the upper two-thirds (root) and thicker at the tip. Additionally, the skin of the root has more mobility and fewer sebaceous glands.

The skin covers everything I do during rhinoplasty, and that’s why I draw attention to this important detail: thick skin reveals less of the refinements made. It’s like a thick blanket - hard to show what’s underneath. On the other hand, thin skin shows the smallest details. This means that a person with thick skin may have more difficulty achieving a very thin tip.

Thin Skin X Thick Skin

In general, patients with predominantly thinner skin on the nose will achieve the desired results more quickly and more visibly compared to patients with predominantly thicker skin. These patients will need to wait longer for the results to reach complete healing.

Evaluation of the Anterior Septal Angle: Is There Support at the Tip?

To determine if the tip has support, I perform a simple test: I pinch the tip with my finger. If it sinks, it has little support and I can correct it with grafts. If it remains firm in place, the tip is well supported and does not need reinforcement in this aspect.

Medications to Be Discontinued Before Surgery

I contraindicate the use of certain medications before surgery. Some interfere with blood coagulation, sedatives, anesthesia, and adrenaline. They should be discontinued fifteen days before and after the surgery. Among them are:

• Acetylsalicylic acid, known as ASA, marketed under the name Aspirin, Alka seltzer, Bufferin, etc.;
• Ginkgo biloba;
• Arnica, as it directly interferes with blood coagulation;
• Tricyclic antidepressants (amitriptyline, clomipramine, nortriptyline, etc.);
• Oral anticoagulants (marcumar, marevan, etc.);
• Appetite suppressants and weight loss medications (amphetamines, sibutramine, etc.).

Always inform your plastic surgeon about all medications you take, including natural ones.

Necessary Exams

Before the surgery, I request some exams to evaluate your health and provide greater safety for the procedure. The exams I usually request include:

• Complete blood count;
• PAT with INR + APTT;
• Urea and creatinine;
• Fasting blood glucose;
• TGO and TGP;
• TSH and free T4;
• Vitamin C;
• Vitamin D;
• AgHBs;
• Anti-HBs;
• Anti-HBc IgG and IgM;
• Anti-HCV;
• HIV serology;
• Total proteins and fractions;
• Urine I;
• Electrocardiogram;
• Surgical risk (evaluation with a cardiologist);
• Computed tomography of the nose and sinuses.

I need to know about your respiratory capacity, history of trauma, previous surgeries, rhinitis, or sinusitis. I evaluate septal deviations and the nose as a whole. I usually examine the inside of the nose for synechiae, septal deviations, or turbinate hypertrophy for a complete assessment.

General Anesthesia

For a complete rhinoplasty, which involves osteotomy (fracture), grafts, and tip treatment, the indicated anesthesia is general. Only local anesthesia is not satisfactory and safe in these cases. When I indicate only tip treatment, the procedure can be performed with local anesthesia and venous sedation.

We use the term "general anesthesia" to refer to the anesthetic technique that promotes total unconsciousness (hypnosis) of the patient, pain relief (analgesia), and muscle relaxation. General anesthesia allows for the performance of any necessary maneuvers during the nose surgery, as intubation protects the airways. Local anesthesia leaves me a bit limited, as this type of anesthesia is not indicated when the patient must undergo osteotomy, for example.

After the anesthetic induction, which is the transition period from consciousness to the unconscious state of the patient, the preparation of the nasal vestibules is necessary, at which point I trim the nasal vibrissae (nose hairs) and perform antisepsis on the inside and outside of the nose.

Once the vestibules are prepared for the plastic surgery of the nose, about 20 ml of a solution with 1% lidocaine and 1:80,000 adrenaline is injected to minimize bleeding during rhinoplasty, thus also avoiding bruising and pain in the postoperative period.

The areas where I apply this solution are: nasal dorsum, tip, anterior nasal spine, fracture line, alar mucosa, and septum. I wait approximately 12 minutes for the complete effect of the adrenaline before starting.

For greater safety, a specialized anesthetist accompanies the entire surgery with me, from start to finish. They monitor blood pressure, pulse, temperature, respiration, level of sedation, and hydration throughout the procedure.

Rhinoseptoplasty and Turbinoplasty (or Turbinectomy): Functional Treatment of the Nose

In the pre-operative evaluation, I can detect septal deviation and hypertrophy of the turbinates. The deviation can be congenital (present at birth) or acquired (after trauma). When the patient needs functional improvement beyond aesthetics, I perform rhinoseptoplasty with treatment of the turbinates when necessary - I take care of everything in the same surgery. There are several ways to correct a septal deviation: simple removal of the deviated part, or removal, correction with incisions, and reinsertion. When the deviation is low and has a spur, it is called a spur. The turbinates can be treated with turbinoplasty (repositioning) or turbinectomy (removal).

Turbinectomy or Turbinoplasty: Correcting Turbinate Hypertrophy

Often, the septal deviation is not the only villain hindering respiratory function in patients candidates for nasal plastic surgery. The nose is composed of several turbinates, also known as turbinates or shells, which are inserted into the lateral walls of the nose and can be enlarged, making breathing difficult. During rhinoplasty or rhinoseptoplasty, it may be necessary to associate the surgery with turbinoplasty or turbinectomy. Turbinoplasty modifies the position of the turbinates, increasing airflow. If the enlargement is too great, turbinectomy may be necessary, which consists of total or partial removal of one or more turbinates. Most of the time, the turbinate that interferes with breathing is the inferior one, which is also the largest.

The splint and Synechia

During rhinoplasty with septoplasty and/or turbinectomy, it is often necessary to place, in addition to the packing, a nasal splint, which is a small plastic or silicone plate in each nostril. Besides helping to support and fix the septum postoperatively, it prevents contact between raw areas of the septum and the lateral wall of the nose, also avoiding a condition called synechia. Synechia in the nose is a scar that forms a bridge between the septum and the lateral wall of the nose after surgery involving septoplasty or turbinectomy where there was a raw area (without epithelium) at the same height as the septum and the lateral wall of the nose. Symptoms of synechia can include nasal obstruction or wheezing (whistling during nasal breathing). Its treatment may involve either a cross incision or total removal, followed by protection with a nasal splint.

Frequently Asked Questions about Rhinoplasty

Fears

Piggy Nose

A short, very upturned nose, with nostrils showing, the piggy nose is one of the biggest fears of those who are going to undergo rhinoplasty. I have never left anyone with a piggy nose. In fact, I once refused to operate on a patient who asked me to give her a bulldog nose because I didn’t think it would look good or natural for her.

Michael Jackson Nose

Another example of a feared result, with an unnatural nose, full of stigmas of having been operated on, with a tip that is too thin, too straight, with nostrils that have been excessively removed. Michael Jackson's nose was probably the most talked about in history, and at the same time became an anti-example of a desirable rhinoplasty result. After all, 17 nose surgeries were performed, as confessed to me by the American plastic surgeon who did the first rhinoplasty on the singer.

Secondary Rhinoplasty

Secondary is the plastic surgery of the nose for those who have already undergone a primary rhinoplasty (the first one being called primary). Often, it is necessary to complete an incomplete fracture, lower the dorsum, raise the dorsum with cartilage grafts, correct an inverted "V" with a spreader graft, correct the supratip, improve projection or definition of the tip with cartilage grafts or cartilage remodeling, correct superficial irregularities, improve scars from open rhinoplasty or nostril rotation, correct deviations, among others.

Changes in Surgical Planning

When performing secondary rhinoplasty, I do not use the same techniques as in primary rhinoplasty, or conventional rhinoplasty, because there will be the presence of fibrous scar tissue, changes that arose as a result of the 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, rasping, etc. performed in the first plastic surgery of the nose.

For me to consider the possibility of revising a rhinoplasty, it is ideal for the patient to have waited a year from the date of the primary nose plastic surgery (first rhinoplasty), as this is the necessary time for total recovery from a rhinoplasty, for the entire nasal structure to be completely healed, recovered, and with swelling gone. Technically, secondary rhinoplasty is more complex, as I will be dealing with distorted or even absent anatomy. Especially due to swelling, it is not advisable for secondary rhinoplasty to be performed before one year from the primary, as swelling is still present. The swelling between the nasal skeleton and the skin covering it can cause me to lose the parameters of the original structure of the nose, posing a high risk for the results, which may not align with what the patient desires. Therefore, I recommend waiting one year from the primary before undergoing secondary rhinoplasty.

Candidates for Secondary Rhinoplasty

In general, there are some prerequisites for a patient to undergo secondary nose plastic surgery, which are:

• patients over 15 years old who have undergone a primary rhinoplasty, not achieving the desired results or who have experienced complications that prevented the desired result from being achieved;
• patients dissatisfied with any visibly unaesthetic and/or perceptibly functional defect;
• emotionally stable patients, that is, who are in good emotional and mental condition;
• patients in good health and who have no contraindications to undergo secondary rhinoplasty;
• patients aware and willing to undergo cartilage grafting, if necessary;
• patients who are prepared, having an optimistic and realistic view of secondary rhinoplasty itself, always remembering the limitations involved in this procedure.

These are just some of the general prerequisites, and even if the patient is in compatible conditions according to the requirements, they must undergo a prior consultation with me, during which I evaluate the possible aesthetic and/or functional defects to diagnose the reasons for the failure of the previous surgery. I conduct a meticulous assessment of all the problems and points of dissatisfaction that bother the patient, so that I can outline the surgical planning that, this time, will be much more complex than that of a primary nose plastic surgery.

Cartilage Graft

Considering that most cases of treatment through secondary rhinoplasty that come to me involve patients with a lack of cartilage to produce a satisfactory nasal reconstruction, in my clinic, this procedure has as its basic repair technique the use of grafts. When we deal with primary rhinoplasty, harvesting cartilage is usually not a problem, as this material is found in large quantities in the cartilaginous septum and in both ears. The preference is to use cartilage from the septum, to make the nose plastic surgery as minimally invasive as possible, however, harvesting cartilage from the septum is not always possible, as the patient may have had a deviated septum surgery in the first operation.

Nothing prevents me from using cartilage from the septum and ears when they are available and will not weaken the nasal skeleton in secondary rhinoplasty. The cases of grafts vary greatly when we are treating rhinoplasty, especially secondary. Despite being quite complex, it is also very important to always aim for individuality, naturalness, and compatibility with the patient's ethnicity in performing secondary rhinoplasty, as well as in primary rhinoplasty.