Rhinoplasty — with Tummy Fat?

Plastic surgeons in England and a few other places are offering some nose surgery procedures with fat taken from fleshy abdomens.

(The same technique can be applied to breast augmentation. Read our blog post about breast enlargement with fat.)

If the technique should become more widespread, that would mean some nose surgery techniques could be done, not with scalpels, but with needles.

Here’s how it works:

The plastic surgeon takes some of your own fat from areas where you can spare it – perhaps your tummy or thighs. In plastic surgery, it’s a fairly new and growing specialty known as autologous fat transfer.

The fat is then carefully prepared.

It goes into a centrifuge, a device that whirls the fat around in a circle to separate blood, anesthetic and other fluids from the donated fat; it’s known to cosmetic surgeons and plastic surgeons as lipoaspirate.

Next, the surgeon gives the patient a local anesthetic and fills his syringe with the prepared fat cells. The surgeon can then:

• Flatten bumps on the nose
• Make crooked noses appear straighter
• Widen tiny noses
• Fill depressions on the nose

However, large noses cannot be made smaller. Only nose surgery can do that.

Plastic surgeons can also perform the same treatments with fillers like Juvederm, Radiesse and Restylane although those substances are absorbed by the body in 12 to 18 months. While the body may absorb some fat, most is permanent.

Unlike rhinoplasty in which bone or cartilage is added, moved or rearranged with the patent asleep under a general anesthesia, injection nose surgery offers:

• Less cost
• Quicker recovery
• Minimal bruising
• A return to work in several days for patients

Nose-job with fat patients must not touch their noses or wear spectacles for seven days.

Rhinoplasty and Microsurgery

If you have read our bio, you already know we trained for a year in microsurgery so that micro-vascular surgery is one of our specialties.

What does it do? Short answer: makes repairs on very tiny things in the body.

Recently, there was a case in Minot, North Dakota, in which a man’s nose was torn from his face in a motorcycle accident.

Coming to the victim’s aid was not a plastic surgeon, but Dr. Juan Ulloa, a dentist with four years training in oral and maxillofacial surgery. (Read more about the rhinoplasty reattachment.)

As you might guess from the name, microsurgery is performing surgery under a microscope.

Dr. Ulloa was under the gun because the past has shown that he has about two hours to reattach a nose and stand a reasonable chance of it remaining alive on the patient’s face.

Just how tiny are the items involved in microsurgery?

The thread used to reattached blood vessels is ten times thinner than a human hair. So, your first guess is correct. The surgeon absolutely needs a microscope or ultra high bionic lenses on his or her glasses to see the work.

Before reattaching,  blood vessels must have clean, not ragged, edges so they will grow back together.

Dr. Juan Ulloa and patient

The work is extremely exacting: the blood vessels and nerves on which the surgeon works can be as small as two to four millimeters.  (One millimeter equals the width of the period at the end of this
sentence.)

The facial transplants that took place at the Cleveland Clinic required reconnecting multiple areas of the face with microsurgery.

According to news reports, Dr. Ulloa reattached the patient’s nose by finding the severed ends of his nasal arteries and veins and sutured them together. He then reattached the nasal tissue and splinted his nose to keep the bones in place.

“Cartilage in the nose is very soft and it’s difficult to get an acceptable result in such a case,” said Dr. Ulla who was holding his breath about the outcome.

But the patient had about the best outcome that could be hoped for.

While infection is always a possibility in cases like these, good aftercare resulted in the patient having a nose that looks normal, has sensation and – last, but certainly not least – one that he can breathe through.

Rhinoplasty Reconstruction

A very advanced form of nose surgery is Rhinoplasty reconstruction.

Usually, some terrible accident or injury has smashed the bones in the nose and they need to be replaced.

The best framework for a reconstructed nose is bone and cartilage taken from the ribs. In some cases, ears can contribute small pieces of cartilage.

In a recent case in Mumbai, India, a ten-year-old girl got a rare but powerful microbial infection known as Noma (caused by the organisms Fusobactgerium necrophorum or Prevotella intermedia.) Both are due to living in conditions of poor hygiene.

Results? Because the infection is attracted to soft flesh, it ate away her nose and left ear. The unfortunate child was left with two nostril holes in the middle of her face.

Although the child came from a very poor family, she was able to attend school and was making good progress. But as her nose disappeared, the teasing and ridiculing eventually became too much and she quit.

Even though plastic surgeons were able to build a proper nose framework, they need the girl’s own skin to wrap and cover the bony nose structure.

Solution? Tissue expanders are often used in cosmetic breast reconstruction, are inserted under the skin and gradually filled with saline. That forces more skin to grow over time.

The same technique was used to grow extra skin to cover the girl’s nose.

A silicone balloon was inserted through a tiny incision in her forehead and then slowly expanded for four weeks. That provided enough skin to cover her nose. Presumably, the surgeons also made sure the girl could breathe through her nose.

The young patient told the Mumbai Mirror: “I feel very happy when I see myself in a mirror; people can’t make fun of me anymore..” Plus, she is back in school.

The nose is so important because it is the central focal point of the face.

When a nose has more-or-less normal parameters, the eye sees the face and profile in balance ; few people ever actually notice a normal nose. Instead, the eye usually deflects its attention to the eyes.

But when a nose is too large, misshapen, crooked, humped or drooping, observers’ eyes tend drag down from the subject’s eyes, concentrating more on the nose. The result is the eyes seem smaller.

Her partial ear can be covered by hair until more surgery can take place.

Rhinoplasty and Surgery on the Older Nose

Nose jobs are appropriate for people in their teens to senior citizens. But there are some special considerations in plastic surgery on the older nose. As we age – and with the help of gravity – many older noses also droop and appear longer and less attractive.

Those noses also tend to develop humps on the middle part of the nose.

So the surgeon must carefully consider the following about older rhinoplasty patients:

• Current medical problems
• Medications taken
• The patient’s expectations from surgery

Writes Rod Rohrich, M.D. a Texas board-certified plastic surgeon who has authored technical articles on performing the mature rhinoplasty: “Less is indeed more; mature patients do not want the big changes wanted by younger patients.”

Dr. Rohrich was president of the American Society of Plastic Surgery from 2003 to 2004 and is professor and chairman, department of plastic surgery at the University of Texas Southwestern Medical Center.

It’s an important topic because the first of the huge numbers of baby boomers (everybody born between 1946 and 1964) will fill doctors’ offices in two years. Perhaps you’ve read that baby boomers are not retiring like previous generations and often take up new careers.

Facial makeovers to look more energetic, rested and refreshed are often part of that boomers new career.

Nonetheless, all that energy and ambition is contained in a 65-year-old body!

Sometimes, the rhinoplasty surgeon finds, as the nose droops and grows longer, the internal nasal valve is also pinched, restricting breathing.

Solution? The surgeon uses a technique known as spreader grafts to safeguard the airway.

A piece of donor cartilage is inserted in the middle part of the nose to prop the nostrils open.

The surgeon also must carefully consider how the passing decades and gravity have affected changes in the patient’s skin, cartilage and the bony framework inside the nose.

To make the older nose look better the surgeon usually must:

• Bring up and straighten the tip
• Lengthen the columella, the strip of skin between the nostrils

Experts also say older patients heal more slowly and might have bruising and tenderness longer than younger patients.

If the patient is really concerned about his or her appearance, a neck lift or chin augmentation might also help improve the person’s facial profile.

Another bright idea: find a surgeon who has done many older noses!

Rhinoplasty With the Open or Closed Techniques

When a plastic surgeon or a head and neck surgeon starts a rhinoplasty, he or she is going to start the procedure using one of two approaches:

• The open, or external, technique

The surgeon makes a small incision in the strip of skin that separates your two nostrils and pulls the skin back to reveal the architecture of the nose. Imagine opening the hood of a very tiny car.

• The closed technique

The surgeon operates through your nostrils. Some surgeons, including the ones at California Surgical Institute, favor this approach although it requires extra training and is more demanding due to the small tolerances in the nose.

Also known as the endonasal approach, the closed technique offers some advantages, including allowing the surgeon to immediately see what the final result is going to look like.

But if the surgeon is using the open technique, the nose skin must first be pulled back into place over the nose framework to get an idea of the nose’s final outcome.

The closed approach can heal faster. When the nasal skin is peeled back, the lymphatic drainage system is interrupted; that also causes more swelling.

Most surgeons who use the closed technique learn it from an older, more experienced plastic surgeon and that might require a year-long fellowship.

Of course, there are exceptions: if the surgeon is doing a repair of a previous nose job – a revision rhinoplasty — there may be too much scar tissue to allow the surgeon to get to the area where he needs to work. He may then switch to the open approach.

Or, if the surgeon is not getting the results wanted, he or she may go ahead and open the nose up for better visibility.

However, if the surgeon starts with an open, he or she can’t go back to a closed and enjoy its particular benefits.

A closed may be best for removing a nasal hump while changes in the tip of the nose may require an open.

Which is best?

If you like the quicker healing of the closed approach, do the next logical thing and look at the surgeon’s before and after rhinoplasty pictures and make sure all the noses you see look natural and fit well within the faces shown.