Reasons for Rhinoplasty

As a triple board-certified plastic surgeon and rhinoplasty specialist with over 30 years of experience, Dr. Chaffoo has performed a wide variety of rhinoplasty procedures for San Diego and La Jolla patients. On this page, he reviews some of the most common concerns patients have about their nose and describes how he addresses these concerns with rhinoplasty.

Obstructed Breathing

I perform functional rhinoplasty which may include septoplasty and turbinate reduction surgery to correct breathing that is impaired in 1 or both nostrils.  Nasal obstruction may be constant, intermittent, year-round, or seasonal. Functional rhinoplasty will often improve an airway obstruction that is constant and long term in duration, indicating an anatomic obstruction. Intermittent and seasonal nasal airway obstruction can indicate an underlying allergy, which may be improved with turbinate surgery.

Prior Surgery or Trauma

I perform revision rhinoplasty for patients who have previously undergone rhinoplasty and have concerns about the appearance of their nose for many reasons. For example, they may feel there were little to no changes in the nasal appearance after surgery. Some patients complain the nose appears worse or different after prior rhinoplasty, and in some cases, airway obstruction following prior rhinoplasty may be unchanged or even worsened.

Prior nasal trauma and nasal fracture often produce deformities in the appearance of the nose (such as a pinched nasal tip and other concerns discussed on this page). Trauma can also impact function, including airway obstruction, so the surgery may be both cosmetic and functional.

Large or Wide Tip

I like to use a hand-held mirror and have the patient show me exactly what he/she feels is “too large” or “too wide” in the nasal tip. Are the cartilages too bulbous? Is the tip not well-defined? Are the nostrils flaring?

Solution: Rhinoplasty for the nasal tip includes removing excess tip cartilage and using suture techniques to create more definition and narrowing of the nasal tip.

Before & After Nasal Tip Rhinoplasty

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Pinched Tip

The nasal tip may look too narrow, pointed, or “pinched” as a result of prior rhinoplasty, thin nasal tip skin, or prior nasal trauma. It is often necessary to reconstruct the tip cartilages with grafts obtained from the nasal septum, or, when septal cartilage has already been removed during a previous surgery the graft may be obtained from the ear. These cartilage grafts restore the shape of the nasal tip and improve the nasal airway by correcting the external nasal valve.

Before & After Rhinoplasty Pinched Nasal Tip

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Drooping Tip or Long Nose

The nasal tip may not appear prominent enough and actually drop with smiling or other facial expressions, making the nose look longer and the face appear older.

Solution: In these cases, tip rhinoplasty often requires trimming the tip cartilages and lifting the nasal tip with a combination of struts and tip grafts. Struts are cartilage grafts placed between the medial crura inside the nose to improve support; tip grafts are placed between the skin of the nasal tip and underlying tip cartilages to lift the drooping or ptotic tip and give it more definition.

Before & After Rhinoplasty Drooping Nasal Tip

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Hanging Columella

When the columella (the strip of skin between the nostrils) is prominent and heavy looking, we call this a hanging columella. There are several issues that can cause this deformity. If the nasal septum is too long and prominent, the columella appears more prominent and hangs down too low. The lower lateral cartilages may be poorly supported and may tend to droop, causing the nasal tip to drop and possibly making the nose appear too long on profile.

Solution: To correct the hanging columella, I remove excess nasal septum and place cartilage grafts between the tip cartilages to lift the drooping tip.

Before & After Hanging Columella

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Nostril Retraction/Notching

If the lower lateral cartilages have been over-resected by previous rhinoplasty or are too weak, the nostrils (alar rims) will appear elevated or notched, often making the patient look like he/she is sneering. This gives the nose an unnatural appearance and gives the female nose a more masculine look.

Solution: Cartilage grafts can be placed along the nostril rims from incisions inside the nostrils to lower the nasal skin and correct the elevation of the nostril borders.

Before & After Nasal Retraction

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Over-Projected Tip (Pinocchio Nose) & Nasal Boss

The nasal tip is formed by 2 lateral cartilages that sit on either side of the columella. If the lower lateral cartilages are too long, the nasal tip may be too prominent for the nasal profile. The nasal tip may be over-projected, giving the nose an unnatural appearance and making it appear too long (hence the name Pinocchio) and overpowering as the tip cartilages dominate the nasal profile.

Solution: The over-projected tip cartilages can be carefully reduced in size and reconstructed during tip rhinoplasty to correct the overly long nasal tip.

A “nasal bossa” is a palpable or visible irregularity, knuckling, prominence, or protruberance of the lower lateral nasal tip cartilages. This condition is usually the result of previous rhinoplasty but may also be seen in some patients who are considering primary rhinoplasty. Early nasal bossae are often due to uncorrected or accidentally created asymmetries, while late nasal bossae may be due to fibrosis or scar contracture acting on a weakened lower lateral cartilaginous framework.

Solution: A nasal bossa can also be carefully excised with reconstruction of the tip cartilages using sutures.

Before & After Over-Projected Tip & Nasal Boss

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Weak Tip

The opposite of the over-projected tip can also occur when the lower lateral cartilages are weak and provide poor support for the nasal tip. In this case, the nasal tip is ill defined and less prominent than the nasal dorsum or bridge creating a “hook nose” or “beak appearance.”

Solution: Tip projection and prominence can be established using struts and tip grafts to lengthen the nasal tip.

Before & After Weak Tip

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Thick Nasal Skin

Many patients are unaware that rhinoplasty is simply an operation on the underlying skeletal framework of the nose—the cartilage and bone. It is not a skin operation, and thick skin can limit the final outcome of surgery despite the surgeon’s best efforts. This means that the nasal tip may still appear somewhat wide and poorly defined due entirely to the nasal tip skin. Results of surgery on the nasal dorsum or bridge may also be affected by thick skin even when the nasal bridge has been adequately reduced and narrowed.

Before & After Rhinoplasty Involving Thick Nasal Skin

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Thin Nasal Skin

The opposite is true when the nasal skin is especially thin and delicate. The cartilages are obvious and defined since there is little soft tissue coverage. Consequently, surgery on the nasal tip and bridge or dorsum may create visible and palpable asymmetries and irregularities that the surgeon can often predict and prevent at the time of rhinoplasty. The patient’s own soft tissue can often be harvested at the time of rhinoplasty to act as a natural soft tissue “filler” that is safe, permanent, completely eliminates any visible nasal irregularities.

Before & After Rhinoplasty Involving Thin Nasal Skin

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Shortened Nose or Retracted Columella

The columella is composed of the central parts of both lower lateral cartilages and the overlying skin membrane. It can be distorted or retracted (elevated) with excessive removal of the nasal septum and/or lower lateral cartilages. The nasal tip drops or hangs, making the nose appear too long.

Solution: Correction often includes the use of cartilage grafts called struts placed between the tip cartilages and the use of tip grafts to support the nasal tip.

Before & After Retracted Columella

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Shortened Upper Lip

When the front end of the nasal septum is too long and/or the nose has a prominent nasal spine, tension is placed upon the central portion of the upper lip. The lip is placed under tension and is shortened or elevated which is exaggerated with smiling.

Solution: Rhinoplasty can lengthen the central upper lip by dividing the muscles that insert into the nasal septum. It is also possible to reduce the nasal septum if it is too long and puts tension on the upper lip.

Before & After Shortened Upper Lip

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Twisted Tip

The nasal tip can be deviated or twisted from prior nasal surgery or nasal trauma, or the condition can be congenital. Facial asymmetry can create some mild asymmetries to the nasal tip and nasal bridge as well.

Solution: Rhinoplasty can correct a twisted tip with sutures and tip grafts.

Before & After Twisted Tip

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Wide Bridge

The nasal bridge or dorsum can appear too wide in the region of the nasal septum, upper lateral cartilages, nasal bones, or any combination of these areas. Patients may state that it’s difficult to wear glasses at times if the frames are not wide enough.

Solution: Rhinoplasty for this concern includes osteotomies, which involve using small surgical chisels to “rebreak” the nasal bones and set them in a more symmetrical and narrowed position.

Before & After Wide Bridge

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Prominent Nasal Bump

This is a very common complaint. The bridge appears to have a hump or hook-like appearance, making the nose look too large and disproportionate for the face.

Solution: Rhinoplasty includes removing the prominent nasal hump with surgical chisels and narrowing the nasal bones to create a straight nasal profile.

Before & After Prominent Nasal Bump

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“Scooped or Ski Slope” Nose

This concern is the opposite of the prominent nasal bump. The nasal bridge is too low or scooped out, creating a nose that looks too short and turned up. The nasal bridge is not well-defined and makes the middle of the face look “sunken” or “washed out.” A scooped nose is usually the result of prior rhinoplasty or nasal trauma. It is also seen congenitally in certain ethnic groups who have small nasal bones, such as in some patients of Asian or African American descent.

Solution: If minimal, a scooped nose can be corrected with surgical chisels to narrow the nasal bones and provide some nasal height. If the condition is more extensive, it may be necessary to use the patient’s own cartilage and fascia (soft tissue) grafts to correct a low nasal bridge.

Before & After Scooped Nose

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Crooked Nose

Asymmetry of the face (and nose) is probably the rule rather than the exception. The nose may appear crooked or deviated because of the nasal bones and/or middle vault. You can usually see even a minor deviation of the nose from how the light reflex appears on the bridge of the nose. If it curves to 1 side, there is usually a deviation of the nose and/or facial asymmetry.

Before & After Crooked Nose

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Nasal Bridge Depressions, Irregularities, & Ridges

Indentations and irregularities can occur anywhere on the nose, most often along the nasal bridge or the nasal tip. They may be due to excessive or uneven removal of cartilage and bone or inadequate soft tissue coverage from thin skin. Irregularities can be visible or only noticed when a patient runs a finger on the surface of the nose. Causes include uneven or over-resection of underlying cartilage or bones. Ridges typically occur along the sides of the nasal bones and are often seen when a patient complains of a nasal hump or convexity. These concerns are usually seen more often in patients who have thin nasal skin.

Revision Rhinoplasty Before & After Nasal Ridges

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Facial Asymmetry

Facial asymmetry in humans is the rule, not the exception. I always explain to patients that the 2 halves of the face develop separately and ultimately fuse (incomplete fusion results in cleft lip and palate deformities). Facial asymmetry can involve the position of the eyes, midface, or lower jaw. One eye can be slighter higher in position, as in this patient case, which can make the nose appear crooked or deviated. I find it easy to show my patients facial asymmetry by looking at photos or computer images of their face at the consultation.

Solution: Rhinoplasty will improve the shape of the nose but not deviations of the nose related to underlying facial asymmetry.

Before & After Rhinoplasty With Facial Asymmetry

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Weak Chin

Nearly 1/3 of patients who see me for rhinoplasty would also benefit from augmentation of the chin to balance the facial proportions on profile. The chin may appear weak or under projected, making the nose appear larger in size.

Solution: Augmenting the chin with a medical grade implant placed through a small incision underneath the chin restores balance to the face and makes the nose appear smaller and more proportional.

Before & After Rhinoplasty & Chin Augmentation

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Next Steps

When you decide to undergo rhinoplasty, it’s important to feel comfortable and confident about the plastic surgeon you choose. Patients appreciate triple board-certified plastic surgeon Dr. Richard Chaffoo because he makes their goals a priority and strives to exceed their expectations with natural-looking improvements. To learn more, request your complimentary cosmetic consultation online or call (858) 623-6333 for an appointment.

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