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Asymmetry in Rhinoplasty, Facial implants and Facial fillers

Facial asymmetry, it’s more common than you think

As a facial plastic surgeon, people are coming in for facial analysis for treatment of their noses, faces, chins etc. Most people have at least minor facial asymmetry. One eye and/or corner of the mouth is higher. Very often someone comments that their faces look more crooked in photos than in real life. Therefore the “outside world” must see them as being much more crooked than they really are. Some people actually avoid having photos taken or insist on a photo from their “good side.”  Why is that?

We are much more used to the way we look in the mirror. You look in the mirror many times a day; brushing your teeth, coming your hair, putting on makeup or aftershave. We rarely look at our faces up close in photos, except when confronted with a picture.

So for patients with asymmetric faces or noses, the first thing I do is use the reverse mirror image tool my computer to show what they normally see. Toggling back and forth helps to demonstrate that they might not be as asymmetric as they think. I can also compare ¾ views since we rarely see a true profile or ourselves in mirrors or photos. If a spouse or parent is present for the consultation, they are surprised at the mirror image and comment that what the patient sees in the mirror appears more crooked than in real life’, since they are more used to the photographic image. 

As for treatment, they range from simple to complex. For minor facial asymmetries, facial fillers are great. I just use more on one side of the face. Facial implants can be also used, either by carving stock implants to fit the asymmetry or computer generated custom facial implants. Custom implants are created from a model constructed using a 3-D CT scan. Implantech has this amazing technology and is very helpful when it comes to custom facial implants.

As for noses, the tip of the nose, even if crooked, often points down the center of the upper lip. Whatever trauma caused their nose to become that way created an impact in the center of the nose creating a “C” or “S” shape but the tip ends up down the center.

For crooked noses, that is one of the reasons why I might choose to use an open approach for rhinoplasty instead of an intra-nasal, or closed, rhinoplasty. My preferences and indications for closed vs. open rhinoplasty was discussed in an earlier blog.

Facial asymmetry is more common than you think. Facial analysis and treatment with the advent of computer and 3-D imaging is a great tool to both point this out and plan treatment. Steven J. Pearlman, MD, FACS

Open Rhinoplasty vs. Closed (endonasal) Rhinoplasty from a Rhinoplasty Specialist

There has been a lot of hoopla over the past two decades over the incisions used for both primary rhinoplasty and revision rhinoplasty. There even has been name calling at medical meetings: open rhinoplasty is equated with and open mind and closed rhinoplasty attributed to a closed mind. Well this is not true and why I don’t use the term closed very often.

There is a lot of history behind the surgical approaches in rhinoplasty dates back to nasal reconstruction techniques in India in 800 BCE and in the 1600’s in Italy by Tagliacozzi. Modern intranasal or closed rhinoplasty is attributed to Drs. Jacques Joseph and John Orlando Roe in the 1890’s. In 1927 Rethi introduced the columellar, or modern open, incision. This fell out of favor until it was reintroduced by Padovan in the 1970’s. Since that time, many highly regarded nasal surgeons, such as Drs. Jack Anderson, Calvin Johnson, Dean Toriumi and Jack Gunter have advocated the open approach. Other experts, including Drs. Eugene Tardy, Frank Kamer, Jack Sheen and Thomas Rees still relied on a mostly the intranasal approach for their superior results.

So enough with the history, this is not a book chapter for doctors. Which of the two is the best way to get a superior result in rhinoplasty? There is no good answer and it really depends more on the individual surgeon. I feel that in primary (never operated) rhinoplasty I can obtain equal if not a better cosmetic result using an endonasal approach in over 90% of patients, without any incision across the bottom of the nose (this part of the nose is called the columella).  It’s more important that your surgeon understands the anatomy of the nose and is an expert in rhinoplasty, than what incision they use.

Then, why would I use the open incision at all in primary rhinoplasty? The indications, medical speak for reasons, in my opinion for using the open approach are 1. A very crooked nose, 2. A short nose that needs to be made much longer, 3. A nose that requires many grafts.

For revision rhinoplasty, which comprises about a third of my nasal procedures, I use the open approach on most. My indications for this incision are 1. Unexpected changes that may have occurred during the first surgery, 2. scarring and 3. Altered anatomy from both surgical and changes during healing. These are findings that often occur in revision rhinoplasty, otherwise the patient wouldn’t be seeking revision. Going back to primary rhinoplasty, a good surgeon should be able to tell the patent’s underlying anatomy from an external exam alone, by looking at the nose, touching the nose and looking inside the nose. So, making changes should be predictable. When surgery has been performed prior, there are changes that may not be accounted for in old operative notes, scarring and often stitches that holds structures in place and defy moving  (the technical term is delivering) the cartilage around as is done to modify the nasal tip in a primary case.

As for the open rhinoplasty incision, across the columella, this incision is tiny and usually barely noticeable if at all. Of course, all incisions are pink for up to 6 months, but as it heals, I feel that unless someone is looking up your nose, know what they are looking for and close enough to count nose hairs; they are unlikely to notice the incision.

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