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Dean Toriumi, M.D. |
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My Philosophy ~ Rhinoplasty |
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Rhinoplasty is one of the most difficult operations in facial plastic
surgery. The operation is difficult because every nose is different
and the anatomy varies from patient to patient. As the anatomy varies
so must the techniques used for correction. The surgeon must be able
to perform a precise and complete nasal analysis to spot all of the
aesthetic and functional deformities. Then the surgeon must formulate
a surgical plan that is conceived to correct the specific deformities.
It takes a great deal of experience to accomplish these steps. As a
surgeons rhinoplasty practice matures, one encounters more of the
different combinations of anatomy and is better able to effectively
correct the problems at hand. More common problems such as a bulbous
nasal tip and a small dorsal hump are less complicated to correct than
the previously operated and severely over-resected nose. However, even
the less complicated nasal surgeries require attention to detail and
precision in execution.
This patient presented with a bulbous nasal tip and small dorsal
hump. However, her nasal tip cartilages were very stiff and round and
required special grafting maneuvers to reshape her tip cartilages
while maintaining a good nasal airway. Over many years her nose has
taken on a favorable shape. The photographs represent a two-year
postoperative outcome.
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Pre-Operative Photos |
Post-Operative Photos |
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Dr. Toriumi does not have a standard aesthetic goal in rhinoplasty.
He believes there is no required aesthetic standard. However, he prefers
a nose that looks good from the frontal view as this is the perspective
that one sees when they look into the mirror or while conversing with
others. Dr. Toriumi also feels it is important to have the nose balance
with the other facial structures. In patients with a weak chin, chin
augmentation is important to help balance the nose with the weak chin.
This patient has an under-projected chin. Chin augmentation
provided balance between the increased tip projection and the deficient
chin.The photographs represent a two year postoperative outcome. |
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Pre-Operative Photos |
Post-Operative Photos |
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In patients with thick skin it is important to keep the nose slightly
larger (higher bridge and increased tip projection) to avoid problems
with skin redraping or formation of a polly-beak deformity (when the
tip droops below the bridge). In patients with thick skin Dr. Toriumi
will recommend keeping the nose larger on lateral view to allow
expanding the thick skin and form a better look on the frontal view.
This is one of the more difficult concepts for patients to understand.
Noses will always look narrower and more defined when they are more
projected.
In patients with thin skin, the nose can be made smaller with a lower
dorsum as the thin skin is more likely to contract and accommodate the
underlying nasal framework.
This patient
suffered from nasal obstruction and nasal deformity. She had a crooked
nose and over-projected nasal tip. Special care was taken to
straighten her septal deviation to correct her airway obstruction. Her
nasal tip was de-projected (brought closer to her face) and her dorsum
was reduced. She also had a small radix graft placed to raise her
radix (the root of the nose, between her eyes). Her thin skin redraped
well leaving her with a good improvement in nasal contour. The
photographs demonstrate a one year postoperative outcome. |
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Pre-Operative Photos |
Post-Operative Photos |
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Patients with thin skin require the highest level of attention as they
are at greater risk for visible or palpable irregularities. Patients
with medium thickness skin are ideal as their skin will contract to
some extent but will camouflage the underlying cartilage and bone
better than thin skin.
Dr. Toriumi will sit with the patient during their consultation and
perform computer imaging of the patients nose. He always does the
imaging himself because only he knows what is a realistic potential
outcome for that patients particular anatomy, skin thickness and
expectations. Dr. Toriumi will allow for differing degrees of variance
in many parameters such as dorsal height, radix height, tip
projection, rotation, etc.
This patient had a
crooked nose with a large dorsal hump. His dorsal hump was reduced and
his radix augmented to provide a straighter profile. The patient had
larger nostrils that were reduced to provide a more normal alar base.
Some degree of ethnic contour was preserved in this patient as well.
The photographs show his one year postoperative outcome. |
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Pre-Operative Photos |
Post-Operative Photos |
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Dr. Toriumi's patients have a wide range of nasal shapes as he has no set
aesthetic standard. The ultimate nasal contour that is agreed upon is
frequently the result of discussions with the patient. Dr. Toriumi
then takes the imaging with him to the operating room to use as a
guide to the final outcome. He views the computer images many times
during the procedure to aid him attaining his final outcome. The
images are not a guarantee of a result but in most cases Dr. Toriumi
gets close to the computer image. The key is that Dr. Toriumi images
only realistic outcomes during the consultation.
Dr. Toriumi uses a technique of rhinoplasty that emphasizes
preservation of nasal structure with minimal excision of supporting
tissues. Excessive removal of supporting structures results in an
operated look that frequently exhibits a pinched, upturned tip, with
nasal obstruction. These problems can be lessened or avoided by
minimizing excision of supporting tissues such as the cartilages of
the nose. Dr. Toriumi uses cartilage grafts taken from the patients
own septal cartilage (from inside of the nose) and uses these
cartilage grafts to increase the strength of the nose and minimize the
undesirable changes that can otherwise occur. In more complex cases,
Dr. Toriumi may use ear cartilage or rib cartilage for the structural
grafts.
There are a number of complications that are very common after
rhinoplasty. Dr. Toriumi has developed a rhinoplasty technique that
will aid in avoiding these common complications. For example, many
patients who undergo typical reductive rhinoplasty techniques develop
collapse of the lateral wall of their nose with resultant nasal
obstruction. To avoid this problem Dr. Toriumi will minimize excision
of nasal tip cartilages and routinely place alar batten grafts ( small
curved cartilage grafts) to stabilize the lateral wall of the nose.
These grafts may create some increased fullness in the side of the
nose that may last for months and even years in some patients. In
almost all patients, this lateral wall fullness will flatten out and
look normal. By supporting the lateral wall of the nose, his patients
rarely develop lateral wall or nasal valve collapse and rarely have
breathing problems.
This patient presents with a dorsal hump and nasal obstruction. She
had a weak lateral
nasal wall that would collapse when she breathed in through her nose. Alar batten grafts were used in the
lateral walls of her nose to prevent collapse and stabilize her
airway. The grafts created some lateral wall fullness that has
decreased over time. Her dorsal hump is reduced and her nasal
obstruction is corrected. The photographs represent her two year
postoperative result. |
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<click on images to enlarge>
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Pre-Operative Photos |
Post-Operative Photos |
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Patients who undergo rhinoplasty frequently develop a pinched or
over-narrowed nasal tip over many years. In many cases, the nose will
look good initially then get smaller and more pinched over time. This
is because the swelling decreases and scar contracture occurs which
results in further narrowing of the nasal structure over the patients
lifetime. The secondary (revision) rhinoplasty patients frequently
state that their nose looked good when the cast came off and then got
worse over time. Dr. Toriumis techniques make the nose strong and
well supported so that it will initially look large then get smaller
and better looking as time passes. This is particularly important in
younger patients who have a lifetime of healing that will continue to
make their nose smaller.
This younger patient
had a bulbous nasal tip and dorsal hump. The dorsal hump was reduced
and the radix was slightly elevated. With time the nose has become
more defined yet the structure added to her nose will prevent collapse
or pinching over time. The photographs show her two-year
postoperative outcome. |
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Pre-Operative Photos |
Post-Operative Photos |
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Another common complication after reduction rhinoplasty is a pinched
middle nasal vault (the part of the bridge above the tip). To avoid
this problem, Dr. Toriumi will place spreader grafts that will
slightly over correct the width of the middle vault. As time passes
the width of the middle vault will narrow and leave the patient with
an acceptable contour and good nasal function.
Nasal function is critical to Dr. Toriumi and he considers it as
important as the aesthetic outcome. Dr. Toriumi will not compromise
nasal function to give a patient a smaller nose. In fact, most of his
patients breathe better after surgery and have improved nasal function
over the long term. Even if the patient denies nasal obstruction, Dr.
Toriumi will maximize the nasal airway to avoid nasal obstruction as
they age. There is no need to compromise nasal function for a better
looking nose.
Dr. Toriumi uses the open rhinoplasty approach to the nose when he
feels it is indicated. In this approach, an incision is made on the
skin of the columella (the tissue between the nostrils) under the nose
allowing the surgeon to gain better access to the cartilage and bone
of the nose. He can then make precise and symmetric changes to the
supportive structures and provide the best chance of a good cosmetic
and functional outcome. It only makes sense that one can attain the
best result when one can make a precise diagnosis and correct the
anatomy while looking directly at the structures involved. The
disadvantage is a small incision made across the skin of the bottom of
the nose. If closed properly, this incision, as with any other
incision, should heal with little evidence of a scar. Surgeons who are
meticulous with the closure of this incision have good results and
still gain the benefits of the open approach. If you speak to Dr.
Toriumis patients who have undergone the open approach, most all of
them will not comment on the incision and will not even remember that
they underwent the open approach. Surgeons who are not experienced in
the open approach are more likely to have problems with the scar and
more postoperative swelling.
Dr. Toriumi frequently uses costal (rib) cartilage to correct more
severe deformities. Patients with saddle nose deformities (when the nose
is too scooped out) may need larger amounts of cartilage to correct the
deformity. In these cases, costal cartilage can be harvested from the
chest for reconstruction.
This patient presented with a saddle nose deformity and nasal
obstruction. Costal cartilage was harvested from his right chest wall
and used for the reconstruction. Years after his reconstruction he
continues to have a good aesthetic and functional outcome. The
photographs show a three year postoperative outcome.
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Pre-Operative Photos |
Post-Operative Photos |
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Dr. Toriumi spends a great deal of time
carving the costal cartilage grafts to decrease the chances of warping.
Warping or bending of the cartilage occurs in less than 5% of his cases.
Patients with a foreshortened nose (upturned tip) frequently need costal
cartilage grafting.
This patient had a congenitally short nose. Costal cartilage was
used to lengthen her nose and create a more normal appearing lateral
view. The photographs show her six month postoperative outcome. |
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Pre-Operative Photos |
Post-Operative Photos |
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Dr. Toriumi has expertise in Asian and other forms of ethnic
rhinoplasty. These patients frequently have a deficiency in tip
support and dorsal height. Dr. Toriumi strives for a natural look and
uses computer imaging to discuss a proposed aesthetic outcome. In
Asia, many patients undergo placement of silastic and other forms of
artificial implants. Dr. Toriumi feels strongly that the patients own
tissues should be used for augmentation in rhinoplasty. Therefore, he
prefers to use septal, ear and costal (rib) cartilage for grafting and
augmentation. Costal cartilage provides sufficient material for major
augmentation and can also be used in patients who have no other
cartilage available due to multiple previous surgeries. Costal cartilage can also be used in patients who have no other
cartilage available due to multiple previous surgeries.
This patient underwent previous surgery in the orient and had
erosion of a silastic implant through the skin of the nasal tip. This
left a depressed scar over the nasal tip and tremendous scar tissue.
The patient underwent a secondary rhinoplasty with placement of a
costal cartilage rib graft to her bridge and tip. She also had a
costal cartilage strut to support her tip. The photographs represent a
one year postoperative result. |
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Pre-Operative Photos |
Post-Operative Photos |
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Dr. Toriumi also believes that noses must be made strong to resist the
forces of scar contracture that occur over time. He follows his
patients over many years and works closely with them to maximize their
long-term result. He believes that a nose is only about 50% to 60%
healed at one year with the remainder of the healing occurring over
the patients lifetime. Long-term follow-up is critical to insuring a
good result and Dr. Toriumi encourages his patients to see him on a
very regular and long term postoperative schedule. Patients who keep
their appointments will maximize their postoperative outcome as Dr.
Toriumi frequently has patients do nasal exercises, taping and
occasional steroid injections. These postoperative maneuvers can have
a major impact on the long term outcome.
A good portion of Dr. Toriumis practice is devoted to secondary
rhinoplasty (correction of problems from a previous rhinoplasty).
Secondary rhinoplasty is much more difficult than primary rhinoplasty
(no previous rhinoplasty surgery). Most patient undergoing secondary
rhinoplasty require some degree of reduction and augmentation.
This patient had an under-projected nasal tip and extra
cartilage above in the supratip area (above the tip). She underwent
reduction in some areas of her nose and augmentation in other areas.
The photographs show her two year postoperative outcome. |
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Pre-Operative Photos |
Post-Operative Photos |
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Some patients have had significant
over-reduction and may require primarily augmentation using structural
grafting techniques to reconstruct deficiencies in the patients nasal
support structures.
This patient underwent multiple previous reductive
rhinoplasties resulting in her deformity. She had a larger nose that
was made smaller and the tissues were not able to contract to the size
of the reduced supportive structures. Correcting her deformity
required making her nose larger. Even though her nose is larger it is
better balanced. Most importantly, she breathes much better.
The photographs show her two and one half year postoperative outcome. |
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Pre-Operative Photos |
Post-Operative Photos |
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In primary rhinoplasty, supporting tissues can be conservatively
reduced or rearranged to improve nasal contour. Normal existing
supportive structures can be reshaped to change nasal contour. In
secondary rhinoplasty, many patients must undergo construction of a
new supporting structure that will provide the proper shape.
Performing such major reconstructions are very difficult and require
an accurate understanding of three-dimensional nasal contours. When a
patient undergoes secondary rhinoplasty, scar tissues develop which
complicate subsequent reconstructions. There is tremendous variability
in secondary rhinoplasty deformities and some patients have problems
that are much more difficult to correct. This is why some patients can
be effectively corrected and others carry a higher risk of problems or
persistent deformity.
Dr.
Toriumi understands that when he performs a rhinoplasty he has a great
opportunity to enhance ones facial appearance and nasal function. He
also understands that rhinoplasty is a very difficult operation and
that you must do everything possible to provide the patient with the
best outcome. For this reason, Dr. Toriumi takes as much time as is
necessary to correct all of the deformities to his satisfaction. A
typical primary rhinoplasty will take him 3 to 4 hours. A moderately
complex secondary case will take 5 to 6 hours. Due to this extra
operative time spent attending to fine details it will be more
expensive to have surgery with Dr. Toriumi. However, he will do his
best to give you the best outcome that he can. After all, his intent
is to make it your last rhinoplasty operation. |
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