Rhinoplasty is one of the most popular forms of facial plastic surgery and is performed on patients of all ages. This interview with J. David Holcomb, MD of Holcomb-Kreithen Plastic Surgery located in Sarasota, FL, discusses the latest trends in rhinoplasty surgery. There are many options available to patients, whether they seek a rhinoplasty for cosmetic refinement or to repair a nasal deformity related to an injury or prior cosmetic surgery. Dr. Holcomb is an expert in rhinoplasty as well as in surgical management of the nasal airway. His standard care for rhinoplasty includes Vectra 3D Facial Imaging during the initial consultation to demonstrate the possibilities of the shape of a patient’s new nose utilizing state-of-the-art visually interactive technology, as well as proper testing to determine the extent of breathing problems, if any, so as to be certain of an excellent outcome for the patient. To learn more, visit www.sarasota-med.com.
Do you think your head and neck surgery training sets you apart from other physicians that perform rhinoplasty?
There are substantial differences in training for various cosmetic surgery procedures they perform. Head and Neck surgeons become experts in management of the nasal airway along with the cosmetic part of nasal surgery, rhinoplasty. We learn how to manage the nasal septum, including straightening, removal of septal spurs, etc. Beyond that, there’s a very common issue that we address: Nasal Vestibular Stenosis. It is where the side walls of the nose are too weak to offset the negative pressure that is generated when we breathe air through the nose. The sidewalls of the nose can then collapse inward, rendering the nasal airway dysfunctional. Some patients will come in and say, “I really can’t breathe at all when I sleep, so I use a Breathe Right Strip”. Right away that’s an indication that there may be something going on with the nasal valve and the structural support of the sidewalls of the nose. These are procedures that require much more knowledge and expertise to manage. Depending on the way it is done, moving the nasal bones can actually make the nasal airway worse. My recommendation is if you are going to have cosmetic surgery of the nose (with or without accompanying nasal airway dysfunction), you definitely need a doctor who’s also an expert in the management of the nasal airway. That way, at the very minimum, you will maintain good function of your nasal airway while improving the cosmetic aspects of your nose.
Would you characterize rhinoplasty as being one of the more difficult and complex surgeries performed?
Yes. I think most plastic surgeons would acknowledge that rhinoplasty may be the most challenging of operations that we undertake, because it involves manipulating bone, cartilage, skin, and stabilizing the structures of the nose in a way that not only helps in terms of appearance, but also maintains normal, functional breathing.
What is a non-surgical rhinoplasty?
Non-surgical rhinoplasty typically would involve injecting a filler material, such as Radiesse, into the bridge of the nose. For instance, on a smaller nose where the nose has a slight bump (dorsal hump) and is slightly deficient above; you can fill in the area above the bump and end up with a straighter dorsum, which improves the appearance of the nose on profile. That can work for some patients, but for a larger nose with a larger dorsal hump, it makes the nose seem much larger and really isn’t a good option. A non-surgical rhinoplasty is not suitable for patients that want a significant change, or for patients with breathing issues.
What is the difference between open rhinoplasty vs. closed rhinoplasty?
With an open rhinoplasty procedure there is a small inverted triangle incision made on the columella, the skin beneath the nasal tip that goes down to the upper lip. The incisions are very small, around 3 – 4mm, and can hardly be seen by the human eye once it’s healed. I like the open-rhinoplasty technique because I prefer to be able to clearly visualize the internal structures that I am manipulating. However, there are some situations where there is very little dorsum and tip work required. In that case, I may perform a closed rhinoplasty where there is no incision. Both techniques are good and I determine which is best based on the needs of the patient, and the size and scope of the rhinoplasty procedure I am going to perform.
Do you agree that a rhinoplasty can be a life-changing procedure?
It is. Patients derive a great deal of satisfaction and self-improvement from that procedure. The nose, neck and sometimes the chin, which we haven’t talked about yet, help to provide that ideal harmony of facial structures especially in a side view. If the chin is a little short and the nose is a little bit larger, the chin will seem that much shorter and the nose will seem that much larger. If you take down the nose just a little bit, the chin will seem more within range and, conversely, if you just add a little bit of length to the chin, perhaps with a small chin implant, then the nose won’t seem quite as large. Very often, we will end up doing procedures on the nose as well as chin lengthening and possibly neck contouring to improve facial harmony as observed from that side view.
Can you elaborate on the chin procedure and implant you referred to in terms of bringing greater balance and harmony to the facial profile?
You don’t see too many changes to the front view of the face unless the pre-jowl area is fairly weak. There are some implants that add length to the chin and also some width and filling in of the pre-jowl area. If that area is okay, then adding length to the chin won’t really make a difference from the front view of the face. It’s in the side view where adding a little bit of length really helps to improve facial harmony. In some cases, if we add length to the chin with a chin implant, we might not need to do quite as much work on the nose, which then provides better balance to the face.
What is the typical age of a rhinoplasty patient?
On the younger side, fourteen is the earliest point where we would typically consider rhinoplasty surgery. At that age the nasal septum and the nose are generally fully developed. On the other side of the spectrum, there really isn’t an arbitrary cutoff. I have performed rhinoplasty procedures in patients who are certainly in their early to mid-50’s and even beyond that into the 70’s. The concern as we get older is the vascular supply of the tissue and worry about healing issues, but it can certainly be performed successfully in older patients.
What is the typical downtime and preparation for such a delicate procedure?
In the consultation process, we offer simulated computer imaging for the after appearance of the nose before surgery is even done. We use a special camera system, Vectra 3D facial imaging, that takes multiple photos at the same time from different angles and stitches them together using a complex computer program so that we can then see a composite image of the nose and manipulate the image to create the desired look for the patient. For example, we can show reducing that bump or hump on the top of the nose, narrowing the tip, lifting the tip, narrowing the base, etc. This exercise is invaluable as it solidifies between the patient and the doctor what the actual goals of the surgery are. Once we arrive at the simulated after image that we all agree on, we print that out, we give a copy to the patient, keep a copy for our records, and we take that copy to the actual operating room so we can get as close to that after-image as we possibly can during surgery. It’s nice when I can say, “Okay we’re done,” and put the final sutures into place and then put a splint on the nose. It’s an excellent way for me communicate with the patient and to guide the actual decisions that are made intra-operatively during surgery to achieve the goals that the patient and our team has agreed to.
At what point after the procedure do you sit down with the patient to do a comparison?
That varies from patient to patient. As mentioned, each rhinoplasty is different and is determined by many things from size and shape, to levels of internal structure repair and breathing issue. Therefore, how rapidly the nose heals after surgery is also variable. In general, it can take a number of months for the nose to fully settle in. It can take as long as 6 to 12 months, depending on the complexity of the procedure. Sometimes if it’s a revision rhinoplasty or they’ve had several other rhinoplasties, there’s more scarring and it can take a while for the nose to settle in. We do compare the imaged photo with the patient as early as two months following a procedure, but it could be ten to twelve months before the comparison can be accurately made.
What advice would you give a patient preparing for a rhinoplasty procedure, and how can they select a surgeon to help them achieve their goals?
As with any plastic surgery procedure, a patient should feel comfortable with their surgeon. Rapport should be good and the patient should feel that their questions are being answered. Do they feel that the surgeon has their best interest at heart? Also, the patient should feel comfortable with the staff because they will be doing a lot of the post-operative wound care, taking calls, and connecting the patient with the doctor if there’s something needed urgently. Comfort with the physician, the staff, and the facility are all very important. In terms of preparation, the main thing for rhinoplasty surgery would be to avoid taking anything that promotes bleeding for at least 10 days, preferably 14 days before surgery. That includes things such as fish oil, garlic, aspirin, nonsteroidal anti-inflammatory medications, vitamin E, and things like that. Anything that can potentially thin the blood causes a bit more bleeding, and the nose is an extremely a vascular structure. Less bleeding during surgery makes the surgery easier and smoother for the surgeon and patient. In terms of surgeon selection, a Facial Plastic Surgeon and head and neck specialist generally has the most training in terms of the nose, but I would recommend that they review the doctor’s credentials, look at pictures and speak with patients who have had a previous rhinoplasty surgery with that doctor if possible.
About Holcomb – Kreithen Plastic Surgery and MedSpa
With their main office located in beautiful downtown Sarasota, and services also available at locations in Lakewood Ranch and Tampa, Holcomb – Kreithen Plastic Surgery and H|K MedSpa offers a comprehensive range of aesthetic surgical and non-surgical treatments that enhance the lives of men and women. The AAAASF-accredited facility includes a private outpatient ambulatory surgical center. The founding physicians of the practice include J. David Holcomb, M.D. (Facial Plastic and Cosmetic Laser Surgeon) and Joshua Kreithen, M.D. (Breast and Body Contouring Specialist). Dr. Kriston J. Kent, MD (Facial Plastic Surgeon) recently joined the practice’s Tampa division.
Holcomb – Kreithen Plastic Surgery is renowned for its expertise in facial plastic surgery, plastic surgery of the breasts and body and cosmetic laser surgery. Additional core areas of focus within H|K MedSpa include non- and minimally-invasive body contouring, facial aesthetics, medical hair restoration, laser skin rejuvenation and medical skin care. With its comprehensive range of services and dedicated staff the practice has developed a reputation as one of the most advanced centers in Florida. Receipt of the Allergan “Black Diamond Award” is an objective benchmark for the practice’ success, ranking it among the top 1% of practices in the entire country providing Botox Cosmetic, Juvederm (including Voluma) injectable gel, Latisse, Natrelle breast implants and SkinMedica skin care.
The Holcomb – Kreithen Plastic Surgery and MedSpa staff is comprised of an extraordinary group of professionals whose primary goal is to safely empower individuals to reach their full potential. They are committed to always treating patients and each other with kindness, compassion and dignity. For more information, visit www.sarasota-med.com or www.tampa-med.com.
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