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Dean Toriumi, M.D.


FAQ

 
Why does Dr. Toriumi like big and wide noses?
 

I personally do not like large and wide noses. However, my experience has led me to believe that every patient's nose has a different size range that can be realistically accomplished. The size of the nose that is created at the time of surgery is based on several factors. These factors differ from patient to patient, and I have no set aesthetic size that I adhere to when operating on noses. However, some patients just cannot have a small nose based on their anatomy, skin thickness, or effects from previous surgery.  In the ideal setting all patients would have whatever sized nose that they want. Unfortunately, this is not reality.

Patients who have thinner, pliable skin and noses that are larger are more likely to tolerate a significant downsizing of their nose. In these patients, their thinner skin will tend to shrink over time to accommodate the reduction in their nasal cartilage and bone structure. This shrinkage may take many months or even years. Therefore, these patients will likely be unhappy early-on, before their swelling subsides and the skin shrinks to accommodate the new nasal structure. If the nose is made too small, the skin may never completely contract and may leave a deformity.

For most rhinoplasty patients I will perform digital imaging during the initial consultation to demonstrate what I feel is a realistic outcome. I will try to make the nose smaller if I feel the skin will accommodate such a change. This requires a great deal of judgment, and I prefer to make a nice improvement by decreasing the size of ones nose by a safe degree as opposed to making it too small and having the skin droop.

 Illustrative patient cases:

 

<click on images to enlarge>

 

The patient shown below had a prominent over projected asymmetric nasal tip and wide dorsum. In order to create better balance in her nose I decreased her nasal tip projection. Her preoperative computer imaging showed a larger nose than what was achieved at the time of surgery. Because her skin was relatively thin and redraped well I was able to make her nose smaller than the preoperative computer imaging. I also narrowed her bridge and straightened her asymmetric nasal tip.

 

 

 

 

 

 

 
 
 

In following my patients over many years, I have found that the middle vault region (mid portion) of the nose tends to narrow dramatically over time. Patients on whom I operated tended to develop narrowing of the middle vault region over many years. In patients with thinner skin and shorter nasal bones, their middle vault region tended to narrow too much and become pinched years after surgery.

The patient shown below was operated 9 years ago. She had a bulbous tip and dorsal hump. I performed a dorsal hump reduction and placed spreader grafts. Despite the spreader grafts her middle nasal vault gradually collapsed over many years. The collapse occurred because the patient has thin skin, short nasal bones and long upper lateral cartilages. If this patient had thick skin her deformity would be less prominent. This patient needed thicker spreader grafts or a slight degree of over correction of her middle nasal vault to prevent this collapse. By following my patients long term I am able to see these problems and make adjustments in my technique.  

 

 

 

 

 
 
 

Coincidently, one of the most common findings in patients who are seeking secondary rhinoplasty is a pinched, narrowed middle nasal vault. Frequently, patients with this problem will tell me that their nose looked great for a couple of years and then, years later, began to pinch and narrow compromising their breathing, as well.

The patient below underwent a previous rhinoplasty by another surgeon leaving her with a pinched middle nasal vault. Correction of her problem required placement of spreader grafts. These grafts act to support the middle vault and prevent collapse over time. She wanted to keep a relatively small nose. Since she had relatively thin skin, I could leave her with a smaller nose. Initially after surgery, her middle vault was very wide.  Her one year postoperative photos show an appropriate middle vault width.

 

 

 

 

 

 

 
 
 

In order to prevent excessive narrowing of the middle vault in my patients, I tend to over-correct the width of the middle vault in patients who are at higher risk of middle vault collapse. These tend to be patients with thinner skin and shorter nasal bones. This intentional over-correction will make the middle vault portion of nose a couple of millimeters wider than ideal in anticipation of the contracture phase that tends to narrow noses. With this approach, patients are less likely to have collapse of their middle nasal vault and tend to improve in appearance over time.

Many patients want an ideal nose immediately after surgery.  Every nose swells after surgery, so if the nose is swollen, it only makes sense that it will look wider than ideal after surgery.  Once the swelling subsides, the nose will look narrower. This desire for immediate results is one of the primary reasons why many secondary rhinoplasty patients end up undergoing multiple revisions.  The surgeon is trying to please the patient and provide immediately-visible refinement after surgery instead of compensating for swelling and long term changes that will occur over the patients lifetime. This is a short term answer to the problem and is not wise unless a patient does not mind having revision surgeries every 5 to 10 years. Some patients tell me that they want their nose to look good now and do not care what it looks like in ten years. Unfortunately, most would think differently if they were unable to breathe through their noses or needed splints or external nasal strips to hold a pinched nose open in order to sleep at night.

If you have had previous nasal surgery, you can likely see the long term effects of this narrowing and contracture in your own nose. With high quality close up photos of your nose, you can compare your early postoperative photos with your present photos. If you have thinner skin and shorter nasal bones, it is likely that your nose has narrowed over time. This narrowing will tend to continue over your lifetime and is more pronounced in some patients with certain anatomy. Every time you breathe in, you create negative pressure in your nose that also tends to pull in the cartilages of the middle nasal vault. The combination of the scar contracture and negative pressure can create tremendous change over ones lifetime. Remember that your nose will be with you forever.  I can assure you that it will tend to narrow and contract over time and not get wider.

My goal is to create an improvement in ones nasal shape that will continue to improve over the years. These changes tend to be slow in coming and relatively subtle. I tell patients preoperatively that their nose will be wide and ugly early on due to swelling and overcorrection. This is a very difficult time for patients, especially those who disregarded my preoperative counseling and instead believed that their nose will look good early postoperatively. What you see at one month, one year or ten years is not the final outcome. This is the toughest part of the recovery period and is another reason that patients need to come back for follow up, as I can provide instructions for nasal exercises or taping that can help decrease the swelling and width in a symmetric fashion. 

Once I operate on a patient, I expect them to come back for follow up for their lifetime. This obviously fills my office with patients on whom I have already operated. I want to see my postoperative patients long term to insure that their noses are moving in the right direction toward the proper narrowing and proper contour. A more profitable approach would be to just see new patients to add more surgeries and shorten my new patient waiting time. Instead I spend at least half of my office hours seeing postoperative patients, which limits the number of new patients that I can see. My intent is not to be more profitable. My intent is to provide patients with the best long term outcome, and that requires long term follow-up.

With the long term follow-up I am also able to see what happens to my patients over time. I frequently see patients that I operated on 10 to 15 years ago and critically assess their outcome. I correlate suboptimal outcomes with my very precise rhinoplasty operative diagrams that show what was done at the time of surgery. This information allows me to modify my techniques to better insure a long term favorable outcome. Using this constant critical analysis of my results, I can fine tune my approach and constantly improve my results. I am always changing my techniques based on this follow-up. If you look at books such as the "Rhinoplasty Dissection Manual" and papers that I have published in the past and look my more recent articles on nasal tip contouring and rhinoplasty philosophy, you will see that I have dramatically changed how I perform rhinoplasty over recent years. These changes are based on long term follow up of my patients and allow me to constantly improve at this operation. Once a surgeon feels that he or she is good enough, the surgeon will not improve.  In contrast, I know there is always room for improvement.

If I could get the nose to reach a certain size and shape and then freeze it at that ideal shape, then I would not over correct any noses and instead make each nose the exact size desired.  In fact, it is not difficult to make a nose look good early postoperatively. The real difficult part of rhinoplasty is to make a nose that will heal well, look good, and function well over the long term.  Having such a result is dependant on many years of experience and long term follow-up.  Eighteen years of practice and intense study of many patients long term after rhinoplasty has led me to my present philosophy of rhinoplasty. I will always do whatever is best for the long term good of the patient. The problem with this approach is that many patients think I want to give them a big nose or that my aesthetics reflect a goal in making big noses. I can assure you that I can make the nose very small.  However, I must also take into account a patients skin and anatomy when determining what is really the right size of a nose.  This is the question that eludes many surgeons.

I frequently see patients in my office who have had surgery to make their nose smaller that resulted in deformity. Patients with thick skin and a large nose are the most problematic. At the time of the consultation I will perform computer imaging and digitally manipulate the image to show a larger nose on profile view. This is to increase the likelihood that the frontal view image is good. If you make a large nose with thick skin smaller it will tend to become a mass of thick hanging skin and create what we call a pollybeak deformity. The only way to correct this deformity is to make the nose bigger on the lateral view to stretch the skin and create definition. This is the reason why I make some noses larger in length and projection. Trust me I do not like to make these noses long and projected. However, my goal is to make the frontal view look better by making the nose larger.

The patient below had a wide nasal tip and very thick skin. In order to make her nasal tip look narrower on frontal view I increased her nasal tip projection and made her nose larger. I demonstrated this change on the computer imaging preoperatively. Postoperatively she looks much better on the frontal view due to better balance and expansion of her thick skin envelope.  

 

 

 

 

 

 

 
 
 

The size of the nose that I propose when we do the computer imaging is what I consider a realistic outcome for a specific patient. I always try to show what I think is very realistic with the imaging. If the skin and anatomy allows, I will try to make the nose closer to what the patient feels is ideal. That means if I think I can make the nose smaller without compromising the long-term outcome, I will do so. However, I will not compromise the long term outcome by making a smaller nose for the short term.

To conclude, I do not like big and wide noses. I prefer noses that look unoperated and appropriate for the patients facial features.  The nose should not draw attention, as the most important feature of the face should be the eyes. The nose should look natural and function effectively providing good breathing over the long term.

 

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