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Dean Toriumi, M.D.


My Philosophy ~ Rhinoplasty

 
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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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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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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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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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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Pre-Operative Photos Post-Operative Photos

 

 
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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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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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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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

 

 
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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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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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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