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This young professional woman in her twenties came to Dr. Hubbard after her rhinoplasty by another surgeon.  She was concerned that her nose had taken on an odd shape.  She could recognize the tip was excessively wide, her nostrils showed too much and her breathing was worse. With her holding a mirror she and Dr Hubbard discussed the details of exactly what was unattractive with her nose, why she had the difficulty breathing and what could be done about it.  Her nose was over rotated (shortened).  When the tip is turned up like this, often the inside of the nose becomes too exposed.  Excessive nostril show is a common concern with patients even if they have not had surgery in the past.  No more than 2 to 4 mm should be seen.   The excess can be due to the columella (skin bridge between nostrils) hanging down too much and/or the side of the nose margin pulled up.  Notice the tip of her nose also fell to the right leading to crookedness.  During her revision surgery Dr Hubbard found, as expected, the tip cartilage had moved over the septum and had fallen to the right.  The main cause of her problem was the previous surgery did not control the tip position. Using a technique called septal extension grafting, which Dr Hubbard began using in the early 1990s, the tip was brought down to its proper position.  This same graft was used in such a way that it also functioned as a spreader graft which greatly improved her breathing. When the tip was maneuvered downward it also brought it to the midline.  A rhinoplasty surgeon must ensure the nose is straight by looking from both above and below during surgery.  When her tip was brought to the proper position, it also brought the sides of nose margins down, resolving excessive nostril show.  Dr Hubbard has presented both national and internationally on nasal length issues.  In one talk in Canada he presented four such patients who were over rotated by other surgeons leading to this type of turned up nose with all of the related deformities.  Dr Hubbard feels strongly that surgeons should include measuring nasal length as part of rhinoplasty intermittently throughout the surgery.   It is not difficult to do these measurements and in experienced hands they can avoid such problems and the revisions that result.

Surgeon: Dr. Thomas Hubbard
Patient Gender: Female

Case Number: 108

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