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About Face

Chapter Eight The Nose The Psychology of Rhinoplasty Patients Expectations Initial Surgery Making the Nose Smaller Saddle Nose Columella Deformity Revisional Treatment Recovery

Saddle Nose

Another fairly common request is for surgery to correct what we call “saddle nose deformity.” This is a somewhat dramatic phrase that describes the nose with a concave bridge. The “saddle” is the part of the bridge, or dorsum, that lacks enough bone and/or cartilage to allow the nose a proper vault. Often the tip of the nose is normal, which serves to accentuate the problem.

The two main causes of saddle nose are heredity and trauma. Trauma means the cause was an accident of some sort, leading to a loss of some of the bone or cartilage from the dorsum of the nose. Trauma often results in a functional problem as well as a cosmetic problem; the septum might have collapsed, causing difficulty with breathing.

As for heredity, any family can pass along a ski-jump, but broadly speaking, blacks and Orientals seek out cosmetic surgery more often that other races to refine the natural “saddle” shape of their nose.

This is not to say, by the way, that they want a drastically changed nose that looks Caucasian (most are aware of and not impressed by rock star Michael Jackson’s transformation). Rather, they want a nose that is more harmonious with the rest of their face. This often involves building up the dorsum and reducing the size of the nasal base, and/or the tip.

Once the surgeon has made a basic assessment of the problem - looking for breathing problems and determining the severity of the “sadly”, or depression - he will be able to decide which materials to use to build up the dorsum. This depends on whether the depression has been caused by a lack of bone, a lack of cartilage, or both. The general rule is to use like material to replace missing matter. For example, a cartilaginous depression is corrected with a cartilaginous transplant rather than by bone. Bone would give an unnatural feeling to the nose by being hard and still in a normally pliant area.

If the problem is a lack of cartilage, I favor taking a transplant from the patient’s own nose to create the “three-dimensional volume filler” that I need. This is an expression we use to describe material that must correct depth, width and height at the same time - as opposed to skin, for example, which is a two-dimensional material not expected to correct problems of depth, or depression. I can only use the patient’s own nasal cartilage if the “saddle” is shallow enough that we need only a small amount.

If the depression is deep and I need extra cartilage, I will harvest is from the patient’s ears. Specifically, it is conchal ear cartilage that works well as a nasal volume filler. The conchal part of the ear is the internal “cup” above the lobe; the cartilage can be harvested from behind the ear so that no scarring shows. In rare cases when there is not enough combined cartilage for the job in the patient’s own nose and ears, and, if there is a need for bone filler as well, we can harvest what we need from the patient’s hip. Unfortunately, this is a rather painful procedure and the patient may have to walk with a cane for a week afterward.

It can be upsetting to look in the mirror after an operation to correct a saddle nose deformity: often the nose looks noticeably larger. This is partly because it takes a while to get used to a new nose, but also because it is wise for a surgeon to overcompensate during this procedure. Cartilage and bone have a tendency to absorb into the body as they “take” or graft during healing. After two years, only eighty to ninety percent of the originally transplanted material is likely to remain. As a result, the amount of filler used should exceed 100 percent of what is needed at the time of the operation.

The scenarios I’ve described above apply to the more severe cases of saddle nose deformity. If the cause of the depression is heredity, the problem is usually more minor in nature. The patient might need only a small amount of augmentation, in which case we can use a medical-grade implant instead of harvesting material from another part of the body.

In the early 1960s, medical-grade implants for the nose were make from solid Sialastic plastic, and sometimes they gave us some trouble. Sialastics extruded through the nasal skin after cosmetic surgery. As a resident, I saw this happen often enough. The problem was the Sialastics in the dorsum of the nose were too rigid - eventually, the natural movement of the nose caused them to poke through the skin. Today we use hugely improved medical-grade implants for the nose made from a synthetic material called Medpor, which closely resembles natural bone in composition. The implants remind me of the material used to make Styrofoam coffee cups; it is white and porous and feels similarly dry and slightly rough to the touch. Medpor actually allows the patient’s flesh to “in-grow”, or meld with the implant as it heals. (Another implant is Gore-Tex, which is soft and pliable.) This allows for flexibility in the nose where it should naturally be, and hence the risk of extrusion has been all but eliminated.

As with the chin, implants for the nose come in a variety of shapes and sizes, and they can be further shaped to suit the exact needs of any patient with a saddle nose.

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