Dean Toriumi: Facelift Surgery

If you are unhappy with the lower two-thirds of your face, Dr. Toriumi may suggest you undergo a rhytidectomy procedure. A rhytidectomy, or facelift, is designed to correct conditions associated with an aging face. Visible indicators include saggy or loose skin and loss of facial muscle tone. A facelift can correct these indicators by removing excess skin from the face and neck, and sculpting the underlying tissues and muscles in your jaw, cheek, and neck area.

A facelift can be combined with other procedures to strengthen your chin and improve your brow or eye area. These include brow, chin, or eyelid surgery. 

Pre-Operative Instructions: Before Surgery:

This information is designed to answer questions about your pre-operative care. To achieve the most satisfactory results, you should follow these instructions closely and familiarize yourself with these instructions. Please attempt to follow these instructions faithfully.

1. Do not take any aspirin, compounds containing aspirin, or non-steroidal anti-inflammatory medications (Motrin, Ibuprofen, Advil, Aleve, Vioxx, Celebrex, Naprosyn, etc.) for four weeks prior to and four weeks after your surgery.

2. If you require pain medications, you may safely take Tylenol products in the period from surgery preparation until you return home. If you require stronger pain management, consult Dr. Thomas.

3. Do not take Vitamin E or herbal supplements such as gingko, ginseng, fish oil, garlic, St. John's wort, etc. for four weeks prior to your surgery and four weeks after your surgery.

4. Avoid alcoholic beverages 48 hours prior to surgery.

5. If you smoke tobacco or use smokeless tobacco products, stop using them at least four weeks prior to surgery and refrain from them for at least four weeks after surgery. Smoking is directly related to poor wound healing and possible skin loss.

Post Surgery:

To expedite healing and minimize discomfort, please follow Dr. Toriumi's explicit directions. Dr. Toriumi will advise you to avoid strenuous activities right after surgery.

Surgeon’s Review of Dr. Dean Toriumi’s Surgical Techniques: 2

Testimonial on Dr. Toriumi's Surgical Techniques 
 -Mauricio Buitrago, MD.   

Dean M. Toriumi MD. came to San Jose Costa Rica on a probono mission trip to help patients with complex nasal deformities from April 22 to April 28 2013. Dr. Toriumi used complex surgical techniques that are not commonly used in Costa Rica. He harvested rib cartilage and performed complex cartilage grafting on a young man with a bilateral cleft lip nasal deformity . This patient underwent several previous surgeries and had severely deficient nasal tip projection and a very wide nasal tip with nasal obstruction. Dr. Toriumi performed a very successful operation and the patient has done very well since surgery and is very happy with his outcome both from an appearance point of view and from a functional standpoint. Dr. Toriumi also operated on a patient with a severely deviated nose with nasal obstruction who underwent a couple of previous surgeries. He performed rib cartilage harvest and cartilage grafting to correct the patients breathing problems. Dr. Toriumi performed the surgeries at the Clinica Biblica Hospital and the public children's hospital in San Jose. Other patients had severe functional problems and complex nasal deformities.

In addition to performing the surgeries on the patients Dr. Toriumi also taught Costa Rican surgeons in the operating room. He provided a very concise didactic experience explaining all of the maneuvers so the observing surgeons could understand the surgeries . He also gave an 80 minute presentation to the Costa Rican surgeons to augment the teaching points made in surgery.

This was a very special mission trip donated by Dr. Torium i and we are very grateful for his generosity and donated time and expense.

Mauricio Buitrago, MD.
Otolaryngology Department Hospital Clinica Biblica
Costa Rica

Dean Toriumi: Anti-inflammatory Diet

Many prominent physicians –including Dr. Barry Sears, Andrew Weil, and “Dr. Oz” – and dozens of books have advocated healthier, anti-inflammatory diets for improved health and weight loss. A few have addressed the connection between diets and allergy. But Dean M. Toriumi, M.D., a noted facial plastic surgeon and Professor of Otolaryngology-Head and Neck Surgery at UIC, has adapted the antiinflammatory diet trend to his facial plastic surgery patients – with significant results, results that help improve healing and quality of life for many patients post-surgery.

Many Americans consume diets high in pro-inflammatory foods – processed fats and meats, hydrogenated oils, trans fats, and refined grains and sugars. These ingredients can radically affect how we respond to food ingredients that can induce allergic reactions, often instantly. On average, the more inflammatory substances we put into our body, Dr. Toriumi noted, the greater the allergic response. Symptoms - from congestion and sneezing to watery eyes and skin irritation - can result. For Dr. Toriumi, a world-renowned facial plastic surgeon, the effects of inflammation on his patients’ nasal symptoms, especially among those recovering from surgery, were of particular concern. Nasal congestion, breathing difficulties, and related inflammation problems can be amplified in surgical patients, causing significant discomfort and slowing recovery –an important factor for patient outcomes.

So Dr. Toriumi began prescribing his anti-inflammatory diet – developed over many years and has some similarities to the Sears “Zone Diet” and the proven Mediterranean diet – to surgical patients. “Some facial plastic surgery patients have expectations about how quickly they’ll get the look they’re seeking from surgery,” he noted. “While some patients clearly have unrealistic expectations that everything will look great instantaneously, clearly diet can make a difference, expediting people’s recovery by contributing to a reduction of swelling,” he noted.

Dr. Toriumi’s clinical studies found that the diet, when adhered to in a highly disciplined way, contributed to many patients’ health and recovery. He would prescribe his diet – including a lot of leafy green and vegetables, minimal animal fat (unless it’s from grass-fed animals who don’t consume a lot of corn – corn ingested either directly through their body or through an animal that ate corn is highly inflammatory, he noted), green tea, and olive/fish oils – to patients for three months and asked them to record their symptoms. “Among those who were really disciplined and committed to the diet, the results were astounding,” Dr. Toriumi noted. “Regardless of their nasal problem before the antiinflammatory diet – congestion, swelling, breathing difficulties, etc. – the symptoms were significantly reduced and quality of life improved demonstrably with the diet,” he said.

Patients felt better, noticed speedier recovery from surgery, and were better able based on the symptoms they had to understand and gauge those foods that particularly contributed to their allergic conditions. From there, Dr. Toriumi noted, they were better able to dictate and control their own intake of the most inflammatory foods to help manage their diet and allergies going forward, he said. And there were other benefits – aside from the weight loss that typically occurs when people adopt an antiinflammatory diet: patients needed fewer or no medications to manage their allergies. “Because the body through food and nutrition is naturally preventing allergic reactions, many patients don’t need any more pharmaceuticals to do the job for them,” Dr. Toriumi said.

His focus on nasal symptoms, diet, and how it these relate to surgical patients applies to patients both pre- and post-surgery, even years after their initial surgery. In short, with the right diet, anything inflammatory gets better. This is the case for any allergy, he added, whether food-based or not. “It all has to do with the body’s response to the allergen and its connection to anti-inflammatory agents,” he noted.

As a facial plastic surgeon, Dr. Toriumi’s work is unique among the tomes of diet books and TV shows we see today. “It is a bit out of left field for a surgeon to look into these issues, but it feeds well into my practice and patients,” he noted.

“Most patients really want to take care of themselves and be in control of their health. Particularly among surgical patients, who tend to be well educated and sophisticated – not to mention very much in tune with any nasal symptom that gets in the way of their recovery and outcomes, this is right up their alley,” Dr. Toriumi noted.

Dean Toriumi Gives You Balanced Features

Dr. Toriumi Gives You Balanced Features

This patient presented with an under-projected chin.

To help balance her nose with her other facial features, Dr. Toriumi augmented her chin and increased the projection of her her nasal tip.

The photographs represent a two year postoperative outcome.

Pre-Operative Photos	Post-Operative Photos

Dean Toriumi: In News

Dr. Toriumi Coordinates Global Meeting on Rhinoplasty

CHICAGO (December, 2012):  Dean M. Toriumi, M.D., Professor of Otolaryngology – Head and Neck Surgery and Head of the Division of Facial Plastic & Reconstructive Surgery at the University of Illinois at Chicago, served as co-organizer of the “Cutting Edge 2012 Aesthetic Surgery Symposium Advanced Sculpting of the Nose” meeting in New York City, November 29 to December 1 in New York City.

Along with colleagues Dr. Sherrell Aston and Dan Baker, Dr. Toriumi organized the interdisciplinary symposium, which drew more than 600 surgeons from 55 countries, including some of the most highly regarded international experts in rhinoplasty.   Major topics addressed in panels included new and more established rhinoplasty techniques in areas such as nasal tip surgery, osteotomies, dorsal augmentation, nasal function, the deviated nose, revision rhinoplasty, ethnic rhinoplasty, and others.

“The meeting was a smashing success, given its overwhelming attendance,” Dr. Toriumi said.  “Many of the attendees said it was the best rhinoplasty meeting that they had ever attended, telling us that the focused presentations, panels of top rhinoplasty surgeons from all over the world, and use of video made the symposium highly educational and useful.”

M. Eugene Tardy, M.D., former Chair of the Department, gave a keynote presentation, as did Dr. Toriumi, who spoke on his new methods of managing nasal tip contour and tip position.

Dean Toriumi: Replacing the Nasal Septum

Does Dr. Toriumi take out and replace the nasal septum, and, if so, under what circumstances ? 

Dean Toriumi:

Rarely do I remove the nasal septum and replace it. The vast majority of patients will undergo a conventional septoplasty to straighten their septal deviation. In the conventional septoplasty operation, deviated portions of the septal cartilage are removed leaving an intact L-shaped septal strut (see figures 1 and 2). It is important to preserve this L-shaped septal strut to avoid loss of support and possible collapse of the nose. 

Perhaps some of the confusion arises from the name of a graft that I commonly use, called a caudal septal extension graft. In many cases I will place a caudal septal extension graft, which is a cartilage graft that is positioned end to end or may overlap the existing caudal nasal septum (see figure 3). 

A caudal septal extension graft is similar to a columellar strut except it is more stable, as it is connected to the existing caudal septum. This graft provides excellent support to the nasal tip without changing the existing septum. The caudal septal extension graft prevents postoperative loss of tip projection and sets nasal length as well as other parameters. I find this graft very helpful to avoid common rhinoplasty complications, such as postoperative loss of tip projection (resulting in a polybeak deformity), short nose deformity, overrotated nose ("turned up nose"), etc. However, use of this graft is clearly not equivalent to replacing the nasal septum, as it is a cartilage graft that is added to the existing nasal septum to provide support. 

Patient A.S. underwent a primary rhinoplasty after suffering trauma to her nose leaving her with a deviated nose, nasal obstruction and nasal deformity. She requested that her nose be straightened, her nasal tip shape be improved, and her airway corrected. She also requested to keep her nose on the shorter side. Her surgery required straightening the nasal septum, and a caudal septal extension graft was used to stabilize and straighten her nasal tip. Her caudal septum was not replaced, but, rather, the extension graft was added to provide tip support and move her tip back to the midline. This is the method used in the majority of primary cases. Rarely do I remove and replace the septum. Postoperatively, her nose is noted to be straight, and her airway is dramatically improved. 

Patient J.F. underwent a primary rhinoplasty to correct an overprojected nose and large dorsal hump. In her operation her nasal septum was straightened. Only the deviated portion of the nasal septum was removed, leaving an L-shaped septal strut behind. This is typical and does not require replacing the nasal septum. Postoperatively, her nose is noted to be straighter, and her dorsal hump was reduced. 

This patient underwent a fairly typical primary rhinoplasty using the open rhinoplasty approach, dorsal hump reduction, placement of spreader grafts, and tip work to reshape her tip. She had plenty of her own septal cartilage to perform the necessary grafts and provide her with excellent structure to better insure a long term outcome.

On rare occasions I do replace the caudal portion of the septum. The primary indications include the severely deviated caudal septum, unstable caudal septum, or a previously over-resected caudal septum. In the case of the severely deviated nasal septum, removal and replacement of the deviation is the best method in my hands to create a straight nose with a good airway. Many surgeons will leave the deviated septum or try to manipulate it, which can be successful but also has a high incidence of failure or partial correction. Failure to straighten the septum may leave the patient with a deviated nasal septum and nasal obstruction. Many surgeons try to resect the deviated portions of the deviated caudal septum without replacing it, leaving the patient with a potential loss of tip support. These patients will frequently be left with a residual septal deviation, inadequate tip projection, turned up short nose, retraction of the columella, etc. To prevent these deformities I prefer to replace the deviated septal cartilage that is removed in order to reestablish appropriate tip support and prevent complications.

Patient S.L. had a crooked nose deformity and severely deviated caudal septum that was blocking her airway on the right side. Correction required removal of the existing caudal septum and replacing it with another piece of her own cartilage to recreate a stable nasal septal structure. Using this technique her nose could be reconstructed around this new midline caudal septum. The postoperative result shows correction of the deviation of her nose, excellent symmetry to the base of the nose with an open nasal airway. 

This patient is very happy with her outcome and has excellent nasal function with no consequences of replacing her deviated caudal septum.The patients who undergo this type of operation do well, and what is accomplished is the reconstruction of the caudal septum to a state that would be considered normal instead of deviated. In my opinion it is better to reconstruct a new straight caudal septum that will support the tip and create an excellent airway instead of doing a less stable operation potentially leaving deviation and obstruction. Over the past 20 years, I have had great success with this approach to correct severe septal deviations. I published this technique in 1994 in an article entitled, "Subtotal septal reconstruction of the nasal septum," (Toriumi DM, Laryngoscope Vol. 104, 7, July 2004). Since then many other surgeons have adopted this technique for correction of the deviated caudal septum, overresection of the septum, lengthening the nose, etc.

One of the most common steps in a typical reductive rhinoplasty is to trim the existing caudal septum to shorten the nose or rotate the nasal tip. This frequently leaves patients with a severely deficient caudal septum. When these patients come to me for revision, I often find that the caudal septum is essentially gone or severely damaged. I prefer to place a new caudal septum in these cases to replace the normal anatomy and regain tip support. Patient C.F. underwent a previous rhinoplasty in which an excessive amount of caudal septum was resected in a previous operation. This resulted in a severe loss of tip support, loss of tip projection, and drooping of the nasal tip. Replacement of the deficient caudal septum allowed replacement of support and improved tip contour 

This is the type of patient that requires structural grafting to insure a good outcome. To overview, surgical management of the nasal base involves either placement of a columellar strut, caudal extension graft, or rarely replacement of the caudal septum. Patients undergo placement of a caudal septal extension graft that does not involve replacement of the caudal septum. The caudal septal extension graft actually involves placement of a graft that acts as an extension off of the existing caudal septum. This is a very powerful graft, enables stabilization of the base of the nose, and helps prevent postoperative loss of tip projection, drooping of the tip and shortening of the nose. The caudal septal extension graft or caudal septal replacement can result in stiffness of the nasal tip or change in upper lip feel and position.. We discuss these potential sequellae with patients if such grafting maneuvers may be used. Over the past 20 years, I have noted that the vast majority of patients have no negative consequences from such grafts and do well with a good, long-lasting outcome. 

Dean Toriumi: Nasal Shape Changes Over Lifetime

Why is my nose so wide and large and will it ever get smaller?

Dean Toriumi:
Rhinoplasty is a very unique operation in that changes in nasal shape continue to occur over the patient's lifetime. Most other operations heal over a finite period of time and then stabilize. This is not the case with rhinoplasty. Many patients whom we see for secondary surgery tell us that soon after the cast came off, their noses looked good. Then, over time, the swelling decreased, and the nose became narrowed and then deformed. Patients also state that their nasal breathing worsened over time after rhinoplasty. Some patients describe a situation in which their noses were fine for more than 15 years and then changes occurred that resulted in deformity.

Why does this occur with rhinoplasty?

When one undergoes rhinoplasty, there are two primary healing processes that occur. The first healing process is the resolution of the initial postoperative swelling. The rate at which this swelling goes down is variable from patient to patient and also depends on whether a patient underwent previous surgery or if he/she has a lot of scar tissue. In most thin-skinned patients, this initial swelling goes down in several months. In patients with thick skin, swelling can persist for many years.

Even after the initial postoperative swelling after rhinoplasty has resolved, the secondary healing process continues. In this case, the layer of scar tissue that forms over the nasal structures gradually contracts over time. In most patients, this scar contracture occurs over their lifetime. This is why many patients state that their nose continued to change years after surgery. Some patients may not realize that their nose is still changing, but if they were to look at a series of high quality close up photographs, they likely would see the changes. Patients with thicker skin have less pronounced changes than patients with medium to thin skin. In fact, some patients with thicker skin may see that their nose stabilized over time, with minimal changes after the initial healing process was completed.

I have noted these changes described in patients who have undergone rhinoplasty, and I am acutely aware of the long-term healing process after rhinoplasty. Therefore, I have adopted a method of surgery that employs a degree of overcorrection when performing rhinoplasty. In other words, the nose is made about 10 to 15 percent larger than ideal during surgery and then, as the long-term scar contracture process occurs, the patient can expect to see gradual improvement in his or her nasal contour instead of initially looking good and worsening over the years. This method is very difficult for the patient, especially early on after surgery, as the patient just sees a big nose. Fortunately, this process of scar contracture helps to improve nasal contour over time, which helps to alleviate the patient's concerns.

It would be much easier to perform rhinoplasty in a way that makes the nose look good early on. However, that approach could result in poor long-term outcomes for many rhinoplasty patients. When I approach a rhinoplasty, my primary concern is a good long-term result for every patient. My intent is to perform every rhinoplasty as though it is the patient's last nasal operation, even if it is a primary rhinoplasty.

Some patients are at high risk for collapse of the middle portion (middle vault) of their nose. In these patients, we also tend to overcorrect the width of the middle portion of the nose. As time goes by, the forces of scar contracture lead to narrowing of the middle portion of the nose, resulting in a more normal width. This overcorrection also will help to maximize the patient's nasal breathing. This is important, as I will never compromise nasal function for aesthetics.

Another reason why some patients are very swollen and wide after rhinoplasty is that their nose may have been made smaller. Any time that a nose is made smaller and/or less projected, the skin envelope over the nose must shrink to accommodate the new smaller nasal structure. Unfortunately, it takes many months, and sometimes years, for the skin envelope to contract. Patients with thinner skin will experience this shrinking faster than those with thicker skin.

In fact, most patients with thicker skin may need to keep a large nose to keep the skin expanded. This is because if the nose is made too small in a patient with thick skin, the skin may never shrink and will continue to appear very wide on frontal view. These factors I must take into consideration when deciding how small I can make a nose on the lateral view.

Illustrative patient case:

 

This patient presented requesting both aesthetic and functional improvements with her nose. She had nasal obstruction that compromised her ability to sleep and exercise. She was also concerned about the size of her nose. She stated that her nose was too long and that it "stuck out" too far.

On exam, it was noted that she had an over-projected and long nose. Her skin was of medium thickness. In surgery, I made the nose as small as I felt possible without compromising the ability of her skin envelope to shrink over the smaller nasal structure.
In the series of frontal photos shown, one can see how wide her nose looked early on in her postoperative course. As one might imagine, this patient was concerned, but she recalled our preoperative discussions, emphasizing how her nose would be very wide initially and then narrow over time, which helped to alleviate her concerns. By 7 months after surgery, her nose has a reasonable width and looks normal. These photos demonstrate how wide a nose can appear after rhinoplasty, especially when the size of the nose is reduced. The photos also demonstrate how the nose will tend to shrink over time, as explained above.



The comparison of the preoperative and postoperative photographs shows the patient at 10 months postoperatively. This patient's lateral view is still a bit larger than ideal. It will continue shrink to some degree, but the lateral view changes will not be as dramatic as the changes on the frontal view. When looking at the lateral view, one should try not to look at that view as an isolated image but put it in perspective to how large her nose was preoperatively. Then, with the information just given above, one should be able to see a nice improvement on the lateral view with a concurrent good-looking frontal view.

When the nose is made smaller, the decision on how small to make it depends on the estimated capability of the skin of the nose to shrink over time. Preoperative perspective is always very important.

I felt that her nasal skin envelope would not tolerate any further reduction, which means that her lateral view is a bit larger than ideal.



This patient's nasal skin shrank at the average rate, with the nose looking good at around 6 to 8 months postoperatively. 

Her nose will continue to shrink and eventually reach a plateau.



When the nasal structure is made so small that the skin envelope cannot shrink down around it, the frontal view often looks wide and poorly-defined. 

In summary, most of my patients will look wide and swollen for many months postoperatively in an effort to provide a good long-term outcome. This is why I tell my patients that their nose will be big, wide, and ugly initially, as seen in this patient's early postoperative photographs. 

Dean Toriumi: Secondary Rhinoplasty surgeries

Secondary Rhinoplasty: 3

Why does Dr. Toriumi only use rib cartilage for secondary rhinoplasty surgeries? 

Dean Toriumi's Answer: 

I noted that when I used ear cartilage for dorsal augmentation, the edges of the ear cartilage grafts would tend to curl or deform over time leaving dorsal irregularity. I also noted that if I stacked multiple layers of auricular cartilage to gain height on the nasal dorsum, some of this cartilage resorbed over time. For this reason I usually avoid stacking more than two layers of ear cartilage. Less severe deformities such as those limited to the tip, lateral wall of the nose or less severe middle vault collapse often can be corrected with ear and/or septal cartilage.

It has become apparent to me that most patients who come to my office are prepared to hear that I may need to use a rib graft in their surgery. It is true that most secondary rhinoplasty patients will need a rib graft to get the maximal outcome. However, on occasion, a patient's rib cartilage is calcified or they prefer that I use ear cartilage instead of rib cartilage. In many of these patients I am able to do a more than adequate reconstruction using ear cartilage. I actually have more experience using ear cartilage for secondary rhinoplasty than I do with rib cartilage. It has only been over the past six years that I have gone primarily to rib cartilage for secondary rhinoplasty, although I have used rib cartilage for over 18 years, but, in my early years in practice, I only used rib cartilage in more severe cases that required a lot of grafting material or when both ears were already taken. As I gained more experience with rib grafting we found that the patients did well and the pain from the rib graft harvest was no greater or less than the ear cartilage harvest. For many surgeons, harvesting and using rib cartilage is a big ordeal with a large incision, risk of a collapsed lung, and bending or warping of the cartilage. Over the years I have become very efficient harvesting and using rib cartilage leaving the patient with only a very small scar (usually less than 2 cm), short-lived postoperative pain, and very low risk of bending or warping of the rib cartilage.

Over the past three years I have done more than 300 rib grafts in patients and have further refined my technique so I am able to make the grafts much thinner and smaller without warping. We measure the thickness of nearly all structural grafts placed in the nose. Using these measurements I know what graft thickness is necessary for a narrow nose or wider nose. This allows me to reliably control the width, length and rotation of the nose. Unfortunately, numerous sources have deemed that I like "big wide noses." I can assure you that this is not the case. It is true that many patients will have swelling early postoperatively that will make their nose wider and larger. However, with time, this swelling will dissipate, and the nose will look narrower and smaller. Patients with thick skin are at the highest risk of being swollen for a long period of time. With healing almost all noses will get smaller and narrower over time. Therefore, our patients will improve over time and tend not to collapse, as I have seen in patients who had ear cartilage grafts placed in surgery. The postoperative follow-up is critical to insuring that the nose heals properly. Some patients will need to perform nasal exercises or tape their nose to create the proper width and shape. If patients do not come back for their follow-up they are at much higher risk for a suboptimal outcome.

If a patient desires to have ear cartilage used for reconstruction and the defect is amenable, I am willing to consider using ear cartilage as long as he or she understands the differences in the potential outcome. The disadvantages with ear cartilage are that the long-term outcome may not be as good with ear cartilage compared to rib cartilage, with a higher chance of unfavorable changes occurring years after surgery. This problem with ear cartilage is apparent in many patients who have undergone a revision every two to five years after using ear cartilage. The nose initially looks good and then narrows and pinches over time. When performing reconstructions on patients with ear cartilage in place, the ear cartilage grafts are very weak and are frequently deformed. The ear cartilage frequently breaks apart when it is dissected and is usually not usable. Because of the lack of ear cartilage strength, it is useful as a filler graft but not as a structural graft. There also may be some change to the shape of the ear donor site and the initial postoperative pain with the ear cartilage is frequently greater than harvesting rib cartilage.

With rib cartilage the patient will have a scar at the bottom of the right breast. In most patients this scar heals nicely. We have decreased the length of our rib cartilage harvest scars to 2 cm or less. Most of our scars measure between 1.5 cm to 1.7 cm . This smaller scar is much easier to hide. Patients in whom I use rib cartilage for grafting usually will note that they have a stiffer nose, which can be worrisome to the patient, but improves over time. The more dramatic the deformity, the more likely the nose will be stiff because of the need for more structural grafting in the severely deformed nose. We have made our columellar struts thinner and more pliable, which makes the nose less stiff with a more normal feel. I think these refinements have allowed me to make much smaller and narrower noses. Rib cartilage grafting is very technique-dependant and executing these techniques requires a great deal of experience. This is a very important advancement in rib grafting and will allow patients who desire smaller noses to be treated with rib cartilage. 

I felt compelled to answer this question on my website because I have been told by many patients that those interested in secondary rhinoplasty who do not want a rib graft do not come to see me. I was also told by many patients that other surgeons tell them that Dr. Toriumi only does rib grafts. I can assure you that my experience is not limited to rib grafting, and I can always call on my years of experience using ear cartilage to correct secondary rhinoplasty deformities in patients with deformities that are treatable with ear cartilage. It is also important to know that I will not compromise a potential outcome to use ear cartilage in a patient who really needs a large amount of cartilage to correct their deformity.

The primary reason that I have transitioned to rib cartilage is that I was frequently frustrated by the scenario where I was short on cartilage and forced to make a compromise on certain grafts during surgery. By following these patients long term I found that the compromised graft frequently resulted in an unfavorable outcome many years later. Now I am rarely in this situation because there is always enough of rib cartilage available. Seven years ago it was a big deal to take a rib graft with longer operating time and longer recovery. At this time harvesting rib does not add much time to the surgery and it has become routine. In my hands the disadvantages to using rib cartilage are few but the advantages are numerous.