Toriumi Facial Plastics

This 18-year-old patient presented for rhinoplasty requesting improving her profile and refining her nasal tip. She underwent an open rhinoplasty approach using dorsal preservation on the nasal dorsum and structure on the nasal tip. I used a subdorsal Z-flap, as introduced by .miloskovacevic , for the dorsal hump reduction. I used a foundation technique with a letdown. I used a caudal septal extension graft with short lateral crural strut grafts and obliquely oriented dome sutures to flatten and support the lateral crura (no repositioning). She is doing well with good contours and excellent nasal function at 13 months postoperative.
This hybrid structural preservation approach to primary rhinoplasty is very effective and provides excellent aesthetic and functional outcomes 👏🏼

This patient presented for revision rhinoplasty in 1998. She underwent prior rhinoplasty and presented with an asymmetric tip and nasal obstruction. She underwent a secondary rhinoplasty with placement of lateral crural strut grafts and a shield tip graft. She presents back for surgery unrelated to her nose. She is very happy with her nose, and she breathes well.
Lateral crural strut grafts were first introduced by Dr. Jack Gunter in the 1990s. They are cartilage grafts placed under the existing tip cartilages to shape and support the lateral wall of the nose. These grafts must be properly positioned and curved to open the airway. They are different from alar rim grafts. I have published our functional outcomes with lateral crural strut grafts, showing excellent long-term outcomes.
I am a strong believer in supporting the airway to provide excellent long-term functional and aesthetic outcomes. We must all follow our patient’s long term to fully assess the result of our techniques.

(⚠️ slides 7-9) This patient presented with a severe deformity after she underwent revision rhinoplasty at the same time as an upper lip lift. She suffered necrosis of her columella, and her surgeon sutured her tip to her upper lip, leaving her with a severely underprojected nasal tip and near complete bilateral nasal obstruction. She was as concerned about her severe obstruction as her severe nasal deformity. Her nasal tip skin had a severely compromised blood supply and required a couple of sessions of nanofat with hyperbaric oxygen treatments. This helped to improve the blood supply to her nasal tip skin. She then underwent a multiple-stage reconstruction using her own rib cartilage. I used a caudal septal replacement graft with lateral crural replacement graft and lateral crural strut grafts. In the first stage, I projected her nasal tip, leaving a 12 mm defect between her tip and upper lip. I used an interpolated melolabial flap to replace the missing columellar skin. After a debulking stage, the flap was divided, and the left cheek defect was repaired.

Over a year after her pedicle division, she is doing well with a patent nasal airway, dramatically increased nasal tip projection, and symmetric alar margins. Despite being a poor candidate for a melolabial flap with her darker skin color, her left cheek scar has healed well

Excited to join the Persana group of verified physicians! 🌟 This select group of surgeons underwent a rigorous selection process that evaluated their expertise in specialized fields, endorsed by esteemed peers.

Learn more through the link in my bio!

⚠️ SLIDES 7-9⚠️ This patient presented requesting an ethnically appropriate change in the appearance of his nose. He wanted more projection of his dorsum and tip and a narrower nasal base. I accomplished these changes using preservation and structure techniques. He had very little septum requiring harvesting his rib cartilage. His calcified rib was ideal for the subdorsal cantilever graft employed to raise his radix and dorsum. I used a caudal septal replacement graft to support his tip. A shield tip graft with articulated rim grafts provides an effective yet natural narrowing of his nasal tip. I used alar flaps to narrow his nasal base and to downsize his nostrils. He is doing well both aesthetically and functionally just over a year postoperative. 👏🏼

When performing ethnic rhinoplasty, it is important to preserve the ethnicity of the patient. I use structural grafting to achieve natural changes to the nasal dorsum and nasal tip. Preservation of his dorsum by “pushing it up” from below eliminates the need for any dorsal onlay grafting or DCF. The thicker skin is managed by projecting structure into the skin envelope to create favorable frontal view changes that are enduring

(⚠️ slides 7-10) This 20-year-old Asian patient presented requesting augmentation rhinoplasty. She wanted a narrower nose but did not want to raise her radix position. She had thick skin and poor tip definition. I used her own rib cartilage which was harvested from a 1.6 cm incision. I used a subdorsal cantilever graft to raise and narrow her low middle vault which appeared saddled after increasing her tip projection. I used a shield tip graft with articulated alar rim grafts for her tip and lateral wall support.

She is doing well two years postoperative with excellent nasal tip projection and good dorsal contours. Her nasal function is excellent as well. Her smile is unchanged postoperatively despite the caudal septal extension graft. 👍🏼

I believe using the patient’s own cartilage is important, particularly in younger patients who need a sixty-plus-year structural outcome. I have seen excellent long-term outcomes when using the patient’s own rib cartilage.

This patient presented after undergoing two prior rhinoplasties. She had nasal obstruction and nasal deformity. Correction required harvesting her own rib cartilage and using structure techniques to correct her deformity. I used a caudal septal extension graft, lateral crural replacement grafts, and lateral crural strut grafts. Preoperatively we noted she had a high left alar insertion due to a left facial skeletal deficiency. On preoperative frontal view, you see less of her nostril sill as it is set back posteriorly.
Correction, in this case, required inserting small cubes of costal cartilage under the left alar insertion. The cubes of cartilage are inserted via an alar base excision site directly into a tight pocket made under the left alar insertion point. The cubes are 2 mm to 3 mm in size and typically 20 to 30 small cubes of cartilage are inserted to correct the asymmetry. Full correction is not possible but the symmetry of the alar insertions can be improved. 👃🏼
The patient is doing very well one year postoperative with excellent nasal function and improved symmetry of her nasal base with more symmetric alar insertions. In the one-year postoperative closeup left lateral view you can see how the left alar insertion has moved anteriorly compared to the preoperative closeup lateral view.

I am honored to participate as faculty at the Structure & Preservation Rhinoplasty meeting in Istanbul, Turkey this week. Presenting on: Concepts in Nasal Tip Contouring: Long-term follow-up 👃🏼 🇹🇷

(⚠️ CW:slides 7-8) This patient presented with nasal deformity and a severely deviated septum. A big part of his surgery was the correction of his nasal obstruction. I used a low strip/SPQR dorsal preservation technique to correct his septal deviation and to reduce his small dorsal hump. The low strip is a very powerful technique that can straighten the septum, open the airway, reduce a dorsal hump, and straighten a deviated nose. The incorporation of this technique has improved my outcomes and simplified the operation. He is doing well with excellent nasal function and improved nasal shape one year after surgery.
I encourage you to come to learn dorsal preservation at the meeting of the year in Istanbul Turkey May 23 to 26, 2024. Learn by watching live surgeries and extensive lectures on structural preservation rhinoplasty. I also invite you to come to Ft. Lauderdale Florida November 22 to 24, 2024. This hands-on cadaver lab “The Course” features three days of intense didactics and lab work where you will learn the high strip, intermediate strip, and low strip from expert international faculty.
✨It is the time to delve into as outstanding learning opportunities are readily available. Don’t be left behind. 👨🏻‍⚕️

Yesterday, I gave a keynote presentation on “How I Incorporated dorsal preservation into my practice after thirty years of structure.” I have been a structural rhinoplasty surgeon for thirty five years. In June of 2019 I started using dorsal preservation and it has dramatically improved my outcomes. I use a hybrid of dorsal preservation for the upper two thirds of the nose (dorsal hump reduction and dorsal augmentation) and structure in the nasal tip. This hybrid approach employs the best of both philosophies. 👨🏻‍⚕️

Join us in Istanbul in May for the Structure Preservation Meeting 📆

Come to Fort Lauderdale to the cadaver lab “The Course” in November to learn preservation from the masters 🌴

I am honored to have given a keynote presentation at the Rhinoplasty meeting in Orlando, Fla. The title of the presentation was “Innovative Management of the Complex Nasal Deformity” 🌴👨🏻‍⚕️

This patient presented for rhinoplasty and correction of her nasal obstruction. She had a bulbous nasal tip and supratip prominence. I performed an external rhinoplasty approach with a caudal septal extension graft. I released her lateral crura and placed lateral crural strut grafts to flatten her bulbous tip and improve symmetry. 👏🏼
Four years postoperatively she has a nice nasal contour and excellent nasal function.
It is important to follow patients long-term to assess your aesthetic and functional outcomes. Four years is still early postop but at this point, it is unlikely that she will have significant deterioration of her outcome. The lateral crural strut grafts provide maximal lateral wall support to prevent lateral wall collapse or alar retraction.

Today we mourn the passing of an icon in rhinoplasty. Wilson Dewes () was an originator of dorsal preservation in South America. He was a mentor to many and taught tirelessly over generations of new students. Many of these students went on to become giants in the field of rhinoplasty and will carry on his legacy.
After meeting Dr. Dewes several years ago it was evident that he had a very gentle demeanor and attracted others to him through his kindness. He carried the torch for dorsal preservation at a time when the approach was not considered mainstream. At the end of career, he was able to see the fruit of his many years of hard work preaching the word about dorsal preservation. 👃🏼
In his most recent course, many students from all over Brazil came to honor this man and beloved teacher. We are saddened by his passing and grateful to have known such an outstanding person.
Rest in peace 🕊️

I am honored to have given a four hour presentation at the Workshop de Cirurgia Plastica Facial in honor of Wilson Dewes. Dr. Dewes is a pioneer in dorsal preservation surgery in Brazil. 🇧🇷
I also performed a live surgery this morning demonstrating dorsal preservation and structural tip surgery. It was a pleasure visiting Lajeado, Brazil to be with Dr. Dewes and many of the surgeons he has mentored over the years. Dr. Dewes is truly an icon who blazed a trail for dorsal preservation in Brazil 🇧🇷

(⚠️ slides 6-8) This patient presented for rhinoplasty and requested a smaller less projected shorter nose. She had a sizeable septal perforation and there was no harvestable septal cartilage. She also had filler in her nose to hide her dorsal hump. Repair of her nose and correcting her nasal obstruction required harvesting some rib cartilage. I used dorsal preservation for managing her dorsal hump and to preserve her dorsal aesthetic lines. The presence of the filler makes managing the dorsum more difficult as it can alter the actual dorsal line. I used lateral crural release and repositioning to downsize her large cartilages, and to deproject and rotate her nasal tip. She is two and a half years postoperative and is doing well with excellent nasal function. Her nose is less projected, rotated, shorter, and more feminine in appearance. She has the slightest dorsal convexity which adds a natural look to her profile. 👃🏼

Using , I was able to preserve the frontal view appearance of her nose which she liked and wanted to keep. I did not need spreader grafts or spreader flaps to reconstruct her middle vault or hide irregularities after bony hump removal. In the past, I would have to reconstruct the middle vault with spreader grafts that could make the dorsum too wide. Now I can keep the narrowness of the dorsum because it is not cut away. Dorsal preservation is an ideal technique to use if you want to keep the appearance of your nasal dorsum on front view but would like to reduce a dorsal hump on the side view. Dorsal preservation is the biggest change to my practice and has dramatically improved my outcomes. 👍🏼

We have two very big meetings coming up on structural preservation rhinoplasty. The first is May 23 to 26, 2024 in Istanbul, Turkey. The next is with in Fort Lauderdale Florida November 22 to 24, 2024. 🌎
We also have the new edition of the Preservation Rhinoplasty book series, called “Structural Preservation Rhinoplasty.” This will be the most comprehensive book on structural preservation rhinoplasty and can be ordered through later this year 📖

Honored to give a keynote presentation on “My Journey in Preservation Rhinoplasty” today at the Meeting in Nice, France 🇫🇷

(⚠️: slides 7-10) This 60-year-old patient presented for after undergoing several rhinoplasties. She had nasal obstruction and deformity. She underwent revision rhinoplasty using her costal cartilage. As one would expect, her cartilage was extensively calcified. To prevent resorption, I left the native perichondrium on her cartilage grafts. This is very important to enhance rapid vascularization, decrease the chances of fracturing a graft, and minimize graft resorption. Note the perichondrium was left on her caudal septal replacement graft and on the undersurface of her lateral crural strut grafts. This also ensured proper curvature of her lateral crura to maximize her airway. I used lateral crural replacement grafts with lateral crural strut grafts to stabilize her alar margins, correct her alar retraction, and support her airway.

She has done well with excellent nasal function and improved nasal contour one year postoperative. At one year she is only about 30% healed and will continue to heal and improve over time. I expect narrowing of the upper two-thirds and more refinement of her nasal tip. 👃🏼
It is imperative that these patients follow up long-term to achieve the outcome we are seeking. If lost to follow up then we may not reach the agreed upon goals of surgery.
Some believe the nose is done healing one year after rhinoplasty. If you follow your patients, you will see that is not the case. Most of my patients continue to follow up many years after surgery and can continue to see improvement well beyond a year. Postoperative steroid injections, taping, compression exercises, etc. will continue to improve the outcome.
If you are a patient and have undergone rhinoplasty in the past, you will likely recall that your nose changed well beyond a year after surgery. Look at a series of photos over time and you may see the changes. If the nose is properly structured and healing is modulated, the changes that occur long-term can be very favorable. 👍🏼

(CW ⚠️ slides 7-10) This patient suffered trauma to her nose as a child that resulted in a saddle nose deformity and severe septal deviation. She underwent a subtotal septal reconstruction using her rib cartilage. At the time she was 14 years old. We followed the patient for several years and her nasal obstruction was compromising her ability to sleep and perform sports. 🥍 For that reason, we decided to intervene when she was 14 years of age. Using rib cartilage at that age is difficult due to the higher tendency for the cartilage to warp or deform. I used a technique of subtotal septal reconstruction that I published in the Laryngoscope in 1994. ✍🏼The technique has worked well over the years and this patient has a great outcome over 18 years postoperatively.

It is important for surgeons to follow their patients long-term to see how the nose heals over the lifetime of the patient. Using the patient’s own rib cartilage is one of the keys to this patient’s excellent aesthetic and functional outcome. This is the main reason I only use the patient’s own rib cartilage as I know it does well supporting the nose over the lifetime of the patient. I use the patient’s rib primarily in revision cases, augmentation rhinoplasty, and cases requiring septal reconstruction as in this patient.
It is also important to follow patients long-term to verify that the techniques we use are reliable in the long term. We may ask ourselves, what is the “warranty” on a rhinoplasty? I believe the warranty should be the lifetime of the patient. That is a tall order and requires a stable structural approach using the patient’s cartilage. Unfortunately, too many patients do well for a year or two and then their result fades or deteriorates requiring another surgery. A lifetime result requires a structurally sound approach. 👍🏼

This 32-year-old patient presented after undergoing prior augmentation rhinoplasty using a implant. She didn’t like the deviation of the implant and the narrow unnatural-looking bridge. She requested a similar radix height with improved tip definition and a more natural-appearing dorsum. After removing the her dorsum was very low (see image). A subdorsal cantilever graft type B carved from her rib cartilage was used for the graft. This graft was used to raise her dorsum and radix after making bone cuts to release her nasal dorsum and upper lateral cartilages (lateral keystone release). A shield tip graft with articulated rim grafts was used to increase her tip projection and define her tip. She is doing well 1.5 years postoperative. 😊👍🏼

Removal of implants and reconstructing to reestablish proper dorsal height is a very difficult task. The skin on the dorsum of the nose tends to be thinned out from the silastic implant and the skin tends to contract over any graft placed on top of the dorsum. In this case, I used an SDCG type B to raise her native dorsum with no implant or graft on her bridge that could become visible over time. When you look at the dorsum of her nose you are looking at her bones and cartilages that were elevated to a new position with the underlying graft. This can also be called a “push up” as the dorsum is being pushed up to a new height. In this patient, I also raised her radix as she wanted to keep a similar radix height as before.
I published this technique in in 2022 📓

This sixteen-year-old patient with a presented for after undergoing 16 prior surgeries on her nose, lip, and palate.
Correction involved for her dorsal hump using a subdorsal Z-flap and let down. Her nasal tip cartilages were deformed with an unfavorable orientation of the lateral crura. Reconstruction of the tip involved dissection of the lateral crura, amputation of the tip cartilages, and reconstruction using lateral crural replacement grafts. Septal cartilage lateral crural strut grafts were used as well. The use of dorsal preservation for her dorsal hump avoided the need for spreader grafts and allowed me to use her septal cartilage for the entire reconstruction.
The structure technique for managing the tip in the cleft nasal deformity was published this month in 💻
Subalar excisions were needed to move the alar insertions into proper position. Due to the multiple prior surgeries and tension on the columellar closure, a second operation was required to complete the reconstruction without compromising the blood supply to the tip.
With the asymmetric and unfavorably oriented tip cartilages in the cleft nasal deformity, symmetric correction often requires setting strong tip support using a caudal septal extension graft. In her case, the tip cartilages were amputated, and lateral crural replacement grafts were fashioned and sutured to the septal extension graft. The placement of lateral crural strut grafts stabilized the lateral wall. As in this patient with a bilateral cleft deformity, increasing tip projection is key to the correction. The short columella and infantile tip lobule with deficient skin required two procedures to get the desired tip projection. Placing excessive tension on the columellar closure can result in skin necrosis or poor healing.
Managing the cleft nasal deformity is one of the most satisfying rhinoplasty procedures. The patients deserve a nasal contour that complements their other facial features such as their eyes. The impact of correcting their nasal deformity can be life-changing. This is why it is one of my favorite operations to perform.

Wishing you all a healthy and prosperous year ✨✨✨

(CW ⚠️ slides 6-10)This patient presented ten years ago for rhinoplasty to improve her nasal contour. Her nose was too long with a dorsal hump and bulbous tip. Her upper lip was very short as well. Her nose was shortened and her upper lip was relaxed by setting her tip back and then releasing her tip cartilages to reposition her cephalically positioned lateral crura. Preoperatively her lateral walls were very weak because of her malpositioned lateral crura. The repositioning of her lateral crura with lateral crural strut grafts helped to contour her tip, eliminate the bulbous contour, and add support to her lateral wall. Her nose has held up well over ten years with good nasal function.
Cephalic positioning of the lateral crura is a true anatomic variant that creates fullness in the tip with a lack of lateral wall support. Inadequate correction can leave a misshapen tip and lateral wall collapse.
I have been using lateral crural repositioning for over 25 years with excellent aesthetic and functional outcomes. In a recent publication in Facial Plastic Surgery, we presented our long-term functional outcomes with lateral crural repositioning. Outcomes research is critical to assess how different techniques do over the long term. Such studies are critical to see how your patients are doing over time.

(CW ⚠️ slides 6-9) This 25-year-old patient presented after undergoing rhinoplasty in 2015. She presented with nasal obstruction and nasal deformity. She wanted to eliminate her dorsal hump and lift her droopy tip. At the time of surgery, it was noted that she had all of her septal cartilage available. This allowed me to perform her surgery using just her septal cartilage. A key was the implementation of a dorsal preservation technique to reduce her dorsal hump. I used a subdorsal Z-flap that was initially introduced by .miloskovacevic. I also performed a let-down foundational maneuver to move her bones. By using this dorsal preservation technique, I did not have to remove the roof of her nasal dorsum, obviating the need to reconstruct the middle vault using spreader grafts. If I had not used a dorsal preservation technique, I would have had to harvest her rib and then place spreader grafts. This is a crucial factor in her surgery as this prevented the potential pain associated with rib cartilage harvest and also avoided the risk of warping of the rib cartilage. At 25 years of age, she would have been at higher risk for warping of her grafts if rib cartilage was used and there is virtually no risk of warping with septal cartilage.

I use dorsal preservation in most revision rhinoplasty patients with a dorsal hump who have an intact nasal bone and middle vault. In this patient, her bones were only rasped in her prior surgery which allowed me to employ dorsal preservation techniques. I used her septum for a septal extension graft and lateral crural strut grafts.
(Continued in comments)

(⚠️CW: Slides 6-8) This patient presented for primary augmentation rhinoplasty with the primary request being the elevation of the nasal dorsum. For major radix and dorsal augmentation in Asian patients, I use a subdorsal cantilever graft type B. This novel approach to dorsal augmentation extends dorsal preservation principles to allow “pushing up” the nasal dorsum. This technique is unique in that the graft used for augmentation is placed below the nasal dorsum to push it up. When a patient has a dorsal hump, we use dorsal preservation to reduce the dorsal hump. In this case, the opposite occurs, and the nasal dorsum is fully released and then pushed up from below using the subdorsal cantilever graft.
Placement of this graft requires fully releasing the bony and cartilaginous dorsum and then placing the graft underneath to hold the bridge in a higher position. The major advantage of this technique is that there are no large grafts placed on top of the dorsum. Large grafts placed on top of the dorsum can become visible over time, shift, etc. This graft is hidden under the dorsum and is not seen. In fact, all you see or feel are the patient’s own nasal bones and cartilages. It provides a very natural appearing bridge of the nose.
This patient is doing well one year postoperative with excellent nasal function and a natural appearing change in her nasal dorsum.
This is a more complex technique that requires harvesting the patient’s own rib cartilage and using bone cuts and cartilage release as used in dorsal preservation techniques. This technique used for ethnic augmentation rhinoplasty was published in Facial Plastic Surgery and Aesthetic Medicine in 2022.

(CW ⚠️ last 5 slides) This patient presented after undergoing two prior rhinoplasties. She complained of nasal obstruction and had marked asymmetries of her nasal base, columella, and nostrils. Reconstruction required harvesting costal cartilage and reconstructing her nasal tip with a septal extension graft and lateral crural replacement grafts. The lateral crural strut grafts were curved with the concave surface facing the airway. This curvature was preserved by leaving the native perichondrium on the undersurface of the lateral crural strut grafts. Tall spreader grafts were used to stabilize the middle vault and slightly raise the nasal dorsum. The columellar scar was excised to allow proper closure and improved scars.
She is doing well with excellent nasal function and much-improved aesthetics sixteen months postoperative. I believe the nose is less than 30 percent healed at one year and her nose will continue to change over time. Her nose will likely become more defined (narrower) over time. Many patients believe their nose is done healing at one year and this is not the case. This is why I continue to follow my patients long-term and monitor their healing. We can see significant changes even after five years post op.
This case illustrates how complex reconstructions may require rebuilding the nasal tip cartilages using autologous costal cartilage. These reconstructions are complex but can effectively correct secondary nasal defects. I show all four views and a close-up frontal view to show the imperfections. We can make significant improvements, but perfection is not possible. Patients must have realistic expectations going into revisional surgery. 👨🏻‍⚕️