PRICES REDEMPTION: Due to the high number of requests received from patients with surgeries awaiting booking, a ONE-TIME-ONLY price redemption period is opened during the month of FEBRUARY, so that patients already assesed in medical consultation can book their treatment enjoying previously valid prices, with a scheduling deadline up to April 30th; offer non applicable for subsequent surgery dates or for patients not assessed in consultation before February 1st. PROMOTIONS: Check discounts from our Combo Specials and Day Specials.
Very poor result of a previous rhinoplasty leading a multiple deformities, some of them evident and aggravated by the skinny features of the cutaneous cover of the nose, and other only found after surgical access and direct visualization of the work done before.
The main issues and challenges of this difficult revision rhinoplasty begin with an explicit open roof deformity, noticeable like few other cases due to the dorsal transparency, forming a typical combination of wide gap between nasal bones, visible ridges at its sides, flat dorsum which is also poorly or undefined; this was caused by failing to perform the required osteotomies which are mandatory after hump removal, leading thus in this case a fully blown typical tetrad of deformities.
Like a chain reaction cascade, every and each revision rhinoplasty scenario due to failing to perform competent osteotomies, such an important maneuver, lead to a tetrad of associated issues in a higher or lesser grade depending on the quality of the nasal tissues, which are the open roof deformity, a broad nasal pyramid with broad base, the inverted V deformity and a pinched middle vault.
The nasal wall is formed by a rigid and solid upper part made by the nasal bones, plus a lower part formed by the upper lateral cartilages which are soft; in absence of competent osteotomies or infractures of the nasal bones after shaving the hump, performing paramedial bone resections or both, the osseous walls stand their position leaving a gap between them at the dorsum, which is the so called open roof, being its closure accomplished by the aforementioned osteotomies; such separation between bones lead to a broad or square flat dorsum without any suitable definition and visible side ridges, the lower or larger the hump resection the more undefined and wide the dorsum is and the more open the roof becomes.
As may sound evident, failing to perform osteotomies leads to a broad nasal base and a broad pyramid or, should this be an asymmetrical failure, a lopsided pyramid or asymmetric one.
Subsequently to the missing osteotomies, when the surgeon, unaware of his actions, pushes the lateral walls of the pyramid to the midline, then the cartilaginous walls made by the upper lateral cartilages lean medially due to the natural hinge they have at their maxillary stand, whilst the bony wall nasal bones remain solidary to the maxilla and stay firm in place, thus due this uneven closure of the nasal walls the lower pyramid upper lateral cartilages dissociate and dislocate from the upper pyramid nasal bones leading to a visible inverted V, being such V ridge the lower edges of the nasal bones and the gap between them and inwardly dislocated upper lateral cartilages which separate from the former.
The formerly described phenomenon allows closure of the open roof only at the lower and soft part, not at the upper hard one where the open roof deformity stays, and in between the two halves, hard and soft, of the pyramid a ridge of separation between bones and cartilages is created, however the upper lateral cartilages not only lean towards the midline cartilaginous septum but also do collapse beneath the dorsum level and pinch the middle vault because the fail to receive the support of the normally solidary nasal bones and end in a free fall only supported by the weak mucosa lining of the airway, being such pinched middle vault a visible deformity and in many cases also a functional breathing impairment.
In an ideal scenario there should exist an en bloc displacement of the entire nasal pyramid walls to the midline to prevent the tetrad of deformities, and for this goal the infracture osteotomies are essential to allow the nasal bones free float in parallel with and synchrony with the upper lateral cartilages, without any dissociation and therefore without any kind of deformity, achieving total roof closure and good stability of the pyramid, with or without other additional maneuvers in selected indications.
A maneuver of such paramount importance like the nasal bones osteotomies is a very basic and simple one, of low difficulty indeed, being very hard to understand and even more difficult to justify why some surgeons still fail to execute it when, in all the medical literature, is considered as mandatory whenever a nasal pyramid dorsum gap is created; since Dr. Joseph and disciples' invention of the basic rhinoplasty technique and the specific surgical instruments for its execution in the first decade of 20th century, the surgeons know that osteotomies are a must, in spite performing them brings swelling and bruising to patients and require specific surgical training and good skills to avoid accidents; surgeons face and assume risks to achieve safe and successful rhinoplasties, that is their work; whoever does not feel ready to perform osteotomies in noses should not carry out any single rhinoplasty in his career.
Treatment of the tetrad of deformities due to missing or incompetent osteotomies begins with something as obvious and easy as performing proper and competent osteotomies, since this will close the open roof, will redefine the dorsum, make it narrow, get rid of the ridges and narrow the nasal base and the pyramid; to correct the collapsed upper lateral cartilages, the inverted V deformity and the pinched middle vault there exist two options; whenever it is possible a direct suture of the upper lateral cartilages to the cartilaginous septum may suffice in non mutilated cases which not too pinched which did not receive the deformity long ago; otherwise spacer or spreader grafts are bound to be used, well planned, very thin to prevent thick dorsums and sutured in place to prevent their migration, displacement or visibility; may the skin be very thin and allow visibility of the work done on the dorsum then a temporalis fascia graft has to be used to camouflage the dorsum and make it look neat and smooth.
This case is a paradigm of all the former, the complete tetrad of cascading deformities due to such an avoidable cause as failing to perform osteotomies of the nasal bones after removing the dorsal hump.
There are other three visually evident issues in this nose plus another which, as mentioned at the beginning, is undetectable externally but was discovered during the surgical direct visualization; another perfect reason why open approach access is absolutely mandatory in revision rhinoplasties.
This nose received total or subtotal resection and damage of the lateral cruras of the alar cartilages, the domes of the tip and pinching of the nose and the nasal valve; this is the external diagnosis by such typical and obviously pinched look of the tip, the tip bossing and the too sharp tip shape; intraoperatively this diagnosis was confirmed and expanded, since both tip domes had been mutilated, severed and the lateral cruras subtotally resected and the remains damaged beyond repair; all this makes a real write off for the tip, columella and alae, which required total rebuild with newly made handicraft elements.
Also externally visible and palpable there was a oversized, too long and over prominent strut graft between the medial cruras of the columella, which probably was not initially indicated or, should it have been, its calibration was poor; this strut graft made a hearable clicking when the patient spoke or chewed, something very annoying, and lead to a Pinocchio nose due to the over projection of the tip; this issue was intraoperatively confirmed.
Somehow clearly it can be seen the tip is upturned with an excessive nasolabial angle or angle between columella and the horizontal plane crossing the upper lip; the nostril rims were totally collapsed and unsupported; probably due to the damage to the lateral cruras.
Finally, one unforeseeable and preoperatively undetectable issue was the soft dorsum, this means the lower half, was over resected into a saddle nose deformity; however this hollow loss of substance was not visible externally because the missing dorsum was replaced and the profile stood by a mass of fibrotic tissue; this fibrosis has, necessarily, to be removed in every and each revision rhinoplasty, so in an ordeal of unexpected complexity the correction of a saddle nose deformity was added to the surgical plan; additional problem, the septal cartilage was not available for graft harvesting since it was previously touched to build the strut graft.
After thorough debridement or removal of fibrosis and non viable structures, both ear concha bowls were used as donor site for the grafting required in this case; after trimming down the excessive columellar strut an extended tip and columella entire grafting with meticulous scoring was used to either rebuild the tip, lower the nasolabial angle, derotate the tip and shape the wished new tip domes; two handmade new lateral cruras were applied and repositioned to provide support to alae, nostril rims and nasal valve, in order to correct the pinching too; two spacer or spreader grafts were sutured between the upper lateral cartilages and the soft septum to treat the pinching at the middle vault and the inverted V deformities; of course complete and proper osteotomies were applied; finally an onlay dorsal graft was tailored and applied with suturing to restore the right dorsum level which was sunken due to over resection.
The brilliant and natural final result allows full restoration of a harmonious and feminine nose, no evidence or trace of any of the initial deformities, no signs suspicious of having underwent two previous rhinoplasties and with a well balanced, supported, functional and suitable in shape and size nose.
RATE THIS CASE FOR THE COMMUNITY
How much did you like the case?
How much has been useful to you?
CURRENT PRICES QUOTATION FOR THIS CASE
Choose body area and select your products purchase
This information is indicative only and does not represent an obligation with patients or a prediction of forthcoming events, since is based on statistical means for large groups of patients, with the variability that implies, and the biased experience of medical professionals.
Medicine and Surgery are not exact sciences, therefore it is not possible to foretell the most likely evolution neither establish the most suitable management for each individual case until the moment the physicians can preoperatively evaluate the patient and receive feedback about the postoperative.
One surgical process can't be fully predictable or be rigidly scheduled on a previous protocol, so the management plan may be modified at any time based on the requirements that could be considered as necessary or most suitable.
Healing is an imprecise and always unpredictable process due to the uniqueness nature of each patient; even with your physician prioritising post-op patient care excellence and scar minimisation techniques and treatments your evolution and results may be likely different to the information contained on this website, therefore your physician cannot guarantee any specific scenario and outcome commitment regarding your procedures.
Remember that all surgery is likely to produce lasting swelling and a lifetime permanent scar, which is likely to partially evolve over approximately 12 to 18 months or longer because this is an issue of unpredictable kind; some patients may be prone to permanent swelling and bad scarring.
Information on our website is not a substitute for a personalised, individual consultation that includes a physical examination, history taking, a discussion of the potential risks including potential common complications, pros and cons of various procedural options, and the likely outcome expectations of your surgical procedure. Only an in-person consultation and examination can help your physician to provide you with information about what you, personally, as a unique individual, can expect.
Dr. Alejandro Nogueira's opinions, indications, procedures, techniques and methods of diagnosis, treatment and management change frequently as new information is available due to scientific knowledge and state-of-the-art medical practice progress; we aim to keep information updated, but it is possible that some information may have been superseded and is in process of being added to our website, therefore it may not represent Dr. Alejandro Nogueira's most current methods or protocols.
All images are genuine, trustworthy and real standard views of the "before" situation and the long term settled "after" actual results of Dr. Alejandro Nogueira’s work, as well as true intraoperative surgical views and authentic technical or clinical scenarios depicting real practice hands-on cases belonging to Dr. Alejandro Nogueira's skills and expertise.
No other professional but Dr. Alejandro Nogueira himself as leading and executing surgeon has carried out the techniques, procedures and surgeries shown in the galleries.
No images were staged, digitally edited or modified in any way, except for cropping, adjusting and resizing to fit gallery format, removing identifiable elements and blanking with anonymity purposes.
The images of results, treatments, techniques and clinical situations are mere guidance examples aiming to help the patients in their decision-making process, providing an average overview of Dr. Alejandro Nogueira's work; no one of them can be considered as an obligation of any particular results nor a commitment for the application of any specific techniques, therefore you should not base your results expectations on them.
Every patient has to be assessed individually in order to establish a customized prognosis of results and design an individual surgical plan, being somehow unpredictable the real final outcome of any procedure as well the surgical gestures applied during the intervention, since they will depend on multiple particular, frequently unpredictable and sometimes uncontrollable factors.
Even when you feel that you look very similar to another patient in their images, your results will likely vary significantly, because you are a unique person and every individual has not only a completely unique physique, but also uniquely individualistic body healing capacities, scarring tendencies and recovery processes, some of which are unpredictable even in very-healthy patients who rest adequately and do all the other right and prescribed things before and after their procedure.
Previous successful results of a physician do not guarantee future successful procedures and patient's satisfaction.
The images may display content that is graphic in nature showing explicit surgery, clinical events and that may depict partial or total nudity; if you find such material offensive or you are sensitive to it you should not use this feature and should exercise caution before accessing other explicit features of the website.
The images are appropriate for a mature-only audience; if you are under the age of 18 you should not view the content of this website.
All the prices and quotations visible on our website belong to or are calculated out of the reduced price list and do already enjoy by default a -20% discount from the standard price list for our treatments as compensating remuneration for the release and transfer of the intellectual property, the rights of image, the medical records and the personal data of our patients for scientific dissemination, medical teaching, public communication, commercial promotion, advertising marketing, commercial exploitation and disclosure in general, unless they express the opposite at their surgery day booking by opting for the standard prices.
READ MORE ABOUT BENEFITS OF THE COLLABORATIVE MODEL
Our prices are quotations valid for the majority of cases operated on; notwithstanding a few cases are non standard, atypical, requiring exceptional resources and, therefore, needing customized quote calculation; do seek the advice of our Medical and Sales Teams to find out whether your case lies within the standard protocol of management, which actually is the most likely scenario.
Standard quotations do cover the planned protocol of management, including preoperative consultation with the surgeon, preanesthesia examination, basic preoperative tests, surgeon, anesthetist and assistant fees, planned operating room, rental time, regular intraoperative surgical supplies (materials, drugs, etc.), agreed implants (breast, etc.), one recommended postoperative garment (brassiere, corset, etc.), 1 hour recovery unit stay, individual ward room, regular hospital supplies (materials, drugs, etc.) and postoperative office-based care.
Not included in standard quotations are, among others, non basic preoperative tests, pre and postoperative consultant referrals for assessment, additional garments, non hospital supplies (materials, drugs, etc.), postoperative tests and any kind of postoperative re-interventions, postoperative medical or surgical emergencies and costs exceeding the planned protocol of management like unplanned, unforeseeable and unavoidable extended surgical time rental of the operating room, extended hospital stay in standard ward or Intensive Care Unit (ICU) room and all the associated costs with any hospital-based assistance of complications, medicalized repatriation, hostelry accommodation, maintenance and travel costs; we do not take account of any costs not within the scheduled treatment pre and postoperative planned and agreed management.
We do not offer trip packages; the patient is bound to organize and pay for any trip, accommodation, food, transport, etc.
Prices do include the V.A.T.
Prices do not include any kind of travel or revision insurance; do read about the Surgery Shield for revision surgery here should you wish to be covered in such a case.
Treatments are payable in Euros only; we do not accept other currencies as payment of the treatments.
Any currency conversion is non accurate and has indicative purposes only.
Combo Specials discounts are percentages of reduction applied on the retail price of the standard quotations for the treatments of the price list; these discounts are not applicable on non standard cases, customized quotations and charges not included in the standard quotations.
The treatments Breast implants custom XL or Breast reconstruction autologous and the Surgery Shield for any body area treament is expressly excluded from any price reduction, discount and promotion, among them the Combo Specials.
Combo Specials are applied and calculated for each purchase of treatments to be performed simultaneously; Combo Specials are not allowed on treatments to be performed in different anesthetic procedures or different surgical episodes; any given purchase of treatments to be performed simultaneously may include more than one Combo Special.
One given treatment cannot be affected by more than one discount, be it Combo Specials or other discounts; in the event of a conflict due to the coincidence of more than one Combo Specials discount affecting a given treatment, the discount that produces the greatest gross discount in favor of the patient calculated at the given treatment in conflict level will be applied.
The lowcostmetic's General Combo Special only applies to treatments other than those affected by treatment-specific Combo Specials at any given purchase of treatments to be performed simultaneously; for the calculation of the lowcostmetic's General Combo Special all the treatments affected by treatment-specific Combo Specials are considered a single treatment.
Any urgent matter of medical or commercial kind must be addressed through our Telephone Assistance which is operative 24/7/365 to contact with the Medical Team or through our Telephone Support which is available in office hours to contact with the Sales Team.
Due to the competitiveness scenario of the markets most plastic surgery clinics and plastic surgeons feel forced to invest large sums of money into advertising and marketing campaigns; this non medical additional cost is always and necessarily charged on top of the final price paid by patients, leading thus to an overprice of surgeries and treatments. No one patient wishes to bear that financial burden embedded in the surgical costs, furthermore neither surgeons nor clinics are happy to increase their retail prices and penalize their customers with costs not bringing any kind of special medical benefit, safety enhancements or results improvement; the promotion budget aims only to disseminate the public knowledge of a services provider and raise the awareness about its presence to potential customers, but not to make the service or the product a better one.
Seems like this model is a no-way-out labyrinth from which no one can be freed, furthermore it is such a tempting, easy and hassle-free way that actually most patients and plastic surgery providers are locked into it, happily or with resignation, paying a high price due to being non collaborative; however there is an ideal alternative, based on keeping up a good hard work based on a strive for providing quality service and achieving patients' satisfaction, which necessarily requires the decided support of the clients and somehow their involvement in such virtuous business model grounded on top-notch results
READ ABOUT BENEFITS OF THE COLLABORATIVE MODEL
When plastic surgery providers and patients do actively engage into a collaborative economy scenario a win-win basis is set for their relationship, since the clinics and surgeons obtain the best promotion ever possible with no budget for marketing investment and the patients get in return rid of any additional and unnecessary costs; such a price reduction does not represent any loss in the quality of the treatment they are receiving, furthermore this saving achieved will actually reward customers with a reinforced confidence and guarantee the service providers will strive to perform the best job possible and obtain results second to none.
It is not a paradox or contradiction; under a collaborative economy umbrella plastic surgery patients enjoy a greater plus of confidence that clinics and surgeons will do their very best and beyond to satisfy their customers, in spite the price is lower than in marketing-based non collaborative models; plastic surgery providers who found their business sustainability on the pillars of exclusively or mainly incremental budget investment in ongoing promotion campaigns do have little incentive in achieving first-class results and the best patient experiences, since their business model is not based on returning patients after word-of-mouth dissemination of their reputation but on the attraction of cold clients with sophisticated advertising methods of higher or lesser moral acceptability, attracting customers as parachutists randomly landing on unknown land, which is a perverse business model frequently leading to an unavoidable degradation of safety and results quality besides an uncontrollable increase in costs and prices; this marketing-based model creates no incentives to keep up the good work and pushes the prices higher on and on due to require increasing promotional investments.
On the other side, which is definitely our side, clinics and surgeons who rely solely or mostly their existence and survival in the competitive plastic surgery market enjoying the widespread of their excellence extended by their own patients results and satisfaction, like a mill driven by the winds of prestige, have the strongest ever incentive to be the best service providers around, sourced from the support of happy clients and their operated cases as proof of their excellent jobs; needless to say such supporters, the patients, have to enjoy a share of this benefit so that the incentive is reciprocal; under this scenario clinics and surgeons strive to provide the best service and accordingly patients release and transfer in a fair exchange the materials and tools required to build a marketing-budget-free and virtuous business model which creates the perfect incentives to build the best sponsorship-free reputation, based on the grounds of medical quality thus allowing prices control within affordability thanks to the minimal cost of its maintenance.
This is the deal; patients give in our favor the release and transfer of the intellectual property, the rights of image, the medical records and the personal data of their cases for scientific dissemination, medical teaching, public communication, commercial promotion, advertising marketing, commercial exploitation and disclosure in general, and they receive in exchange a compensating remuneration of a -20% discount from the standard price list for our treatments, as it is publicly visible by default in all the prices and quotations on our website.
As can be observed our visible prices are highly competitive if compared with other plastic surgery providers, actually the difference is approximately a -20% from the average price of each particular treatment in other clinics and surgeons from similar economical areas and countries of comparable development; this is not due to any quality or safety downgrading but to our collaborative business model; in other words, the budget which theoretically should be invested in marketing and promotion campaigns is discounted from the retail prices and, unlike other plastic surgery providers, is not wasted into pointless advertising to patients which entails no kind of added value for them; such campaigns are replaced with our superb results publicized thanks our patients support by letting us use their cases' Before & After and Intraoperative & Technical images and medical details; this explains that price gap between us and other clinics and surgeons.
READ LESS ABOUT BENEFITS OF THE COLLABORATIVE MODEL
Patients gain a highly affordable pricing model with yet world-class standards of medical practice, safety and results, and we gain competitiveness within the industry by means of saving the budget theoretically bound to be wasted in marketing.
Patients contribute with their images and medical details and we compensate them with a -20% discount from the expectable average price quoted by comparable clinics and surgeons.
We receive a boost of unbeatable promotion and market penetration by using our awesome operated cases and the patients enjoy a plus of guarantee that we will strive to conduct ourselves to the highest level of excellence and obtain results better than one can imagine.
We help you access the best plastic surgery results and you help us win the race of the market.
Should you feel not interested in collaborating with our business model and still wish to be our patient? No worries, this perfectly possible under the same philosophy of professionalism, devotion and quality, you have to simply express your opposition at surgery day booking by opting for the standard prices and thus give up the -20% discount of the collaborative model, budget which will be used to promote our business in sponsorships, campaigns or one-time actions aiming to attract new customers who, without your help to take the right decision for their surgery, may need sponsored channels to know about us.
Keep in mind that taking part in our collaborative business model is also an altruist way to help other prospective patients to find the medically right and commercially suitable plastic surgery provider, besides collaborating in the medical education of other surgeons and medical professionals.
We offer a flexible consumer-to-business relationship by letting our patients choose between a release & transfer quotation model in which the standard price list receives a -20% discount becoming thus the reduced price list, and a no disclosure quotation in which the standard price list applies and the patient misses such compensating remuneration.
Two models under the same quality involving different prices and marketing-building strategies; you receive always one guarantee: our commitment we will give you our best.
You attempted an unauthorized action. All contents of this site are private and protected. Print screen are not allowed. We have reported with your data location to prevent any ilegal action against the protected contents of this website.