This typical case of saddle nose deformity was a difficult revision rhinoplasty aiming to repair a severe over resection of the dorsum which led to a sunken dorsum or a an almost nonexistent nasal pyramid; additionally the failure to perform the mandatory osteotomies caused an open roof deformity, inverted V deformity and a pinched middle vault.
There was also an overprojected or Pinoccio's nasal tip which was left unattended during the previous intervention; finally a left nostril collapse required investigation and repair.
Considering and large amount of dorsum missing according to this patient's facial features, it was deemed necessary the use of rib cartilage grafting harvested from the 7th arch so that enough amount of tissue supply with the suitable firmness would be supplied.
This case shows how reliable and useful, even essential in some situations, is the rib as donor of cartilage grafting during revision, ethnic and some structure rhinoplasties; it can be seen how the core or central shaft of the rib cartilage does not warp or experience any deformity as long as the surgeon knows the basics of its harvesting and tailoring; the cortex of the rib cartilage is the only one prone to warp, whilst the central part of the rib cartilage is form stable.
Notwithstanding, the 7th and 6th rib arcs have perfectly straight and flat portions of cartilage near the sternum bone which offer surgeons material of excellent quality and straight cartilaginous streaks which, in any case, prevent warping and late onset of nasal deformities.
The images show how difficult may be the dissection and how delicate has to be the surgeon's dexterity to extract the cartilage not producing pleural tears and pneumothorax, a serious complications which eventually and accidentally might be associated to rib harvesting maneuvers; particularly in cases like this one in which the 7th rib had thick, long and strong synchondrosis or cartilaginous bridges of fusion between it and the precedent 6th and the lower 8th ribs.
The plane of dissection to harvest the rib can be subperichondral, this means under the perichondrium sheath around the cartilage, versus extra or supraperichondral plane which takes place between the perichondrium and the parietal pleura or sheath around the lungs; should the parietal pleura be punctured or torn the occurrence of a pneumothorax is likely.
In spite of being a more tedious dissection the choice was the subperichondral plane of dissection to harvest the rib cartilage, in order to carry a safer maneuver far from the parietal pleura; in this patient's peculiar anatomy the thick synchondrosis between 7th and the neighbouring ribs made the dissection highly intricate.
Once the cartilage was freed and the donor site meticulously closed by means of layered sutures, the sculpting stage started so that the necessary anatomical elements could be restored in this patient's nose.
The customized dorsal block of cartilage had a quadruple role aiming to correct the saddle nose deformity, the open roof deformity, the inverted V deformity and the pinching of the middle vault; in other cases and with other technical options the pack of grafting for this purpose would have been spreader or spacer grafts, onlay dorsal grafts and probably temporalis fascia graft as onlay camouflage.
However with the design depicted in this case's images, one single fragment of cartilage was shaped as dorsal rebuild graft with two rails or ridges sticking out from the undersurface of such dorsal graft; these rails had a double purpose, firstly act as spacer or spreader grafts at the middle vault, and secondly provide stability by blockage obtained when inserted in the slots formed by the open roof deformity at the recipient site between the nasal walls and the nasal septum; this means the nasal septum fits in between the rails of the graft and the nasal wall at the outer side of such rails.
This dorsal graft has other very tricky and interesting geometrical features in its design, like the beveled upper end to match the contour of the nasal radix and the frontalis bone at the frontonasal sulcus, the slope gradient at its lower end to prevent a supratip prominence or polly beak deformity, the somehow imperfect broken contour at its sides in a very slightly rhomboid shape to mimic a natural bridge and avoid a plasticized nasal look, and the thin on top towards thick on bottom of dorsum gradient of dorsal raise in order to create a correct nasal profile.
During the procedure it could be stated the cause of the left alar collapse was a random and unexplainable damage to the left lateral crura; the right alar cartilage had a iatrogenic damage transecting the tip dome at the union of the medial and lateral cruras.
Once the dorsal grafting block was thoroughly tested and deemed as definitive in terms of aesthetic effect and mechanical stability, the tip was ambitiously deprojected by means of resection of lateral and medial cruras segments; the interdomal and intercrural fibrofatty pad was intact and therefore was removed to reduce bulbosity; then an extended columellar strut graft and lateral cruras strut grafts were used to repair and support the alar cartilages; some suture plications allowed final tip shaping without any additional grafting at that point.
Due to the relatively massive, if the size of the rib and nose are compared, amount of donor material available no ear or septal cartilage was employed; the smooth contour and the perfection of the tailoring of the dorsal block made unnecessary additional camouflage with temporalis fascia or specific blockage gestures to prevent its displacement, since the final assembly was a perfect puzzle matching under pressure between the frontalis bone and the slots of the open roof deformity.
Experience, fine skills and large amounts of creativity are of paramount importance in order to successfully approach these complex rib cartilage revision rhinoplasties.
#1After completing the initial debridement or surgical cleansing of fibrosis, this is the dorsal defect assessed intraoperatively as the main reconstruction goal.
Note how the nasal pyramid was barely existent and the dorsal profile totally parallel to the maxilla.
The tip was overprojected and so far not treated at this stage.
#2This line shows the ideal dorsal level and intends to make understandable that almost 40% of the dorsal height was missing.
#3The huge deficit of tissues at the dorsum associated with the Pinoccio tip deformity is very well noticed in this image; note how he dorsum is totally parallel to the maxilla and the nasal pyramid was almost fully missing.
#4This line between the frontalis bone and the theoretical new and shortened tip level shows the shortfall of the radix, central bridge and supratip that was in need of thick cartilaginous tissue supply.
#5Putting the skin under tension shows the real extent of the problem.
#6See the open roof and the inverted V deformities in this image.
#7The upper circle shows the missing dorsum due to previous surgery over resection and the slots of the open roof deformity; the lower circle shows the intact interdomal and intercrural fibrofatty pad.
One arrow points to the iatrogenic transection of the right tip dome; two arrows show the missing fragments of the left lateral crura which were the cause of the left nostril collapse.
#8One arrow points to the iatrogenic transection of the right tip dome; two arrows show the missing fragments of the left lateral crura which were the cause of the left nostril collapse; the left lateral crura was totally separated from the left medial crura, when in a normal anatomy or after a proper surgical gesture they should be structurally connected.
The asymmetry between both alar cartilages is more than evident.
The circle shows the intact interdomal and intercrural fibrofatty pad.
#9This is the right 7th rib donor site seen from the surgeon's perspective, the landmarks are patient's head below and feet above of the image, sternum on the left and armpit at the right of the image; the layers that have to be crossed to reach the rib cartilage (C) are the skin, the subcutaneous (SC) fat, the rectus abdominis muscle (M) y the perichondrium (PC).
#10The cartilage segment of the 7th rib already freed from its perichondrium sheath and ready to be sculpted; in spite it seems enormous compared with the size of a nose, it is to be taken into account that a large part of it has to be discarded and only the core shaft is valid as form stable and warping free.
Note the lower circle showing the long and thick synchondrosis or fusion bridge between the 7th rib and the upper 6th rib; the upper circle spots the synchondrosis between the 7th and the 8th rib, of smaller entity; these synchondroses make the dissection difficult and delicate.
#11The extracted cartilage segment of the 7th rib flipped over to show its undersurface; the large circle spots the fusion synchondrosis to the 6th rib and the small circle shows the synchondrosis to the 8th rib.
#12Comprehensive anatomical view after finishing the cartilage extraction showing the subcutaneous tissue (SC), the rectus abdominis muscle (M), the perichondrium sheath (PC), the rib cartilage (C), the ribs (6, 7 and 8) and the circles spotting the synchondroses.
#13In detail view of the problematic synchondroses, between 6th and 7th ribs (SC 6+7) and between 7th and 8th ribs (SC 7+8); the rib arcs are numbered (6, 7 and 8).
#14Dorsal view of the cartilage block acting as radix, bridge and supratip reconstruction, spreader or spacer graft and stabilization element; note how each of its ends has a different design to allow a perfect adjustment within the remaining anatomy.
#15The superior (S) and inferior (I) ends of the dorsal graft seen from above; the lines represent the customized design and the humanization of the new dorsum which makes the aesthetic result natural.
#16Undersurface of the dorsal cartilage block showing the two rails which will act as spacer or spreader grafts and as stabilization elements to achieve interlocking between nasal walls from outside and septum in the middle.
#17The lines remark the very special geometrical design of the dorsal block and its rails; the superior (S) and inferior (I) ends of it are designed in different manner; the superior adapts to the frontalis bone contour at the radix and the inferior to the supratip reconstruction requirements.
#18The rails of the graft and its section geometry can be seen in this image.
#19The nasal septum is planned to fit into the middle slot, while the arrows show the space designed to host the nasal wall, made by the nasal bones at the upper part and the triangular cartilages at the lower part.
#20Theoretical design planned for the dorsal block of cartilage graft, with differential superior (S) and inferior (I) ends, a smooth gradient at the dorsal surface (D) and the rails at the ventral surface (V).
Seen from the lateral the upper end is beveled to fit the frontalis bone contour, however the inferior end is cut straight to match the shape of the triangular or upper lateral cartilages; seen from above the superior and inferior ends are truncated triangles, blunt the upper and sharper the lower so that the natural anatomy is closely replicated.
#21Axial section of the theoretical design planned for the dorsal block, showing how the assembly achieved interlocking stability; the septum (S) fits in between the graft undersurface rails; the nasal wall (N) lies at the outer gaps of the rails; this configuration is, at the same time, a pair of spacer or spreader grafts.
#22Adson forceps sized 12 cm are a reference for understanding the dimensions of the dorsal block of cartilage; superior view.
#23Adson forceps sized 12 cm are a reference for understanding the dimensions of the dorsal block of cartilage; inferior view.
#24After finishing the fitting of the dorsal block of cartilage, having accomplished the tip deprojection and after correcting the iatrogenic damage of the lateral cruras, the nose shows a perfect stability and an optimal profile, with excellent balance between the neo pyramid and the deprojected and reshaped tip.
#25Note how natural looks the new bridge, thanks to the slight rhomboid shape which humanizes its effect; the supratip and the radix are perfectly finished; the tip has good shape and an adequate length; the alar rims and nostrils are well supported.
#26The intraoperative view from top shows the nicely shaped dorsum with slight rhomboidal shape, tip with canonical pentagonal shape and straight alar rims.
#27The lines remark the fine detail of the nicely shaped dorsum with slight rhomboidal shape, tip with canonical pentagonal shape and straight alar rims.
#28Intraoperative views of the post-debridement of fibrosis state of the nose and its situation at the very right end of the procedure; note how the dorsal contour is smooth and exempt of irregularities, in spite no camouflage gesture was applied to conceal the dorsal graft, this was obviously unnecessary.
#29Outlining of the planned dorsum and tip profiles before starting with the reconstruction process and the final skeletal frame achieved; this awesome result would have been unfeasible with other technique or procedure.
#30Original nose (left) and the intraoperative new nasal skeleton (right).
#31Original nose (left) and the prismatic scheme of the dorsal reconstruction graft three dimensional design the in intraoperative new nasal skeleton (right).
#32Original nose (left) and the intraoperative new nasal skeleton (right).
#33Original nose (left) and the prismatic scheme of the dorsal reconstruction graft three dimensional designs the in intraoperative new nasal skeleton (right).
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.
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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.
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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
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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.
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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.
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