Rhinoplasty - should I have external scars?

Dear Jay, NYNY

As a plastic surgeon I perform the rhinoplasty procedure either with internal (inside the nose only) incisions,  or sometimes combined with skin, or external incisions.  This distinction is otherwise known as either the "closed" or "open" technique.  Much of this is determined on the difficulty of the procedure, and/or the training of the surgeon.  When perorming an "open" approach the additional external incision is placed across the the mid point of the skin bridge between the nostrils (columella).

However, in some cases in addition to these two choices of incision technique the surgeon may also need to shape, or narrow, the width of the nostrils.  This is commonly referred to as performing Alar, or Weir, Incisions.  By your description it seems that this is what you are referring to.  

I hope this helps clarify.

Best wishes,

S.P. Maggi, MD, FACS 

There are certain circumstances where incisions on the outside of the nose are necessary to provide the best results. 

The incision across the columella (the structure between the nostrils) is very common and allows the surgeon to perform an "open" rhinoplasty.  In this operation, the structures of the nose are seen directly rather than through incisions only in the nostrils.  Many believe this provides greater accuracy and predictability of the result.  The scar is almost never visible here.

If the base of the nose is wide, removal of tissue in the alar corners can narrow the base.  This can be a more visible scar on occasion than the columellar scar.  This is frequently a part of ethnic rhinoplasties.

Your surgeon should have discussed these options with you before surgery in most circumstances.

All types of rhinoplasties share the same incisions inside the nose. However, there are three areas on the outside that a surgeon may make an incision:

• Collumela - This is the bridge between the nostrils. This is the most common incision in open rhinoplasty. Majority of surgeons use this incision in their technique. The incision could be step or V shaped. The best thing about this incision is that with time it is undetectable. The fact is that most famous plastic surgeons perform most of their rhinoplasties through an open approach.

• Alar - This is the side of the nostrils. This incision is designed to reduce the size or flare of the nostrils. This incision is very common in ethnic rhinoplasties (black, Asian, or Hispanic). About 10% of rhinoplasties may involve this type incision. In the hands of a good rhinoplatic surgeon these incisions are almost undetectable. By looking at alar incisions one may differentiate a skilled from a common surgeon.

• Dorsum - These are small stab incisions on the side of the bridge of the nose. This incision is done to narrow and/or straighten the bridge of the nose. This is the least common incision. Most surgeons place these incisions inside the nose. Only very few surgeons do this from the outside. Since these are small stab incisions they do not pose any major problem.

Make sure you ask your surgeon where he is planning to make his incisions. Usually a caring plastic surgeon will discuss the incisions without being asked.

Treatment of scars:

• New scars: You may use common over the counter scar creams or tapes.

• Old scars: The old scar usually can be excised and revised with fairly good result.

It depends on the type of rhinoplasty that you had and the actual parts of the operation which were performed. The two main types of rhinoplasty are open and closed. In a closed rhinoplasty, all incisions are made on the inside of the nose. Unfortunately this is not the best approach for some patients. In an open rhinoplasty, most incisions are on the inside of the nose except for one that goes across the columella, the bridge of skin that goes from the tip of your nose to your upper lip. When healed, this incision is generally not an issue. At times, additional incisions may need to be made on the side of the nose near the eyes to break the nose or along the alar rim, the out part of the nose that connects to the upper lip, to narrow the nose. In all, any of these incisions should heal without much of a problem.

In general if you have had an open rhinoplasty, incisions are placed on the columella (the divider of your nostrils) and occasionally at the base of your nostrils (if your surgeon has narrowed the base of your nose).

I am unsure as to the significance of the circles you describe. It does not sound normal to me, but you will just have to see what happens when your bandages come off. More than likely it is a normal variant and you have nothing to fear.

Incisions on the side of the nose, by what are called the alar rims, are performed in patients that either have too much flare of the nostrils, or for nostrils that are too wide. Usually the stitches are removed within 1 week.

I am surprised you did not anticipate this, because if I plan to do an excision along the alar base I always discuss this with my patients beforehand.