Dr Anthony Bared Photo Album 2021

Dr Anthony Bared Photo Album 2021

Welcome and thank you for considering me as your rhinoplasty surgeon. Rhinoplasty is considered to be the most challenging of all facial plastic surgeries. It is this very complexity that drewme into the field of facial plastic surgery. I have a deep passion for rhinoplasty. I can assure you that I will place your well-being above all else and will employ the most modern and proven techniques in attaining your goals for rhinoplasty. Before our meeting please take the time to view this collection of some of my rhinoplasty work. It is not a collection to showcase my ‘best’ work but it is more to serve as a tool of education demonstrating various types of noses of patients of various ethnic backgrounds, anatomy, and the techniques I use to help achieve the most natural results. I have included examples of various nasal tip anatomies, skin thicknesses, degrees of nasal crookedness, and bridge projections. I have noted these anatomical variations throughout the text preceding each photo. I have also included a glossary of terms to help you understand the various terminology. Every nose is different and my technique is tailored to each individual. Both your patient advisor and I are here to help you. I will present you with realistic expectations during our consultation of what can be achieved in your specific case based on my knowledge and vast experience in rhinoplasty. My goal is foremost the well-being of my patients and to help them realize their aesthetic goals.

-

Dr. Bared

Glossary of rhinoplasty terms

Bilateral—a technique involving both sides (Left and Right)

Unilateral—a technique involving one side (Left or Right)

Caudal—In the direction of the nose towards to tip

Dorsal—In the direction of the nose towards the bridge

Cephalic—In the direction of the nose towards the forehead

Medial—In the direction towards the middle or midline

Lateral—In the direction away from the midline

Spreader grafts—Thin, cartilage grafts placed on either side of the septum at the level of the bridge. They are used to prevent unwanted pinching of the bridge and are used in cases of nasal deviations.

Clocking suture—A suture placed along the bridge to help correct subtle deviations of the bridge

“Swinging door” septoplasty—A technique used in septoplasty to help correct caudal septal deviations

Lateral crural strut grafts—Thin, cartilage grafts placed on the undersurface of the existing tip cartilages to help flatten and re-orient bulbous and weak tip cartilages. Also, help prevent breathing obstruction.

Upper lateral cartilages—The nose consists of two pairs of cartilages. The upper lateral cartilages are found just under the nasal bones and comprise the bridge of the nose. If these cartilages are not adequately supported breathing issues can ensue as can a pinched bridge.

Lower lateral cartilages— Pair of cartilages which make up the tip

Nasal bones—Pair of bones which comprise around 1/3 of the structure of the nose

Alar rim grafts—Thin cartilage grafts placed along the rim of the nostril to improve nostril shape

Radix—The area of the nose where the bridge meets the foreheadsupport

Radix graft—A graft placed in the radix to help depressions of the radix which can augment the appearance of a hump

Supratip break—The small depression best seen on profile view which helps to demarcate the tip from the bridge

Columella—The anatomic area in the midline between the nostrils

Columellar strut—A free floating graft placed between the lower lateral cartilages to help provide tip support

Perichondrium—A thin outer film found on all cartilage. Utilized in rib cartilage cases to serve as added covering and camouflage

Caudal septal extension graft—A graft which is extended off the septum to secure the tip cartilages and prevent tip dropping or retracting over time

Columellar strut—A graft placed in between the tip cartilages which is not secured to the septum to prevent tip dropping over time

Shield graft—A graft used in cases of patient with thicker nasal skin to provide adequate tip definition

Cephalic trim—Technique where the tip cartilages are trimmed to provide for tip refinement. Careful and very conservative removal (if any) is performed to prevent unwanted tip asymmetries

Nasal tip domes—the highest point of tip cartilages projection which on the skin surface provides the tip highlights

Turbinates—Pairs of outpouching of mucosa and bone on either side of the nose internally which serve to humidify and warm the air before reaching out lungs. In the case of allergies, the inferior turbinate may be large and cause nasal congestion and difficulty breathing through the nose.

Submucosal turbinate reduction—Surgical technique where the size of the inferior turbinate can be reduced while still preserving the function of the turbinate

Septum—Composed of cartilage and bone and divides both sides of the nose. If this is deviated towards one side or both it can result in nasal obstruction

Septoplasty—Surgical technique where the deviated portion of cartilage and bone of the septum is removed. The removed piece of cartilage can then serve as grafts to stabilize the nose in rhinoplasty.

Skin thickness—degree of apparent thickness of the skin of the nose. The extremes in thickness pose an extra challenge to rhinoplasty.

Crushed cartilage—Technique whereby cartilage grafts are crushed to serve for various purposes in rhinoplasty

Projection—Descriptive term indicating the degree of which the nose “sticks out” from the face

Dorsum—The roof of the nose (also called the nasal bridge)

Rotation—Descriptive term to denote the angle composed of the lower part of the tip and the upper lip. Increasing rotation, increases this angle and vice versa.

Nasal Anatomy

Nasal and Sinus Anatomy

FEMALE RHINOPLASTY

Female patient with a complicated case of a crooked nose. She reports having no previous trauma to the nose but was born with a crooked nose. The correction of the crooked nose is the most complicated case in rhinoplasty. In her case, cartilage and soft tissue grafts were used from her nose as well as her temporalis. Rhinoplasty techniques included:

- Asymmetric osteotomies to improve the nasal bone deviation

- Harvesting and utilization of the superficial layer of the deep temporal fascia

- Batten grafts

- Asymmetric spreader graft placement

- Caudal septal extension graft

- Tip onlay graft

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Female patient whose concerns included a wide bridge and crooked nose on the frontal view. Her profile concerns included a droopy tip and slight hump. She was noted to have medium/ thick skin. Her nose showed deviation to the right with tenting of her upper lip to the right side. Primary rhinoplasty included:

- Push and Pull technique utilizing spreader grafts

- Clocking suture to further improve tip straightening

- Swinging door septoplasty to reposition the septum

- Dorsal alignment

- Osteotomies

- Cephalic trim

- Caudal septal extension graft

- Crushed cartilage tip graft for tip refinement

Post-operative findings demonstrate a straighter appearance to the nose with less tenting of her upper lip towards the right side. Bridge narrowing and tip refinements are seen.

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Female patient with concerns of significant nasal deviation towards the right side, dorsal hump, and bulbous tip. She was noted to have medium skin thickness. Primary rhinoplasty techniques included:

- “Push and Pull” technique utilizing spreader grafts

- “Clocking suture” to further improve tip straightening

- Septoplasty

- Caudal septal extension graft

- Cephalic trim for tip refinement

- Cephalic trim tip graft

Post-operatively, findings include a straighter appearance to the nose with tip refinements and narrowing. Base view changes from a more trapezoidal shape to a more pyramidal shape.

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Female patient with complaints of a dorsal hump, droopy tip, and a wide tip. She was noted to have medium thickness skin. Primary rhinoplasty included the following techniques:

- Bilateral spreader grafts

- Caudal septal extension graft

- Cephalic trim

- Tip only graft

Patient seen post-operatively with a lower bridge and slightly rotated tip. Tip narrowing was achieved with tip cartilage repositioning and maintaining tip domes slightly apart to avoid a pinched tip appearance.

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Female patient who desired refinements to her nose. This is a complicated case of a patient with breathing difficulty and thin nasal skin. She presents with a crooked nose, over-projected bridge, and cephalically oriented tip cartilages. Rhinoplasty techniques included:

- Hump reduction dorsal alignment

- Bilateral osteotomies

- Bilateral extended spreader grafts

- Caudal septal extension graft

- Tip cartilage repositioning with lateral crural strut grafts

- Soft tissue tip onlay graft

BEFORE

AFTER

Female patient with concerns of a droopy tip on profile view and desiring refinement to the bridge and tip on the frontal view. She was noted to have medium-thick skin. Her primary rhinoplasty included:

- Bilateral osteotomies

- Tip support and elevation with caudal septal extension graft

- Tip cartilage repositioning with lateral crural strut grafts

- Tip onlay graft

BEFORE

AFTER

Female patient had concerns over difficulty breathing through the nose, a crooked nose, and twisted tip from previous nasal trauma. She was seeking to give her nose a straighter appearance from the front and to elevate the tip and lower the bridge from the profile. Rhinoplasty techniques in her case entailed a very complicated maneuver of an extra-corporeal septoplasty to help straighten her nose. This technique entails the removal of the entire deviated septum, the reconstruction of the septum outside of the body, then the replacement of the newly reconstructed septumwithout the use of artificial materials.

- Extra-corporeal septoplasty

- Bilateral osteotomies

- Hump reduction

BEFORE

AFTER

Female patient with medium to thin nasal skin. She was seeking refinements to her nose as she was bothered by the profile with the hump of the bridge and droopiness of the tip as well as the shape of the tip from the front of the nose. Primary Rhinoplasty techniques included:

- Hump reduction

- Soft tissue radix graft

- Bilateral osteotomies

- Bilateral spreader grafts

- Lower lateral cartilage tip repositioning for cephalically oriented tip cartilages

- Tip onlay graft

BEFORE

AFTER

Female patient with medium to thick nasal skin who desired to reduce the bridge from the profile. To achieve better profile balance, a small chin implant was placed as well as submental liposuctioning was performed. Rhinoplasty techniques included:

- Hump reduction

- Bilateral spreader grafts

- Bilateral Osteotomies

- Small chin implant with submental liposuctioning

BEFORE

AFTER

Female patient who had the concerns of a bulbous tip and a droopy tip from the profile view of the nose. Rhinoplasty techniques included:

- Bilateral osteotomies

- Caudal septal extension graft secured with splinting grafts

- Lateral crural strut grafts to help flatten and reposition the tip cartilages

BEFORE

AFTER

Asian female patient with thick nasal skin who desired nasal refinements and to slightly raise the height of her bridge. In order to avoid artificial implants in the nose diced ear cartilage grafts enveloped in temporalis fascia was used. Rhinoplasty techniques included:

- Bridge augmentation with diced ear cartilage and temporalis fascia

- Bilateral osteotomies

- Tip support with caudal septal extension graft

- Tip shield graft

- Alar flare reductions

BEFORE

AFTER

Female patient who desired refinements to her nose. She was bothered on the profile by the hump of the bridge and the droopiness of the tip. From the front she was noted to be deviated to the left side. To address her concerns the hump was reduced and soft tissue radix graft was placed. In order to provide a straighter appearance to the nose, asymmetric placement of spreader grafts was utilized as well and asymmetric osteotomies. Rhinoplasty techniques also included:

- Hump reduction

- Soft tissue radix graft

- Bilateral spreader grafts

- Caudal septal extension graft

- Tip graft

BEFORE

AFTER

ETHNIC RHINOPLASTY

African-Caribbean female patient who desired the elevation of her bridge, the narrowing of her tip, and the narrowing of the base of her nose. Techniques employed included:

- Bridge augmentation with diced ear cartilage

- Bilateral osteotomies

- Caudal septal extension graft with septal cartilage for tip support

- Tip de-fatting and Tip graft for tip refinement

- Alar base reductions

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

African American male patient with complaints of a wide bridge, wide tip and droopy tip on profile view. The patient wanted to refine his nose while preserving his ethnic features. Patient is noted to have thick skin. A primary rhinoplasty was performed which entailed:

- Caudal septal extension graft for tip support

- A tip shield graft for tip refinement

- Cephalic trim for tip narrowing

- De-fatting of the nasal skin

- Osteotomies to narrow bridge

- Alar base reductions to narrow his nostrils and nasal base (Base view demonstrates the narrowing of the tip and the width of the base. The base width narrowing was accomplished in a significant but not overly aggressive manner to preserve a natural appearing result. An overly narrowed base would result in triangular rather than a round, natural nostril shape.) - Radix graft to straighten his hump on the profile view. (Note that his hump was not reduced. Rather the radix—where the nose meets the forehead—was raised. This allowed for the simultaneous alignment of his profile and the narrowing of his bridge on the frontal view. This is a key maneuver to create narrowing of the bridge in a patient with thick skin. If the dorsumwould have been lowered his bridge would have widened.)

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

African Carribbean female patient who desired to reduce the flare of her nostrils and elevate her tip. Her goals were to not significantly change the tip from the frontal view other than the reduction of the nasal flare. Rhinoplasty techniques included:

- Alar flare reduction in combination with a cinching suture

- Tip elevation and support with a septal extension grafts

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

African American female who desired refinements to her nose, the reduction of the nostril flare, and the narrowing of the base of the nose. Rhinoplasty techniques included:

- Bilateral osteotomies

- Tip skin de-fatting

- Tip shield graft with buttress graft for tip refinment

- Caudal septal extension graft

- Alar flare reductions

BEFORE

AFTER

African American female who was seeking to primarily straighten the nose from the profile view. She wanted to straighten the bridge and remove the hump. She did not desire much change from the front of the nose. Rhinoplasty techniques entailed:

- Radix augmentation with soft tissue taken from the tip de-fatting

- Minimal bridge lowering

- Bilateral osteotomies

- Caudal septal extension graft with septal cartilage

- Tip onlay gaft

- Alar base reductions

BEFORE

AFTER

African American female patient who desired refinements to the tip and bridge as well as bridge elevation. Rhinoplasty techniques included the elevation of the bridge avoiding artificial implants to the nose by using the patient’s own cartilage.

- Bilateral osteotomies

- Diced ear cartilage dorsal graft

- Caudal septal extension graft with septal cartilage for tip support

- Tip de-fatting and Tip graft for tip refinement

- Alar base reductions

BEFORE

AFTER

African American female patient who was displeased primarily with her profile of her nose. She felt that her tip drooped and she had a bump. In this case, the patient does not have a “bump” but rather very weak tip support and a low radix giving the illusion of the hump. Primary rhinoplasty techniques entailed proving adequate tip support and raising the radix of the nose.

- Radix augmentation with soft tissue taken from the tip de-fatting

- Bilateral osteotomies

- Caudal septal extension graft with septal cartilage

- Tip onlay gaft

- Alar base reductions

BEFORE

AFTER

MALE RHINOPLASTY

Male patient with the complaints of a “large nose.” Patient felt his nose to be overly projected at the bridge with a dorsal hump and tip. He was also found to have a needed chin projection and was proposed to have a chin implant. Primary rhinoplasty techniques included:

- Septoplasty

- Bilateral osteotomies

- Bilateral spreader grafts

- Tongue-in-groove of the nasal tip cartilages on to the existing septum for nasal tip setback

- Cephalic trims

- Medium, extended anatomic chin implant

He is noted to have improved chin projection to help balance his nasal projection and profile. Chin implants are placed through a small incision on the underside of the chin. In male patients, the dorsum can be left a little higher than in female patients to allow for a more masculine profile.

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Young male patient with history of multiple nasal traumas related to sports injuries. Presented with complaints of a severely deviated nose and bilateral nasal obstruction. He is noted to have medium skin thickness. Primary rhinoplasty included:

- Asymmetric osteotomies with out-fracturing of the right bone including both medial and lateral osteotomies and in-fracturing of the left bone.

- “Swinging door” septoplasty towards the right

- Bilateral spreader grafts with double spreader grafts on the right side

- “Clocking suture”

- Tongue-in-groove of the nasal tip cartilages for tip support

- Cephalic trim

Post-operative findings with improvement of nasal deviation, dorsal alignment, and corrected nasal obstruction.

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Male patient with the complaints of a large and over-projected nose. I use this case to demonstrate the goals in male profile aesthetics for men who wish to preserve a straighter, masculine profile. This is a complicated primary Rhinoplasty case of a patient with a severely over-projected bridge and nasal tip. He did not desire the placement of a chin implant to help profile balance. In this case, note (before and after) that the patient had a very obtuse nasal labial angle—a feature that is seen in patient with what is known as a ‘tension nose deformity.’ To help alleviate the tension on the upper lip and soften this angle, aggressive de-projection techniques were employed where the medial crura were released and sutured through a drill hole made within the bone called the maxillary crest. This technique helps to significantly ‘relax’ the upper lip and de-project the tip. As seen in the after photos, the upper lip takes on a longer and more relaxed appearance.

BEFORE

AFTER

Male patient who was bothered by the appearance of the tip of his nose. He desired to raise the tip of the nose while maintaining a masculine profile. Goals in surgery were to raise and support his tip without overly rotating the nasal tip. Primary Rhinoplasty techniques included:

- Bilateral spreader grafts

- Caudal septal extension graft

- Footplate suture

- Tip onlay graft

BEFORE

AFTER

Young male patient who felt his nose was “too large.” He had difficulty breathing through both sides of his nose. He found his bridge to be too large with a hump and his tip too large. He is noted to have a crooked nose with a very deviated nasal septum. Complicated primary case in that his tip cartilages were very cephalically oriented and contributed to the “hump” on the profile view. He was also noted to have a low radix which also contributed to the large hump appearance of the profile. Primary Rhinoplasty techniques included the repositioning of his tip cartilages employing lateral crural strut grafts to both help with his breathing difficulty and his aesthetics to provide for the most natural appearing outcome. Techniques included:

- Hump reduction with radix graft placement

- Bilateral medial and lateral osteotomies

- Bilateral extended spreader grafts

- Caudal septal extension graft

- Lateral crural strut graft with lower lateral cartilage repositioning

- Tip onlay graft

BEFORE

AFTER

REVISION RHINOPLASTY

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Patient with a significant nasal deformity and nasal obstruction. He was found to have a collapse of his nose related to a total septal perforation. He had undergone a previous attempt at reconstruction with a silicone implant. The silicone implant had extruded from the scar along the base of his nose. Revision rhinoplasty entailed rib cartilage and the following techniques:

- Bilateral speader graft

- Caudal septal replacement graft

- Lateral crural strut grafts

- Tip only grafts

- Composite graft from ear

- Scar revision

Post-operatively, the patient was noted to have improvement in bridge and tip projection. Closure of the total perforation was not attempted. Patient noted significant improvement in breathing after surgery.

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Patient who had undergone a previous rhinoplasty which resulted in a severely crooked nose. She was noted on examination to have a near total septal perforation. Her surgery entailed the use of rib cartilage. Revision rhinoplasty included:

- Left, unilateral spreader graft

- Caudal septal extension graft

- Lateral crural strut graft

- Left batten graft

- Tip onlay graft

Repair of the septal perforation was not attempted. Post-operative correction of the severely crooked nasal appearance was achieved through the use of spreader graft utilizing rib cartilage and batten grafts.

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

Patient who had undergone a previous rhinoplasty which over time resulted in a severely upturned nasal tip as well as an amorphous appearance to the tip. She was noted to have thick nasal skin. Revision rhinoplasty included the use of rib cartilage. Intra-operative findings included the complete absence of her nasal tip cartilages. Techniques to reconstruct the tip included:

- Bilateral splinting grafts

- Caudal septal replacement graft

- Tip cartilage dome reconstruction with rib cartilage perichondrium

- Lateral crural strut grafts

- Tip onlay grafts

Post-operative the tip was able to be de-rotated into a more aesthetic angle.

BEFORE

AFTER