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Rhinoplastytoronto.ca - A Resource for Patient Information Provided by Richard Rival, MD, FRCS

How Is the Surgery Done?

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As a rhinoplasty specialist, Toronto facial plastic surgeon Dr. Richard Rival is experienced performing rhinoplasty with both an internal and external approach. He will choose the one that will best allow him to provide the desired improvements. This page provides details, along with graphic photographs, of how he performs these techniques.

To learn more about how rhinoplasty is performed, request a rhinoplasty consultation with Toronto facial plastic surgeon Dr. Richard Rival at one of his three offices. If you are interested in a facial plastic surgery procedure other than rhinoplasty, visit Dr. Rival's main site at www.rivalcosmeticsurgery.com.

Richard Rival, MD, FRCS

Board-certified in Facial Plastic Surgery and Otolaryngology, Dr. Rival devotes his practice exclusively to enhancement of the face and neck, with a focused specialty in rhinoplasty.

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Internal Approach Rhinoplasty

Internal approach rhinoplasty with tip cartilages pulled into nostrils.

Internal approach rhinoplasty with both tip cartilages delivered into the nostrils.

Internal approach rhinoplasty with tip cartilages pulled into the right nostril.

Internal approach rhinoplasty showing both tip cartilages in the right nostril.

In general during rhinoplasty surgery, facial plastic surgeon Dr. Richard Rival modifies the underlying nasal bone and cartilage usually by a combination of reducing, reshaping or augmenting it. To gain access to these structures he generally uses one of two approaches. The internal approach involves making inscisions inside the nostrils and then elevating the skin to expose the bone and cartilage to be changed. The tip cartilages are sometimes delivered through the nostrils modified and then replaced inside the nose.

Suture in nasal tip cartilagesDuring internal approach rhinoplasty, sometimes both cartilages can be delivered into one nostril where suture techniques are used to create narrowing to improve definition of the tip. Once the tip cartilages are exposed a suture is placed to narrow them (this is the blue thread in the picture to the right).

External Approach Rhinoplasty

Typical location and configuration of incision for rhinoplasty.The other approach most commonly used by Toronto rhinoplasty surgeons is termed the external or open approach. In addition to the cuts made inside the nose, a small incision is made across the skin in between the nostrils called the columella. This allows the rhinoplasty surgeon excellent exposure to make major changes to the anatomy of the nose. The incision fades with time and is extremely hard to see when fully healed. Dr. Rival uses the external approach when major change to the tip anatomy is required or often to fix a twisted nose. An experienced surgeon performing rhinoplasty in Toronto should have extensive skill in both approaches in order to handle the variations in nasal anatomy. Generally the external approach incision heals very well with a scar that is difficult to see.

Nasal incision and exposed cartilages.

The incision across the base of the nose is connected to internal incisions along the nostril rims and the skin is elevated to expose the tip cartilages.

The nasal skin is elevated.

The elevation of the nasal skin is continued to expose the bridge. Excellent exposure allows precise surgical maneuvers to be performed.

External approach rhinoplasty showing the full anatomy of the nose.

External approach rhinoplasty showing the full anatomy of the nose.

External approach rhinoplasty showing very irregular and asymmetric nasal tip cartilages.

External approach rhinoplasty showing very irregular and asymmetric nasal tip cartilages.

External approach incision at 1 month after surgery (still red).

External approach incision at 1 month after surgery (still red).

External rhinoplasty incision at 1 year after surgery.

External rhinoplasty incision at 1 year after surgery.

External rhinoplasty incision at 1 year after surgery.

External rhinoplasty incision at 1 year after surgery.

Reducing the Nasal Bridge

During rhinoplasty the bridge of the nose is commonly reduced. The upper part of the bridge is bone and the lower part is cartilage. The bone is reduced by shaving it down gradually with an instrument like a file we call a nasal rasp. The cartilage must be reduced sharply with either a scalpel or specially designed surgical scissors. Although seemingly an easy maneuver, a Toronto rhinoplasty surgeon must anticipate the effects of healing and swelling to obtain a pleasing aesthetic result.

Nasal profile prior to hump reduction.

Nasal profile prior to hump reduction.

Cartilage portion of hump (lower part) has been reduced.

Cartilage portion of hump (lower part) has been reduced.

The bone part (upper part) has now been reduced with a rasp.

The bone part (upper part) has now been reduced with a rasp.


Once the hump is reduced this creates a wide flat area over the bridge of the nose much like a landing strip. In rhinoplasty terms this is called an open roof. In order to re-narrow the nose the surgeon must create a controlled cut in the bone on either side in order to allow the bones to move closer together. Surgeons call this an osteotomy - patients refer to this as breaking the nose. This maneuver is often responsible for most of the bruising that follows rhinoplasty.

After hump reduction rhinoplasty.

Patient immediately following hump reduction rhinoplasty. Note the wide flat appearance of the nasal bridge.

After osteotomies to narrow nasal bridge.

Patient immediately following osteotomies to narrow nasal bridge again.

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