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Rhinoplasty — Open vs. Closed San Francisco Nose Surgery

Deciding on a rhinoplasty technique can be a confusing task if the patient has no understanding of their choices. Here is a brief description between two of the major choices patients will be faced with: the open and closed techniques.

When using the open rhinoplasty approach, your plastic surgeon will make a tiny incision on the external skin that separates the nostrils. The nasal skin can then be lifted, offering a great deal of surgical access to the underlying architecture of the nose. This technique involves an incision that is more visible after surgery. Hiding the incision is preferable for many patients.

The closed rhinoplasty technique features tiny incisions within the nostrils – more specifically, between the internal nasal cartilages. Most people opt for closed, because the incisions are better hidden from view.

To learn more about the rhinoplasty procedure, contact Dr. Evan Ransom at his San Francisco office to set up an appointment for a consultation.

Just Breathe

Before you read any further, stop for a second. Close your eyes, take a deep breath. How did that feel? Was your mouth open or did you just breathe through your nose? In your nose, was there any resistance, on one side or both? Now what if you were jogging? Or sleeping? I’m sure that this isn’t something you think about all the time, but it’s hard to say that breathing is overrated. In fact, there is a type of mindfulness meditation based in part on what you just did – pranayama. In this practice attention is focused on the simple act of breathing as a way of calming the spirit, and medical studies have shown positive effects on stress-related diseases.

Nasal obstruction has many causes, some of them physiologic (related to temporary conditions) and some anatomic (related to the position and arrangement of specific structures). Regardless of etiology, the manifestation is similar: snoring, dry mouth, poor sleep quality, even reduced exercise tolerance. About 30% of people over 30 snore, and at least 40% of people over 40. Men snore a bit more than women. This can be disruptive to your daily routine (and your bed partner’s!), and is an overlooked cause of fatigue. An important distinction that should be made is between snoring and obstructive sleep apnea (OSA). While the two can happen together, OSA is a more serious problem in which the airflow is blocked entirely during sleep. Over time, this can cause or exacerbate heart and lung problems and lead to weight gain. In severe cases, chronic tiredness increases the likelihood of workplace injuries and car accidents.

Causes of nasal breathing problems are wide-ranging. The most common cause, across gender and age groups, is allergy. Seasonal and environmental allergies are reported by more than 40 million people in the United States! Common treatments include saltwater irrigation (e.g., sinus rinse kit or Neti pot), antihistamines, and nasal steroid sprays. Some patients with specific allergies benefit from immunotherapy (also known as “allergy shots”). These medical treatments are effective in most mild cases, and are still beneficial in more severe cases. Other causes may be related to hormonal shifts (as in pregnancy or menopause), medication side effects, and age-related changes.

For some people, allergies are not the whole story. In these patients, there is an anatomic problem with the nose: something is blocking the passage of air. This can be a fixed obstruction (like a deviated septum or a broken nose) or a dynamic obstruction. The latter problem is common yet often overlooked. As we breathe through the nose, the air must pass through two key areas, referred to as the internal and external nasal valves. These are not true valves, such as the kind you find in the heart; rather, they are areas of narrowing and potential airway collapse. The external valve is basically the nostril rim and the entrance to the nose. In some people, the nostril opening is very narrow; while others have very weak support and experience collapse when breathing in. The internal nasal valve is inside the nose, underneath the soft cartilages that connect the nasal bones to the nasal tip. This is the narrowest part of the nose and creates the highest resistance in the entire airway – from the tip of the nose to the bottom of the lungs.

When I see patients for nasal obstruction, we always start with nonsurgical options. In most cases, this begins with nasal rinses, nasal sprays, even Breathe Right Strips® for exercise or sleeping. If there is a history indicative of sleep apnea, further diagnostic testing is needed. For patients with anatomic obstruction, surgery may be indicated. In straightforward cases, this can be just a septoplasty, a simple operation for straightening the cartilage and bone in between the two sides of the nose. In many instances, however, a more complex functional rhinoplasty is needed. In this surgery, the internal and external nasal valves are repaired with cartilage shaping techniques, placement of key sutures, and addition of structural grafts.

For most people breathing is automatic. But for people who have chronic nasal obstruction, there are treatments available. As a dedicated rhinoplasty surgeon, improving breathing is always on my mind – in functional nasal surgery and even in purely cosmetic cases. If breathing issues are negatively impacting your daily life, exploring your options is well worth your time. Here’s to a better run, a clearer head, and a full, restful, and quiet sleep!

Evan R. Ransom, MD is a facial plastic surgeon practicing in San Francisco and Marin County. He specializes in rhinoplasty (both functional and cosmetic), as well as aesthetic and reconstructive surgery of the face, neck, and eyelids. Dr. Ransom regularly performs nasal surgery to improve patients’ breathing. For more information, visit him on the web at

Pranayama: the importance of breathing in mindfulness meditation

It’s hard to imagine that breathing could be underrated (I mean, without breathing, where would we be?), but it really is.  The simple act of airflow through the nose and mouth is not only necessary for life, but also can be an integral part of a feeling of calm, centeredness, and well-being. Pranayama is a Sanskrit word meaning “breath or breathing” and, in some contexts, “controlled breathing.”  It is a combination of Prana (“life force”) and ayama (“to draw out”).  Numerous forms and practices exist, involving the timing, manner, and rhythm of the breath.  This can include alternating nostrils, adding pauses or specific sounds and phrases, shaping the mouth in a particular way, etc.

The key point is that Pranayama is deliberate and requires focused attention.  When was the last time you took a moment to pause and focus on your breathing?  Maybe you should.  A growing body of medical research supports simple meditation practices as therapeutic tools in depression, anxiety, blood pressure control, and even heart and lung function.

During a recent follow up appointment with a dear patient, I was reminded about these simple truths.  My patient had undergone an extensive nasal reconstruction after removal of a large skin cancer, which unfortunately meant that one entire nostril and a part of the tip of the nose had to be recreated.  His nasal reconstruction required three separate surgeries and involved tissue flaps and grafts from the forehead, the external ear, and septum.  As we concluded our visit, he reminded me that we should all take a minute to breathe – and appreciate that we are doing so.

For more information about reconstructive surgery, facial cosmetic surgery including rhinoplasty (nose job) in San Francisco,  non-surgical rejuvenation, or a variety of other treatments, please contact us or call 415-550-1077 today for a comprehensive consultation!

A nose is just a nose, except when it isn’t

rhinoplasty_sanfranciscoOver the years, plastic surgeons and other physicians and scientists interested in aesthetics have explored the “ideal proportions” of the human face and its features. This has led to myriad schemes for classifying facial types, suggesting courses of treatment, and even planning surgical modifications. More recently, we have begun to focus on facial recognition – using experimental psychology techniques to find out exactly how people recognize each other or assign certain faces to particular groups (e.g., age groups, ethnicities, etc.). Out of this inquiry has come an interesting body of literature regarding facial features that the brain uses as shorthand for gender – how a person can decide on the gender of a face after seeing a single image flashed on a screen for less than a second. This work has determined that the ridge of the brow plays an important role, as well as the prominence of the jaw.

Comparatively less attention has been paid to the size and shape of the nose in aesthetic assessments of masculinity or femininity. Some general rules hold true across studies: smaller noses are considered more feminine; the presence of a dorsal hump (“bump”) is associated with a more masculine nose. Less commonly considered variables include the angle that the nose makes with the upper lip and the forehead (larger angles are generally more feminine). Obviously each nose is presented in the context of the face where it lives, and consideration must be given to the other facial features in any discussion of nose reshaping. The brow, the lower eyelids, and the upper lip form an essential “backdrop” for the contours of the nose. That’s why when I see a consultation for rhinoplasty, we always discuss the nose at it relates to the rest of the face – as well as the patient’s desired aesthetic. This helps in all types of cases, but is especially important in patients seeking ethnic rhinoplasty or nose reshaping to feminize the nose.

For more information about rhinoplasty and surgical or non-surgical rejuvenation of the face and neck, please visit or call 415-550-1077 today for a comprehensive consultation!

The Princess’s Nose

Of all the obsessive publicity and incessant attention surrounding Prince William and Kate Middleton, the most interesting item I’ve seen recently was about the Duchess of Cambridge’s nose. Apparently, according to the Transform Cosmetic Surgery Group, her nose was the most popular celebrity lookalike feature in the United Kingdom for 2012 ( The timing is curious since only a few weeks later the unveiling of the official portrait of Kate was met with widespread disappointment ( To my eye, the portrait looks quite accurate in terms of facial proportions, coloring, and even expression . . . yet somehow it is not beautiful. Much more could be said on this topic, but we’ll leave that for another day.

We all know the childhood joke (“You can pick your friends, you can pick your nose . . .”), but in a rhinoplasty (nose reshaping) operation, can you really pick a celebrity’s nose? Should you pick a celebrity’s nose?! If you had to choose, Kate Middleton’s nose would be a good choice: it is straight, well-proportioned, appropriately projected and rotated, and has a nice brow-tip aesthetic. The tip is slightly bulbous, but again, it’s a great nose and most importantly it fits her face. The question you should really ask yourself, however, is would it fit my face?

At the San Francisco Center, I work closely with my patients to first identify the characteristics of their noses that they like. Then we discuss areas for improvement. It is very rare that someone truly, after an honest conversation and some introspection, wants a completely different nose. In the end, when people seek cosmetic or even reconstructive facial surgery, they still want to look like themselves . . . only better. After all, I think we can agree that Kate Middleton’s nose wouldn’t look that attractive on Jennifer Lopez – just like Ryan Reynolds’s nose wouldn’t do much for Sly Stallone.