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I have a new website dedicated to rhinoplasty and I included in that website or will be including in that website a whole section on excisions on the nose. Specifically the two types of excisions that I usually perform would be scar revision on the nose and removal of moles on the nose. To me, there are categorically similar because you’re making an excision of cutting something out, whether that be a mole or informal terms – Nevis or a scar usually a linear scar or jagged scar in there. So, why is the mole or the scar on the nose so unique compared to the rest of the face? So, if we first have to understand the nature of the nose. So, the nose is a functional organ. In other words, it has to help with breathing. So you don’t ever want to compromise it. For example, if the nostrils, if you cut a mole on the nostril, you could scar the nostril and have it shrink in and cause a problem with breathing, as well as a cosmetic deformity, now why is that the case? So, it’s very interesting in the ala or in the nostril is that there is very little cartilage in there. There is actually almost no cartilage, the cartilage extends upwards, so the base of the nostril is actually just free soft tissue. So, if you excised a mole there, you can have the mole cause contraction of the nostril up like a notch, which is a problem. And when I used to cancer operations to help fix this, I would have to actually harvest a piece of cartilage and put a piece of cartilage, prevent the notching. So, that’s one example of how unique a mole on the nose, as people think I was just a mole, now, if I shave it off superficially that should be safe. So that’s very different. Now, the second problem with the nose is that if we go up the nose, if you take your finger and feel the tip of your nose, you’ll feel that the tip of the nose can actually move quite a bit and as you go up the nose becomes more fixed like bone. What’s interesting is that the exact opposite is true, in terms of the skin adherence to the underlying cartilage? If you try to slide the skin over the cartilage on the tip of the nose, you can’t do it. It’s very stuck down and barely moves as you go farther up the nose, you’re going to feel like the skin can actually slide over the cartilage and bone, much more easily. That is actually the more important of the two entities when you’re thinking about removing tissue. Because when you remove tissue up on the top portion of the nose, you can typically have plenty of room to close it because the skin slides down and closes pretty easily. Whereas if the farther down the nose tip you go, if you try to cut the nose, this tissue out and close it not only are you risking some of the puckering that I mentioned before but you simply can’t make the closure. The skin is too tight and you’re going to cause distortion and actually a ward scar. So, have I remove moles and scars off the tip of the nose? Absolutely yes. As I always say that the punishment fit the crime. So, in other words if it looks really bad then you’ve got to treat it more severely. So, for example, I had a lady that had a disfiguring circular raised mole on the tip of the nose that look like a wart and it was very distracting and disfiguring. So, I actually excised the whole mole full depth and that I did what’s called a by lobe rotational flap warm, as it’s exactly like a cancer operation where I have scars all over the top of the nose to cover that. So, I slid and borrowed progressive skin from the top of the nose, down onto the tip of the nose. So, that it would not cause distortion and that it would close well. Now, what is the trade-off of removing this nose scars across the nose? He said, well, why would you ever do that Dr. Lam because those scars typically heal. Well, but there will always be these fine scars there. But to me, the mole on the tip of the nose was so unsightly and large and there’s no way because shaved it off because if I shaved it off the recurrence rate would be too high. In that situation, I did a cancer operation to remove a mole. Now, that’s incredibly rare most times a mole is not that ugly on the tip of the nose. It’s a little black, little raised, whatever it may be and that case I’m not going to need to do that but what I do is I shave it off. By shaving it off the biggest issues you’re going to have a higher recurrence rate. You need to know that. The only mole that I’m very careful to remove as if it’s on the absolute edge of the nostril that can cause the notching, so that’s an area that you don’t want to just do that for all the reasons I’ve mentioned above. So, when I’m talking about the tip of the nose most times you want to be really careful doing it even excision that several millimeters. You cannot close it well, unless you’re borrowing tissue and causing a larger scars sometimes is justified, sometimes that’s not. When you’re looking up to the top of the nose, you can do more creative work in terms of excisions with much more impunity or in other words with less punishment or more freedom. When you’re looking at scars, it’s very similar all those scars sometimes, if it’s a linear scar, it’s very fine scar that typically, if I don’t make wide limbs on both sides, which are called a geometric broken line, in other words, something to help make that scar difficult to see and I encourage you to look at that part of my website on scar revision to understand what a geometric broken line it’s all about. But essentially, if I can make very limited limbs, I may be able to address a scar into the tip of the nose, through some undermining, which is my next topic. I’ll talk about in a second what that means? But as I go up the nose, I’m actually much more freer to be able to do some corrective work that the close you go to the tip of the nose and the wider the scar is the more problematic and the more creative I have to be in terms of making additional decisions on the nose. So you can really see that the nose is incredibly difficult. You may not even understand everything I’m telling you but it’s not the same as the cheek where I just make an incision in the subcutaneous plane or underneath the fat, and just close it, where there’s plenty of generous extra tissue, there’s no risk of functional issues, distortion, Etc. Now, the final topic that I have to talk about is what is the plane of dissection? In other words, when you undermined released issue tension, do I just do it like in the cheek where I just make a little cut underneath the skin to release the tension so I can close it. The answer is absolutely not. There’s a layer in the nose called the smas a very fancy word that stands for a superficial musculoaponeurotic system. It’s basically a muscular fibrous adhesions that includes the nasal musculature and it’s above the periosteum or lining of the bone. The blood supply is embedded into this layer if you cut above this area, in the subcutaneous plane, your flap, or your advancement of that tissue does not have enough blood supply and you can create a puckered distorted look to the nose. So, when you’re making a cut through the nose, you actually have to cut quite a bit deeper to preserve the blood supply and allow that advancement flap coming forward to have adequate blood supply in to limit the puckering that I’m talking about. So you need to cut through that tissue. And in fact where it is if you take your finger and slide up and down on the bridge of your nose and you can feel that movement that is the smas. So that you’re in that’s the plane that sliding plane is a plane I’ve got at work on in the nose. It’s much deeper than what I do on a face for a mole. That’s actually the plane that I do a facelift on. I go below this smas to elevate. So, the nose is such a unique animal in terms of being different, when I’m addressing it for a mole or for a scar revision. This is only touching the tip of the iceberg in terms of the complicated, understanding of when I make a cut on the nose and external cut on the nose, but I just want you to understand the level of complexity is there. And so if you don’t understand this, listen to it a few times and then when you come in for consultation, I can briefly tell you if you’re a candidate or not based on these criteria.