Dr Paul O’Keeffe Retires – Template Rhinoplasty

Retirement of Dr O’Keeffe Plastic Surgeon and a Top Rhinoplasty Surgeon in Sydney

Congratulations to Dr Paul O’Keefe on your recent retirement from Plastic Surgery. Dr Paul O’Keeffe retired in January 2021. He was a leading Australian Specialist Plastic Surgeon and top rhinoplasty surgeon based in Sydney NSW.

Dr O’Keeffe is an innovator, a pioneer, author and an artist. His academic accomplishments are well known internationally. He spent many years writing, educating and working within the public healthcare sector. Dr O’Keeffe continues to contribute to ongoing advancements within the medical industry.

Dr O’Keefe’s performed thousands of nose surgeries and closed rhinoplasty was his favourite operation. He also performed alar base reduction, septoplasty and nose reconstruction with the thin medpor nasal shell implants and grafts.

Dr Paul O’Keeffe is an author and famous for developing an exacting and stable closed rhinoplasty technique called the template rhinoplasty.  

For Dr O’Keeffe’s Past Patient records

Dr Scott Turner in Dee Why has been given access to records for Dr O’Keeffe’s past patients who had a procedure in the preceding 7 years (a longer time for child patients).

About Dr Paul O’Keeffe

Dr Paul O’Keeffe is a retired Specialist Plastic & Reconstructive Surgeon. He is a Fellow of the Royal Australian College of Surgeons (RACS) and is also a member of the Australasian Society of Aesthetic Plastic Surgeons (ASAPS) and the Australian Society of Plastic Surgeons (ASPS).

Dr Paul O’Keeffe’s attended medical school at University of Sydney followed by surgical training in Sydney, Adelaide, Scotland and England. Specialist plastic surgery training was at Norwich in England.

His Public hospital appointments were Royal North Shore Hospital, a teaching hospital for University of Sydney, and Manly District Hospital in Sydney.

In 1989 Dr O’Keeffe’s practice became focussed on rhinoplasty in 1989 and moved solely into the private hospital sector.

Memberships

Dr Paul was a member is a Fellow of the Royal College of Surgeons and the Royal Australasian College of Surgeons. He is an active member of the Australian Society of Plastic Surgeons, a founder member of the Australasian Society of Aesthetic Plastic Surgery and a member of the International Society of Aesthetic Plastic Surgery and the Australian Medical Association. Paul is also a Corresponding Member of the American Society of Plastic Surgeons.

Awards

Dr Paul O’Keeffe Awards


Dr Paul O’Keeffe was honoured to win the 1999 Mentor Travelling Fellowship ($10,000) at the Annual Scientific Meeting of the Australasian Society of Aesthetic Plastic Surgeons in Adelaide. The prize is awarded for the scientific paper chosen as best by a panel of judges. The recipient is required to travel to an overseas conference and report back to the society.

In March 2005 Dr Paul O’Keeffe was honoured to be a guest speaker at the 9th Congress of the Asian Pacific Section of the International Confederation of Plastic Reconstructive and Aesthetic Surgery in Mumbai. His presentation was titled “Template Rhinoplasty”.

Dr O’Keefe’s Presentations and Publications

Papers on Nasal Anatomy and Template Rhinoplasty have been presented at the Annual Scientific Meetings of the Australasian Society of Aesthetic Plastic Surgery. The society may be contacted via the Australian Society of Plastic Surgeons.

The various techniques described here have been presented at Rhinoplasty Workshops in Australia and New Zealand.

Template Rhinoplasty was an invited presentation at the 9th Asian Pacific Section meeting of IPRAS held in Mumbai, India, during March 2005.

Dr O’Keeffe’s Book on Closed Rhinoplasty

In 2019 Springer published Dr Paul O’Keeffe’s 156 page book, Closed Rhinoplasty – The Next Generation, that describes in detail the steps in planning and executing a closed rhinoplasty. There are 11 chapters: 1 Introduction, 2 Research, 3 Problems and Misconceptions, 4 Anatomy of the Prominent Nose, 5 Patient Desires, 6 New Strategy, 7 Consultation, 8 Planning Session, 9 Instrumentation, 10 The Operation, 11 Post-operation Results.

Dr Paul O’Keeffe Book Closed Rhinoplasty

The original closed rhinoplasty procedure had many issues such as “Poly Beak” deformity and an unstable tip. Open rhinoplasty had less of these problems and it was easier to teach so it became the new standard.

However, it too has issues of its own due to total release of the nasal skin from the skeleton. This limits the amount of skeletal reduction and it is often necessary to add anatomically abnormal cartilage grafts such as columella struts to push the nose tip into the skin.

The Next Generation Closed Rhinoplasty addresses these issues. Results are more stable and greater nasal reductions are possible because skin control is maintained. Results are accurate because the changes are measured and controlled with a template. We can call this operation “Template Rhinoplasty”.

Template Rhinoplasty by Dr Paul O’Keeffe Dr Paul O’Keeffe Template Rhinoplasty Illustration

Template rhinoplasty is based on the proposition that the nose tip is dynamic, changing position with smiling, sucking, etc and returning to a position of rest determined by muscular and elastic tissue forces.

Changing the shape of the nose may lead to a new nose tip resting position. Calculating this position pre-operatively and placing the nose tip accordingly should produce a more stable rhinoplasty result.

The nose tip is repositioned first and then the bridge line (nasal pyramid) is modified to suit the new tip position. This contrasts with other methods in which the pyramid is reduced to pleasing proportions first and then the tip is sutured in a pleasing relationship (which may not be dynamically stable) to the pyramid.

With template rhinoplasty the skeletal changes are measured pre-operatively and guided by a profile template which is custom made for each patient.

The standard or traditional closed rhinoplasty may produce a nose with an unstablerounded and featureless tip. The tip can droop and there appears to be swelling above the tip, so called supra tip swelling.

Investigators have described skin and subcutaneous tissue thickening in the supra tip area which is probably secondary to skin bunching. The skin bunches up because the skeleton is reduced, usually by resection of the upper portion of the alar cartilages and resection of the anterior (dorsal) margin of the septal cartilage, but no skin is removed.

A second, less well recognised, cause of the rounded and drooping tip is loss of nose tip projection due to retrusion of the columella. This change is best appreciated at the lip-columella angle which changes from more obtuse to more acute. This change is very likely to occur if the nose is shortened by resection of the caudal margin of the septal cartilage.

Supra tip swelling can be improved by widely undermining the skin over the nose and redraping it towards the cheeks. Some surgeons may be reluctant to try this technique because they fear the extra dissection will lead to more tissue swelling. However, extra skin is required for draping over the infractured nasal bones at the lateral osteotomies so the excess from the supra tip area can be taken up there if the undermining is wide enough.

Retrusion of the columella secondary to nasal shortening is very difficult to control. Strong permanent sutures can be placed between the columella cartilages and the septal cartilage to force the columella forward but this will immobilise the nose tip. Another recommended technique is placement of a cartilage strut in the columella base. To be reliable the strut has to be very large. These findings suggest the presence of some sort of tether between the columella cartilages and the lip. The tether resists elongation by pulling the columella back.

Anatomical Study by Dr Paul O’Keeffe

Dr Paul O’Keeffe investigated the anatomy of the columella base and membranous septum during 1989. The study was carried out at the Sydney Morgue in Glebe.

Young cadavers were found to have on each side a relatively large pyramidal-shaped muscle arising from a fibrous layer on the anterior surface of the orbicularis oris muscle and inserting into the medial surface of the ipsilateral footplate of the columella cartilage. This muscle may be called the superficial depressor septi muscle. The muscle appeared to be smaller in older cadavers who had a short distance between the foot plates and the orbicularis oris muscle. The muscle would appear to be the functional tether between the columella and the lip.

Elastic fibres are stained black

The membranous septum was resected and examined histologically. It was stained for elastin revealing a rich elastic fibre content. The elastic fibres are arranged primarily in one direction and their orientation would protrude the columella and nose tip after retrusion caused by contraction of the superficial depressor septi muscle. The elasticised mucous membrane covers the caudal margin of the septal cartilage.

Dynamic Nose Tip Position

The superficial depressor septi muscle acts like a tether preventing elongation of the distance between the upper anterior surface of the orbicularis muscle and the footplates of the columella cartilages. The distance can stay the same or shorten.

Protrusion of the tip depends on the balance between the tone of the superficial depressor septi muscle pulling the columella backwards and the elastic tissue in the membranous septum pulling the columella forwards. Thus, it is important to restore the elastic tissue attachments when forward projection is to be maintained. This is facilitated by pre-marking the tissue attachment with a small cross incision or ink.

Tip tilt depends on the relative lengths of the columella plus tip  9  and the alar cartilage plus lateral alar ligament  10 .

The lateral alar ligament should be shortened to maintain tip tilt when the columella plus tip is set back. Shortening the alar ligament more than the columella plus tip set back tilts the tip upwards. Setting the columella plus tip back while maintaining alar ligament length tilts the nose tip downwards.

Nasal Bridge Tip Support

projecting nasal bridge (tension nose) adds a forward vector (crane effect) to the balance of forces acting on the nose tip. The nose tip settles back when the bridgeline is lowered and this must be taken into account when calculating the new dynamic position of the nose tip. The elastic tissue set back should be discounted at least 50% as judged by long term results.

If the patient has good tip definition, the bridgeline being posterior to the tip profile, the elastic tissue is set back exactly as calculated.

Template Rhinoplasty Operation by Dr Paul O’Keefe

  1. Mark forehead key 
  2. Mark bridge reduction with template on side of nose 
  3. Inject local anaesthetic and adrenaline as usual
  4. Incise septal mucosa at junction of mobile and fixed mucosa and cross cut for reference 
  5. Expose septal caudal margin and reduce as planned
  6. Intra- or inter-cartilaginous vestibular incision extends laterally to pyriform margin
  7. Resect measured amount of lateral alar ligament and mucosa 
  8. Carefully elevate skin and underlying muscle off the upper lateral cartilages
  9. Skeletonise pyramid widely and reduce dorsum until matches new bridge line
  10. Medial nasal osteotomy
  11. Lateral nasal osteotomy via lateral alar ligament window
  12. In-fracture and bone graft to dorsum and lateral osteotomy if gap 
  13. Suture septal mucosa according to planned setback, suture lateral alar ligaments and suture vestibular incisions 
  14. Tape, splint and pack nose 
  15. Eye pads to reduce peri orbital ecchymosis

Template Rhinoplasty – Dr Paul O’Keefe’s Results

These results represent one person’s experience and there is no guarantee that any other patient will experience similar results.

The profile template is excellent for assessing the results of rhinoplasty. The template is keyed to the forehead for accurate assessment of bridge line, tip projection and tip-tilt.

The described operative technique produces excellent profile matches for primary rhinoplastySecondary rhinoplasty is less reliable probably because there is some pre-existing slackness of the lateral alar ligament and reduction of the ligament length by the calculated length does not elevate the tip as much as expected. Thus, the secondary post-op profile may have a slightly drooping tip. This can be corrected by tertiary ligament shortening as an office procedure.

Very little supra tip swelling is seen post-operatively even when the nose is maximally reduced because the alar setback drives redundant skin to the lateral osteotomies. The alar cartilages are minimally reduced with this method and the overlying skin remains attached thereto.

 

Nose Surgery FAQs – Dr Paul O’Keeffe’s Best Questions about Rhino Surgery

How do I find the nose I want?

  • Do not try to find somebody who has a face like yours. That is way too difficult to do. It is better to imagine a room with 100 people in it. Your task is to select 5 people who, in your opinion, have the best noses. You take these people to a separate room. After your surgery you should rightfully be in this room too. Now look for photos of people who you might have chosen to be in this room with you.

Can I blow my nose after rhinoplasty?

  • Yes, you may blow your nose gently. It helps to moisten the inside of the nose with the nasal spray before blowing the nose. Don’t blow hard as it may cause bleeding.

Something large came from my nose two weeks after surgery. What was it?

  • It is common for a large crust to come from the nose about two weeks after surgery. It happens more commonly if the turbinates have been reduced. In the weeks after surgery the fine hairs, called cilia, on the mucus membrane are not working properly. The cilia should propel the mucus to the back of the nose but when they are not working the mucus stays put and becomes dried out. Eventually the dried mucus comes away and often it looks like a piece of packing that might have been placed inside the nose during surgery.

When can I resume exercise at the gym?

  • You can resume your exercise routine about two weeks after surgery. Don’t do anything that might increase nasal swelling so avoid having your head lower than your heart. Exercise gently at first and see how you go.

Can I take a trip in a plane?

  • Yes you can. Take a box of tissues just in case you have a nose bleed!

How long does the swelling last?

  • 12 months. The nose is refining over this time and it looks quite good even at two weeks after surgery. It will look better at 6 months and better still at 12 months.

Will rhinoplasty change the lips in any way?

  • This depends on the operative plan. A long nose may be associated with a short upper lip and shortening the nose can lengthen the lip. Taken further, the lip may be elevated to expose more of the upper teeth on smiling.

Does rhinoplasty help sinusitis?

  • It certainly can particularly if the nose was previously bent and a septoplasty has been performed to straighten the septum.

Will rhinoplasty change my breathing?

  • It can do. A survey of Paul O’Keeffe’s Template Rhinoplasty patients over three years ending 1997 showed improvement in 90%. That was due to tightening of the lateral alar ligament, an integral part of the operation. By contrast, conventional closed rhinoplasty has an incidence of reduced airway patency on breathing in due to slackness of the lateral alar ligament. The soft sides of the nose are sucked in during inspiration, blocking the nose. This can be helped by a minor operation, removing a small part of the ligament and stitching it tighter.

How common is septal perforation following rhinoplasty?

  • Very rare following rhinoplasty alone. Septal perforation, a hole going through from one airway to the other, can occur following septoplasty or SMR (submucous resection of the septal cartilage). Great care is required during these operations to prevent this complication. Septal perforations may occur in approximately 1% of septoplasties/SMRs. Small perforations cause dry mucus to stick to the septum and when it comes away bleeding may occur. There can be a whistling sound while breathing. Small perforations can be repaired. Large perforations cause less problems and are usually best left alone.

A friend of mine has pain following rhinoplasty. How likely is that?

  • A painful nose is not usual after rhinoplasty but it can happen. The nose receives nerves from different directions, some coming down from the top of the nose, some from the cheeks and some from inside along the septum. Nerves do not like to be squeezed by scar tissue so that could be a cause for pain in the nose following rhinoplasty. The nerves coming down the nose from the top run under the nasal bones and over the upper cartilages where they may be damaged or cut. You would expect to see more pain and discomfort on the sides of the nose than we do see. To answer the question, perhaps 10% of patients complain of some pain in the nose but it is usually not a problem. Only a very small minority would rather they had not had the surgery.

Dr O’Keeffe’s Past Clinic Address 6 Alfred Rd, Brookvale NSW 2100

Dr O’Keeffe’s Past Clinic Phone (02) 9938 3577

For further information about Dr Paul O’Keefe’s patient records and technique – contact Dr Scott Turner.

About Dr Scott Turner FRACS (Plas) – Specialist Plastic Surgeon

Dr Scott Turner - Top Plastic Surgeon Sydney and Best plastic surgeon Newcastle

Dr Scott J Turner has spent a lifetime acquiring the qualifications, education, training, and hands-on surgical experience to perform superior cosmetic plastic surgery to give you natural, beautiful results and the improved sense of well-being you want. He is one of the top Specialist Plastic Surgeons with a Breast and Body Surgery focus in New South Wales.

Achieving this personal goal requires not only in-depth knowledge of human anatomy and refined surgical techniques but an ongoing commitment to learning the latest procedures around the world. This is why Dr Turner regularly attends both local and international surgeon meetings – discussing these advances with the leaders around the world in order to offer you the most natural, effective and safest surgical procedures. He is a committed board member of ASAPS – Australia Society of Aesthetic Plastic Surgeons

Dr Turner and his highly trained staff will do everything to ensure that you are fully informed, while providing exceptional, world-class cosmetic plastic surgery, in a personal and caring environment.

Next Steps

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Contact us or call on  1300 641 199  to arrange your consultation in Sydney or Newcastle.

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