Beverly Hills Rhinoplasty Surgery Blog

A bulbous nasal tip is one of the most common reasons for patients to seek rhinoplasty. A bulbous tip, often called a boxy tip, refers to a tip that is too wide and prominent in proportion to the rest of the nose and other facial features. The key focus in our approach to bulbous tips is in emphasizing creation of a sense of tip refinement and definition rather than excessive narrowing.

To accomplish this, we rely heavily on suture techniques that draw the tip cartilages into exactly the shape we want rather than relying too much on older techniques that involve removal of strips of cartilage from the tip in order to make it smaller. The advantage of our approach is an extraordinary degree of reliability and predictability that can do away with potential problems like pinching of the tip, loss of tip support, and breathing issues.

One other consideration in evaluating bulbous tips is the need to address any other contributing factors. Many bulbous tips are not just wide — they are too prominent in all dimensions including being overprojected, or pointing out too far away from the face. Often, and especially in ethnic patients, the fatty tissue overlying the tip cartilage is also thick and needs to be dealt with if we hope to get the best possible result. The open technique is by far the superior approach for dealing with both of these issues because the cartilage and fatty tissue can be addressed directly as opposed to using indirect methods to deproject the tip that potentially weaken tip support. This allows us to create a tip that is symmetrical, smooth, and strong enough to hold up for a lifetime.

The patient below is shown before and 1 year after open rhinoplasty for refinement of a bulbous tip. Note how the boxy appearance has been transformed into a more triangular contour while remaining smooth and without looking pinched.

You often hear that it can take a year or longer after a nose job before you’ll see the final result. Many of you may be skeptical and a small number of you probably roll your eyes when you hear a statement like this. Does it really take that long to see results or are surgeons just telling you that so they can buy time in case you’re not seeing what you want to see after surgery?

The answer is that surgeons aren’t just feeding you a line. It really does take time for the skin to shrink down and wrap onto the new structure underneath. That’s not to say that you’ll be miserable for months. Our patients generally bound into the office for their 3 month visit ecstatic about their noses. Still, when we take photos, we can see that there is still some swelling that needs to settle so that more definition can show through. The photos below are a perfect example of just how much your nose changes over the first year after rhinoplasty. In cases of revision rhinoplasty, thick skin, or when the nose has been deprojected or brought in significantly, this process happens even more gradually.

Looking at these photos, you can understand why we tell our patients that it matters far more to us how their noses look at 1, 2, or 10 years after surgery than it does at 2 weeks after surgery. At 2 weeks, your nose will look good but puffy. If a surgeon is showing you photos that look absolutely perfect 2 weeks after surgery, be very wary. You can bet that those same perfectly cute noses at 2 weeks will probably look scooped and overdone at 2 years once the skin contracts. It’s important to make sure your prospective surgeon is showing you long-term results.  

The young woman below underwent primary open septorhinoplasty with us at Profiles Surgery Center. Photos below (from left) show her pre-op, at 3 months, and 1 year after her surgery. Note how her 3-month photos still show some fullness and rounding while at 1 year we see a lot more definition.

Fat transfer has become more and more popular in the last decade  for restoring facial volume lost to aging and even as an alternative to breast implants. And why not? Fat is plentiful, easy to harvest, and it’s your own tissue so no need to worry about a reaction. And it works (well, mostly). The problem that has hampered fat transplantation from becoming universally accepted as the ideal volume procedure is that it can be hard to predict how much of it and how well it will last. That’s because the fat is being separated from its natural blood supply, is then transferred to a new area of the body, and is expected to develop a new blood supply that will allow it to survive. Sadly, not all of the transferred fat makes it.

In an effort to improve predictability of results, surgeons have tried all kinds of things to enhance extraction, handling, processing, and reinjection of the harvested fat. Still, even, with these precautions, about half of the fat that is transferred has a meaningful long-term survival and that’s about as good as anyone can get with traditional fat transfer. Thankfully for most patients, half of the transferred fat does very well and we have almost never had to repeat the procedure. Still, it would be nice to be able to offer an even more robust and predictable enhancement. And, that is the promise of stem cells.

In the last few years, scientists have discovered that fat contains a type of stem cell known as adipose-derived regenerative cells (ADRCs). These cells have shown the ability to improve long-term fat graft retention by secreting key growth factors that enhance blood vessel formation and promote cell survival. Cytori Therapeutics, a leader in the area, has developed technology that can isolate and concentrate these stem cells into a so-called cell-enriched fat transfer procedure.

In the latest article published in the February issue of the Annals of Plastic Surgery, the study of this technology in mice revealed after 6- and 9-month intervals that not only was the quality of transferred fat cells improved but the quantity and retention of fat cells had increased two-fold over controls. There is always a trade-off of course and, in this case, the procedure is expected to add about 90 minutes to surgical times along with increased associated costs. But, if studies in humans can match the findings in animals, this could prove to be a very valuable innovation on the horizon. The medical device technology is currently available in Asia and Europe but not yet approved for clinical use in the USA. We’ll keep you posted on the latest updates.

The Hanging Columella or Notched Ala: Why you see so much of your columella and septum on profile and how we fix it
The Appearance of Retracted Nostrils or of  Too Much Visible Septum

If you are looking at this blog, you (or someone you hold dear) probably had a rhinoplasty (nose job) sometime in the past and now when you see yourself, especially on profile, all you see is that the middle part of your nose at the bottom (the columella and the septum behind it) is way too visible. Perhaps you have been thinking all this time that your septum shows way too much or that the middle part just seems to hang so low.  You may have seen your original surgeon who said you “healed badly” or you just figured it can’t really be fixed. And unfortunately, frequently this is a problem that even many surgeons find confusing.

So lets’ start at the beginning. Ideally, the distance on profile between the edge of the nostril and the bottom edge of the columella (the middle part of the bottom of your nose) should be no more than a few millimeters. Anything more creates a very unflattering look (some say it looks like a snarl). The main point is that we have to decide whether your septum is “hanging” too low (hanging columella) or your nostril(s) are “pulled” too far back (retracted ala, or alar notching). And making this even more complicated is that sometimes both problems are happening at the same time. Maintaining or re-establishing the integrity of this relationship is critical to ensuring a great new look that lasts over time.

Even in the revision setting, correction of nostril retraction and hanging columella can make a world of difference and result in a truly beautiful look

Something we hear often from women in their 30’s, 40’s and 50’s is the phrase, “More and more, I look in the mirror and I’m starting to see my mother; and I’m not ready for that!” Well, it’s official. If you think that you’re starting to see more and more of your Mom in the mirror, it’s because you probably are. A new study from researchers at Loma Linda University compared information using sophisticated 3D camera facial imaging techniques in 40 mother-daughter pairs and concluded that mothers and daughters appeared to share strikingly similar aging patterns. The earliest changes seen were volume loss leading to hollowing in the lower eyelid and cheek areas starting in the mid-30s and progressing throughout life. Something more to thank your mother for…

While looking like Mom is not a bad thing, those who aren’t quite ready can benefit from an array of anti-aging options available from good skin care to Botox and fillers to longer-lasting volume restoration with fat transfer. Ask us for more details.

LaRoche, the drugmaker responsible for Accutane, has been slapped with a $25 million judgment against it for inadequate labeling of its popular acne drug. This is the latest in a series of personal injury judgments against the embattled manufacturer blaming them for chronic ailments such as inflammatory bowel disease suffered after using the oral drug. While Accutane, or isotretinoin, was highly effective and often used as a last resort in treating patients with severe acne who failed to respond to other treatments, it also had significant potential side effects requiring frequent monitoring. In addition to being associated with birth defects, there were other serious effects that apparently were not spelled out clearly enough by the manufacturer according to these juries. Reportedly, Accutane has been unavailable from LaRoche as of last year.

This is yet another example of what we believe will be a backlash against drug manufacturers who today advertise directly to consumers day and night while paying little attention to properly educating them as patients. As for acne, all but the most severe sufferers can benefit from daily topical treatments that include exfoliants, topical retinoids (vitamin A derivatives), and other effective ingredients that do not carry the risk for these types of systemic side effects. See our post on JolieMD or our JolieMD site for more details on effective skincare.

Because our practice focuses heavily on rhinoplasty and revision rhinoplasty, we see many patients every week who are unhappy with their previous rhinoplasty result. One of the greatest sources of unhappiness is a poorly performed nostril reduction. Nostril reduction or narrowing is a relatively common procedure performed along with rhinoplasty and, done well, it often is a really nice finishing touch to a great nose job. See our blog of Dec 08 to get a sense of how we do alar base reduction differently.

Problems usually occur after nostril narrowing because of poor technique and especially overaggressive removal of nostril tissue. This can lead to the typically triangular, pinched, tethered nostril appearance, a dreaded look that should really never happen. We’ve also seen this problem occasionally after lip lifting procedures where tissue is removed from the bottom of the nostrils across the columella to try to pull up and show more of the upper lip. Sometimes, the lip is not lifted so much as the base of the nose is pulled down. We’ve blogged before about how to prevent nostril narrowing problems. But, what can you do if you’re already there?!?

The answers are unfortunately not simple nor perfect but, there is some promise of help in many cases. In our experience, there are a few reliable ways of getting some degree of improvement in this situation depending on the severity. If the problem is merely poor scars, this can be pretty readily treated with resurfacing techniques such as chemical peels, laser, or dermabrasion. If the problem is mild notching or tethering of  the nostril, this can sometimes be improved with what is called a V to Y advancement. See the diagram below to get a picture. Essentially, when the scar is revised, some tissue is ‘borrowed’ from the cheek/lip area where it meets the nostril edge in order to elevate the nostril attachment. The downside of this approach is that it leaves a vertical scar along the upper lip although every attempt is made to hide it in the natural crease in this area.

When the situation is more severe, there is no choice but to return some normal tissue to the area where too much nostril tissue has been lost. As shown in the diagram below, the nostril scar must be opened and some skin (usually taken from behind the ear or some other non-visible area) must be placed into the area to try to recreate the normal curvature of the nostril.

This can produce a very nice result but it does create some potential headaches of its own because of visible scars and possible skin color matching issues. Obviously, the absolute best result is achieved by getting it right the first time. If it’s your first rhinoplasty, don’t let posts like this discourage you…just find the right rhinoplasty specialist for your procedure.

As facial plastic surgeons working in Beverly Hills we were constantly seeing women of every ethnicity who presented unsatisfied with their skin, looking for answers.  And having spent a lot of time looking at all the various prescription and over-the-counter brands available, we genuinely felt that we could create a better skin care system.

So while creating a better skin care system we kept forefront in our minds:

1. It had to work- First and foremost, as doctors (and facial plastic surgeons) we researched  to find ingredients that had real science showing how they worked, what effect they had, and what concentration was required to make them work
2. It had to be simple to use- today’s women simply do not have the time for a 6 step process that takes 15 minutes in the morning and again at night
3. It had to address all women’s most pressing concerns- acne, wrinkles, red and brown spots
4. It had to be for women of all ethnicities- as facial plastic surgeons who are constantly working above and below the skin, we saw that women of different ethnicities have far more in common than most people believe. And there are too many women who are concerned that the available products “were not made for them.”  So we wanted to make sure people know that JolieMD was “made for you”
5. It had to be beautiful- We wanted to create a new style of doctor’s skin care- driven like plastic surgery with an eye toward everything aesthetic:  We wanted glamour, beauty, fashion. It had to look, smell and feel beautiful.

The result of this process is JolieMD’s Metamorphosis, our exclusive, new skincare line created for women of all ethnicities. Transformative in every way- it provides a simple method for brighter, healthier skin, without a prescription.

For more info www.joliemd.com

A new twin study published in the Archives of Dermatology last month has demonstrated the hazardous effects of environmental factors on skin aging. According to the  report, 65 pairs of twins were studied for differences in environmental and lifestyle factors that might contribute to wrinkles. The conclusion according to news sources is that these factors, such as smoking, sun exposure, and weight change may play a larger role in facial skin aging than does genetics.

While we clearly agree that sun exposure and smoking are huge factors in causing wrinkles, we have to point out a flaw with this study’s design. Of the 65 pairs of twins, 52 were fraternal twins sharing the same percentage of genes as do non-twin siblings. While fraternal twins share about half their genes, this is nothing close to the identical genetic make-up shared by identical twins. A really revealing result would be if identical twins with different levels of environmental exposure also showed different levels of skin aging. As is, this study is mostly a study of siblings– it can’t fully control for genetic factors and so it doesn’t really tell us anything new at all.

The bottom line is… you can’t change your genetics anyway no matter how big a role they play, at least not yet. The best thing you can still do to prevent poor skin aging is to avoid smoking and sun exposure. And you didn’t need a flawed study to tell you that.