Beverly Hills Rhinoplasty Surgery Blog

Continuing from our last post, we want to show you another example of how closely computer imaged results compare to the final surgical rhinoplasty outcome. This young woman had undergone previous rhinoplasty that left her with a wide, unrefined tip from the front view and a pollybeak-type fullness above the tip on profile view. Our pre-op computer imaging (middle photos) showed tip and alar base narrowing and refinement along with creation of a straight profile, and this was readily accomplished with revision rhinoplasty surgery as can be seen in these one-year After photos on the right.

Computer imaging is extremely important in our practice in helping our patients to articulate their goals for rhinoplasty surgery and for us to be able to communicate effectively what can or cannot be accomplished with surgery. It is not just about drawing a picture of a good-looking nose. For us, it is about being able to show accurately how each proposed change in surgery will truly affect every other aspect of the nose. It is critical for us that we are honest, precise, and real in our imaging. For that reason, we do not over-image but, instead, image a change that we know we can deliver. As a result, we are not only comfortable sending our patients their images before surgery; we use these images as a vital tool to facilitate conversation during the final pre-op visit to make sure that we completely understand the desired aesthetic. And then, we do not deviate from this aesthetic during surgery.

We have compiled images of several patients that we will post over the next several blogs to give you an idea of just how closely the imaged result can predict the final outcome. In these images, you will see the Before Unimaged photo on the left, the Before Imaged photo in the middle and the one-year After photo on the right.

This patient suffered a severely twisted and collapsed nose resulting from prior surgery. The goal and result was achievement of a smooth, natural nose that corrected the scoop, over-projection, nostril retraction and hanging columella while restoring normal breathing. On a side note, the neck liposuction result was even better than predicted.

Please note: We are happy to see that our blog is of some help to many of you who are considering or recovering from rhinoplasty. While we would like to address your concerns directly, we are not able to dispense medical advice over the internet. Your own surgeon is your best resource in the first weeks and months after surgery. If, after 5-6 months, you continue to feel unhappy with your result, feel free to contact us via our practice site www.beverlyhillsprofiles.com and we can arrange time to discuss your concerns. All the best for a happy outcome.

How fast you heal after rhinoplasty is a major question on everyone’s mind, whether it’s your first surgery or a revision. No matter how careful or meticulous your surgeon, there will still be some swelling afterwards. Your nose will not look exactly like the computer-imaged ‘after’ picture as soon as the splint comes off. It will take some time for your skin to contract and ’shrink wrap’ down onto the new structure underneath to really give your nose a lot of definition. Of course, the goal is to get you feeling good about your nose as soon as possible and we do whatever we can to make sure that happens. We want you to skip the puffy stage and move straight on to liking your nose…really liking it. That’s why we are fans of asking patients to tape their noses at night after surgery and of using steroid medication, both during and after surgery, to speed up healing.

There are a number of studies that have supported the use of steroids in rhinoplasty to reduce swelling, bruising, and discomfort from surgery. We offer most of our patients a short course of oral steroids after surgery. When the splint comes off 6 days later, we find it makes the difference between “Wow! I love it already!” with steroids and “I can see it’s gonna be great but it’s puffy right now” without steroids. Beyond the first month, we find judicious use of steroid injections to be enormously helpful in reducing swelling in certain stubborn areas of the nose like just above the tip where the skin is thicker.

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.