Archive for February, 2008

Should I have an Open or Closed Rhinoplasty?

February 29th, 2008 | Category: Rhinoplasty Philosophy,Rhinoplasty Techniques

This is a question that is still a ‘hot button’ issue among surgeons who have very strong feelings one way or the other. But, the debate thankfully is not quite as big a deal today as it was once was. When rhinoplasty first became very popular in the last century, all of the work was done through the nostrils from the inside. The surgeon tunneled under the skin over the bridge of the nose and made alterations almost blindly. This is called a Closed Rhinoplasty because all of the incisions are enclosed inside the nose. It’s a bit like trying to carve a delicate glass figurine (the nasal cartilage) while working under a blanket (the skin). And, it’s still done almost the very same way today. There are variations where the surgeon makes a couple extra incisions inside your nose and ‘delivers’ the tip cartilages outside your nostril so he or she can see some of the changes being made. But, this procedure provides a slightly distorted view of the anatomy and, sometimes, it may hamper the surgeon’s ability to make precise changes. Read more

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How young is too young for rhinoplasty?

February 29th, 2008 | Category: Rhinoplasty Philosophy

We are often asked to perform rhinoplasty in young adolescents. Nasal surgery on children has long been a focus of discussion in the medical literature. As experts in rhinoplasty and nasal surgery, at Profiles we believe that discussion regarding nasal surgery in children has to be divided between functional surgery and cosmetic rhinoplasty.

When dealing with children with functional problems, surgery such as septoplasty can be done as early as necessary in order to restore nasal function and to prevent the consequences that may arise due to misplaced anatomic structures. In these patients, extra care must be taken to preserve as many structural supports and as much septal continuity as possible in order to insure normal nasal growth.

When considering cosmetic surgery of the nose, we generally believe surgery should be delayed until the nose is fully grown. This commonly means rhinoplasty can be done on girls when they have had their period for at least 2 years and in boys when they are at least 14 years old. Another good indicator of nasal growth is the patients’ height compared to their parents. If the patient is as tall as their tallest parent, then they are probably finished growing and so has their nose. Exceptions for younger children are made for those patients who have a significant anatomic deformity and a very strong desire for surgery to correct it.

The problem with operating on patients earlier than these target ages is that the nose may continue to grow in an unpredictable fashion. So, despite creating a balanced nose after the rhinoplasty, the continued nasal growth can distort the proportions that were created.

Finally and perhaps more important than the physical maturity, we also believe that all our adolescent patients must have the emotional maturity to deal with their surgery. It is very important that the patient himself/ herself is interested in having the surgery and that it is not only being done because the parent wants surgery.

With all of this said, we believe that the psychological benefit that rhinoplasty can afford during puberty, a very critical time in emotional development, is significant and should be considered for the right patients.

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I read your recent blog about rhinoplasty in African American patients but I have a problem with keloids and was wondering how big of a problem this will be if I do have rhinoplasty.

Your concerns are valid and it is important to discuss your history of poor scarring whenever you undergo any type of surgery. You should note however that different parts of the body will heal differently. The simple answer is that keloids rarely develop in the central face and we here at Profiles have never seen a keloid develop after we have done rhinoplasty.

A more in depth explanation begins with an explanation of scarring. First, we need to help you in understanding the difference between a hypertrophic scar and a keloid. Clinically, hypertrophic scars are enlarged scars that stabilize or shrink with time. Keloids, however, initially develop as hypertrophic scars but later extend beyond the original injury area. They rarely regress on their own and have a propensity for recurrence after excision.

Keloids may affect virtually any surface on the body with the central chest, deltoid/shoulder region, and back having the highest frequency. And this has led some doctors to speculate that motion and tension play a large role in causing keloids to develop. While this may be true to some extent, the earlobes, which are one of the most frequent sites affected, are obviously subject to minimal motion or tension forces.

photos Before and After Earlobe Keloid Scar Excision

photo Before and After Earlobe Keloid Scar Excision

This African American patient demonstrates a typical example of a large keloid scar of the earlobe that was removed in one session with flap reconstruction of the back of the ear. The After photo to the right shows her postoperative result over 6 months after the procedure.

All this being said, while you should explore this issue with your doctor before surgery, you should feel some comfort in knowing that the nose is rarely a site for keloid development after rhinoplasty or nasal surgery. In fact, we did a literature review to check on your answer and were unable to find any papers which could point to a case of a keloid after rhinoplasty.

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I am considering rhinoplasty, but have heard that rhinoplasty often causes trouble breathing afterwards. Is this true?

February 25th, 2008 | Category: Breathing problems

The short answer is no.

The typical rhinoplasty done in the 1980’s or even 1990’s relied heavily on reduction of prominent cartilage and bone to achieve a more refined look. Knowledge of the long-term effects of such techniques was spotty and, so, many unfortunate patients were left with the trademark ‘operated’ appearance of a pinched, droopy, or distorted tip, and scooped-out nasal bridge.

These occurred because the newly-weakened structural elements of the nose could no longer provide the necessary support, often leading to breathing trouble. The forces of healing are dynamic and often operate for several years before these outcomes are evident. So, a postoperative result may look great immediately after surgery, yet evolve into a dismal failure over time. Likewise, collapse of the nose’s structural supports will compromise the basic function of the nose, namely breathing.

Modern thoughts on rhinoplasty take a much more conservationist approach. As much as possible, reshaping and contouring are achieved with suture and graft techniques that will usually leave the nose ‘stronger’ than it was preoperatively. While many surgeons think of nasal breathing more as an afterthought, those who have an interest and experience in rhinoplasty will assign as much importance to nasal function as to aesthetics. The result, at Profiles Beverly Hills, is that once short-term swelling is resolved, your breathing should be as good or better than before and the changes to your nose should remain ‘stable’ for a lifetime.

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I had surgery with another surgeon and am not happy with my Rhinoplasty result after 1 month. What should I do? Can you help?

February 25th, 2008 | Category: Revision Rhinoplasty,Rhinoplasty Recovery

First and foremost, do not panic.

Early changes after Rhinoplasty are influenced by swelling and do not necessarily reflect the end result nor what was done during your operation. Trust your instincts and talk to your doctor about your concerns. There may be a perfectly good explanation for what you’re seeing. Sometimes, reassurance is all that is needed.

Once the cast comes off your nose, the natural tendency is to stare in the mirror for far too long- looking for the smallest of changes. This is precisely the most harmful thing to do because it will not change your healing and will only make you more nervous.

You will find that you are more swollen in the morning, when you are more active, or after lying down for long periods of time. This is because blood and fluid pools in the area of your nose and cheeks. Aside from that, healing happens in drips and drabs. You may not notice any changes for a few days, and then suddenly see a big reduction in swelling. There is a range of ‘normal’ healing. Don’t be alarmed if you are on the edge of that range. Your surgeon should let you know if anything unexpected is happening. If you are still unhappy at six months or a year, it may be time to talk about your options for improvement.

Your original surgeon is still the best place to start with this conversation, if he or she still has your trust. If not, consult a surgeon who has an experienced practice in Revision Rhinoplasty to see if this is a good option for you.

If you have any questions, please feel free to give us a call or send an email.

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I have trouble breathing through my nose but my doctor says my nose looks normal. What should I do?

February 23rd, 2008 | Category: Breathing problems,Revision Rhinoplasty

Nasal obstruction is a complicated issue that is all too often ignored or attributed to “allergies,” “sinuses,” or to a “deviated septum.” Here at Profiles we often have patients who present to us who have been previously evaluated by other physicians who were unable to determine the cause of nasal obstruction.

We always begin by explaining that it is important to understand that nasal obstruction is a subjective sensation and that it occasionally does not correlate with anatomic problems. In other words, some people can have a slightly deviated septum and complain profusely of their difficulty breathing, while other people are completely obstructed on one side of the nose without ever even realizing they have a problem. So if you have trouble breathing through your nose, it is important to let us do a thorough evaluation.

It is true that oftentimes nasal obstruction is due to:

1. A Deviated Septum- where the midline cartilage and/or bone that separates the two sides of your nose is crooked

2. Nasal Allergies- whether seasonal or year-round.

3. “Sinus Problems”- This diagnosis is unfortunately all too commonly applied to patients without proper evaluation.

Nasal obstruction is a complex problem and there are numerous possible explanations with even more possible solutions. We recognize how nagging this problem can be and we understand how complex the solution is. The important thing for you is to find the doctor who will take the time to find out what your source of obstruction is and more importantly knows how to correct this problem.

For further info we recommend you go to our Modern Rhinoplasty online book and read further on Functional Rhinoplasty.

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How is Rhinoplasty in Hispanic patients different than in other patients?

February 22nd, 2008 | Category: Ethnic Rhinoplasty,Rhinoplasty Techniques

As would be expected with any ethnic population, we have found that there is a continuum of nasal features in our Hispanic population, rather than distinct types. Rather than trying to categorize various subgroups, here at Profiles we focus on your individual characteristics and your goals.

In general, we have found that our Hispanic patients’ facial and nasal characteristics can be differentiated from our Caucasian patients in the following ways:

(1) Broader faces, commonly with prominent cheek bones and a relatively small nose

(2) A slightly small chin(3) A nasal hump(5) Wider nostrils (6) Wider and lower nasal bridge

(7) Moderately thick, sebaceous skin

So what does this mean to you?

It means that it is important for you to work with surgeons who will take the time to understand what you are trying to achieve and who are comfortable in dealing with different ethnic populations. We take these differences in anatomic and structural components into consideration in planning your surgery and in explaining to you, what can be accomplished with your surgery. During your consultation we will work together to define what your goals are using computer imaging. Based on your desires and your individual anatomy, we will then devise a surgical plan which is best suited to achieve your individual goals.

For further info we recommend you go to our Modern Rhinoplasty online book and read further on Hispanic Rhinoplasty.

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Why does my skin thickness matter?

Skin quality and thickness is one of the most important factors in determining your final Rhinoplasty result. And it can also be one of the hardest to predict. When we perform Rhinoplasty, most of what we do involves altering the cartilage and bone that makes up the nasal skeleton. We shape the cartilage and bone in many ways to take on the new desired contour. During the healing period for many months after surgery, the skin and soft tissue that lays over this skeleton must contract inwards and ‘shrink wrap’ onto this altered framework for the desired changes to become noticeable. That’s why you don’t see real definition for weeks to months after surgery while the skin and soft tissue is swollen.

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Why do some surgeons seem to do the same nose for everyone?

February 20th, 2008 | Category: Rhinoplasty Philosophy,Rhinoplasty Techniques

That’s a good question that doesn’t have a very good answer. Some surgeons in certain geographic areas will tend to attract a more homogeneous group of patients with similar features who may desire similar types of results. But, in a multiethnic large city, you shouldn’t be able to pass someone on the street and say to yourself, “Hey, that’s a Dr. Smith nose.” Ideally, you shouldn’t recognize a good rhinoplasty result at all.

The most common cause for this finding is that many surgeons train in and are comfortable with specific Rhinoplasty techniques. As a result, they may not vary their technique substantially from patient to patient. It’s not so much a formula. But, many have honed their skills within a particular zone of comfort and they feel that this skill set has worked for them in their practices. Sometimes it’s not a surgeon’s technique but a surgeon’s aesthetic standards that are at cause. Some surgeons have very strongly felt and unwavering ideas of what constitutes an ideal nose and they may indirectly impose these on their patients.

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Is it possible to ask too many questions before surgery?

February 18th, 2008 | Category: Rhinoplasty Philosophy

Have you ever noticed that when you ask a person regarding something they have a passion for, they will never tire in answering your questions? You almost will find a gleam in their eyes to show you why they have a passion for the subject. Well, at Profiles, Rhinoplasty and Revision Rhinoplasty are our passions.

We often have patients who have had a previous rhinoplasty or who have friends who have had rhinoplasty with less than ideal results. And many, if not all of our patients, have understandable concerns and are very good about doing their due diligence before proceeding with rhinoplasty.

At Profiles, we encourage our patients to ask any and all questions they have regarding their surgery and we take a great deal of time in the preoperative consultations in trying to assess your concerns and in helping you understand what the plan is. Because rhinoplasty and revision rhinoplasty are often elective procedures, we feel it is even more important that our patients feel comfortable with us and with the surgery we are suggesting.

During our consultations we take and utilize your photographs to show you and to learn from you what the problem areas are that should be addressed. We then take the next step of using our state of the art computer imaging to give you an accurate idea of what changes we can effect with rhinoplasty. The process is detailed but we truly feel that when our patients are educated as to what we are able to do and when they understand what limitations their anatomy presents, our patients have real expectations that we know we can meet, and together we are able to achieve the goals they are seeking with rhinoplasty.

Moreover, here on our blog as well as on our website (www.beverlyhillsprofiles.com) , you will find an extensive data base including a complete textbook written for you our patients (Modern Rhinoplasty). We encourage our patients to read as much as they want before their consultation but we go even further by providing you printed answers to all the most frequently asked questions regarding your rhinoplasty, including your preoperative and postoperative instructions as well as all the risks and benefits associated with surgery. We then will even suggest further specific pages in the online textbook to read for issues that specifically affect you and your surgery. And then we make a second visit before your surgery so that you can go and read as much as you want and so you can look at your images, so that during your second consult we can address any new or further concerns you have.

We welcome you to experience the difference. And we will do all we can to show you why we are dedicated to being the rhinoplasty and revision rhinoplasty experts.

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