Sure, we can. Your situation is something that happens often after rhinoplasty and is one of the more common reasons that patients come to us for a revision. That’s because taking down a bony hump on your bridge is fairly straightforward. Techniques to make the nasal tip smaller are more advanced and many plastic surgeons are simply not comfortable with them. So, we frequently see people with persistent tip concerns after surgery elsewhere.

What you are asking for is referred to as a tip-plasty because the intended changes are only to the tip. That doesn’t necessarily mean that the procedure is less challenging but it will usually take a little less time than a rhinoplasty that also addresses additional concerns.

Your tip can be manipulated without affecting the rest of your nose. It sounds like you are looking for some deprojection of your tip to make it more refined and to bring it closer in to your face. We can do that in several ways, but the workhorse techniques for making these changes are called vertical dome division and lateral crural overlay.

The photos shown here demonstrate what a vertical dome division can do. The photo on the left is the Before view. The photo on the right shows a vertical dome division and overlap done on just the left tip cartilage. The right side was left untouched in this photo. If you compare the left to the right, you can see that the tip cartilage is shorter but retains its shape and contour. The overlapped edges are sewn together to maintain the strength of the tip. This is a powerful technique that can be used to reliably address a big or wide tip, a boxy tip, a droopy tip, a hanging tip, and any tip asymmetries or irregularities.

We won’t bore you with all the technical details. But, in both these techniques, the tip cartilages are made smaller by carefully cutting the cartilage, overlapping the edges, and suturing them together again. By doing that, the cartilage is made just as strong, if not stronger, so that the desired change will last for a lifetime without putting you at risk for collapse down the road. We choose which technique to use based on whether you also want your tip to be rotated up or down or other changes to be made. You can view the photos above to see how these techniques can decrease the size of your tip. Check out our Modern Rhinoplasty online textbook on our main site for more details.

If you see an experienced rhinoplasty surgeon, you should feel confident that your concern can be addressed in a very predictable and satisfying way.

As rhinoplasty surgeons and revision rhinoplasty experts, we often come across patients who’ve started asking about “non surgical nose jobs,” “injectible rhinoplasty,” or “liquid rhinoplasty.” As a result, we have done a lot of research and work in the area, and even asked some of the country’s other foremost experts in rhinoplasty what their thoughts are on this new phenomenon. What follows is our genuine attempt to give the best answers we can presently find with regards to this potentially new exciting area in facial plastic surgery.

In the last 10 years, facial plastic surgery and cosmetic surgery, in general, have seen explosive growth in minimally invasive and non surgical procedures. For most patients the reasons for this are simple: you do not have the time for recovery from surgery; traditional surgery may cost too much; non-surgical implies and is marketed as “no or little risk”; surgery is painful.

As a result, the various fillers have seen an enormous increase in their utilization. And today, we use these various fillers to achieve younger, more symmetric appearances not just by filling in wrinkles but also by restoring lost volume. More recently some of these fillers, which have only been approved by the FDA for use in the nasolabial fold, are increasingly being used for an ever wider array of “off- label” procedures including reshaping the jawline and chin, filling the cheeks, and more recently to reshape the nose- ie the “non- surgical” nose job, “liquid rhinoplasty,” and “injectible rhinoplasty.”

Some facial plastic surgeons use restylane for injection rhinoplasty

Let’s start by pointing out that the idea of injecting materials into the nose is not new even though there are plenty of doctors publicizing that they are the ones who started “injectible rhinoplasty or non-surgical rhinoplasty.” The truth is that the idea of injectable rhinoplasty for correcting nasal asymmetry can be traced back over a hundred years. And in that time a lot of different materials have been used- olive oil, goose grease, petroleum jelly, fat, paraffin, silicone, and others. Unfortunately, the results of these procedures were less than favorable and all of these materials have fallen out of favor due to their complications.

In the past plastic surgeons have used a variety of different fillers for non surgical rhinoplasty

Presently, there are many doctors starting to inject the nose with the newer dermal fillers- Restylane, Radiesse, Perlane, Juvederm, and even Artefill. However, the fact is that there have only been a few small studies published to date and only on a few of these materials. Moreover, these reports have largely been case reports and pilot studies using a small number of patients followed for short periods of time- generally less than a year. As a result, no one can say that injectible rhinoplasty, even with these new fillers, is absolutely safe.

Radiesse and Juvederm are other facial fillers used by some West Hollywood Facial Plastic Surgeons when doing liquid rhinoplasty

Traditional rhinoplasty done by a good rhinoplasty surgeon who specializes in the procedure can cost anywhere from $5000 to $10,000; yes there are surgeons who will charge $20000 for primary surgery but they are the outliers. If you’ve had previously surgery and need revision done by a revision rhinoplasty surgeon, this cost can vary depending on the complexity of the problem from as little as $2,000 for a very minor tweak to $25,000 for a total nasal reconstruction.

With injectible rhinoplasty, the costs are between $1000 to $2000 for each procedure; however, how long these results last is unknown but, in general, most doctors have found the result is less than one year. The permanent fillers may be different but at this time few doctors are willing to subject patients to the risks involved with permanent fillers, until more studies are available.

So one of the questions with liquid rhinoplasty is how much are you willing to pay knowing in time you will have to do it again and again?

Risks, Complications, and Recovery

All procedures have potential risks and complications. As revision rhinoplasty surgeons, we are very aware that rhinoplasty is an exacting procedure that really should be done by people who specialize in the field, and we take great care in explaining to all our patients the possible risks of anesthesia and surgery. As for pain, our patients tell us this is not an issue. It may be because of the way we do surgery and because we do not use splints and packing in the nose, but almost unanimously our patients tell us that outside of perhaps a pill or two for pain that first night, that they experience little more than a dull ache or discomfort.

For injection rhinoplasty, the issues of safety are still largely unknown, especially long term. On the positive side, there is no need for anesthesia and this is great for both recovery time as well as in obviously negating all the risks that generally come with general anesthesia. The problem with using fillers developed for the nasolabial folds in the nose is partially due to anatomy. In the laugh lines, cheek and jawline, the skin is thick and has a thick layer of tissue deep to the skin. As a result, we are able to inject below the skin and restore volume without causing skin irregularities.

The anatomy of nasal skin is different and therefore an expert in rhinoplasty who understands this anatomy is important when considering Non Surgical Nose Job

Nasal skin is very different, and varies not only in different ethnicities but even in the same person from one area of the nose to the next. As a result, though the non surgical rhinoplasty is marketed as a “lunch time” and “15 minute” rhinoplasty, the truth is that patients can and often do have swelling and redness that can last for weeks. It can also result in: 1) Skin irregularities- occasionally when injected superficially it results in little bumps of the filler; 2) Infection- many doctors have found that material injected into the nose can result in both short term infections as well as serious chronic infections; though rare, it has occurred; 3) Bruising and hematoma- just like surgery, anytime you get an injection it’s possible to get bruising; 4) Skin necrosis- this is probably one of the more serious problems but thankfully relatively rare; the skin overlying the injected area can simply die. This is a devastating problem because its repair can be very difficult.

Aesthetics- How the nose looks?

There are two major problems with the aesthetics of injectible rhinoplasty: almost by definition injectible rhinoplasty = augmentation rhinoplasty; those doing non surgical rhinoplasty are not necessarily trained in nasal anatomy or aesthetics

Injection rhinoplasty is like augmentation rhinoplasty and therefore can refine the nose, but you have to be wary so that your nose is not made to look too big

It is often said that if one has only a hammer, over time everything can begin to look like a nail. With injection rhinoplasty, not everyone is a good candidate. Most patients who come in to see us want to have smaller noses or more refined noses. For some patients, especially those with thick skin and certain ethnicities, that does occasionally mean that in order to refine the nose we actually have to put cartilage in to add definition or build the bridge. As a result some of these patients are good candidates for injection rhinoplasty if they do not want a nose job. However, for all the other patients who present with a bump, a twisted nose, tip problems or breathing issues- injection rhinoplasty is simply not the best answer.

As facial plastic surgeons we spend a lot of time studying and developing our aesthetic sense, especially in relation to rhinoplasty, “nose jobs.” However, as we write this paper, injection rhinoplasty is being done increasingly by many physicians who do not have any training in the aesthetics or in the anatomy of the nose and face. And unfortunately for patients, unlike with surgery where a certain level of expertise is expected by you before you trust your face to a surgeon, a procedure like injection rhinoplasty is being marketed as a simple procedure with little risk. As a result a variety of physicians and physician allied professionals who may not have any expertise in the anatomy and aesthetics of the nose are now injecting the nose with semi-permanent or permanent fillers which can and do occasionally cause an array of devastating complications.

Conclusions

More studies regarding injection rhinoplasty need to be done in order to determine what materials, if any, are safe long-term. At the present time, we would recommend that patients who are interested in injectible rhinoplasty see surgeons and doctors who have experience in both injectible rhinoplasty and in surgical rhinoplasty; and as with all elective procedures you should see more than one doctor before you decide.

Yes, it’s increasingly possible that they can. A group of graduate students and professors at Tel Aviv University have ‘taught’ a computer to judge facial beauty. The results were published in a recent edition of the journal Vision Research. In the experiment, 30 men and women were asked to rate the beauty and attractiveness of 100 similarly-aged Caucasian women on a scale of 1 to 7. The ratings were then fed into a computer and the subjects facial geometry was mathematically mapped.

The result??? In a fresh set of faces, the computer was in agreement with the human judges. So, while many of us think that Beauty is in the Eye of the Beholder, it is also apparently in the hard drive of your local PC. This study is more proof positive that there is a mathematical science to Beauty. Researchers from the same university have gone one step further and created a software program that can automatically beautify a face.

Now, a sense of aesthetics, on the other hand, is not something that we think you can easily teach. True, a computer may be able to morph a person’s image to make it appear more attractive based on a mathematical algorithm. But to take that same person and translate those desirable aesthetic changes to make them a reality is a much more difficult undertaking. When a computer can be taught to do that, it’ll be time for us to look for another career….in computers.

The complaint of a nostril that is “too wide” is a problem which we more frequently encounter among certain ethnic groups: African Americans, Asians, and some Hispanics. Alar base (“nostril narrowing”) surgery poses a unique set of difficulties, which should not be understated.

All too often many surgeons make it sound like, “No problem, we’ll just take a little wedge of tissue out from both nostrils.”

Unfortunately, external incisions can be noticeable, even when designed correctly. Most commonly, evidence of alar resection is noted as a teardrop or “Q” deformity in the base of the nostril. In others, the nasal base appears abnormal, as the smooth contour of the nostril has been interrupted (see Michael Jackson) or because resection has resulted in more marked asymmetry. Moreover, overresection can result in a narrow dysfunctional nostril opening that is difficult, if not impossible, to correct.

 Michael before surgery had relatively wide nostrils.

  When Michael first had rhinoplasty you see transition after alar base reduction to a smaller nostril size, but it still looked relatively normal.

 Michael Jackson after numerous revision rhinoplasties has ended up having very irregular nostrils, which are dead give away for having been “done”

In general, we employ alar base modifications in the context of an overall surgical plan and normally defer this portion of the case to the end of the surgery. No surgeon can determine preoperatively the exact location, shape, and amount of alar base alteration which is required because nostril size and shape as well as alar base width and flare (see our online textbook for more information regarding these definitions) are all affected by other modifications made during rhinoplasty. Specifically, increased tip projection (making the tip bigger), will often sharply reduce the alar flare and alar base width. On the other hand, retrodisplacement of the nasal tip (making the tip smaller) has, at least classically, been noted to create alar flaring as well as a rounded nostril.

So if you have wide nostrils, we recommend you view alar base surgery as a useful adjunctive measure that can be used to provide an additional measure of refinement. With this in mind, and in the right hands, alard base reduction can maximize the chances for a smooth, natural nostril contour with no discernible scar. When its overdone, or done incorrectly the results can be difficult to fix.

Recently a number of reports have come out regarding increasing calls for better regulation of plastic and “cosmetic” surgery in Ontario and the UK.  Believe us when we say that in general we are not big fans of socialized, heavily regulated medicine as it is practiced in Canada; which explains why my partner Dr Litner moved to sunny California. However, the proposed legislation seems to be directed at patient safety, and that is what government intervention should be about in our opinion.

In Ontario, as in the U.S., at the moment any medical doctor can advertise himself/herself as a “cosmetic surgeon”; even if they have had no formal surgical training.  The reason being that cosmetic surgeon is a made up concept; there is no specialty in cosmetic surgery. As a result, a growing number of “health care professionals” in Canada, especially family doctors, have been calling themselves “cosmetic surgeons” and carrying out such procedures as liposuctions and breast enlargements, even though they have had no surgical training. This may change due to the tragic outcome of a young lady who underwent liposuction by a “cosmetic surgeon” in Ontario a few months back.

The new proposed rules in Ontario prohibit untrained or uncertified doctors (who are not surgeons) from promoting themselves as surgeons - they will not be allowed to use the word ’surgeon’ in their title.  We think this is an important step toward patient safety, and perhaps it will help patients from having similar problems as Priscilla Presley (see blog yesterday).

The proposed changes would:
1. Prohibit doctors who are not formally certified as surgeons from advertising themselves as such.

2. Prohibit doctors from advertising themselves as practitioners of medical specializations if they have not been accredited for that (those) specialization(s).

The aim of the rule changes is to give Canadians better information so that they can then decide for themselves whether they would prefer to have “cosmetic surgery” with a surgeon or a doctor who is not a surgeon.  Unfortunately, here in California we have a governor who signed a bill only a year or two ago further deregulating plastic surgery so oral surgeons can do plastic surgery. Hopefully, with time we will see similar movement toward patient safety here in California.

 More about the UK tomorrow…

In general, we try really hard to stay away from gossipy blog topics but we thought this article in the LA Times to be kind of interesting.

In addressing the phenomenon of plastic surgery and its entrance into main stream society and pop culture, Ms McNamara, LATImes TV critic, notes that because television is a “visual art” she does not know how to address the issue of an actress whose “face seems incapable of movement or her eyes appear to be moving toward the sides of her head or her lips just look weird?” She then goes on to say, “Reviewing many of the new shows for the past fall season and midseason replacements, I noticed at least three fairly famous faces that looked decidedly, and distractingly, different, frozen or tugged into almost immobility that made certain emotional scenes almost laughable.”- We’d like to know who these people are because frankly we think the myth of the frozen face is much more common than the reality, especially in big name stars who can afford to go to those who do better work.

Ms McNamara ends by saying, “But when we see bad things happen to good faces, when cosmetic decisions interfere with performances, I think we need to speak out. Otherwise the younger generation will think that a fish-mouth smile and those shiny cheeks are normal and that the Posh Beckham look is something to aspire to.”

There is a lot to digest here because of the new accessibility of plastic surgery and the entrance of so varied a group of physicians into “cosmetic surgery.” The truth is that like most anything else the problem is not with plastic surgery but rather with the results when things are over done or not done correctly. Having a practice in Beverly Hills/ West Hollywood, we’ve learned that when we see our Botox patients that we really need to gauge the patients expectations, and the truth is that many people want to have a totally frozen forehead. As facial plastic surgeons we try always to educate our patients to say that a little bit of botox or fillers can sometimes go a long way toward achieving the desired goals, but occasionally we do find that patients really are not satisfied unless they have frozen muscles. Still worse, you may think that it’s the doctors fault that there are all these women with duck lips, and all too often it is because done correctly the lips can be fuller without being ducky; but sometimes patients, it seems, want people to know they had things done- natural is not enough for them. We don’t generally treat these patients whose aesthetic is too different from ours.

Priscilla Presley unfortunately had low grade silicone injected by an unlicensed surgeon.

However, to take the discussion and point to Priscilla Presley, who it appears was the unfortunate patient of a bad physician and to relegate those results onto plastic surgery in general is unfair. Even more, in speaking about “what normal looks like” it’s either funny or sad that Ms McNamara states that she worries that young people will think “that the Posh Beckham look is something to aspire to.”

We looked at a lot of pictures of Mrs Beckham, and while she has had breast augmentation, her face looks untouched since these pictures (she may have had rhinoplasty before). And while some may find her look a little too striking, we think that most people would love to look as glamorous and beautiful.

Posh Spice has had breast augmentation (and at some point she may have had rhinoplasty), but based on the picture above, other than weight loss and make up, we don’t see signs of surgery.

http://www.latimes.com/entertainment/news/tv/la-ca-plasticsurgery13apr13,0,7143847.story

From the Los Angeles Times

We came across an interesting and somewhat appalling article in The Times http://technology.timesonline.co.uk/tol/news/tech_and_web/the_web/article3613881.ece in the UK discussing a popular online game called Miss Bimbo. The game is targeted at girls aged 9 to 16. The premise is for girls to ‘maintain’ their virtual Bimbo characters by dieting and buying their characters fashionable clothing and even plastic surgery. The game was first introduced in France and has had over a million viewers there. In the first month since its introduction in the UK, it has attracted over 200,000 users.

Now, we have not seen the game so our comments are reserved for the concept in general. We are not big believers that these types of influences determine popular culture, but are more likely reflections of that culture. Everyone should be able to poke some fun at themselves and at our society. After all, it’s just a game. But, one can’t help but think that these kinds of interactions are not particularly healthy for the developing psyche. Adults are much better equipped to place these types of influences into context and to make conscientious choices about their bodies.

The fact that plastic surgery is so often lumped in with hairstyles and fashion trends has made it just another beauty accessory. This can be acceptable to a limited degree. But, when it is reduced to a being part of a game aimed at prepubescent girls, then we risk removing it from the realm of medicine altogether and tossing it into the world of entertainment. The rising trend for plastic surgery in teenagers is alarming. The next generation will surely benefit from the amazing advances occurring in our specialty, but we collectively would do well to remember that Botox is not a party and plastic surgery is not a game.

It’s getting harder and harder to see through the hype these days when talking about face lifts, what with all the marketing around thread lifts, contour lifts, S-lifts, J-lifts, mini-lifts, lunchtime lifts, etc. Everyone wants to take years off without going through a big procedure. We understand that desire. Besides, who has the time for a long recovery?

Well, the answer is you get what you bargained for. In our study on the operative results of different types of face lifts, we found that, at the time of surgery, Deep Plane face lift techniques obtained much greater lifts than Standard face lifts or Mini-type lifts.

What is a Deep Plane face lift, you ask?

It is a technique wherein not only sagging skin, but sagging fatty and muscle tissues are lifted as well over the cheek and jaw line. And it has about the same convalescence as a standard lift.

The trade off? Slightly higher, though still small, risk. But a risk that’s well worth it to many patients. If you’d like to know more about a Deep Plane face lift, give us a call or email.

In the last couple of weeks, we have seen several patients seeking revision augmentation rhinoplasty who have had silicone or medpor implants previously placed in the nose. These have become warped and displaced and are in need of revision.

Here at Profiles, we are fans of silicone rubber (silastic) implants for chin, cheek, and jaw augmentation. But, for the nose, we much prefer to use your own cartilage for augmentation, if available. Why is that?

There are several good reasons for this philosophy:

1. Chin, cheek, and jaw implants are ‘contour’ implants; that is, they are placed only to improve the overall contour of the cheek or jawline. Whereas, nasal implants must improve contour while also providing structure, definition, and support to the nasal bridge and tip. And, cartilage does a better job of that.

2. The skin, muscle, and fat covering the chin and cheek areas are quite thick whereas these same soft tissues overlying the nose are quite thin by comparison. One risk of a foreign implant is the possibility that it may place pressure on the nasal skin and further thin it over time, especially in the tip area, risking exposure of the implant. Also, in areas of thinner skin, implants can sometimes appear more visibly obvious. Again, cartilage is not a risk here.

3. Moreover, the chin and cheek skeleton is made up of a large continuous bony surface, areas that lend themselves well to coverage by a large solid implant. The nasal skeleton, on the other hand, is made up of an intricate group of cartilage structures that give the nose its unique surface appearance. For this reason, a single lump of silicone can look unnatural in the nose. Cartilage grafts can be tailored to more naturally reconstruct this elaborate topography.

4. Cartilage is desirable for other reasons, including a lower risk of infection and tissue rejection, since it is your own tissue. We also suture cartilage grafts in place so the risk of migration or displacement is minimized.

The end result? You have the best chance of getting a great rhinoplasty result that lasts for a lifetime. Read more about this and other rhinoplasty topics in our online Modern Rhinoplasty text.

There is a lot of talk these days about minimally-invasive facelifts of every kind. And each one seems to have a catchier name than the last; whether it’s the mini-lift, S-lift, J-lift, Weekend lift, Lunchtime lift, Executive lift, Lifestyle lift, Quicklift Md and the list goes on and on. Each of these lifts declares itself new, unique, and exciting, with outstanding results attainable at minimal risk. Very often they are accompanied by very impressive patient photos that seem almost too good to be true. But is the hype surrounding these lifts for real?

Well, the truth is that these lifts are not new nor are they very distinct. They are all variations on a theme. As Shakespeare said, “That which we call a rose by any other name…” holds true here. These lifts are actually well-entrenched in surgical history and are only recently being newly minted and repackaged for modern consumption. “Inventing” the next big (Insert name here) Lift has become something of a cottage industry in plastic surgery today. When, in fact, these procedures have been performed in nearly the same way for 30 years! They are all modifications of what is called a Short-flap facelift. This was originally popularized many years ago as a “tuck-up” procedure done commonly one to several years after a facelift in which only skin was removed.

Does aggressive marketing of the latest and greatest mini-lift make for great sound bites? Sure.

But, do they really work? Well, the answer depends on what you expect them to do for you. A recent consumer satisfaction survey by consumer plastic surgery review website Realself.com showed that only 49% of patients undergoing a Lifestyle Lift said it was “worth it” compared to 86% undergoing a more traditional facelift. The average procedure fee paid for the Lifestyle Lift was $4293 compared to $8284 for a traditional facelift. Now, this survey was not scientifically designed and is not a perfect way to evaluate the worth of a procedure.  We also found this link interesting,   http://www.infomercialscams.com/scams/lifestyle_lift_complaints

And as facial plastic surgeons we take the results seriously because there are lessons to be learned here.

Does this poor showing mean that this type of mini-lift is a bad procedure? Not at all. Again, it all depends on a patient’s expectations of the results. The problem lies not in the procedure but in the person at the end of the mouthpiece. Many articles, advertorials, newscasts, and websites promote “dramatic results” that are seen “immediately, before leaving the office” without the “trauma and downtime of extreme plastic surgery.” This is claimed to be the “complete opposite” of “the old way” where you “don’t look like yourself for months, even years.” But what exactly do these lifts do and just where does the hype end and the truth begin?

In this procedure, the skin in front of and just below the ear is lifted to a limited extent. The incisions are somewhat shorter than a traditional facelift in that they do not extend into the hairlines at the temple or behind the ear. The deeper layer of tissue under the skin called the SMAS may be tightened with one or two sutures. Finally, the excess skin is removed. All of these processes are performed more extensively in a traditional lift. Because the dissection is more limited here, the procedure offers several real benefits:

It is shorter in duration than a traditional lift

It is offered and can usually be done under local anesthesia with or without sedation

It has potentially fewer risks

It causes less tissue trauma resulting in a more rapid recovery

Because it can be accomplished more quickly, the fees are usually a fraction of a traditional lift

But, like everything in life, you get what you bargained for. No one should publicize nor should you believe that the results achievable are nearly as good as a more extensive lift. And the upsides in terms of recovery are often oversold. Yes, it’s true that the convalescent period may be shorter by a few days to a week with less swelling and bruising as a rule. But, are you doing this over your lunch break or dancing at your wedding the next day? Absolutely not! Remember, this is still surgery, no matter what you hear on the six-o’clock news.

And the downsides are just as real. In a recent study published by us, we found that, for the same patient, in the operating room, we could obtain twice the amount of lift with an extended facelift as compared to a mini-lift procedure (See our publications page for details or to read the article). So, for someone undergoing a mini-lift, this can mean:

The improvements may be less than expected or desired

The improvements may be shorter-lasting

There is still potential for complications

There is potential for resultant dissatisfaction

So, where should mini-facelifts fit in to the surgical spectrum for improvement of age-related facial changes? For us, this question is answered during our Imaging Consultation once we have gauged the degree of aging and skin laxity among other factors, and weighed these against your needs, desires, fears, and limitations. You may be a good candidate for a mini-lift if you:

Are younger with good skin elasticity and early signs of aging

Have cosmetic concerns limited to the jowl, jawline, and neck area

Would be happy enough with a reasonable, as opposed to optimal, cosmetic improvement

Have significant time restrictions or are extremely risk-averse

Have medical problems that would prohibit general anesthesia or a “bigger” procedure

Are older but have residual or new cosmetic concerns after a previous facelift

So, the final word is that, for the right patient with reasonable and clear expectations of what can be achieved, the mini-lift has the potential to be a highly satisfying procedure. But, if you’re being promised the moon for a song, you may want to consider looking elsewhere.