Beverly Hills Rhinoplasty Surgery Blog

We’ve been doing a lot of lip augmentations lately with dermal fillers such as Restylane and Juvederm. It’s a popular procedure for women, young and not entirely young, to augment volume to thin lips or just to add a little bit of that pout to their look.

But, in the land of movie stars, some people take their cues from what they see the stars doing. Well, the stars should definitely not be setting the trends when it comes to lip augmentation. In fact, we wish so very much that they would stop. We won’t be cruel enough to point out these mistakes. You know who they are.

If you’re considering adding volume to your lips, consider these few pointers to get the best natural look:

1. Don’t ask for too much volume in the upper lip.

Many young women come in and tell us that they just want upper lip augmentation. They say “I don’t want you to do anything for my lower lip”. Most of the time, we advise against this because your upper lip should always be about 20% smaller than your lower lip. So, that proportion should be maintained. Isolated upper lip augmentation, if overdone, is probably the most common dead giveaway that someone’s had someone else near their lips with a needle. Check out the photos below to get an idea of what we’re talking about.

Below we see Liv Tyler on the left and Carla Bruni on the right. Many people think that both are beautiful women but, exotic Photoshopped image aside, Carla’s lips look naturally shapely and sensuous while Liv’s lips just look ‘top heavy’. What’s the difference?? Carla’s lips maintain the natural ratio mentioned above. Now, we’re not saying that either celebrity has had lip augmentation, we’re merely highlighting a point….

2. More is NOT Better.

A lot of people think that if a little enhancement is good, then a lot must be better…not the case. Overdoing it where lips are concerned is a sure way to have people talking about your new look, and not in a flattering light. Lip augmentation should be just that, an enhancement… a subtle addition to your feminized look, not the dominating force that overshadows all other features.

3. Technique matters.

Many people, including doctors (sadly), treat Botox and fillers like they are childs’ play. Yes, they’re minimally-invasive. But, that doesn’t mean that someone at the end of a syringe can’t mess things up just as much as someone at the end of a scalpel. A lot of doctors or nurses who’ve had filler training over a weekend treat lips and faces like they are all the same. A cookie cutter approach to lip augmentation is guaranteed to create an unnatural look just as it does for surgical procedures. A very experienced injector knows to work with what you’ve got. Some people need a little drop here but not there. The key is to sculpt your lips, not just balloon them out.

4.  Some areas need more help than others.

The area of the lips that benefit most from augmentation is the area in between the corner of the mouth and the philthrum (or the line where the upper lip begins to descend into that cute depression in the center that we call the “cupid’s bow”). Too much filler in the center of the lip gives a pulled down look. Too much filler near the corners of the upper lip gives the lip an unnatural overhang. Your upper lip should not hang over your lower lip. And the worst offender of all is filler placed mostly at the lip edge where it borders your skin. This gives the lips a ‘ducky’ look or ‘trout lip’ appearance where the lip is pulled too far forward. When your lips enter the room before you do, that is not a desirable look.

5. Be very careful about permanent lip enhancement.

A bad lip enhancement with a temporary filler is bad enough, but at least you know it will go away with time. But, a bad lip enhancement with a permanent filler or implant is a whole different story. There are a number of permanent options out there…permanent fillers such as Artefill or silicone and implants such as Alloderm or Goretex and other surgical procedures. Artefill can be an option, but you should recognize that these are off-label uses and long-term safety has not been proven completely. We’re not big fans of implants in the lips because they can give an artificial look and feel. So, be REALLY careful if you’re going to go this route. ALWAYS try a temporary filler first with the doctor you are considering to make sure you like the look and you’re both on the same page. And, even then you should go slowly because it’s almost impossible to go back.

These are just some of our thoughts on lips…

Plastic surgery, and rhinoplasty in particular, in Beverly Hills has become ever more concerned with aesthetic perfection. Unfortunately, rhinoplasty is a particularly demanding procedure that demands the most exacting attention to detail and technique if you want long term great results.

Finesse rhinoplasty is the name we give to the patient who needs or desires the most subtle of refinements. In some cases, these are the patients whose family or friends tell them that there is nothing wrong and that they should leave well enough alone. Many are very attractive and have good noses to begin with… but they wish to get even closer to their ideal.

You may wonder why operate at all, but for those of us who love this procedure, these are the cases that challenge us to be our very best, to pay heed to the most refined details… these are the ones that beckon us to be even better. Counter- intuitively, while small changes are sought, these are the most demanding cases because the window for improvement is likewise small. In other words, when you show up with a big bump, it’s pretty easy to get you a dramatically better result; it’s much harder to explain that to correct that little bump (bossae) at the tip of your nose permanently and safely, may necessitate a couple hours of surgery.

Jessica Biel is a spectacularly beautiful woman, but due to her thin skin you can see a number of irregularities in her nose in this picture

Often the patients wanting finesse rhinoplasty have a professional persona that demands that they look their best- models, actresses, entertainers. And most recently, we have had a number of very thin skinned patients (and we don’t mean metaphorically), who presented to us after having had surgery elsewhere. Unfortunately, they had been left with subtle but distinct tip asymmetries and bony irregularities.

Occasionally, in some instances we can recommend a non surgical nose job (see our blog on liquid rhinoplasty) in those patients with the minutest of surgical concerns. In these cases, the run is not worth the slide, ie the results achievable with surgery can be closely approximated by injection of a small amount of soft tissue filler such as Restylane, Juvederm, or Radiesse.

Unfortunately, when the irregularity is more pervasive, as was the case with these patients, we do not recommend fillers because they do not last long enough and have potential risks that we do not want to expose our patients to. In these cases, we found that after rasping (sandpapering) away as much of the irregularities as possible without bringing the bridge down, a thin layer of alloderm resulted in a fantastic cover for any minute palpable irregularities that we would otherwise be afraid could show years later in these very thin skinned patients.

Hope everyone had a great memorial day.

Very recently we saw an article saying that Aquamid just published new 5 year follow up on this new product and so far the results including patient satisfaction seem to be great.

For those who don’t know Aquamid is a polyacrylamide hydrogel- a facial augmentation filler that has been on the market in Europe and Australia for many years now.

We’re pretty excited about this product because we were one of a few centers around the country that were part of the FDA trial that has been ongoing for the last year.

We don’t know all the results from all the centers but so far it seems pretty exciting. I think we can tell you it injects about as easily as Juvederm but based on the European experience lasts for years with relatively few side effects and adverse outcomes. Of course, we’ll let you know when we are allowed to tell you more…

In the NY Times Magazine last week we came across these stunning pictures of Yasmine Warsame, a beautiful East African model from Somalia who grew up in Canada.

We looked her up since we had never seen her before and we came across her myspace site where she’s quoted as saying:

“I believe that ’Black beauty’ is understated and isn’t appreciated, so that’s what I want to represent in this modeling industry. I want to inspire young girls and women all around the world to follow their dreams, especially women of color.”

When Jennifer Hudson was featured on the cover of Vogue last year, a controversy arose because she was one of a small handful of black women ever to appear along on the cover.  It got us thinking about all of our ethnic patients who ask if we have expertise in ethnic rhinoplasty and facial plastic surgery. It’s a fair question, but one that requires a nuanced response. Yes, we do have expertise in working with a variety of ethnic patients…but truthfully, that’s less important than an understanding of aesthetics and anatomy in each individual.

No ethnic group can be pigeonholed into one group, though broad generalizations can be made (see our online book). You, your face and your nose are unique and individual to you, regardless of race or ethnicity.

So, getting back to black beauty – here are just a few of the beautiful black women who grace the landscape of our media world. You’ll note they’re all very different and yet stunning in their own way…

In the last two posts we have taken care of imaging for a poor rhinoplasty result to address problems with the nasal bridge. Now it’s time to take a look at the tip. A frequent problem after an overaggressive rhinoplasty is a tip that becomes distorted and lacking in support. This usually happens when too much of the tip cartilages are removed in trying to narrow and refine the tip. Instead, you just end up with a tip that is unstable. We have lumped these 3 problems together because they often occur together after a Rhinoplasty in which the tip cartilages collapsed.

The diagram below shows the area of the tip cartilages (in red) that is commonly removed during a rhinoplasty. This would be considered a reasonable amount in most patients depending on their skin thickness. The key of course is not to remove too much.

Many surgeons are very aggressive with these maneuvers and may take out most of this cartilage or slice right through it without repairing the edges. They do this because the short-term changes can be very dramatic. You can turn a wide boxy tip into a very narrow one. But, the long-term results are usually devastating as the tip becomes progressively pinched and distorted over years.

If too much cartilage is removed in this area, the tip can start to collapse. It can often look asymmetrical with formation of bossae or little deformities and bumps in the cartilage that show through the skin. Also, the tip can start to rotate up too much. This gives the nose an upturned and shortened “Ms. Piggy” appearance that is positively despised by everyone who is unfortunate enough to inherit this problem.

This problem can be exaggerated when surgeons also remove the nasal spine (the bone at the bottom of the tip) and the bottom part of the septum. To figure out which part of your nose we’re talking about, you can feel around just inside your nostrils. First, look around and make sure no one is looking. Now, if you pinch the skin between your nostrils and advance your finger and thumb back a bit, you will feel a firm but wiggly piece of cartilage that is the bottom part of the septum. Are your eyes watering yet?

Maintaining the integrity of this anatomy is critical to ensuring a good, strong result over time. If the above mistakes are made, the columella or structure separating the nostrils can appear to hang down too much, called a hanging columella. Also, the rim of the nostrils can appear pulled back or retracted. Ideally, the distance between the edge of the nostril and the bottom edge of the columella should be no more than a few millimeters. Anything more creates a very unflattering look that resembles a snarl. What’s worse is that breathing can also be affected. These problems can be fixed but it can take a lot of effort including complex cartilage grafting.

Take a look at the imaged photos below to see the final step in improving the appearance of this nose. The photo on the left has only the bridge imaged while the photo on the right also addresses the tip. You can see that the columella is pulled up, the nostril rim is pulled down, and the angle between the tip and the upper lip is better. Notice that the tip still projects outward by the same amount, but it looks so much less dominant and heavy when these problems are corrected.

So there you have it. We have illustrated a handful of the most common rhinoplasty mistakes and how we can fix them. There are a lot of sticky details that go into this, and a case such as this can take us many hours to perform.

The photos below show the original post-rhinoplasty picture on the left, the planned changes in the middle, and the imaged ideal result on the right. The green shaded areas are areas to be augmented or built up. The blue shaded areas are areas to be shaved down. This image has obviously been heavily doctored and we make it imperfect on purpose so that we don’t over-sell the possible results. But, you can at least get an idea of what needs to be done to bring this nose back into a balanced and harmonious state.

We hope this was a helpful exercise! Best of luck with your rhinoplasty and let us know if you have any questions or suggestions for future lessons….

So, what is a pollybeak deformity? Well, that’s the unpleasant and unkind name we give to a nose in which the area just above the tip is too full. Normally, there should be a little dip or depression just above your nasal tip that defines the transition from your bridge to your tip on profile. When that area is high or filled in, we call it a pollybeak.

When it is very full, it can even make the nose look down-turned like a parrot’s beak, thus the name. The reason for this is that the area above the tip often becomes the part of your nose that sticks out or projects the most from your face. This is not the way it should be. Your tip should be the most projecting point of your nose.

Check out the photo below to see a pollybeak deformity indicated by the arrows.

OK, what causes a pollybeak deformity?

Well, a few things can and they are all preventable. First, a surgeon may not reduce the cartilage enough in the area above your tip. Second, the surgeon may be overaggressive in reducing that area too much in someone with thick skin. In this case, the skin doesn’t contract and flatten out as much as it should and, instead, the area fills in with thick scar tissue. Finally, a surgeon may not provide enough support to your nasal tip. Over time, your tip may droop and make the area above the tip look too full.

Look below to see the plan for fixing this pollybeak deformity. The green area is the area of the bridge that was built up in the last blog post. The blue shaded area shows the cartilage that has to be shaved down to correct this appearance. Notice how the tip itself also has to be deprojected or brought in closer to the face.

See the two photos below for a simulation of this correction. On the left, only the pollybeak was taken down but the tip was not brought in so it looks too high and too pointy. This is not a good look but it is something we also see a lot after first-time rhinoplasty because tip correction is harder to do. On the right, you can see how much more balanced the tip looks now.

This is by no means a final image. Even the picture on the right doesn’t look right yet because we haven’t addressed the other problems with this nasal tip. It still looks pulled down and rounded and the nostrils have to be addressed. Tune in to our next post to see us pull together the final imaged picture.

In the last post we told you about how a rhinoplasty can go wrong. Now we’ll take you through each of the most common problems we see one step at a time and show what must be done to fix them.

A scooped out profile is probably one of the most common problems we see after rhinoplasty. It usually occurs after a typical reduction rhinoplasty when there was a bump on the bridge that was shaved down too much.

Below is a diagram of a nasal hump reduction.

This can happen for a few reasons. Many surgeons still prefer to make a bony bump smaller using a chisel or osteotome shown below on the left. We prefer nasal rasps, which are essentially fine files shown below on the right.

Osteotomes are sharp instruments that cut through the bone at a desired level to lower the hump. This is an all-or-nothing thing where the bump is removed in one shot. The problem is one of judgment and execution. Sometimes the angle isn’t right or the surgeon thinks he or she is taking down the bone to a certain level only to find out that he or she misjudged.

It can be even easier to make this mistake using a closed rhinoplasty approach (from inside the nostril) where this maneuver is being done under the cover of the nasal skin. In this case, you can’t exactly see what you’re doing, so most of the work is done by ‘feel’. It takes a lot of experience to develop that ‘touch’ and to consistently get it right. We prefer to use rasps to reduce a bump. These instruments can be used to slowly whittle or file down the bony bump. That way we can accomplish this three-dimensionally in a very careful and controlled way.

When the bone is reduced too much, the nasal profile will look scooped and the bridge will look washed out and child-like from the front view. To fix this, we need to build the bony bridge back up again, most often with your own cartilage.

See the photos below to show the area of bone that was over-reduced, and what the bony profile should look like.

Now remember, we haven’t addressed any of the other problems with this nose yet. Check out our upcoming posts to see us make this nose beautiful again one step at a time.

Since we focus a large part of our practice on rhinoplasty, we see a lot of patients who are unhappy with their previous rhinoplasty result and would love for us to fix it. So, a big percentage of the rhinoplasties we do are revisions or re-do procedures. Over the years, we’ve seen a lot of the same problems and complaints coming up, especially when it comes to rhinoplasties that were meant to make the nose smaller. Most of these problems are from technical errors that are preventable.

We thought we’d let you in on the 10 most frequent rhinoplasty problems we see and give you an explanation of why these happen. Check out the photo below to get a first-hand view of a rhinoplasty gone wrong.

You can call these the 10 deadly sins of rhinoplasty:

• bony over-reduction (scooped out bridge)
• pollybeak deformity
• tip knuckling (bossae) or asymmetry
• excessive rounding or shortening of the tip
• a hanging columella
• alar (nostril) retraction or flaring
• persistently over-projected tip
• nasal valve collapse (inverted V deformity)
• open roof deformity or bridge irregularities
• a crooked or twisted nose

These terms probably don’t mean much to you now, but we’ll try to give you a brief and easy-to-understand description of each of these in the posts that follow.

Many of the problems such as these encountered during a revision rhinoplasty can be fixed and your nose can be made to look a lot better. But, it is obviously far better to avoid them in the first place. It is so much harder to get a great result from a revision than to do it right the first time around. So, be sure to see a rhinoplasty expert for your new nose.

When you look at Juvederm and Restylane in detail, it’s a lot like trying to tease out differences between Obama and Clinton; in most instances they are pretty much the same.

Recently, a doctor who is an investigator for Juvederm published a report saying that she has found that patients preferred Juvederm and had longer lasting results than with Restylane.

In our own experience, we’ve found we prefer Juvederm slightly over Restylane in terms of ease of injection but we were a little dumbfounded by the report which said that the patients in the study had less pain during the injection and less bruising after when Juvederm was used. This really doesn’t make sense because pain and bruising really should be injector dependent and it may be as simple as the fact that these patients had previously been injected so they were not as anxious about the procedure- and therefore experienced less pain.

Moreover, it really was not a fair study because the patients in the study had all previously been injected with Restylane in the year or so preceding the study. Well why is that important?

1. Most of the hyaluronic acid- the filler in both Restylane and Juvederm- does go away with time but there may be some that remains even long term. This may explain why less Juvederm was needed when injecting the patients with Juvederm. It may also explain why the patients felt the Juvederm lasted longer.

2. When we see reports like this that were very likely funded by the makers of one of the fillers- in this case Juvederm (ie Allergan)- you wonder how the patients were instructed regarding the study and who was the judge of efficacy. Was it perhaps someone who may be influenced to prefer one more than another.

Anyways for what its worth we thought you should know our take on the issue. For those interested we have the link to the report on the study here.

And the better question is…does anybody really want to hear it? 

We chew on this daily. In Beverly Hills, the “plastic surgery capitol of the world,” patients are bombarded with advertisements, news stories and magazine articles telling them that this new procedure or that new laser can achieve Everything You Ever Wanted! in just ten minutes and with absolutely no down time.  If you hear it on ABC or read about it in US, it must be true, right?

Then we’re left trying to explain the full story you didn’t hear: sure, mini face lifts work, but the results simply won’t last that long. (Ten years?  Try two. Surveys show that, after a year, only 60% of patients are satisfied with their mini-lifts, and many require additional surgery.)  The “15 minute nose job”?  It hasn’t really been tested for safety, and you’ll be lucky if results last longer than six months. And if not done correctly, the “liquid facelift” can cause inflammatory reactions that then require steroid injections.

We tell patients, “Try to understand, it’s not that the procedure is bad or that the product doesn’t work.  It does…just not the way it’s advertised.”  When you promise miracles, disappointment is inevitable.

Great examples: the “Lifestyle Lift” or the “Insert plastic surgeon last name here” Lift.  Common perception holds that some or another plastic surgeon—often right here in Beverly Hills—revolutionized facelifts, and is now performing them under local anesthesia with “great!” results in just one hour.  The unsexy truth is that these procedures have been around for thirty years and are quite literally new in name only.  But why let a little thing like truth and reality spoil all the marketing fun? 

So there’s the rub.

(And PS: When one guy published testimonials from patients regarding poor results from one type of lift, he was sued.  Luckily, the courts just decided that the First Amendment was more important than lining somebody’s pockets.)