You may remember back in May we began reviewing the 10 most common rhinoplasty mistakes that we see in our revision rhinoplasty practice here at Profiles. You can also see these and other details at our dedicated rhinoplasty site. We wanted to share with you how this patient’s revision rhinoplasty is turning out so far.

The photos below show the original before revision rhinoplasty photo on the left, the imaged result in the middle, and our real patient’s actual post-operative after photo on the right after Revision Rhinoplasty by the Beverly Hills Rhinoplasty experts at Profiles. We make the imaged photo 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 profile back into a balanced and harmonious state. We can’t make the surgical result match the imaged result perfectly but we can get pretty close. And we hope you’ll agree that we were able to accomplish our goals. There is still some swelling in the 3-month after photo at this stage and we expect it to settle over the next few months. The patient was ecstatic with the result and thinks her new nose looks even better than the imaged version. And that couldn’t make us any happier!

 For more information on what we can do to give you the nose you want, feel free to contact us or send us your photos.

A  few months back we posted a blog titled:

Why is the NY Times promoting off label usage of Fillers for the

Treatment of Dark Eye Circles?

In the blog we ruminated that while they noted the off label nature of this treatment, we thought that they understated the number of problems encountered by patients who have undergone this treatment.

A few things we noted included the lumpiness some patients had encountered as well as some patients complaining about a blue hue after being injected. This blue hue arises due to the Tyndall effect which is the blue light we notice when light is scattered by a colloidal particle.  The same phenomenon explains why the sky is blue and why our veins appear blue even though we all know our blood is red.

As to problems with lumpiness,  we noted that due to the thinner skin overlying the eyelids patients were much more prone to have problems with fillers under the eyes as opposed to in the nasolabial folds and cheeks.

So we lamented that unfortunately the number of people who read our blog would be far less than those who read the NY Times article and go running to whichever doctor they could find seeking this “cure” for under eye circles.

Thankfully we noted that this last week Ms Natasha Singer  posted a new article-Questions on Using Fillers Near Eyes. In the article she not only expounds on the off label nature of these uses but the growing number of patients having problems with these injections.

We want to be clear that doctors use medicine off label all the time. Most antibiotics get approved to treat one problem- say sinus infections- and then get used for other needs. So off label by itself is not the problem. We believe that the skin around the eyes by its very nature is more fragile and thinner and as a result, in less experienced hands injections can cause problems like lumpiness. We believe that doctors should be more clear in the potential problems. However, the quote by a doctor saying any injection can cause blindness is also unfair. It is technically true, but its like saying anyone crossing the street can be hit by a car.

Our next blog will be on our use of fat for under the eyes and the concertina effect.

The final problem we will talk about is the twisted nose. A twist in the nose can happen anywhere from the nasal bones to the middle third of the nose and down to the tip. Getting a nose completely and perfectly straight is one of the hardest things to do in Rhinoplasty and is especially hard in revision Rhinoplasty.  That’s why you need to see a very experienced Rhinoplasty expert like the Los Angeles Rhinoplasty surgeons at Profiles.

A frequent cause for a twisted nose is crooked nasal bones. This can result when a pre-existing crooked bridge simply was not corrected appropriately or when poorly performed osteotomies caused the bones to shift. Osteotomies, as mentioned in a previous post, are one of the most underrated parts of this complicated procedure by inexperienced surgeons who get caught with some of these post-rhinoplasty problems. Very careful planning and execution of each and every maneuver can go a long way to preventing these problems.If the cartilage of the mid-nose or tip is twisted, sometimes it can be corrected by re-suspending or stabilizing the cartilage with sutures. This includes repairing the normal connections between anatomical parts that have often been lost with prior surgery.  

More often than not, we find during revision Rhinoplasty that many of these normal structures have been damaged or removed, causing the lower part of the nose to buckle and warp. Sadly, this is often beyond simple repair. In these cases, grafts of cartilage taken from your septum (if available), your ear, or rarely your rib, are needed to rebuild the lost tissues and reconfigure their normal connections and supports.

The patient shown above needed six different cartilage grafts to rebuild her nose to improve breathing and to restore a secure and appealing aesthetic. The important thing for you to understand is that no matter how bad your perceived concerns are, the Rhinoplasty experts at Profiles can help.

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 cases such as these can take us many hours to perform. But, we take as much time as we need to get it just right because our overarching goal is that your first Rhinoplasty with us should also be your last!If you’ve thought about a Rhinoplasty or Revision Rhinoplasty, we would love to see you in consultation, or feel free to send us your own pictures or questions so we can begin working on getting you the beautiful face and nose you have always wanted.

The nasal bones are not so much like a pyramid but more like an arched covered bridge or tunnel. When a bump is made smaller, the top of the bones are shaved or cut shorter to reduce the bump. This leaves an opening in the roof of the tunnel. That’s one of the reasons why we have to cut the base of the bones during surgery (called osteotomies). We perform osteotomies in order to push the bones inward towards each other so that this opening can be closed.

If the opening is not closed properly, we call the resulting problem an ‘open roof’ deformity. The photos below give you a sense of what this problem looks like. When you have an open roof, the middle part of the bridge will look and feel unnaturally flat. The edges of the bones are separated and can be seen and felt as a prominent bump at the side edge of the bridge.  

In the above photos, you can see how shaving down a bump on the bridge creates an ‘open roof’ deformity, shown here in purple. If this is not closed, the result is an unnaturally flat and irregular bridge shown by the arrows on the right.

Dr. Solieman and Dr. Litner have extensive experience correcting these and many other Rhinoplasty deformities. To repair an ‘open roof’ deformity, the bones need to be brought back together again. Sometimes, the bones have been so shortened and whittled away that it is impossible to bring them together without pinching the top of the nose completely. In this situation, it is necessary to rebuild the roof with grafts. Whatever the extent of your Rhinoplasty concerns, the Profiles surgeons are well-versed at tailoring your procedure to address your individual issues.Check out our site dedicated to rhinoplasty to learn more about your options for rhinoplasty revision.

The nasal valve is a term used to describe the narrowest part of the nose internally. This is the area that determines if someone feels normal or obstructed breathing through the nose. When this area is overly narrowed and blocked, we call it nasal valve collapse.

There really are two types of nasal valve collapse. The collapse of the tip cartilages described above can cause external valve collapse where the blockage is just past the nostril. When most surgeons discuss valve collapse, though, they are talking about internal valve collapse. This occurs when the upper lateral cartilages in the middle of the nose have been too narrowed. Check out the attached diagram to see where these are. This problem happens when a nasal bump is taken down too much and when the cartilages themselves are shortened or not reattached during a Rhinoplasty.

   Above left, you see normal nasal anatomy with the nasal bones in grey, the upper lateral cartilages in pink and the tip cartilages in white at the bottom of the photo. The center photo shows a common finding after a poorly done Rhinoplasty in which these structures have been aggressively reduced and separated. The resulting changes are seen on the right. The arrows indicated the collapse of the upper lateral cartilages as they fall inwards and affect breathing.  The problem seems to occur more often after a closed Rhinoplasty because most surgeons detach these cartilages without repairing and reattaching them at the end of the procedure. When the natural cartilage supports have been lost, they simply fall inwards and collapse.

The result is poor breathing and two visible cosmetic deformities. One is called an ‘inverted V deformity’. That’s because the collapsed area where these cartilages attach to the nasal bones looks like an upside-down letter V. Check out the photos below to see an ‘inverted V deformity’. The second problem is that the middle part of the bridge can start to look very pinched.

Here we see the full view of the same nose from the front. The photo on the right shows the ‘inverted V’ deformity caused by collapse of the upper lateral cartilages. Scroll forward to the last photo to see how we fixed this Rhinoplasty mistake.

This is a common problem after Rhinoplasty and the revision Rhinoplasty experts at Profiles Beverly Hills fix it using extended spreader grafts among other techniques. Click here to see our blog on the use of spreader grafts. In the last section, we took care of this patient’s tip abnormalities. Next, we turn our attention to the upper two thirds of the nose to correct her remaining problems.

Think of the tip cartilages like a pair of wings. You can get an idea of what these look like from the photos below. The tip cartilages (lower lateral cartrilages) are like a bent spring that holds the nostril’s shape and keeps it open to allow normal breathing. In many poorly done rhinoplasties, this cartilage is aggressively cut or removed so that it loses this natural spring. Over time, whatever cartilage is left starts to bend and twist under the weight of the skin. As the cartilage twists on itself, the weak points at the ‘joints’ of this cartilage can start to form bumps or knuckles, called bossae, that are very noticeable through the skin. Check out the diagram below to see what we mean.

In the photos above, you can see normal anatomy of the tip cartilages on the left. The center photo shows the weakened and twisted cartilages commonly found after over-aggressive cartilage removal. The corresponding bumps (bossae) seen on the surface are shown by the arrows on the right.

Many surgeons treat these bossae by going back and trimming them, weakening the cartilage even more. Anyone can appreciate that this is probably not a good long-term solution. The Beverly Hills Rhinoplasty experts at Profiles know that the tip cartilages must be reconstructed in order to restore their natural strength and resiliency while improving on the cosmetic appearance of the tip. The photos below show the above Revision Rhinoplasty patient treated at Profiles to take care of her tip bossae and other post-rhinoplasty concerns highlighted in the next few sections.

Above is shown a before and after photo of a Profiles Revision Rhinoplasty to treat a twisted tip with tip bossae.

Seeing red? Feeling blue? Now that the election is over, let’s all come together and reunite! Whatever your politics, the one thing we can all agree on is beauty…and if it’s affordable, even better!

So, just because the economy is on a roller-coaster doesn’t mean your skin should suffer. Between now and January 1st, we’re offering our friends the revolutionary skin smoothing Vi Peel for 50% off…a $300 value for only $150.

To see before and after photos, check out our own Nadine’s blog. She swears by the results and is finally able to go without makeup!

http://jolienadine.com/blog/2008/07/22/vi-peel-before-and-after-photosand-videos/#comment-7927

We love how the Vi Peel gets rid of pigmentation, acne marks and fine lines, and it’s the first peel that works on *any* skintone, even African-American complexions. Give us a call at 310-276-6800 to set up your appointment.

– Profiles Beverly Hills

Source: jolienadine.com
Et voila! You asked for my Vi Peel photos, and here they are. On the left is the “before” photo, taken six weeks ago. On the right is the “after” photo, taken this afternoon. …

Now that the hangover from the election is finally over, we wanted to announce the introduction of our two new dedicated websites. As you know our main site facial plastic surgery site is www.beverlyhillsprofiles.com. Here you can read about all the details of the gamut of procedures that we perform, read about us, as well as contact us regarding consults and questions.

Since you are reading this, you are aware that as rhinoplasty and revision rhinoplasty experts, we frequently blog at www.rhinoplastyinbeverlyhills.com. However, as facial plastic surgeons we like to cover the range of issues and questions that our patients ask us about regarding facial rejuvenation- face lifts, brow lifts, eyelid lifts, fillers- juvederm, restylane, Elevess, as well as peels like the blue peel and Vi peels, etc.

Because so many patients look to us as the Los Angeles rhinoplasty experts as well as the originators of the new Hybrid Facelift procedure we have now developed two more dedicated sites that will focus on these two focuses. The first is

www.beverlyhills-rhinoplasty.net

Here we focus on the major niche of our practice and our passion- rhinoplasty and revision rhinoplasty, including all the various things that you should know before you undergo rhinoplasty as well as all the things we can correct for those who are looking for BeverlyHills expert revision rhinoplasty surgeons.

The next site is our dedicated facelift site which focuses on our innovative trademarked procedure the Hybrid Facelift. Since our development of this procedure and our appearance on the Insider, we have had an enormous turnout of people wanting to know what the Hybrid Lift is exactly, how it differs from the traditional facelift, and if it is better for them than the so- called mini lifts.  We developed the site to clearly delineate for you why the Hybrid Lift is the final evolution  of facial rejuvenation and why we perform it is more cost effective than having repeated filler procedures. This information as well as continual updates of patient’s before and after photographs can all be found here:

www.beverlyhills-facelift.net

We thank all of you for your support and welcome suggestions regarding what you want to see and hear about.

This morning as we were reading through some new editorials, we came across this article from today’s Washington Post which addressed what we blogged about yesterday, namely how fillers are used and whether they increase collagen production.

The paper’s dermatologist, Dr. Herschenfeld says “that Sculptra and Radiesse, which stimulate the body’s natural ability to form collagen, can be used to fill hollows under the eyes, to rebuild cheekbones, fill in sunken temples and even smooth the jawline. ‘Although they cannot tighten skin the way surgery can, they can produce striking improvements in appearance without cutting, stitching, scarring and all the down time that comes with a facelift.’”

We agree that volume enhancement is an essential part of facial rejuvenation, and it is one of the main reasons we have developed the Hybrid Facelift (more on HybridLift here). However, we found two things compelling about the article:

1. It is interesting to note that major newspapers report the utilization of fillers for off- label uses like filling in the hollows under the eyes without any disclaimers, and
2.  Perhaps more interestingly, a new study in the Archives of Facial Plastic Surgery looking at Radiesse concluded “We found no evidence of new collagen formation 1, 6, or 18 months after injection.”

Granted the study numbers in both papers are small. However, the utilization of the Radiesse in this more recent study was much more in line with how most practitioners use fillers. As we blogged yesterday, the study most people site in speaking about new collagen production (Archives of Dermatology) utilized an entire syringe of Restylane per area of the forearm injected. We suspect, as the original authors concluded, that when this much filler is injected into one small area of forearm skin, the skin is put under tremendous stretch, much like the case of tissue expanders, and responds by producing new collagen. Perhaps this accounts for the discrepancy between the two papers. We think the second paper is more accurate because it reflects how fillers are generally utilized in the face.

In early 2007, the Archives of Dermatology published a report saying that injection of cross- linked hyaluronic acid fillers, like Restylane and Juvederm, stimulated new collagen production. Since that time many dermatologists and others who work primarily with fillers have used this report to increasingly tout their philosophies. They claim that lifting procedures may not be necessary because fillers can increase collagen production and tighten skin. This contention has always been dubious at best since the amount of collagen production necessary to lift sagging facial skin would have to be a lot.

However, the study findings need to be re- examined in more depth because a new study looking at injection of Radiesse (calcium hydroxylapatite) found no increase in collagen production.

We decided to review both papers to see if we could find the source of the discrepancy, and we think we may have. It seems that those who cite the original Restylane paper may not have noticed that, in the study, volunteers had an entire syringe of Restylane injected in one small area identified on the forearm. One to three separate sites were injected this way and then samples were taken that showed increased collagen production. Why is this important?

Simply put, this study does not make a lot of sense for at least 2 reasons. First, and most important, no one injects an entire syringe of Restylane into one designated area. It is generally used in the face to fill in wrinkles distributed over some distance. Since the doctors propose that mechanical stretch is the reason they think new collagen production is induced, we now can discern that it would take a whole lot of Restylane to be injected into any one area of the face to allow for collagen production. Not only would this likely be cost prohibitive, but it would also counter normal aesthetics. Second, the study used the forearm of participants to examine the effects, and we know that skin from different areas of the body respond differently to injection of these fillers.

This also explains why, in the more recent finding, new collagen production did not occur when Radiesse was injected. One would suspect that if the mechanism was simply mechanical stretch that it would not matter which of the fillers was injected, but the study found no new collagen on examination. Why is the second study likely more reliable?

1. They used a crease behind the ear as the site of injection. One would reason that this skin is more like the rest of the skin in the face than is forearm skin.
2. They injected only 0.1 ml into the area. This is closer to the amount that is normally injected into any one wrinkle area.

So, while fillers work well for temporary improvement of wrinkles, the evidence that they have any real effects on collagen production is lacking.