Beverly Hills Rhinoplasty Surgery Blog

We are often asked about using fillers in the nose. We usually don’t advocate the use of fillers or fat in the nose for anyone who needs more nasal support, structure, or definition. Your nasal cartilage and bone are hard tissues and their appearance seen from the outside can’t be reproduced using fillers. In these cases, a rhinoplasty or revision rhinoplasty is the answer.

Sometimes though, there is a tiny depression or contour change that is present after rhinoplasty. Using a filler to plump up this area sounds enticing when compared to having to go through another surgical procedure to correct it. Let us say this about fillers in the nose. Proceed with caution. Hyaluronic acid fillers such as Restylane and Juvederm are fine in the nose if done by an experienced injector if care is taken to avoid problems. Longer lasting fillers such as Radiesse or Artefill (more on Artefill later) are not a good idea in our opinion and you can check out the photo below to see why.

This photo shows a recent revision rhinoplasty done at Profiles in which there was filler previously placed in the nose. From the look of it, this was probably a hydroxyapatite-based filler such as Radiesse. While filler in the nose may sound like a great idea to some, it can make any future revision surgical procedure exceedingly difficult. You can see the calcified filler particles at the tip of the scissor. Notice how it is incorporated into the skin which makes safe dissection very precarious.

Normally, we count on healthy planes between tissues to make surgery go smoothly with the least possible trauma. While tissue planes are never perfect in revision rhinoplasty, the picture is complicated by the use of fillers as seen above. These fillers can cause so much inflammation and scarring beneath the skin that it is next to impossible to remove them entirely during a revision surgery. So, if you are considering filler for your nose, think about talking to a rhinoplasty expert before you make your decision.

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To crush, or not to crush, — that is the question: —

Whether ’tis better in the mind to only think about crushing

The cartilage, but leaving it intact for grafting,

Or to take arms against the cartilage,

And by crushing it? — To sleep, knowing the cartilage will not show through, —

The heart-ache, and the thousand natural shocks

That cartilage is heir to, — ’tis a consummation…

To sleep, perchance to dream: — ay, there’s the rub;

For in that sleep of crushed cartilage what dreams may come,

The perfect nose…

For those of us who do a lot of rhinoplasty and revision rhinoplasty, there is often the moment some time during the case when we question whether we should crush cartilage hoping that it will last and lie more discreetly? Or whether we should leave it intact fearing that if we crush it, over time it will reabsorb?

Recently there was an interesting article that looked at the survival of crushed cartilage vs non crushed cartilage in the Archives of Facial Plastic Surgery. Not surprisingly, they found that crushed cartilage did not appear to survive as well in their animal model.

Unfortunately for those of us who operate on people, the study looking into crushed cartilage from rabbits really does not help answer any questions. For one thing, while they tried to standardize how hard they crushed, in real life this is very difficult to translate into our own practice.  Moreover, they placed all the noncrushed cartilage on the dorsum and all crushed cartilage on the nasal sidewall- perhaps they could have switched it up to see if placement made a difference.

So what does this mean to anyone doing or having rhinoplasty: simply said, it appears that crushed cartilage is a great way to conceal irregularities, fill defects and create smoother surfaces, but it is important to be experienced so that the cartilage is not so crushed that it disappears over time….there is the rub.

Recently, the Archives of Facial Plastic Surgery reviewed the progress made and things learned regarding brow lifts by facial plastic surgeons over the last 10 years.

For many people reading this blog you may be wondering why do open forehead lift when endoscopic techniques are available?

For some people, when they hear about open browlift, they think back to their mom or grandmother who had the traditional coronal brow lift that spanned from ear to ear. And they fear the potentially longer scar and even hair loss they heard about. Luckily, we can now do a different lift called a trichophytic lift that allows us to elevate your brow without moving your hair line higher while making an incision that is completely hidden.

Notice that a few weeks after trichophytic browlift, the incision line is inconspicuous in the hair line

Since the early ‘90s, numerous authors have reviewed their experiences with the endoscopic technique and have reported that the endoscopic technique allows surgical access through small incisions, resulting in quicker recovery times, less morbidity, greater patient acceptance of surgery, and satisfactory results. Unfortunately, some reports question the effectiveness of the endoscopic forehead rejuvenation and characterize it as being cumbersome and not as effective long term.

In our experience, most of the flaws associated with the endoscopic technique are the result of a surgeon’s inexperience. However, that is not to say that there are not potential downsides to the endoscopic technique which need to be addressed.  The study points out, and we agree, that the main flaws with the endoscopic treatment include:

1. inadequate arcus marginalis release- this is the lining overlying the bone  just over the brow that has to be released to allow for permanent upward movement of the brow
2. inadequate frontalis muscle weakening- this is what allows us to weaken the muscle so you do not need as much Botox after,
3. lack of fixation, especially in the lateral eyebrow- in the endoscopic technique since no skin is removed, there are numerous ways surgeons attempt to “fix” the brow into the new elevated brow position
4. thick skinned patients with deep frontal and glabellar wrinkles- generally we recommend these patients strongly consider open techniques because it is simply very difficult to get the heavy skin to stay in the new elevated position

So if you are considering a brow lift, it is imperative for you and your surgeon to evaluate and accomplish:

1. Do a thorough preoperative evaluation of the upper face- including discussion of asymmetries;

2.  Wide release;

3. Complete periosteal release at the arcus marginalis;

4. Variable transection of the depressor musculature;

5. Maintenance of the integrity of the frontalis muscle;

6. and,  in endoscopic cases, adequate fixation of the forehead tissues to the elevated position, especially in the lateral portion of the eyebrow.

The truth is there are still many unanswered questions when it comes to the endoscopic technique. The study points out that there is a dearth of meaningful blinded trials with long-term follow-up to evaluate the plane of dissection, method of fixation, and muscle manipulation in endoscopic browlift techniques.

Many rhinoplasty patients are interested in narrowing their wide nostrils at the base of their nose but many are afraid of obvious scars or of having a distorted or pinched look. There is the potential for these sorts of problems if nostril narrowing is not planned and done properly but, with care and appropriate technique, this can be a really nice finishing touch to a great rhinoplasty.

There are a few different techniques for narrowing wide nostrils, known as alar base reduction. The 2 most popular techniques are shown below followed by the technique that we use. We’ll illustrate for you how it is done and the effect that each technique has on the nostril shape.

The photos above show the most popular technique for nostril reduction, called Weir incisions. This involves removing a wedge of tissue from the edge of the nostril where it meets the cheek (shaded in blue). The arrow indicates the direction in which the edge of the nostril is then pulled down and re-sewn. While the scar is well hidden here, it has a tendency to flatten the nostril by removing its natural curvature. When done over-aggressively, the tip can take on a very unnaturally pinched triangular shape as seen on the right. When too much skin is removed, the skin closure is under tension and can result in a poor scar that will need further treatment to get it looking acceptable.

The photos above show another common technique for nostril narrowing, called Joseph incisions. This involves removal of a wedge of skin from the base of the nose in an area known as the nasal sill (the blue shaded area). The edges of skin are then pulled together in the direction of the arrows under some tension. Again, over-reliance on this technique can cause scars that are widened and nostrils that appear abnormally notched as shown in the photo on the right.

The final set of photos above demonstrate our modified alar base narrowing technique. This is the method we use for Beverly Hills nostril reduction in our patients. Our method involves removal of a crescent-shaped wedge of skin from the sill followed by incision just above the nostril crease. The entire nostril is then moved inwards in the direction of the arrow to recreate a normal nostril contour.

The benefits of this technique are numerous. The scars are well concealed under no tension whatsoever, so they tend to heal invisibly within a couple of weeks even in ethnic patients and thicker-skinned patients. The natural curve of the nostril is maintained. The normal crease between the nostril and cheek is preserved. And, best of the all, this one procedure can be individually tailored to each nose to variably address nostril width, nostril flare, and to improve the internal shape of the nostril. The simulation on the right shows how this technique can achieve a beautifully-proportioned natural nostril narrowing. Check out our dedicated rhinoplasty site or our online rhinoplasty textbook for more details.

With all the interest in dark under eye circles and injectible fillers used under the eyes, we decided to post a little youtube video.  For those interested we review why we prefer fat to other fillers in this area and show one of our patients who underwent the procedure.

www.youtube.com/bhprofiles

We welcome your thoughts and questions. And for more information you can read more in our other blogs on the topic

Why do many people who have eyelid procedures often look like a deer caught in the headlights? Are their surgeons just pulling their lids a little too tight or is it something more? Recent studies have shed some light on this issue and shown us that the whole concept of eyelid aging has been wrong and is in need of an overhaul.

             For a long time, it has been thought that as we age, the support structures that ‘hold in’ the eye weaken allowing for fat from around the eye to protrude and cause baggy pockets. As a result, the “correction” for heavy and tired eyelids for decades has been to remove this so-called ‘extra’ fat.

Unfortunately the results of this approach are eyelids that look smoother for a time but eventually, due to removal of the fat, the eyes can often come to look aged and hollowed. In actual fact, studies show that the fat and bone beneath the eye and over the cheek shrink over time. So, the cheek flattens and the lower eyelid loses its foundation and ‘folds down’ like an accordion. This accordion-like folding is known as the “concertina effect”, the same kind of rippling we see in a caterpillar’s movement or in traffic clogs long after the blockage has cleared.

              The answer is not to remove or reposition the fat from inside the eye to make a flatter eyelid to fit a flatter cheek. That’s not youthful at all. A youthful look is all about convexity when it comes to cheeks and eyelids. We don’t remove fat from the eye at all. Instead, we restore a truly vibrant convexity by replacing the fat volume where it is needed, in the hollows beneath the eyes. By combining this with trimming of the stretchy skin over the eyelid, we have seen a real change from very good results with older techniques to remarkable results with our new Profiles Eye Lift. We welcome you to see the evolution of eyelid procedures for yourself. You won’t believe your eyes.