Beverly Hills Rhinoplasty Surgery Blog

Here is another one from the Q&A file that can be a source of concern for people soon after a rhinoplasty. We were recently asked about vertical lines/shadows showing up after rhinoplasty on either side of the bridge. What was more worrisome for this person was the fact that she was able to feel small gaps when she pressed on the area.

The lines you may feel at the sides of the bridge are most likely fracture lines in the bones that were created to narrow or straighten them. If your bones were wide or crooked, then the surgeon must create these cuts in the bones in order to manipulate them to the desired shape.

If there was a lot of narrowing accomplished, you can sometimes feel a little gap in this area which can be perceived as a small ’step-off’ in appearance.

Don’t worry too much, though. If this is noticeable at all (and most people will not notice this), it will not last long. The bones will heal and the apparent gap should diminish in most situations. This rarely ever becomes a long-term problem, and usually only when the bony cuts were made too high near the bridge. If you are having a similar concern, you have reason to be reassured.

We were recently asked this question by someone who was understandably worried about these persistent symptoms about one year after a revision rhinoplasty. She wondered whether steroid injection would still work at this stage.

While discoloration is admittedly unusual at this stage, the key to this question is fluctuation. If swelling and redness were persistent and not getting better, we would be concerned about a possible low grade infection or chronic inflammatory condition, especially if there were a graft of foreign material placed in the nose. When swelling or discoloration fluctuates between being present and then going away, we are not nearly as concerned.

Whenever rhinoplasty is performed, the surgeon is lifting the skin and soft tissues of your nose to alter the cartilage and bony framework. By definition, this process involves disrupting the little nerves that provide sensation to some areas of skin and the little vessels that allow normal drainage of fluid from your skin. Thankfully, this ‘injury’ heals and all goes back to normal. With each successive surgery though, this healing can take longer and it is uncommon, but not abnormal, to have some of the symptoms being talked about even at one year after a revision.

These symptoms are definitely annoying, but the fluctuating nature of these symptoms is really a good sign. That means that there is still some healing to go and things will continue to improve. Some people pass this stage at 9 months. For others, it may sometimes take another six months or, rarely, longer until you see this go away completely. Steroid injections are meant to help you get there faster and can still help at your stage of healing.

Until then, it is normal to have flushing of the skin in hot environments, bluish discoloration in colder temperatures, and fluctuating swelling and congestion, especially when laying down for long periods or when exercising or doing any activity where fluid collects in the area.

The marker of healing is fluctuation. As time goes by, the swings from ’swollen’ to ‘happy’ days will start to narrow and the fluctuation will eventually stop. That’s when you know you’ve reached a near-final result.

As is often the case, it really is not possible to tell you for sure if septoplasty alone can straighten your twisted nasal tip; but we can tell you that in our own experience we’ve had a few cases where simply correcting the septum did straighten the tip.

While it is relatively rare, and in our experience only occurred in a few patients, we have had patients who had a septal fracture in the front part of the septum which resulted in a twisted nasal tip. In general these are not simple septum repairs that can be corrected via a routine septoplasty, but rather need to be approached through an open approach- which is the approach we use for rhinoplasty in many cases anyways.

If there is an anterior septal fracture, this approach will allow us to address the nasal tip even if the septoplasty alone does not completely straighten the tip- this can occur due to scarring or memory in the tip cartilages that would keep the tip twisted even after the septum is straightened.

However, all this being said we find that in general most of our patients have needed a rhinoplasty that focused on the tip in order to genuinely get a straight nasal tip. Each particular case has to be analyzed individually to determine if septoplasty alone will help in making the tip straighter, but ultimately until we operate and see what happens and what if any scar tissue is present we leave our options open so that we do not leave the OR until your tip is straightened.

We were recently asked if rhinoplasty is customized to each person because this individual liked her longer nose but wanted a smaller tip and a less droopy appearance. Rhinoplasty absolutely is and should always be individualized to your features, skin type, and specific goals and desires for your nose!

In the old days, the short, upturned, ‘cutesy’ nose was the only way a rhinoplasty was done. Sadly, this is sometimes still the case today, but those days should really be gone. We like to say that the object of a successful rhinoplasty should be to give you the nose you were meant to be born with. It is not meant to radically change the way you look. The results should look totally natural and completely in balance with your other features.

When done properly, your nose should blend into the background and no longer be a focus of attention. When done poorly, a rhinoplasty can really change your look in a way you may not have wanted, so you are absolutely right to explore these questions. Check out our previous blog on the topic for more info. Your rhinoplasty should be tailored individually to your features and goals, and should never rob you of your character.

If you find yourself having similar mixed feelings about your nose, there is nothing wrong with asking your surgeon to preserve certain aspects of your nose while changing others. You should recognize that every aspect of your nose is tied in to every other aspect so a change in one part will have a certain effect on the whole. But, in most cases, your goals and desires will turn out to be very reasonable and achievable in the hands of a rhinoplasty specialist.

If you have a longer and narrower face to match your longer nose, you may decide to keep the length; it will look good on you and give a sophisticated, elegant look. Your surgeon should be able to help you tease out what can be accomplished using computer imaging. Remember, this is an operation of millimeters. It is not and should not be an all-or-nothing procedure.

Indications for Tip Grafts in Revision Rhinoplasty

In the revision rhinoplasty patient tip grafts may be necessary if: (1) there is a pollybeak deformity (2) there is an asymmetric tip or nasal bossae (3) there is a poorly defined nasal tip (4) in the overly shortened nose, or (5) there was failure to recognize false tip projection at the time of primary surgery or there was loss of normal tip support mechanisms after primary rhinoplasty. We will explore each of these situations in turn and post representative examples in future blogs.

Underprojected Nasal Tip and Pollybeak Deformity

Perhaps the most commonly utilized purpose for the tip graft in our practice continues to be the one for which it was originally devised. In his exploration of his 30 year experience with tip grafts, Sheen noted that poor tip projection and supratip deformity are very commonly seen in post- rhinoplasty patients. For a long time the principle cause of this supratip deformity was thought to be excessive skeletal tissue in the supratip region. As a result, surgeons used to routinely revise pollybeak deformities by removing even more tissue in the supratip region with a resultant exacerbation of the problem. Sheen’s proposal that the vast majority of these pollybeak deformities were the result of overzealous resection of the nasal dorsum is widely accepted today, and it is thought that the supratip deformity arises as a result of scar tissue deposition which naturally occurs in order to eliminate the dead space produced by overresection.

The factors to consider in patients with postoperative supratip convexities include:

• overresection of the caudal nasal dorsum with scar tissue deposition,
• insufficient removal of the dorsal cartilaginous septum,
• inadequate resection of the cephalic portion of the lower lateral crura (LLC),
• and inadequate tip projection.

Moreover, sometimes the surgeon focusing on a large dorsal hump or supratip deformity misses the concomitant underprojected nasal tip. It is therefore critical in correcting pollybeak deformity for the surgeon to make the aesthetic decision as to whether there is adequate tip projection. All too often patients are still misdiagnosed and consequently undergo the inappropriate treatment. Excessive attention to the dorsal hump results in overreduction of the dorsum with resultant long term resultant pollybeak deformity as the skin soft tissue envelope is unable to contract to the newly reduced skeletal framework.

To make this determination we evaluate certain characteristics which can serve as signs for underprojected nasal tip: shortened columella, acute nasolabial angle, maxillary retrusion, and small, weak alar cartilages. The use of tip grafts, particularly in revision surgery, for the treatment of supratip deformity often is the only means of correction available. Suture techniques, such as the lateral crural steal, which increase projection in patients, are often simply not sufficient to project the tip to the desired level. These patients have often undergone overresection of the alar cartilages and have resultant weakened tip support. In addressing these patients tip grafts provide the needed cartilaginous skeletal framework needed to support the weakened alar cartilages.

Overresected Nasal Tip

When the nasal tip has been overly resected, in revision surgery we are often faced with excessive tip narrowing, bossae formation, asymmetric and occasionally external valve collapse. In the over- resected nasal tip, bossae are generally thought to result from the dynamic forces of scar contracture. In general terms, the surgical maneuvers that contribute to bossae formation are those that fail to secure symmetric dome cartilages, those that promote separation of the domes, and those that weaken the cephalic margin of the LLCs. While it would be nice if all surgeons prevented bossae by reconstituting the domes, reinforcing weak cartilage and avoiding sharp edges, nasal tip bossae continue to constitute one of the major causes of revision rhinoplasty for our practice.

In those patients with an asymmetric nasal tip, the asymmetry is often the result of unequal LLC removal or distorting forces on the medial or lateral crura that twist the tip. If adequate tip projection and tip strength are present, correction requires separation of the medial and lateral components followed by repositioning and trimming. Very commonly, unfortunately, overresection has occurred concomitantly and necessitates grafting in order to camouflage and support. In some of our revision cases the tip graft is often the only means of correction when overresection of the ala has resulted in bossae formation, excessive tip narrowing, asymmetry, or external valve collapse.

Poor Tip Definition

Poor tip definition continues to represent the most difficult challenge for the rhinoplasty surgeon operating on ethnic rhinoplasty patients. While wide variability exists in the ethnic patient population as a whole, generalizations can be made which can be used as a guide when planning rhinoplasty in this patient population. Specifically, when compared to the Caucasian standard, numerous studies have shown that African American and Hispanic patients tend to have combinations of:

Thick, sebaceous, relatively inelastic skin
Weak lower lateral cartilages
Wide bulbous tip
Excess fibrofatty tissue in the nasal tip
Acute nasolabial angle
Short medial crura
Thin weak septal cartilage

In this type of nose it is important to implement structured augmentation in order to not only provide adequate support but also to give meaningful definition and refinement.The shield graft is useful in ethnic patients when additional tip defining techniques are needed because the standard suturing tip procedures often do not give an entirely satisfactory result. Over the years we have found that the most challenging assignment in ethnic rhinoplasty is correcting the deficiency in tip projection in the face of a bulbous, amorphic tip with thick skin.  In particular, as many of these patients prefer thinner, more refined nasal tips it is important not to build up too much. As a result a balance must be delineated between appropriate refinement without excessive projection.

Overshortened Nose

The aesthetically short nose appears when excessive upward tilt of the nasal tip results in a foreshortened appearance. In the revision patient, the overshortened nose generally occurs after excessive shortening of the caudal septum. Over time, the result is an increased nasolabial angle with increased nostril show. When we are faced with these challenging patients, correction generally entails the use of a caudal septal graft in order to lengthen the nose as well as a tip graft to restructure and reproject the tip.

False Tip Projection or Loss of Tip Support Mechanisms

Many routine techniques in rhinoplasty result in false tip projection at the time of surgery or result in loss of tip projection in the long term. If the primary surgeon is cognizant of these considerations at the primary setting, the revision surgeon would not find indication for the need of increased projection. Unfortunately, while occasionally these patients can have correction with more conservative techniques such as the lateral crural steal, we have found occasion for the use of tip grafts in these patients in order to achieve adequate projection.

Moreover, many surgeons continue to find that an initially satisfactory result ultimately becomes an underprojected tip with the illusion of supratip deformity. The reason is often secondary to the utilization of techniques that weaken major and or minor tip support mechanisms which then in time result in loss of projection. Specifically, the cartilage splitting, cartilage delivery techniques and cephalic trimming of LLCs all result in disruption of the major supportive attachment of the ULCs to the LLCs in the scroll area. Full transfixion incisions interrupt the attachments between the LLC and the anterior septal angle and, if carried low enough, will disrupt the attachment of the medial crus feet to the posterior septal angle. And lowering the cartilaginous dorsum and shortening the caudal septum contribute to loss of minor tip support mechanisms. Finally, it is imperative for the surgeon in the primary setting to consider operative tip swelling secondary to infiltration of local anesthetics, the edema of surgical trauma, and repeated stretching of the nostrils with the nasal speculum. The increased tip projection  is transient and it subsides early in the healing phase as the extra interstitial fluids are mobilized back into the intravascular space.

We have been getting numerous questions lately about whether it’s possible to fix an overshortened nose. A large part of our practice is helping people who previously went in for rhinoplasty with a plastic surgeon to fix a specific complaint and did not get what they were hoping for. Of all of these unhappy people, those with over-rotated noses (turned up too much) or over-shortened noses are some of the unhappiest. This is a harder problem to fix but it can most definitely be accomplished.

So how does this result happen in the first place? Well, it has everything to do with the techniques that are used to reduce a long or projected nose. Take a look at the images below to get a picture of normal nose anatomy.

In the top image, you can see the normal bony and cartilage anatomy of the nose in profile. The picture on the bottom shows the anatomy of the septum inside your nose in relation to the external anatomy. The septum, shown in white, makes up the foundation for the middle part of your nose (the upper lateral cartilages) and, to some extent, your tip as well. It is a large block of cartilage and bone that sits on the upper jaw and provides some nasal stability. The bone to which it attaches along the floor of your nose is called the maxillary crest, and the very front of this bone is a projection called the nasal spine, shown in blue. You can normally feel this as a hard piece of bone at the base of your columella. These are important structures that we’ll tell you about next.

So how is it that some rhinoplasties have such problematic outcomes? Many surgeons, shorten a long nose by removing the nasal spine and the front part of the septum. See the image below for details.

On the other hand, when we want to shorten a nose or rotate the tip, we focus on altering the shape of the tip cartilages themselves to create the contour we want. In this way we are able to provide a predictable result that does not weaken your nose (if anything, it makes it stronger).

Seen above are the cutting methods used by many surgeons to shorten a long nose. This is a bit like shortening a building by knocking out the foundation. The structure sinks, and not in a good way. When the nasal spine or septum are shortened many patients have an acceptable result for the first year, but they are highly unpredictable and often do not last the test of time. They depend on scar tissue build-up to determine the movement and the ultimate shape of your nose. When the foundation is removed, your tip might fall forwards and droop or it might fall backwards and look too short and upturned but, either way, there is a good chance it will collapse and lose refinement over several years.

Why do some surgeons do this?? That’s a good question that we don’t know the answer to. However, most likely, it’s because cutting is quicker and easier than the methods of reshaping the nose and tip to achieve lasting predictable deprojection and rotation. These more reliable techniques are also more difficult to perform, especially through a closed approach. And, since many of the problems that arise from these cutting techniques may not be seen for several years after rhinoplasty, many surgeons may not even realize their patients are having these problems.

So, how do we fix this problem? These revisions are often complicated by virtue of the scar tissue that must be removed to gain the needed length. We then have to restore the cartilage that was lost using grafts known as septal extension grafts and/or extended spreader grafts. Sometimes, a tip graft is used to achieve added length and projection. The good news is that a balanced profile can be achieved, the nose can be lengthened and you can be made happy again.

Above is a Before and After Rhinoplasty photo of a patient who had revision rhinoplasty surgery at Profiles Beverly Hills by Los Angeles Rhinoplasty Surgeons Drs. Peyman Solieman and Dr. Jason Litner. Note the overshortened, overrotated, undefined, and scooped appearance on the left and the restoration of an harmonious and natural profile after surgery. For more information on other rhinoplasty mistakes, visit our dedicated rhinoplasty site.

We all know that art is not truth. Art is a lie that makes us realize the truth. – Pablo Picasso

Recently there was a great article in the archives of facial plastic surgery that used Picasso’s Girl in the Mirror to discuss body dysmorphic syndome. The author wrote:

“A portrait may represent a subject in many different ways. It can be a literal representation or it can represent a person symbolically. It can capture a person’s physical characteristics and/or attempt to represent their emotions or personality. In the Girl Before a Mirror, Picasso portrays a young woman surveying herself in an oval mirror. The woman in this painting is Marie-Thérèse Walter, one of Picasso’s girlfriends, with whom he lived and had a child, Maya. In this portrait she is examining and inspecting her appearance in a mirror, but Marie-Thérèse and her reflection are not identical. Art critics have suggested that this represents a symbolic duality, that is, 2 different sides of her character. However, closer scrutiny of this painting indicates a woman who sees herself in a distorted way, which resembles what in clinical psychology is termed altered self-recognition.

Picasso often experimented by showing multiple views of an object on the same canvas to convey more information than could be contained in a single, limited view. For example, he has painted the face of Marie-Thérèse in 2 halves, a frontal view and profile view, which enhance one another. The expression on her face unveils a distinct sadness at the image she sees in the mirror staring back at her. In the distorted reflection she sees her nose as long, whereas the lower third of her face is vertically shortened and retrusive. Her almond-shaped eye is seen as a large ellipsoidal rectangle, with the sclera missing. She sees the reflection of her smooth olive skin as blemished and chalky lilac. The left side of her forehead, upper third of her face, and nose reflect a substantial scarlet stain, resembling a port-wine stain. Her full blond hair is reflected as thin and green. In her reflection she observes vertical asymmetry in the position of her breasts, which appear scarred. She sees herself not the way she looks but as a visual fallacy. Her mind has deformed her face and body.

Most clinicians involved in the treatment of patients with facial deformities will encounter the patient who is excessively concerned with a minor or imperceptible defect in their appearance or patients who reveal extreme dissatisfaction despite good treatment results. In cases in which such a preoccupation with appearance causes the patient marked distress in their social or occupational functioning, the patient may have nondelusional dysmorphophobia, also known as body dysmorphic disorder (BDD). The prevalence of BDD is unknown but is thought to be on the order of 1% in the general population. The condition is likely to be underdiagnosed and underrepresented owing to the secrecy of those affected. However, the prevalence has been found to be higher in cosmetic surgery and dermatology clinics (5% to 12%, respectively).

In severe cases of BDD, patients experience self-inflicted mental torture and anguish. Without appropriate diagnosis and psychiatric treatment, these patients are condemned to a life of distress and misery, held captive by the stigma of a perceived deformity. With this painting, Picasso has given form to the terror that such individuals experience, capturing the patient’s torment in a work of art that will last an eternity.

Throughout his life, Picasso remained a researcher and an experimentalist. He said, “Paintings are but research and experiment.” Girl Before a Mirror may seem to the casual onlooker to be a child’s drawing, yet it is a most powerful and meaningful work of art. As Voltaire said, “It is not sufficient to see and to know the beauty of a work; we must feel and be affected by it.”"

Facial Plastic Surgeons should be more interested in ethnic rhinoplasty because the number of interested African Americans, East Asians, and Hispanics is rising dramatically! It still represents a minority of most rhinoplasty practices, though. Ethnic rhinoplasty requires a totally different view of aesthetics, principles, and tools to achieve appropriate augmentation and definition. A dramatic change in a profile pic after shaving down a big bump is probably the easiest thing to do in rhinoplasty. So, you see surgeons’ websites full of these examples. (Hint: look for a surgeon who shows you the other views too…the front view and three quarter views are often the most important because that is how the world sees you). The differences in skin thickness, cartilage consistency, and other factors in ethnic patients can often mean that it is harder to achieve a dramatic change. Most ethnic patients have a tendency towards thicker skin combined with softer, less distinct cartilage. A lot more grafting is required than in a typical primary reduction rhinoplasty that makes a nose smaller. But, if you see a rhinoplasty specialist, the type of pleasing, balanced result you are looking for should be achievable. You just might have to dig a little deeper to find a surgeon with lots of experience in Augmentation Rhinoplasty.

Is Botox safe during pregnancy

There was a disturbing article regarding news from Australia about an expectant mother who in 2005 was treated in her first week of pregnancy with a botox rival, Dysport, and gave birth to a baby who was deaf and blind. The report goes on to say that the Australian version of the FDA, released documents last month detailing the case including a report from the manufacturer of Dysport which states there may be a “possible” link with the drugs usage during pregnancy and the unfortunate outcome.

Now for those of you in the states a few things should be known:
1. There are a lack of controlled studies into the effects of Botox on pregnant women and their unborn children, therefore it is impossible to say conclusively either way whether it is safe.
2. For the sake of erring on the side of caution, Botox’s manufacturers recommend that it is not used on either pregnant women or nursing mothers.
3. As with the effects during pregnancy, there is a lack of information on whether Botox injections can pass the toxin into breast milk.

There have been a number of animal studies in rabbits and rodents which show that in high doses, there is a link between botulinum toxin and low birth weight, problems with bone development, and even possible miscarriage. It should be highlighted that the doses used in the animal studies were far more than anyone would get for cosmetic or medicinal purposes.

Here in the US, no physician we know would do botox in a pregnant patient for cosmetic purposes. The reason is simple, if there isn’t enough information to know conclusively that it is not a possibility, it simply is not done. It should be noted again however, that if you have had botox recently and now find out that you are pregnant, the chances of this being a problem is exceedingly low- the amount of botox normally injected is simply not enough to circulate and cross the placenta in a high enough concentration to cause any problems. In fact, there is one case study out of Tennessee of a woman with cervical dystonia, a muscular disorder, who underwent 4 apparently uncomplicated full term pregnancies while receiving botox treatments regularly for her disorder.

The point is while there is little chance of this being a problem, if you are pregnant or thinking of becoming pregnant in the near future you should tell your doctor before undergoing any treatment.