Beverly Hills Rhinoplasty Surgery Blog

Occasionally we get young and often times older patients who present and tell us that after years of staring at their profile in the mirror that they are now noticing a bump when they did not have one before.

In most cases this apparent bump is due to a loss in tip projection.  As we age, we lose some tip support and for some the result is a tip drop and an apparent bump. Many of you may have noticed a grand parent who seems to have a nose that had grown over the years and has developed a bump. The fact is that the nose has not actually grown. As the tip has lost support, it has started to droop resulting in a longer nose and oftentimes in a new bump.  See our online textbook for more details (the Aging Nose)

In some cases a tip graft alone is all that is needed but there are other suture techniques that can also increase tip projection without using grafts (that can sometimes cause problems long term). The key is to look at the nose in all its dimensions and get a real sense of what is needed. Some may think of using nasal fillers, but while this may help the profile view in short term, on front view the nose will often look fuller/ bigger and less defined (not to mention the potential risks- nasal fillers

Finally, since we have a niche rhinoplasty/ revision rhinoplasty practice, my strongest advice would be to go to a facial plastic surgeon/ general plastic surgeon who does a lot of rhinoplasty and try not to have cost be the overriding factor. Not that you have to go with the most expensive by any means, but in the long run we think the time, money and emotional investment that can come with having to go through revision is far outweighed by going to someone who does it right the first time.

An interesting question that came up on the RealSelf forum had to do with radix grafts. A radix graft is a (usually) small piece of cartilage placed at the root of your nose between your eyes. It’s meant to add height to this area and is potentially used for several reasons.

We don’t often use radix grafts but may do so when someone’s bridge has been taken down too much in this area during prior surgery. In some patients, the root of the nose starts very low giving the appearance of an exaggerated bump on the bridge or an overly shortened appearance to the nose. Because the nasal root is so deeply-set, the angle between the nose and the forehead is exaggerated.

In these cases, a radix graft can be appropriate as a better alternative to taking down the bump so much that it brings the bridge too low or shortens the nose too much. A radix graft can preserve or augment nasal length by giving the nose the appearance of ‘taking off’ a little higher from the forehead.

The particular question today had to do with the effect of a radix graft on the appearance of the eyes. This person had closely-set eyes to begin with and was afraid that a radix graft might worsen that appearance. It is true that a washed out nasal bridge can give the sense that your eyes are farther apart. Conversely, adding height to the bridge can theoretically give the sense that eyes are drawn closer together.

But (and this a big but here), if you are considering this question, you must think about where you are coming from. If your bridge was taken down too low during a previous surgery and you are considering adding back some natural height and length to balance your nose, then the impact of a radix graft on the appearance of your eye width will be minimal.

On the other hand, improving a washed out appearance of your bridge would have the effect of creating more nasal narrowing and refinement from the frontal view. And, this is hopefully what you’re trying to accomplish. So, while we consider any graft carefully before recommending it, a radix graft is sometimes just the right fit for the problem at hand. For more information about nasal aesthetics, check out our online rhinoplasty textbook.

How about neither? We are often asked about nasal implants. These are primarily used for East Asians, African Americans, and others seeking a stronger, higher nasal bridge and a more refined tip. They are also sometimes recommended for patients whose bridge has been lowered too much during previous surgery. Implants can be of various materials but the most commonly used implants are made of silicone/silastic.

Above you can see the typical shape of a nasal L-strut implant. This particular one happens to made of Medpor which can be a real problem to revise…but that’s another story.

We were recently asked about revision of an L-shaped implant that gave this particular patient’s nose a pointy, unnatural appearance. She had been happy with her natural tip but the surgeon recommended an L-strut anyways. Now, she didn’t like the look and was also starting to notice some redness of her tip 3 months after her surgery.

Let us say first off that we’re not big fans. We much prefer your own cartilage for augmenting or rebuilding the nose, whether it is from the septum, ear, or rib, or even sometimes irradiated rib.

The concerns mentioned can sometimes arise after use of a nasal implant, and that’s part of the reason we’re not big fans. An L-strut lays over the entire bridge and extends down under the tip to the base of the columella. It gives the tip definition by placing a fair bit of pressure over a small area of skin to tent the skin out. It cannot reproduce or retain the natural shape of your tip. As a result, it can look a little too pointy and unnatural.Sometimes, this pressure on the skin can become too much for the skin to bear. If you are noticing redness at your tip after an implant, you should see your surgeon or another rhinoplasty expert early to determine the cause. If the skin is under too much tension, this would be a good reason to intervene early with a revision procedure to avoid injury to the skin.

The other problem with an L-shaped implant is the possibility that it will twist or move over time and cause your nasal contour to appear crooked. These problems are less likely with an I-shaped implant that stops just above your tip because the forces of healing and skin contraction do not act on it in the same way. An I-shaped implant really justs rests on your bridge without providing the same type of structural support that an L-shaped implant is intended to give. Still, an I-shaped implant can look bulky, blocky, and unnatural. Your own natural nose is not one continuous block of cartilage…so a long, bulky, continuous implant does not make sense to us. We should replace your own lost or deficient tissues with similar tissues.

Our preference for ethnic augmentation rhinoplasty is to use your own cartilage for augmentation. If you are happy with your natural tip, you should be able to keep that roundness. Augmentation of your bridge can be done by itself to balance with your tip and other features. If you continue to be unsatisfied with a nasal implant, rest assured that you can achieve a refined but natural nose.

Every so often we are confronted by the patient who has gone overseas to have surgery only to return with a botched result. Now this is not to say that surgeons outside the US are not good or as accomplished but simply that once you have surgery overseas your ability to have adeuate follow up or in the worst case scenario recourse toward revision are dramatically decreased.

While most people go abroad thinking they can have surgery done cheaper in some exotic location, the problem is you really cannot be sure what you will get in terms of surgeon or facility once you get there. The truth is that facilities in the US are held to a standard that is not matched by many of the destination countries people look to when thinking about surgery abroad. Moreover, in case of an infection or other complication, there is little patients can do since they usually have not planned to stay more than the few days they thought would be necessary. And all this is not too mention the problems of a long flight after long surgery which can result in a blod clot or more serious problems.

This problem becomes especially important to us because rhinoplasty is more complex than some other procedures and the potential for long term poor outcomes is much higher. We address this because whether your Asian and considering augmentation rhinoplasty or if you are Persian and think that you can have surgery done in Iran, the decision on who to have do your surgery should not be based on cost.

That being said, we are not saying that the most expensive is the best, we know that that is not true either. Rather we advocate for choosing a doctor who you can speak to, whose results you can see, and who takes the time to understand what you want to achieve. If you go abroad, this may be difficult if you and the doctor don’t speak the same language.