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.

The diagram below shows the area of the tip cartilages (in red) that is commonly removed during a rhinoplasty. The key of course is not to remove too much.

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.

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.

The short answer is no.

The typical rhinoplasty done in the 1980’s or even 1990’s relied heavily on reduction of prominent cartilage and bone to achieve a more refined look. Knowledge of the long-term effects of such techniques was spotty and, so, many unfortunate patients were left with the trademark ‘operated’ appearance of a pinched, droopy, or distorted tip, and scooped-out nasal bridge.

These occurred because the newly-weakened structural elements of the nose could no longer provide the necessary support, often leading to breathing trouble. The forces of healing are dynamic and often operate for several years before these outcomes are evident. So, a postoperative result may look great immediately after surgery, yet evolve into a dismal failure over time. Likewise, collapse of the nose’s structural supports will compromise the basic function of the nose, namely breathing.

Modern thoughts on rhinoplasty take a much more conservationist approach. As much as possible, reshaping and contouring are achieved with suture and graft techniques that will usually leave the nose ‘stronger’ than it was preoperatively. While many surgeons think of nasal breathing more as an afterthought, those who have an interest and experience in rhinoplasty will assign as much importance to nasal function as to aesthetics. The result, at Profiles Beverly Hills, is that once short-term swelling is resolved, your breathing should be as good or better than before and the changes to your nose should remain ‘stable’ for a lifetime.

Nasal obstruction is a complicated issue that is all too often ignored or attributed to “allergies,” “sinuses,” or to a “deviated septum.” Here at Profiles we often have patients who present to us who have been previously evaluated by other physicians who were unable to determine the cause of nasal obstruction.

We always begin by explaining that it is important to understand that nasal obstruction is a subjective sensation and that it occasionally does not correlate with anatomic problems. In other words, some people can have a slightly deviated septum and complain profusely of their difficulty breathing, while other people are completely obstructed on one side of the nose without ever even realizing they have a problem. So if you have trouble breathing through your nose, it is important to let us do a thorough evaluation.

It is true that oftentimes nasal obstruction is due to:

1. A Deviated Septum- where the midline cartilage and/or bone that separates the two sides of your nose is crooked

2. Nasal Allergies- whether seasonal or year-round.

3. “Sinus Problems”- This diagnosis is unfortunately all too commonly applied to patients without proper evaluation.

Nasal obstruction is a complex problem and there are numerous possible explanations with even more possible solutions. We recognize how nagging this problem can be and we understand how complex the solution is. The important thing for you is to find the doctor who will take the time to find out what your source of obstruction is and more importantly knows how to correct this problem.

For further info we recommend you go to our Modern Rhinoplasty online book and read further on Functional Rhinoplasty.

We always appreciate patients who present to us having done some homework on their own because it lets us know that they are really preparing for their surgery and more importantly because it allows us to spend more time in really discussing the available surgical options.

We find a lot of our patients, men and women, present with exactly this question and the answer largely depends on each particular patient’s anatomy.

Sometimes, patients present with a large hump which makes their nose look large, and you will often see these pictures on people’s websites because in reality, though they are the most dramatic results, they are relatively easier to accomplish. Occasionally, these patients also have smaller chins and a chin implant goes a long way in balancing their appearance.

The more difficult cases are those patients who like the overall shape of their nose but feel like their whole nose is just too large. In these cases the tip, middle third of the nose and bridge all have to be reduced equally. While we can and often do exactly this procedure for our patients, it is important in these cases to be very cognizant of skin thickness. In those patients who have thick skin, we caution that while the nose can be made smaller, it should still maintain definition and refinement. In our patients with thick skin, we always let them know that if we attempt to make the nose too small the tip can lose its shape and appear amorphous. So while we make the nose smaller, we stress the importance of tip definition and refinement.

Finally, and perhaps most importantly, we must remember that the primary function of the nose is to help in breathing and this function is critical. Unfortunately, a lot of times with all the mass media exposure to airbrushed pictures, we are exposed to images of people who are not real and to noses that cannot be reproduced without causing problems in breathing. And its for this reason that at Profiles, we always admonish that Form must not supercede Function.

Nasal Allergies, whether seasonal or year-round, generally are not a factor in rhinoplasty. If you experience nasal allergy symptoms, you should be thoroughly evaluated to see if there are any other factors that may exacerbate your breathing problems- such as a deviated septum or enlarged turbinates. If these problems are also present they should be addressed during your rhinoplasty.

Otherwise we find that in general patients have a period of reprieve from their allergy symptoms following surgery. We do counsel our patients not to blow their nose for about 2 weeks after surgery and also to keep your mouth open if you have to sneeze. Overall, there should be no reason why your allergies should affect your surgery with us.