Beverly Hills Rhinoplasty Surgery Blog

This is a big question for people. There is a lot of fear about the open rhinoplasty incision. Will it be noticeable? Maybe you’ve seen examples of poor scars from an open rhinoplasty. The fact is poor scars happen when poor technique is used.

You should know that, in the hands of a careful and experienced open rhinoplasty surgeon, the open incision heals beautifully. Below is a typical example of how one of our open rhinoplasties looks before and after just 3 months. We hope you’ll agree that without showing you where the incision is placed in red, you’d have a pretty hard time finding it.

One or more of these incisions is made depending on how much work is planned for the tip. The incision on the far right also needs to be made if the septum is addressed as well. In contrast, work on the tip, bridge, and septum can all be accomplished in open rhinoplasty through the same external incision.

It’s not as important to understand the different incisions as it is to understand that the internal incisions made in closed rhinoplasty often pose real healing problems too. Some of these incisions are made near the narrowest part of your nasal airway so just a little bit of excess scar tissue can seriously compromise your breathing and potentially destabilize your tip.

Every surgical technique has advantages as well as potential downsides and trade-offs to consider. Don’t get too hung up on whether your preferred surgeon suggests an open or closed rhinoplasty for your nose. We like to say that far more important than how the surgeon opens, is what he does to the underlying structure once he’s there- that’s what in the long term gives you the beautiful, stable results we are all looking for. So, while we use both approaches, far more often than not we find that an open rhinoplasty is what it will take to achieve just the right change for you.

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.

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 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.

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After seeing the title to this blog you may be wondering:

“what is a spreader graft and who cares?”

- that is of course if you continued to read.

Well the truth is unless you have broken your nose or had previous rhinoplasty, you probably can ignore this blog. However, if you are either of these people then this blog might interest you.

Patients who have broken their nose or present requesting revision rhinoplasty often are noted to have a depressed area in the middle portion of their nose- an “inverted V deformity.” Frequently this is associated with nasal obstruction, but not always. And unfortunately, many doctors and plastic surgeons continue to overlook or miss it.

We’re not going into the details of the internal valve or spreader grafts here (for those interested you can go to our internal valve chapter or our twisted nose chapter ).

Bilateral Spreader grafts can be seen in position between the upper lateral cartilages and the septum.

Suffice it to say that when the nose is broken or after previous rhinoplasty, the cartilage that makes up the middle side wall of your nose may have collapsed inward, resulting in the depression you see. For us to correct this problem, one of the things we occasionally have to do is place a spreader graft. The spreader graft is a small rectangular piece of your own cartilage that is generally 3-4 mm long, 1 mm wide which is inserted into the space between your septum and the upper lateral cartilage. While there is no agreement of how spreader grafts work, studies have shown that they are effective in both improving breathing and in improving aesthetics. One potential problem with spreader grafts has always been the belief that spreader grafts widen the nose when placed. Well a very recent study looked to find out if there was anything to this belief. And well, the answer was that spreader grafts do widen the nose a little, but it took a computer to see the difference. And perhaps more importantly, none of the patients in the study complained about the small increase in width when they noticed the positive effects the grafts produced.

If you are one of the 35 million American who suffers from nasal allergies, you might soon start hearing that a botox injection is one of the better treatment options for allergies.

Turns out a recent study was completed in Korea that compared patients with allergies who were either injected with botox, steroids, or normal saline into their nasal turbinates.

The study found that those injected with botox had both better overall improvement as well as longer lasting improvement than those who received steroid injections when they compared runny nose symptoms, nasal obstruction symptoms, and itching symptoms.

Stay tuned and we’ll let you know more as information becomes available, but this was an interesting preliminary study.

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. We have lumped these 3 problems together because they often occur together after a Rhinoplasty in which the tip cartilages collapsed.

The diagram below shows the area of the tip cartilages (in red) that is commonly removed during a rhinoplasty. This would be considered a reasonable amount in most patients depending on their skin thickness. The key of course is not to remove too much.

Many surgeons are very aggressive with these maneuvers and may take out most of this cartilage or slice right through it without repairing the edges. They do this because the short-term changes can be very dramatic. You can turn a wide boxy tip into a very narrow one. But, the long-term results are usually devastating as the tip becomes progressively pinched and distorted over years.

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.