Beverly Hills Rhinoplasty Surgery Blog

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.

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.

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.

We have gotten a number of emails recently asking about what can be done for bad nostril scars. These usually result from a poorly planned nostril reduction procedure, often called alar base reduction. For many ethnic rhinoplasties, narrowing of the nostrils is a desirable goal to bring the tip into balance. There are a number of ways of doing this but all involve some sort of incision along the opening or rim of the nostril (at least that’s the only way to get a permanent change). If done well, these scars should be invisible once they are healed (watch out for our upcoming post with pics on how to do it right!).

When it’s not done wrong, it’s a whole different story. The scars can be quite visible or widened and the nostrils themselves can appear distorted or unnatural. Because deeper skin tones tend to react more strongly to injury, they are at higher risk for problems with healing in this area.

When you find yourself in that situation, help is still available. The color and contour of the scars themselves can often be improved by resurfacing them. Tools for doing this include dermabrasion, various lasers, and deep peels. These can be very effective but may require more than one treatment to see the results you want. If caught early enough, silicone gel and steroid injections may be helpful in getting the scars to settle down. If all else fails or if the nostrils are unnaturally distorted or flattened, it can get more complicated. It may be necessary to revise the procedure, remove the scars, and do other things to get some improvement.

Tune in for our upcoming blog in the near future that will show you how an alar base reduction is done right.

In the NY Times Magazine last week we came across these stunning pictures of Yasmine Warsame, a beautiful East African model from Somalia who grew up in Canada.

We looked her up since we had never seen her before and we came across her myspace site where she’s quoted as saying:

“I believe that ’Black beauty’ is understated and isn’t appreciated, so that’s what I want to represent in this modeling industry. I want to inspire young girls and women all around the world to follow their dreams, especially women of color.”

When Jennifer Hudson was featured on the cover of Vogue last year, a controversy arose because she was one of a small handful of black women ever to appear along on the cover.  It got us thinking about all of our ethnic patients who ask if we have expertise in ethnic rhinoplasty and facial plastic surgery. It’s a fair question, but one that requires a nuanced response. Yes, we do have expertise in working with a variety of ethnic patients…but truthfully, that’s less important than an understanding of aesthetics and anatomy in each individual.

No ethnic group can be pigeonholed into one group, though broad generalizations can be made (see our online book). You, your face and your nose are unique and individual to you, regardless of race or ethnicity.

So, getting back to black beauty – here are just a few of the beautiful black women who grace the landscape of our media world. You’ll note they’re all very different and yet stunning in their own way…

Sure, we can. Your situation is something that happens often after rhinoplasty and is one of the more common reasons that patients come to us for a revision. That’s because taking down a bony hump on your bridge is fairly straightforward. Techniques to make the nasal tip smaller are more advanced and many plastic surgeons are simply not comfortable with them. So, we frequently see people with persistent tip concerns after surgery elsewhere.

What you are asking for is referred to as a tip-plasty because the intended changes are only to the tip. That doesn’t necessarily mean that the procedure is less challenging but it will usually take a little less time than a rhinoplasty that also addresses additional concerns.

Your tip can be manipulated without affecting the rest of your nose. It sounds like you are looking for some deprojection of your tip to make it more refined and to bring it closer in to your face. We can do that in several ways, but the workhorse techniques for making these changes are called vertical dome division and lateral crural overlay.

The photos shown here demonstrate what a vertical dome division can do. The photo on the left is the Before view. The photo on the right shows a vertical dome division and overlap done on just the left tip cartilage. The right side was left untouched in this photo. If you compare the left to the right, you can see that the tip cartilage is shorter but retains its shape and contour. The overlapped edges are sewn together to maintain the strength of the tip. This is a powerful technique that can be used to reliably address a big or wide tip, a boxy tip, a droopy tip, a hanging tip, and any tip asymmetries or irregularities.

We won’t bore you with all the technical details. But, in both these techniques, the tip cartilages are made smaller by carefully cutting the cartilage, overlapping the edges, and suturing them together again. By doing that, the cartilage is made just as strong, if not stronger, so that the desired change will last for a lifetime without putting you at risk for collapse down the road. We choose which technique to use based on whether you also want your tip to be rotated up or down or other changes to be made. You can view the photos above to see how these techniques can decrease the size of your tip. Check out our Modern Rhinoplasty online textbook on our main site for more details.

If you see an experienced rhinoplasty surgeon, you should feel confident that your concern can be addressed in a very predictable and satisfying way.

The complaint of a nostril that is “too wide” is a problem which we more frequently encounter among certain ethnic groups: African Americans, Asians, and some Hispanics. Alar base (“nostril narrowing”) surgery poses a unique set of difficulties, which should not be understated.

All too often many surgeons make it sound like, “No problem, we’ll just take a little wedge of tissue out from both nostrils.”

Unfortunately, external incisions can be noticeable, even when designed correctly. Most commonly, evidence of alar resection is noted as a teardrop or “Q” deformity in the base of the nostril. In others, the nasal base appears abnormal, as the smooth contour of the nostril has been interrupted (see Michael Jackson) or because resection has resulted in more marked asymmetry. Moreover, overresection can result in a narrow dysfunctional nostril opening that is difficult, if not impossible, to correct.

Michael before surgery had relatively wide nostrils.

When Michael first had rhinoplasty you see transition after alar base reduction to a smaller nostril size, but it still looked relatively normal.

Michael Jackson after numerous revision rhinoplasties has ended up having very irregular nostrils, which are dead give away for having been “done”

In general, we employ alar base modifications in the context of an overall surgical plan and normally defer this portion of the case to the end of the surgery. No surgeon can determine preoperatively the exact location, shape, and amount of alar base alteration which is required because nostril size and shape as well as alar base width and flare (see our online textbook for more information regarding these definitions) are all affected by other modifications made during rhinoplasty. Specifically, increased tip projection (making the tip bigger), will often sharply reduce the alar flare and alar base width. On the other hand, retrodisplacement of the nasal tip (making the tip smaller) has, at least classically, been noted to create alar flaring as well as a rounded nostril.

So if you have wide nostrils, we recommend you view alar base surgery as a useful adjunctive measure that can be used to provide an additional measure of refinement. With this in mind, and in the right hands, alard base reduction can maximize the chances for a smooth, natural nostril contour with no discernible scar. When its overdone, or done incorrectly the results can be difficult to fix.

In the last couple of weeks, we have seen several patients seeking revision augmentation rhinoplasty who have had silicone or medpor implants previously placed in the nose. These have become warped and displaced and are in need of revision.

Here at Profiles, we are fans of silicone rubber (silastic) implants for chin, cheek, and jaw augmentation. But, for the nose, we much prefer to use your own cartilage for augmentation, if available. Why is that?

There are several good reasons for this philosophy:

1. Chin, cheek, and jaw implants are ‘contour’ implants; that is, they are placed only to improve the overall contour of the cheek or jawline. Whereas, nasal implants must improve contour while also providing structure, definition, and support to the nasal bridge and tip. And, cartilage does a better job of that.

2. The skin, muscle, and fat covering the chin and cheek areas are quite thick whereas these same soft tissues overlying the nose are quite thin by comparison. One risk of a foreign implant is the possibility that it may place pressure on the nasal skin and further thin it over time, especially in the tip area, risking exposure of the implant. Also, in areas of thinner skin, implants can sometimes appear more visibly obvious. Again, cartilage is not a risk here.

3. Moreover, the chin and cheek skeleton is made up of a large continuous bony surface, areas that lend themselves well to coverage by a large solid implant. The nasal skeleton, on the other hand, is made up of an intricate group of cartilage structures that give the nose its unique surface appearance. For this reason, a single lump of silicone can look unnatural in the nose. Cartilage grafts can be tailored to more naturally reconstruct this elaborate topography.

4. Cartilage is desirable for other reasons, including a lower risk of infection and tissue rejection, since it is your own tissue. We also suture cartilage grafts in place so the risk of migration or displacement is minimized.

The end result? You have the best chance of getting a great rhinoplasty result that lasts for a lifetime. Read more about this and other rhinoplasty topics in our online Modern Rhinoplasty text.

Your concerns are valid and it is important to discuss your history of poor scarring whenever you undergo any type of surgery. You should note however that different parts of the body will heal differently. The simple answer is that keloids rarely develop in the central face and we here at Profiles have never seen a keloid develop after we have done rhinoplasty.

A more in depth explanation begins with an explanation of scarring. First, we need to help you in understanding the difference between a hypertrophic scar and a keloid. Clinically, hypertrophic scars are enlarged scars that stabilize or shrink with time. Keloids, however, initially develop as hypertrophic scars but later extend beyond the original injury area. They rarely regress on their own and have a propensity for recurrence after excision.

Keloids may affect virtually any surface on the body with the central chest, deltoid/shoulder region, and back having the highest frequency. And this has led some doctors to speculate that motion and tension play a large role in causing keloids to develop. While this may be true to some extent, the earlobes, which are one of the most frequent sites affected, are obviously subject to minimal motion or tension forces.

This African American patient demonstrates a typical example of a large keloid scar of the earlobe that was removed in one session with flap reconstruction of the back of the ear. The After photo to the right shows her postoperative result over 6 months after the procedure.

All this being said, while you should explore this issue with your doctor before surgery, you should feel some comfort in knowing that the nose is rarely a site for keloid development after rhinoplasty or nasal surgery. In fact, we did a literature review to check on your answer and were unable to find any papers which could point to a case of a keloid after rhinoplasty.

As would be expected with any ethnic population, we have found that there is a continuum of nasal features in our Hispanic population, rather than distinct types. Rather than trying to categorize various subgroups, here at Profiles we focus on your individual characteristics and your goals.

In general, we have found that our Hispanic patients’ facial and nasal characteristics can be differentiated from our Caucasian patients in the following ways:

(1) Broader faces, commonly with prominent cheek bones and a relatively small nose

(2) A slightly small chin(3) A nasal hump(5) Wider nostrils (6) Wider and lower nasal bridge

(7) Moderately thick, sebaceous skin

So what does this mean to you?

It means that it is important for you to work with surgeons who will take the time to understand what you are trying to achieve and who are comfortable in dealing with different ethnic populations. We take these differences in anatomic and structural components into consideration in planning your surgery and in explaining to you, what can be accomplished with your surgery. During your consultation we will work together to define what your goals are using computer imaging. Based on your desires and your individual anatomy, we will then devise a surgical plan which is best suited to achieve your individual goals.

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