Plastic surgery, and rhinoplasty in particular, in Beverly Hills has become ever more concerned with aesthetic perfection. Unfortunately, rhinoplasty is a particularly demanding procedure that demands the most exacting attention to detail and technique if you want long term great results.

Finesse rhinoplasty is the name we give to the patient who needs or desires the most subtle of refinements. In some cases, these are the patients whose family or friends tell them that there is nothing wrong and that they should leave well enough alone. Many are very attractive and have good noses to begin with… but they wish to get even closer to their ideal.

You may wonder why operate at all, but for those of us who love this procedure, these are the cases that challenge us to be our very best, to pay heed to the most refined details… these are the ones that beckon us to be even better. Counter- intuitively, while small changes are sought, these are the most demanding cases because the window for improvement is likewise small. In other words, when you show up with a big bump, it’s pretty easy to get you a dramatically better result; it’s much harder to explain that to correct that little bump (bossae) at the tip of your nose permanently and safely, may necessitate a couple hours of surgery.

Jessica Biel is a spectacularly beautiful woman, but due to her thin skin you can see a number of irregularities in her nose in this picture

Often the patients wanting finesse rhinoplasty have a professional persona that demands that they look their best- models, actresses, entertainers. And most recently, we have had a number of very thin skinned patients (and we don’t mean metaphorically), who presented to us after having had surgery elsewhere. Unfortunately, they had been left with subtle but distinct tip asymmetries and bony irregularities.

Occasionally, in some instances we can recommend a non surgical nose job (see our blog on liquid rhinoplasty) in those patients with the minutest of surgical concerns. In these cases, the run is not worth the slide, ie the results achievable with surgery can be closely approximated by injection of a small amount of soft tissue filler such as Restylane, Juvederm, or Radiesse.

Unfortunately, when the irregularity is more pervasive, as was the case with these patients, we do not recommend fillers because they do not last long enough and have potential risks that we do not want to expose our patients to. In these cases, we found that after rasping (sandpapering) away as much of the irregularities as possible without bringing the bridge down, a thin layer of alloderm resulted in a fantastic cover for any minute palpable irregularities that we would otherwise be afraid could show years later in these very thin skinned patients.

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.

In the last post we told you about how a rhinoplasty can go wrong. Now we’ll take you through each of the most common problems we see one step at a time and show what must be done to fix them.

A scooped out profile is probably one of the most common problems we see after rhinoplasty. It usually occurs after a typical reduction rhinoplasty when there was a bump on the bridge that was shaved down too much.

Below is a diagram of a nasal hump reduction.

This can happen for a few reasons. Many surgeons still prefer to make a bony bump smaller using a chisel or osteotome shown below on the left. We prefer nasal rasps, which are essentially fine files shown below on the right.

Osteotomes are sharp instruments that cut through the bone at a desired level to lower the hump. This is an all-or-nothing thing where the bump is removed in one shot. The problem is one of judgment and execution. Sometimes the angle isn’t right or the surgeon thinks he or she is taking down the bone to a certain level only to find out that he or she misjudged.

It can be even easier to make this mistake using a closed rhinoplasty approach (from inside the nostril) where this maneuver is being done under the cover of the nasal skin. In this case, you can’t exactly see what you’re doing, so most of the work is done by ‘feel’. It takes a lot of experience to develop that ‘touch’ and to consistently get it right. We prefer to use rasps to reduce a bump. These instruments can be used to slowly whittle or file down the bony bump. That way we can accomplish this three-dimensionally in a very careful and controlled way.

When the bone is reduced too much, the nasal profile will look scooped and the bridge will look washed out and child-like from the front view. To fix this, we need to build the bony bridge back up again, most often with your own cartilage.

See the photos below to show the area of bone that was over-reduced, and what the bony profile should look like.

Now remember, we haven’t addressed any of the other problems with this nose yet. Check out our upcoming posts to see us make this nose beautiful again one step at a time.

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.

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.

As rhinoplasty surgeons and revision rhinoplasty experts, we often come across patients who’ve started asking about “non surgical nose jobs,” “injectible rhinoplasty,” or “liquid rhinoplasty.” As a result, we have done a lot of research and work in the area, and even asked some of the country’s other foremost experts in rhinoplasty what their thoughts are on this new phenomenon. What follows is our genuine attempt to give the best answers we can presently find with regards to this potentially new exciting area in facial plastic surgery.

In the last 10 years, facial plastic surgery and cosmetic surgery, in general, have seen explosive growth in minimally invasive and non surgical procedures. For most patients the reasons for this are simple: you do not have the time for recovery from surgery; traditional surgery may cost too much; non-surgical implies and is marketed as “no or little risk”; surgery is painful.

As a result, the various fillers have seen an enormous increase in their utilization. And today, we use these various fillers to achieve younger, more symmetric appearances not just by filling in wrinkles but also by restoring lost volume. More recently some of these fillers, which have only been approved by the FDA for use in the nasolabial fold, are increasingly being used for an ever wider array of “off- label” procedures including reshaping the jawline and chin, filling the cheeks, and more recently to reshape the nose- ie the “non- surgical” nose job, “liquid rhinoplasty,” and “injectible rhinoplasty.”

Some facial plastic surgeons use restylane for injection rhinoplasty

Let’s start by pointing out that the idea of injecting materials into the nose is not new even though there are plenty of doctors publicizing that they are the ones who started “injectible rhinoplasty or non-surgical rhinoplasty.” The truth is that the idea of injectable rhinoplasty for correcting nasal asymmetry can be traced back over a hundred years. And in that time a lot of different materials have been used- olive oil, goose grease, petroleum jelly, fat, paraffin, silicone, and others. Unfortunately, the results of these procedures were less than favorable and all of these materials have fallen out of favor due to their complications.

In the past plastic surgeons have used a variety of different fillers for non surgical rhinoplasty

Presently, there are many doctors starting to inject the nose with the newer dermal fillers- Restylane, Radiesse, Perlane, Juvederm, and even Artefill. However, the fact is that there have only been a few small studies published to date and only on a few of these materials. Moreover, these reports have largely been case reports and pilot studies using a small number of patients followed for short periods of time- generally less than a year. As a result, no one can say that injectible rhinoplasty, even with these new fillers, is absolutely safe.

Radiesse and Juvederm are other facial fillers used by some West Hollywood Facial Plastic Surgeons when doing liquid rhinoplasty

Traditional rhinoplasty done by a good rhinoplasty surgeon who specializes in the procedure can cost anywhere from $5000 to $10,000; yes there are surgeons who will charge $20000 for primary surgery but they are the outliers. If you’ve had previously surgery and need revision done by a revision rhinoplasty surgeon, this cost can vary depending on the complexity of the problem from as little as $2,000 for a very minor tweak to $25,000 for a total nasal reconstruction.

With injectible rhinoplasty, the costs are between $1000 to $2000 for each procedure; however, how long these results last is unknown but, in general, most doctors have found the result is less than one year. The permanent fillers may be different but at this time few doctors are willing to subject patients to the risks involved with permanent fillers, until more studies are available.

So one of the questions with liquid rhinoplasty is how much are you willing to pay knowing in time you will have to do it again and again?

Risks, Complications, and Recovery

All procedures have potential risks and complications. As revision rhinoplasty surgeons, we are very aware that rhinoplasty is an exacting procedure that really should be done by people who specialize in the field, and we take great care in explaining to all our patients the possible risks of anesthesia and surgery. As for pain, our patients tell us this is not an issue. It may be because of the way we do surgery and because we do not use splints and packing in the nose, but almost unanimously our patients tell us that outside of perhaps a pill or two for pain that first night, that they experience little more than a dull ache or discomfort.

For injection rhinoplasty, the issues of safety are still largely unknown, especially long term. On the positive side, there is no need for anesthesia and this is great for both recovery time as well as in obviously negating all the risks that generally come with general anesthesia. The problem with using fillers developed for the nasolabial folds in the nose is partially due to anatomy. In the laugh lines, cheek and jawline, the skin is thick and has a thick layer of tissue deep to the skin. As a result, we are able to inject below the skin and restore volume without causing skin irregularities.

The anatomy of nasal skin is different and therefore an expert in rhinoplasty who understands this anatomy is important when considering Non Surgical Nose Job

Nasal skin is very different, and varies not only in different ethnicities but even in the same person from one area of the nose to the next. As a result, though the non surgical rhinoplasty is marketed as a “lunch time” and “15 minute” rhinoplasty, the truth is that patients can and often do have swelling and redness that can last for weeks. It can also result in: 1) Skin irregularities- occasionally when injected superficially it results in little bumps of the filler; 2) Infection- many doctors have found that material injected into the nose can result in both short term infections as well as serious chronic infections; though rare, it has occurred; 3) Bruising and hematoma- just like surgery, anytime you get an injection it’s possible to get bruising; 4) Skin necrosis- this is probably one of the more serious problems but thankfully relatively rare; the skin overlying the injected area can simply die. This is a devastating problem because its repair can be very difficult.

Aesthetics- How the nose looks?

There are two major problems with the aesthetics of injectible rhinoplasty: almost by definition injectible rhinoplasty = augmentation rhinoplasty; those doing non surgical rhinoplasty are not necessarily trained in nasal anatomy or aesthetics

Injection rhinoplasty is like augmentation rhinoplasty and therefore can refine the nose, but you have to be wary so that your nose is not made to look too big

It is often said that if one has only a hammer, over time everything can begin to look like a nail. With injection rhinoplasty, not everyone is a good candidate. Most patients who come in to see us want to have smaller noses or more refined noses. For some patients, especially those with thick skin and certain ethnicities, that does occasionally mean that in order to refine the nose we actually have to put cartilage in to add definition or build the bridge. As a result some of these patients are good candidates for injection rhinoplasty if they do not want a nose job. However, for all the other patients who present with a bump, a twisted nose, tip problems or breathing issues- injection rhinoplasty is simply not the best answer.

As facial plastic surgeons we spend a lot of time studying and developing our aesthetic sense, especially in relation to rhinoplasty, “nose jobs.” However, as we write this paper, injection rhinoplasty is being done increasingly by many physicians who do not have any training in the aesthetics or in the anatomy of the nose and face. And unfortunately for patients, unlike with surgery where a certain level of expertise is expected by you before you trust your face to a surgeon, a procedure like injection rhinoplasty is being marketed as a simple procedure with little risk. As a result a variety of physicians and physician allied professionals who may not have any expertise in the anatomy and aesthetics of the nose are now injecting the nose with semi-permanent or permanent fillers which can and do occasionally cause an array of devastating complications.

Conclusions

More studies regarding injection rhinoplasty need to be done in order to determine what materials, if any, are safe long-term. At the present time, we would recommend that patients who are interested in injectible rhinoplasty see surgeons and doctors who have experience in both injectible rhinoplasty and in surgical rhinoplasty; and as with all elective procedures you should see more than one doctor before you decide.

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.

No one likes to think about going through surgery and recovery more than once.

At Profiles Beverly Hills, patients who have not been entirely happy with prior cosmetic results often are referred to us seeking revision surgery. This is not to say that many patients are unhappy after surgery…quite the contrary is true. A great majority of patients are happy with their outcomes and most are not looking for perfection. What is a minor imperfection to some, though, is not so to others.

Still fewer patients are left with a more significant deformity. Conditions that may increase chances for a suboptimal result are poor technique or lack of surgical experience, an uncommon complication such as an infection, or sometimes simply the unpredictability of healing. An honest dialogue between patient and surgeon regarding desires and expectations can go a long way toward avoiding postoperative disappointment.

This woman was unhappy with her twisted and bulbous, boxy tip despite a previous Rhinoplasty. Also, her nasal septum was poorly supported and deviated so much that it was jutting into her right nostril and compromising her breathing. She wanted an overall smaller, smoother, and more feminine nose with improvement in her breathing. The 1 year postoperative photo on the right shows that these goals were achieved and she was thrilled that her new nose no longer dominated her face. 

If you have a suboptimal result, it can often be improved upon. However, you should be aware that the chances for unbridled success must be downgraded slightly in this situation. This is because we are faced with having to revise surgical alterations against a background of scar tissue and distorted or lost anatomy. Scar tissue also tends to build upon itself with each subsequent surgery while normal structures or layers within and below the skin may thin out or atrophy. Nevertheless, in well-considered cases, we have had numerous successes in third, fourth, or even fifth rhinoplasty revisions. There is no magic number for allowable procedures.

We consider each patient on an individual basis. If we believe that a person’s concerns are clear, motivations are honest, and desired improvements are achievable in our hands with acceptable risk, we may recommend proceeding. Sometimes, though, things are better left alone, and we will be frank with you in that event. If you have questions about revision surgery, feel free to contact us for a more detailed discussion.

First and foremost, do not panic.

Early changes after Rhinoplasty are influenced by swelling and do not necessarily reflect the end result nor what was done during your operation. Trust your instincts and talk to your doctor about your concerns. There may be a perfectly good explanation for what you’re seeing. Sometimes, reassurance is all that is needed.

Once the cast comes off your nose, the natural tendency is to stare in the mirror for far too long- looking for the smallest of changes. This is precisely the most harmful thing to do because it will not change your healing and will only make you more nervous.

You will find that you are more swollen in the morning, when you are more active, or after lying down for long periods of time. This is because blood and fluid pools in the area of your nose and cheeks. Aside from that, healing happens in drips and drabs. You may not notice any changes for a few days, and then suddenly see a big reduction in swelling. There is a range of ‘normal’ healing. Don’t be alarmed if you are on the edge of that range. Your surgeon should let you know if anything unexpected is happening. If you are still unhappy at six months or a year, it may be time to talk about your options for improvement.

Your original surgeon is still the best place to start with this conversation, if he or she still has your trust. If not, consult a surgeon who has an experienced practice in Revision Rhinoplasty to see if this is a good option for you.

If you have any questions, please feel free to give us a call or send an email.