Beverly Hills Rhinoplasty Surgery Blog

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.

We were recently asked this question by someone who was understandably worried about these persistent symptoms about one year after a revision rhinoplasty. She wondered whether steroid injection would still work at this stage.

While discoloration is admittedly unusual at this stage, the key to this question is fluctuation. If swelling and redness were persistent and not getting better, we would be concerned about a possible low grade infection or chronic inflammatory condition, especially if there were a graft of foreign material placed in the nose. When swelling or discoloration fluctuates between being present and then going away, we are not nearly as concerned.

Whenever rhinoplasty is performed, the surgeon is lifting the skin and soft tissues of your nose to alter the cartilage and bony framework. By definition, this process involves disrupting the little nerves that provide sensation to some areas of skin and the little vessels that allow normal drainage of fluid from your skin. Thankfully, this ‘injury’ heals and all goes back to normal. With each successive surgery though, this healing can take longer and it is uncommon, but not abnormal, to have some of the symptoms being talked about even at one year after a revision.

These symptoms are definitely annoying, but the fluctuating nature of these symptoms is really a good sign. That means that there is still some healing to go and things will continue to improve. Some people pass this stage at 9 months. For others, it may sometimes take another six months or, rarely, longer until you see this go away completely. Steroid injections are meant to help you get there faster and can still help at your stage of healing.

Until then, it is normal to have flushing of the skin in hot environments, bluish discoloration in colder temperatures, and fluctuating swelling and congestion, especially when laying down for long periods or when exercising or doing any activity where fluid collects in the area.

The marker of healing is fluctuation. As time goes by, the swings from ’swollen’ to ‘happy’ days will start to narrow and the fluctuation will eventually stop. That’s when you know you’ve reached a near-final result.

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.

We have been getting numerous questions lately about whether it’s possible to fix an overshortened nose. A large part of our practice is helping people who previously went in for rhinoplasty with a plastic surgeon to fix a specific complaint and did not get what they were hoping for. Of all of these unhappy people, those with over-rotated noses (turned up too much) or over-shortened noses are some of the unhappiest. This is a harder problem to fix but it can most definitely be accomplished.

So how does this result happen in the first place? Well, it has everything to do with the techniques that are used to reduce a long or projected nose. Take a look at the images below to get a picture of normal nose anatomy.

In the top image, you can see the normal bony and cartilage anatomy of the nose in profile. The picture on the bottom shows the anatomy of the septum inside your nose in relation to the external anatomy. The septum, shown in white, makes up the foundation for the middle part of your nose (the upper lateral cartilages) and, to some extent, your tip as well. It is a large block of cartilage and bone that sits on the upper jaw and provides some nasal stability. The bone to which it attaches along the floor of your nose is called the maxillary crest, and the very front of this bone is a projection called the nasal spine, shown in blue. You can normally feel this as a hard piece of bone at the base of your columella. These are important structures that we’ll tell you about next.

So how is it that some rhinoplasties have such problematic outcomes? Many surgeons, shorten a long nose by removing the nasal spine and the front part of the septum. See the image below for details.

On the other hand, when we want to shorten a nose or rotate the tip, we focus on altering the shape of the tip cartilages themselves to create the contour we want. In this way we are able to provide a predictable result that does not weaken your nose (if anything, it makes it stronger).

Seen above are the cutting methods used by many surgeons to shorten a long nose. This is a bit like shortening a building by knocking out the foundation. The structure sinks, and not in a good way. When the nasal spine or septum are shortened many patients have an acceptable result for the first year, but they are highly unpredictable and often do not last the test of time. They depend on scar tissue build-up to determine the movement and the ultimate shape of your nose. When the foundation is removed, your tip might fall forwards and droop or it might fall backwards and look too short and upturned but, either way, there is a good chance it will collapse and lose refinement over several years.

Why do some surgeons do this?? That’s a good question that we don’t know the answer to. However, most likely, it’s because cutting is quicker and easier than the methods of reshaping the nose and tip to achieve lasting predictable deprojection and rotation. These more reliable techniques are also more difficult to perform, especially through a closed approach. And, since many of the problems that arise from these cutting techniques may not be seen for several years after rhinoplasty, many surgeons may not even realize their patients are having these problems.

So, how do we fix this problem? These revisions are often complicated by virtue of the scar tissue that must be removed to gain the needed length. We then have to restore the cartilage that was lost using grafts known as septal extension grafts and/or extended spreader grafts. Sometimes, a tip graft is used to achieve added length and projection. The good news is that a balanced profile can be achieved, the nose can be lengthened and you can be made happy again.

Above is a Before and After Rhinoplasty photo of a patient who had revision rhinoplasty surgery at Profiles Beverly Hills by Los Angeles Rhinoplasty Surgeons Drs. Peyman Solieman and Dr. Jason Litner. Note the overshortened, overrotated, undefined, and scooped appearance on the left and the restoration of an harmonious and natural profile after surgery. For more information on other rhinoplasty mistakes, visit our dedicated rhinoplasty site.

As most of you are aware by now, accutane can be quite abrasive to the skin. What some may not be aware of, is how damaging rhinoplasty can be to the skin envelope when not done by an experienced rhinoplasty surgeon. Sadly, we are very often presented with patients who in their previous surgery had either a hole made through the skin or because the surgeon was in an improper plane, massive amounts of scar tissue was created after surgery.

Luckily, in the majority of revision rhinoplasty cases the skin envelope is healthy and viable, allowing us to correct any other issues. As such, this particular question partially has to be made on a case by case basis. For those people wanting primary rhinoplasty (first time nose job) or in whom the previous rhinoplasty did not injure the skin envelope, waiting a month to 6 weeks after finishing accutane is likely enough time to proceed. If there is lots of scar tissue or other skin damage, the question has to be answered based on the extent of the problem. It may be wiser in those cases to either wait 3-6 months, or in the rare case it may be advisable not to operate ever because the risks would not outweigh the benefits.

The only further caveat is to make sure you see someone who does lots of revision rhinoplasty. This is particularly important in complicated cases like this so that you can feel safe in the knowledge your surgeon has the experience to make an honest appraisal.

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We are often asked about using fillers in the nose. We usually don’t advocate the use of fillers or fat in the nose for anyone who needs more nasal support, structure, or definition. Your nasal cartilage and bone are hard tissues and their appearance seen from the outside can’t be reproduced using fillers. In these cases, a rhinoplasty or revision rhinoplasty is the answer.

Sometimes though, there is a tiny depression or contour change that is present after rhinoplasty. Using a filler to plump up this area sounds enticing when compared to having to go through another surgical procedure to correct it. Let us say this about fillers in the nose. Proceed with caution. Hyaluronic acid fillers such as Restylane and Juvederm are fine in the nose if done by an experienced injector if care is taken to avoid problems. Longer lasting fillers such as Radiesse or Artefill (more on Artefill later) are not a good idea in our opinion and you can check out the photo below to see why.

This photo shows a recent revision rhinoplasty done at Profiles in which there was filler previously placed in the nose. From the look of it, this was probably a hydroxyapatite-based filler such as Radiesse. While filler in the nose may sound like a great idea to some, it can make any future revision surgical procedure exceedingly difficult. You can see the calcified filler particles at the tip of the scissor. Notice how it is incorporated into the skin which makes safe dissection very precarious.

Normally, we count on healthy planes between tissues to make surgery go smoothly with the least possible trauma. While tissue planes are never perfect in revision rhinoplasty, the picture is complicated by the use of fillers as seen above. These fillers can cause so much inflammation and scarring beneath the skin that it is next to impossible to remove them entirely during a revision surgery. So, if you are considering filler for your nose, think about talking to a rhinoplasty expert before you make your decision.

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To crush, or not to crush, — that is the question: —

Whether ’tis better in the mind to only think about crushing

The cartilage, but leaving it intact for grafting,

Or to take arms against the cartilage,

And by crushing it? — To sleep, knowing the cartilage will not show through, —

The heart-ache, and the thousand natural shocks

That cartilage is heir to, — ’tis a consummation…

To sleep, perchance to dream: — ay, there’s the rub;

For in that sleep of crushed cartilage what dreams may come,

The perfect nose…

For those of us who do a lot of rhinoplasty and revision rhinoplasty, there is often the moment some time during the case when we question whether we should crush cartilage hoping that it will last and lie more discreetly? Or whether we should leave it intact fearing that if we crush it, over time it will reabsorb?

Recently there was an interesting article that looked at the survival of crushed cartilage vs non crushed cartilage in the Archives of Facial Plastic Surgery. Not surprisingly, they found that crushed cartilage did not appear to survive as well in their animal model.

Unfortunately for those of us who operate on people, the study looking into crushed cartilage from rabbits really does not help answer any questions. For one thing, while they tried to standardize how hard they crushed, in real life this is very difficult to translate into our own practice.  Moreover, they placed all the noncrushed cartilage on the dorsum and all crushed cartilage on the nasal sidewall- perhaps they could have switched it up to see if placement made a difference.

So what does this mean to anyone doing or having rhinoplasty: simply said, it appears that crushed cartilage is a great way to conceal irregularities, fill defects and create smoother surfaces, but it is important to be experienced so that the cartilage is not so crushed that it disappears over time….there is the rub.

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.

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.