Here’s a typical scenario. You’re considering facial plastic surgery to take care of a bump on your nose, a droopy tip, or a sagging jaw line. The feature may be subtle, but it’s definitely there. And you’ve been thinking of doing something about it for so long.

 You’ve finally worked up the courage to tell your husband/mother/sister/brother/best friend (insert loved one here) about it and, instead of uncompromising support, you hear something like “Your nose is fine. Why would you mess with it?”. Other reactions are “Whatever makes you happy, honey” or, “I was wondering when you were gonna take care of that honker”. But, the overwhelming #1 reaction is the first one.

You’re crestfallen. You start to second guess yourself. You think “I’m not imagining this. There is a noticeable bump on my nose. Why doesn’t anyone else see it?”. Well, the answer is, they do and they don’t. They can see the feature you’re pointing to just as well as you can. The human eye is capable of incredible feats. Our eyes can discriminate between two objects down to 1/25th of an inch or about 1 mm. So, if we show you a photo of your nose and another photo with your bump shaved down just one millimeter, you’ll be able to see the difference every time. And, we all also have a built-in, hard-wired aesthetic sense of proportion, symmetry and ‘belonging’ness when we compare one feature to the rest of the whole. So, they know deep down that the bump is there.

But, your family or friends may not “see” what you’re talking about because they don’t wish to and they don’t attach the same level of importance to it as you do. They care for you as you are, as they should. And, they’re afraid for you. Afraid of the risk, even if it’s very small. And, afraid that you’ll change too much. After all, you may want a subtle change or a dramatic change, but they don’t necessarily see what you see.

 Some of our patients who are REALLY close to family and friends and look to them for advice are really freaked out by this. We’ve even had a few patients recently who’ve nearly psyched themselves out of their decision. The important thing here is not to try to force your loved one to feel about your proposed surgery the way you do. Family are never quite as enthusiastic as you may be. Instead, you should let them know how important this decision is to you, and how much better you’ll feel if you have a positive outcome. That will often turn them around because what’s important to you is often what’s important to them. The decision to have surgery is a very personal one and is ultimately yours. You can reassure them that, if you’ve chosen the right surgeon, your results will look natural and won’t remove your identity.

 What’s interesting is that the most resistant family member or friend is usually your most astonished and glowing supporter after the surgery once they see how happy you are with the change. This is just something to consider when you sit down to have “the talk”.

It’s funny how you don’t really notice noses until you notice them….and then you can’t stop yourself. Most people can meet you, have a nice conversation, and go on their merry ways without ever really noticing your nose. Our eyes tend to be attracted to other people’s eyes. After all, they are the so-called windows to the soul. Next, we notice lips and smiles, especially when talking. These are the features that tend to be important in communicating and building a rapport with people. And finally, placing a distant fourth, other striking or not so striking features come up on the radar. Unless your nose is very out of place with your other facial features, it will tend to melt into the background even though it is smack-in-the-middle of your face.

People who tend to see noses everywhere are usually either very concerned with their own noses, have had or are planning to have a rhinoplasty, or are facial plastic surgeons. Most other people just don’t pay that much attention, until you point it out to them. And that’s why a lot of imperfect noses are walking around on some of our most iconic beauties. Take supermodels and celebrities as perfect examples.

Adriana Lima and Gisele Bundchen are known for their exotic beauty and are two of the most highly sought after supermodels in the world. Granted, they have a lot of other things going for them; but, try for a moment, to take all those positives out of the equation and concentrate on their noses. Adriana’s tip is decidely wide and boxy. And Gisele’s profile has a prominent bump and a droopy tip. But, that defines their looks.

Paris Hilton is another pop culture icon whose nose is a prime example of a thin, pinched, and hanging tip. Of course, that doesn’t stop her from being a tabloid media darling.

These noses aren’t perfect but, then again, they don’t have to be. And, the one thing they all have in common is that they add some character to their owners. Now, many of you are thinking that, sure, these women have so many other stunning attributes that noone would ever notice their noses. Maybe so. But, the same thing applies to the rest of us. Your nose doesn’t have to be perfect, it just has to blend in. And, that’s where we come in.

So, be careful of asking for a too-generic nose. A good nose job shouldn’t sacrifice your identity.

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 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…

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.

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.

Rhinoplasty is different for men and women in almost every respect starting out with facial aesthetics. While there is a lot of individual variation, facial aesthetics differ substantially between the sexes. In general, compared to women, the following features are considered more masculinizing and, therefore, more desirable for most men:

• a more acute nasofrontal angle (the angle between the forehead and the nose seen from the profile)
• a more acute nasolabial angle (the angle between the nose and the upper lip seen from profile - usually about 90-100 degrees)
• a straighter profile
• a higher bridge (even a slight bump)
• a more sharply defined, angular tip
• a longer nose
• more tip projection (the degree to which the tip juts out from the face)

In addition to the above, there are other factors we have to consider when contemplating Rhinoplasty in men vs. women. Men tend to have stronger, heavier cartilages and bone along with thicker skin in many cases. This will influence what needs to be done to create the desired changes and also the expected timeline of healing. We will vary our discussions with men depending on whether they have very strong, angular features or softer, rounder features. After all, the nose must fit the face. In general, though, men can tolerate a slightly high bridge and overprojected tip. By contrast, a male nose that is slightly scooped, too short, or too rounded does not go over well at all. So, we will always err on the side of maintaining a strong, masculine nose for male patients. There are some women who prefer and would benefit from some of these features, albeit to a lesser degree. Very tall women with longer faces, for example, usually look better with a straighter profile while very slight-featured, petite women can better tolerate a petite, softer, ‘cutesy’ nose.

This blog only begins to scratch the surface of the differences between the sexes when it comes to Rhinoplasty. And these only serve as the basis for our assessment in creating a highly individualized surgical plan for you.