Beverly Hills Rhinoplasty Surgery Blog

How fast you heal after rhinoplasty is a major question on everyone’s mind, whether it’s your first surgery or a revision. No matter how careful or meticulous your surgeon, there will still be some swelling afterwards. Your nose will not look exactly like the computer-imaged ‘after’ picture as soon as the splint comes off. It will take some time for your skin to contract and ’shrink wrap’ down onto the new structure underneath to really give your nose a lot of definition. Of course, the goal is to get you feeling good about your nose as soon as possible and we do whatever we can to make sure that happens. We want you to skip the puffy stage and move straight on to liking your nose…really liking it. That’s why we are fans of asking patients to tape their noses at night after surgery and of using steroid medication, both during and after surgery, to speed up healing.

There are a number of studies that have supported the use of steroids in rhinoplasty to reduce swelling, bruising, and discomfort from surgery. We offer most of our patients a short course of oral steroids after surgery. When the splint comes off 6 days later, we find it makes the difference between “Wow! I love it already!” with steroids and “I can see it’s gonna be great but it’s puffy right now” without steroids. Beyond the first month, we find judicious use of steroid injections to be enormously helpful in reducing swelling in certain stubborn areas of the nose like just above the tip where the skin is thicker.

You often hear that it can take a year or longer after a nose job before you’ll see the final result. Many of you may be skeptical and a small number of you probably roll your eyes when you hear a statement like this. Does it really take that long to see results or are surgeons just telling you that so they can buy time in case you’re not seeing what you want to see after surgery?

The answer is that surgeons aren’t just feeding you a line. It really does take time for the skin to shrink down and wrap onto the new structure underneath. That’s not to say that you’ll be miserable for months. Our patients generally bound into the office for their 3 month visit ecstatic about their noses. Still, when we take photos, we can see that there is still some swelling that needs to settle so that more definition can show through. The photos below are a perfect example of just how much your nose changes over the first year after rhinoplasty. In cases of revision rhinoplasty, thick skin, or when the nose has been deprojected or brought in significantly, this process happens even more gradually.

Looking at these photos, you can understand why we tell our patients that it matters far more to us how their noses look at 1, 2, or 10 years after surgery than it does at 2 weeks after surgery. At 2 weeks, your nose will look good but puffy. If a surgeon is showing you photos that look absolutely perfect 2 weeks after surgery, be very wary. You can bet that those same perfectly cute noses at 2 weeks will probably look scooped and overdone at 2 years once the skin contracts. It’s important to make sure your prospective surgeon is showing you long-term results.  

The young woman below underwent primary open septorhinoplasty with us at Profiles Surgery Center. Photos below (from left) show her pre-op, at 3 months, and 1 year after her surgery. Note how her 3-month photos still show some fullness and rounding while at 1 year we see a lot more definition.

It is only natural when you are reading and learning about rhinoplasty for you to be drawn to a particular idea of what needs to be done to your nose to achieve the rhinoplasty results you are hoping for. This is especially true of revision patients who have been ‘burned’ before and want to do everything possible to make sure that their outcome this time around is a decidedly different and positive experience. We have prospective patients coming to see us every week who have pretty well-developed pre-conceived ideas, like they don’t want an open incision or they must need a rib graft to fix their noses. A lot of this stems from having heard or read about a poor result with a particular procedure or from hearing mixed messages from surgeons about how they would approach their surgery. In fact, these are really not mixed messages at all, but actually just reflections of each surgeon’s individual style that developed from personal experience.

Getting a number of vastly differing opinions can be frustrating. But, think about it this way. If you were to give a project to 5 different architects to design a home for a particular space in a particular style, you would get 5 totally different results. None of these designs is right or wrong, but you will find that you probably like one or two a lot more than the others. Is it important that the house is not only beautiful but well-built on a solid foundation? Absolutely. Would you know if using a particular material for a certain support beam makes a difference? Probably not. Likewise with rhinoplasty– If you are in the hands of an experienced rhinoplasty and revision rhinoplasty specialist (and that’s a serious if), you can be pretty sure that your nose is not going to fall apart down the road. It is whether your surgeon truly understands your aesthetic sense that is the most important factor in our minds.

By all means, ask as many technical questions as you want about how your surgeon intends to achieve your goals. But, as you go about trying to decide on a surgeon, we would humbly suggest that you focus on communicating the look you are trying to achieve more than on the technical aspects of the procedure. At Profiles, we fight against applying an individual style and instead try to focus on you, your aesthetic and tailoring your procedure individually to your features and desires. At the end of the day, if your surgeon hasn’t spent enough time getting to know you and doesn’t understand your aesthetic, then you aren’t likely to be happy with your result, no matter whether your procedure was done open or closed, with or without rib or ear cartilage grafts, etc.

Recently we’ve seen a number of people who have asked about the use of ethmoid bone in revision rhinoplasty. Each had previously undergone a nose job that had over time either resulted in loss of tip support- resulting in a droopy nasal tip- or had a twisted nose which had been partially corrected but over time had twisted again- resulting in a crooked nasal tip.

There have been a number of papers over the last few years regarding the use of ethmoid bone as stents in an attempt at correcting a caudal (anterior/front) septal deviation. We’ve also heard of their utilization in a similar manner with other grafts. While the initial results look pretty good, we have yet to go to ethmoid bone as a source for a couple reasons.

First, and foremost, even in 3rd and 4th time revision nose jobs, we have always found enough cartilage via the septum and/ or ears. These sources bring cartilage, as opposed to bone, and as such are much more in line with normal anatomy found in the areas of the nose usually requiring correction. As for correction of anterior/ caudal deflection we have also found that in almost every case this can be corrected without a stent, though we have no objection to the use of a stent graft for correction when necessary. Finally, our major concern with the use of ethmoid grafts in other areas of the nose as stand alone grafts is the high likelihood of resorption long term. One of the original innovators in the use of ethmoid bone was the now retired Dr Jack Sheen. In a conversation with him in the year prior to his retirement, he intimated that he had stopped using ethmoid bone grafts due to their high resorption rate.

Having had more experience than anyone else we know of, and taking into consideration all of the other potential sources of grafting material, ethmoid bone is lower on our personal list of graft sources.

We have recently heard from a couple of prospective patients who are concerned about having open rhinoplasty to narrow the tip and a nostril narrowing procedure (alar base reduction) at the same time. They had been to see other surgeons who had advised against this because of fear of risk to the blood supply of the nasal tip.

Quite frankly, we were a little surprised by this recommendation. The beauty of surgery is that it is not an exact science and there are many ways to arrive at the desired goal. However, the concern that tip rhinoplasty and nostril narrowing, when done together, might compromise the blood supply to the tip skin is really unfounded. In fact, most surgeons who make rhinoplasty a focus of their practice will tell you that they routinely perform these procedures together without issue. That has been our experience.

Some surgeons also advocate waiting to do nostril narrowing as a second procedure so that they can better assess how much narrowing is needed. To the contrary, we have found that we can very readily assess at the time of the initial tip work how much nostril reduction is needed if at all. To our minds, the initial surgery is the best time at which to make these desired changes to create a tip that is balanced and harmonious by reducing nostril width, flare, and asymmetry. We leave this part of the procedure to the very end so we can best determine how much nostril width and flare is still an issue after the other tip enhancements have been achieved. In experienced hands, the minimal swelling that occurs during surgery is not a factor.

There’s no real harm in waiting, of course, other than having to go through a second procedure later on. It can be done fairly easily under local anesthesia. In rare cases, when we feel that someone is very borderline in terms of need for nostril narrowing, we’ll wait. We almost always find later on that indeed it was not necessary. But, our overriding philosophy is that we want our patients’ first rhinoplasty with us to also be the last time they need anything done for their noses. So, when alar base reduction would be beneficial, we want to take care of it at the same time.

We often see ethnic patients wanting a more defined nose. Many ethnic noses tend to have thicker skin. Achieving the definition, narrowing, and refinement you desire has everything to do with how that thick skin wraps around the cartilage structure underneath. If the cartilage structure is well-defined and well-supported, you can achieve excellent definition. If the cartilage lacks shape, your tip will look the same- bulbous, wide, full, and lacking in shape. On top of that, ethnic patients often have a thicker layer of tissue under the skin that lays on top of the tip cartilage. In these cases, it is necessary to carefully ‘thin out’ the thicker pad of tissue under your skin so that the newly-defined cartilage can show through.

Ethnic rhinoplasty depends more on cartilage grafting (using your own cartilage to create definition where it is lacking) than does traditional rhinoplasty. So, you should see a rhinoplasty expert who has experience in ethnic rhinoplasty to ensure your chances at a great result. We have found that a combination of tip cartilage suturing/grafting and soft tissue thinning, along with augmentation of your bridge and nostril narrowing, if required, can produce a beautiful and natural result. You’ll see some examples of the results you can achieve on our website.

Everyone who has suffered a poor Rhinoplasty result experiences a range of negative emotions. All are understandably unhappy about their noses and fearful of misplacing their trust once more. Yet, there are some who experience a more extreme reaction, a few of whom we’ve seen recently.

These are patients who have what is termed ‘loss of identity’ syndrome, a feeling of dissociation from themselves because they cannot relate to the change in the way they look. Patients with loss of identity tell us they just don’t feel like themselves anymore. They just can’t reconcile their new appearance. We were reminded of this by a recent patient who, by all accounts, is a beautiful woman, but who was truly devastated by her previous Rhinoplasty.

This kind of thing happens more frequently after Rhinoplasty than other facial plastic procedures. There are many Rhinoplasty deformities that can lead to this feeling, but the most common by far occurs when the nasal bridge is taken down too much, especially in men. Removing a person’s sense of having a strong nose can be as simple as shaving a few too many millimeters of bone, but those few millimeters can make a huge difference.

That’s why it’s so important to see a Rhinoplasty specialist for your primary or revision nose job. In the hands of a highly experienced Rhinoplasty surgeon, there is no reason for anxiety. A surgeon who understands your aesthetic goals and who has the technical ability to achieve them can help you to transform your self-identity and recapture the confidence you deserve. That is why we find revision Rhinoplasty so rewarding. If you are experiencing some of these emotions, maybe it’s time to take another chance on a better outcome. Feel free to contact us so we can discuss your case in more detail and take the next step to finding happiness with your nose.

When you’re thinking about a nose job, you either don’t care how it’s done… you just want to make sure your surgeon can deliver the result you want and that’s it. Final. Over. Period. Or, you may join a growing group of people who want to research the procedure in detail to learn the pluses and minuses of open vs. closed rhinoplasty or Technique A vs. Technique B. If that sounds familiar, this blog is for you.

Most people have a hard time understanding nasal tip surgery. Taking down a bump on the bridge is easy to understand. A little shave here or there…it makes sense. But, it’s harder to wrap your head around how we make your tip smaller without removing a lot of cartilage and having it fall in over time.

Many plastic surgeons aren’t even comfortable working on your tip. For example, tip deprojection or bringing your tip closer to your face, is one of the harder things to do in rhinoplasty. Many plastic surgeons tend to avoid significant changes to the tip in favor of making the nose smaller by concentrating on that bump on the bridge (sometimes a little too much). So, one of the most common reasons both men and women want a revision nose job is that they think their tip is still too big.

So how do we do it? We use highly controlled procedures. One of our favorite techniques involves dividing the tip cartilage, overlapping the edges by a measured amount, and suturing it back together in a way that is stronger than it was at first (shown below). We can measure exactly how much we want your tip to move. And, depending on where along the cartilage we divide it, we can also change the angle your tip makes with your upper lip and correct any tip asymmetries without having to worry about it changing over time. 

So, whether you’re considering your first nose job or a revision, you should know that these tools, if done right, can be a really powerful and predictable way to give you the smaller, refined tip you want like the one you see below. For more before and after photos of our rhinoplasty and revision rhinoplasty results, check out our rhinoplasty gallery.

The photo above gives you a peek inside at the anatomy of a boxy tip. For many years, the standard technique for tip narrowing was thinning of the upper edge of the tip cartilages, what we call a cephalic trim or cephalic margin resection shown below. When an excessively wide and thick tip cartilage is contributing to a boxy tip, this maneuver is helpful, but it’s very important that the surgeon doesn’t do so much thinning that the tip cartilages are destabilized.

The diagram below shows a reasonable amount of cartilage thinning (shown in red) that will preserve structural integrity and prevent collapse over time. This is especially important in thicker-skinned patients where stronger cartilage is necessary to support the thicker skin. Sadly, we continue to see potential revision patients every day where most or all of the tip cartilage was removed in this area resulting in predictable collapse over time.

Suture techniques for tip narrowing and refinement

 You can see from the above real patient photos that these techniques can produce a dramatic improvement. We need to be careful to preserve just the right angle between these cartilages so that light will reflect favorably on your new tip. An inexperienced or careless surgeon may draw the cartilages too close together or may introduce asymmetries that show up later on, or he may not account for skin thickness and other factors. But, in the right hands, suture techniques provide a powerful way to safely provide the refinement and narrowing you are looking for without compromising breathing. In a future post, we’ll show you how we address tips that are too overprojected.

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

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

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

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

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