Beverly Hills Rhinoplasty Surgery Blog

And now for the final installation in our series of photos demonstrating the comparison of simulated surgical results done pre-operatively with actual rhinoplasty results obtained over one year after surgery. This already beautiful young woman wanted her nose to better balance with her face through hump reduction, tip narrowing and refinement, deprojection, and correction of a hanging columella. In the After photos on the right, you can see how this sense of definition and balance was achieved while maintaining a beautiful, natural look.

Continuing from our last post, we want to show you another example of how closely computer imaged results compare to the final surgical rhinoplasty outcome. This young woman had undergone previous rhinoplasty that left her with a wide, unrefined tip from the front view and a pollybeak-type fullness above the tip on profile view. Our pre-op computer imaging (middle photos) showed tip and alar base narrowing and refinement along with creation of a straight profile, and this was readily accomplished with revision rhinoplasty surgery as can be seen in these one-year After photos on the right.

Computer imaging is extremely important in our practice in helping our patients to articulate their goals for rhinoplasty surgery and for us to be able to communicate effectively what can or cannot be accomplished with surgery. It is not just about drawing a picture of a good-looking nose. For us, it is about being able to show accurately how each proposed change in surgery will truly affect every other aspect of the nose. It is critical for us that we are honest, precise, and real in our imaging. For that reason, we do not over-image but, instead, image a change that we know we can deliver. As a result, we are not only comfortable sending our patients their images before surgery; we use these images as a vital tool to facilitate conversation during the final pre-op visit to make sure that we completely understand the desired aesthetic. And then, we do not deviate from this aesthetic during surgery.

We have compiled images of several patients that we will post over the next several blogs to give you an idea of just how closely the imaged result can predict the final outcome. In these images, you will see the Before Unimaged photo on the left, the Before Imaged photo in the middle and the one-year After photo on the right.

This patient suffered a severely twisted and collapsed nose resulting from prior surgery. The goal and result was achievement of a smooth, natural nose that corrected the scoop, over-projection, nostril retraction and hanging columella while restoring normal breathing. On a side note, the neck liposuction result was even better than predicted.

Please note: We are happy to see that our blog is of some help to many of you who are considering or recovering from rhinoplasty. While we would like to address your concerns directly, we are not able to dispense medical advice over the internet. Your own surgeon is your best resource in the first weeks and months after surgery. If, after 5-6 months, you continue to feel unhappy with your result, feel free to contact us via our practice site www.beverlyhillsprofiles.com and we can arrange time to discuss your concerns. All the best for a happy outcome.

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.