Beverly Hills Rhinoplasty Surgery Blog

This is a great question that we get in our practice a fair bit and that we have looked into. In fact, we in association with our colleagues reviewed the largest series of injectible rhinoplasties (non surgical nose jobs, liquid rhinoplasty) done by anyone to date. In the study we examined all the patients over a year that had non surgical nose jobs with Radiesse to see how long it lasted and what if any problems occurred.

Side note- We will not make this blog a long diatribe about the merits of injectible rhinoplasty or about the aesthetics of the procedure, except to say that you should recognize that most people getting rhinoplasty want their nose at least slightly smaller whereas injectible nose jobs are by definition an augmenting procedure where the nose is made larger.

In short answer to the question, in our study we found that approximately 25% of patients required a touch up before 6 months, either due to partial resorption of the filler or because they wanted further augmentation.Over the remaining portion of the year, many more of the patients returned as the fillers dissolved. It is hard to say if the fillers dissolve completely because it partially depends on which filler material is use, but with the temporary fillers we suspect that the great majority of the filler dissolves with time.

For those wondering what about using other injectible fillers such as Sculptra, Aquamid Artefill, etc, it is true that they likely would stay longer in the nose but they can also cause inflammation, chronic infection, skin slough or a host of other problems. In fact, if you go to our blog a few weeks back we show an example of a patient in whom we did surgery who had had injectible nose job done some 7-8 months previously. (previous blog) In him, you can still see the injectible filler material that had to be removed. He is now very happy with his nose and he did great but it made surgery more difficult than it otherwise needed to be.

The point to all of this is that non surgical nose jobs, in our opinion, can be great to fill in minor defects or irregularities, but they should not necessarily replace or help achieve the goals that most people wanting a nose job want.

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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This is a great question that we get in our practice a fair bit and that we have looked into. In fact, we in association with our colleagues reviewed the largest series of injectible rhinoplasties done by anyone to date.I don’t want to make this a long diatribe about the merits of injectible rhinoplasty and if the aesthetics make a lot of sense, except to say that you should recognize that most people getting rhinoplasty want their nose at least slightly smaller whereas injectible nose jobs are by definition an augmenting procedure where the nose is made larger.

Getting injections done now can lead to distortion of what your nose really looks like and make it harder for your surgeon to know what your nose looks like originally. While it is true that injections can be temporary if done with restylane or juvederm, they can cause scarring or inflammation or infection  that can create further problems.

Moreover, other more longer lasting injectibles such as radiesse, sculptra, artefill, etc can and do stay longer in the nose causing further inflammation and needing to be removed at the time of surgery. In fact, if you go to our blog a few weeks back we show an example of a patient in whom we did surgery who had had injectible nose job done some 7-8 months previously. (previous blog) In him, you can still see the injectible material that had to be removed. He is now very happy with his nose and he did great but it made surgery more difficult than it otherwise needed to be.

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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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.

The nasal bones are not so much like a pyramid but more like an arched covered bridge or tunnel. When a bump is made smaller, the top of the bones are shaved or cut shorter to reduce the bump. This leaves an opening in the roof of the tunnel. That’s one of the reasons why we have to cut the base of the bones during surgery (called osteotomies). We perform osteotomies in order to push the bones inward towards each other so that this opening can be closed.

If the opening is not closed properly, we call the resulting problem an ‘open roof’ deformity. The photos below give you a sense of what this problem looks like. When you have an open roof, the middle part of the bridge will look and feel unnaturally flat. The edges of the bones are separated and can be seen and felt as a prominent bump at the side edge of the bridge. 

In the above photos, you can see how shaving down a bump on the bridge creates an ‘open roof’ deformity, shown here in purple. If this is not closed, the result is an unnaturally flat and irregular bridge shown by the arrows on the right.

Dr. Solieman and Dr. Litner have extensive experience correcting these and many other Rhinoplasty deformities. To repair an ‘open roof’ deformity, the bones need to be brought back together again. Sometimes, the bones have been so shortened and whittled away that it is impossible to bring them together without pinching the top of the nose completely. In this situation, it is necessary to rebuild the roof with grafts. Whatever the extent of your Rhinoplasty concerns, the Profiles surgeons are well-versed at tailoring your procedure to address your individual issues.Check out our site dedicated to rhinoplasty to learn more about your options for rhinoplasty revision.

The nasal valve is a term used to describe the narrowest part of the nose internally. This is the area that determines if someone feels normal or obstructed breathing through the nose. When this area is overly narrowed and blocked, we call it nasal valve collapse.

There really are two types of nasal valve collapse. The collapse of the tip cartilages described above can cause external valve collapse where the blockage is just past the nostril. When most surgeons discuss valve collapse, though, they are talking about internal valve collapse. This occurs when the upper lateral cartilages in the middle of the nose have been too narrowed. Check out the attached diagram to see where these are. This problem happens when a nasal bump is taken down too much and when the cartilages themselves are shortened or not reattached during a Rhinoplasty.

Above left, you see normal nasal anatomy with the nasal bones in grey, the upper lateral cartilages in pink and the tip cartilages in white at the bottom of the photo. The center photo shows a common finding after a poorly done Rhinoplasty in which these structures have been aggressively reduced and separated. The resulting changes are seen on the right. The arrows indicated the collapse of the upper lateral cartilages as they fall inwards and affect breathing. The problem seems to occur more often after a closed Rhinoplasty because most surgeons detach these cartilages without repairing and reattaching them at the end of the procedure. When the natural cartilage supports have been lost, they simply fall inwards and collapse.

The result is poor breathing and two visible cosmetic deformities. One is called an ‘inverted V deformity’. That’s because the collapsed area where these cartilages attach to the nasal bones looks like an upside-down letter V. Check out the photos below to see an ‘inverted V deformity’. The second problem is that the middle part of the bridge can start to look very pinched.

Here we see the full view of the same nose from the front. The photo on the right shows the ‘inverted V’ deformity caused by collapse of the upper lateral cartilages. Scroll forward to the last photo to see how we fixed this Rhinoplasty mistake.

This is a common problem after Rhinoplasty and the revision Rhinoplasty experts at Profiles Beverly Hills fix it using extended spreader grafts among other techniques. Click here to see our blog on the use of spreader grafts. In the last section, we took care of this patient’s tip abnormalities. Next, we turn our attention to the upper two thirds of the nose to correct her remaining problems.

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Think of the tip cartilages like a pair of wings. You can get an idea of what these look like from the photos below. The tip cartilages (lower lateral cartrilages) are like a bent spring that holds the nostril’s shape and keeps it open to allow normal breathing. In many poorly done rhinoplasties, this cartilage is aggressively cut or removed so that it loses this natural spring. Over time, whatever cartilage is left starts to bend and twist under the weight of the skin. As the cartilage twists on itself, the weak points at the ‘joints’ of this cartilage can start to form bumps or knuckles, called bossae, that are very noticeable through the skin. Check out the diagram below to see what we mean.

In the photos above, you can see normal anatomy of the tip cartilages on the left. The center photo shows the weakened and twisted cartilages commonly found after over-aggressive cartilage removal. The corresponding bumps (bossae) seen on the surface are shown by the arrows on the right.

Many surgeons treat these bossae by going back and trimming them, weakening the cartilage even more. Anyone can appreciate that this is probably not a good long-term solution. The Beverly Hills Rhinoplasty experts at Profiles know that the tip cartilages must be reconstructed in order to restore their natural strength and resiliency while improving on the cosmetic appearance of the tip. The photos below show the above Revision Rhinoplasty patient treated at Profiles to take care of her tip bossae and other post-rhinoplasty concerns highlighted in the next few sections.

Above is shown a before and after photo of a Profiles Revision Rhinoplasty to treat a twisted tip with tip bossae.