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.

A bulbous nasal tip is one of the most common reasons for patients to seek rhinoplasty. A bulbous tip, often called a boxy tip, refers to a tip that is too wide and prominent in proportion to the rest of the nose and other facial features. The key focus in our approach to bulbous tips is in emphasizing creation of a sense of tip refinement and definition rather than excessive narrowing.

To accomplish this, we rely heavily on suture techniques that draw the tip cartilages into exactly the shape we want rather than relying too much on older techniques that involve removal of strips of cartilage from the tip in order to make it smaller. The advantage of our approach is an extraordinary degree of reliability and predictability that can do away with potential problems like pinching of the tip, loss of tip support, and breathing issues.

One other consideration in evaluating bulbous tips is the need to address any other contributing factors. Many bulbous tips are not just wide — they are too prominent in all dimensions including being overprojected, or pointing out too far away from the face. Often, and especially in ethnic patients, the fatty tissue overlying the tip cartilage is also thick and needs to be dealt with if we hope to get the best possible result. The open technique is by far the superior approach for dealing with both of these issues because the cartilage and fatty tissue can be addressed directly as opposed to using indirect methods to deproject the tip that potentially weaken tip support. This allows us to create a tip that is symmetrical, smooth, and strong enough to hold up for a lifetime.

The patient below is shown before and 1 year after open rhinoplasty for refinement of a bulbous tip. Note how the boxy appearance has been transformed into a more triangular contour while remaining smooth and without looking pinched.

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.

Recently we came across a post from someone asking about the “nose huggie.”

Intrigued we looked it up and found what appears to be a modified hair clip being touted as a rhinoplasty alternative. Sadly, although it is true that the nose is made up of a lot of cartilage, you cannot simply mold the nose or its cartilage with pressure. In fact, when discussing rhinoplasty with our patients we go to great lengths to explain that cartilage and bone cannot simply be molded like clay.

So while there are occasional patients who we think can benefit from injection rhinoplasty, also called non surgical rhinoplasty- the nose huggie is not something that we frankly think works as a non surgical alternative to a real nose job.

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.

An interesting question that came up on the RealSelf forum had to do with radix grafts. A radix graft is a (usually) small piece of cartilage placed at the root of your nose between your eyes. It’s meant to add height to this area and is potentially used for several reasons.

We don’t often use radix grafts but may do so when someone’s bridge has been taken down too much in this area during prior surgery. In some patients, the root of the nose starts very low giving the appearance of an exaggerated bump on the bridge or an overly shortened appearance to the nose. Because the nasal root is so deeply-set, the angle between the nose and the forehead is exaggerated.

In these cases, a radix graft can be appropriate as a better alternative to taking down the bump so much that it brings the bridge too low or shortens the nose too much. A radix graft can preserve or augment nasal length by giving the nose the appearance of ‘taking off’ a little higher from the forehead.

The particular question today had to do with the effect of a radix graft on the appearance of the eyes. This person had closely-set eyes to begin with and was afraid that a radix graft might worsen that appearance. It is true that a washed out nasal bridge can give the sense that your eyes are farther apart. Conversely, adding height to the bridge can theoretically give the sense that eyes are drawn closer together.

But (and this a big but here), if you are considering this question, you must think about where you are coming from. If your bridge was taken down too low during a previous surgery and you are considering adding back some natural height and length to balance your nose, then the impact of a radix graft on the appearance of your eye width will be minimal.

On the other hand, improving a washed out appearance of your bridge would have the effect of creating more nasal narrowing and refinement from the frontal view. And, this is hopefully what you’re trying to accomplish. So, while we consider any graft carefully before recommending it, a radix graft is sometimes just the right fit for the problem at hand. For more information about nasal aesthetics, check out our online rhinoplasty textbook.