Beverly Hills Rhinoplasty Surgery Blog

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.

How about neither? We are often asked about nasal implants. These are primarily used for East Asians, African Americans, and others seeking a stronger, higher nasal bridge and a more refined tip. They are also sometimes recommended for patients whose bridge has been lowered too much during previous surgery. Implants can be of various materials but the most commonly used implants are made of silicone/silastic.

Above you can see the typical shape of a nasal L-strut implant. This particular one happens to made of Medpor which can be a real problem to revise…but that’s another story.

We were recently asked about revision of an L-shaped implant that gave this particular patient’s nose a pointy, unnatural appearance. She had been happy with her natural tip but the surgeon recommended an L-strut anyways. Now, she didn’t like the look and was also starting to notice some redness of her tip 3 months after her surgery.

Let us say first off that we’re not big fans. We much prefer your own cartilage for augmenting or rebuilding the nose, whether it is from the septum, ear, or rib, or even sometimes irradiated rib.

The concerns mentioned can sometimes arise after use of a nasal implant, and that’s part of the reason we’re not big fans. An L-strut lays over the entire bridge and extends down under the tip to the base of the columella. It gives the tip definition by placing a fair bit of pressure over a small area of skin to tent the skin out. It cannot reproduce or retain the natural shape of your tip. As a result, it can look a little too pointy and unnatural.Sometimes, this pressure on the skin can become too much for the skin to bear. If you are noticing redness at your tip after an implant, you should see your surgeon or another rhinoplasty expert early to determine the cause. If the skin is under too much tension, this would be a good reason to intervene early with a revision procedure to avoid injury to the skin.

The other problem with an L-shaped implant is the possibility that it will twist or move over time and cause your nasal contour to appear crooked. These problems are less likely with an I-shaped implant that stops just above your tip because the forces of healing and skin contraction do not act on it in the same way. An I-shaped implant really justs rests on your bridge without providing the same type of structural support that an L-shaped implant is intended to give. Still, an I-shaped implant can look bulky, blocky, and unnatural. Your own natural nose is not one continuous block of cartilage…so a long, bulky, continuous implant does not make sense to us. We should replace your own lost or deficient tissues with similar tissues.

Our preference for ethnic augmentation rhinoplasty is to use your own cartilage for augmentation. If you are happy with your natural tip, you should be able to keep that roundness. Augmentation of your bridge can be done by itself to balance with your tip and other features. If you continue to be unsatisfied with a nasal implant, rest assured that you can achieve a refined but natural nose.

Here is another one from the Q&A file that can be a source of concern for people soon after a rhinoplasty. We were recently asked about vertical lines/shadows showing up after rhinoplasty on either side of the bridge. What was more worrisome for this person was the fact that she was able to feel small gaps when she pressed on the area.

The lines you may feel at the sides of the bridge are most likely fracture lines in the bones that were created to narrow or straighten them. If your bones were wide or crooked, then the surgeon must create these cuts in the bones in order to manipulate them to the desired shape.

If there was a lot of narrowing accomplished, you can sometimes feel a little gap in this area which can be perceived as a small ’step-off’ in appearance.

Don’t worry too much, though. If this is noticeable at all (and most people will not notice this), it will not last long. The bones will heal and the apparent gap should diminish in most situations. This rarely ever becomes a long-term problem, and usually only when the bony cuts were made too high near the bridge. If you are having a similar concern, you have reason to be reassured.