Beverly Hills Rhinoplasty Surgery Blog

As is often the case, it really is not possible to tell you for sure if septoplasty alone can straighten your twisted nasal tip; but we can tell you that in our own experience we’ve had a few cases where simply correcting the septum did straighten the tip.

While it is relatively rare, and in our experience only occurred in a few patients, we have had patients who had a septal fracture in the front part of the septum which resulted in a twisted nasal tip. In general these are not simple septum repairs that can be corrected via a routine septoplasty, but rather need to be approached through an open approach- which is the approach we use for rhinoplasty in many cases anyways.

If there is an anterior septal fracture, this approach will allow us to address the nasal tip even if the septoplasty alone does not completely straighten the tip- this can occur due to scarring or memory in the tip cartilages that would keep the tip twisted even after the septum is straightened.

However, all this being said we find that in general most of our patients have needed a rhinoplasty that focused on the tip in order to genuinely get a straight nasal tip. Each particular case has to be analyzed individually to determine if septoplasty alone will help in making the tip straighter, but ultimately until we operate and see what happens and what if any scar tissue is present we leave our options open so that we do not leave the OR until your tip is straightened.

Indications for Tip Grafts in Revision Rhinoplasty

In the revision rhinoplasty patient tip grafts may be necessary if: (1) there is a pollybeak deformity (2) there is an asymmetric tip or nasal bossae (3) there is a poorly defined nasal tip (4) in the overly shortened nose, or (5) there was failure to recognize false tip projection at the time of primary surgery or there was loss of normal tip support mechanisms after primary rhinoplasty. We will explore each of these situations in turn and post representative examples in future blogs.

Underprojected Nasal Tip and Pollybeak Deformity

Perhaps the most commonly utilized purpose for the tip graft in our practice continues to be the one for which it was originally devised. In his exploration of his 30 year experience with tip grafts, Sheen noted that poor tip projection and supratip deformity are very commonly seen in post- rhinoplasty patients. For a long time the principle cause of this supratip deformity was thought to be excessive skeletal tissue in the supratip region. As a result, surgeons used to routinely revise pollybeak deformities by removing even more tissue in the supratip region with a resultant exacerbation of the problem. Sheen’s proposal that the vast majority of these pollybeak deformities were the result of overzealous resection of the nasal dorsum is widely accepted today, and it is thought that the supratip deformity arises as a result of scar tissue deposition which naturally occurs in order to eliminate the dead space produced by overresection.

The factors to consider in patients with postoperative supratip convexities include:

• overresection of the caudal nasal dorsum with scar tissue deposition,
• insufficient removal of the dorsal cartilaginous septum,
• inadequate resection of the cephalic portion of the lower lateral crura (LLC),
• and inadequate tip projection.

Moreover, sometimes the surgeon focusing on a large dorsal hump or supratip deformity misses the concomitant underprojected nasal tip. It is therefore critical in correcting pollybeak deformity for the surgeon to make the aesthetic decision as to whether there is adequate tip projection. All too often patients are still misdiagnosed and consequently undergo the inappropriate treatment. Excessive attention to the dorsal hump results in overreduction of the dorsum with resultant long term resultant pollybeak deformity as the skin soft tissue envelope is unable to contract to the newly reduced skeletal framework.

To make this determination we evaluate certain characteristics which can serve as signs for underprojected nasal tip: shortened columella, acute nasolabial angle, maxillary retrusion, and small, weak alar cartilages. The use of tip grafts, particularly in revision surgery, for the treatment of supratip deformity often is the only means of correction available. Suture techniques, such as the lateral crural steal, which increase projection in patients, are often simply not sufficient to project the tip to the desired level. These patients have often undergone overresection of the alar cartilages and have resultant weakened tip support. In addressing these patients tip grafts provide the needed cartilaginous skeletal framework needed to support the weakened alar cartilages.

Overresected Nasal Tip

When the nasal tip has been overly resected, in revision surgery we are often faced with excessive tip narrowing, bossae formation, asymmetric and occasionally external valve collapse. In the over- resected nasal tip, bossae are generally thought to result from the dynamic forces of scar contracture. In general terms, the surgical maneuvers that contribute to bossae formation are those that fail to secure symmetric dome cartilages, those that promote separation of the domes, and those that weaken the cephalic margin of the LLCs. While it would be nice if all surgeons prevented bossae by reconstituting the domes, reinforcing weak cartilage and avoiding sharp edges, nasal tip bossae continue to constitute one of the major causes of revision rhinoplasty for our practice.

In those patients with an asymmetric nasal tip, the asymmetry is often the result of unequal LLC removal or distorting forces on the medial or lateral crura that twist the tip. If adequate tip projection and tip strength are present, correction requires separation of the medial and lateral components followed by repositioning and trimming. Very commonly, unfortunately, overresection has occurred concomitantly and necessitates grafting in order to camouflage and support. In some of our revision cases the tip graft is often the only means of correction when overresection of the ala has resulted in bossae formation, excessive tip narrowing, asymmetry, or external valve collapse.

Poor Tip Definition

Poor tip definition continues to represent the most difficult challenge for the rhinoplasty surgeon operating on ethnic rhinoplasty patients. While wide variability exists in the ethnic patient population as a whole, generalizations can be made which can be used as a guide when planning rhinoplasty in this patient population. Specifically, when compared to the Caucasian standard, numerous studies have shown that African American and Hispanic patients tend to have combinations of:

Thick, sebaceous, relatively inelastic skin
Weak lower lateral cartilages
Wide bulbous tip
Excess fibrofatty tissue in the nasal tip
Acute nasolabial angle
Short medial crura
Thin weak septal cartilage

In this type of nose it is important to implement structured augmentation in order to not only provide adequate support but also to give meaningful definition and refinement.The shield graft is useful in ethnic patients when additional tip defining techniques are needed because the standard suturing tip procedures often do not give an entirely satisfactory result. Over the years we have found that the most challenging assignment in ethnic rhinoplasty is correcting the deficiency in tip projection in the face of a bulbous, amorphic tip with thick skin.  In particular, as many of these patients prefer thinner, more refined nasal tips it is important not to build up too much. As a result a balance must be delineated between appropriate refinement without excessive projection.

Overshortened Nose

The aesthetically short nose appears when excessive upward tilt of the nasal tip results in a foreshortened appearance. In the revision patient, the overshortened nose generally occurs after excessive shortening of the caudal septum. Over time, the result is an increased nasolabial angle with increased nostril show. When we are faced with these challenging patients, correction generally entails the use of a caudal septal graft in order to lengthen the nose as well as a tip graft to restructure and reproject the tip.

False Tip Projection or Loss of Tip Support Mechanisms

Many routine techniques in rhinoplasty result in false tip projection at the time of surgery or result in loss of tip projection in the long term. If the primary surgeon is cognizant of these considerations at the primary setting, the revision surgeon would not find indication for the need of increased projection. Unfortunately, while occasionally these patients can have correction with more conservative techniques such as the lateral crural steal, we have found occasion for the use of tip grafts in these patients in order to achieve adequate projection.

Moreover, many surgeons continue to find that an initially satisfactory result ultimately becomes an underprojected tip with the illusion of supratip deformity. The reason is often secondary to the utilization of techniques that weaken major and or minor tip support mechanisms which then in time result in loss of projection. Specifically, the cartilage splitting, cartilage delivery techniques and cephalic trimming of LLCs all result in disruption of the major supportive attachment of the ULCs to the LLCs in the scroll area. Full transfixion incisions interrupt the attachments between the LLC and the anterior septal angle and, if carried low enough, will disrupt the attachment of the medial crus feet to the posterior septal angle. And lowering the cartilaginous dorsum and shortening the caudal septum contribute to loss of minor tip support mechanisms. Finally, it is imperative for the surgeon in the primary setting to consider operative tip swelling secondary to infiltration of local anesthetics, the edema of surgical trauma, and repeated stretching of the nostrils with the nasal speculum. The increased tip projection  is transient and it subsides early in the healing phase as the extra interstitial fluids are mobilized back into the intravascular space.

We have been getting numerous questions lately about whether it’s possible to fix an overshortened nose. A large part of our practice is helping people who previously went in for rhinoplasty with a plastic surgeon to fix a specific complaint and did not get what they were hoping for. Of all of these unhappy people, those with over-rotated noses (turned up too much) or over-shortened noses are some of the unhappiest. This is a harder problem to fix but it can most definitely be accomplished.

So how does this result happen in the first place? Well, it has everything to do with the techniques that are used to reduce a long or projected nose. Take a look at the images below to get a picture of normal nose anatomy.

In the top image, you can see the normal bony and cartilage anatomy of the nose in profile. The picture on the bottom shows the anatomy of the septum inside your nose in relation to the external anatomy. The septum, shown in white, makes up the foundation for the middle part of your nose (the upper lateral cartilages) and, to some extent, your tip as well. It is a large block of cartilage and bone that sits on the upper jaw and provides some nasal stability. The bone to which it attaches along the floor of your nose is called the maxillary crest, and the very front of this bone is a projection called the nasal spine, shown in blue. You can normally feel this as a hard piece of bone at the base of your columella. These are important structures that we’ll tell you about next.

So how is it that some rhinoplasties have such problematic outcomes? Many surgeons, shorten a long nose by removing the nasal spine and the front part of the septum. See the image below for details.

On the other hand, when we want to shorten a nose or rotate the tip, we focus on altering the shape of the tip cartilages themselves to create the contour we want. In this way we are able to provide a predictable result that does not weaken your nose (if anything, it makes it stronger).

Seen above are the cutting methods used by many surgeons to shorten a long nose. This is a bit like shortening a building by knocking out the foundation. The structure sinks, and not in a good way. When the nasal spine or septum are shortened many patients have an acceptable result for the first year, but they are highly unpredictable and often do not last the test of time. They depend on scar tissue build-up to determine the movement and the ultimate shape of your nose. When the foundation is removed, your tip might fall forwards and droop or it might fall backwards and look too short and upturned but, either way, there is a good chance it will collapse and lose refinement over several years.

Why do some surgeons do this?? That’s a good question that we don’t know the answer to. However, most likely, it’s because cutting is quicker and easier than the methods of reshaping the nose and tip to achieve lasting predictable deprojection and rotation. These more reliable techniques are also more difficult to perform, especially through a closed approach. And, since many of the problems that arise from these cutting techniques may not be seen for several years after rhinoplasty, many surgeons may not even realize their patients are having these problems.

So, how do we fix this problem? These revisions are often complicated by virtue of the scar tissue that must be removed to gain the needed length. We then have to restore the cartilage that was lost using grafts known as septal extension grafts and/or extended spreader grafts. Sometimes, a tip graft is used to achieve added length and projection. The good news is that a balanced profile can be achieved, the nose can be lengthened and you can be made happy again.

Above is a Before and After Rhinoplasty photo of a patient who had revision rhinoplasty surgery at Profiles Beverly Hills by Los Angeles Rhinoplasty Surgeons Drs. Peyman Solieman and Dr. Jason Litner. Note the overshortened, overrotated, undefined, and scooped appearance on the left and the restoration of an harmonious and natural profile after surgery. For more information on other rhinoplasty mistakes, visit our dedicated rhinoplasty site.

Facial Plastic Surgeons should be more interested in ethnic rhinoplasty because the number of interested African Americans, East Asians, and Hispanics is rising dramatically! It still represents a minority of most rhinoplasty practices, though. Ethnic rhinoplasty requires a totally different view of aesthetics, principles, and tools to achieve appropriate augmentation and definition. A dramatic change in a profile pic after shaving down a big bump is probably the easiest thing to do in rhinoplasty. So, you see surgeons’ websites full of these examples. (Hint: look for a surgeon who shows you the other views too…the front view and three quarter views are often the most important because that is how the world sees you). The differences in skin thickness, cartilage consistency, and other factors in ethnic patients can often mean that it is harder to achieve a dramatic change. Most ethnic patients have a tendency towards thicker skin combined with softer, less distinct cartilage. A lot more grafting is required than in a typical primary reduction rhinoplasty that makes a nose smaller. But, if you see a rhinoplasty specialist, the type of pleasing, balanced result you are looking for should be achievable. You just might have to dig a little deeper to find a surgeon with lots of experience in Augmentation Rhinoplasty.

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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To crush, or not to crush, — that is the question: —

Whether ’tis better in the mind to only think about crushing

The cartilage, but leaving it intact for grafting,

Or to take arms against the cartilage,

And by crushing it? — To sleep, knowing the cartilage will not show through, —

The heart-ache, and the thousand natural shocks

That cartilage is heir to, — ’tis a consummation…

To sleep, perchance to dream: — ay, there’s the rub;

For in that sleep of crushed cartilage what dreams may come,

The perfect nose…

For those of us who do a lot of rhinoplasty and revision rhinoplasty, there is often the moment some time during the case when we question whether we should crush cartilage hoping that it will last and lie more discreetly? Or whether we should leave it intact fearing that if we crush it, over time it will reabsorb?

Recently there was an interesting article that looked at the survival of crushed cartilage vs non crushed cartilage in the Archives of Facial Plastic Surgery. Not surprisingly, they found that crushed cartilage did not appear to survive as well in their animal model.

Unfortunately for those of us who operate on people, the study looking into crushed cartilage from rabbits really does not help answer any questions. For one thing, while they tried to standardize how hard they crushed, in real life this is very difficult to translate into our own practice.  Moreover, they placed all the noncrushed cartilage on the dorsum and all crushed cartilage on the nasal sidewall- perhaps they could have switched it up to see if placement made a difference.

So what does this mean to anyone doing or having rhinoplasty: simply said, it appears that crushed cartilage is a great way to conceal irregularities, fill defects and create smoother surfaces, but it is important to be experienced so that the cartilage is not so crushed that it disappears over time….there is the rub.

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.