Beverly Hills Rhinoplasty Surgery Blog

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.

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 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.

No comments

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.

An extremely frequent mistake seen after primary Rhinoplasty is a persistently over-projected tip. This means that the nasal tip still appears to stick out too far from your face. There’s a reason that this mistake is so common.

The first reason is that many patients are initially more concerned about their bump than anything else and are happy if the bump is all that is removed. Many patients afterwards, however, realize that the tip still appears too prominent and then they’re not so happy anymore.

The second reason is that technical maneuvers to reduce the nasal tip’s projection are more sophisticated. Many Rhinoplasty surgeons were never trained in these maneuvers and simply don’t do them. Many have tried them but have experienced problems and now choose to avoid deprojecting the tip.

Lastly, it is almost impossible to achieve meaningful deprojection of the tip through a standard closed Rhinoplasty approach in a way that still provides enough support. So, you get what we see in the photos below. Below is an example of one of our patients who was unhappy with her tip projection among other things. You can see that her tip looks too prominent. Her bridge is a little too sloped as well from her previous Rhinoplasty which makes her tip look even more pointy.

Her Profiles Beverly Hills Revision Rhinoplasty included some augmentation of the bridge with tip deprojection, effectively restoring a more natural, attractive balance to the profile. And, even better, because of the way we perform this procedure, her nose will stay stronger than if she had never had anything done.

For more information, check out our dedicated rhinoplasty site here.

We have gotten a number of emails recently asking about what can be done for bad nostril scars. These usually result from a poorly planned nostril reduction procedure, often called alar base reduction. For many ethnic rhinoplasties, narrowing of the nostrils is a desirable goal to bring the tip into balance. There are a number of ways of doing this but all involve some sort of incision along the opening or rim of the nostril (at least that’s the only way to get a permanent change). If done well, these scars should be invisible once they are healed (watch out for our upcoming post with pics on how to do it right!).

When it’s not done wrong, it’s a whole different story. The scars can be quite visible or widened and the nostrils themselves can appear distorted or unnatural. Because deeper skin tones tend to react more strongly to injury, they are at higher risk for problems with healing in this area.

When you find yourself in that situation, help is still available. The color and contour of the scars themselves can often be improved by resurfacing them. Tools for doing this include dermabrasion, various lasers, and deep peels. These can be very effective but may require more than one treatment to see the results you want. If caught early enough, silicone gel and steroid injections may be helpful in getting the scars to settle down. If all else fails or if the nostrils are unnaturally distorted or flattened, it can get more complicated. It may be necessary to revise the procedure, remove the scars, and do other things to get some improvement.

Tune in for our upcoming blog in the near future that will show you how an alar base reduction is done right.

Plastic surgery, and rhinoplasty in particular, in Beverly Hills has become ever more concerned with aesthetic perfection. Unfortunately, rhinoplasty is a particularly demanding procedure that demands the most exacting attention to detail and technique if you want long term great results.

Finesse rhinoplasty is the name we give to the patient who needs or desires the most subtle of refinements. In some cases, these are the patients whose family or friends tell them that there is nothing wrong and that they should leave well enough alone. Many are very attractive and have good noses to begin with… but they wish to get even closer to their ideal.

You may wonder why operate at all, but for those of us who love this procedure, these are the cases that challenge us to be our very best, to pay heed to the most refined details… these are the ones that beckon us to be even better. Counter- intuitively, while small changes are sought, these are the most demanding cases because the window for improvement is likewise small. In other words, when you show up with a big bump, it’s pretty easy to get you a dramatically better result; it’s much harder to explain that to correct that little bump (bossae) at the tip of your nose permanently and safely, may necessitate a couple hours of surgery.

Jessica Biel is a spectacularly beautiful woman, but due to her thin skin you can see a number of irregularities in her nose in this picture

Often the patients wanting finesse rhinoplasty have a professional persona that demands that they look their best- models, actresses, entertainers. And most recently, we have had a number of very thin skinned patients (and we don’t mean metaphorically), who presented to us after having had surgery elsewhere. Unfortunately, they had been left with subtle but distinct tip asymmetries and bony irregularities.

Occasionally, in some instances we can recommend a non surgical nose job (see our blog on liquid rhinoplasty) in those patients with the minutest of surgical concerns. In these cases, the run is not worth the slide, ie the results achievable with surgery can be closely approximated by injection of a small amount of soft tissue filler such as Restylane, Juvederm, or Radiesse.

Unfortunately, when the irregularity is more pervasive, as was the case with these patients, we do not recommend fillers because they do not last long enough and have potential risks that we do not want to expose our patients to. In these cases, we found that after rasping (sandpapering) away as much of the irregularities as possible without bringing the bridge down, a thin layer of alloderm resulted in a fantastic cover for any minute palpable irregularities that we would otherwise be afraid could show years later in these very thin skinned patients.

In the last two posts we have taken care of imaging for a poor rhinoplasty result to address problems with the nasal bridge. Now it’s time to take a look at the tip. A frequent problem after an overaggressive rhinoplasty is a tip that becomes distorted and lacking in support. This usually happens when too much of the tip cartilages are removed in trying to narrow and refine the tip. Instead, you just end up with a tip that is unstable. We have lumped these 3 problems together because they often occur together after a Rhinoplasty in which the tip cartilages collapsed.

The diagram below shows the area of the tip cartilages (in red) that is commonly removed during a rhinoplasty. This would be considered a reasonable amount in most patients depending on their skin thickness. The key of course is not to remove too much.

Many surgeons are very aggressive with these maneuvers and may take out most of this cartilage or slice right through it without repairing the edges. They do this because the short-term changes can be very dramatic. You can turn a wide boxy tip into a very narrow one. But, the long-term results are usually devastating as the tip becomes progressively pinched and distorted over years.

If too much cartilage is removed in this area, the tip can start to collapse. It can often look asymmetrical with formation of bossae or little deformities and bumps in the cartilage that show through the skin. Also, the tip can start to rotate up too much. This gives the nose an upturned and shortened “Ms. Piggy” appearance that is positively despised by everyone who is unfortunate enough to inherit this problem.

This problem can be exaggerated when surgeons also remove the nasal spine (the bone at the bottom of the tip) and the bottom part of the septum. To figure out which part of your nose we’re talking about, you can feel around just inside your nostrils. First, look around and make sure no one is looking. Now, if you pinch the skin between your nostrils and advance your finger and thumb back a bit, you will feel a firm but wiggly piece of cartilage that is the bottom part of the septum. Are your eyes watering yet?

Maintaining the integrity of this anatomy is critical to ensuring a good, strong result over time. If the above mistakes are made, the columella or structure separating the nostrils can appear to hang down too much, called a hanging columella. Also, the rim of the nostrils can appear pulled back or retracted. Ideally, the distance between the edge of the nostril and the bottom edge of the columella should be no more than a few millimeters. Anything more creates a very unflattering look that resembles a snarl. What’s worse is that breathing can also be affected. These problems can be fixed but it can take a lot of effort including complex cartilage grafting.

Take a look at the imaged photos below to see the final step in improving the appearance of this nose. The photo on the left has only the bridge imaged while the photo on the right also addresses the tip. You can see that the columella is pulled up, the nostril rim is pulled down, and the angle between the tip and the upper lip is better. Notice that the tip still projects outward by the same amount, but it looks so much less dominant and heavy when these problems are corrected.

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 a case such as this can take us many hours to perform.

The photos below show the original post-rhinoplasty picture on the left, the planned changes in the middle, and the imaged ideal result on the right. The green shaded areas are areas to be augmented or built up. The blue shaded areas are areas to be shaved down. This image has obviously been heavily doctored and we make it 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 nose back into a balanced and harmonious state.

We hope this was a helpful exercise! Best of luck with your rhinoplasty and let us know if you have any questions or suggestions for future lessons….