Beverly Hills Rhinoplasty Surgery Blog

It is only natural when you are reading and learning about rhinoplasty for you to be drawn to a particular idea of what needs to be done to your nose to achieve the rhinoplasty results you are hoping for. This is especially true of revision patients who have been ‘burned’ before and want to do everything possible to make sure that their outcome this time around is a decidedly different and positive experience. We have prospective patients coming to see us every week who have pretty well-developed pre-conceived ideas, like they don’t want an open incision or they must need a rib graft to fix their noses. A lot of this stems from having heard or read about a poor result with a particular procedure or from hearing mixed messages from surgeons about how they would approach their surgery. In fact, these are really not mixed messages at all, but actually just reflections of each surgeon’s individual style that developed from personal experience.

Getting a number of vastly differing opinions can be frustrating. But, think about it this way. If you were to give a project to 5 different architects to design a home for a particular space in a particular style, you would get 5 totally different results. None of these designs is right or wrong, but you will find that you probably like one or two a lot more than the others. Is it important that the house is not only beautiful but well-built on a solid foundation? Absolutely. Would you know if using a particular material for a certain support beam makes a difference? Probably not. Likewise with rhinoplasty– If you are in the hands of an experienced rhinoplasty and revision rhinoplasty specialist (and that’s a serious if), you can be pretty sure that your nose is not going to fall apart down the road. It is whether your surgeon truly understands your aesthetic sense that is the most important factor in our minds.

By all means, ask as many technical questions as you want about how your surgeon intends to achieve your goals. But, as you go about trying to decide on a surgeon, we would humbly suggest that you focus on communicating the look you are trying to achieve more than on the technical aspects of the procedure. At Profiles, we fight against applying an individual style and instead try to focus on you, your aesthetic and tailoring your procedure individually to your features and desires. At the end of the day, if your surgeon hasn’t spent enough time getting to know you and doesn’t understand your aesthetic, then you aren’t likely to be happy with your result, no matter whether your procedure was done open or closed, with or without rib or ear cartilage grafts, etc.

Almost every day we see a patient or two who have a crooked nose, with the obvious question of how can it be fixed. What most patients and even many surgeons still do not realize is that correction of a crooked nose is truly one of the more difficult things to achieve with rhinoplasty. So how do we suggest you get it done?

First scenario, is in the acute situation, say after a car accident or some other injury.  You may or may not go to the Emergency Room at the nearest hospital, where they may or may not even notice your nose depending on the level of other injuries. Occasionally you may also have a nose bleed, which then causes the ER doctor to place some Merocel or other packing to stop the bleeding.  What’s next?

If the ER doc calls and you are lucky enough to have a specialist come in to see you it may be either a “plastic surgeon” or an “ENT.” The problem here is that you have no idea if this doctor really has genuine expertise in the nose or rhinoplasty in particular. Let me be clear, obviously either of these doctors can manage the acute trauma and have treated patients with broken noses before. The issue I am raising is that rhinoplasty is perhaps the most exacting of all plastic surgery procedures- as the difference of a millimeter can really be the difference between a straight nose and a crooked nose, or a straight profile or small bump.

What we find is that there are many surgeons who still recommend a “simple” closed reduction of the fracture. In other words, they can numb the nose and surrounding area and simply push the broken bone back to its original position. If you live in Canada or if the present health care reform package in the House passes, this will likely be the course of treatment the vast majority of people will receive. And truthfully, if there is a simple non-comminuted, non depressed fracture and no deviation of the septum, this treatment will suffice.

But in the majority of other cases we have found that simple closed reduction does not correct all of the problems. In our experience, in the majority of cases the nasal fracture is not so simple. Oftentimes the septum and/or the upper lateral cartilages are involved. So what does that mean and how does that change the treatment algorithm?

The problem is that if the fracture results in deviation of the septum and/ or upper lateral cartilage, closed reduction will not address these areas. In general, if the septum is fractured, it must be corrected, both to correct your new breathing obstruction and also to allow for the fractured bone to move to its original position, and more importantly have the bone stay there.  If the septum fracture is not repaired, we have found that over time the bone can drift back to a crooked position due to the pressure from the septum.

As for the upper lateral cartilage, this comes into play when the nasal bone is depressed (pushed in) due to the fracture. Nasal anatomy teaches us that the upper lateral cartilages slide under the nasal bones in their upper connection. Therefore, when the nasal bone gets fractured in, the upper lateral cartilage can and often does get pushed in along with it resulting in an internal valve collapse. Unfortunately, the reverse is not true- if the nasal bone is pushed back out, as in a closed reduction, this does not necessarily lead to the upper lateral cartilage moving as well.

Often times, in the acute situation when there is facial and nasal swelling as well as other potential injuries, some of these nuances can and often are missed on initial examinations. As a result, with experience we have learned that it is often better to simply wait a few weeks to allow for all the swelling to settle allowing us to better assess the full extent of injury. What we have learned is that by doing so we are able to correct all of the associated injuries, which means that we can have a high success rate in achieving a happy patient who does not have to have revision surgery down the road.

For many people reading this blog, you may think- what’s the big deal if a 5% tax is imposed on cosmetic surgery? You may think those people are rich after all- aren’t they?

But the truth of the matter is that some 86% of cosmetic surgery patients are working women ages 35-50, with an average annual income of $55,000 per year. Hardly the case of a tax on the rich and famous.

Well, what about the case that this tax would bring in nearly $6 billion dollars in revenue needed for this “reform” bill? Fact is the only state that has passed a similar bill- New Jersey has a similar 6% tax- has found that the tax has only brought in about 25 percent of anticipated revenue since it was enacted. The state legislature in both houses voted to repeal the bill due to the bureaucratic nightmare but were vetoed by the governor- who just lost his seat.

This does not even begin the discussion which is perhaps the most important- what right does the government have to your medical records? How is the government to be allowed to know when you need breast reduction for back pain or a nose job after an accident, as opposed to for just cosmetic reasons, especially since you are paying for it yourself- not via insurance. The idea that this information is readily available without intrusion is simply false, since cosmetic surgery is not billed to insurance and is rarely coded as such.

Finally, and perhaps the saddest part of this misinformed new tax is the fact that it was not even thought through. As with much of this new health care “reform bill,” when they needed to show some new source of revenue to explain the massive new costs involved, they simply put this new provision in.  In July we all heard:

The Senate Finance Committee has discussed imposing a 10 percent excise tax on cosmetic surgery deemed unnecessary for medical purposes. The idea was broached in a meeting with OMB Director Orszag in mid-July, after which Senate Finance Chairman Max Baucus told reporters he had heard some “interesting,” “creative,” and “kind of fun” ideas.

But back in July Committee Chairman Max Baucus shot the idea down, saying it is not under active consideration.
“Oh, that is not on any list I have seen in a long time,” Baucus told reporters. “It was discussed briefly but I haven’t seen that on any list.”

Sadly if unchecked, you will have to pay a tax to Congress for the privilege of using your own money to pursue elective cosmetic procedures.

For those interested you can write to your Senator by either going to the link here or by writing to your state senator.

[date]

Dear Senator_________:

My name is [ ] and I am a constituent of yours from [City/Town] and a woman. I write in strong opposition to the new Excise Tax on Elective Cosmetic Medical Procedures included in the Senate Health Reform Bill (HR 3590), as the imposition of this tax discriminates against women.

Contrary to popular belief, cosmetic surgery is no longer an exclusive luxury afforded by the very wealthy. Eighty six percent (86%) of cosmetic surgery patients are working women and this five percent tax discriminates against us. In the first research of its kind, conducted with people planning to have cosmetic surgery within the next two years, 60% of respondents reported a household income of $30,000-$90,000 a year. Most importantly, 40% of the 60% reported income of $30,000-$60,000. Only 10% of respondents reported household income over $90,000. These data clearly refute the suggestion that elective surgery taxes are “luxury” or “sin” taxes affecting a privileged few.

It is my understanding that New Jersey – the only state to adopt a tax on elective medical procedures – which passed a 6% tax on elective medical procedures in 2004 has experienced a 59% shortfall of projected revenue estimates. In fact, New Jersey Assemblyman Joseph Cryan, the sponsor of the original tax bill, is leading efforts to repeal it.

As you may know, the line between “cosmetic” and “reconstructive” surgery is not always clear and this bill will leave the determination of medical necessity up to bureaucrats—a completely inappropriate proposition – and one which might open up privacy issues during the audit of a patient’s medical records. In addition, the implementation of this subjectively imposed tax will require an inordinate amount of time to interpret and administer with questionable return.

This provision places government between the physicians and the patient and in the worse possible scenario… that of doctor as tax collector, and holds physicians liable should an individual fails or refuses to pay the tax. The provision also will place an incredible burden on physician offices.

Medical procedure taxes should not be part of any health reform legislation being considered. Thank you for your serious consideration of the issues I have raised in this letter.

Sincerely,

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 wanted to commend the bloggers at Boing Boing for their principled stance against Ralph Lauren. Turns out they had re- posted a blog pointing to Photoshop Disaster. In it their was a re-touched image of a model that was so shockingly thin that someone had posted the comment, “Dude, her head’s bigger than her pelvis.”

In response RL had sent a letter threatening suit for copyright infringement.

The response to the letter from Boing Boing is classic:
“Copyright law doesn’t give you the right to threaten your critics for pointing out the problems with your offerings. You should know better. And every time you threaten to sue us over stuff like this, we will:

a) Reproduce the original criticism, making damned sure that all our readers get a good, long look at it, and;

b) Publish your spurious legal threat along with copious mockery, so that it becomes highly ranked in search engines where other people you threaten can find it and take heart; and

c) Offer nourishing soup and sandwiches to your models.”

The image and post can be found here

Plastic surgery today has become widely accessible and more socially acceptable. The result has been a much wider public understanding and acceptance of plastic surgery across the spectrum, including the various ethnic populations that make up the world and, particularly, the United States. As a result we see patients from around the world that make up almost any ethnicity one could think of. The key to good outcomes for all of these patients is an individualized approach that seeks to identify the nose that would best suit each person’s unique face. In general, the traditional “reduction” rhinoplasty that is done for Caucasian patients is usually not best for many ethnic patients who have thicker skin, but for us this does not mean that the costs for this surgery needs to be more. Occasionally, anesthesia costs or facility costs may be higher, simply because it may take longer to harvest needed cartilage to build the bridge, but the difference in fees from standard rhinoplasty is generally nominal.

Is there a possibility that you may someday be able to have your botox without the annoying needles? According to one ongoing study, it may just be. Granted, the study looking at the effectiveness of a topically-applied botulinum gel, has only just finished a phase II clinical trial. But, the study’s lead investigator, Dr. Michael Kane, has reported that a large number of participants showed positive results. The final answer on this interesting question is not in, but we’ll keep you posted on this potential new formulation as we hear more.

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.

There was an interesting article in Science Daily reporting on the preliminary results of a combination therapy of LED lights and a cream with Green Tea Extract. LED lights have long been used for phototherapy to help heal any number of inflammatory skin conditions.

However, LED exposure, like any light energy exposure can also increase the production of free radicals that can injure the skin. Green tea was added to the mix because it contains a potent antioxidant that combats this harmful effect. The results? According to the German study, the same level of wrinkle improvement occurred in only one-tenth the time it took when treated with LED light alone. This underscores the importance of addressing inflammation and free radical injury as part of any effective anti-aging regimen.

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.