Beverly Hills Rhinoplasty Surgery Blog

Because our practice focuses heavily on rhinoplasty and revision rhinoplasty, we see many patients every week who are unhappy with their previous rhinoplasty result. One of the greatest sources of unhappiness is a poorly performed nostril reduction. Nostril reduction or narrowing is a relatively common procedure performed along with rhinoplasty and, done well, it often is a really nice finishing touch to a great nose job. See our blog of Dec 08 to get a sense of how we do alar base reduction differently.

Problems usually occur after nostril narrowing because of poor technique and especially overaggressive removal of nostril tissue. This can lead to the typically triangular, pinched, tethered nostril appearance, a dreaded look that should really never happen. We’ve also seen this problem occasionally after lip lifting procedures where tissue is removed from the bottom of the nostrils across the columella to try to pull up and show more of the upper lip. Sometimes, the lip is not lifted so much as the base of the nose is pulled down. We’ve blogged before about how to prevent nostril narrowing problems. But, what can you do if you’re already there?!?

The answers are unfortunately not simple nor perfect but, there is some promise of help in many cases. In our experience, there are a few reliable ways of getting some degree of improvement in this situation depending on the severity. If the problem is merely poor scars, this can be pretty readily treated with resurfacing techniques such as chemical peels, laser, or dermabrasion. If the problem is mild notching or tethering of  the nostril, this can sometimes be improved with what is called a V to Y advancement. See the diagram below to get a picture. Essentially, when the scar is revised, some tissue is ‘borrowed’ from the cheek/lip area where it meets the nostril edge in order to elevate the nostril attachment. The downside of this approach is that it leaves a vertical scar along the upper lip although every attempt is made to hide it in the natural crease in this area.

When the situation is more severe, there is no choice but to return some normal tissue to the area where too much nostril tissue has been lost. As shown in the diagram below, the nostril scar must be opened and some skin (usually taken from behind the ear or some other non-visible area) must be placed into the area to try to recreate the normal curvature of the nostril.

This can produce a very nice result but it does create some potential headaches of its own because of visible scars and possible skin color matching issues. Obviously, the absolute best result is achieved by getting it right the first time. If it’s your first rhinoplasty, don’t let posts like this discourage you…just find the right rhinoplasty specialist for your procedure.

As facial plastic surgeons working in Beverly Hills we were constantly seeing women of every ethnicity who presented unsatisfied with their skin, looking for answers.  And having spent a lot of time looking at all the various prescription and over-the-counter brands available, we genuinely felt that we could create a better skin care system.

So while creating a better skin care system we kept forefront in our minds:

1. It had to work- First and foremost, as doctors (and facial plastic surgeons) we researched  to find ingredients that had real science showing how they worked, what effect they had, and what concentration was required to make them work
2. It had to be simple to use- today’s women simply do not have the time for a 6 step process that takes 15 minutes in the morning and again at night
3. It had to address all women’s most pressing concerns- acne, wrinkles, red and brown spots
4. It had to be for women of all ethnicities- as facial plastic surgeons who are constantly working above and below the skin, we saw that women of different ethnicities have far more in common than most people believe. And there are too many women who are concerned that the available products “were not made for them.”  So we wanted to make sure people know that JolieMD was “made for you”
5. It had to be beautiful- We wanted to create a new style of doctor’s skin care- driven like plastic surgery with an eye toward everything aesthetic:  We wanted glamour, beauty, fashion. It had to look, smell and feel beautiful.

The result of this process is JolieMD’s Metamorphosis, our exclusive, new skincare line created for women of all ethnicities. Transformative in every way- it provides a simple method for brighter, healthier skin, without a prescription.

For more info www.joliemd.com

A new twin study published in the Archives of Dermatology last month has demonstrated the hazardous effects of environmental factors on skin aging. According to the  report, 65 pairs of twins were studied for differences in environmental and lifestyle factors that might contribute to wrinkles. The conclusion according to news sources is that these factors, such as smoking, sun exposure, and weight change may play a larger role in facial skin aging than does genetics.

While we clearly agree that sun exposure and smoking are huge factors in causing wrinkles, we have to point out a flaw with this study’s design. Of the 65 pairs of twins, 52 were fraternal twins sharing the same percentage of genes as do non-twin siblings. While fraternal twins share about half their genes, this is nothing close to the identical genetic make-up shared by identical twins. A really revealing result would be if identical twins with different levels of environmental exposure also showed different levels of skin aging. As is, this study is mostly a study of siblings– it can’t fully control for genetic factors and so it doesn’t really tell us anything new at all.

The bottom line is… you can’t change your genetics anyway no matter how big a role they play, at least not yet. The best thing you can still do to prevent poor skin aging is to avoid smoking and sun exposure. And you didn’t need a flawed study to tell you that.

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.