Beverly Hills Rhinoplasty Surgery Blog

Everyone who has suffered a poor Rhinoplasty result experiences a range of negative emotions. All are understandably unhappy about their noses and fearful of misplacing their trust once more. Yet, there are some who experience a more extreme reaction, a few of whom we’ve seen recently.

These are patients who have what is termed ‘loss of identity’ syndrome, a feeling of dissociation from themselves because they cannot relate to the change in the way they look. Patients with loss of identity tell us they just don’t feel like themselves anymore. They just can’t reconcile their new appearance. We were reminded of this by a recent patient who, by all accounts, is a beautiful woman, but who was truly devastated by her previous Rhinoplasty.

This kind of thing happens more frequently after Rhinoplasty than other facial plastic procedures. There are many Rhinoplasty deformities that can lead to this feeling, but the most common by far occurs when the nasal bridge is taken down too much, especially in men. Removing a person’s sense of having a strong nose can be as simple as shaving a few too many millimeters of bone, but those few millimeters can make a huge difference.

That’s why it’s so important to see a Rhinoplasty specialist for your primary or revision nose job. In the hands of a highly experienced Rhinoplasty surgeon, there is no reason for anxiety. A surgeon who understands your aesthetic goals and who has the technical ability to achieve them can help you to transform your self-identity and recapture the confidence you deserve. That is why we find revision Rhinoplasty so rewarding. If you are experiencing some of these emotions, maybe it’s time to take another chance on a better outcome. Feel free to contact us so we can discuss your case in more detail and take the next step to finding happiness with your nose.

In many ways, the very challenging correction of the twisted or broken nose can be viewed as the final step in the mastery of rhinoplasty. It challenges the great surgeon to restore the various deformities present using a detailed understanding of both cosmetic rhinoplasty and functional reconstruction. This is because septal deviation or septal fracture is very common with twisted and/or broken noses and its correction, in large measure, determines the long-term success in treatment of the associated crooked cosmetic deformities. That is why oftentimes, people who have broken their noses and had them treated in the emergency room, long term end up with a still crooked nose- the bones were straightened but because the septum was not, over time the nose twists.

Oftentimes, surgeons treating the crooked nose fall into one of two camps, those who attempt to simply “camouflage” existing deformities and those who attempt to restore and reconstruct the pre- injury state. Rarely, following acute trauma where minimal or no functional problems are present, we can use cartilage grafts to restore the pre-injury straight appearance. These thin slices of cartilage are placed over areas of depression or curvature to hide the contour irregularities. The irregularities themselves are left uncorrected. However, while camouflage techniques preserve maximal support, they may lead to a nose that is overly prominent and wide. That is why, in general, we also do not use or recommend injection rhinoplasty in these patients- it can make your nose too wide.

For most patients presenting with broken or crooked noses there is a vague history of previous trauma, often during childhood, which was not treated and eventually led to a twisted nose. Oftentimes in correcting the twisted tip or asymmetric nostrils, we have found that it is the deviated or fractured septum that is the main cause and not the broken bones. Reconstruction provides optimal aesthetics in these cases because it not only allows us to make the nose look straighter but also to restore the underlying framework to its normal pre- injury positions. This approach is  balanced and allows us to address each cosmetic concern while maintaining and maximizing long-term support and function.

Correction of the Broken and Crooked Nose- Sports can lead to not only a crooked nose outside but also a crooked septum as well. Treatment of both is necessary to restore the nose to its natural pre- injury look

In December of this year, Botox will be celebrating its 20th anniversary on the market after approval by the FDA in 1989 for the treatment of eyelid spasm. While it has only been approved for cosmetic indications since 2002, Botox has long been a staple of plastic surgery and dermatology offices everywhere. In those 20 years, Botox has enjoyed a virtual monopoly with no competition in North America.

That is, until now. After recent years of obscene growth in popularity, the honeymoon will soon be over. Medicis, the makers of the wrinkle filler Restylane, has just announced FDA approval of their Botox rival, called Reloxin (already marketed in Europe under the name Dysport). The company is poised to begin marketing and distributing the product within the next several months.

Not much is known about the newest entrant into the wrinkle-relaxing field. There have been some conflicting reports about its effectiveness compared to Botox. One study suggested that, in a ratio of 3 units of Reloxin to 1 unit of Botox, the new product showed slightly faster onset and appeared to last longer. In another study, though,at a ratio of 2.5 units to 1 unit of Botox, its cosmetic effect appeared to wear off about a month sooner. So, clearly it will take a little tweaking to determine the equivalent dosing to what people are now used to with Botox.

Of interest to everyone, it is thought that Reloxin will be priced about 15% lower than Botox, an especially welcome turn of events in this sour economy. And, other potential competitors are quick on their heels with PurTox (Johnson and Johnson/Mentor) and Xeomin (Merz) on the horizon and predicted to reach market by 2011. While we’re sure there will be a small learning curve, if these products can equal the safety and reliability that Botox has boasted over the years, they will be a very welcome addition to the office-based cosmetic anti-aging market.

Short answer is yes- when used correctly.

For those interested the more nuanced answer would still be probably yes but if used incorrectly or too much it may cause problems. A recent article which featured a number of different oculoplastic surgeons- specialists in reconstructive and plastic surgery around the lids found that a number of them felt that some problems may occur.

It should be noted that Latisse is and was first developed and promoted for patients who needed treatment for glaucoma because it lowers the intraocular pressure- the pressure in your eyes. Having noted that one of the “side effects” they noticed in these patients was increased eye lash length, Allergan subsequently patented the use of the medicine for this indication.

The most recent study by the company found good results and few side effects when Latisse was applied to the upper eyelashes, as 78% of the trial group found increased eyelash length after 16 weeks as opposed to only 18% when treated by placebo.(why the 18% placebo effect is interesting but a discussino for another time)

The important other points for this article were that the study specifically only tested the upper lashes in order to decrease the chances of this getting into the eyes and potentially causing any problems. SO what are those problems- possible inflammation and  redness lasting days to weeks, skin discoloration, and changes to the color of your eyes (potentially darkening), not too mention decreased eye pressure.

Our point is simple, latisse is safe but use it as it was tested until more studies are done to check safety when applied to the lower lids.

When you’re thinking about a nose job, you either don’t care how it’s done… you just want to make sure your surgeon can deliver the result you want and that’s it. Final. Over. Period. Or, you may join a growing group of people who want to research the procedure in detail to learn the pluses and minuses of open vs. closed rhinoplasty or Technique A vs. Technique B. If that sounds familiar, this blog is for you.

Most people have a hard time understanding nasal tip surgery. Taking down a bump on the bridge is easy to understand. A little shave here or there…it makes sense. But, it’s harder to wrap your head around how we make your tip smaller without removing a lot of cartilage and having it fall in over time.

Many plastic surgeons aren’t even comfortable working on your tip. For example, tip deprojection or bringing your tip closer to your face, is one of the harder things to do in rhinoplasty. Many plastic surgeons tend to avoid significant changes to the tip in favor of making the nose smaller by concentrating on that bump on the bridge (sometimes a little too much). So, one of the most common reasons both men and women want a revision nose job is that they think their tip is still too big.

So how do we do it? We use highly controlled procedures. One of our favorite techniques involves dividing the tip cartilage, overlapping the edges by a measured amount, and suturing it back together in a way that is stronger than it was at first (shown below). We can measure exactly how much we want your tip to move. And, depending on where along the cartilage we divide it, we can also change the angle your tip makes with your upper lip and correct any tip asymmetries without having to worry about it changing over time. 

So, whether you’re considering your first nose job or a revision, you should know that these tools, if done right, can be a really powerful and predictable way to give you the smaller, refined tip you want like the one you see below. For more before and after photos of our rhinoplasty and revision rhinoplasty results, check out our rhinoplasty gallery.

The photo above gives you a peek inside at the anatomy of a boxy tip. For many years, the standard technique for tip narrowing was thinning of the upper edge of the tip cartilages, what we call a cephalic trim or cephalic margin resection shown below. When an excessively wide and thick tip cartilage is contributing to a boxy tip, this maneuver is helpful, but it’s very important that the surgeon doesn’t do so much thinning that the tip cartilages are destabilized.

The diagram below shows a reasonable amount of cartilage thinning (shown in red) that will preserve structural integrity and prevent collapse over time. This is especially important in thicker-skinned patients where stronger cartilage is necessary to support the thicker skin. Sadly, we continue to see potential revision patients every day where most or all of the tip cartilage was removed in this area resulting in predictable collapse over time.

Suture techniques for tip narrowing and refinement

 You can see from the above real patient photos that these techniques can produce a dramatic improvement. We need to be careful to preserve just the right angle between these cartilages so that light will reflect favorably on your new tip. An inexperienced or careless surgeon may draw the cartilages too close together or may introduce asymmetries that show up later on, or he may not account for skin thickness and other factors. But, in the right hands, suture techniques provide a powerful way to safely provide the refinement and narrowing you are looking for without compromising breathing. In a future post, we’ll show you how we address tips that are too overprojected.

Many of our African American patients who present for rhinoplasty feel that their nose is too wide, “too big,” and undefined for their face. So you can imagine many of them become confused when we explain that they need to have augmentation rhinoplasty in order to make their nose look smaller.

While we recognize that there is tremendous variability in every parameter of the African American noses: including nostril shape and flare, nasal length, skin thickness, columella length, nasal projection, and bridge height; numerous studies have shown that African American patients, on average, tend to have:

1.      Weak, Short Tip Cartilages- results in tip looking short and droopy

2.      Wider, Bulbous Nasal Tips

3.      Wider Variability in Nostril Shape

4.      Greater Nostril Flare (bigger nostril curvature)- makes tip look wide

5.      Acute Nasolabial Angle- again can make tip look droopy

6.      Thin, Weak Septal Cartilage- harder to support and refine nose

7.      Wider, Lower Nasal Bridges- makes nose look wide and washed out

8.      Thicker Skin- makes it more difficult to add tip definition and refinement

9.      Excess Tissue in the Nasal Tip- resulting in poor tip definition

With all of this being said, over the years we have found that the most challenging part in African American rhinoplasty is correcting the deficiency in tip projection in the face of a bulbous, amorphic tip with thick skin.  In other words, the nose is at once short and wide.

As a result, in this type of nose it is important to build up and add to the tip structure in order to not only provide adequate support but also to give lasting tip definition and refinement. And at the same tip we must recognize that most of our patients are seeking a thinner, more refined nasal tip that is not built up too much. So as you can see in our example below a balance must be created between appropriate refinement without excessive projection.

This professional African American presented after noticing that over time his nose had started to droop and widen. You will note that even 3 months after surgery the improvement in tip definition and refinement is significant.

This is a big question for people. There is a lot of fear about the open rhinoplasty incision. Will it be noticeable? Maybe you’ve seen examples of poor scars from an open rhinoplasty. The fact is poor scars happen when poor technique is used.

You should know that, in the hands of a careful and experienced open rhinoplasty surgeon, the open incision heals beautifully. Below is a typical example of how one of our open rhinoplasties looks before and after just 3 months. We hope you’ll agree that without showing you where the incision is placed in red, you’d have a pretty hard time finding it.

One or more of these incisions is made depending on how much work is planned for the tip. The incision on the far right also needs to be made if the septum is addressed as well. In contrast, work on the tip, bridge, and septum can all be accomplished in open rhinoplasty through the same external incision.

It’s not as important to understand the different incisions as it is to understand that the internal incisions made in closed rhinoplasty often pose real healing problems too. Some of these incisions are made near the narrowest part of your nasal airway so just a little bit of excess scar tissue can seriously compromise your breathing and potentially destabilize your tip.

Every surgical technique has advantages as well as potential downsides and trade-offs to consider. Don’t get too hung up on whether your preferred surgeon suggests an open or closed rhinoplasty for your nose. We like to say that far more important than how the surgeon opens, is what he does to the underlying structure once he’s there- that’s what in the long term gives you the beautiful, stable results we are all looking for. So, while we use both approaches, far more often than not we find that an open rhinoplasty is what it will take to achieve just the right change for you.

Occasionally we get young and often times older patients who present and tell us that after years of staring at their profile in the mirror that they are now noticing a bump when they did not have one before.

In most cases this apparent bump is due to a loss in tip projection.  As we age, we lose some tip support and for some the result is a tip drop and an apparent bump. Many of you may have noticed a grand parent who seems to have a nose that had grown over the years and has developed a bump. The fact is that the nose has not actually grown. As the tip has lost support, it has started to droop resulting in a longer nose and oftentimes in a new bump.  See our online textbook for more details (the Aging Nose)

In some cases a tip graft alone is all that is needed but there are other suture techniques that can also increase tip projection without using grafts (that can sometimes cause problems long term). The key is to look at the nose in all its dimensions and get a real sense of what is needed. Some may think of using nasal fillers, but while this may help the profile view in short term, on front view the nose will often look fuller/ bigger and less defined (not to mention the potential risks- nasal fillers

Finally, since we have a niche rhinoplasty/ revision rhinoplasty practice, my strongest advice would be to go to a facial plastic surgeon/ general plastic surgeon who does a lot of rhinoplasty and try not to have cost be the overriding factor. Not that you have to go with the most expensive by any means, but in the long run we think the time, money and emotional investment that can come with having to go through revision is far outweighed by going to someone who does it right the first time.

An interesting question that came up on the RealSelf forum had to do with radix grafts. A radix graft is a (usually) small piece of cartilage placed at the root of your nose between your eyes. It’s meant to add height to this area and is potentially used for several reasons.

We don’t often use radix grafts but may do so when someone’s bridge has been taken down too much in this area during prior surgery. In some patients, the root of the nose starts very low giving the appearance of an exaggerated bump on the bridge or an overly shortened appearance to the nose. Because the nasal root is so deeply-set, the angle between the nose and the forehead is exaggerated.

In these cases, a radix graft can be appropriate as a better alternative to taking down the bump so much that it brings the bridge too low or shortens the nose too much. A radix graft can preserve or augment nasal length by giving the nose the appearance of ‘taking off’ a little higher from the forehead.

The particular question today had to do with the effect of a radix graft on the appearance of the eyes. This person had closely-set eyes to begin with and was afraid that a radix graft might worsen that appearance. It is true that a washed out nasal bridge can give the sense that your eyes are farther apart. Conversely, adding height to the bridge can theoretically give the sense that eyes are drawn closer together.

But (and this a big but here), if you are considering this question, you must think about where you are coming from. If your bridge was taken down too low during a previous surgery and you are considering adding back some natural height and length to balance your nose, then the impact of a radix graft on the appearance of your eye width will be minimal.

On the other hand, improving a washed out appearance of your bridge would have the effect of creating more nasal narrowing and refinement from the frontal view. And, this is hopefully what you’re trying to accomplish. So, while we consider any graft carefully before recommending it, a radix graft is sometimes just the right fit for the problem at hand. For more information about nasal aesthetics, check out our online rhinoplasty textbook.