Archive for the ‘Revision Rhinoplasty’ Category

Rhinoplasty – “Samurai Nostrils”?

As one of the leading rhinoplasty specialists in the United States, Dr. Randal Haworth continues to challenge himself to be the best he can be. By constantly questioning his results and asking himself how he can do things better, he feels he is subjecting himself to the highest quality assurance and delivering the best possible outcomes in plastic surgery .

Performing rhinoplasties are one of my favorite specialty since the nose place such a central role in the total harmony of the face. Consider it like one of the leading instruments in the orchestra. Though most plastic surgeons and patients alike obsess on nasal humps, wide bones as well as drooping, boxy, pinched and ill-defined tips and, of course, the width of the nostrils, little attention is paid to the actual shape of the nostrils. In other words, a surgeon should not only assess whether the nostrils are wide at their base, but also whether they are arched, pointy, thick or sigmoid in shape.

One of the most common and unflattering nostril shape is that of the “samurai nostril”. Look at the following two photographs and you will see what I mean.

Seven samurai

Another example of these flared nostrils that may look appropriate as a menacing sign but not a flattering one for beautiful woman

Flared nostrils of the nose before a rhinoplasty

A samurai mask manifesting the flared, aggressive shaped nostrils that are unappealing in a woman

There are a few ways to correct this but probably the most reliable is to harvest a “composite” graft from the hidden portion of one’s ear. This detailed surgery involves insinuating this graft between an incision made on the inside of the nose, corresponding to the actual width of the retracted portion of the nostril. This graft is then sutured into place with the skin side facing the actual inside of the nostril to maintain the continuity of it’s lining. One can lower the nostril about 3 to 4 mm with this technique. Of course, some resorption of the graft occurs so it is best to over-correct this.

Other techniques involve strategic V-Y plasties, which are essentially internal tissue rearrangements of the inner aspect of the nostril in order to lower its rim, cartilage grafts in the actual substance of the nostril to help correct pinched tips while lowering the rim and, finally, filler. These latter techniques, though successful to some degree, are not as effective as an ear “composite” graft.

Note the following two cases in which “composite” grafts were taken from the ear and placed within the nostril to lower them. Of note, simultaneous upper lip lifts to further enhance a feminine appearance were performed.

Preoperative transgender patient with retracted nostrils

Transgender patient was retracted nostrils, long upper lip and droopy corners of the lip

Transgender patient after composite grafts to lower the nostril rims and an upper lip lift with DAO release

Dr. HAWORTH performed a modified rhinoplasty by lowering the nasal arched “samurai” rims (nostrils) as well as an upper lip lift and DAO release to lift up the droopy corners of the mouth

Patient with a long upper lip and retracted "Samurai"nostrils after a previous rhinoplasty

Patient with a long upper lip and retracted “Samurai”nostrils after a previous rhinoplasty by  another surgeon

Dr. Haworth performed an upper lip lit along with nostril rim lowering and fat transfer to the lips

Dr. Haworth performed an upper lip lift along with nostril rim lowering via a composite graft from the ear. Fat transfer was also performed into the upper and lower lips. Notice the more feminine harmony

 

 

 

Open vs Closed Rhinoplasty in Beverly Hills

In order to perform a nose job or rhinoplasty whether in Beverly Hills, Los Angeles or wherever, the plastic surgeon must be physically able to manipulate only two things under the nasal skin-cartilages and bone, Well, the debate rages on and on as to what is the best of the two methods in gaining access to the internal cartilaginous and bony structures of the nose. The two methods are the “closed” and “open” techniques.

The “closed” technique involves creating incisions confined solely to within the actual nose (usually located just within the nostrils proper) whereas the “open” utilizes the same incisions as the “closed” but also incorporates a small additional one across the columella (the fleshy partition separating the left and right nostril at the bottom of the nose).

In this age of less invasive surgery afforded by modern technology through the use of endoscopes, modern radiology, etc. one would think that the “closed” technique represents a newer evolution in rhinoplasty surgery, but surprisingly, the opposite is true. The “closed” technique is the more traditional approach while the “open” evolved and gained in popularity as both patient and surgeons expectations grew. Perhaps unrealistically, patients increasingly expect perfection and in their quest to deliver the acme of results, surgeons need as much control as possible when performing the surgery. Control involves extremely accurate symmetrical suture placement (to reshape cartilage), hemostasis (to minimize bleeding), strategic cartilage graft location and stabilization among other factors. In order to gain the most control as possible, visibility must be maximized and this is where the “open” method far surpasses the”closed”.

Proponents of the “closed” technique cite prolonged swelling and a potentially visible scar across the columella as two distinct disadvantages to the “open”. However, in proper hands these supposed shortcomings can almost always be avoided. I, as a rhinoplasty specialist, used to perform 80% of my rhinoplasties as “closed”, but now I carry out 90% as “open” and I can safely say that over 95% of my rhinoplasty patients are delighted with their new nose by the end of the second week. If the surgery is carefully undertaken, I have seen essentially no difference in swelling between the “closed” and “open” techniques. However, the one difference I have seen are the clearly superior results afforded by the “open” method.

To see many “open” rhinoplasty results, click here and here for revision rhinoplasty.

Dr Randal Haworth can be contacted at 310 273 3000 and Is a Board Certified Plastic Surgeon (American Board of Plastic Surgery)  who practices at The Haworth Institute in Beverly Hills.

Rhinoplasty – The rib graft mafia

Over the last 3 to 4 years I, as a primary and revision rhinoplasty specialist, have noticed an increasing and disturbing trend being practiced amongst those facial and classic plastic surgeons in my immediate community of Beverly Hills and other cities. This trend revolves around the use of rib grafts for not only revision but also primary rhinoplasty (!) (or in common parlance, nose job).

A good number of rhinoplasties require cartilage in order to achieve exemplary results. Cartilage is used to either build a bridge, fill depressions, augment or support the nasal tip. It is mainly harvested from the septum (that partition that exists in the midline of the nose which separates the left and right nostril) or the ear. Though I am fully trained general surgeon and am comfortable operating in and around the lungs and heart, I rarely employ rid graft as a source of cartilage. For most, it is generally a last resort when absolutely no other cartilage source is available. Admittedly, rib provides a strong support and is generally in plentiful supply. However, a number of downsides arise when rib is harvested: a permanent visible scar is created below the breast. Additionally, significant pain can arise from the harvesting as well as a small chance of creating a pneumothorax (or a collapsed lung) . Finally, rib can be notorious for warping thereby creating a nose that is crooked.
Despite these drawbacks, I will use rib when there is a collapsed nasal septum (or dorsum creating a saddle nose deformity) or when plentiful cartilage is needed while other sources are exhausted.

See the accompanying photos.

beverly hills nosejob, beverly hills rhinoplasty beverly hills nosejob, beverly hills rhinoplasty
A Collapsed Nasal Bridge or Saddle-Nose Deformity After a Revision Rhinoplasty Utilizing Rib Graft
beverly hills nosejob, beverly hills rhinoplasty beverly hills nosejob, beverly hills rhinoplasty
A Severe Saddle-nose Deformity after Infection After Rib Graft Reconstruction
I always use cartilage to highlight and augment the nasal tip, however, when there is not enough cartilage present and I only need to build the bridge by a small amount, I do not hesitate to employ some artificial material such as Goretex®. I utilize this only when the chance of infection is remote. When patients are properly selected for utilizing Goretex®, the chance of infection extremely minimal in my experience. Unfortunately, the surgeons who habitually use rib grafts will scare the bejesus out of their patients into choosing the rib graft method by overstating the chance of infection and poor outcome if Goretex® is used.

So if I am writing that rib grafts are over utilized, then why do the rib graft cartel tell their patients otherwise?

I feel it is simply a matter of finance. When a rib graft is harvested, the surgeon can charge a lot more for both his services and the operating room, especially if insurance is billed. Most patients will not question their surgeon’s motivated choices and indeed, feel that they have no choice at all, believing that the rib-graft-mafia method is their only solution.

What is especially unsettling is that these doctors who are members of the rib graft cartel are now utilizing rib grafts for primary rhinoplasties (first time nose jobs). This is very puzzling because there is plenty of prime cartilage graft material available from the septum and ear and there is little to no reason to subject the patient to a rib surgery.

All I can say is that this is a dangerous trend which introduces unnecessary risk and morbidity to the operation.

A good patient is an educated patient and the purpose of my blog is to merely propagate information in the most objective way possible so that patients can make their own decisions as sentient adults. To learn more about primary and revision rhinoplasty , you can click here.

Dr Randal Haworth

Beverly Hills, California