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.
Dr. Haworth of Beverly Hills gained much of his advanced experience as both a primary and revision rhinoplasty specialist back in the Middle East. He performed literally hundreds of nose jobs there on patients from all walks of life. One of the most common complaints there are boxy and bulbous nasal tips.
What constitutes a bulbous nasal tip?
The bulbous nasal tip is most likely caused by thick alar cartilages (see accompanying diagram)and/or alar cartilages that are splayed out instead of shaped in a neat triangular formation.
This anatomic situation can be exacerbated by a thick layer of oily, sebaceous nasal tip skin. Think of the latter as a sleeping bag as opposed to a thin silk sheet., draped over delicate structures
How does an experienced plastic surgeon correct the thick bulbous nasal tip during a nose job?
In my hands, I prefer performing a rhinoplasty utilizing an “open” approach because it affords me vital binocular vision so I can assess up to half-a-millimeter asymmetries that otherwise I would would be unable to appreciate utilizing a closed approach. The closed approach is one where the incisions are solely confined to the inner rims of the nostril, whereas an open approach utilizes the same aforementioned incisions in addition to a small hidden incision below the columella (that fleshy partition that separate the left and right nostril). The open approach allows me to see both the left and right nasal tip cartilages simultaneously so that any maneuver I would perform on the other can be immediately assessed with its opposite counterpart. Sutures are meticulously placed in a strategic fashion in order to change the shape of the cartilages from a round convex shape into more of a triangular one which, in turn, will translate to a more refined, elegant nasal tip. Think of assembling a ship in a bottle via strings, so to speak. The rhinoplasty surgeon cannot just bend cartridges, he must utilize sutures in order to shape them. This is part of the stock-in-trade of nasal tip/nasal cartilage manipulation.
Of course, some cartilage is removed as the surgeon sees fit. The importance of not being too aggressive cannot be overemphasized since doing so could result in an unsightly “pinched tip”. Finally, it is more often than not necessary to “defat” the under surface of the thick sebaceous nasal skin that would accompany such a bulbous tip. This allows the thick “sleeping bag” to redrape more fluidly over the newly reconstructed nasal cartilages.
Swelling of the nose may take many months to even a couple of years to fully disappear. This does not mean that the patient would not enjoy the effects of a rhinoplasty before then. It is just that the skin can remain slightly swollen for prolonged periods of time. The last area for swelling to dissipate is at the nasal tip area. So even though great of a 95% of my patients love their nose at the 21st day postoperatively, some will say that they would like their nasal tip to become further defined. I may either inject some Cortizone underneath the skin to turbocharge the swelling to go away quicker or just recommend patients. Sometimes that’s the hardest thing for inpatient to digest.
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.
A Collapsed Nasal Bridge or Saddle-Nose Deformity
After a Revision Rhinoplasty Utilizing Rib Graft
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.
As a primary and revision rhinoplasty specialist, Dr. Randal Haworth of Beverly Hills excels with all types of complicated nose jobs, but sometimes it is a simple pleasure to be confronted with a classic reduction rhinoplasty. Though these are relatively simple in concept, all nosejobs (or rhinoplasties) must be handled with utmost care and dedication to excellence.
Why does a prospective patient consult with me requesting a nosejob?
Is it that their nose is asymmetrical, twisted, dented and scarred from a past rhinoplasty gone wrong?
Is it that their nose is too small for their face with a flat bridge and wide flat tip perhaps due to Asian heritage?
Is it that their nose is too wide with a bulbous tip?
Or is it that their nose is too big, with an associated hump, wide bones and big, drooping tip (especially when smiling)?
Well, most come to me with the latter concerns such as: “Doc, my nose is just too big for my face”, “I always hated my hump”, “My tip is falling like a bird’s beak”, etc., etc.
Upon examination, the nose will usually manifest the aforementioned undesirable characteristics to varying degrees:
Is there a hump? Check
Is it comprised of bone and cartilage? Check
Does the nasal tip droop (with an acute angle between the upper lip and bottom of the nose/columella) especially with smiling? Check
Is the nasal tip wide and/or bulbous? Check
Are the nasal bones wide (where they emerge from the cheeks to form the bridge)? Check
If this common checklist is mainly affirmative, then the patient will need a classic reduction rhinoplasty. In this surgery, the tip is made narrow with either tip grafts (composed of cartilage usually invisibly harvested from the patient’s own septum), strategic suturing or both. The nasal hump is either chiseled or filed down and finally the nasal bones are narrowed by delicately in-fracturing them (“breaking the bones”). If this latter maneuver is bypassed, then an”open roof” deformity may likely arise in which the nasal bridge will look artificially flat and wide itself. Therefore the nasal bones (which comprise the sidewalls of the nose) are carefully angled inwards towards the midline in order to close the open roof which resulted from the hump removal in the first place.
Check out this patient, who underwent a classic reduction rhinoplasty on the Swan.
Here is a typical example of a classic reduction rhinoplasty,even though only subtle changes were performed. Note that a radix graft (to raise the nasal frontal angle) was placed to add height and therefore elegance to her nose.
This lesser known anatomic point of the nose is often purposely overlooked by rhinoplasty specialist surgeons because of the challenges it poses to those attempting to alter it. It is represented by the angle formed by the uppermost portion of the nose as it blends into the forehead proper. Yes, altering this area does have a subtle, yet profound influence upon the final appearance of a nose job- it can differentiate an excellent result from a “so-so” one. The surgeon can raise the radix so that the nose blends into the forehead at a higher latitude as well as softly elevate the natural valley that can exist at this are if it is too deep. Furthermore, one can deepen the radix if too much bone is present between the eyeball and the bridge on profile view.
The ideal position of the radix lies approximately at the latitude of the upper eyelash/upper eyelid crease. Beverly Hills plastic surgeon, Dr Randal Haworth can raise it by placing a precisely shaped softened cartilage graft (usually harvested from the nasal septum or ear) with beveled edges onto the bone of the radix area. Alternatively the radix or nasion can be rasped or chiseled with specialized delicate instruments to a lower, deeper position.
Why does raising a radix from a low position improve the final appearance of a nose? Well, imagine two noses which are identical in shape and forward projection except that one has a low radix while the other has a high one. The one with the low radix is shorter compared to the one with the high. Now imagine two men, both with the same 34 inch waist, but one is short while the other tall. Who appears fatter? The short person does, of course. This same optical illusion applies to the nose with a low radix-it appears as it projects further out from the face as compared with the one with the higher radix and not necessarily in an attractive way.
The following photos represent a beautiful result of a corner lip lift and concomitant rhinoplasty in which the radix was raised.
Note where her radix point lies. It is lower than the level of her eyelash, making the nose look more projecting than it really is.
The result after a corner lip lift and a rhinoplasty with Radix enhancement.
Work here results in some extra swelling localized to the space between the eyebrows in the sense that it lasts a few days longer. Dr Haworth at the Haworth Institute has a few tricks up his sleeve to accelerate the resolution of the nasal swelling by injecting a dilute mix of Kenalog under the skin (and it is relatively painless) two weeks out. This “turbocharges” the swelling to go away!
Of course, the radix can also be augmented with a filler of some sort, such as fat, Radiesse, Juvederm, Aquamid and Artefill.
In the era of Twitter, Facebook, texting, rapid- fire music video editing, etc. everyone (including those not diagnosed with ADD) wants instant results. So what is unusual with wanting an instant nose job or rhinoplasty? Absolutely nothing. An instant nosejob is performed by strategically injecting a pre-chosen filler just below the nasal skin in an aesthetically sensitive manner. Temporary fillers such as Hyaluronic acids (Restylane™, Perlane™, Juvederm™, etc.) and calcium hydroxyappatite (Radiesse™) may be used as a “dress rehearsal” to confirm if the patients like their result. If so, many will then opt for a more permanent filler, either in the form of fat, Artefil ™ or Aquamid ™ (which is not yet FDA approved).
The appeal is obvious: less bruising, less prolonged swelling, less initial expense, less scary for the wary and more predictable (in the proper hands) with less risks. However, the injectable technique cannot be used to correct all types of cosmetic nasal problems and deformities. This is especially true for noses that need to be reduced in size and refined in shape. One does not need to be a genius to realize that fillers may do little to make a nose smaller by removing humps, refining tips and narrowing bones, no matter how well injected they are. The ideal candidate for an injectable rhinoplasty is the nose that needs to be augmented, either via it’s bridge (or dorsum) or it’s tip or both. A drooping tip can be elevated only to a subtle degree with filler.
Filler is also a great solution to those noses that have minor irregularities stemming from prior rhinoplasties. Filler will generally not help breathing problems. To learn more about this elegant solution to a rather common problem, check out these videos:
Everyone undergoing elective cosmetic surgery truly expects their results to be exemplary and rarely contemplate what they will do if something does not turn out as they expected. Rhinoplasty, or nose job surgery, is one of the most challenging sub specialties in aesthetic plastic surgery and Dr Randal Haworth is one of the leading specialists in revision rhinoplasty. Despite the fact that the nasal area is generally less than 2″ x 1″ x 1 ” in dimension, a small amount of unpredictability always exists in terms of obtaining the “perfect result”. Of course, the more experienced and better the nasal surgeon is, the more he or she is able to harness that unpredictability and secure an excellent result.
Among the more common complications that occur from a rhinoplasty are asymmetry, difficulty breathing, incompetent internal nasal valves (inverted V deformity) and a pinched tip. Modern rhinoplasty techniques involve far more subtle maneuvers than old-fashioned cutting out cartilage and breaking bones. Since the shape of the nasal tip is determined both by skin thickness and the underlying shape of the nasal cartilages, it used to be taught that to avoid a pinched nasal tip, all the surgeon has to do is avoid cutting out too much cartilage. Otherwise, the nostrils will loose the supportive function of the cartridges and collapse upon themselves thus leading to a “pinch tip” appearance. In actuality, the situation is more complicated than that. While it is indeed important to leave enough catilage as support, modern techniques of rhinoplasty involve delicately placing precise sutures in order to control the tip and projection of the nasal tip. If the knots are tied ever so slightly tighter than normal, the supportive nature of the cartilage may be overcome by the scar tissue that will develop in the postoperative period. The cartilages will then become concave in appearance thus leading to a pinched tip as seen in the accompanying photo.
Diagram showing severe nasal deformity after a previous nosejob
Preoperative nasal deformity after previous rhinoplasty. Note inverted “V” deformity, asymmetry and pinched tip
Also seen in this photo is an inverted “V” deformity. This occurs when the upper lateral cartridges separate away from the midline septum as well as the upper nasal bones. This results in an irregularly appearing nose along its bridge on full frontal view including an altered brow-tip curvilinear line.
Both a pinch tip and an inverted “V” deformity can result in difficulty breathing through the nose. Correction as part of a revision rhinoplasty involves carefully separating the cartilage from the surrounding scar (which may appear deceptively similar in texture and look during surgery) and carefully placing precisely defined cartilage grafts on to the pre-existing weakened cartilage as support. Spreader grafts are needed to correct an inverted “V” deformity. These are small strips of cartilage fashioned from either the septum or ear which are secured between the midline septum and the inner border of the upper lateral cartilage is-in effect, reconstructing the middle vault up the nose. If this remains uncorrected, not only does the visual deformity processed, but nasal obstruction will also occur upon inspiration. This occurs in a similar fashion to a loose canvas roof of a tent which gets sucked in by high mountain winds.
The postoperative photo of the same patient clearly demonstrates the correction of the pinched tip and inverted “V” deformity via cartilage placement, scar removal and judicious fracture of the nasal bones. I also be rotated the tip in order to make the nose look “less done”.
After revision rhinoplasty by Dr Haworth, including placement of spreader and lateral crural strut grafts
To cut a long story short, added support in the form of cartilage is needed to correct the weakness in the form and function resulting from a rhinoplasty gone awry. Rhinoplasty is similar to a chess game. It is the only surgery that takes me longer to perform than I did 10 years ago. This is because I recognize and deal with any potential pitfalls that may result during the initial surgery. I have to think several steps ahead similar to a game of chess. Finally, not only do I have to make the nose look beautiful, but I have to erase all evidence that anything had been performed by a human hand. this takes time, aesthetic sensibility and patience.
This video shows how a pinched tip can be successfully repaired:
For further information about what one may expect after a rhinoplasty click here
For further information go to www.drhaworth.com or call his office in Beverly Hills to schedule a consultation.
While many surgeons feel uncomfortable with performing an upper lip lift, let alone one simultaneously with a rhinoplasty, it can be safely done. The concern revolves around the fear of losing vital blood supply to the columella (the fleshy straight partition that exists between the nostrils), because if the blood flow is compromised to this area then necrosis or loss of the columellar skin can result. This, in turn, can lead to a possible unsightly scar. If the nose job is performed through an endonasal or closed approach ( whereby all incisions are strictly confined to within the nose itself) there should be little concern for this. However, caution must be exerted when the rhinoplasty is performed with an open technique- one that involves making a scar across the columella in order to gain better access and therefore better visualization and control of the operation. In a normal open technique the incision is placed about halfway up on the columella. Since an upper lip lift necessitates making an incision at the base of the columella (where it joins with the upper lip), the incision needed for the open rhinoplasty can also be the same one- so the incision will be used for two different purposes.
Scar placement for rhinoplasty alone and in combination with an upper lip lift
The situation becomes more complicated, however, when a persisting scar stemming from a previous open nose job is present. In this situation, the plastic surgeon must carefully plan his incisions so as not to compromise the blood supply. More often than not it is safer to keep the upper lip lift incision separate from the rhinoplasty’s in these revision cases.
The planning becomes even more critical when the nostrils need to be narrowed during the nasal aesthetic surgery ( Weir excisions). Not only does the upper lip lift need to be blended well onto the columella, but it also needs to be conformed to a freshly narrowed nasal base, with minimal undesired tension across the final scar ( which can increase the chance of it being noticeable). Intricate surgery along with an intimate knowledge of the regional anatomy and the biophysics of an upper lip lift are key ingredients to a beautiful outcome in this combination surgery. Following are two examples of before and afters of this combo surgery.
Rhinoplasty, or what people refer to in colloquial parlance as “nose job” surgery, is one of my favorite specialities. I have performed literally thousands of these challenging procedures as far afield as the Middle East, Europe and South East Asia. What I find so fascinating about rhinoplasty is how it can impart such dramatically positive change to the face as a whole – a classic case of the final result being greater than the sum of it’s parts.
Not only do I find it immensely gratifying to invent new solutions to challenging problems, I actually like the ” feel” of the surgery- the intricate interplay between skin, cartilage and bone. Even after 16 years of private practice, I discover new, exciting nuances in techniques that the average surgeon performs without feeling. Though I considered myself “top of my game” at the time I was doing plastic surgery on ” The Swan” in 2004, I look back upon those patients today and realize I could do better on a third of those rhinoplasties I performed! Like an artist, I always aim to do better and realize that my work today is better than it was in 2004 and will be better still 5 years from now, barring some personal tragedy.
The first era for me in rhinoplasty surgery was about creating beauty and my second era is about controlling beauty- imbuing a subtle softness into the result, and erasing all signs that humans hands had anything to do with the patient”s nose. A good pianists doesn’t just play the notes and chords accurately but also with crescendo and pianissimo- with feeling.
My next series of blog posts will revolve around the subject of nasal surgery and aim to share with you certain concepts, both basic and advanced, that are important to both the lay person and surgeon alike.
Dr Randal Haworth of Beverly Hills is a specialist in all forms of aesthetic plastic surgery including primary and revision rhinoplasty.For further information go to drhaworth.com