Rhinoplasty Revision

Beverly Hills plastic surgeon Dr. Pincus provides patients revision rhinoplasty surgery as part of his range of cosmetic surgery procedures. The operation consists of correcting areas of asymmetry and deformity resulting from a prior surgery. Generally speaking, additional surgery is performed no sooner than 6 months after the original operation. This allows time for all the swelling to subside and the nose to settle, so that any deformities/asymmetries that were masked will become manifest. As with the original operation, a revision rhinoplasty can be performed under general anesthesia (totally asleep) or under intravenous sedation (twilight sleep). It is usually a more complex operation because of the scarring and disruption from the original surgery. Additionally, material used to correct the deformities such as nasal septal cartilage may not be available as graft material, and ear cartilage, rib cartilage or synthetic material may be needed. Though most corrections can be accomplished in one revision, occasionally additional procedures may be necessary. The postoperative care is generally the same as with the original procedure, and most patients are healed enough to return to work after one week.

Since each additional surgery is usually more complicated than the previous, it is crucial to ascertain your surgeon’s skill in doing revision rhinoplasties. You should look at as many examples of his work as you can. Remember that not all surgeons who do straightforward, primary rhinoplasties know the techniques or have the experience to do revisions.

The Procedure: Lips

The lips should be full and wide with the upper lip slightly rotated, revealing the lower portion of the front teeth. The lower lip should be comparable in size and slightly rolled forward. There are numerous procedures to enhance the appearance of the lips. They can be augmented with the use of fillers like Juvederm, Restylane or fat or they can be enhanced by rolling the mucous membrane from within the mouth to the outside. Additionally, an elongated upper lip can be reduced by excising some of the skin immediately beneath the nose. In this latter instance, the upper lip is considered to consist of “white” and “red” components.

Facial Plastic Surgeon

Dr. Pincus is board certified by the American Board of Otolaryngology (ABOto) and the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS). He is also a member of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

Make Your Consultation Today
Since each person’s face is different, the results of a facelift will vary from person to person. Dr. Pincus can explain the details of the various facelift methods along with additional procedures such as rhinoplasty, necklift, eyelid surgery, and forehead lift discuss with you which method will best suit your needs. When combined, these cosmetic surgery procedures can help patients achieve an overall facial rejuvenation to help them regain a more youthful appearance.

If you decide to have a facelift, please contact our office to schedule a consultation appointment. A consultation visit is an important part of every facelift process. Feel free to view our website to learn more about the facelift and other procedures we offer. If there is anything you don’t understand about the facelift procedure, contact Beverly Hills facial plastic surgeon Dr. Pincus for more information or to schedule your consultation visit.

Cheek Augmentation

It has always been my impression that a good looking, balanced face is more square than oval. This necessitates having well developed cheeks and angles to the jaw. For a face to look more feminine, the cheeks are stronger than the angles. And vice versa for a face to be more masculine. To this end, we usually augment the cheeks with either the person’s own fat, injectable fillers or synthetic cheek implants. The implants I use are made of silicone and are screwed to the cheekbone with a tiny titanium steel screw. This ensures that stability and symmetry will be maintained and not change over time. The approach is under the upper lip, and either a malar implant is used to augment the cheekbone area or a combined implant is used to augment both the cheekbone and sub-cheekbone areas.

Cheek augmentation (before & after)

Hairline

One of the most distressing male features in someone transitioning from male to female is the male pattern of baldness. This usually starts out as temporal recessions but may proceed to a significant loss along the entire frontal hairline. A female hairline is rather straight  across and appears to be positioned approximately one third the height of the frontal face when measured up from the eyebrows. Correction to achieve this goal may involve a scalp advancement, hair transplants or a combination of the two.

Facial Feminization Services

So many aspects of the face suggest either a masculine or more feminine appearance. Dr. Stephen Pincus understands the importance of creating a natural result with facial feminization surgery, and he has dedicated much of his practice to meeting the needs of his transgender patients. Over the past several years, he has identified the areas of the head and neck that benefit the most from this procedure. Dr. Pincus has a specialized way of achieving the most feminine, natural-looking results while maintaining the patient’s identifiable facial characteristics.

Forehead

Brow bone is reduced and forehead is occasionally made rounder and softer

Hair

More Feminine hairline is achieved

Neck

The Adams apple is reduced

Nose

Nose is made smaller and more refined

Cheeks

Cheeks are augmented to create a youthful, feminine face

Lips

Upper lip is reduced and are made fuller

Chin & Jawline

A prominent chin or jawline is reduced

Eyebrows

Eyebrows are lifted and arched

Browlift in the MtF TS patient

The female eyebrow is arched compared to the flat eyebrow in the male. The ends of the eyebrow (the club and the tail) are at the same level, and the highpoint of the arch is between the outside of the iris and the corner of the eye. Since many MtF TS patients have their supra-orbital ridges reduced, the eyebrows can be elevated at the same time by pulling the forehead skin upward in this open approach. On the other hand, if brow bossing is not an issue, endoscopic (closed) browlifting or even brow elevation through an upper eyelid incision can be performed. This latter technique would be a good approach if upper eyelid surgery were also being performed and most of the elevation that was needed was on the outside or lateral aspect of the eyebrow without significant drooping of the inside or medial aspect of the eyebrow.

Browlift (before & after)

RHINOPLASTY BEVERLY HILLS

Rhinoplasty is a surgical procedure designed to reshape the nose. Beverly Hills rhinoplasty and facial plastic surgery specialist, Dr. Stephen Pincus, offers rhinoplasty, revision rhinoplasty, facelift, necklift, cheekfold lift, and eylid and eyebrow surgery at his Marina del Rey and Beverly Hills cosmetic surgery clinics.

Thinking of changing the shape of your nose? Read on….. It is said that the nose is the facial feature most noted after initial eye contact with another individual. Being centrally located, it should blend harmoniously with the other facial features and not draw attention to itself. People seeking to change the shape of their nose do so because of several reasons: The nose has been an unattractive feature that may be affecting their career in modeling or acting; it may be crooked or asymmetric (from birth or injury); or it just may not fit in with the rest of their face as the individual feels it should. In this last instance, such preoccupation with the nose may be realistic, unrealistic or misplaced. On profile, a small chin or short upper lip will make a nose look bigger. Also, some individuals seek corrective nasal surgery to establish a more youthful look. With aging and gravity, the cartilage in the tip of the nose starts drooping, producing an apparent lengthening of the nose with a slight hump. Finally, some people have breathing difficulties, headaches or sinus problems due to deformities within the nose. Many times these internal deformities will express themselves externally as well, as with a very deviated septum. In this instance, correcting the deviated septum will help straighten a crooked nose. Form and function should always go hand in hand, and the form of the nose should never be altered at the expense of function. Actually, it is generally found that an aesthetically pleasing nose works well, too.

When discussing nasal surgery, several terms always appear. Rhinoplasty or “nose job” comes from Greek derivatives: “rhino” which means nose and “plasty” means reshaping. If the internal midline structures of the nose, the septum, need to be straightened, we call it septoplasty. Within the nose, on the side walls are several small bones which have a very vascular lining. These bony structures are called turbinates. By swelling up with blood, they can affect airway resistance, humidification and heating. They are responsible for nasal blockage during” colds” or “allergy attacks.” Certain abnormal states can exist which leave these structures abnormally enlarged and then partial removal (SMR or sub mucous resection) may be needed.

WHAT IS DONE

The actual rhinoplasty operation consists of removing excess bone or cartilage and then rearranging and reshaping the remaining nasal structures. In all but a very few cases, the in RHINOPLASTY BEVERLY HILLS
Rhinoplasty is a surgical procedure designed to reshape the nose. Beverly Hills rhinoplasty and facial plastic surgery specialist, Dr. Stephen Pincus, offers rhinoplasty, revision rhinoplasty, facelift, necklift, cheekfold lift, and eylid and eyebrow surgery at his Marina del Rey and Beverly Hills cosmetic surgery clinics.

Thinking of changing the shape of your nose? Read on….. It is said that the nose is the facial feature most noted after initial eye contact with another individual. Being centrally located, it should blend harmoniously with the other facial features and not draw attention to itself. People seeking to change the shape of their nose do so because of several reasons: The nose has been an unattractive feature that may be affecting their career in modeling or acting; it may be crooked or asymmetric (from birth or injury); or it just may not fit in with the rest of their face as the individual feels it should. In this last instance, such preoccupation with the nose may be realistic, unrealistic or misplaced. On profile, a small chin or short upper lip will make a nose look bigger. Also, some individuals seek corrective nasal surgery to establish a more youthful look. With aging and gravity, the cartilage in the tip of the nose starts drooping, producing an apparent lengthening of the nose with a slight hump. Finally, some people have breathing difficulties, headaches or sinus problems due to deformities within the nose. Many times these internal deformities will express themselves externally as well, as with a very deviated septum. In this instance, correcting the deviated septum will help straighten a crooked nose. Form and function should always go hand in hand, and the form of the nose should never be altered at the expense of function. Actually, it is generally found that an aesthetically pleasing nose works well, too.

When discussing nasal surgery, several terms always appear. Rhinoplasty or “nose job” comes from Greek derivatives: “rhino” which means nose and “plasty” means reshaping. If the internal midline structures of the nose, the septum, need to be straightened, we call it septoplasty. Within the nose, on the side wcisions are made entirely within the nose. Generally, bone and cartilage over the upper two-thirds of the nose is reduced in height and is also narrowed. Occasionally, augmentation rather than reduction is necessary if too much has been removed from some prior surgery or if it has been depressed from previous trauma. Augmentation is also used many times for the “Westernization” of certain oriental noses. Finally, the tip cartilages are made more delicate and aesthetic by means of selective resection, rotation and reshaping.

THE PERFECT NOSE

The ideal nose is generally considered to have a well defined tip which projects slightly above the plane of the remainder of the nose when seen in profile. Women usually prefer a slight slope over the remainder of the nose, whereas men generally prefer a strong straight profile. Furthermore, the angle at which the nose is tilted upward also varies. The ideal male nose shows an angle of 90° to 100° between the lip and nasal tip, while the female has an angle of 100° to 120°. Taller people require less rotation to avoid excessive “nostril show.” Additional facial cosmetic procedures such as chin augmentation or reduction and upper lip lengthening or shortening may also be needed to establish facial harmony. While certain ideal aesthetics are always kept in mind, it is most important to have a nose that is natural in appearance and fits the individual. With the advent of video-facial computer analysis, many of these proposed changes can be performed on a frozen picture displayed on a TV screen. This gives the patient an excellent idea of how much reduction, narrowing or rotation the surgeon has in mind. However, the changes displayed should be realistic since the computer can do things which the scalpel cannot.

THE OPERATION

The actual surgery can be performed with the patient under general anesthesia (totally asleep) or under intravenous sedation (twilight sleep). In either instance, it can be done in a hospital, surgicenter or office operating suite. Depending on the complexity, the procedure will take between one and three hours. Following surgery, the patient has a very small intranasal packing and some form of protective external splint.

Usually, the packing is removed the next day and the splint five to seven days later. Surprising to most patients is the fact that pain is either quite minimal or nonexistent. There is usually some swelling and bruising around the eyes which is 90% resolved within the first week. At this time, most people are healed enough to return to work. Most of the usual daily activities can be resumed at this time. However, vigorous exercising or straining is to be avoided for three to six weeks. In some patients, especially those with thicker skin, a certain amount of swelling will persist for several weeks after surgery. Generally, this is more noticeable to the patient than to those around him. Also, it is somewhat worse upon arising each morning and gradually diminishes throughout the day. Head elevation during sleep and avoidance of prolonged sun exposure helps this last bit of swelling to resolve.

In summary, it should be stressed that the goals of rhinoplasty should be realistic and personal. Being an operation that can be either subtle or quite dramatic, it is something that a person should want to do for himself and not merely to please someone else. All questions should be thoroughly answered prior to surgery, and the surgeon should be quite willing to show many examples of his work in this field.

CONSULTATION

To learn more about rhinoplasty, please feel free to view the information provided on this website. Rhinoplasty candidates in Beverly Hills should contact Dr. Pincus to schedule a consultation appointment. Consultation is an important part of the rhinoplasty process as it allows the doctor a chance to examine your nose and facial features and to discuss your options, goals and expectations.
Contact Beverly Hills rhinoplasty specialist Dr. Stephen Pincus today for more information or to make your appointment.

COSMETIC SURGERY OF THE NASAL TIP OR “TIP-PLASTY

It has been said that “he who masters the tip, masters rhinoplasty”. To a large extent this is true. Creating a delicate, symmetric nasal tip that has the right projection, rotation and proportion to the other elements of the nose is a key factor in a successful rhinoplasty. It is the focal point that is initially noted and must be aesthetically pleasing for the overall appearance of the nose to look good. A great deal of experience and technical expertise is required to create a tip that is appropriate for the different skin types and anatomical variations that are encountered. Each rhinoplasty is different and, consequently, a “cookie cutter” approach is totally inappropriate. Some tips require manipulation of the cartilages already present in the area, whereas others may require either solid or crushed cartilage grafting. The cartilage necessary is usually obtained from the nasal septum or occasionally from an ear or rib. Synthetic material is not a good option, since it may extrude through the skin. Additionally, once the tip has been set, it is often necessary to adjust the surrounding tissues to produce a seamless result.

POST-OPERATIVE NASAL IRREGULARITIES

In rare instances, an irregularity will develop under the skin following a very successful rhinoplasty.  It usually becomes apparent days or weeks after the procedure as the swelling subsides. In some instances, it is bony in nature and may present as a spicule of bone, resulting from the irritated periosteum (lining over the bridge) or a larger area of bone, if there is a shifting or displacement of the reconstructed bony bridge. The treatment for this may be a simple procedure under local anesthesia in a treatment room or a more involved procedure in an operating room.  For a small spicule of bone, the area can be anesthetized locally and a tiny incision made in the club of the eyebrow. Through this incision a narrow chisel can be used to reduce the bony prominence…usually with one or two taps of the mallet. Unfortunately, if the bony irregularity is much larger in nature, a return to the operating room is usually necessary. In this case, rasping or even chiseling is needed and usually takes only a few minutes to accomplish.

If the irregularity noted under the skin is cartilaginous in nature from shifting of a graft or repositioning of the cartilaginous dorsum, an initial attempt at correction can be via a transcutaneous needle. In this case, the area is anesthetized and a small gauge needle is placed through the skin to fracture and progressively crush the cartilage. But, as with the larger bony deformity, if the cartilaginous deformity is large or unaffected by the transcutaneous approach, an intra-operative approach to trim it would be required.

CORRECTING THE BULBOUS NASAL TIP

By definition, a bulbous tip is one that resembles a “bulb” or appears as a rounded mass. And the two main components that establish this appearance are the structural tip cartilages and the overlying skin. One can have strong or flimsy cartilages as well as thick or thin skin. The most easily corrected combination is having strong cartilages, which allow for appropriate sculpting and repositioning, and thin overlying skin, which allows the cartilaginous contours to show through. The most challenging combination is having flimsy cartilages, which do little to express their shape externally, and thick skin, which masks the underlying structures. In this latter case, cartilage grafting is necessary to produce the appropriate contours. The grafts are usually taken from the nasal septum or ear or, rarely, a rib. Their shape and placement usually bear little resemblance to the normal anatomy in this area and is usually placed over it. The object is to create the external appearance of improved nasal aesthetics. In some cases, removing subcutaneous fat or scar from prior surgery may be necessary to help accomplish the desired result. Also, in many instances, the area is infiltrated with solutions such as steroids or fluorouracil to help prevent scar formation that may mask the final result.  Finally, it is sometimes necessary to do nightly taping or even periodic casting to direct the healing and create the desired shape.

I have two examples, which illustrate these extremes.


The first nose had strong tip cartilages with relatively thin skin. All that was necessary was to partially resect and then reconstruct and reposition the cartilages. In contrast, the second nose had flimsy cartilages, thick skin and scar tissue from prior surgeries.


In this case, soft tissue debulking was necessary along with cartilage grafting. The judicious use of injectable kenalog with fluorouracil and post-operative casting and then nightly taping was also employed.

Rhinoplasty and Lips

Feminizing Rhinoplasty in MtF TS patients
It is important to understand the difference between a male nose versus a female nose when attempting a feminizing procedure. Additionally, the angle between the bottom of the nose and the upper lip is made more obtuse (95-110 degrees) and the tip is made more refined and angular. Consequently, we aim to reduce the overall framework in a male nose and produce a gentle slope or concavity over the bridge with subtle indenting curves along the side walls, rather than the straight walls seen in men. Additionally, the angle between the bottom of the nose and the upper lip is more obtuse (95-110 degrees) and the tip is more refined and angular. Imperfections are less tolerated in a female nose, and it should blend harmoniously with the other facial features.

Feminizing rhinoplasty (before)

Feminizing rhinoplasty (after)

Feminizing rhinoplasty (before)

Feminizing rhinoplasty (after)

DE-ROTATION OF THE NASAL TIP

As a surgeon who does many nasal revisions, I am often asked to correct an overly rotated nose: the so-called “pig’s nose or snout”. It generally results from an over-resection of cartilage at the end of the nasal septum (wall separating the two nasal chambers), but can result from other inappropriate maneuvers, as well.

Depending on the degree of over-rotation, as well as the amount of associated nostril retraction, there are several methods of correcting this. Since the nasal tip and adjacent nostrils are intimately connected, we can use a cartilage graft placed at the end of the septum to push the entire lower third of the nose down. This “septal extension graft” essentially replaces what was removed in an earlier surgery. Also, because the graft has to be lined with mucous membrane, a moderate amount of freeing up of the internal lining has to be performed to allow for this advancement.

Finally, other lesser procedures can be employed for less severe cases. A cartilage tip graft can be placed below the nasal tip, to give the illusion of de-rotation . And a composite graft composed of cartilage and skin can be placed within the nostril to selectively de-rotate that.

NOSTRIL RE-SHAPING

One of the most difficult aspects of rhinoplasty is changing the shape of a nostril. Additionally, because there are two, it is important that they both match. The main deformities that we see are the following:

1. The nostril is too wide or flared, with the long axis in a horizontal rather than a vertical direction.
2. The nostril is too narrow.
3. There is a notch or retraction along the superior border.
4. There is an overhang of tissue along the superior border.

To correct a wide or flared nostril, we can remove tissue at the posterior aspect of the nostril before it attaches to the cheek or, at times, remove tissue from the nasal floor.

In less severe cases, a suture may be placed beneath the nose to cinch the nostrils closer to the midline. “Additionally, freeing the nostrils from their underlying bony attachments allows the nostrils to contract inward.”

To correct a narrow nostril, a straight cartilaginous strut can be placed along the margin of the nostril to widen the opening. In more severe cases, a flap of tissue located to the side of the nostril can be rotated in to expand the opening. This latter procedure is especially useful for patients with restricted airways to improve breathing.

When there is a notch or retraction along the superior border of the nostril, there are two methods that can be used to correct this. In mild cases, skin can be rotated downward and outward from within the nose, either with or without a cartilage graft for stability. In more severe cases, a composite graft of skin and cartilage, taken from the ear, can be placed within the nose to lower the rim.

Finally, in cases where there is excessive overhang along the superior border, this tissue can be pulled up internally and trimmed.

SIGNS OF A BAD RHINOPLASTY

Having revised thousands of rhinoplasties, I have noticed certain features common to all.

 

Look for Proportion

Even a structurally symmetric, aesthetically pleasing nose can be a poor result if it is out of proportion with the other facial features by being too small or too large.

 

Clues to Bad Rhinoplasty

The real clues to a poor result are the asymmetries; malpositions, disproportions and decreased function that are seen.

For example, in the image below we can see collapse of the side walls and/or nostrils producing a “pinched look” or asymmetry between the two sides.

The bridge can be too low or too high, and the tip can be overly rotated or not rotated enough. There can be too much “nostril show” from aggressive cartilage resection causing upward migration of the nostril rims. Or too much nostril show from failure to raise the columella (area between the nostrils). Also, irregularities or distortions in the nasal tip can occur which can present technical challenges to the revision surgeon. There can be deflections or angulations of the tip or the entire nose.

As mentioned above, nostril asymmetries are particularly common with one nostril appearing higher or wider than its companion.

 

Worse Breathing

Finally, there can be a worsening of breathing , especially if a reductive rhinoplasty was performed. Making a nose smaller has to be accompanied, many times, by measures to assure that the airflow is not compromised. This means correcting any septal deviations and/or turbinate enlargement, as well as maintaining adequate openings through the nostrils and the areas above called the internal valves.

I’ve included photos of a nose showing most of these deformities with the subsequent post-operative results, after I corrected them below. Learn more about rhinoplasty here. If you would like me to take a look at your nose, you can contact me by filling out the online contact form.

Facial Feminization in a Male to Female Transsexual

The process of facial feminization involves an understanding of what characterizes the male versus the female physiognomy or facial structure. Unlike the transformation seen in facial masculinization, which occurs when male hormone is taken in a female to male (FtM) transsexual, no such transformation occurs in MtF transsexuals taking female hormone. In FtM’s facial hair grows and occasionally a male pattern baldness also occurs. Despite the fact that male features are generally larger and less delicate, the changes produced with male hormone seem adequate enough to produce the desired result for most FtM’s. Since there are specific anatomical characteristics that must be addressed when doing facial feminization, I will now point these out.

"For A More Thorough Explanation About Male Facial Feminization" See Guide.

The female face has a fuller frontal hairline without the temporal recessions seen in males. There is no significant ridge of bone noted above the eyebrows, which characterizes the male skull. And the eyebrows in a female are arched rather than flat. To produce these changes, a forehead or brow lift is performed to raise and arch the eyebrows. At the same time, the (supra-orbital) ridge of bone can be reduced. Various hair techniques, including skin excision with rotation of scalp flaps or hair transplantation, are some of the options to reverse the male pattern baldness.

Proceeding down the face, we note that females generally have more prominent cheekbones than males, as well as a finer, more delicate nose which is usually slightly rotated at the tip. To reach these goals, cheek implants or fat transfer may be employed along with a rhinoplasty (nosejob).

Further down the face we come to the angles of the jaw, the lips and the chin. Women tend to have less prominent jawlines and chins with fuller lips. Reducing the bony angles of the jaw is rarely performed. Occasionally, injections of Botox in this area are done to accomplish a similar effect by shrinking the soft tissue components. Chin reduction, however, is a definite option for the right candidate. And finally, there are numerous lip procedures that can augment the upper and lower lips, change the shape of the lips and even produce a slight upward rotation or pout to the upper lip. In many instances, the area between the bottom of the nose and upper lip can be reduced by skin/muscle excision to further enhance the results.

A final word should be said about the “laryngeal shave”, often mistakenly called a “tracheal shave”. Though not a facial feature since it’s part of the neck anatomy, reducing this prominence (Adam’s apple) goes a long way towards completing the feminization transformation.

Cosmetic Surgery of the Nasal Tip or “Tip-Plasty

It has been said that “he who masters the tip, masters rhinoplasty”. To a large extent this is true. Creating a delicate, symmetric nasal tip that has the right projection, rotation and proportion to the other elements of the nose is a key factor in a successful rhinoplasty. It is the focal point that is initially noted and must be aesthetically pleasing for the overall appearance of the nose to look good. A great deal of experience and technical expertise is required to create a tip that is appropriate for the different skin types and anatomical variations that are encountered.

Each rhinoplasty is different and, consequently, a “cookie cutter” approach is totally inappropriate. Some tips require manipulation of the cartilages already present in the area, whereas others may require either solid or crushed cartilage grafting. The cartilage necessary is usually obtained from the nasal septum or occasionally from an ear or rib. Synthetic material is not a good option, since it may extrude through the skin. Additionally, once the tip has been set, it is often necessary to adjust the surrounding tissues to produce a seamless result.

Browlift in the MtF TS patient

The female eyebrow is arched compared to the flat eyebrow in the male. The ends of the eyebrow (the club and the tail) are at the same level, and the high point of the arch is between the outside of the iris and the corner of the eye. Since many MtF TS patients have their supra-orbital ridges reduced, the eyebrows can be elevated at the same time by pulling the forehead skin upward in this open approach.

On the other hand, if brow bossing is not an issue, endoscopic (closed) browlifting or even brow elevation through an upper eyelid incision can be performed. This latter technique would be a good approach if upper eyelid surgery were also being performed and most of the elevation that was needed was on the outside or lateral aspect of the eyebrow without significant drooping of the inside or medial aspect of the eyebrow.

Forehead Feminization

Male foreheads differ from female foreheads by having a bony prominence (supra-orbital ridge or brow bone) over the eyebrows. In other words, the bone over the eye sockets projects farther forward than the bone in female foreheads. Additionally, the forehead above this prominence is usually flatter or occasionally tilted backwards compared to the female forehead, which is usually more vertical or even slightly rounded or convex. Located behind these ridges are the frontal sinuses. However, they are absent in 5% of the population and only on one side in 15%.

To reduce the brow bossing, an incision is made in the scalp which allows the forehead skin to be elevated for access to this area. It is then burred down with an electric drill. In patients with very flat or posteriorly directed foreheads, a synthetic material (methyl methacrylate) is occasionally used to produce the more feminine, rounded contour. And, finally, if the frontal sinuses are very enlarged, the anterior wall may, at times, have to be set back.

Lips

The lips should be full and wide with the upper lip slightly rotated, revealing the lower portion of the front teeth. The lower lip should be comparable in size and slightly rolled forward. There are numerous procedures to enhance the appearance of the lips. They can be augmented with the use of fillers like Juvederm, Restylane or fat or they can be enhanced by rolling the mucous membrane from within the mouth to the outside. Additionally, an elongated upper lip can be reduced by excising some of the skin immediately beneath the nose. In this latter instance, the upper lip is considered to consist of “white” and “red” components.