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.

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

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.

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)