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.

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.

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.

Neck Lift

A necklift in Beverly Hills can help enhance one's appearance as well as provide a boost to one's self-confidence and self-esteem.

There are many reasons why one would want to enhance the appearance of their neck. Some individuals may possess loose, hanging skin in the neck area and under the jawline. These conditions can present the appearance of a fleshy neck or a turkey neck.

Necklift Procedure

The necklift is a procedure to tighten and better define the jawline and the areas below it. In some instances, this effect can reach all the way down to the collar bones. It is generally included as part of a facelift, but can be performed as a separate, independent procedure, if the face does not need any tightening. The operation may involve liposuction, as well as suture tightening and/or suspension of the neck muscles. The incisions are inconspicuous and are below the chin and behind the ears.

The procedure can be performed under intravenous sedation (twilight sleep) or under general anesthesia. Depending on the deformity to be corrected, excess tissue (muscle, fat or glandular) may need to be removed, and the entire area under the jawline tightened. Overnight drains are occasionally placed depending on the degree of surgical dissection. Finally, a removable chin strap may also be used for several days to further help define the neck and reduce swelling. A necklift can be performed alone, or as part of a facelift operation. Liposuction may also be combined if any excess fat needs to be removed from the neck region. A necklift is available at the Beverly Hills cosmetic surgery practice of Dr. Stephen J. Pincus.

Contact Our Office Today

If you are considering undergoing a necklift in the Beverly Hills or Los Angeles area, contact Beverly Hills facial plastic surgeon Dr. Pincus to schedule a consultation appointment. This visit allows the doctor to examine the current state of your neck region and to explain your options for enhancing its appearance.

RHINOPLASTY

Being centrally located on the face, the nose is the first feature noted after initial eye contact. And changing it can have a dramatic, if not transformative, effect. The operation that changes the shape of the nose is called a “rhinoplasty”. It comes from Greek terminology. “Rhino” means “nose” and “plasty” means “to change or mold”. This procedure is often sought after by those who have suffered deforming injuries, were never happy with their nose from birth or as part of a procedure to improve breathing. The nose should blend harmoniously with the other facial features and not stand out, unless it was exquisite!

The nose occupies the central mid third of the face and is roughly one eye width wide. Variations exist based upon ethnicity and gender. In general, male noses are larger, wider, higher and not as upturned as female noses. And the male bridge is usually straight or slightly convex versus the female bridge which is most pleasing with a slight concave slope.

The ideal candidate is one who is realistic in their expectations and is looking for improvement rather than perfection! Additionally, it should not be done to please someone else or in the hope of getting an acting role or recovering a lost love! It is generally done after the face is fully grown (~15 y/o for females, ~18 y/o for males), so that it is not proportionately small if the face is continuing to grow. And the best candidate is one who has a specific idea of what anatomical change they would like rather than the one who merely states that they “just don’t like their nose”! And, if there is a breathing problem, it can usually addressed at the same time.

Prior to surgery, the patient is cautioned about taking certain medications and neutriceuticals that could cause bleeding (aspirin, ibuprofen, vitamin E, fish oils, et al), and is usually given such a list. Plus, alcohol and sunburns should also be avoided pre-operatively.

The procedure is performed as an outpatient in a surgi-center or hospital setting under general or twilight anesthesia. It usually takes a few hours, depending on the complexity, and may be either a “closed” or “open” approach. The difference between the two approaches is a single, imperceptible incision between the nostrils that allows the skin to be elevated off of the underlying bony-cartilaginous framework. Open rhinoplasty is most often employed in traumatic or revision cases where asymmetries can be better evaluated, difficult dissections can be accomplished from multiple vantage points and grafts can be more accurately placed and secured.

There are very few serious risks and complications with this surgery, other than the usual ones seen in any surgery such as bleeding or infection. Though not really a “complication”, but an “unexpected result”, might be a result falling short of one’s expectation. This may be due to poor healing or not following post-op instructions, unrealistic expectations or an exaggerated result promised by the surgeon.

Eyelid and Eyebrow Surgery

The eyes are the first features noted when people meet. And having puffy, sagging or wrinkled eyelids can convey a false image of being tired, sad or old. Luckily there are many techniques that can reverse these physical signs. The actual technique(s) chosen depends on what combination of deformities is present. Are the eyebrows too low producing an appearance of excess skin over the upper eyelashes and hooding or hanging of skin towards the outermost part of the eye? This condition is treated with one of several browlift procedures. In addition to the descent of skin below the eyebrow, is there excess skin in the upper eyelid proper? And are these conditions associated with puffiness from fatty protrusions? Upper eyelid surgery (blepharoplasty) with removal of skin and fat is the treatment for this.

Of course, it is critical that the eyebrows are in their proper position above the orbital rim before eyelid surgery is considered. To perform an upper blepharoplasty when a browlift should have been performed will result in pulling the eyebrows even lower and producing a small, contracted appearance in this area.

Finally, when considering deformities of the lower eyelid, we look at the degree of puffiness or hollowness, wrinkling, pigmentation, laxity and vertical descent below the orbital rim. Puffiness is easily handled by fat removal from the back or conjunctival side of the lower eyelid. On the other hand, occasionally fat has to be pulled forward from within the orbit to fill out hollowness of the lower lid. Laxity of skin usually requires minimal excision, though resurfacing using the LASER or chemical peeling agents can sometimes be sufficient. And resurfacing is certainly the treatment of choice for wrinkling and most pigmentation problems. Finally, vertical descent of the lower lid below the orbital rim may require more extensive procedures such as a midfacelift which pulls the entire cheek upwards.

Facelift Surgery

As we grow older, signs of aging begin to form on our facial appearance. A facelift is a cosmetic procedure designed to improve the most visible signs of aging by removing excess fat, tightening underlying muscles and redraping the skin of your face and neck. This does not stop a person's face from aging, but what it can do is restore youthfulness to one's face.

A facelift in Beverly Hills is offered by Dr. Pincus for those seeking a more youthful and healthy facial appearance. Along with a caring staff, Dr. Pincus strives to provide patients with the best care; from the initial consultation through the post-surgery appointments, the patient's satisfaction is number one. Beverly Hills facelift specialist, Dr. Pincus, offers two approaches to the facelift procedure:

• the midfacelift
• and the traditional facelift

The Upper Liplift

The upper liplift, discussed in my blog posting dated 24June15, demonstrates the liplift with fat transfer to augment the vermilion simultaneously. If a patient is just interested in reducing a long upper "white" lip without augmenting the vermilion or "red" lip, then that can be easily accomplished with excellent results.

Once again, we attempt to show at least 2-4 mm of the lower portion of the upper front teeth. Alternatively, if the vermilion or red lip is very thin and unable to be augmented with fillers or fat injections, then an internal mucosal advancement (V to Y plasty) can be performed at the same time as the upper liplift.

There have also been occasions where fat or some other permanent filler has been inappropriately injected into the vermilion in a long upper lip, so that reduction of the vermilion or red lip must be undertaken at the same time as the upper liplift. The same reduction can be performed if the vermilion is too prominent to bring the entire upper lip and surrounding anatomy into better proportion.

The Beverly Hills Neck Lift

A necklift in Beverly Hills can help enhance one's appearance as well as provide a boost to one's self-confidence and self-esteem.

There are many reasons why one would want to enhance the appearance of their neck. Some individuals may possess loose, hanging skin in the neck area and under the jawline. These conditions can present the appearance of a fleshy neck or a turkey neck.

 

Necklift Procedure

The necklift is a procedure to tighten and better define the jawline and the areas below it. In some instances, this effect can reach all the way down to the collar bones. It is generally included as part of a facelift, but can be performed as a separate, independent procedure, if the face does not need any tightening. The operation may involve liposuction, as well as suture tightening and/or suspension of the neck muscles. The incisions are inconspicuous and are below the chin and behind the ears.

The procedure can be performed under intravenous sedation (twilight sleep) or under general anesthesia. Depending on the deformity to be corrected, excess tissue (muscle, fat or glandular) may need to be removed, and the entire area under the jawline tightened. Overnight drains are occasionally placed depending on the degree of surgical dissection. Finally, a removable chin strap may also be used for several days to further help define the neck and reduce swelling. A necklift can be performed alone, or as part of a facelift operation. Liposuction may also be combined if any excess fat needs to be removed from the neck region. A necklift is available at the Beverly Hills cosmetic surgery practice of Dr. Stephen J. Pincus.

 

Contact Our Office Today

If you are considering undergoing a necklift in the Beverly Hills or Los Angeles area, contact Beverly Hills facial plastic surgeonplastic surgeon Dr. Pincus to schedule a consultation appointment. This visit allows the doctor to examine the current state of your neck region and to explain your options for enhancing its appearance.

Revision Rhinoplasty Surgery

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.

Revision Rhinoplasty Cost:

The cost for a revision is generally more than that for the primary or initial surgery. This is directly related to the increase in time and technical expertise required to accomplish the desired goals. As mentioned earlier, graft material may also be needed which requires additional surgery. Because of the increased scarring and anatomical derangement usually seen, the surgical dissection is generally slower and more demanding. Finally, patients place a great deal of hope on the revision surgeon and are much less likely to accept an unfavorable result.

RHINOPLASTY

Being centrally located on the face, the nose is the first feature noted after initial eye contact. And changing it can have a dramatic, if not transformative, effect. The operation that changes the shape of the nose is called a “rhinoplasty”. It comes from Greek terminology. “Rhino” means “nose” and “plasty” means “to change or mold”. This procedure is often sought after by those who have suffered deforming injuries, were never happy with their nose from birth or as part of a procedure to improve breathing. The nose should blend harmoniously with the other facial features and not stand out, unless it was exquisite!

The nose occupies the central mid third of the face and is roughly one eye width wide. Variations exist based upon ethnicity and gender. In general, male noses are larger, wider, higher and not as upturned as female noses. And the male bridge is usually straight or slightly convex versus the female bridge which is most pleasing with a slight concave slope.

The ideal candidate is one who is realistic in their expectations and is looking for improvement rather than perfection! Additionally, it should not be done to please someone else or in the hope of getting an acting role or recovering a lost love! It is generally done after the face is fully grown (~15 y/o for females, ~18 y/o for males), so that it is not proportionately small if the face is continuing to grow. And the best candidate is one who has a specific idea of what anatomical change they would like rather than the one who merely states that they “just don’t like their nose”! And, if there is a breathing problem, it can usually addressed at the same time.

Prior to surgery, the patient is cautioned about taking certain medications and neutriceuticals that could cause bleeding (aspirin, ibuprofen, vitamin E, fish oils, et al), and is usually given such a list. Plus, alcohol and sunburns should also be avoided pre-operatively.

The procedure is performed as an outpatient in a surgi-center or hospital setting under general or twilight anesthesia. It usually takes a few hours, depending on the complexity, and may be either a “closed” or “open” approach. The difference between the two approaches is a single, imperceptible incision between the nostrils that allows the skin to be elevated off of the underlying bony-cartilaginous framework. Open rhinoplasty is most often employed in traumatic or revision cases where asymmetries can be better evaluated, difficult dissections can be accomplished from multiple vantage points and grafts can be more accurately placed and secured.

There are very few serious risks and complications with this surgery, other than the usual ones seen in any surgery such as bleeding or infection. Though not really a “complication”, but an “unexpected result”, might be a result falling short of one’s expectation. This may be due to poor healing or not following post-op instructions, unrealistic expectations or an exaggerated result promised by the surgeon.