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.

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.

NASAL IMPLANTS

Though many rhinoplasties are of the “reductive” variety, with the object being to make the nose smaller, occasionally an “augmentative” rhinoplasty is the procedure of choice. This may be necessary in certain ethnic groups, such as Asian and African, or for nasal revisions, if too much tissue has been removed during the initial surgery. The best material to use for this is the patient’s own cartilage. This is usually harvested from the nasal septum, the ear or from a rib. However, if cartilage is unavailable at these sites or if the patient refuses this additional surgery, then an implant may be necessary. Implants are synthetic materials that may or may not bond with the patient’s own tissue. The use of cadaver homograft cartilage is another option which I generally avoid because of its brittleness, lack of true incorporation at the recipient site and the possibility of resorption. Among the synthetic materials in use, we have silastic, Medpor (high-density porous polyethylene) and Gore-Tex (expanded-polytetrafluoroethyl ene). All have been used to augment the nasal bridge.

Silastic implants are usually pre-formed, though can be trimmed, and form a capsule of scar tissue around themselves. Because of this, they are never truly incorporated into the tissue. Consequently, you can move it side to side manually and, occasionally, it will break through the overlying tissue. I never use this implant material.

Medpor comes in various shapes and sizes, is somewhat firm, and can be carved or trimmed. It can be placed over the bridge or in areas to create lateral nasal support or even tip support, as long as there is soft tissue and cartilage covering it. There is a minimal amount of tissue ingrowth which tends to fix it in place.

Gore-Tex is a very popular implant, which also allows for a slight amount of tissue ingrowth enabling it to be fixed and stabilized. It comes in several thicknesses, is easily trimmed and is quite malleable. It makes for an excellent dorsal implant. However, as with any foreign material, there is a slight chance of infection. Also, Gore-Tex has to be fixed securely because it has a tendency to change shape or even allow for the formation of fluid under it.

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.