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Avoiding the Beverly Hills Rhinoplasty Saddle Nose

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Avoiding the Beverly Hills Rhinoplasty Saddle Nose
 

A rhinoplasty saddle nose occurs because the internal supports have been weakened or removed.  The upper bridge of the nose is bone but the lower portion of the bridge of the nose is cartilage.  If too much of the septum underneath either is removed, there will be a collapse of the bones and/or collapse of the upper lateral cartilages which rests upon the septum and when they “fall” into the nose, the outside appearance looks like a saddle. 

Assuming that the breathing has not been impaired, the correction is by insertion of the patient’s own or transplanted tissue.  Some surgeons prefer bone.  Others prefer cartilage and some use another material, from under the skin, called fascia.  Or one can insert a custom-made or custom-trimmed prosthetic part.  Generally these are solid medical-grade silicone, the same material that is used in artificial heart valves and artificial joints.  It can be sculpted to the size of the saddle-depression and then tucked underneath the skin through internal nasal incisions. Afterwards, there is no saddle and the profile is straight.  But an alternative is filling injections.  Temporary injections are fine but most patients coming to Beverly Hills for revision rhinoplasty certainly are also offered the possibility of a permanent filling injection.   Medical grade liquid silicone which has been used in the United States for over 50 years, in droplet form, is a very practical solution to correcting a saddle nose post-rhinoplasty.

Beverly Hills Revision Rhinoplasty For Aging Noses

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Beverly Hills Revision Rhinoplasty For Aging Noses
 

 

Some patients had a rhinoplasty when they were young. Although the nose ages less in terms of drooping, it still may have some elongation with age.  For that reason, generally, a relatively straightforward and uncomplicated “lift” is performed for senior citizens.  Since the general outline of the nose is satisfactory after the original rhinoplasty, this is a matter of shoring up the tip which has tended to droop.  If the patient has an overactive muscle which depresses the tip with smiling, then that needs to be released from the tip of the nose so that there is no constant downward pull by this depressor septi-muscle that originates in the upper lip.  

Typically there is a stretching of the internal tissues of the nose with age and by removing some of the internal tissues, this will raise the tip, and make the face look less elderly.

 

It is interesting to observe Leonardo da Vinci’s anatomical and facial sketches.  He very clearly and accurately depicted the changes in facial structure that occur with age including lengthening and drooping of the nose, the drooping of the cheeks and the chin.

 

 

 

 

 

Beverly Hills Closed Rhinoplasty

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Beverly Hills Closed Rhinoplasty

Closed rhinoplasty refers to the standard and classical technique of making all the incisions necessary to perform cosmetic nasal surgery within the nostrils and confines of the nose.  Many surgeons, particularly those rhinoplasty superspecialists with long experience cosmetic plastic nasal surgery, feel that they can accomplish what needs to be done entirely through those internal incisions.  There is no question that it requires more skill and manual dexterity.

A recognized advantage of the closed rhinoplasty technique is that, by avoiding an external incision below the nose tip, there is a reduction  the chance of compromised circulation to the tip of the nose. Should there be poor  tip skin circulation in the post-operative period, there is some risk of loss of the skin and underlying tissues, which is catastrophic. Likewise, using the closed rhinoplasty approach, generally, there is a lesser chance of infection and wound breakdown with scarring. That is also related to circulation, the currency of good healing. Infection tends to take hold where circulation has been compromised. These are risks that one should want to avoid if possible.

Personally, I like the closed approach since I was raised on it. Very comfortable with my consistent technique.

 I have performed over 4,000 nasal surgeries, most including a cosmetic component and I used the closed rhinoplasty technique for nearly all. Only two or three operations utilizing the open rhinoplasty or external approach. I wasn’t unhappy with the external approach, and it was not difficult,  but I do feel that if I am capable of delivering satisfactory results through an internal, scar-free procedure, that’s better for patients.

A Balance And Natural Look Is The Desire Of Every Beverly Hills Rhinoplasty Surgeon

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A Balance And Natural Look Is The Desire Of Every Beverly Hills Rhinoplasty Surgeon

It is very important that a nose look natural.  This includes balance.  Balance is defined as appropriate relationship between the tip and the bridge.  If at rhinoplasty, the bridge is created too low, there becomes a ski-slope appearance which actually makes the nose look more protuberant from the face.  This is never satisfactory.  Also, if the tip drops and looks round after surgery, then the bridge looks higher and the nose has a very unsatisfactory look.  This lack of balance can be corrected, of course, but it is best to have the original surgery avoid this problem. 

The other issue, which I discuss in my book, Secrets of a Bevelry Hills Cosmetic Surgeon, is how the nose looks from the front with respect to the tip versus the bridge.  If the tip is too wide for the bridge, particularly if the bridge has been overly narrowed by previous surgery, then the answer lies in correcting the bridge and not the tip.  On the other hand, sometimes if the bridge looks quite satisfactory, the tip of the nose is too bulbous, too wide, too bulky, then the tip must be addressed to bring it in harmony with the bridge.

Cost of Dysport in Beverly Hills

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Cost of Dysport in Beverly Hills

Dysport, which is distributed by the same company, Medicis, which markets the well known facial filling injection, Restylane, is now available.

FDA-approved Dysport works essentially like Botox with respect to its paralyzing effect upon the nerves which power the muscles on the face. As the nerves lose their ability to stimulate muscle contractions, the frown lines, horizontal forehead lines and crow’s feet—smile lines around the eyes — tend to soften or diminish.

Dysport has a long history outside the United States. Nearly 20 years ago, it was developed in England and, as was Botox, originally was used in ophthalmology and other specialties. Dysport and Botox both have long track records of efficacy and safety.

It is important for us to try to evaluate and come to some judgements as to whether Dysport has advantages over the well established Botox. Apparently, the onset of the action of Dysport is quicker than that for Botox. This allows one to see the results quicker. Of course, if there is a little “touch up” or add- on necessary, that can be performed. Another stated advantage is that it seems to generate less of a stark or frozen look. The reports are that people don’t look “done.” There is evidence to show that it also lasts longer.

Currently, there is a cost differential. Introductory price for Dysport is about 15% less than for a comparable dose of Botox. So, if in fact the over four month duration of Dysport exceeds that of Botox and the cost is less, then we can expect to see more utilization of Dysport and then we will know more about it.

Remember, it always takes time for doctors to understand the benefits and disappointments of new medications or treatments. Stay tuned.

Modifying The Tip Of The Nose Gives The Beverly Hills Rhinoplasty Look

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Modifying The Tip Of The Nose Gives The Beverly Hills Rhinoplasty Look

The classic Beverly Hills rhinoplasty look is a natural look.  The tip should never look unusual, asymmetrical, pinched, overdone or in any way suggesting that this nose is not the one that the owner was born with.

Now, there are several techniques that each surgeon should have in his toolbox to address the specific problems.  The most common problem is the tip is too bulbous or bulky or too plump.  Generally, this can be addressed by making the incision on the inside of the nostril along the dome of the cartilage which comprises the major portion of the tip and removing a portion of that cartilage along with the attached lining skin.  This will allow, as healing takes place, for the tip of the nose to refine and narrow.  As with all aspects of nasal surgery, but particularly in the tip, the process of narrowing, shrinking or tightening towards the ultimate results takes several months.  Not that one does not look good in 7 to 10 to 14 days, but one will look better with the passage of time.

For some people with very thick skin and an ultrabulbous tip, it is often necessary to perform a slightly different maneuver.  A surgeon executes what is know as the “delivery” technique by which through two parallel incisions within the nostril, the cartilage is actually brought out of the nose. While still attached, it is modified to make it thinner and less spring-like.  Then the smaller cartilages are returned back to their bed and the incisions closed.  This technique is commonly used if there also has been previous surgery and the surgeon is not certain exactly as to what maneuvers were performed in the original rhinoplasty procedure.

When all incisions are internal and invisible, the technique is called closed rhinoplasty. Some surgeons prefer to approach the tip of the nose using an open rhinoplasty method.  The open rhinoplasty involves in addition to the usual incisions inside the nostril, a horizontal incision connecting the two nostril openings halfway between the lip and the tip.  Typically this incision heals well wit minimal visibility.

What is a “Liquid Facelift” in Beverly Hills?

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What is a “Liquid Facelift” in Beverly Hills?

 

The advent of the various injectable filling products which began with collagen and evolved to Juvéderm, Restylane, Perlane, Artefill and Sculptra has spawned a change in concept of facial rejuvenation.  In addition to these FDA-improved skin fillers, there is Botox and now Dysport which are not fillers, but which have a place in rejuvenation of the face by reduction of wrinkles and even reversing the stippled appearance that some chins have because of continual muscle contraction.

Frankly, “liquid facelift” is somewhat of a misnomer because in fact there is no lifting or elevation of the sagging tissues which occurs with age, but rather a plumping.  Now, plumping is not bad.  We need plumping because as we age there is shrinkage of the fat underneath the skin which begins around the mouth and then later occurs around the eyes and cheeks.  Likewise, plumping is good for those who have a rather thin lip and wish to have the lip look a little fuller, which is generally desirable. 

Reduction of wrinkles, improvement of creases, folds and restoration of natural curved facial contours all do help provide improvement to the face.  However, one should not believe that these are substitutes for certain surgical procedures.  For example, one of the earliest signs of aging for most people is in the jaw and neck.  None of these “liquid facelift” substances can help the gravity-driven sag which creates jowls that hang down below the jaw bone and the double chin or vertical bands in the neck.  These will require surgery.  In fact, most of the photo examples that one sees on the manufacturer’s web sites are of younger people who are not old enough to show the ravages of the gravity induced jowling and neck sagging.

However, the nice thing about these products is they are low risk.  Because they are temporary, if one does not like the look or appearance, there is no cause for alarm because they will disappear within some period of time.

We recommend that patients consider fillers and Botox or Dysport often as an adjunct to blepharoplasty, either upper blepharoplasty or lower blepharoplasty.  Likewise, as the “frosting on the cake” after a neck sculpture or face and neck lift.

Why A Non Surgical Nose Job Is Often Preferred By Beverly Hills Rhinoplasty Patients

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Why Non Surgical Nose Job Is Often Preferred By Beverly Hills Rhinoplasty Patients

Oftentimes, a patient comes to Beverly Hills to have corrective surgery after an unhappy experience with one or more previous rhinoplasty surgeries.  Often part of the problem is a deviated septum.  Sometimes the septum is deviated causing crookedness and diminished airflow.  Or, the problem is that the tip is too bulbous or asymmetrical. The tip is too narrow and asymmetrical or the bridge may be too low or asymmetrical because the nasal bones were not properly corrected.   In any event, often while surgery is feasible, it is not always the optimal treatment. 

Surgery is sometimes necessary.  However, there are many circumstances where patients have had surgery and perhaps they might have been satisfied by non-surgical means.  The most practical answer for many patients is a series of filling injections.   Filling injections are using either temporary or permanent fillers in the office under a topical skin anesthetic.  Fillers raise depressed areas and correct asymmetries.  Some patients are amazed when they are told that they do not necessarily have to have another operation, particularly those who have had three or four previous rhinoplasty surgeries.  The prospect of having yet another surgery with again the possibility of an uncertain outcome is not very palatable.  But hearing that the office treatment can be done and that the patient can participate by judging the results of each of the series of injections is very attractive and practical.

The cost is less, there is no time off work, and that is why for many patients, filling injections – not surgery -  is preferable.

Deviated Septum in Beverly Hills

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Deviated Septum in Beverly Hills

We see many patients who come to us who are unhappy with their breathing.  Now, ours is not a typical “plastic surgery” practice.  First, of course, we only operate on the face and neck.  Secondly, 70% of the practice is devoted to nose surgery.  My background is a head and neck (ear, nose and throat) specialist and my additional formal training in cosmetic, plastic and reconstructive surgery of the nose plus my military experience gives me comfort in limiting my practice so narrowly and majoring in nasal surgery, including rhinoplasty, revision rhinoplasty, correction broken nose, nasal septoplasty and turbinate resection.

Patients do come to Beverly Hills because their sense, and it is usually correct, is that the most sophisticated superspecialists practice here.   We see patients with problems of a deviated septum because they have either had previously unsuccessful surgery or, in fact, had a rhinoplasty surgery and never had the problem of the crooked nose or the breathing addressed.  Typically when there is a deviated nasal septum, there will be in addition to a breathing difficulty, a high percentage of patients who also have crookedness to the nose.

The significance to the patient is that if you have trouble breathing and your nose is crooked, you will have to have surgery on that deviated nasal septum to achieve an optimal result.

Beverly Hills Before and After Photos Will Help You Decide On Rhinoplasty Surgery?

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Will Viewing Before and After Photos Help You Decide Whether Or Not You Should Have Your Revision Rhinoplasty in Beverly Hills?

The purpose of the consultation with the cosmetic surgeon is to learn more.  One of the most valuable components of that visit is the chance to view a large number of typical “before and after” examples.  The primary reason for some people’s post-surgical remorse and the need to come to Beverly Hills for revisional surgery is the original failure to study the first doctor’s work.   You need to get a sense of his art form, his style and his results.  Photographs offer an impression of that particular surgeon’s idea of reasonable improvement.   They also help give you, the patient, a grasp of the realistic results of your rhinoplasty.

I am often amazed when I learn of people who have been disappointed with their cosmetic surgery and when asked:  “Did you see the doctor’s work before?  Did you see a lot of before and after photographic examples of his work?”  They answer:  “No, I didn’t.  I asked the doctor for before and after pictures but the doctor said he didn’t have any for me to look at,” or the reply is:   “Well, he only had a couple to show me.”

That was a tip-off that they were not dealing with a rhinoplasty superspecialist.  A surgeon whose practice is focused on rhinoplasty will have dozens of examples to show you and you should be able to see within those examples a case study similar to yours.