Being a facial plastic surgeon who specializes in nasal surgery, I have been somewhat dismayed by the relatively recent increase in cosmetic as well as reconstructive procedures that are much more extensive than they need to be. This is not to say that the results aren’t acceptable or that it is being performed by inexperienced surgeons. However, one must always consider the associated morbidity or “collateral damage” that these procedures produce. When we consider cosmetic nasal surgery, especially revisional following prior poorly executed rhinoplasty, I am seeing many patients who come for second opinions because they were told they need a “rib graft”. While a rib graft may get the job done, it results in another operative site on the chest with its associated scarring, pain  and risk of lung collapse. It is my procedure of “last choice” when there are no other alternatives such as nasal septal cartilage, ear cartilage or occasionally synthetic implants. And, to this date, I have never been disappointed in a result from the use of these materials in patients who were told that they needed a rib graft.

Regarding reconstructive nasal surgery following trauma or cancer surgery, I have seen a huge increase in the use of forehead flaps. These require an unsightly flap of tissue from the forehead attached to the nose for a period of three weeks, a second or more additional surgeries and resultant forehead scarring (which is usually acceptable). Once again, there are usually many alternatives like local flaps, skin grafts or composite (skin plus cartilage) grafts. Obviously, the main object of cancer surgery is complete removal of disease. However, it is still important to “factor in” the post-operative morbidity and, at least, to consider these other alternatives.

I recently did an interesting and challenging rhinoplasty on a patient in which I lowered and widened his nostril using an adjacent skin flap.
I will post the final results on a later blog.

Recently came across a video, which was brought to my attention by a patient, which was made many years ago while a consultant for The Morrow Institute. Despite it being several years old, I think many of the points I bring out are quite relevant, so I thought I’d share it. Click on the link below or on the image to view the video.

Rhinoplasty With Stephen Pincus, MD | American Health Journal.

The Subtle or Minimal Rhinoplasty

I see many patients who, for the most part, are satisfied with the way their nose looks, but wish it could be changed ever so slightly. This might mean a minimal upward rotation or a little narrowing of the tip. But, due to the subtle nature of the change, many will “leave well enough alone” for fear that something could go wrong and they would actually look worse. On the other hand, many patients feel that the change is so minimal as to not warrant a surgical procedure with its associated costs and downtime. In actuality, these procedures are fairly predictable, easily performed and with minimal costs and downtime. And given the fact that a little “tweak” can sometimes have a dramatic effect on the perception of beauty, it is well worth the time and expense.

Fall Fashion 2011 issue, expert opinion page from the current issue of GENLUX

NOSE EXPERT
For more info visit drstephenpincus.com

I recently vacationed in Asia and was struck by the wide variation in facial anatomy, especially nasal anatomy. These observations, coupled with my own extensive experience, reinforced my belief that a high, narrow bridge, a well-defined tip, obliquely rather than horizontally oriented nostrils and some degree of “nostril show” (where the columella between the nostrils is lower than the sides of the nostrils) looks better. 
To this end, there are many approaches to accomplish this result. Obviously, the approach has to be individualized depending on the variations in anatomy and the patient’s wishes. Though nasal bridge augmentation in the Orient usually involves placing a synthetic implant with acceptable results, I have found them to be unsatisfactory. Besides being moveable over the bridge, many  get infected or extrude. I generally prefer cartilage grafting, with or without a fascia covering. Sometimes it is necessary to fracture the nasal bones inward. Also, cartilage is usually needed to provide an angular defined tip, as well as structural support for the tip in the form of a strut.  The strut is also useful in lowering the columella. And finally, the nostrils may be narrowed via tissue excision, suture cinching, wide undermining or a combination of these.

Cosmetic surgery is being performed in ever increasing numbers, including many teenagers  who are getting nosejobs as high school graduation presents. With such a premium on youth and beauty nowadays, many teenagers and young adults are trying to emulate their favorite TV or movie idols. Additionally, since cosmetic surgery is now considered fairly mainstream and not just for the wealthy or vain, many teenagers are jumping on the bandwagon.
 The most common procedure we see in this age group is rhinoplasty or nosejob. Since having a large or very unattractive nose can be the source of much derision and loss of confidence growing up, it can be quite transformational in terms of self esteem, if performed correctly with a natural appearance. In days gone by, many teenagers would be embarrassed to make this change, thinking that it would be an insult to the parents whose features they inherited or that they might lose their ethnic identity. However, in these cases, conservative approaches can be used to maintain the same general look but with a feature that integrates better with their face and self-image.
The procedure is usually performed when the teenager stops growing in height. This generally corresponds with their face being fairly mature looking. For girls this is 15-16 years old and for boys it is 17-18 years old. There are several reasons for delaying surgery. The most important is that surgical intervention before the nose has fully matured can affect growth centers within the nose. This could produce an infantile or stunted nose or asymmetries of the nose. Another reason for delaying surgery would be to allow an immature face to “catch up to” or “grow into” better balance with a nose that might appear too large. Some exceptions to this rule might be acute nasal trauma, severe nasal obstruction or significant psychological problems.

In addition to rhinoplasty, some teenagers and young adults are having chin augmentation to balance out a profile or add “strength” to the lower face, as well as cheek augmentation to widen an overly narrow face. Other procedures, such as removing fat from the lower eyelids or cheeks and raising congenitally low eyebrows, are also occasionally being performed.
Unfortunately, when too many procedures are performed, especially if done incorrectly or not conservatively, the effect can be to lose the subtle beauty of youth and produce a result that may seem unnatural.

I recently performed  a difficult rhinoplasty in Torrance, CA which required a constellation of procedures to obtain a perfect result. Firstly, the nasal bones were quite hard and thick.  Because of this, multiple fractures had to be created to narrow the bridge and establish symmetry. Both horizontal and vertical fractures were made in the bones, as well as a horizontal linear fracture along the root of the nose between the eyes. This last fracture was made through a tiny incision in the club or medial portion of the eyebrow. And because of the inherent asymmetry between the top or root of the nose and the base or bottom of the nose, cartilage grafts had to be placed along the side walls of the nose to give the appearance of a midline structure.

As a general rule, it is best to forestall any nasal surgery in children until they have stopped growing. This usually means waiting till after the puberty growth spurt. As a general rule, the nose stops growing when the individual stops growing in height. Though there are exceptions, it is around 15-16 years old for girls and 17-18 years old for boys. However, even after this final growth spurt, it has been reported that there can be some further septal growth up to the age 25, which could lead to late postsurgical distortions requiring possible revision surgery. But, I think, this would be rare.
There are several reasons for delaying surgery. The most important is that surgical intervention before the nose has fully matured can affect the growth centers within the nose. This could produce an infantile or stunted nose or asymmetries of the nose. Another reason for delaying surgery would be to allow an immature face to “catch up to” or “grow into” better balance with a nose that might appear too large. Exceptions to this rule might be acute nasal trauma, septal abscess, tumors, severe airway obstruction, significant deformities, as with a cleft-lip nose or significant psychological problems.

Many patients present to me in Beverly Hills with asymmetric noses. Being centrally located, it is the first feature noted after initial eye contact. And because of its prominent location in relation to the other facial features, asymmetries are easily recognized. These may be developmental or from previous trauma.   

   When we evaluate nasal symmetry, we first check to see the overall facial symmetry. Since the root of the nose starts between the eyebrows and the base of the nose ends over Cupid’s bow of the upper lip, it would be impossible to straighten a nose if the centers of these two landmarks were not directly in line. However, through differential cartilage grafting, we can give the illusion of a straighter nose. Next we evaluate the upper, middle and lower thirds of the nose. The upper third is generally bony and can be straightened via various fracturing techniques. The middle third is mostly cartilaginous and may require cartilage repositioning, resecting or grafting. And, finally, the lower third involves the cartilage and soft tissue of the nasal tip and nostrils— either of which can be asymmetric or unequal.

There are numerous techniques for addressing deformities of these nasal structures. The tip cartilages can be equalized and re-positioned, if necessary, and the nostrils can be made more equivalent through techniques that raise or lower the rims and narrow or expand the openings.