Cut-off Nostrils Following a Nose Job (Rhinoplasty)
One of the ugliest things that I see with a traditional rhinoplasty, or nose job, are cut-off nostrils.  A nostril should naturally taper and curve onto the face with a shelf like portion on the upper lip known as the nasal sill, like a window sill.  When this sill is missing, the nose looks simply weird.  Think of Michael Jackson but also even Janet Jackson.  There is this pinched look that is not natural in appearance.  How do you fix this problem?  The problem is that you really cannot.  When I do an alar-base reduction (removing a wedge of tissue to make the nose smaller) I leave a small flap so that when the nostril is brought in the sill is preserved.  This is an important thing to do if you want to maintain a natural appearance to the nose.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ rhinoplasty procedures or to ask Dr Lam a question please visit his rhinoplasty forum.

Notched Nostrils Following a Nose Job (Rhinoplasty)

Another problem after a bad rhinoplasty that to me is a telltale sign of bad work is a notched or V-shaped nostril.  The curvature of the nostril rim should form a gentle upside U-shape.  When it has been operated on in the past, it can look like an inverted V shape, which to me is a very obvious sign that a rhinoplasty was performed.  To help correct this problem, you can put a graft to lower the nostril rim or I have had success with putting a permanent filler in there like Artefill or silicone to lower the rim to make it look less notched in appearance.

 

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.

Cartilage grafts for Nose Jobs/Rhinoplasties:  Pros and Cons

There are three principal supplies for cartilage grafts to build up a nose.  They are the septum (from inside partition of the nose), the ear (conchal bowl cartilage), and rib (either cadaver or one’s own).  Each type of cartilage has its pros and cons for use in the nose and they are worth elaborating.  Perhaps the closest cartilage to an ideal is septal cartilage, not in every case but in many.  It has the strength and the rigidity that is needed for structural grafting but can be hammered thin to act closer to that of ear.  It typically can be harvested during a rhinoplasty, especially a virgin case, in which the nose has not been operated on before since it is oftentimes already taken for a revision procedure.  Removing some septum can also help straighten out the airway and help breathing without compromising any internal structure or support so long as a generous L-shaped strut is left intact within the nose.

The ear cartilage has many good and many bad attributes that can be somewhat modified for clinical usages.  The ear cartilage when removed does not make the ear deformed, as many prospective patients worry.  However, ear or conchal cartilage is incredibly soft and round and is not ideal in many respects for grafting.  Used on the bridge of the nose, it is also a bit too round.  However, for the tip of the nose to contour a soft tip or nostril rim it can mimic that shape well.  To add extra rigidity, a new technology known as a PDS plate has arisen that has been amazing to add rigidity and strength to the cartilage.  The plate, which reinforces the cartilage, dissolves over a period of 6 months or so during which time the cartilage becomes more rigid through scarification process.

Finally, rib grafting can be used for more severe cases in which donor supply of cartilage from the ear and nose are insufficient.  I prefer cadaveric rib graft since there are no donor-site problems like a scar on the middle of the chest, and it works well in malformed noses.  It has incredible rigidity but almost too much and must be thinned down to simulate septum.  Nevertheless, there is considerable amount of cartilage from the rib that can be used and it is a great source for individuals who need a lot of cartilage to improve the shape and structure of the nose.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ rhinoplasty procedures or to ask Dr Lam a question please visit his rhinoplasty forum.

Revision Rhinoplasty:  What Are My Standards of Naturalness

I had a lady who came to me wanting to perform facial enhancement and I asked if she had any previous surgeries.  She said, “No.”  I asked her, “How about your rhinoplasty?”  She was startled that I could tell.  I reassured her that probably most people could not tell but that since I did a lot of rhinoplasties I was able to detect signs of unnaturalness that others could not.

In general, I do not push many people who come to me for other reasons to undergo revision rhinoplasty because it is a delicate subject and an arduous surgery fraught with risk for a “perfect” outcome.  Scars underneath can lead to problems in which the result is not perfectly how one would imagine it.  Nevertheless, at times revision rhinoplasty is warranted when the nose looks fake or perhaps does not function well as manifested by nasal airway obstruction.

Although there are many things that bother patients about their nose, I would like to list a few of the major things that I think make a nose fake looking in my eyes:

1. The bridge has a overly scooped nose.  I like the saying that “God did not make scooped noses only man has.”  Noses should have a straight or humped bridged.  Rarely if ever do they have a concave shape.
2. An inverted V-deformity.  The nose bones are short and collapse inward creating an inverted V-shape on the bridge.
3. The “uni-tip”.  An overly tightened tip with a traditional “dome-binding suture” can lead to this weird deformity.  I use only “double dome-binding sutures” to narrow a broad tip so that the natural splay on the bottom edge of the tip is still present.
4. Notched ala.  The nostril rims that are notched upwards are another telltale sign.  A natural nostril should curve in a gentle concave upside U shape and never in a notched V shape.
5. Pinched nostrils.  When the nostril shape has been cut down so that the nasal sill (the part of the nostril that sits on the upper lip like a window sill) is violated or absent the nose looks fake.  This is the old Janet or Michael Jackson nose.  Using what is known as a “Sheen flap” in which the curve of the nose is maintained, this can be easily avoided.

Although the list of other fake travesties that beset bad rhinoplasty results can go on for pages, I decided to list the top offenders that oftentimes mandate a corrective rhinoplasty procedure to achieve a more natural-looking result.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ rhinoplasty procedures or to ask Dr Lam a question please visit his rhinoplasty forums.

Functional & Cosmetic Rhinoplasty in My Facial Plastic Surgery Practice

Most of what I do is cosmetic in nature with very little functional surgery for the face. About the only thing that I do that is functional in nature is rhinoplasty, i.e., to help one breathe better afterward. However, first of all I do not take insurance, and any patient who desires rhinoplasty from me must know that fact. However, I do not charge extra for the functional component and just bill for the cosmetic part of the procedure. (I can help you with the rhinoplasty codes and also provide you with a copy of my history and physical examination but you must submit for any insurance codes. Be forewarned that I practice ethical medicine and anything that I feel is not justifiable I will not dictate in a note if I believe the claim is false. Also, most insurance companies today compensate very poorly so be warned that you may not receive much back on the insurance part of the procedure.) Since I do not charge for the insurance part of the procedure, I believe that I am practically doing this for free if you will. One caveat since I am focused on cosmetic results, I do not perform standalone functional rhinoplasty, i.e., I do not just perform septoplasty. I also do not perform functional sinus surgery. I have worked with surgeons who can do a combination surgery with me in which they perform the functional component using your insurance and I perform the cosmetic portion for cash pay. One final note, if you are needing to have a functional septoplasty (correcting a deviated septum), please consider having this procedure done at the same time as the cosmetic portion because I use the septum to support the nasal tip and when it is gone I have to use ear cartilage, which is far inferior to the tensile strength and straightness of the septum. Hopefully, this blog article helps to clarify how I manage functional rhinoplasty in my clinical practice.

Samuel M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To learn more about Dr Lam’s rhinoplasty procedures please call (972) 312-8188 to schedule a consultation. If you would like to ask Dr Lam a question about rhinoplasty please visit our rhinoplasty forum.