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.

Heidi Montag Plastic Surgery:  What Are My Thoughts

Obviously, when a famous celebrity gets plastic surgery, there is a thunderstorm of opinions that surround that event.  Mostly these opinions originate from the lay press, and at other times these opinions appear as sound bites from a media-hungry or media-savvy plastic surgeon.  My goal in this blog article is to express my thoughts on Heidi Montag’s plastic surgery and what may have motivated the procedures and what perhaps could be the long-term consequences of the surgery.

When an individual has a significant number of plastic-surgery procedures at a very tender age, the red flag that comes to my mind is a condition known as body dysmorphic disorder (BDD).  Obviously, I am not saying that is what Ms. Montag has since it would be gross speculation and unfair.  However, I would at least venture to state that it would be a sincere concern of mine.  BDD as a definition in short is a psychological condition in which someone has an obsession over a body part that is disproportionate to what in actuality it may appear to be and that may in turn socially cripple that person.  When an older person seeks a fat graft, a facelift, and related procedures to aging, I am not as concerned if that person fits the psychological profile of someone who is reasonable and not socially handicapped by his or her looks.  However, when someone in her early 20s has a significant number of procedures, then the question certainly must be raised or at least properly investigated.

Safety of having so many procedures all at one time regarding anesthesia risk should also be considered.  The occasion of individuals having experienced anesthetic risk has arisen when facial procedures were combined with extensive body surgery.  Body procedures, especially aggressive liposuction, alter body fluids and chemistries and poses risk when extended surgical times are required.  Again, surgeon judgment and patient selection are mandatory here when deciding the right, safe combination of procedures to be performed at any given time.

Finally, this is a big one for me:  how are all of these procedures going to age for Ms. Montag.  My opinion, not well.  Aggressive rhinoplasty with a revision procedure can lead to unfavorable nasal changes over time.  To me (I may be wrong) she appears not to have had a conservative approach to her nasal surgery, as indicated by some early nasal notching that I see. In addition, if you know me, you know that I have come to despise browlifts.  With the fullness in her brows now, they don’t look too bad (but in my opinion not very good either).  I think as her brows hollow out, she will look particularly bad by her late 30s.  Fat grafting is my specialty and I am very careful in selecting the right patient for this procedure.  I believe that her having had this procedure done at such an early age with future metabolic changes and bearing children could lead to the fat aging very poorly.  How?  The fat may enlarge if she gains significant weight with further aging, and the remaining part of the face that was not transplanted will probably look unusual as the areas that were transplanted start to separate from untransplanted areas.  In general (but not always) I prefer to operate on women for fat grafting who are at least mid-thirties in age.  For all of the above reasons, I remain circumspect about Ms. Montag’s motivations and the safety in the long run of her many procedures that she underwent.

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