REVISION RHINOPLASTY

A scooped-out profile usually occurs after routine reduction rhinoplasty where there was a bump on the bridge that was shaved down too much. This can be particularly problematic when this occurs in men, as it is a feminizing feature.

Many rhinoplasty surgeons still prefer to make a bony bump smaller using a chisel or osteotome shown below on the left. Osteotomes are sharp instruments that cut through the bone at the desired level to lower the hump. This is an all-or-nothing tool where the bump is removed in one shot. The problem is one of judgment and execution. Sometimes the angle is not right or the surgeon thinks the bone is being taken down to a certain level only to discover that he or she misjudged. At PROFILES Beverly Hills, our expert surgeons prefer to use rasps to reduce a bump. Nasal rasps are essentially fine files, shown below on the right. These instruments can be used to slowly whittle or file down the bony bump. That way we can accomplish this three-dimensionally in a very careful and controlled way.

Moreover, it can be even easier to make a bump reduction mistake using a closed rhinoplasty approach (from inside the nostril) where this maneuver is being done under the cover of the nasal skin. In this case, it is difficult for the surgeon to see, so most of the work is done by ‘feel’. It takes a lot of experience to develop that ‘touch’ and to consistently get nasal hump reduction right.

In revision rhinoplasty, when the bone has been reduced too much, the nasal profile will look scooped and the bridge will look washed out and child-like from the front view. To fix this, we need to build the bony bridge back up again, most often with the patient’s own cartilage.

The photos below show the area of bone that was over-reduced, and what the bony profile should look like. The green shaded area is the area of the bridge to be built up.

A pollybeak deformity refers to a nose in which the area just above the tip is too full. When it is very full, it can make the nose look down-turned, like a parrot’s beak, thus the name. Normally, there should be a little dip or depression just above your nasal tip that defines the transition from your bridge to your tip on profile. In a woman, that little dip is a feminizing feature. Your tip should be the most projecting point of your nose. Check out the photo below to see a pollybeak deformity indicated by the arrows.

The reason the nose can look like a parrot’s beak is that the area above the tip often becomes the part of your nose that sticks out or projects the most from your face. This is not the way it should be. Your tip should be the most projecting point of your nose. Check out the photo below to see a pollybeak deformity indicated by the arrows.

A few factors can cause this deformity, and they are all preventable.

• First, a surgeon may not reduce the cartilage enough in the area above your tip.
• Second, the surgeon may be overaggressive in reducing that area too much in someone with thick skin. In this case, the skin does not contract and flatten out as much as it should, and instead, the area fills in with thick scar tissue.
• Finally, a surgeon may not provide enough support to your nasal tip. Over time, your tip may droop and make the area above the tip look too full.

Look at the image above to see the plan for fixing this pollybeak deformity. The green area is the area of the bridge that was built up in the last rhinoplasty. The blue shaded area shows the cartilage that has to be shaved down to correct it. Notice how the tip itself also has to be deprojected or brought in closer to the face.

When fixing this issue, if just the pollybeak was taken down, without the tip being brought in, it would look too high and too pointy. Although this is not an ideal look, it is something we also see a lot after first-time rhinoplasty procedures because tip correction is considerably difficult to perform. On the right, you can see how much more balanced the tip looks now. Note, that this is by no means a final image. In fact, the picture on the right does not show a completely improved appearance because we have not yet addressed the other problems with this nasal tip. It still looks pulled down and rounded, and the nostrils have to be addressed as well.

A frequent problem after an overaggressive rhinoplasty is a tip that becomes distorted and lacking in support. This usually happens when too much of the tip cartilages are removed in trying to narrow and refine the tip. Instead, you just end up with a tip that is unstable. We have lumped these 3 rhinoplasty surgery problems together because they often occur together after a rhinoplasty in which the tip cartilages collapsed.

The rhinoplasty diagram above shows the area of the tip cartilages (in red) that is commonly removed during a rhinoplasty. This is considered a reasonable amount in most rhinoplasty patients, depending on their skin thickness. The key of course, is not to remove too much. Many rhinoplasty surgeons are very aggressive with these maneuvers and may take out most of this cartilage or slice right through it without repairing the edges. They often do this because the short-term changes can be very dramatic as you can turn a wide boxy tip into a very narrow one. However, the long-term results are usually devastating as the tip becomes progressively pinched and distorted over the years.

Furthermore, it is important to note that if too much cartilage is removed in this area, the tip can start to collapse. It can often look asymmetrical with the formation of bossae or little deformities and bumps in the cartilage that show through the skin. Also, the tip can start to rotate up too much. Unfortunately, this gives the nose an upturned and shortened “Ms. Piggy” appearance, which most patients are extremely unhappy with. This problem can be exaggerated when surgeons also remove the nasal spine (the bone at the bottom of the tip) and the bottom part of the septum. To figure out which part of your nose we are talking about, you can feel around just inside your nostrils. If you pinch the skin between your nostrils and advance your finger and thumb back a bit, you will feel a firm, yet wiggly piece of cartilage that is at the bottom part of the septum.

Maintaining the integrity of this anatomy is critical to ensuring good, strong results over time. If the above mistakes are made, the columella or structure separating the nostrils can appear to hang down too much, called a hanging columella. In addition, the rim of the nostrils can appear pulled back or retracted. Ideally, the distance between the edge of the nostril and the bottom edge of the columella should be no more than a few millimeters. Anything more creates a very unflattering look that resembles a snarl. Breathing can also be affected. These problems can be fixed but it takes a lot of expertise and complex techniques, including cartilage grafting.

Take a look at the imaged photos below to see the final step in improving the appearance of this nose with revision rhinoplasty surgery. The green shaded areas on the imaged photo are areas to be augmented or built up. The blue-shaded areas are to be shaved down. You can see that the columella is pulled up, the nostril rim is pulled down, and the angle between the tip and the upper lip is better. Notice that the tip still projects outward by almost the same amount, but it looks so much less dominant and heavy when these problems are corrected.

THE FINAL RESULT

The rhinoplasty photos below show the original before revision rhinoplasty photo on the left, the imaged result in the middle, and the patient’s actual postoperative photo on the right. We make the revision rhinoplasty before and after imaged photo imperfect on purpose so that we do not over-sell the possible results.

A frequent mistake seen after primary rhinoplasty surgery is a persistently over-projected tip. This means that the nasal tip still appears to stick out too far from your face. There are two reasons that this mistake is so common:

• The first reason is that many rhinoplasty surgery patients are initially more concerned about their bump than anything else, and are happy if the bump is all that is removed. Afterward, many patients realize that the tip still appears too prominent.
• The second reason is that technical maneuvers to reduce the nasal tip’s projection are more sophisticated. Many rhinoplasty surgeons were never trained in these maneuvers and simply do not perform them. Many surgeons have tried in the past but have experienced problems, and now choose to avoid deprojecting the tip.
• Lastly, it is almost impossible to achieve meaningful deprojection of the tip through a standard closed rhinoplasty approach in a way that still provides enough support.

Below is an example of one of our revision rhinoplasty surgery patients that was unhappy with her tip projection, among other things. You can see that her tip looks too prominent. Her bridge is a little too sloped from her previous rhinoplasty, which makes her tip look even more pointy. The patient’s Beverly Hills PROFILES revision rhinoplasty included some augmentation of the bridge with tip deprojection, effectively restoring a more natural, attractive balance to her profile. Even better, because of the way we perform this procedure, her nose is now stronger than if she never had anything done.

Think of the tip cartilages like a pair of wings. You can get an idea of what these look like from the rhinoplasty photos below. The cartilages are like a bent spring that holds the nostril’s shape, keeping it open to allow for normal breathing. In many poorly done rhinoplasty surgeries, this cartilage is aggressively cut or removed so that it loses this natural spring.

Over time, whatever cartilage is left starts to bend and twist under the weight of the skin. As the cartilage twists on itself, the weak points at the ‘joints’ of this cartilage can start to form bumps or knuckles, called bossae, that are very noticeable through the skin. Many rhinoplasty surgeons treat these bossae by going back and trimming them, weakening the cartilage even more. This is not a good long-term solution. Check out the diagram below to see what we mean.

The Beverly Hills PROFILES revision rhinoplasty experts know that the tip cartilages must be reconstructed in order to restore their natural strength and resilience while improving the cosmetic appearance of the tip. The revision rhinoplasty surgery photos below show a patient treated at PROFILES. The patient had her tip bossae treated, as well as other post-rhinoplasty concerns that are highlighted in the next few sections.

The nasal valve is a term used to describe the narrowest part of the nose internally. This is the area that determines if someone feels normal or obstructed breathing through the nose. When this area is overly narrowed and blocked, we call it a nasal valve collapse.

There are two types of nasal valve collapses. The collapse of the tip cartilages described above can cause external valve collapse where the blockage is just past the nostril. However, when most rhinoplasty surgeons discuss valve collapse, they are talking about internal valve collapse. This occurs when the upper lateral cartilages in the middle of the nose have been too narrowed. Take a look at the below diagram to see where these are. This problem happens when a nasal bump is taken down too much and when the cartilages themselves are shortened or not reattached during a rhinoplasty.

Nasal valve collapse issues seem to occur more often after a closed rhinoplasty, because most surgeons detach these cartilages without repairing and reattaching them at the end of the procedure. When the natural cartilage supports have been lost, they simply fall inwards and collapse. The result is poor breathing and two visible cosmetic deformities. One is called an ‘inverted V deformity’. That is because the collapsed area where these cartilages attach to the nasal bones looks like an upside-down letter V. Take a look at the photos below to see an ‘inverted V deformity’.

The second visible cosmetic deformity is when the middle part of the bridge starts to look very pinched. This issue is common after primary rhinoplasty.

The revision rhinoplasty experts at Beverly Hills PROFILES fix a pinched bridge using extended spreader grafts among other techniques.

The nasal bones are not so much like a pyramid, but more like an arched-covered bridge or tunnel. When a bump is made smaller, the top of the bones is shaved or cut shorter to reduce the bump. This leaves an opening in the roof of the bridge. That’s one of the reasons we have to cut the base of the bones during rhinoplasty surgery (called osteotomies). We perform osteotomies in order to push the bones inward towards each other so that this opening can be closed.

If the opening is not closed properly, we call the resulting problem an ‘open roof’ deformity. The photos below give you a sense of what this rhinoplasty problem looks like. When you have an open roof deformity, the middle part of the bridge will look and feel unnaturally flat. The edges of the bones are separated and can be seen and felt as a prominent bump at the side edge of the bridge.

To repair an ‘open roof’ deformity, the bones need to be brought back together. However, sometimes the bones have been so shortened and whittled away that it is impossible to bring them together without pinching the top of the nose completely. In this situation, it is necessary to rebuild the roof with grafts. Whatever the extent of your rhinoplasty concerns, the PROFILES surgeons are well-versed in tailoring your procedure to address your individual issues.

A twist in the nose can happen anywhere from the nasal bones to the middle third of the nose and down to the tip. Getting a nose completely and perfectly straight is one of the hardest things to do in rhinoplasty, and is especially hard in revision rhinoplasty. That is why you need to see an experienced rhinoplasty specialist like our revision rhinoplasty specialists at Beverly Hills PROFILES in Los Angeles.

A frequent cause of a twisted nose is crooked nasal bones. This can result when a pre-existing crooked bridge simply was not corrected properly, or when poorly performed osteotomies caused the bones to shift. If the cartilage of the mid-nose or tip is twisted, sometimes it can be corrected by re-suspending or stabilizing the cartilage with sutures. This includes repairing the normal connections between anatomical parts that are often lost during prior surgery. It is important to note that careful planning and execution of each maneuver goes a long way in preventing these problems.

Furthermore, more often than not, we find that during revision rhinoplasty many of these normal structures have been damaged or removed in the primary rhinoplasty done elsewhere, causing the lower part of the nose to buckle and warp. Sadly, this is often beyond simple repair. In these cases, grafts of cartilage taken from your septum (if available), your ear, or rib (which is rarely done), are needed to rebuild the lost tissues and reconfigure their normal connections and supports.