Friday, October 26, 2018

Revision Rhinoplasty

Dr. Sam Rizk:  “The nose should not be the focus of the face.  We try to make the eyes the focus of the face, other parts of the face.  We try to make the nose disappear.” 
by Delia von Neuschatz

Have you had a nose job and are unhappy with the results?  If you are considering a revision rhinoplasty, the article below outlines the considerations of undergoing a surgical procedure and provides information on a noninvasive option too.

“The nose should not be the focus of the face,” says New York City plastic surgeon, Dr. Sam Rizk. “The problem with a bad nose job is that it brings attention to itself.  We try to make the nose disappear.”  “The goal of the nose is to blend in and fit the face,” concurs Dr. Steven Pearlman, who counts more than half of the patients at his Park Avenue plastic surgery practice as seeking a revision rhinoplasty. 
Dr. Steven Pearlman:  “The nose is not just a cosmetic appendage on the outside of your face.  It’s a functional structure that has to be respected.  That’s why primary rhinoplasty should be done by someone who does a lot of rhinoplasty and revisions by someone who specializes in revisions because it's much more complex to try and rebuild the nose than just doing a simple cosmetic operation.”
But aesthetic considerations are not the only driving force behind this highly specialized surgery.  The other is functional issues.  “It’s a combination of visual dissatisfaction and also a breathing dissatisfaction.  There’s an aesthetic and a functional component,” explains renowned facial plastic surgeon, Dr. David Rosenberg.
Dr. David Rosenberg:  “The whole idea of revision rhinoplasty is to make people look like nothing was done – to take away the aesthetic of surgery and also make them breathe better.  The marketplace, the population around here in New York has evolved - whether it’s a nose job or a facelift - to have the work look beautiful without looking done.”
Keeping in mind, however, that “the average person is not rushing to get general anesthesia and get their face cut open,” according to plastic surgeon, Dr. Lara Devgan, there is a nonsurgical alternative that addresses aesthetic concerns.  For those wishing to avoid surgery or who want to see what the results of a revision rhinoplasty may look like, a “liquid nose job” whereby fillers are strategically injected to form a more pleasing nose, will provide a temporary option.
Dr. Lara Devgan:  “Nonsurgical rhinoplasty is wonderful for an aesthetic perfectionist.  It is extremely precise and I sometimes use the analogy of a mechanical pencil versus a crayon where a mechanical pencil is the nonsurgical rhinoplasty and a crayon is the surgical rhinoplasty where it’s more durable, but it’s not as fine.”
The aesthetic considerations of a revision rhinoplasty are numerous.  The most common problem is overdone noses according to Dr. Rizk.  In other words, a pinched nasal tip, a scooped nose, technically called a saddle nose, an inverted “V” or narrowing of the middle third of the nose, all result from an overaggressive initial rhinoplasty.  Overresection, or excessive removal of tissue, can also result in an overly shortened tip or “pig’s snout” when too much of the septum has been removed.  Conversely, overresection can also result in a droopy tip due to the excision of a disproportionate amount of cartilage at the end of the nose.  Failure to ensure proper tip support can likewise lead to a hanging columella whereby too much of structure separating the nostrils is exposed resulting in an unflattering snarl-like appearance. 

The anatomy of the nose:
For Dr. Rizk, a good number of his revision rhinoplasty patients are women in their 40s who had their noses done 20 years ago when the norm was to take out more cartilage.  “Now we're learning to be more conservative with noses where we leave enough cartilage so it doesn’t collapse, so that so that it doesn't look like a ski slope, so it looks natural and functions better because the nose is not like a breast implant," says the surgeon.  “You can’t go as small as you want or as large as you want.  The smaller you go, the higher the risk of a functional breathing deficit.  Sometimes even when we leave the appropriate amount of cartilage, you will get reduced air flow in a smaller nose.”  “That’s the goal of revision rhinoplasty,” says Dr. Rosenberg “to take away the aesthetic of surgery and also make the patient breathe better.”

Before and After photos for Dr. Rizk:
Before: A 26-year-old female patient had a revision rhinoplasty to correct a collapsed right side as well as droopy tip.
After: Cartilage was used to support tip and to correct the collapse on the right side of the nose.  She is shown two months after revision rhinoplasty and will take one year to completely heal.
A 35-year-old female patient who had rhinoplasty when she was 15 had too much cartilage removed which resulted in a severely pinched tip, a very short nose, and a scooped out area on the left side of her nostril. 
A bilateral lower lateral cartilage graft fixed the pinched tip, a caudal septal extension graft from her septum helped lengthen the nose, and a left alar rim cartilage graft fixed the scooped out hole. Her post-op pictures show her nine months after revision rhinoplasty with an open approach rhinoplasty.
Rhinoplasty is the most complex operation in cosmetic surgery, according to Dr. Pearlman.  Why?  Because there are numerous moving parts including nasal bones, the rigid cartilaginous septum and the soft cartilaginous tip.  “Everything you touch has numerous consequences,” says Dr. Pearlman.  “If someone has a wide tip and you trim a little bit of cartilage off, it affects not only the width of the tip but the angle of the tip how far the tip sticks out from the face and may even cause some twisting if you weaken it too much.  This is something that even the best experts are studying through their entire career.”

Before and After photos for Dr. Pearlman:
The female patient was in a car accident and fractured her nose as well as the bones between the eyes.  This caused the nasal bones to collapse backward into her face.  She had surgery by another doctor to repair the fractures and reconstruct her nasal bridge with bone from the outside table of her skull. The same surgeon revised this surgery using donor cartilage to further improve her nose as well.  Dr. Pearlman removed all the grafts and re-broke the bones to bring them to the midline. Then he rebuilt the bridge of her nose with a segment of her own rib cartilage.
The male patient had his nose augmented (the bridge raised up) with a synthetic material called Medpor by another surgeon. His original nose had a low bridge and poorly defined, wide nasal tip.  This material is sometimes used for this purpose.  However when a synthetic implant becomes infected, it needs to be removed.  He was on a few months of antibiotics with no help.  The before picture is his chronically infected nose and implant.  Dr. Pearlman removed the implant and rebuilt his nose with donor cartilage that was obtained from a cartilage bank.  Ethnic rhinoplasty is an important consideration according to Dr. Pearlman.  “Someone who's African-American or Asian may want to have the nose augmented or to raise their profile or narrow the tip.  They don't come in wanting a Caucasian nose, just like a Caucasian who has a big hump and wants a lower bridge doesn't say ‘I want an African American or Asian nose.’  They want to fit their ethnicity.  Natural means it doesn’t scream rhinoplasty.”
Revision rhinoplasty is even more complex as it requires using body parts – cartilage from the ears or ribs and something called temporalis fascia – a layer of fibrous tissue located at the temple – to rebuild the nose.  With regard to re-building with cartilage, “the number one and the best source of cartilage is the septum [the wall that separates the two nostrils],” reveals Dr. Rosenberg.”  The next source is ear cartilage taken from behind the ear.  The problem with ear cartilage, however, is that it’s curved, soft and mushy as Dr. Pearlman explains.  So, it’s suitable for adding volume, but not for straightening a crooked nose, for example.  In that case, if the septum is an inadequate source of cartilage, the option is using rib cartilage – harvested either from one’s own rib or from a donor bank.  Dr. Pearlman is partial to using a patient’s own rib:  “The rib cartilage incision is two centimeters or less.  It doesn’t cause a deformity.” 

Dr. Rizk and Dr. Rosenberg, on the other hand, by and large prefer using donor cartilage if the septum is not an option.  Known as costal cartilage, the tissue has been treated with radiation and chemicals so that it does not carry disease.   “Human ribs works very well,” says Dr. Rizk.  “It’s been used millions of times in the nation without a problem,” reveals Dr. Rosenberg.  “At times we have been using this three times a week with tremendous success.”  The cartilage is shaved into a wafer-thin sheet that is grated onto existing tissue, forming an internal beam of support. 

This type of rhinoplasty, used to correct central defects such as a crooked, under-projected or pinched tip, requires an “open” approach whereby the skin is pulled back to reveal the underlying structures.  Lateral defects such as an external valve collapse are corrected via a closed surgery.  The latter has no scarring while the former leaves a very fine, nearly imperceptible scar across the columella.

Before and After photos for Dr. Rosenberg:
This patient underwent prior surgery eight years earlier.  In the pre-op pictures, the side view reveals excessive nostril show and a drooping tip with a smile.  These were corrected with cartilage grafting and support maneuvers.  The pre-op views also reveal an overly bulbous contour just above the formal tip, and asymmetries.  These were corrected with internal sutures.  The after result photos were taken just 15 days after surgery, showing the rapid recovery.  “The patient now feels like she ‘has the nose she wishes she was born with,’” says Dr. Rosenberg.
This patient, a surgeon and mother of three, underwent closed rhinoplasty as a teenager. Over time the tip dropped, the nostrils flared and asymmetries developed.  The post-op photographs show a proportionate nasal contour with excellent tip support, elegant definition and greatly improved symmetry. 
So, how to choose a doctor for this complex surgery?  Research, research, research!  “In each city, there’s only a handful of extraordinary revision rhinoplasty surgeons,” explains Dr. Rosenberg.  “You’ve got to find the right surgeon.  That’s everything.”  The doctor and patient need to see eye to eye on the aesthetics, advises Dr. Rizk.  Patients should ask to see pictures.  “If they don't like that surgeon’s work, they're not going to be happy regardless of a successful operation.”  Also, continues Dr. Rosenberg, assess the atmosphere.  “Is the place spotless?  Is the staff appropriate?  You want to consider every detail because you want someone who is detail oriented to the max.”  Costs range from about $18,000 to $28,000 with a top New York City surgeon.  The surgery can last anywhere from two to six hours depending on the complexity and the recovery is about the same as that for a rhinoplasty.  That is, black and blue eyes are present for a week, to a week and a half.  The cast and stitches come out eight days after surgery and approximately 85% of the swelling will diminish in a month’s time.  Most people, even with a rib graft, can be back to work in a week and a half with cover makeup according to Dr. Pearlman.

Choosing a doctor carefully is just as important when it comes to non-surgical liquid rhinoplasty as there are several complications associated with this procedure.  Because the nose has terminal blood vessels, improper injection can result in tissue necrosis and in some cases, even blindness according to Dr. Devgan.  That is why it is crucial to go to a very experienced doctor.  Dr. Devgan, who performs up to ten liquid rhinoplasties a day, has this further advice on choosing the right doctor:  “Go to someone who is familiar with the three-dimensional intraoperative anatomy of the nose.  If you don’t know how to do a surgical rhinoplasty, you should not do a nonsurgical rhinoplasty.”

A liquid rhinoplasty is a technique in which the injection of a hyaluronic acid-based filler like Restylane, is used to create a more aesthetically pleasing nose.  It does not repair functional issues.  Ideal candidates for this non-invasive procedure, according to Dr. Devgan, are those concerned with the dorsal hump of the nose or a bump on the nose, a downward pointing or droopy nasal tip, a bulbous tip that they would like to appear more delicate or those who wish to correct post-surgical irregularities, asymmetries, divets or dents.  “In a lot of ways, nonsurgical rhinoplasty is almost an optical illusion because by manipulating the proportions and structure of the nose in a careful way, you can create the feeling of a much smaller nose even though technically, you’re not making the nose any smaller,” explains Dr. Devgan.

In fact, a lot of the stigma of a bad nose job can be camouflaged with liquid rhinoplasty:  inverted V deformity, pollybeak deformity, a hanging columella or a downward–pointing bulbous tip.  Telltale signs of a nose job such as alar notching and pinched tips can also be addressed with injections.  “All of those things can be nicely refined with injectables,” says Dr. Devgan.  The procedure itself takes about five minutes and there is zero downtime.  Results can last up to one to two years. 

The longevity of the fillers depends on an individual’s metabolism and unique anatomic characteristics, explains to Dr. Devgan.  The presence of scar tissue and the thickness of the skin will impact the fillers’ duration.  Similarly, someone who wears heavy glasses or gets weekly pore extractions will have less durable results.  The bottom line is that the more you handle filler, the faster it breaks down.  Fees ranges from $2,500 to $5,000.  For the average patient, only one syringe of filler is needed and pricing for that is $2,500 with Dr. Devgan.

Before and After photos for Dr. Devgan:
This patient had a dorsal hump, bulbous tip, and downward pointing nose. This was her second nonsurgical rhinoplasty. Dr. Devgan performed her first one, which lasted over a year. Average duration is 8 months to 2 years.
This patient had a large dorsal hump, hook-shaped nose, droopy nasal tip, and low radix.  She was very happy with her nonsurgical rhinoplasty and many people commented that they didn’t realize until after the procedure that she looked like Julia Roberts, according to Dr. Devgan.
The future for this increasingly popular procedure looks bright.  “Nonsurgical rhinoplasty is a really cool technique and I think it’s going to become even cooler as technology with fillers progresses and we have longer duration fillers that are still fully dissolvable,” says Dr. Devgan.  “That’s going to happen in our lifetimes.  I bet in the foreseeable future we’ll have a dissolvable hyaluronic acid filler that last for five or even ten years.” 
Beauty tips: For Dr. Devgan’s advice on how to avoid the services of a plastic surgeon, listen carefully below:
For more beauty tips and information, follow Delia on Instagram: @chasingbeautywithdvn