The Art of Rhinoplasty
The nose should balance the face.
The face should balance the nose.
Dr. Neavin has advanced training in rhinoplasty and revision rhinoplasty surgery from an advanced aesthetic surgery fellowship under world renowned rhinoplasty and fat grafting surgeon, Dr. Richard Ellenbogen.
Rhinoplasty, or nose surgery, is one of Dr. Neavin’s favorite surgeries. It is literally surgery that involves sub-millimeters of correction. Patience, precision, and attention to detail are the keys to beautiful, long lasting results with rhinoplasty. Dr. Neavin’s approach might be different than many other plastic surgeons.
The nose should not be viewed as an independent unit on the face. The nose is just one sub-unit of the entire face including the chin, mid-face, and lips. One should always evaluate the chin projection and mid-face projection and lip aesthetics so that all units are in balance. A balanced face is important to frame a beautiful nose, and a beautiful nose is the centerpiece of a beautiful face.
When we look at the nose, our minds measure it to its base at the mid-face and its relation to the chin. Therefore, facial fat grafting is often included at no additional cost with rhinoplasty to balance the mid-face and the nose. Surprisingly, some patients who want a nose job may not really need one. Large noses can sometimes be adjusted by augmenting the chin and mid-face with fat grafting and small chin implants. The result is often a more balanced face and a rejuvenated, younger face without touching the nose.
Rhinoplasty refers to the reshaping of the nose mainly for cosmetic purposes. Because the nose is the centerpiece of the face, an unattractive nose can make you feel self-conscious about your appearance.
The areas addressed during nose reshaping include the dorm (hump or bump), the tip, the ala (area that surrounds the nostrils, the columella (the column between the nostrils), the projection (how far the nose sticks out from the face, and the angle (how much is the nose upturned or tilted). Other characteristics of concern may also be addressed during this surgery.
Rhinoplasty almost always includes an analysis of the chin, cheeks, and lips. Chin projection (or lack thereof) will necessarily change the relative size of the nose and even influence the shape. Small chins make a nose look more projected. Flat cheeks will have the same effect. The lips can also affect how we perceive the nose. The upper lip, in particular, is intimately related to the nose and the two features can either complement or steal beauty from one another.
Corrective breathing can be another component of rhinoplasty. Enlarged inferior turbinates or a deviated septum can reduce airflow through the nose making breathing difficult.
For more information on commonly asked questions visit the FAQ section.
Am I a candidate?
Candidates for rhinoplasty may have a hump, a pinched nose, boxy tip, bulbous tip, plunging tip, hanging columella, widened nose, or some other cosmetic deformity. The list of potential disharmonious features that can rob a face of its inherent beauty is indeed long.
A large percentage of rhinoplasty patients fall into the category of revision or secondary procedures. This is because Rhinoplasty is a surgery of sub-millimeters, and there is some component of healing unpredictability that affects the outcome in about fifteen to twenty percent of patients. Often, it may take years for unpredictable healing to manifest in the nose, causing some visible deformity. Experience in technique and plan are crucial for the most successful results possible.
Potential future issues such as dropped tip, plunging tip or inverted-V deformity can often be predicted and accounted for. For example, the addition of spreader grafts can be used to maintain a natural looking shape to the mid-nose, columellar struts for extra tip support, and division of the depressor nasals muscle to avoid tip drop with smiling.
The best candidates are men or women who have an obvious deformity that is correctable with either surgery or injectables. For more information about non-surgical rhinoplasty click here.
Patients must also be willing to accept the trade-off of prolonged swelling of the nose after surgery. Final refinements, particularly of the tip, will not be one hundred percent visible for months following surgery. Nasal tip edema can persist for a year in both open or closed approaches. For more information on open and closed rhinoplasty visit the FAQ page.
Poor candidates include men or women who recently had rhinoplasty surgery. Because the nose stays swollen for a prolonged period, it is sometimes necessary to wait at least six months or even up to a year to operate again. The swollen tissue is not only harder to dissect, but it also hides or camouflages irregularities that will otherwise be visible when swelling subsides.
Plan for about one to one-and-a-half hours for your initial visit to our office and your consultation with Dr. Neavin. He will want to review your medical history, medications, and any prior nasal surgeries. Dr. Neavin will examine your nose and may even take photos to demonstrate potential nose shapes after surgery.
Patients who have had a prior rhinoplasty have to wait until swelling subsides before going under the knife again. This can range from a couple of months to up to a year, depending on the region and type of the prior surgery. Small deformities may be correctable simply with injectables and may not necessarily need months to address. During the visit, you may wish to have your nose injected the same day. Because the procedure can be performed in 30 minutes or less, this request often doesn’t need additional scheduling.
During the consultation, you will be asked very specific questions about the shape and size of your nose that bothers you. Many men and women will bring in photos of noses they like. This is helpful because it sets the stage for expectations. Some noses are easier to shape than others depending on skin thickness, which is nearly impossible to change.
Men and women often don’t know precisely what they want changed. They may only ask for a prettier or more handsome nose that fits their face without altering their ethnicity.
Chin projection, face projection, neck, and the lips will all be assessed together since the nose is often treated congruently with the surrounding facial features. Renderings of stronger chins or tighter necks can help deliver a good idea of how small modifications in these areas can contribute to improving nose shape.
Rhinoplasty can be performed using open or closed techniques. Dr. Neavin utilizes both approaches, depending on the goals and plan.
Open procedures will allow better visualization of the tip area and allow for some skin defatting to help refine the nose. The open approach uses an incision in the columella (the tissue between the nostrils). The scar that results from this is almost always not visible. The open approach may result in longer swelling.
In a closed approach, the tip is not visualized unless one performs a cartilage delivery technique. However, even with this modification of a closed rhinoplasty, less precise tip work can be conducted. And, one can’t easily remove fat from the nose without opening it. The only real advantage to a closed rhinoplasty is no potential scar on the columella and less post-operative edema.
For cases where the tip needs no refinement, and the majority of the surgery is focused on a hump, the closed approach is often the best approach. If tip work or defatting is involved, then the nose is almost always opened.
In cases of revisions, the nose may be open or closed, depending on the correction desired.
The surgery is performed under general anesthesia and can take up to three hours. Often, fat grafting and chin augmentation are performed during a rhinoplasty to better to frame the new centerpiece of the face. Other combinations commonly performed include a lip lift or lip augmentation in women and a neck lift in men.
Cartilage is sometimes taken from the nose (from the septum or lower cartilages) and used for either nasal support (as in the case with a columellar strut), cosmetic grafting (such as a tip graft to refine the tip), or spreader grafts to improve the shape of the middle of the nose.
Depending on whether the septum was corrected or portions of it were used for grafting, the nose may or may not be packed for as long as five days. If the nose is fractured, a splint will be placed for a week. If it is not fractured, tape will be worn on the nose for a week. Stitches in the nose will be removed on day seven in the office if an open approach was performed. If a closed approach was performed, all of the stitches will dissolve.
For the first week, it is wise to sleep with your head elevated on pillows. Some minor bleeding or oozing may occur for a few days following rhinoplasty. Any significant bleeding is unusual and would warrant a call to 911 or Dr. Neavin immediately.
The nose, especially the tip, will remain swollen for months. The majority of the swelling will subside within a few weeks. But persistent tip edema is common for up to 6 months or more.
Asymmetry from swelling is not uncommon. Also, diet will play a role in swelling. High salt diets one day will result in more tip edema the following day. Sleeping with the head elevated will help relieve morning swelling.
If the nose is fractured, there is a high likelihood of bruising around the eyes. Usually, this will dissipate within a week.
If chin augmentation, a neck lift, or fat grafting is performed with the rhinoplasty, please refer to their respective sections to learn more about their recovery.
Final results in the tip region may take up to a year to see. The tip will stay sightly swollen and a bit firm for six months or more. The nose will probably appear over-rotated for the first month or two. Much of this is due to swelling. The nose will drop somewhat after swelling subsides.
A closed rhinoplasty will leave no visible scars unless Weir excisions are performed. A Weir excision is placed on a portion of the ala to reduce the width of the nostril area. This procedure, because it can be performed under local anesthesia, is commonly done in the office after the nose has healed if the nostrils change slightly during the recovery process.
Part of the aging face is actually seen in the nose. Young noses are thinner and perkier with an obtuse angle from the lip to the nose. As we age, the nose tends to widen and drop. Combination fat grafting to the face and rhinoplasty is a very powerful combination that can take years off a man or woman’s appearance.
Open vs. Close Rhinoplasty
Rhinoplasty can be performed using an open or closed technique. Open rhinoplasty will include a small incision in the columella. The tissues in an open rhinoplasty are dissected from the underlying cartilage framework and bone and allows a very good view of these components. Because of this additional exposure, open rhinoplasty is often used for tip surgery (such as correcting a boxy or bulbouse tip). The incision heals nicely and scars are almost always unnoticeable. The downside to the open approach is prolonged tip swelling. While a closed rhinoplasty tip may be swollen for six to nine months, an open approach may result in swelling up to a year. However, the majority of swelling that results from both approaches subsides in the first three months.
The closed approach spares an incision through the columella. The operation for the most part is performed with limited visibility. However, with a solid understanding of anatomy, not all of the structures need be visualized. For instance, the tip can be reduced internally without exposure of the entire cartilage framework. In other forms of the closed technique, the cartilage can be “delivered” for exposure. While the nasal tip is poorly visualized in a closed approach, the dorsum and its hump can be visualized quite readily and reduced without difficulty. For this reason, it often makes sense to perform a closed rhinoplasty when only humps need to be removed or the nose needs to be narrowed.
Dr. Neavin performs both closed and open rhinoplasty depending on the patient’s anatomy and desires.
With an evaluation for rhinoplasty, Dr. Neavin will discuss a surgical plan that may include facial fat grafting, chin augmentation, neck contouring, or lip enhancement. While not all rhinoplasty procedures need improvement of these areas, when all of these features are in balance, the nose necessarily will look more proportionate to the rest of the face. This is at the heart of the art of rhinoplasty.
Non-surgical rhinoplasty or liquid rhinoplasty
A non-surgical rhinoplasty refers to the correction of a nasal deformity using injectables (fillers) rather than surgery. It can be done in the office under local anesthesia in just under 30 minutes.
What products are used?
Hyaluronic acid such as Restylane®, Jevederm®, Perlane®, Lift®, or Voluma® can be used. Radiesse® which is calcium hydroxylapatite is also a good product for this procedure.
How is it done?
In a non-surgical rhinoplasty, one must ADD volume. Surgery is generally subtractive in nature where cartilage is removed and bones are either broken or filed down. With humps on the nose, the deformity can be viewed 2 ways; either the hump sticks out too far, or the area above the hump doesn’t protrude enough. When we think of humps as the latter, the solution can be as simple as filling in the depression above the nose. This in turn will blend the hump into the nose without making the nose look bigger overall.
The product is simply injected into the dorsum of the nose , under the skin, extending to where the nose begins to slope from the forehead.
Another uses of this technique are to correct a pinched tip from prior rhinoplasty or create symmetry on the front view. Product added to the sides of the nasal tip will fill in the pinch. In cases of asymmetry, volume addition to one side of the nose will often fix the deformity.
Am I a candidate?
Candidates for this procedure have a hump, a pinched nose, or some other type of nasal deformity. Collapsed noses from over-resection from a prior rhinoplasty may also benefit. Men and women who have had a rhinoplasty within the last six months may still be too swollen for this procedure.
Plan for about a one to one-and-a-half-hour visit to the office. Dr. Neavin will want to review your medical history and any prior nasal surgeries. Patients who have had a prior rhinoplasty generally have to wait until swelling subsides. This can range from a couple of months to up to a year, depending on the region and type of prior surgery.
During the visit, you may wish to have your nose injected the same day. Because the procedure can be performed in 30 minutes or less, this request often doesn’t need additional scheduling.
The results of non-surgical rhinoplasty are immediate. The photo below was taken immediately after injection. Unlike surgical rhinoplasty that has some unpredictable element of healing, a non-surgical rhinoplasty is visible immediately. Depending on the product, the correction can last one to two years.
Procedure Details for Non-Surgical Rhinoplasty
Topical anesthesia will be applied to the nose. With a fine needle, the product will be injected into the deformity. The most commonly used fillers are Restylane, Juvederm, or Radiesse. For more on specific properties of fillers, please visit the “injectables” section (link).
Depending on the area, tape may be applied for a couple of days to a week to hold the product in place. While this isn’t always necessary, the tape can help stabilize the product if a significant amount was injected into the glabella area (where the nose joins the forehead). After the procedure, you may go home. Pain medications can be prescribed but are not usually necessary.
Unlike surgical rhinoplasty, the swelling is minimal and bruising is unlikely. Depending on the product, correction may last a year to two years.
A small needle is used for non-surgical rhinoplasty that leaves no visible scarring.
If you think you may be a candidate for rhinoplasty, or you would prefer a minimally invasive approach to your nose enhancement, schedule a consultation by calling 310‑858‑8811 or text 323‑975‑1287. Be sure to ask about free parking or a valet option.