Does the doctor or the patient decide what the final result should look like?

For the most part, the patient decides, but her desires are tempered by the plastic surgeon showing what is possible and what is not possible.  Here's how I do it: the patient tells me what she notices about her nose, what she doesn't like, and what she would like to have changed.  I then tell the patient what I think can be accomplished, and to what extent.  We discuss any other changes that I recommend, and we bat it back and forth until we come up with a plan for surgery. Sometimes a patient brings photographs of other noses that she likes to the consultation.  That's not particularly helpful, because we can't put someone else's nose on the patient's face; rather, we can only make certain changes to the nose that she already has.  Still, it can be interesting to see the features that the patient finds attractive on other peoples' noses. Plastic surgeons still exist who will not accept input from the patient; they just say that the doctor is in charge and that his judgment will determine how the nose will look.  You should never ever have surgery by a doctor who works that way.  Your plastic surgeon should carefully listen to, and address, every one of your concerns about the appearance of your nose. Another important point to remember: just because a plastic surgeon appears to understand what you want in a nose does not mean that he can accomplish those changes in the operating room.  You must see before and after photographs of his other patients, preferably patients with noses similar to yours, before hiring him to perform your operation.  Go here for more information on finding a competent plastic surgeon.

What's the difference between "open" rhinoplasty and "closed" rhinoplast

In an "open" rhinoplasty, a small incision is made in the columella, which is the little column of skin that separates the two nostrils.  That incision allows the nasal skin to be lifted off of the tip of the nose.  That's the only difference between the two techniques.  In both open and closed rhinoplasty, many other incisions are used up inside of the nose, but the open technique also has that one little extra incision in the base of the nose.

The photos below show the location of the open incision.  The two identical photos were taken after healing is complete.  It's quite hard to find the scar.

The open technique has huge advantages over the closed technique, in my opinion.  The main advantage is that it is much easier for the surgeon to see and work on the nasal tip cartilages in their natural positions.  With the skin lifted up, it's easier for the surgeon to see what needs to be done, and to accomplish those tasks.  The little scar heals superbly.http://www.facialsurgery.com/image/spacers/hspace15.gif

The use of the open technique allowed me to take all of the nice intra-operative photographs that you see in the intra-operative rhinoplasty tutorials on this Web site.  Open rhinoplasty is a great teaching tool.

Plastic surgeons debate the advantages and disadvantages of the open vs. closed techniques, just like they debate practically everything, and you'll find plastic surgeons who argue vehemently for each technique.  I strongly favor the open approach, but some plastic surgeons get excellent results with closed rhinoplasty, so don't select your surgeon based on the open vs. closed question.  Select your surgeon based on his overall skill in performing rhinoplasty.  Go here for more information on finding a competent rhinoplasty surgeon.

I will occasionally use the closed approach for a nose, if all of the following conditions are present before surgery: 

  • the tip of the nose has excellent shape (not too wide, not asymmetric)
  • the tip is not overprojected (sticking out too far away from the face) or underprojected (sits too close to the face)
  • the nose is not too long, with a drooping tip
  • if there is a hump to be corrected, it's only a small hump
  • the nose is not particularly crooked
  • there is no other nasal feature that would require an unusual or complicated surgical technique for its correction

All of those conditions don't happen too frequently; I use the closed technique only about 5% of the time.





When the nose is made smaller, what happens to the extra skin?




Amazingly enough, the skin will "shrink-wrap" to fit the new, smaller size of the nose.  The nasal skin has some elasticity, so even if a nose is made incredibly smaller during the operation, no skin needs to be excised.  That's convenient, because it wouldn't be acceptable to place an obvious scar on the outside of the nose for the removal of some of the nasal skin.




Why is a revision rhinoplasty so much more difficult than a first-time rhinoplasty?

There are many reasons why a revision operation is much more difficult. 

After any rhinoplasty, the nose heals by making scar tissue.  Any body part will create scar tissue as it heals from an operation.  You can't see this scar tissue, because it is underneath the skin of the nose, but it's there, enveloping the cartilages of the nose and coating all of the areas where the surgery was performed.

The surgeon performing a revision rhinoplasty has to fight his way through that scar tissue in order to make the changes that are desired.  The scar makes it difficult to find and alter the cartilages of the nose without possibly tearing or otherwise harming them.

During the first operation, the first surgeon may have removed too much cartilage from various parts of the nose.  In that case, it can be difficult to create shape and support for the nose, and cartilage grafts may be necessary, as well as grafts of artificial materials.  These reconstructive techniques are technically more demanding than the techniques that are typically used during a primary rhinoplasty.

When can I have my nose redone after a previous unsatisfactory rhinoplasty?

It's important to wait one entire year after a rhinoplasty before making another attempt.

The scar tissue that forms underneath the skin of the nose after a primary (first-time) rhinoplasty is hard at first, as is any scar.  If you have a scar from an operation, such as an appendectomy, the scar starts out being quite firm; it feels like a cord underneath the skin.  With time, the scar softens, so that eventually you can't find your appendectomy scar by feeling for it -- you have to look for the scar, because it feels just like the surrounding skin.

The scar tissue in the nose starts out hard, and after a few months it starts to soften.  You can't feel much of the firmness, except perhaps at the tip of the nose, which might feel more solid than natural, but the firm scar tissue is there, underneath all of the nasal skin, until the scar has had time to soften.  It takes about a year for the scar tissue to soften completely.

If a surgeon attempts a revision rhinoplasty before that scar tissue has had a chance to soften completely, he is operating with one hand tied behind his back, because he is guaranteeing himself a difficult time trying to fight through the firm scar.  Even after it has softened, the scar tissue makes a revision operation difficult, but before it has softened, it's just impossible.

Also, as the swelling in the nose decreases after a primary operation, the nose gradually looks different, hopefully better, and it's important to wait until the swelling has resolved and the nose stops changing in appearance before attempting a revision operation.  Scar tissue under the skin of the nose can also shrink as it softens, further helping with the appearance of the nose.  If you operate too early, the surgeon may be operating to correct problems that would at least partially correct themselves as the rest of the swelling resolves.  He doesn't really know how much to do if he operates too early.

Re-operating on a nose too early can be likened to building a house on a soil foundation that is still settling: you want everything to stop moving before you decide exactly what changes to make and attempt those changes.

Finally, we have said that a revision rhinoplasty is much more difficult than a primary rhinoplasty. 

What can be improved during a revision rhinoplasty?

Sometimes great improvements can be made, and sometimes very few.  Let's divide this discussion into two categories: A) where the primary surgeon did not have a good grasp of how to perform a rhinoplasty, and B) where the primary rhinoplasty was competently performed, but after surgery the nose still has features that the patient and her surgeon would like to improve.

A) The primary rhinoplasty was not excellent

In this category, a common complaint is that the nose is still too projecting (sticks out forward too far from the face) or too long.  I'll define those measurements for you.  The nose below left is projecting: it sticks out forward, away from the person's face.  The nose below right is long, where we measure length along the bridge of the nose down to the tip.
Correction of projecting and long noses requires detailed work on the nose's tip cartilages, something most plastic surgeons don't know how to handle.  If those tip cartilages were not severely altered during the first operation, we can often shorten and deproject the nose a great deal during a revision.

If a hump is still present, the hump can usually be taken down more.  Also, if a hump was over-resected, leaving the patient with a "scooped-out" appearance, the height of the nasal bridge can be built up again.

If the upper half of the nose is still too wide, perhaps the nasal bones weren't narrowed during the first operation, and that can be accomplished.  If the lower half of the nose is too wide, work on the tip cartilages can narrow the tip, or perhaps the nose is wide because there is a large amount of scar tissue under the skin, scar tissue that could be removed during the revision operation.

Most complaints that people have after an unsatisfactory primary operation can at least be addressed, and it's up to the revision surgeon to communicate to the patient how much improvement he feels he can achieve in each area of the patient's dissatisfaction.

B) The primary rhinoplasty was competently performed

If the primary rhinoplasty was competently performed, then the patient/surgeon discussion about whether to perform a revision rhinoplasty is usually related an isolated, well-defined feature, such as a small remaining hump, an asymmetry, or the nose not having moved enough in some direction: it's still a little too long, or a little too wide, etc.

What are the risks of the revision?  Any nasal operation comes with risks.  If the feature that the patient notices is improvable, but attempting to correct it would put some other nice features of the nose at great risk, and the feature to correct isn't all that bad, the patient and surgeon might decide to forego an attempt at revision after carefully weighing all of these considerations.


Early face lifts or mini-lifts for younger people

Any plastic surgeon who tells you that he can perform an operation on a 32 year old to make her look 21 years old again is lying.  That is a bizarre and unrealistic expectation from a face lift operation.

In recent years, we have seen surgeons rename and redesign the face lift in order to make the operation more easily marketable to people who are in fact too young to need or benefit from a face lift.  Why?  For the money.  I have never seen a 30 year old who was a candidate for a face lift.

We do not perform face lifts prophylactically.  Before having a face lift, you must have visible signs of aging that can reasonably be corrected with a face lift, and you must see photographs of your surgeon's other patients, of your age, who have shown a good visible improvement from the operation, an improvement that you would like to have for yourself.

What causes the dark circles under my eyes?

Dark circles under the eyes have several possible causes.

In many people, the skin of the lower eyelids is very thin, and the dark that you see is the venous blood in the veins underneath that thin skin.  No good treatment is available for that condition, because we don't know how to coax the veins to carry less blood.

Sometimes the dark circles are actually excess pigment in the skin of the lower eyelids, as if the skin had a huge freckle that covered much of the lower eyelid skin.  You can tell if that's what is going on by stretching the lower eyelid skin down and to the side, and carefully comparing the color of the skin to the color of the adjacent cheek skin.  When pigment is the problem, it can often be treated with topical bleaching creams (not hugely effective) or with a skin peel, which tends to pull excess pigment out of the skin.

The dark circles can just be shadow.  With time, the lower eyelids usually develop little bulges, which represent the fat that cushions the eyeball pushing forward.  The fat bulge makes it look as though there were a little groove underneath the bulge of fat, and that semi-circular groove looks like a dark circle.  Fat bulges can be treated with lower eyelid surgery, also called a lower eyelid blepharoplasty.

Eyelid surgery or brow lift?

When someone complains of the appearance of the upper eyelids, the first thing we do is evaluate whether the problem is excess skin in the upper eyelids, or if the problem is that the eyebrows have lowered in position over time. If the eyebrows are in good position, then we can perform the upper eyelid surgery (also called a blepharoplasty) to remove the excess skin.  If the eyebrows are particularly low, however, it might not be wise to excise skin from the upper eyelids, and in that case a brow lift is the better idea.

If you look in the mirror and with your fingers raise your eyebrows sky high, you'll see that all of the excess skin in your upper eyelids appears to disappear when the brows are elevated.  If the brows are low, raising them can take care of much of the problem of excess skin in the upper lids.

A couple of examples will help here.  In the person pictured below, the before picture shows lots of excess skin in the upper lids.  She had a brow lift, not an upper eyelid blepharoplasty.  In the after picture, there seems to be very little excess in the upper lids.
The woman pictured below has eyebrows that are in excellent position, so the excess in her upper lids can be addressed with just the upper eyelid surgery.

The woman below has what seems to be lots of excess skin in her upper eyelids, but her brows are so low that if we were to just work on her upper lids, the result would be poor.  If you can imagine only taking excess skin out of her upper eyelids, you'd see that we would just about be sewing her upper eyelashes to the bottom of her eyebrows.  She had a brow lift only.

Remember, also, that the purpose of the brow lift or forehead lift is only to elevate, vertically, the position of the eyebrows.  It does not tighten the forehead skin or remove forehead wrinkles.http://www.facialsurgery.com/image/spacers/vspace8.gif