Though I’ve outlined many advantages of the “open” versus “closed” technique, I should state that in a fairly straightforward, primary rhinoplasty, the closed technique is perfectly satisfasctory, predictable and probably most often employed.

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One of the biggest misconceptions is that just about any nose that you desire can be accomplished with the right surgeon. While it is true that experience, technical expertise and aesthetic judgment  vary among surgeons, there are certain limiting factors that no surgeon can overcome. Chief among these is thickness and quality of the skin. The thicker the skin, the less likely it is that it will re-drape  to a smaller, more angular framework. Various techniques such as cross-hatching the dermis, injecting with steroids and other medications such as 5-FU, prolonged casting or nightly taping and the use of Accutane to diminish the oil glands in the skin have been used with variable success. Additionally, as one ages there is a loss of elasticity in the skin making it harder to shrink-wrap down onto a reshaped  bony-cartilaginous framework. Since the skin over the upper one half of the nose is thinner with less oil glands, it is more capable of conforming than the skin over the lower half. Additionally, since the lower half skin will shrink to the smallest volume for its surface area, which is a sphere, we tend to see a rounded lower half of the nose if too much bone and cartilage has been removed for the skin to adapt. This is called the “pollybeak” deformity.

Another misconception is that breaking the nose makes the operation more painful with a longer recovery period. In actuality, nasal surgery is usually painless or minimally painful in the post-operative period, whether or not breaking of the bones was necessary. And it’s been my experience that recovery time is unchanged in either case. Furthermore, I have seen people bruise without bone breaking and no bruising in some patients who required it. It seems more related to capillary fragility, hormonal balance and/or medications or herbal products that they were taking.

Another misconception is that there are some things that can’t be corrected on the nose, such as nostril asymmetries and their  facial attachments . Since wide variation exists between surgeons regarding experience and abilities, it is wise to go to several surgeons if you are told that something can’t be done. It might just mean that this particular surgeon can’t do it!

Another misconception is that you will have no idea what your nose will look like until six to twelve months have passed. While it is true that swelling and settling can take weeks or months to resolve, it has been my experience that you should have a rough idea of what your nose will look like in the immediate post-operative period.  Obviously, there are many variables that play into this, such as skin thickness, techniques used, post-operative care, etc.

Another misconception is that  very “difficult” noses require two operations. While it is true that minor revisions or “tweaking” a result may be warranted in 5%-10% of the time, most of the time all that is needed can be accomplished in one operation.

A final misconception is that a surgeon who performs rhinoplasty can also perform revision rhinoplasty or reconstructive rhinoplasty. In actuality, it’s usually just the reverse. In revision rhinoplasty, the surgeon is trying to establish an aesthetic result in a nose that was operated on with a poor outcome. Like the first  surgeon, he is trying to achieve a nose that is better than it was initially…that is, taking a normal nose and making it “better than normal”. However, in this case there is additional internal scarring, misplaced or absent tissue, shrinkage of internal lining and maybe external scarring as well. In reconstructive rhinoplasty, the surgeon is trying to establish a normal appearing nose from one that is less than normal, from a cancer procedure or trauma. The techniques used may require skin flaps or grafts as well as cartilage or bone from several sources. The internal arrangement of these components may have no resemblance to what normal nasal anatomy is. However, the goal is to establish a nose that looks relatively normal and functions well.

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Direct Browlift

There are several approaches to raising the eyebrows. There is the Direct Browlift which excises skin immediately above the eyebrows. It is a fairly simple and quick procedure and should be performed in a patient whose skin does not form obvious scars. Because it is a sharp, crisp line above the eyebrow, it can be somewhat feminizing. Consequently, it is usually performed on a woman who wants a simple procedure or a man with bushy eyebrows that can obscure the scar.

There is the Mid-Forehead Browlift which excises skin through a wrinkle in the middle of the forehead. This is almost never performed on a woman and is usually reserved for balding men who have deep forehead wrinkles. In the right candidate, the procedure is very effective. However, the scars can be red for six months or longer before they gradually fade away.

Pre-Trichial Browlift

The Pre-Trichial Browlift excises skin immediately in front of the hairline. It is usually reserved for patients who have a high hairline and do not want it raised any higher. This approach can also be employed to pull the hairline forward and actually lower it.

The Coronal Browlift excises hair bearing skin across the top of the head. Because it creates a very long scar and cuts sensory nerves, which results in 6-12 months of numbness, it has given way to the endoscopic browlift. However, there are special instances when it is useful, such as exposure to drill down prominent brow bones above the eyebrows or to attempt at equalizing asymmetric eyebrows.

Endoscopic Browlift

The Endoscopic Browlift, which uses special elevators and rigid telescopes through small scalp incisions, raises and fixes the entire forehead and eyebrows after freeing them from their underlying attachments. It is probably the most popular procedure and avoids long scars and scalp numbness. However, because it raises the hairline, proper patient selection is important.

Browpexy

Finally, there are several less involved procedures that are sometimes employed. There is the Browpexy which suture fixates the eyebrow at a higher level through an upper blepharoplasty incision. Obviously, it is most commonly performed when a blepharoplasty is planned and only minimal brow elevation is sought. Because nerves and blood vessels exit the forehead bone on the medial or inner aspect above the eyebrow, only lateral brow elevation can be accomplished using this technique. And lastly, there are less effective but occasionally employed “cable” procedures. These utilize sutures placed through incisions in the scalp above the eyebrows which go under the forehead skin to lift the eyebrows.

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Silastic implants are usually pre-formed, though can be trimmed, and form a capsule of scar tissue around themselves. Because of this, they are never truly incorporated into the tissue. Consequently, you can move it side to side manually and, occasionally, it will break through the overlying tissue. I never use this implant material.

Medpor comes in various shapes and sizes, is somewhat firm, and can be carved or trimmed. It can be placed over the bridge or in areas to create lateral nasal support or even tip support, as long as there is soft tissue and cartilage covering it. There is a minimal amount of tissue ingrowth which tends to fix it in place.

Gore-Tex is a very popular implant, which also allows for a slight amount of tissue ingrowth enabling it to be fixed and stabilized. It comes in several thicknesses, is easily trimmed and is quite malleable. It makes for an excellent dorsal implant. However, as with any foreign material, there is a slight chance of infection. Also, Gore-Tex has to be fixed securely because it has a tendency to change shape or even allow for the formation of fluid under it.

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I would like to discuss the so-called vertical facelift because it has gotten much attention lately as the “best” approach to reversing the downward effects of gravity. Though the actual term may mean different things to different surgeons, the basic idea is to elevate some, if not most, of the tissue straight up. While this may seem to be the obvious approach to reversing facial aging, it is not that simple. Due to the various connective tissue attachments under the skin and the differences in mobility to the various parts of the face, there appears to be a forward as well as a downward descent. This is all too apparent when we look at the oblique fold of tissue going from the nostril to the corner of the mouth. Complicating this picture of facial aging is the atrophy or loss of the subcutaneous fat that also occurs in some areas, leaving a void or depression that looks as though tissue has fallen away. It appears that the best approach to reversing facial aging is a combination of some vertical as well posterior lifting, coupled with augmentation via fat or implants, if atrophy is also present. The vertical component of the lift can be in the deep subperiosteal plane or more superficially in the SMAS plane or even the subcutaneous plane. But it almost always gives a more natural result if there is some element of posterior lifting, as well. To that end, some surgeons are combining a vertical subperiosteal mid-facelift with a posterior-superior vector SMAS or subcutaneous facelift. Alternatively, others combine a posterior-superior vector MACS (minimal access cranial suspension)lift or SMAS facelift with a vertical subcutaneous facelift.

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Rhinoplasty is one of the most transformational procedures that I do. It can make someone who has been unattractive their whole life more appealing, and it can even make a person look younger by elevating their tip. Eyelid surgery is relatively easy to perform with minimal downtime and does wonders for making someone look more relaxed, less “burned-out” and even younger. Finally, Botox Cosmetic is one of the “lunchtime” procedures, which is easy and quick to perform, relatively inexpensive and produces dramatic results in the right patient. In addition to smoothing out wrinkles of the forehead, between the eyebrows and around the eyes, it can raise downturned corners of the mouth and lessen the prominence of early neck bands.

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