In addition to rhinoplasty, some teenagers and young adults are having chin augmentation to balance out a profile or add “strength” to the lower face, as well as cheek augmentation to widen an overly narrow face. Other procedures, such as removing fat from the lower eyelids or cheeks and raising congenitally low eyebrows, are also occasionally being performed.
Unfortunately, when too many procedures are performed, especially if done incorrectly or not conservatively, the effect can be to lose the subtle beauty of youth and produce a result that may seem unnatural.

I recently performed a procedure to feminize the upper face of a male to female transsexual. To obtain the correct exposure, a coronal incision is first made. Then the bony ridge over the eyes is burred down using an electric hand drill. Following this, an arch to the eyebrows is created, as with a standard open browlift. Finally, there was filling in and rounding out of a depression over the ridge with methyl methacrylate. Though most patients do not need the synthetic augmentation, occasionally it is necessary to obtain the optimal, more feminine result.

I am often asked by my Beverly Hills patients if it is the “right time” to have a certain procedure, or if they have “time to wait”. Certainly, this is a very personal issue and depends on many factors. Having a facial feature that you have never liked, as with a large nose or a receding chin, will never improve with time. So it amounts to deciding on the cost/benfit ratio and if you have the time available to recover. These patients also tend to worry that they may wind up looking worse than before. Consequently, they are torn between their desire for change and the fear of the unknown and tend to procrastinate. To these patients I say that plastic surgery, if done properly by a competent surgeon who understands your goals, will make you look better and will blend harmoniously with your other facial features. Surprisingly, though the result may be quite dramatic to the patient, it is rarely that evident to friends, colleagues and even family, especially if the patient changes their hairstyle, shaves off a moustache or does something else to alter their appearance in another way.
When we consider rejuvenative procedures such as face and neck lifts or eyelid surgery, there are some who think earlier is better and some who think just the opposite. Those who favor the earlier approach argue that the change tends to be less dramatic and, therefore, less obvious. On the other hand, those who favor waiting till it’s unbearable to look in the mirror or uncomfortable to wear tight collars think you get  more “bang for your buck” by waiting. My personal opinion is that you should try to look as good as you can for as long as you can. Since youthful skin has more elastic fibers and better collagen, it tends to re-drape and conform better producing a more rested and healthier appearance. And having a procedure earlier rather than later, allows you to enjoy the benefits for a longer period.

   When we evaluate nasal symmetry, we first check to see the overall facial symmetry. Since the root of the nose starts between the eyebrows and the base of the nose ends over Cupid’s bow of the upper lip, it would be impossible to straighten a nose if the centers of these two landmarks were not directly in line. However, through differential cartilage grafting, we can give the illusion of a straighter nose. Next we evaluate the upper, middle and lower thirds of the nose. The upper third is generally bony and can be straightened via various fracturing techniques. The middle third is mostly cartilaginous and may require cartilage repositioning, resecting or grafting. And, finally, the lower third involves the cartilage and soft tissue of the nasal tip and nostrils— either of which can be asymmetric or unequal.

There are numerous techniques for addressing deformities of these nasal structures. The tip cartilages can be equalized and re-positioned, if necessary, and the nostrils can be made more equivalent through techniques that raise or lower the rims and narrow or expand the openings.

The main difference is an incision between the nostrils which allows for skin elevation off the underlying bony-cartilaginous framework. It is the technique most often employed when access through the top of the nose, as well as through the nostrils, is desirable. By providing this greater degree of visualization, asymmetries are more easily evaluated and graft placement and fixation are more exact. Finally, dissection through intensely scarred areas within the nose from prior surgery or trauma is  made easier.

For female patients, we aim to produce a very gentle slope over the bridge of the nose, ending in a defined tip which is the highpoint on profile. Additionally, the sidewalls of the nose are somewhat narrower in the midsection, producing a subtle curve or “C” shape. Extending this curve into the eyebrow produces a continuous  convexity. Furthermore, the angle between the bottom of the nose and the upper lip is greater than 90 degrees or a right angle. In some cases, it may be as large as 105-110 degrees, producing more “nostril show” than we see in a man.

On the other hand, the angle for a man is around 90 degrees. The bridge tends to be straighter, which forms a “T” with the straight eyebrows above it. And we are generally more accepting of slight imperfections and a larger framework in a man.