Rhinoplasty


Closed rhinoplasty dorsal hump reduction involves meticulous techniques in order to create natural-looking results—i.e., the patient’s new nose looks as if he or she was born with it.

 

Recently, Inland Empire plastic surgery expert Dr. Tarick Smiley has shown images on Snapchat depicting this surgical technique performed on a female patient with nasal aesthetic issues that included prominent dorsal bump, droopy tip, and “nostrils that were showing too much.”

 

 

The patient’s rhinoplasty, or colloquially referred to as nose job, was performed via closed technique in which all the incisions were made inside the nostrils, precisely along their inner lining. Not only it resulted in well-concealed scars, she also mentioned a “relatively easy recovery due to minimal pain, swelling, and bruising.”

 

Dr. Smiley was able to create a “nicer and flatter” dorsal (nasal bridge) by removing the excess bone and cartilage. (Note: The upper one-third of the nose is composed of bone, while the remainder is comprised of cartilaginous framework, which makes it malleable but nonetheless firm.)

 

A piece of cartilage was then cut/reshaped so it could provide a strong tip support, ensuring that the results are stable (can resist or postpone aging and other changes). The same technique has also corrected the drooping tip appearance.

 

In general, a drooping tip, which also elongates the nose, detracts from the feminine face. According to several studies, attractive female noses have an angle of tip rotation that is between 95 and 110 degrees, giving it a slightly upturned appearance.

 

On the other hand, men can tolerate a slightly droopy tip without affecting their facial balance and level of attractiveness.

 

Elevating the patient’s droopy and bulbous tip has also made it appear more refined and narrower, and the nostrils have invariably improved as well.

 

Dr. Smiley says the ideal nose is not strictly defined by specific looks or rigid beauty tenets. The goal is to reshape the nose in a way that it complements the patient’s facial features, gender, ethnicity, age, and even height/body frame.

 

However, certain mathematical ratios that determine the ideal facial proportions do exist that can help plastic surgeons create natural results from rhinoplasty. For instance, for most people the ideal breadth of the nose is equal to the distance between the eyes.

 

Also, the length of the nose is ideally similar to the vertical height of the chin.

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Rhinoplasty for thick skin poses some challenges. Nonetheless, achieving an aesthetically pleasing nose remains possible with meticulous reshaping of the bony and cartilaginous framework, says leading Los Angeles plastic surgeon Dr. Tarick Smiley.

 

During rhinoplasty, or nose job in layman’s term, the cartilage and bone are reshaped and a small piece is removed to eliminate the hump, correct the over-projection, or raise the drooping tip.   Meanwhile, the skin must redrape well to the new framework to achieve a smooth and natural contour.

 

rhinoplasty for thick skin

Ethnic patients often have thick nasal skin. Nonetheless, meticulous rhinoplasty can still provide impressive results.

 

Because thick skin has less flexibility, it does not shrink-wrap as well or as tight as a thin skin. On the upside, it is good at hiding tiny contour irregularities, which could easily show through a markedly thin skin.

 

Dr. Smiley explains some possible maneuvers used in rhinoplasty involving patients with thick nasal skin.

 

  • Go easy on reduction and narrowing.

 

The skin’s elasticity, which is closely linked to its thickness, will determine how much the nose can be reduced or narrowed without looking amorphous especially at the tip. Hence, the surgeon’s training, experience, and ability to predict the amount of skin shrinkage following surgery will play a critical role in the final result.

 

  • Use meticulous dissection to limit scar.

 

Thick skin is susceptible to scars, which could conceal the details of the surgery or cause polly beak deformity in which the nose resembles a parrot’s beak.

 

Polly beak deformity happens when the supratip of the nose (right above the tip) pushes the tip downward.

 

Aside from meticulous dissection, another way to prevent or at least limit the risk of unnatural nose contour and other complications is to use closed rhinoplasty technique in which all the incisions are made inside the nostrils, while the wall of tissue between the nostrils remains intact during the entire surgery.

 

  • Consider thinning of the subdermal fat.

 

When surgeons mention thinning of the skin, they actually mean thinning of the subdermal fat, a surgical maneuver that only suits a small number of patients. It should be done precisely lest the patient ends up with surface irregularities.

 

Thinning of skin may also translate to reducing the pre-existing scar tissue caused by a previous rhinoplasty. In this scenario, doctors should be extra careful and proactive (e.g., possible use of steroid injections postop) to prevent further scarring.

 

  • Steroid injection to treat patients with persistent swelling or a strong history of aggressive scarring.

 

Steroid injections might be a good option in patients with persistent swelling (lasting more than three months) or a strong history of keloids. Occasionally, this is also used after a revision rhinoplasty.

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Patients who have had rhinoplasty, or nose job in layman’s term, were rated higher in terms of facial attractiveness and perceived health and success, as suggested by a web-based survey published by JAMA Facial Plastic Surgery.

 

Rhinoplasty, also referred to as nose-reshaping surgery, was the third most commonly requested cosmetic plastic surgery in 2016, with more than 223,000 procedures performed, according to a survey conducted by the American Society of Plastic Surgeons.

 

rhinoplasty effects

Before-and-after photo that depicts great outcome. (Photo Credit: Dr. Tarick Smiley)

 

The study, which was conducted by researchers at Johns Hopkins University, Baltimore, involved 473 ordinary observers who were asked to rate before-and-after photos of 13 rhinoplastic patients. To prevent confirmation bias, the respondents were shown only one photo of the same patient.

 

Most of the respondents were women, Caucasians, and four-year college graduates.

 

The survey has shown the rhinoplasty effects or “after photos” of patients were rated higher in terms of average attractiveness, average perceived success, and average perceived health.

 

Despite auspicious results, the authors of the survey have pointed out some limitations because of the small number of respondents and patients. Furthermore, it did not include the patients’ self-perceived changes and satisfaction.

 

Also, the patients only represented optimal outcomes, which could be the main reason for higher scores in perceived attractiveness, health, and success. Simply put, the after photos did not reflect the wide spectrum of nose surgery results.

 

However, the survey’s authors said the findings could “help improve physician-patient discussion by providing a reference for an optimal outcome.”

 

Leading Beverly Hills plastic surgeon Dr. Tarick Smiley, who was not part of the study, said creating an attractive nose with surgery boils down to how natural it looks.

 

“We have to create a nose that looks like the patient was born with it. Thus, factors such as gender, ethnicity, facial features, age, and even body frame are all taken into account to deliver results that look both natural and attractive,” says Dr. Smiley.

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Closed rhinoplasty is a technique used in nose-reshaping surgery in which all the incisions are made inside the nostrils, specifically along their inner lining, and thus allows the surgeon to access the bony and cartilaginous framework of the nose.

 

Unlike open rhinoplasty that uses external incision to cut the columella or wall of tissue between the nostrils, the closed technique eliminates the risk of visible scar.

 

closed rhinoplasty benefits

All the incisions are made inside the nostrils; hence, closed rhinoplasty technique eliminates any visible scar.

Inland Empire plastic surgery expert Dr. Tarick Smiley says about 95 percent of his surgeries is performed via closed technique due to its number of benefits such as shorter social recovery, greater control over the final results, and less bleeding and scarring.

 

Meanwhile, he says the remaining 5 percent of his rhinoplastic patients need the open technique, which he generally reserves for individuals who require highly complex changes to their noses as it allows for better exposure of the nasal framework.

 

One of the most notable closed rhinoplasty benefits is the reduced bleeding and surgical trauma, which promotes quicker social recovery thanks to little amount of bruising and swelling. In fact, many patients have claimed they were able to go out in public within a week postop.

 

Since there is no incision across the columella, the blood supply to the skin is not disrupted. This results in less swelling and bruising and quicker healing compared with the open technique.

 

Contrary to popular belief, closed rhinoplasty does not make it harder to visualize the nose in its natural state. Dr. Smiley says the technique even allows him to see the “outside appearance of the nose” while concurrently “reshaping the underlying framework step-by-step.”

 

In open rhinoplasty, meanwhile, the skin is lifted and so the “outside” of the nose is not in its most natural state while the surgeon is reshaping its underlying framework, says Dr. Smiley in his previous Snapchat video.

 

“When you’re molding a piece of clay it is better that you see every subtle change in real time. This can help us achieve smoother results from rhinoplasty,” he further explained.

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Rhinoplasty on big nose involves three specific areas: the width of the nose, the tip, and the hump along the profile. By addressing all of them simultaneously, the overall size is reduced and smooth and natural results are achieved.

 

Reducing the overall size of the nose, according to leading Los Angeles plastic surgeon Dr. Tarick Smiley, is generally more challenging than hump removal because the nose should be made smaller in a way that its new appearance suits the face.

 

rhinoplasty on big nose

 

Further complicating rhinoplasty on big nose is the fact that the surgery only alters the bony and cartilaginous framework and so the skin must shrink down to the smaller underlying structure. However, thick skin can only shrink-wrap to a limited degree without resulting in bulbous appearance specially at the tip.

 

Recently, Dr. Smiley demonstrated a surgery on his Snapchat that involved a female patient with a bulbous and wide tip and a nasal profile that was too big and “too far” from her face.

 

The patient’s surgery involved a closed rhinoplasty technique, meaning all the incisions were made inside the nostrils for optimal scar concealment. The technique allowed Dr. Smiley to remove the “excess” cartilage and ultimately reduce the size of the nose.

 

(Note: The lower two-thirds of the nose is made up of cartilage, while the upper one-third is composed of bone.)

 

For smoother results, Dr. Smiley rasped the bony part of the nose with a use of an instrument that closely resembles a nail file. The device has been designed not to injure the soft tissue of the nose.

 

Meanwhile, Dr. Smiley reshaped and trimmed the patient’s excess cartilage so it could be later used to support the tip in order to make it narrower and more refined. The tip was also conservatively raised (upturned) to achieve a more feminine effect.

 

Because all the incisions were made inside the nostrils, there was less surgical trauma compared to the open rhinoplasty technique in which the wall of tissue between the two nostrils is cut as well. Hence, it is expected that social recovery is shorter—i.e., about a week postop the patient may go out in public without drawing unwanted attention.

 

Nonetheless, all the residual swelling can take up to one year to subside.

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The approach to rhinoplasty should be individualized as the goal is to reshape the nose in a way that it suits the face or as if the patient was born with it. Nonetheless, some people remain adamant that they want the nose of their celebrity idols and so bring their “wish pics” during consultation.

 

In the 70s and 80s, it was fashionable to have a nose with a ski-slope look—i.e., markedly narrow and with a slight upturn tip—which was commonly seen among famous female celebrities at the time. Of course, it rarely gave natural-looking results especially in people of ethnic background.

 

approach to rhinoplasty

The patient’s new nose suits her face thanks to a conservative elevation of the tip and a hump reduction.

 

And even in Caucasian patients, the ski-slope look may not provide the most natural results. This is particularly true for women with elongated face and of “high stature.”

 

More recently, one of the most common requests is the “button nose” or something that closely resembles Kate Middleton’s. The slight aquiline look is also “fashionable” thanks to the growing influence of Ivanka Trump.

 

Renowned Beverly Hills plastic surgeon Dr. Tarick Smiley says the ideal nose is not confined by strict beauty standards, although there are some “anatomic benchmarks” based on some complex angles and measurements. Nonetheless, the results should look natural rather than “manmade,” and must complement the patients’ ethnicity, gender, body frame, and ultimately their face. Even the great philosopher Aristotle, who coined the phrase “the whole is greater than the some of its parts,” would likely agree to such idea.

 

Of course, the person’s cosmetic goals are also of paramount importance. After all, rhinoplasty is a cosmetic, elective procedure in which the goal is to elicit a smile from the patient.

 

The celebrity plastic surgeon says that many patients today like subtle or moderate improvements—e.g., reduction of the hump, slight narrowing of their tip, conservative augmentation or reduction of the entire nasal profile, etc.—instead of dramatic changes.

 

Going the conservative route also prevents common problems associated with drastic changes that often warrant over-aggressive removal of the cartilage, which is the framework of the nose. After all, the nose is an organ whose function must be preserved or improved by the surgery lest the patient is not going to be happy regardless of how much the new nose looks good.

 

When too much cartilage has been removed, the nose may collapse and result in deformity and breathing functions.

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