June 21st, 2010 Dr. Pearlman
There are a lot of misconceptions about rhinoplasty that I will soon be addressing in a section in my website under FAQ’s. Below are two of the more common question asked during a rhinoplasty consultation.
New York, N. Y.
1. Doctor, do you have to “break” my nose? The technical term for this is osteotomy.
In most cases, yes. Osteotomies are necessary in the majority of rhinoplasties. They do not make the nose less stable nor do they make the results less predictable, they actually improve the results in rhinoplasty. This takes about 2 minutes in a two hour operation.
The reasons why I perform osteotomies are two-fold. First, when a hump is removed from the nose it’s like slicing off the top of a pyramid. That leaves a gap called an open roof. If the side walls aren’t closed down then the upper part of the nose has a flat-top and may even look like railroad tracks. I sometimes see this in patients seeking revision rhinoplasty. Secondly, osteotomies are performed to narrow a wide nasal bridge.
The only difference is that the black and blue around the eyes may last a few days longer to get a better looking nose for the rest of your life. Sometimes patients have seen other surgeons who promise that they don’t “need” to break the nose. Maybe they use a euphemism such as “micro-osteotomies” which is really the same thing. What you see on TV is usually dramatized and not as violent as it really is. Using very sharp osteotomies makes a clean cut with little trauma, just like having quality carving knives in the kitchen; there is less tearing and damage to the surrounding tissue.
2. Doctor, can you just remove the “bump?”
Sometimes just the bump can be removed without touching the rest of the nose. However, most of the time even large noses are in balance. That means the nasal tip is usually a little large as well. Removing a hump without narrowing the nasal tip will make the nose look out of balance and un-natural, exaggerating the size of the tip. Another scenario is when there is a mildly drooping tip as well; again, a larger but balanced nose. Removing a bump alone will make the nose appear longer. The bump breaks up the profile. Raising the tip will restore a normal appearing nose.
This is one of the best reasons for using computer imaging for rhinoplasty. I can demonstrate to patients the potential changes from just removing a bump vs. minor reduction of the entire nose to maintain, even improve balance. Most of the time, more natural results can be achieved when the entire nose is addressed. Even if it means a millimeter off here and two millimeters off there, such small changes in multiple areas will yield more beautiful noses.
In summary, “breaking” the nose in rhinoplasty yields superior results in most cases. Bumps alone can be removed, but more beautiful noses are created when the entire nose is addressed. Steven J. Pearlman, M.D., F.A.C.S.
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June 10th, 2010 Dr. Pearlman
Crain’s New York June 7-13: Pomp and Rhinoplasty honor grads
New York, NY. This week I was quoted in an article on plastic surgery as graduation gifts in Crain’s New York. I won’t hassle you with the link since it will prompt you to sign up and create a password etc (even though it’s free). To summarize, it talks about high school students getting cosmetic surgery, mainly rhinoplasties as graduation gifts. These aren’t really the surprise type of gifts that we usually associate with graduations. These are usually more like parents who are giving in to their teenagers who likely have wanted this surgery for a number of years; and now the parents have finally given in. High school graduation is a very good time for this surgery. As long as there is 3 weeks between surgery and going off to college, they are meeting people with their new nose, and often new confidence. Of course it takes a full year to see the final nose, but even at 3 weeks the nose is looking better than prior to surgery.
Graduation is a transition for educational, emotional and even physical maturity. Why not start out on the right foot? It has been proven in numerous psychological studies that improvement of facial appearance goes a long way in instilling and building confidence. What better time than when a teenager is moving on to a new environment about to make new friends and wants to put their “best face” forward. For more information on teenage rhinoplasty, please see my prior blogs. Steven J. Pearlman, MD, FACS
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June 2nd, 2010 Dr. Pearlman
The perfect brow
New York, NY. Eyebrows frame the face and have been one of the most visible and changeable hallmarks of facial beauty over the past century. I recently wrote an article on The Perfect Brow for the prestigious beauty website Inwithskin.com. Beauty is defined by magazines and movies and not Plastic Surgeons. So when I want to demonstrate what the perfect brow looks like to a patient, I usually say “let’s look at a plastic surgery textbook” and then open a fashion magazine and flip through the ads and editorial pages.
Makeup artists and aestheticians have long understood what makes the perfect brow. The brow is club shaped centrally then tapers along the tail. The central portion of the brow begins at a vertical line drawn upward from the edge of the nostril. The tail extends to a line that runs from the corner of the nose through the corner of the eye. The height of the brow should be equal at both ends; typically at or just above the rim of the eye socket. Generally, in women, the brow should arc delicately with the highest peak between the corner of the iris and the corner of the eye. The male brow should rest on or at the rim of the eye socket and is more horizontal in shape.
The skin of the upper eyelid should be smooth and have a youthful fullness, with little folding or wrinkling. Makeup artists love this since it leaves a nice platform to apply eye shadow without flaking or cracking.
All the above is well and good for teens and models, but as we age, the brow may flatten and droop as well as deflate. Before even considering cosmetic surgery, a skilled makeup artist can often shape your brows to restore a youthful arch.
How can we change the brow?
Eyebrows can be elevated and shaped non-surgically by the use of expertly placed Botox. Crow’s feet can also be reduced. Sometimes it’s more a result of flattening of the eyebrow instead of drooping. In that case, fillers such as Restylane or Juvederm can be used to restore youthful fullness. Using a filler to repair deflated eyebrows may work just like a brow lift but actually doesn’t lift the brow.
Eyelids or eyebrows? If you look worried, sad or angry it’s more likely due to a brow problem; looking angry often responds to a quick Botox treatment.
If you look tired, it’s usually more from the eyelids. Another way is to pull out photos of yourself from your mid 20′s, and check where your eyebrows once were and maybe still are.
When is surgery necessary? When there is significant wrinkling and/or folding of the eyelid skin and your eye shadow won’t stay without flaking. Wrinkling of the eyelids is due to either aged skin, drooping of the eyebrows or both. If your eyebrows are in good position and the overhanging skin doesn’t extend far beyond the corner of the eye, a blepharoplasty (eyelift) is the best solution. When the excess skin goes well past the eye, we call that lateral hooding. Hooding means that the brow has dropped; a brow lift is more helpful. Remember, when it comes to a youthful eyebrow/upper eyelid complex, its’ about shape not height.
Steven J. Pearlman, MD, FACS
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