New York, NY. I had the privilege of attending, lecturing at and moderating the afternoon session on Rhinoplasty at the 6^th annual meeting of the Multi-Specialty Foundation on Facial Rejuvenation in Las Vegas last month. This meeting was organized by Drs. Randy Waldman and Eddie Cortez with over 800 cosmetic surgeons in attendance. The first day was devoted to advanced techniques in rhinoplasty. Many of the most well respected teachers of rhinoplasty were on the program from around the country as well as Europe and Asia. It is humbling to see these experts demonstrate nuances they have picked up and wish to share with colleagues. Given the opportunity to sit on a panel with these surgeons as well as discuss techniques off the podium, in the halls, at dinner and on the run is always enlightening.

I presented two lectures. The first was entitled, “What Makes a Nose Look Fixed,” where I explored the main reasons patients come in for a consultation feeling that their noses appear “done” or look as if they had a nose job. In this lecture I explained how and why this happens, tips on how to avoid it in the first place and how I fix these specific issues.

My second lecture was a summary of a study I conducted last year and soon to publish in the Archives of Facial Plastic Surgery. I surveyed 100 consecutive patients seen in consultation for revision rhinoplasty and reported the top concerns they had and the reasons they sought revision surgery. This was a unique study since it was looking at revision rhinoplasty from a fresh perspective: the patient’s point of view.

Some new principles that I picked up at this meeting are, first, that I am doing things right. I acquired a few tips on the best way to use sutures to either curve or straighten cartilage. Also, that the European surgeons tend to like larger noses than their American counterparts.

Among the seasoned experts were Drs. William Silver, Ronald Gruber, Robert Simons, Russell Kridel, Shan Baker and Gaylon McCollough. My peers and colleagues included Drs. Jonathan Sykes, Steven Dayan, Paul Nassif, Rick Davis, Phil Miller, Fred Fedok, Minas Constantinides and Jay Calvert. From Europe and Asia, there were the following leading authorities: Drs. Wolfgang Gubish, Patrick Tonnard, Pietro Palma and Woffles Wu.

In summary, rhinoplasty is a complex procedure. Even the most accomplished nose surgeons still exchange ideas and learn new techniques from their colleagues. Steven J. Pearlman, M.D., F.A.C.S.

New York, NY

This is the third in a series of blogs on revision rhinoplasty. Last week, I reviewed my upcoming publication in “Archives of Facial Plastic Surgery” which chronicles the most common reasons patients seek revision rhinoplasty and why so many revisions are necessary.  Now I will summarize what makes a nose look “fixed.” This is becoming more and more of a concern for patients since there is so much information (and misinformation) now available on both bad and good plastic surgery.  The following characteristics are the most common tell-tale signs that a nose has been over-done:

• Pinched tip
• Pulled up nostrils
• Deep creases above the nostrils
• Tip “knuckles” called bossae
• Narrow middle third with a chevron shaped dent called an inverted-V deformity
• Scooped out profile

There are patients with these kinds of noses all over the country. While it is easy to criticize these noses, many were created in the 60’s and 70’s when this nose was actually in fashion. Additionally, the rhinoplasty procedure back then was all about reduce, reduce, reduce. Doctors did little grafting, so bumps were shaved down to meet the lowest point in the nose. Now, if the nose starts too low or the tip is weak and what we call under-projected, grafts can be added to build up around the hump. That way, less hump is removed and a more balanced, more elegant nose is the result. 

With my experience performing numerous revision rhinoplasties, I have learned what causes most of the abnormal findings that bring patients to my office for revisions. Rhinoplasty surgeons must be aware of all these potential consequences and what anatomic findings can lead to these problems if not recognized.

This is a comprehensive subject that could fill an entire chapter and more, but to summarize the highlights, starting from the tip up; nasal tip cartilages can be weak or strong. Each will react differently to surgery. Strong cartilages will maintain strength and can be shaped more easily. Weak cartilages can buckle and may need grafts to prevent over-narrowing.

The Middle third of the nose houses the internal nasal valve, the narrowest part of the airway. Removing a large hump and/or short nasal bones can lead to narrowing and the inverted-V deformity. Prophylactic spreader grafts can be used to prevent this over-narrowing.

Regarding the bony or top 1/3 of the nose; scooping out of the nose is more common when an osteotome or chisel is used to remove the bump, unless in very skilled hands.  With the exception of a very large bump, rasps are usually safer.

For a very quick summary of what I teach my fellows and residents:

• Pinched tip: leave at least 7 mm of tip cartilage and narrow further with sutures
• Pulled up nostils: make sure that the cartilages aren’t naturally overly rotated upward, if they are use grafts to support them
• Deep creases above the nostrils: Don’t over-resect or over-narrow with sutures. If the tip needs a lot of narrowing use alar support grafts
• Tip “knuckles” called bossae: if cartilages are weak, sew the domes (middle part) together
• Narrow middle third with inverted-V deformity: watch out for anatomic prediliction as discussed above
• Scooped out profile: be careful when removing the hump

In summary, rhinoplasty and even revision rhinoplasty can be a rewarding experience for patients and the surgeon if both are prepared. Steven J. Pearlman, MD, FACS

New York, NY:

Revision rhinoplasty can be a frustrating situation for the patient, which is why it is even more important for surgeons to understand why people seek revision surgery. In October, Drs. Yu and Kim, residents from New York Presbyterian Hospital presented a study at the annual meeting of the American Academy of Facial Plastic and Reconstructive Surgery on revision rhinoplasty that we conducted on my patients. Our goal was to present why patients seek revision rhinoplasty. Prior articles in the medical literature all discussed these findings from the doctor’s point of view. There are many scholarly articles on this subject, but they all looked at what the doctor thought was important. We decided to survey 104 consecutive patients seeking revision rhinoplasty to see what their concerns were, before I chimed in with my opinions. This unique study is to parallel trends in modern medicine and to focus on the patient’s point of view.

104 consecutive patients filled out a comprehensive questionnaire that asked questions about their noses from top to bottom and functional (breathing) complaints. They were also asked to identify their top three reasons for seeking revision rhinoplasty. The most frequently cited concerns were tip asymmetry, crooked middle third of the nose and irregular upper (bony) third of the nose. The three top concerns differed a little with difficulty breathing cited as the second largest concern with tip asymmetry still first and crooked nose third.

Breathing problems was a very common finding. 62% of patients reported nasal obstruction and 71% were found by the surgeon (me) to have blockage of the nose.

At the end of the survey, we asked why patients didn’t go back to their original surgeon and 57% indicated that since the surgery was not successful, they would not go back. 23% reported that their original surgeon was not receptive to their concerns. For the other 20%, surgery was either too long ago, their doctor is no longer in practice or they moved. Therefore, surgeons must be aware that good communication and understanding patient concerns are of the utmost importance in addressing revision rhinoplasty.  Steven J. Pearlman, MD, FACS 

New York, NY: I just launched a new site dedicated to Revision Rhinoplasty. I feel it is important to educate the public about a number of common issues that come up when discussing this topic and will be addressing these issues in my next few blogs:

1. Why do so many patients seek revision rhinoplasty?
2. What are the most common complaints patients considering revision surgery have?
3. What went wrong in the first place that may necessitate revision surgery?
4. Why don’t patients go back to their original surgeon for revision surgery?

Rhinoplasty is considered to be the most difficult procedure in cosmetic surgery. The specific steps may seem easy to an un-initiated surgeon, but to a surgeon who has extensive experience with the procedure like myself, no nose is simple or should be fixed in a “standard,” one-size-fits-all, cookie-cutter fashion. This is the first step in getting into trouble. Each patient needs to be addressed as an individual and not categorized, then treated in a routine fashion.
The Rhinoplasty procedure has also evolved more than most other procedures over the past 3 decades, and may do so even more over the next few years… which is why it is imperative a true rhinoplasty surgeon be a student of the procedure. When I go to meetings, I see the most respected surgeons sitting in the first few rows scribbling notes more furiously than anyone else. This is how they got on top and continue to stay that way. I find that teaching and lecturing on this topic also forces me to stay on top of all new innovations – good or bad – so that I am able to address any and all questions posed by young surgeons seeking guidance.

Not every patient will be happy with their results. The published statistics of patients unhappy with their revision surgery is 5 to 15%, and are provided by the more active and knowledgeable surgeons. So if they have rates from 5 to 15%, imagine what is happening to the doctors who don’t publish? But to make you feel less uncomfortable, at least in my practice, most patients who do have revision are getting minor tweaks. They commonly report that they “love” their nose but have a tiny irregularity or bump that can be taken care of in a simple way.

I will continue to review revision rhinoplasty in my next blog. For more information and before and after photos, please see the articles on revision rhinoplasty posted on my website, www.mdface.com, as well as the new website www.Revisionrhinoplastyny.com

NEW YORK, NY -  There is a steady stream of patients seeking revision rhinoplasty to fix a bad nose job, which is all too common. Primary rhinoplasty is often considered the most difficult procedure in cosmetic surgery. It seems simple, right?  Just shave off a bump and reduce the tip a little. Not so fast. That is when an uninformed surgeon finds himself in trouble, as each and every nose is a little different. The nose has paired nasal bones, which make up only the upper third part. The middle portion has two cartilages called upper lateral cartilages that insert, not into, but beneath the nasal bones, plus the nasal septum in the middle dividing the two sides. Below that is the nasal tip. These paired horseshoe shaped cartilages may sit in a variety of positions and have different shapes as well as strength. The nose is a multi-faceted three dimensional structure that has many fixed parts as mentioned above, plus varying ligaments and muscles holding these parts together. 

To make it even more confusing, modifying any individual part of the nose affects the nose in many ways. Reducing a hump not only accomplishes that, but the gap needs to be closed for an aesthetic result, so we do “osteotomies,” which means closing the open roof to pull in the upper lateral cartilages, which in turn narrows the middle vault as well. This may be a desirable additional change or may require something such as spreader grafts to prevent over-narrowing and an “inverted-V deformity.”

When I review the operative reports from prior surgeons, I often see techniques that a true rhinoplasty expert abandoned years ago. Surgeons need to keep abreast of the latest techniques. Unfortunately, some surgeons take that too seriously as well, and leave too much behind to avoid creating a “pinched” nose. Or, perhaps they learned at a meeting that you should put certain grafts into a nose so they put them in without forethought of what they are really trying to accomplish. If it sounds like I am confounding this issue, I am. The real students of rhinoplasty are the experts, who after 20 or more years in practice are still sitting in the front row of a meeting trying to learn even more from their peers. See some actual before and afters

Dr Pearlman

My background is in Ear, Nose and Throat surgery, so I feel I am adept in creating a more functional and sculpted nose for my patients. To quote a traditional architectural theme, in terms of the nose, “form follows function.” It is my passion to restore this function.
Most of the functional and breathing problems I encounter deal with blockages of the nose from conditions like a deviated septum and sinusitis. I can address both of these issues at the same time.

I perform a thorough exam of the inside of the nose during your consultation, using a specialized headlight for viewing the nose. Sometimes I may need to use nasal endoscopic equipment to get a better view.

Other nasal procedures that I perform are septoplasty, reconstruction of the skin and structures of the nose after removal of skin cancers and correction of septal perforations.

If you have any questions on Rhinoplasty, please feel free to contact my office for a consultation. For more information on Rhinoplasty or other cosmetic surgery procedures, please visit my web site. Here you will find detailed information and before and after photos.