Your frontal view is within the stardards in high-end nose jobs,
however the profile is one of the most difficult scenarios when patients
strive to find what they are looking for and how might this wish be
made technically safe and real. I fully agree you want a "small nose"
and "reduce your nose"... you don't say "I want my bump gone" or "wish
to shave my bridge"... that is the cornerstone of your case, your nose
is oversized, but... you do not have any profile / dorsum bump or bony
prominence... it is neat! straight, but still it is a large nose, why
so? because you have a high dorsum without a bump. This means the
distance between your dorsum and the so called Joseph's angle (angle
between nose and face) is large, but not all the same in all areas; the
dorsum-face distance is normal at the radix (upper part of nose),
moderately large in the center of the vault and extremely oversized at
the caudal or lower end of the dorsum. In other words, the angle between
dorsum and Joseph's line is too wide, must be reduced quite a few
degrees. Other focus: yes, you DO have a bump, a big one, but is not
located in the center of the nose... it is at the END of the dorsum, and
is not peak-shaped, it is slope-shaped.
What are the risks
associated with such atypical profile as I described above? it is clear:
meeting the wrong surgeon. You can't imagine how many catastrophes I
had to reoperate to repair after hump-less high dorsum rhinoplasties
(like yours) performed by other doctors; seems they try to remove an
imaginary bump, and the consequence is a saddle-nose deformity, a
trampoline nose, an upturned tip, etc etc a disaster with extremely
complex solution. Other surgeons may understand the technical
requirement (dorsal lowering without hump removal) but... carry it out
with poor quality; let me explain myself: when you remove a central
peak-shaped hump located around the middle third of nose, you remove the
peak made of bone and cartilage and the attached undelying mucosa
lining, this is a routine maneouver and we don't worry about the mucosa
attached, since it plays no role in breathing, however... the caudal
mucosa of the dorsum and the caudal end of the dorsum do belong to the
critically-functional breathing nasal valve, and MUST be preserver,
therefore in cases of caudal hump / humpless high profile a
mucosa-sparing dissection must be done to meticulously separate the
cartilages from the mucosa, so that when the resection is done such cut
does not include such functionally-critical lining, otherwise your
breathing would be affected and you'd form a pinched dorsum aka
V-deformity; this mucosa undermining must be done under both the
cartilagenous dorsum and the lateral or triangular cartilages to an
extent which exceeed few milimetres the line of dorsal cut, to guarantee
a safe outcome. This maneouver, the dorsal lowering with mucosa
sparing, may take itself 1 hour, when a normal central peak shaped hump
is removed in 10 minutes. You need to find a very good surgeon for this.
with the caudal dorsal lowering... your tip becomes massively
overprojected aka "Pinoccio's nose"; currently your tip does not look
overprojected, but once the dorsum has been lowered it will, so another
refinement in your case is the ability to match the new tip length with
the new caudal dorsum, to achive a very similar balance to the current
one but... lower, I hope you get me; this will require radical
shortening of both, medial and lateral, cruras of the alar cartilages,
secured with sutures (normally it is left floating, risky in your case
that may lead to still long tip).
Finally, the difficult but
standard part: broad boxy cleft tip, needing cartilage trimming plasties
of the domes (Ortiz-Monasterio's alternate incomplete transections),
plication of domes and medial cruras, etc, eventually some kind of tip
grafting. I also notice a moderate alar rip retraction near the tip,
this may require grafting there as well (to hide the exposed septal
mucosa / columella).
With all that said let me suggest you a
thorough research to find a top-notch surgeon and travel wherever the
righ professional might be located, your rhinoplasty is among the most
difficult in primary noses.
Finally, let me suggest a superb
technique associated in your face: a sliding genioplaty (never ever
implants, please), this would make an amazing result for you.
it may be understood... the specifics as to how this is done could not
be more relevant than in your case, both aesthetic and functional in
breathing. Of course you need open approach and a 3 hours procedure,
with 2 weeks spling on nose and bruising 2-3 weeks, besides auricular
donor sites bandages a few days.
Is rhinoplasty right for me?
Thank you for your query.Having rhinoplasty is a personal decision. It may be for functional or aesthetic reasons. I can see that your nose does over-project as you say. You also have an overhanging bifid columella from the front view. You need to find a Plastic Surgeon who carries out this procedure on a regular basis and who also can address your concerns, and explain to you in detail how he plans to proceed. I realise this may not be easy, but there are a few good surgeons around.Kind regards.
Thank you for your question.Do not be discouraged by one consultation. Surgeons used different techniques during their procedures and some are more comfortable performing some than others. I would recommend when looking for a surgeon to perform your rhinoplasty that you choose one who is board certified and specializes in rhinoplasty. You may also want to look on the Rhinoplasty Society website as this lists the top surgeons in the world who specialize in noses. I would also look at the surgeon’s credentials, memberships, educational background, reviews and before and afters. Before and afters are a good indicator of their techniques and outcomes from rhinoplasty surgeries and reading reviews from other patients is a good way to see what their experience with the doctor was like. I think you may benefit from a hump reduction and a tip rhinoplasty which includes trimming the lower lateral cartilages and placing precision sutures to refine the tip and make it look more pleasing. Best of luck in your endeavors.
James Fernau, MD, FACS
Board Certified ENT
Board Certified Plastic Surgery
Member of ASPS, ASAPS, ISAPS, The Rhinoplasty Society, AAFPRS, OTO/HNS, ASLMS, International Federation for Adipose Therapeutics & Science
Is Rhinoplasty right for me?
Greetings Thank you for your question, it is best to visit a plastic Surgeon who will examine and give you 2nd option.There are different kinds of rhinoplasty operations however we can divide them as the one that requires bone excision and the one that does not need bone excision. The main fact that we classify the rhinoplasty operations like that is that the results and postoperative period is associated closely with this fact. In the operations like “nasal tip correction”, “simple rhinoplasty” there is no need for a bone excision however these minor operations cannot be beneficial for everyone. The operation type is need to be determined by the surgeon according to needs of the patient. In these minor operations the rhinoplasty is performed with closed method. The bone and the cartilage tissues are not involved in the surgery directly. Small nasal bumps can be removed in these operations.
In the operation that needs the bone and cartilage tissues to be involved; open approach is used. In the procedures with open approach, the size, shape and functionality of the nose can be improved. The big nasal bumps can be removed and septal deviations can be corrected providing a better nasal airway.
Is Rhinoplasty Right for Me?
Don't be discouraged by one physician's opinion regarding your rhinoplasty goals and facial aesthetic wishes. If you are not satisfied with your first consultation experience then please schedule another consultation with a Rhinoplasty and Facial Plastic Surgery expert and ask for recommendations. I posted some options for you in a previous question which may help you with your discussions. Finding the best physician for you with whom you trust and respect may take some time. This is not unusual. Hope you find the right physician.
Rhinoplasty candidate, some advices:
Thank you very much for sharing your concerns with us.
The harmony between facial parts makes us instinctively recognize the beauty... without knowing it, without defining it, just a perception that surprises and captivates us.
In this regard, I suggest perform a Closed Rhinoplasty (without visible scars) to treat the tip, base and nasal bridge.
With this procedure you get a delicate nose, better harmonize with your other facial features.
Dr. Emmanuel Mallol Cotes.-
Is Rhinoplasty right for me?
Hello Tigger500 - Thanks for your question. It is my opinion that altering your bridge without addressing your overprojection will end with you feeling that your nose sticks out even more. Frankly the correct answer to address your nasal disharmony is to adjust the bridge height and width conservatively, based on deprojection of your nasal tip. You would also benefit from nasal tip surgery because you have malposition of your tip cartilages which gives them that boxy appearance. A chin implant would be a finishing touch to optimize facial harmony. As a member of the Rhinoplasty Society here in the U.S., I see patients with overprojected noses all the time. If you were my patient, this is what my recommendations would be to you as long as this set of procedures met your expectations for a particular outcome. I would also recommend that you have rhinoplasty simulations to better educate you about how a particular set of surgical maneuvers might look on your face. If you don't like what this particular surgeon said to you, then you owe it to yourself to get a second opinion. Please check out my Youtube channel from time to time as I will be posting a full-length video of a talk I'll be giving in London on 9/20/2016 at Guy's and St. Thomas' NHS Foundation Trust Plastic Surgery Service on Primary Rhinoplasty. Good luck, Dr. Shah
Is Rhinoplasty right for me?
A rhinoplasty and, quite possibly, a chin augmentation would most likely give a nice enhancement. Seek a second opinion with an experienced surgeon who uses computer imaging to help assist in communicating your goals.
Is Rhinoplasty Right for Me?
If you're not satisfied with the recommendations provided during your consultation I suggest you talk to other experienced rhinoplasty specialists. Also consider chin augmentation which would make your nose look smaller and improve facial balance.
Rhinoplasty for facial harmony
I can not see a hump and I think you have done well by walking away. The nose will need to be assessed not in isolation but in its relation to the other facial features. A qualified rhinoplasty specialist will be able to tailor the nose to match you facial features. De projecting the tip when required is an essential step in a successful outcome. If you simply remove a "hump" the nose will often appear over projected. Seek an experienced facial plastic surgeon who is a rhinoplasty specialist. Hope this is helpful