Help! I want a more proportionate, attractive face. Rhinoplasty? Chin implant?

Question

Hi, I'm 18/F and have been insecure about my face, especially my nose, ever since I was a little girl. It's very ski slope like, very upturned. Wide & bulbous at the tip. Not only that but it has a bump (almost indent like on one side). Its very out there and I'd rather have it be more subtle. 2nd-Chin is unproportionately small and has indent. What shall I do to create a more attractive face? It would help a lot with my confidence and social life. Could non surgical be an option aswell?PLZ HELP

Steven M. Denenberg, MD · Answer

Click on the "Web reference" link, just below my response, or go here:
FacialSurgery.com/RealSelf/RealSelf_taylorengsxo.html
I made a computer morph of your nose, and an animation of the morph, to show the changes that are possible for your nose in truly expert hands.Mostly, I narrowed the tip of your nose, and also narrowed the bridge a bit. The prominent edges and bumps are all caused by your strong tip cartilages. The woman in the short video just above had similar wide tip cartilages.You might also benefit from a *small* chin implant. Actually, your chin doesn't bother me at all, but it's personal preference.
You should understand that the changes I demonstrated in the morph require advanced techniques, techniques that most plastic surgeons cannot handle.  Be sure to read the section in the "Web reference" link on how to stay out of trouble while searching for a rhinoplasty surgeon. You should only have surgery if you are able to make yourself very confident in your surgeon's skills.
I'd love to hear what you think of the morph. Did it seem to address your main concerns?
Your nose is also a good example of why computer imaging is mandatory in rhinoplasty. You need to know exactly what the surgeon is planning to accomplish -- what features he thinks he can change, and by how much he thinks he can change them. When you see his goals, you'll know whether he has an eye for a beautiful nose, and whether he shares your opinion of what constitutes a beautiful nose. You'll also know whether the changes he proposes are enough to be meaningful to you, and whether he understands your wishes enough to address all of your priorities. But remember, you're not hiring him for his skills with the computer. The doctor must then show you his before and after photos to prove that he can actually accomplish what he draws on the computer.
In your case in particular, you need to find a surgeon who understands the issues I mentioned, and how they fit together, and who can actually accomplish them in surgery. You don't want to be looking for a revision later.

Alejandro Nogueira, MD · Answer

There is no one non-surgical option for your nose and chin, to begin with, you need a very very very (yes, 3 "very's") good  and creative plastic surgeon specialized in high end cases. 
Yours is a very atypical combination of quite common issues and technical challenges, a real combination oddity even for a vastly experienced nose surgeon like I may be, nevetheless each issue separately is quite common (except one), the oddity is meeting all them in the same nose. Moreover, several of the technical issues and anatomical pitfalls your nose has can be considered of high or very high difficulty, requiring top-notch rhinoplasty skills. I'll try to be schematic and explain one by one the problems with their solutions.
What are your specific features which are not normally found in other
 noses? ONLY ONE, read attentively and concentrated, there is only one 
feature in your nose that is a "congenital oddity", and this condition 
is the key diagnosis for you:
CONGENITAL ABSENCE OF THE INTERDOMAL FIBROFATTY PAD AT THE NASAL TIP
Period. End of the discussion.
The other features of your nose, and its other diagnosis can be more 
or less commonly found in rhinoplasties, but the only one that makes you
 different is you are born without a tiny but aesthetically of paramount
 relevance adipous (and somehow fibrous as well) fat pad in between the 
two cartilage domes which form the nasal tip, and this fibrofatty pad 
happens to exist in all human noses in a larger or smaller degree. In 
your case is non existant, leading to your odd nasal tip shape.
Now, some key concepts explaining why the absence of the fibrofatty pad has led to your deformity:
-nasal tip: it is formed by the union at the midline of the domes or 
arcs of both alar cartilages + the presence (in higher or lesser amount 
and extent) in between the domes and over the arcs (depends each 
ethnicity) of a fibroadipous pack of tissue which fills the gap between 
both domes. In some noses the domes match closely and leave no one or 
almost no gap between them (asian, afroamerican, slavic and nordic 
noses), others leave a wide gap between the noses (mediterranean, latin,
 saxon and arab noses). Such gap, if exists in a relevant degree, is 
normally filled by the fibrofatty pad, slightly filled by it, partially,
 largely or massively filled by the fibrofatty pad, even totally sunken 
into a extense fibrofatty pad; well... when there is a gap between alar 
domes not in close contact between them we can classifty the tips as: 
boxy (or square), cleft (or bifid), clown's... and YOURS.

-Boxy or square tip: the alar domes are wide apart but the whole gap 
(and sometimes part of the domes) is filled (and sometimes the domes 
covered) by a huge fibrofatty pad, making an external effect of en-bloc 
square structure or box, but actually and inside underneath the skin is 
made of two cartilagenous arcs (the alar domes) with supporting pillar 
and an in between (the arcs and the pillars) a bridge or natural filler 
of fibroadipous tissue (kind of "filler concrete"). Normally is 
associated with broad pleateaus at the nasal domes, overprojection of 
the tip (long medial and sometimes lateral cruras) and oversized 
cephalic ends of the lateral cruras. Treatment is under open approach 
rhinoplasty to comply with: subtotal removal of the fibroadipous tissue,
 plication of domes and / or pillars to the midline, shortening of the 
pillars to deproject the tip, plasties (sutures, Ortiz-Monasterio's 
alternate incomplete transection technique,etc), trimming the cephalic 
excess of the lateral cruras, and any other additional maneuvers deemed 
accesory.
-Cleft or bifid tip: same than former, but the fibrofatty pad is 
smaller and is unable to fill up some areas of the interdomal space at 
the tip and / or the pillars (beneath the columellar skin), producing a 
groove and an externally visible gap between at tip and / or columella. 
Same treatment as former.
-Clown's tip: same than first, but the fibrofatty pad is tiny, so 
there is very little filler beweet the spaced-apart domes and / or 
pillar, making the externally visible separation at tip and / or 
columella extremely visible. Treatment same than first.
-YOUR tip: same than first but... there is NO fibrofatty pad or 
tissue underneath the tip and columella skin, in between the domes or in
 between the pillars, there is NOTHING remaining of such filler, the 
cartilages are skeletonized and transparent underneath the skin. Treatment? simple... (almost) same than first. Period. This correction is of medium difficulty and quite routinary in the hands of a high-end rhinoplasty surgeon, commonly applied to many kind of noses.
And now, I'll list the issues in your nose that are not oddities and are typically met in many cases, however rarely seen altogether in a single patient:
-Flat dorsum / low bridge: you are right in yuor assessment, your nose has a flat dorsum running almost parallel to the maxilla, somethign very commonly met in asian noses or some afroamerican, but odd in caucasians except thos from nordict european ethnicity or some nordic slavic patients (I assume you have this genetical background). We have two options for this: shortening the tip in order to even it with the current dorsum heigth... or raising the dorsum to meet the tip (tip which can be well likely slightly deprojected)... I'd bet for the latter, I really think and agree with you your dorsum has to be raised with an onlay dorsal cartilage graft (with or without temporal fascial cover to hide its visibility, you seem to have thick skin so might be unnecessary hiding the dorsal graft with fascia). Not a very difficult maneuver but extremely difficult to graduate and calculte, needs a surgeon with very good mental modelling abilities.
-Short nose with short septum and upturned tip: all this pack has the same origin, you have short upper lateral cartilages and nasal bones (structures forming the nasal walls) and a short septum as well, this makes your nasolabial angle unacceptably broad (angle between columella and the horizontal plane); to lower this angle to a resasonable configuration (no more than 10º upwards) you need nasal lengthening (don't mistake with tip lengthening) by means of septal caudal extension grafts, alar caudal extension grafts, eventually with columella-tip shield grafts (to be assessed intraop); this short nose syndrome is not uncommon in nordic european or slavic patients, however its correction is one of the most difficult maneuvers in rhinoplasty and is only accessible to top-notch and vastly experienced professionals.
-Broad dorsum: you need dorsal narrowing, WITHOUT dorsal shaving (obviously, yours is already a sunken dorsum close to be a "saddle nose deformity"; this is made by means of para medial or para septal resection of cartilage (soft lower dorsum) and bone (hard upper dorsum); a delicate but well known maneuver.
I very wish you find a surgeon with very deep anatomical and 
technical understanding of your case, which on one side is very tricky 
and dangerous... but on the other side is not that 
difficult in the hands of a surgeon well experienced in ethnic noses and
 atypical cases (revisions, genetically hybrid, etc.). Do reject any 
opinon or proposal which is not like the one I deployed in my text or at
 least pretty close to it. Nasal difficulty rated 10 out of 10 scale of primary rhinoplasties, can be considered a kind of caucasian ethnic nose subtotal overhaul, surgical time about 5 hours.
About your chin, you are NOT a case for a chin implant or "magic fillers"; in general 
chin implants are very problematic (dislocation, artificialnes, dynamic 
deformities, short lifetime, early removal due to pain or disturbances, 
bone imprint and cortex thinning, infections, etc) and the osseous 
genioplasties (sliding, augmentation with grafting or reduction) are way
 superior and unparalleled in safety, naturalness, beauty and 
versatility.
Your chin is three-dimensionally small (microgenia), this means you 
need a major vertical increase, slight horizontal widening and moderate anterior advancement, 
thus making you a case for the three-dimensional augmentation 
genioplasty, with bone grafting supply (donors elbow / hip) and a very 
well planned preop antropometry of the craniofacial relations, and 
needless to say with good aesthetic judgement. This is a 10 out of 10 difficulty in genioplasties / chin surgery, surgical time 3-4 hours.
Do seek the advice of a really good facial surgeon with experience in 
osseous augmentation genioplasties. Beware: a simple sliding genioplasty
 would not work for you, you'd get a sharp "witch's chin", you must 
also widen it moderately (avoiding masculinization, just to round its 
contour and fill the sides) and increase vertically (to balance it with the rest of your 
face). In good hands the results are simply awesome.

Feel free to request any additional information from me.

Ross A. Clevens, MD, FACS · Answer

Thank you for your question. You are correct in noting that the nose and chin work in symmetry with one another to create your aesthetic appearance. The rhinoplasty can address the bulbous and wide tip, and the bumps. I suggest that you move forward and consult with a board certified facial plastic surgeon to discuss your options and potential solutions.
Best wishes,

Toby Mayer, MD · Answer

Rhinoplasty and chin implant for a more attractive and feminine face?  Yes a chin implant and rhinoplasty will do what you want if you see a very experienced rhinoplasty surgeon. When making the bulbous tip smaller on a short nose (which is what you have)  it is very important to see a surgeon who can narrow and refine your tip without causing more  shortening and creating a pig nose. Therefore see a very experienced  rhinoplasty lsurgeon who does natural results in noses like yours.

P. Daniel Ward, MD · Answer

Hi Taylor,Addressing the nose with a rhinoplasty in the chin with a chin implant will certainly address the issues that bother you. Nonsurgical options could be considered, but are unlikely to give you the degree of  change that he would like to see.  An in person consultation with an experienced rhinoplasty surgeon will give you an idea of what to expect in terms of results and recovery. Please let us know if you have any other questions!

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. Based on your
photograph, you may benefit from a tip refining rhinoplasty. Your surgeon can
accomplish this by trimming, suturing, and reshaping the cartilage in your
lower nose. You may also benefit from nasal tip derotation.  A chin implant can be performed at the same time for improvement in your jawline contour and facial balance.  Make sure you specifically look at before and after
pictures of real patients who have had this surgery performed by your surgeon
and not just a computer animation system. The most important
aspect is to find a surgeon you are comfortable with. I recommend that you seek
consultation with a qualified board-certified plastic surgeon who can evaluate
you in person.
Best wishes and good luck.
Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Gregory Lakin, MD · Answer

You would benefit from a tip rhinoplasty, chin augmentation using a sliding genioplasty, and upper lip fat grafting.
Using an open rhinoplasty technique the surgeon would gain exposure of the nasal cartilages to symmetrically reduce their sizes. You would need the cephalic (upper) edges of the lower lateral cartilages trimmed and then sutures placed to hold the domes of the two cartilages closer together. You may also need the cartilages overlapped on themselves to shorten their overall size. These maneuvers would lead to a smaller and more defined nasal tip.
After your nose is corrected you will want your chin position improved to obtain facial harmony. A sliding genioplasty uses your own chin bone to augment itself. The procedure takes only 45 minutes. A bone cut is made and the chin advanced to an optimal profile, usually a mm or two behind the lower lip along Reidel's line. The bone is fixated with some screws through a prebent plate. You will need to be on a soft diet for two weeks as the oral incision heals. Because you would be  using your own bone, there is less risk of infection and would not risk removing an implant if there were an infection.
A life size and morph can be done beforehand to show you what expected changes could be achieved from the rhinoplasty and genioplasty.
Finally, I would use the Coleman technique for fat grafting where you harvest fat from the infraumbilical region, spin it down in a centrifuge to remove the oil and blood layers, transfer to smaller 1cc syringes, and use micro cannulas to inject into your upper lip. Usually 50% of injected fat will live and stay with you permanently. The results are long lasting as compared to more expensive temporary fillers that are repeated annually. Afterwards you may have mild discomfort in your belly and lip and mild bruising but recovery is only a few days.
I think you are a great candidate for these procedures and will have a fanstastic final result! Good luck!

Summit Kundaria, MD · Answer

taylorengsxo,
Thanks for the question.  Your nose is a complicated one, and would require some grafting to straighten the dorsum, and also to counter-rotate your tip.  I would advise you to go to an experienced surgeon for this, as it is not a "standard" rhinoplasty (if there is such a thing).  I also agree that you would benefit from an extended chin implant, as you need augmentation of the areas lateral to your chin as well as the midline.  Traditional implants focus on the midline, which I do not think would be a good fit for you.  I would caution you from being sold a non-surgical solution to your problems, as the degree of improvement that would get you good results require surgery (in my opinion).

Daniel Shapiro, MD · Answer

Thank you for your inquiry regarding a Rhinoplasty and Chin Implant. Usually a non-invasive Rhinoplasty done with fillers  will only provide you with a minor and temporary correction. I suggest you consult with a board certified plastic surgeon. A surgical Rhinoplasty and a Chin implant can create a beautiful result if done correctly. A chin implant will give you a stronger  looking chin. These two procedures are typically done together which creates a beautiful result.

Myriam Loyo, MD · Answer

Hi Taylor, thank you for sharing your photos and questions.Consider a rhinoplasty and chin augmentation to achieve your goals of refining your nose and improving facial balance/ chin projection. Based on your post, you have already thought of which changes you would like to make. I agree with your assessment of your nose and chin. Your next step is to meet surgeons and discuss expected results. By the way, you have great eyes, lips and beautiful skin!! The changes to the nose and chin will be enhancements.Hope this helps. Good luck

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