Rhinoplasty or Fillers for Nose Tip Indentation?

We have had good success filling bothersome nasal clefts with Silikon-1000, an off-label filler for permanent results. The cleft is visible between your two alar cartilages because you appear to have thin skin. Conservative microdroplet silicone may be considered depending on tour examination. Thank you. Dr Joseph

If you want to do a quick temporary fix, I believe you would be a great candidate for a liquid nose job. Using safe reversible hyaluronic acid based fillers like Juvederm, a doctor can contour a nose to hide asymmetries or mask bumps when they are subtle and/or if the patient cannot undergo surgery or desires not to. Typically results last 1-3 years. If you want a permanent fix I would recommend a rhinoplasty focusing on the tip to correct your concerns.

Fillers can definitely smooth away this indentation, but keep in mind that results would last just a few months. Some patients find that fillers are preferable, though, because they dislike the idea of surgery.

                  Your
pictures suggest a separation of the cartilage in your lower nose. These
cartilage segments are known as the lower lateral cartilages and when they’re
separated there may be several consequences. In your case, they explain the
increased width of your nose, the central indentation and asymmetry.

                  Although
this deformity can be disguised with fillers, this solution is only temporary.
For this reason, we generally recommend surgical correction. This can be
accomplished with open rhinoplasty with direct visualization of the cartilage
abnormalities.

                  This
procedure narrows the nasal tip and removes the indentation at the nasal tip.
It also has the potential to correct nasal tip asymmetry.

                  When
this type of problem occurs, it’s important to consult a board certified
plastic surgeon before proceeding with surgery. It’s important to understand
the risk, benefits, alternatives and possible complications of each treatment
approach. 

Fillers are only a temporary fix for the bifid nasal tip that you are showing.  Although quick the fillers do not address the problem and eventually a tip rhinoplasty will need to be done.

The tip of your nose is known as “bifid” tip. While injectable fillers are wonderful for correcting assymmetries or defects in the dorsum (bridge) of the nose, using an injectable filler in the tip is a little trickier. Because of this, if you are commited to trying an injectable filler rather than surgical correction in this location, my advice would be to try a temporary or even reversible filler such as hyalauronic acid (example: Restylane or Juvederm).  First, I'd advise you to be sure that you can achieve your desired goals before considering a longer lasting type of filler (such as Radiesse or even Artifill). Of course, surgical correction of the nasal tip would provide a long-lasting and often more precise solution for you.

I think if you asked a dermatologist, they would probably recommend a filler, and if you asked many, but not all, plastic surgeons, we would recommend a rhinoplasty. A few thoughts to consider:

A filler such as Restylane has the advantage of being quick and easy, less cost, and little to no downtime. Its purpose is to fill in the space between the two pieces of cartilage that make up the tip of your nose, therefore hiding the natural appearance of your nose, and can last a year or more. The disadvantage, however, is that it is not permanent, which means that not only would you have to have repeat injections, but each time you do, your body will make some amount of scar around the injection site, which over time can give an unnatural or even dimpled result. The other big disadvantage is that if you wanted to have a rhinoplasty in the future, for any reason, having had these injections will make the procedure slightly more difficult and the healing less predictable, simply due to the presence of the Restylane or scar tissue that would almost certainly persist (once you have a filler, it will never look like it does today-- therw ill always be some change from what it looks like now).

The primary disdvantage of a rhinoplasty in this situation is downtime-- you will need a week or two to heal well at least, depending on what is done, as well as increased cost. However, if done properly, it should last a liftetime, and it can even be done without an incision on the skin (called a "closed" rhinoplasty, where all of the incisions are inside the nose) making it impossible for the average person to know you have had surgery.

In the end, I think it is critical to ask yourself how much this bothers you, and then if you do decide it is worth having a procedure of some kind, go to someone who is trained in both the nonsurgical and surgical options, so that they can clearly outline to you the pros and cons of each option.

Good luck!

Dr. Salemy

Natastic,
From the appearance of your pictures, you have had very professional photographs taken. If you are a model, I think you should reconsider your concerns.
The most natural appearing noses have a small indentation between the paired lower lateral or tip cartilages. The indentation corresponds to where the cartilages come together at the midline. Although in some cases the dip appears very dramatic, a complete flattening would not be recommended - from an aesthetic point of view.
Most rhinoplasty surgeons spend much of their free time just looking at pictures. What I have noticed in magazines, advertisments, etc. is that many face models in close-ups have a subtle, but definite cleft or indentation between the tip cartilages. This is what I see in your pictures, and I would say this is a beautiful feature in your well-shot photographs. If this is really the only feature that bothers you about your nose, I would either leave it alone, or consider a HA (hyaluronic acid) filler to soften it -- but I would not recommend completely flattening it.
Keep in mind, there are a few other things about your nose that are evident in the pics that may stand out more after you flatten the line in the center. The tip cartilages have a definite excess in their upper portion. This excess is what you may refer to as "bulbous". A flattening of the line may leave your nose looking more bulbous if the tip is not "divided" by the line in the center. This may even further attract attention to the tip, as the highlights and shadows in the tip change. You will certainly notice this in your headshots. This is purely an artistic analysis.
I would recommend consultation with an experienced rhinoplasty surgeon.

The bulbousness and the appearance of a indentation or cleft in the tip (often called a bifid tip) are caused by the natural curvature of your tip cartilages and would best be corrected with rhinoplasty techniques. While fillers can potentially fill the indentation in the tip, the change would only be temporary.

Many surgeons are begining to see patients who come to their practice for revision surgery because they are displeased with the results of injectable fillers. Most of the products that have been on the market for the last several years are temporary. However, newer, longer-lasting fillers have become available. Some of these are permanent. This poses a problem when the result does not meet the patient's expectations. The large volumes of these substances are changing the way the natural tissues appear, which can make revision surgery more difficult, and in some cases, impossible.

Over time, these fillers have been noted to cause skin changes, such as redness and even skin necrosis, in some patients if they are injected too close to the surface of the skin. They may also give the nose a lumpy appearance.

For correction of the bulbous tip, many surgeons would recommend an open rhinoplasty in which an incision is made across the column of tissue between the nostrils and connected with incision on the inside of your nose. This allows the surgeon to lift the skin off of the delicate tip cartilages so that they can be reshaped.

Fillers would eliminate the separation of the cartilage that creates this anatomic finding. But, fillers would be temporary and will change over the course of time. Thus, immediately after filling it would look great and would fade over time.

Unification of the domes is a surgical technique that would correct this problem permanently.

Best of luck!