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Articles About Rhinoplasty
Written by Dr. Clavin
Combining Cosmetic Fillers and Rhinoplasty for Best Results
Open Versus Closed Rhinoplasty Techniques
The Art of Revision Rhinoplasty Using the Closed Technique
The Natural Nose After Rhinoplasty It Is Possible
Open Versus Closed Rhinoplasty — A 30-Year Experience

Combining Cosmetic Fillers and
Rhinoplasty for Best Results

The combination of surgical Rhinoplasty, either primary or secondary, combined with injecting Juvéderm or Restylane into the nose has gotten superior results and excellent patient satisfaction. Juvéderm and Restylane are hyaluronic acids which can last up to a year and sometimes longer when injected into various facial irregularities, defects, or deep facial lines, such as laugh lines, crease lines, or chin lines. Juvéderm and Restylane have also been known to be used to inject around the mouth area, vertical lip lines, or into the lips themselves. These Cosmetic Fillers are also highly successful when injected into a variety of nasal defects.

Juvéderm and Restylane can be used in both primary and secondary rhinoplasties to help improve the aesthetic result on cosmetic nose surgery without actually doing further invasive surgical procedures to the nose. Some irregularities throughout the nose and tip area, especially those in patients who have had several Rhinoplasty operations, can often be readily improved in an office setting without surgical intervention using approximately 1 cc of Juvéderm (or Restylane) or less with a small gauge needle with minimal patient discomfort.

The nose, nasal dorsum, or tip can be revised substantially and improved tremendously, by injecting these cosmetic fillers. A recommended combined approach for Rhinoplasty or Revision Rhinoplasty using Juvederm or Restylane are to use these fillers as an ancillary procedure during the Rhinoplasty rather than operate on a certain part of the nose, which can be difficult and not as predictable. The Cosmetic Filler is then injected into the nasal tip, the dorsum, or the sides of the nose resulting in a improved surgical result with very minimal downtime to the patient and an extremely fast recovery.

Therefore, in summary, the combination of Juvéderm or Restylane with surgical Rhinoplasty and/or Juvéderm or Restylane alone to nasal defects can significantly improve patient surgical outcome and improve patient satisfaction significantly.

Open Versus Closed Rhinoplasty Techniques

Rhinoplasty, or cosmetic nose surgery is well known to be the most difficult cosmetic surgery performed by plastic surgeons. In order for the physician to perform rhinoplasty, or cosmetic nose surgery, a high degree of skill is required along with judgment and artistic ability. Young plastic surgeons finishing their training usually have difficulty in getting enough experience to perform cosmetic nose surgery in their training, and this is one of the main reasons that the open rhinoplasty technique have become popular. The open rhinoplasty technique, which involves making an incision along the base of the nose and lifting the skin off the bony and cartilaginous structures of the nose, allow better visualization of the structures of the nose and allow for better teaching of young residents in training to perform cosmetic nose surgery. There are drawbacks to the open rhinoplasty procedure, in that it does produce more scarring and requires extra cartilage support in order to reverse some of the disruption of the normal delicate attachments of the skin to the subcutaneous structures of the nose.

Plastic surgeons who ultimately become familiar and comfortable with doing closed rhinoplasty, that being making small incisions in the nose and performing reshaping of the nose through these small incisions, have found this to be a much more desirable procedure. The patients heal much faster, there is significantly less swelling, and the end result can often be more predictable. In order to do rhinoplasty surgery, which, as mentioned above, is already a difficult and a very skillful procedure; it takes years and years of experience and training. When performed properly, rhinoplasty can be very fulfilling and can help change a person’s life by reshaping an undesirable nose that often takes away from certain beautiful facial features that many people have, such as their eyes or lips. Cosmetic nose surgery, when performed properly and with the proper aesthetic balance and natural appearance, can very much enhance a person’s total facial aesthetics.

In Summary, closed rhinoplasty procedures are desirable, in that faster healing with less disruption of the delicate nasal structures occurs. Open rhinoplasty can be performed by many plastic surgeons with success but do cause more inherent trauma to the nose. Open rhinoplasty operations are able to be learned more readily by young plastic surgeons and, therefore, that procedure has increased in popularity. The closed rhinoplasty technique are often a much better choice, especially for people having their noses done cosmetically for the first time; however, it is difficult to find a skilled plastic surgeon with enough experience to perform this procedure adequately.

The Art of Revision Rhinoplasty Using the Closed Technique

The art of revision rhinoplasty has been revised over 35 years of performing this type of surgery using the closed technique.  The open technique limited the surgeon in many aspects of revision surgery.  The open technique does not allow certain degrees of finesse in placing cartilage grafts in exacting locations in order to correct deformities that are found in revisional rhinoplasties.  In my experience, using small incisions and taking cartilage from the septum or the ear, you can accurately place small millimeter-type grafts into various locations throughout the tip, the dorsum, and sides of the nose and spare the patient extensive surgical intervention, which is the case when open technique is used.  The open technique distorts the normal anatomical attachments of the skin to the nasal bones and nasal cartilages, further complicating the surgeon’s ability to perform a natural revision rhinoplasty.

After harvesting cartilage from the nasal septum or the ear, and occasionally the rib, small incisions are made inside the nose in order to accomplish the reconstructive aspects of this rhinoplasty procedure.  Anesthetic used is local in the nose plus intravenous sedation.  Intubation and deep general anesthesia is avoided and, therefore, much less nose bleeding is encountered during the procedure, allowing for even further improvement in technique because of the limited amount of blood loss.  The small cartilage grafts are placed where the surgeon marks the external aspect of the nose with ink in order to allow for exacting placement of the reconstructive cartilage grafts.  The patient is seen in the treatment room preoperatively and in the upright position.  The surgeon has direct communication with the patient prior to surgery, and exact locations for cartilage grafts are discussed and agreed upon by both the patient and the surgeon.  Once the various ink marks are made on the external part of the nose, the patient is then taken to the operating room and given intravenous sedation, avoiding all narcotics and anesthesia gases, which help very significantly in reducing postoperative nausea.  There is very little discomfort to the patient postoperatively, since packing is never used, and nausea after surgery is a rare event.  Discomfort and pain are absolutely minimal because the open technique has been avoided, which prevents unnecessary incisions and unnecessary dissection throughout the nose area.  The exact appearance of the nose is noted right after surgery, and minimal swelling takes place postoperatively.  This avoids the long two to three-month delay in seeing the final result when the open technique is used.

In conclusion, excellent results are obtained with minimal patient discomfort and quick recovery using the above-described technique.

The Natural Nose After Rhinoplasty It Is Possible

Rhinoplasty surgery is considered the most difficult of all cosmetic surgical procedures. One of the reasons this is considered the case has to do with the aesthetic talents of the operating surgeon. Plastic surgical training is extensive, and the surgeons that finally get credentialed by the American Board of Plastic Surgery are highly qualified. They’re intelligent, smart, have mastered the academics and skill required by this prestigious organization, and are very capable.

However, rhinoplasty surgery, or cosmetic nose surgery, requires an aesthetic skill that is not teachable. A special talent is needed, which is born with that individual or is not. Just like you can teach art and can teach individuals the academics of painting and sculpture, there are only a few artists that turn out to be shining lights. The reason for this, is that inherent genetic trait that gives them a special edge to create masterpieces.

To achieve the natural nose, a surgeon has to have that special talent. A natural nose can be created and is absolutely doable no matter what type of nose an individual was genetically born with. It could be a large nose, large hump, wide tip, and thick skin. Surgery can always be performed by a competent surgeon to make the nose better and improved. However, to achieve that truly “natural” look requires a special inherent talent that lets the surgeon look at the individual as a whole, all the facial anatomy as a whole, the size of the individual, the size of their head, the shape of the skull, the facial bones, the location of the eyes, the lips, and the ears, and the location of the eyebrows and cheeks, and putting this whole picture together and basically having the nose blend in with the patient’s total body and, in particular, blend in with their face to look totally natural and unoperated.

This can be done with primary rhinoplasty or revisional rhinoplasty. The skill to create such a natural nose requires a special eye that the surgeon inherently must have to visualize the total picture plus the academic knowledge to create surgically such an end result. Patients should be aware that a natural-looking rhinoplasty result, or cosmetic nose surgery result, is absolutely possible, but they must be inherently careful in choosing a plastic surgeon and being sure that they feel comfortable that the surgeon has this particular talent, which is not teachable, by observing his results, talking to his patients, and truly checking out very carefully to be sure that that surgeon’s rhinoplasty results fit into the category of “the natural nose.”

Revision Rhinoplasty to Create the Natural Nose
All the above is true even with revision rhinoplasty. Revision rhinoplasty surgeons who have this natural inherent talent to create a natural nose can do the same thing when performing revision rhinoplasty. It requires even an extra degree of skill over and beyond the skill for primary rhinoplasty; however, in proper hands, the natural nose can be created in many cases, but not in all cases, when performing revision rhinoplasty. Sometimes so much scar tissue is present, and the nose has been traumatized to such an extent that getting a totally natural result is not always possible; however, a surgeon with the talent, expertise, and the genetic disposition to create natural noses certainly has the highest probability of being able to do revision rhinoplasty and creating as natural a nose as possible, even under the difficult circumstances of doing revision rhinoplasty.

Harold D. Clavin, M.D., F.A.C.S.
1247 7th, Suite 301  •  Santa Monica, CA 90401  •  Phone: (310) 829-5977  •  Fax: (310) 828-0367
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