• Dr. Brent - Actual Patient

Revision Rhinoplasty Details Beverly Hills

Primary and Secondary Rhinoplasty Surgery
A primary rhinoplasty refers to the first time that a nose job is performed on a given person. It can be performed for aesthetic, functional, or reconstructive reasons, or for a combination of all three. During this surgery, Dr. Moelleken may help to restore the skin coverage of your nose, create or recreate normal nasal contours, and even help to correct and increase nasal airflow. The surgery is sometimes used to help repair nasal damage sustained during a traumatic injury. Nasal injury can lead to permanent deformation such as displaced bony humps and dis-alignment of the nasal bones and these problems are typically only fixable by nasal surgery. During this procedure, nasal humps can be reduced and the nasal bones can be realigned.

The majority of people who undergo nose jobs only need one but some patients end up with results that they are not satisfied with. In this case, a secondary nose job, also referred to as a revision nose job, is an option. A secondary nose job is any nose operation that is performed to correct, revise, or improve upon the results of a primary nose job.

In general, patients cite two main reasons for dissatisfaction with their primary nose job:

  • The first is cosmetic as a patient may find that his or her nose job surgeon gave them a nose that they are simply unhappy with. This could come through mistakes made by the surgeon, or simply through a lack of proper communication regarding a patient’s goals.
  • The second reason is more functional. Just as some patients first turn to nasal surgery in order to correct breathing problems, so also some patients turn to secondary nose job surgeries for the same reason. Sometimes an initial surgery, which is meant to help stop breathing problems, may not be entirely successful and unsuccessful nose jobs can contribute to breathing issues.

Because secondary nose job surgeries are much more complicated to execute, the procedure is typically performed using the open technique. This method makes the nose more clearly visible and accessible to Dr. Moelleken and this allows him to more easily see and correct any nasal deformities. Due to advances in nose job techniques, secondary nose jobs provide satisfactory results for most patients.

Rhinoplasty Aesthetic Complications
A complication is defined as an unexpected occurrence of an adverse medical or surgical condition requiring separate attention during or following an operation. While obvious medical and surgical complications are recognizable, aesthetic complications are harder to identify because they are based on the body-image demands of the patient.

A patient’s body-image demands can be categorized as follows:

  • The physical reality of a person’s appearance. Society has agreed on certain definitions of beauty, thereby imposing standards for a vulnerable individual.
  • A person’s individual perception of his or her own appearance. This is how patients see themselves in regard to how they are perceived by others.
  • The degree of importance people attach to their own appearance. Some people attach little importance to how they look while others derive great satisfaction from their appearance.
  • The degree of dissatisfaction a person has with their appearance. Displeasure with one’s appearance ranges from minor to a body dysmorphic disorder. This causes obsessive preoccupation to one’s appearance to the point of interfering with normal function.

Aesthetic sense is difficult to define, and it is much harder to agree on results. Aesthetics depend on variables and a practical approach to aesthetics in the nose begins with an accurate assessment. Frontal views define x-axis (width) and y-axis (height) deformities, lateral views define z-axis (depth/projection) and y-axis deformities, and basal views define x-axis and z-axis deformities. Based on these views, a 3-dimensional concept of the nose is made available for manipulation and the goal of rhinoplasty is to improve the aesthetics without causing functional impairment.

Problems Associated with a Poorly Performed Rhinoplasty
Some of the problems that can occur from a poorly performed nose surgery include:

The Pollybeak Deformity
A Pollybeak deformity is a term given to a nose in which the area just above the tip is too full. Normally, there should be a small dip or depression just above your nasal tip that defines the transition from your bridge to your tip and when this area is too high or filled in, it is called a Pollybeak. A very full Pollybeak can make your nose look down-turned like a parrot’s beak, thus the name. The area above the tip often becomes the part of your nose that sticks out or projects the most from your face and this is not the way it should be as your tip should be the most projecting point of your nose.

If a surgeon does not reduce the cartilage enough in the area above your tip during a rhinoplasty, this will cause a Pollybeak deformity. On the other hand, if a surgeon is overly aggressive in reducing the area too much in someone with thick skin, the skin does not contract and flatten out as much as it should allowing the area to fill in with thick scar tissue. Another problem is if a surgeon does not provide enough support to your nasal tip, eventually causing your tip to droop making the area above the tip look too full.

Balancing dorsal reduction and augmentation aligns a Pollybeak profile. The importance of preoperative nasal analysis cannot be stressed enough as this assessment helps Dr. Moelleken identify problem areas, consider solutions, and mentally perform the operation before embarking on the actual procedure. For the patient with over-reduced nasal bones, the nose may be balanced by using a graft placed in the region of the radix to properly reduce the cartilaginous septum. For the under resected cartilaginous dorsum, resection is recommended, with careful intraoperative assessment of the relationship to the tip and tissue edema should be minimal to accurately judge this relationship. For the external rhinoplasty approach, re-draping the skin-soft tissue envelope is utilized before evaluating the profile.

The Scooped Out Bridge
A scooped out profile is probably one of the most common problems that occurs after rhinoplasty. It usually happens after routine reduction rhinoplasty when there was a bump on the bridge that was shaved down too much. This can happen when a surgeon uses a chisel or osteotome to make a bony bump smaller. Osteotomes are sharp instruments that cut through the bone at a desired level to lower the hump. This is an all-or-nothing procedure where the bump is removed in one excision and this can create a problem because it is based on strictly judgment and execution. Sometimes the angle is not right and the surgeon can misjudge the bone level. It can be even easier to make this mistake using a closed rhinoplasty approach (from inside the nostril) because this maneuver is being performed under the cover of the nasal skin. To get the procedure perfect, immense experience is required because the surgeon is relying on the senses of “touch” and “feel”.

Dr. Moelleken prefers to reduce a bump on the nose by using a nasal rasp. This is essentially a fine file that can be used to slowly whittle or file down the bony bump three-dimensionally in a very careful and controlled manner. When the bone is reduced too much, the nasal profile will look scooped and to fix this, Dr. Moelleken will need to build the bony bridge back up again, most often with your own cartilage.

The Nasal Valve Collapse
Rhinoplasties are the primary cause of nasal valve collapse. The nasal valve is a term used to describe the narrowest part of your nose internally and this is the area that determines if you feel your breathing is normal or obstructed. When the nasal valve is overly narrowed or blocked, it is a deformity known as nasal valve collapse. If a rhinoplasty surgeon detaches your nose’s upper lateral cartilage when removing nasal bone, this will result in an internal valve collapse or an “Inverted-V” deformity. Removal of too much lower lateral cartilage can collapse the sides of the nose causing an external valve collapse.

Most valve collapse is internal valve collapse which occurs when the upper lateral cartilages in the middle of your nose has been overly narrowed. This problem happens when a nasal bump is taken down too much and the cartilages are shortened during a Rhinoplasty. This problem occurs more often after a closed Rhinoplasty because many surgeons detach the cartilages without repairing and reattaching them at the end of the procedure. When the supports in the natural cartilage have been lost, they fall inwards and collapse. The second part of this problem is that the middle part of the bridge on your nose can start to look very pinched. This is a common problem after Rhinoplasty and Dr. Moelleken corrects this by using extended spreader grafts among other techniques.

The Hanging Columella, Nostril Retraction, and Excessively Rounded Tip
A frequent problem after an overaggressive rhinoplasty is a tip that becomes distorted and lacking in support. This usually happens when too much of the cartilages are removed when trying to narrow and refine the tip. This causes the tip to be unstable and all three of the above problems often occur together after a Rhinoplasty in which the tip cartilages collapse. Many rhinoplasty surgeons are very aggressive removing cartilage or they slice through it without repairing the edges. They do this because the short-term changes can be very dramatic but the long-term results are usually devastating as the tip becomes progressively pinched and distorted over the years. If too much cartilage is removed in this area, the tip can start to collapse. It can often look asymmetrical with the formation of bossae or little deformities and bumps in the cartilage that show through the skin. Also, the tip can start to rotate up too much giving the nose an upturned and shortened “Ms. Piggy” appearance.

This problem can be exaggerated when surgeons also remove the nasal spine (the bone at the bottom of the tip) and the bottom part of the septum. Maintaining the integrity of this anatomy is critical to ensuring good results over time and if any of the above mistakes are made, the columella or structure separating your nostrils can appear to hang down too much which is called a hanging columella. Also, the rim of your nostrils can appear pulled back or retracted because normally the distance between the edge of your nostril and the bottom edge of the columella should be no more than a few millimeters. Anything more than this creates a very unflattering look resembling a snarl and your breathing can also be affected.

These problems can be corrected but it takes a lot of effort including complex cartilage grafting. When the columella is pulled up, the nostril rim is pulled down and the angle between the tip and the upper lip improves. The tip still projects outward by almost the same amount but it looks less dominant when corrected.

The Over-projected Tip
An extremely frequent mistake seen after primary rhinoplasty surgeries is a persistently over-projected tip. This means that the nasal tip still appears to stick out too far from your face and there are reasons this mistake is so common. The first reason is that many rhinoplasty surgery patients are initially more concerned about their bump than anything else and they are happy if the bump is all that is removed. Afterwards however, patients realize that the tip still appears too prominent and they are not happy. The second reason is that technical maneuvers to reduce the nasal tip’s projection are very sophisticated and many rhinoplasty surgeons were never trained in the proper maneuvers. Many doctors experience problems so they choose to avoid de-projecting the tip. Lastly, it is almost impossible to achieve meaningful de-projection of the tip through a standard closed rhinoplasty procedure and still provide the necessary support.

Tip Bossae (Knuckling)
You can think of your tip cartilages like a pair of wings. The cartilages are like a bent spring that holds your nostril’s shape and keeps them open to allow normal breathing. In poorly performed rhinoplasty surgeries, this cartilage is aggressively cut or removed so that it loses its natural spring. Eventually, whatever cartilage is left starts to bend and twist under the weight of your skin. As the cartilage twists, the weak points at the joints start to form bumps called bossae. These are very noticeable through your skin and many surgeons correct this deformity by trimming the bossae, weakening the cartilage even more. This is not the proper solution, as the tip cartilages must be reconstructed in order to restore their natural strength.

Open Roof Deformity
Your nasal bones are like a pyramid. When a bump is made smaller, the top of the bones are shaved or cut shorter to reduce the bump. This leaves an opening and is one of the reasons the base of your bones has to be cut during rhinoplasty surgery called osteotomies. Osteotomies are performed in order to push the bones inward towards each other so that this opening can be closed. If the opening is not closed properly, the problems results in an “open roof” deformity. If you have an open roof deformity, the middle part of the bridge on your nose will look and feel unnaturally flat. The edges of the bones are separated and this can be seen as a prominent bump. To repair an “open roof” deformity, the bones have to be brought back together. Sometimes, the bones have been so shortened that it is impossible to bring them together without pinching the top of your nose and in this case, it is necessary to rebuild the roof with grafts.

Wide Nose
The nose can be thought of as having an upper third made primarily of the nasal bones, the lower third made primarily of the nasal tip, and the middle third made primarily of the cartilaginous bridge. Different techniques are used to address wideness in different areas. If the upper portion of your nose is too wide, then osteotomies are usually required. If the tip is too bulbous and wide, then resection and re-orientation of cartilage may be performed to narrow the nose. If the middle third is too wide, then a number of techniques may be applied depending upon the exact cause. A broad upper part of the nose can be thinned by removing bone at the cheek level. Taking a small piece out of the outer base of each nostril can narrow a nose that is too wide in the nostril area. If the nose is too wide at the bottom, a portion of the nostril at the base may be removed to narrow it and this is called an alar base resection.

Twisted Nose
The type of correction needed for a crooked nose depends a great deal on the cause of the problem, which is not always completely evident. In some cases, repositioning misaligned bones can solve the issue. In other cases, cartilage grafting or reshaping of the septum (the cartilage that divides the nasal chambers) is necessary. A twist in your nose can happen anywhere from the nasal bones to the middle third of the nose and down to the tip. Making a nose perfectly straight is one of the biggest challenges for a doctor performing rhinoplasty unless you have an experienced specialist like Dr. Moelleken. The usual cause for a twisted nose is crooked nasal bones. This can be a result of a pre-existing crooked bridge that was simply was not corrected properly or when poorly performed osteotomies causes the bones to shift.

Osteotomies are a complicated procedure and performed by inexperienced surgeons, problems will occur. If the cartilage of your mid-nose or tip is twisted, it can be corrected by re-suspending or stabilizing the cartilage with sutures. This process includes repairing the normal connections between the anatomical parts of your nose that have been lost during your prior surgery. In some cases, the normal structures have been damaged or removed which causes the lower part of your nose to buckle and warp. Unfortunately, sometimes this is not repairable but one option is to take grafts of cartilage from your septum (if available), your ear, or rib to rebuild the lost tissues and reconfigure their normal connections and supports.

Dr. Moelleken has extensive experience correcting rhinoplasty deformities. He derives great pride in taking as much time necessary to get it right because his goal for you is that your first rhinoplasty surgery with him will also be your last.

Revision Rhinoplasty Techniques
Revision rhinoplasty is a very specialized area in the field of Plastic Surgery. It corrects the inferior results of what is often considered the most difficult procedure in cosmetic surgery: rhinoplasty. Revision rhinoplasty is very difficult because the goal is to restore missing parts. When excessive cartilage is removed from the nose improperly, the nose basically starts to collapse in portions and through revision rhinoplasty, those portions are restored. Using his skill as an artist and surgeon, Dr. Moelleken applies the same techniques to revision rhinoplasty as he applies to the many primary rhinoplasty operations he performs by meticulously shaping your nose to fit your face. He knows that no two faces are alike so he looks at the overall pictures, taking the entire facial presentation into account when evaluating rhinoplasty revision patients and establishing a customized plan.

Revision rhinoplasty is designed to improve nasal-facial proportions through a wide range of procedures, from reducing the overall size of the nose to changing the shape of the tip, or narrowing the span of the nostrils. Depending upon the unique situation of each patient, Dr. Moelleken uses either the closed or open method of rhinoplasty. The difference between the two techniques is where the incision is placed. For revision rhinoplasty, the incisions may be confined solely to the inside of your nose or an additional small incision may be made under the tip of your nose. When the incisions are confined to the inside of your nose, the procedure is referred to as a “closed rhinoplasty”, whereas procedures involving an incision under the tip of your nose are referred to as “open rhinoplasty”. Most revision rhinoplasty patients require the open rhinoplasty approach and this method allows Dr. Moelleken to carefully re-arrange nasal tissues and shape the bone structure to create beautiful, proportionate nasal contours.
The closed nose job technique procedure is used more when there are limited bridges or minor tip issues. This nose job technique is more difficult because it is harder to visualize the internal structure of the nose. The type of sculpting and technique Dr. Moelleken chooses will depend on your particular issues.

Revision Rhinoplasty Recovery and Risks
The vast majority of nose job procedures are outpatient surgeries, which means that you can go home on the same day as your surgery. Revision rhinoplasty is usually performed with a combination of local anesthesia and sedation and in some cases, general anesthesia. Once the anesthesia is administered, the incisions are made and this skin of your nose is separated from the underlying bone and cartilage. Depending upon the particular case, cartilage may be repositioned or missing structures may be replaced and when the desired shape is achieved, your skin will be pulled down and the incisions closed. Primary rhinoplasty tends to take between one and two hours to perform and revision rhinoplasty typically takes longer. Revision rhinoplasty tends to involve less pain, as well as less bruising, than primary rhinoplasty procedures but you can be prescribed pain medication to help alleviate any discomfort that you may feel.

You should arrange to have a family member or friend drive you home and it is usually a good idea to have them accompany you to surgery and to your place of recovery afterwards. Most of the bruising that you experience will fade by the tenth day and any swelling, which is common, can takes up to one month to subside. Keeping your head and neck elevated will help reduce swelling and discomfort. The splint and stitches will be removed within a week and most patients are able to return to work within a week after their procedure, although strenuous activities should be avoided at least three weeks following your surgery. You should also avoid any bumping or trauma to your nose and when you go outside, always wear a sunscreen to avoid getting sunburn.

If you follow all of Dr. Moelleken’s guidelines, complications are rare however as with any surgery, there are potential risks. Some of these include adverse anesthesia reactions, excessive scarring, prolonged swelling, pulling of the nose to one side, and small burst blood vessels. You should avoid certain medications, vitamins, and herbs that can cause you to bleed more than normal and if you smoke, all nicotine products should be stopped at least two weeks prior and two weeks after your rhinoplasty revision surgery. Healing is a slow and gradual process and the final results of rhinoplasty will be recognized over time: sometimes up to one year.

A Rhinoplasty Surgeon’s Responsibility
Since up to 20% of all rhinoplasty patients are unhappy, according to recent data compiled by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), Dr. Moelleken feels this is not good advertising for the cosmetic surgery industry. Such a failure rate is unacceptable in other surgical specialties and he feels plastic surgeons need to ask why they are not performing better. In order to answer this, , he feels that a review of the history of the procedure and its evolution will allow conclusions to be drawn that can help improve rhinoplasty outcomes.

Currently, widespread rhinoplasty is being performed by the third generation of surgeons. The first generation, practicing in the 1950s and 1960s, based their work on the core technique of Jacques Joseph, a refugee from Germany. He brought rhinoplasty to the public as a procedure within economic reach of the middle to upper-middle class and the door was opened to the rhinoplasty operating suites during the expansive post-World War II environment.

The second generation of surgeons took the procedure to another quality level and expanded its popularity by refining the techniques and developing variations upon Joseph’s core ideas. The result of this generation’s rhinoplasty procedures made the patient’s nose less overdone and thus the appeal of rhinoplasty broadened. The use of cartilage, fascia, and bone grafts allowed surgeons to better correct primary or secondary deformities. Man-made implants to augment the dorsum, columella, and tip were welcomed from the biotech world and the open rhinoplasty technique, allowing greater visualization of the anterior portion of the nose, allowed better access for the insertion of the transplanted tissue as well as the alloplastic implants.

Today’s surgeons now benefit from the availability of newer “filler” materials and these are performing well in their attack against shrinkage of the facial soft tissues. With better outpatient anesthesia techniques, there is less patient resistance to having a rhinoplasty procedure. Dr. Moelleken feels it is a very good time to be a rhinoplasty surgeon because the public now accepts the surgery as safe, practical, and affordable.

Revision rhinoplasty is a term that encompasses a wide spectrum of problems from straightforward to complex. Many patients that come to Dr. Moelleken for a rhinoplasty revision consultation have lost all hope. He offers hope, however to achieve success, he wants you to know how important it is that you come to a realistic understanding of what can and cannot be accomplished. He lets the patient know that revision surgery is not an exact science and that complications can occur but at the same time, he assures them that he will do everything possible to achieve a shared surgical goal.

Dr. Moelleken understands that the revision rhinoplasty patient needs an atmosphere where they can develop trust again and this can be accomplished through education. Dr. Moelleken takes the time necessary to answer all of your questions and concerns through total honesty. For many rhinoplasty revision patients, life revolves around their nose and it is important to change this focus by correcting the problems that bother them. Dr. Moelleken’s job does not end after surgery. If the result of a revision achieves a patient’s goals, he is professional enough to caution a patient to avoid additional impulse changes. If there are problems that will benefit from additional work, he will address the issue but if not, he will recommend that no further surgery be contemplated. This is why a surgeon and patient must establish a trusting relationship in all aspects of patient care.

Dr. Moelleken uses the example of Michael Jackson when he talks about the theory of too much plastic surgery. He says the Thriller album cover shows Michael Jackson after one rhinoplasty and he feels that result was decent. For some reason however, he continued to have surgery and a doctor continued doing surgeries for him putting the fault on the surgeon as well as the patient. Michael Jackson’s nose kept getting smaller which is a problem in rhinoplasty surgery because many times a patient wants too much taken from their nose and they find a doctor willing to go along with that request. An ethical plastic surgeon will know what a patient can realistically achieve and when they should stop instead of promising something that will never happen.

Dr. Moelleken feels it is very important to maintain a natural look and he recognizes that many patients who visit a plastic surgeon have body dysmorphia. Body dysmorphic disorder is a type of chronic obsession in which you cannot stop thinking about a flaw with your appearance, whether it is real or imagined. In some cases, you feel your appearance is so awful you do not want to be seen by anyone. When you have body dysmorphic disorder, you intensely obsess over your appearance and body image and you may seek out numerous cosmetic procedures to try to “fix” your perceived flaws. Even after surgery however, you are never satisfied and body dysmorphic disorder is also known as dysmorphophobia, the fear of having a deformity. Dr. Moelleken feels that body dysmorphia is not the patient’s fault if they consult with a plastic surgeon and realistic expectations are not fully explained. He believes it is better to be truthful with his patients and tell them, “Here is what we can do and here is what cannot be done.”

Dr. Moelleken feels that the profession of plastic surgery should share the blame with Michael Jackson’s addiction to plastic surgery and the “dismal” results. He said, “Michael Jackson was a cordial gentleman of immense talent but he had a completely unrealistic and disconnected concept of what his physical appearance was. It is a smear on our profession that so many people were willing to continue operating on him.” Dr. Moelleken says the main area he sees in patients seeking a revision rhinoplasty is because too much was initially done.

With the psychological, emotional, and technical factors involved in revision surgery, success is based on good judgment, wisdom, and the accumulated knowledge and experience Dr. Moelleken offers. He designs a plan that will produce excellent results with as little trauma as possible and like all of his surgeries, revision rhinoplasty is both a science and an art. His skill comes from his training, expertise, and wisdom, combined with a huge measure of talent. Dr. Moelleken has a detailed understanding of the multiple anatomic variants encountered. Through his expertise and training, he acquired knowledge of the surgical alterations that occur and how to achieve an improvement or correction when the result is undesirable. His goals are to make the patient happy with the least amount of surgery necessary to achieve this goal.

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