Long gone are the days of the “templated” nose archetype – a small, dainty, doll-like nose expected to fit every face. Today, experts say it is more about designing a custom nose for each person, based on the patient’s desires, anatomy, race and ethnicity.
No Easy Task
“Rhinoplasty, as almost every plastic surgeon will tell you, is the most difficult plastic surgery procedure,” said Ramtin Kassir, MD, a facial plastic surgeon with practices in New Jersey and New York.
It is not only technically difficult – like working with fine jewelry in a small space – but getting a nose to fit one’s face involves a lot of art and science. It is assessing patients’ cultural and ethnic backgrounds, coupled with their expectations, facial anatomies and desires, and then creating a solution that takes all of that into account, according to Dr. Kassir.
“It is pretty hard to miss somebody’s nose. It is the central feature of the face,” said Ali Qureshi, MD, a plastic surgeon at South Coast Plastic Surgery in Irvine, Calif.
“Sometimes it is hard to miss a person’s nose because of how it already looks. But sometimes it can be hard to miss even after somebody has had surgery because of unusual scarring, deformation or just kind of an unnatural appearance,” Dr. Qureshi expressed. “One of the goals we have with rhinoplasty is to create a natural look. We are trying to create a nose that matches the rest of an individual’s features and doesn’t look like it belongs on someone else’s face.”
Rhinoplasty also is about preserving or improving function.
“It is not uncommon for patients who are interested in cosmetic improvement to have some functional airway problems, so I feel very strongly about the need to maintain or improve somebody’s breathing with rhinoplasty,” Dr. Qureshi said.
Dr. Qureshi said he has in-depth conversations with rhinoplasty patients to find out what they want and then builds on that by talking about realistic possibilities.
One of the most important things for a rhinoplasty provider to think about is how to maintain facial proportions, he said.
“I’ve noticed that especially in revision rhinoplasty, where patients have had a reductive rhinoplasty by another surgeon. They have taken a big nose and made it small, but to the point that it is too upturned, or over rotated, creating a “pig-like” nose that doesn’t function correctly,” Dr. Qureshi conveyed.
The revision in those cases often requires that surgeons use a piece of a patient’s rib to reconstruct structure. When Dr. Qureshi performs a structural rhinoplasty, he takes away some of the soft tissue and undesirable nose elements, as well as builds back structure to create a nose that looks good, that functions properly and can withstand the test of time and scarring forces.
Ramtin Kassir, MD Facial Plastic Surgeon Wayne and Ridgewood, NJ New York City, NY
Ali Qureshi, MD Plastic Surgeon
Raj Mohan, MD Plastic Surgeon Arlington, TX
Kian Karimi, MD, FACS Facial Plastic Surgeon
Alexander Z. Rivkin, MD Cosmetic Surgeon
Consider Race, Ethnicity & Geography
Putting the once-trendy sloped nose on patients of certain ethnicities can result in an unnatural, “surgical” appearance, according to plastic surgeon Raj Mohan, MD, who practices in Arlington, Texas.
“You might end up with what has happened to famous celebrities who had numerous rhinoplasties. It doesn’t look like the nose they were born with or what fits their face,” Dr. Mohan explained. “Patients desire modification, but a lot still want to preserve the look that is consistent with their ethnicity. They are just trying to enhance or modify some of the factors that they think might be abnormal or too prominent.”
According to Kian Karimi, MD, a facial plastic surgeon who practices in Los Angeles, Calif., there are generalizations about noses of patients with different racial and ethnic backgrounds.
For example, with the Caucasian nose, generally surgeons will remove a bump, refine the tip, narrow the nose, etc.
“Caucasian noses tend to have strong cartilage,” Dr. Karimi noted.
This is not generally the case with Latin, Asian or African American noses, which often have weaker cartilage. As a result, surgeons might build the nose to give it more structure and support.
“Although the nose might be wide, when you push on the tip in someone of those ethnicities or backgrounds, there is often very poor support of the tip of the nose. As a rhinoplasty surgeon, I know mentally that I might have to use cartilage from the patient’s septum to support the nose. Sometimes, that means adding cartilage to their bridge to raise it up, or adding cartilage to their tip to give them more tip refinement,” Dr. Karimi said.
Dr. Mohan, author of a paper on Latino rhinoplasty published October 2019 in Plastic and Reconstructive Surgery1, said the retrospective review revealed Latino noses do tend to have weaker cartilaginous structures. “This characteristic comes into play if trying to fashion cartilage grafts and also when trying to add support to the underlying framework,” he revealed.
The authors also found that Latino noses tend to have thicker, oilier skin and higher Fitzpatrick skin types than Caucasian rhinoplasty patients. Furthermore, many Latinos have a low radix and a dorsal hump; many have wide bones, or wider noses and much fuller tips. They also tend to have poor tip definition.
These findings have implications for rhinoplasty surgeons and patients.
“The common Western way of approaching rhinoplasty in the U.S. is a reduction rhinoplasty, which makes noses smaller and more refined. That is what these patients generally desire. They want the broader areas to be narrower. They want the hump to be straighter, but keep in mind with the thicker skin it is hard to notice a lot of these changes,” Dr. Mohan disclosed. “Achieving noticeable results depends on the exact technique and dissection to make sure that anything that is manipulated underneath will actually manifest itself.”
Cartilage weakness also has implications, he said. “Latino patients need a lot more cartilage and suture support for the weaker cartilage. Otherwise, the rhinoplasty result is not going to last,” Dr. Mohan pointed out.
Middle Eastern patients tend to be most concerned about the look of the nose tip and hump, Dr. Qureshi advised.
“It can be a young, otherwise beautiful woman that says she has a hump that is just too distracting on side profile. Or it could be a middle-aged man who says he feels like his tip is getting bigger as he gets older,” Dr. Qureshi shared.
Like other patients, Middle Eastern patients have certain concepts about what they want and don’t want their post-procedure noses to look like. So, it is important that rhinoplasty surgeons ask patients to communicate their visions of the ideal nose, versus a nose they don’t like.
“If they can show me pictures as a medium of communication, I think that improves safety and it improves overall results with patients,” Dr. Qureshi said.
Where a person lives can also impact the look they will seek with rhinoplasty. For example, patients in the Northeast U.S. likely want more of a straight, natural nose. In the South, in places like Miami, Dallas and Los Angeles, they want more of a doll nose, or “the Instagram nose,” Dr. Kassir highlighted.
“The average demographic of my rhinoplasty patients is a 23-year-old woman,” he continued. “The vast majority want smaller, more elegant, feminine, aesthetic noses. My goal is to construct a nose that doesn’t draw attention. The less attention a nose draws to the face, the better it is.”
Combination Approaches & Implants
Dr. Kassir said he often combines rhinoplasty with procedures to address function, including straightening the septum, opening the sinuses or trimming the turbinate.
For facial balancing, he might use a chin implant or fillers to address a weak chin and jawline. He also combines some rhinoplasties with a lip lift, which involves making a small incision below the nose to reduce the length of skin above the lip.
Dr. Qureshi said that in his experience, “Many times, I’ll do a patient’s rhinoplasty, give them some time to think about what kind of changes they want to their chin, if at all, and then they will either have a nonsurgical chin augmentation with me or one of our mid-level providers.”
Dr. Mohan generally doesn’t use silicone implants in Latino rhinoplasty patients, but said that colleagues who focus on rhinoplasty in Asian patients might use the implants more frequently.
“I think that like with all procedures, the surgeon has to understand there is a certain rate of infection and failure when incorporating implants. Patients have to understand that too,” he emphasized.
The initial consultation and assessment of the patient’s face with a full facial analysis are key. This comprises proportions of the face, including the forehead, chin and lips, according to Dr. Karimi.
“Beyond that you look at the overall aesthetic of the patient to make sure that the nose you recommend or the nose the patient wants will really, truly fit their face and look like the nose they were always meant to have,” Dr. Karimi said.
“In my practice a 3D morphing software through a technology called Vectra (Canfield Scientific) allows me to actually show different renditions of the patient’s nose to them, right there on the spot. Then, we can both be in agreement in terms of what outcomes we are trying to achieve. Of course, we have to explain that with skin swelling and other post-surgical effects, the result may be indicative of what the nose is going to look like in a year and not necessarily in two weeks.”
Rhinoplasties require very precise pre- operative planning, according to Dr. Mohan.
“That means knowing what the patient is presenting with, what the patient is looking for and how you are going to achieve it. You have to pin that down well before you are in the operating room,” Dr. Mohan said. “It is also important to have a consistent, methodical, well-thought-out approach to the surgery itself.”
Technically, rhinoplasty surgeons should preserve as much tissue as they can, reposition tissue and use as many atraumatic instruments as possible, Dr. Kassir expressed.
At the end of the day, surgical rhinoplasty comes down to gestalt and aesthetics, Dr. Karimi said.
“That is why top rhinoplasty surgeons will create a designer nose that is perfectly suited for the patient’s face, ethnicity and heritage, while mastering expectations,” Dr. Karimi said. “There is a lot of marriage of art and science.”
Liquid rhinoplasty can be a great option for patients who aren’t quite ready for a surgical rhinoplasty and those who have had rhinoplasty and want to fix minor imperfections without another surgery, according to Dr. Kassir, who did his first liquid rhinoplasty in 2005 and is pre- paring a 15-year series for publishing in scientific literature.
“It is great for patients that want to see a change without going under, getting cut or having a recovery,” Dr. Kassir advised. “We use sugar gels, or products like Restylane (Galderma) and Juvéderm (Allergan). What you are doing with the filler is adding it at key points on the nose, for example, before and after the bump and in the tip to lift it. This procedure makes the bump smoother and the nose look shorter and smaller even though you have just added to it.”
There are several things about liquid rhinoplasty that many providers don’t know, said Alexander Z. Rivkin, MD, a cosmetic surgeon in Los Angeles, Calif., who was the first to popularize the procedure in the U.S., in 2004.
“However, not all providers who want to do nonsurgical rhinoplasty fully appreciate the danger of the procedure. The first thing to stress is safety, safety, safety,” Dr. Rivkin continued. “This is a procedure that, when it goes well, is really fantastic. It does not take very much time or much product. And the results are really dramatic and life changing. But when it doesn’t go right, we are talking about issues of ischemia, necrosis and blindness. These side effects are extremely rare, but of all the places that we inject, by far the highest risks of blindness and necrosis are in the nose. Providers should not take injecting the nose lightly. It should be done by people who are absolute expert injectors and know exactly what they are doing, know the anatomy, know the safety procedures and know what to do if anything goes wrong.”
According to Dr. Rivkin, nonsurgical rhinoplasty can be more precise than surgical rhinoplasty. Qualified providers only enhance the areas that need addressing in a manner they can see while doing the procedure.
“You cannot get that kind of precision with surgery,” Dr. Rivkin said.
The other misconception is that nonsurgical rhinoplasty is always temporary. For the most part it is temporary because people use temporary fillers, Dr. Rivkin noted.
“But, there is a filler that is permanent where the effect is quite long lasting, and that is Bellafill (Suneva Medical). I use it frequently, but with great care because it is a permanent filler,” Dr. Rivkin shared. “I have had great success over the last decade injecting Bellafill and have had almost no issues with it.”
When he doesn’t use Bellafill, Dr. Rivkin often uses the hyaluronic acid filler Voluma (Allergan) in the nose. It is long-lasting and fairly robust to lift tissue, he said.
“I like it because it will flow easily through a 31-gauge needle. I backload Voluma into a 0.3 cc 31-gauge fixed-needle syringe. Those are the insulin syringes. I use those as opposed to the 1 cc syringes Voluma comes in. I think that is a major safety advantage because the needle is so tiny, so you are injecting small amounts. This helps with minimizing the risk of side effects. Because these syringes are so small, the injector can be very precise in how much pressure they are putting on the plunger. Low pressure injection is the key to avoiding embolic complications. Injecting small amounts also helps with precision, so your result is better,” Dr. Rivkin said.
Dr. Rivkin doesn’t reflux, which he admits is controversial.
“I think reflux can give people a false sense of security. The force necessary in order to reflux the syringe is enough that a human hand cannot be guaranteed to be in the same place when you’re refluxing and pushing,” he said.
While nonsurgical rhinoplasty is a good option for some, it is not for everybody. Liquid rhinoplasty is not a reductive procedure, for example. Changing the alar width needs to be done with a surgical procedure. And breathing issues need to go to the operating room, according to Dr. Rivkin.
“If a nose is too twisted, it needs surgery. My solution to twisted noses is to add on either side, and if I add too much, it makes the nose look too wide,” Dr. Rivkin said.
“Overall, however, nonsurgical rhinoplasty is powerful enough to change lives. In five minutes, you can dramatically alter the way someone looks, and they are so thrilled and thankful. I get people crying with happiness in the office after they see their result in the mirror on a weekly basis.”
1. https://pubmed.ncbi.nlm.nih.gov/31568291/?from_ single_result=Mohan+R+Latino+rhinoplasty&expa nded_search_query=Mohan+R+Latino+rhinoplasty