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Steven M. Denenberg, M.D.
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In these photos we see another clue, that his nose is over-projecting.  In the after photo, draw these two imaginary lines: a mostly-horizontal line drawn along the base of his nose, and a line drawn along the skin from the base of his nose down to his upper lip.  Those two lines meet at a sharp angle.  In the before picture, however, they don't.  The line that traces the skin of his upper lip curves forward to meet the bottom of his nose in the before photo.

If you grab the tip of your nose and pull it forward, making your nose more projecting, your upper lip skin will do the same thing.  When the upper lip skin pulls forward like that, we call it "tethering of the upper lip," and it's usually an indication that the nose is a projecting nose.

The rhinoplasty section of the Surgery tutorials contains a chapter that discusses the phenomenon of upper lip tethering (the surgery tutorials contain explicit photographs taken during surgery).

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Questioner: Tip plasty - I went to have a consultation by a board certified plastic surgeon.
I went to have a consultation by a board certified plastic surgeon. He quoted me 2999 price for a tip plasty, reduce columella show and cutting the depressor muscle, using only a local. Does this sound like a reasonable price? Also he is in his mid 70's, very experienced with long career, but his hands shake.
(Questioner submitted photos)

Dr. Denenberg's answer: Many factors to consider
It's an interesting question. What's important and what is not important? I'll give you my two cents.

The price: indeed it sounds very low to me. Very, very low. But it's not disqualifying. Most important is that the doctor has before and after photos to show you, photos that demonstrate attractive results on noses with features similar to yours. You must disqualify the doctor if you haven't seen his photos.

The fact that he's in his mid-seventies: not important. It could be a big plus, because (perhaps) he's had lots of experience. Smart doctors get better with experience. Dumb ones don't.

His hands shake: hard to know what to do with that. Maybe it's a "rest tremor" and they're rock steady while he's operating. I'd trust his before and afters more than my evaluation of a tremor.

Local anesthesia: Well, hmm. I personally never use general anesthesia for rhinoplasties, but I *do* use IV sedation so the patient is completely asleep. It *is* possible to do a rhinoplasty safely and comfortably under just local anesthesia, but the doctor would have to take a loooooong time to numb you up and keep you comfortable, and really, you wouldn't want to be awake. If things don't go perfectly smoothly during surgery, you and he would be in a bad position. My advice, use other factors in deciding whether to use him, but ask him to sedate you.

Now here are two factors you may not have considered. 1)The fact that he's board certified: isn't the deciding factor. Trust his before and after photos, not some piece of paper on his wall. 2) The fact that he wants to do a "tip plasty" and "reduce the columellar show." I've been doing rhinoplasty for thirty years and I've never done a "tip plasty." It is exceedingly rare that you only work on the tip (the columella is really part of the tip) and nothing else at all. When you change one part of the nose, then adjacent areas look different, and you have to work to make sure things all fit together.

Summary: I'm worried about the "tip plasty" thing, and that you didn't mention reviewing his before and after photos.

Link to this question on RealSelf.com