Your question: Best rhinoplasty for large nose with thick skin, very high nostril crease, etc? Photo
My gigantic bulbous nose is an inherited deformity. The skin on the nasal tip is very thick and oily. I am over 50. I want a moderate reduction the most important factor to me is to have the very high nostril creases lowered. Please recommend the best method of rhinoplasty as my nose is definitely in the 'unique' category. Any idea of cost? As this is a public forum, I would prefer to send through proper photos directly to surgeons whose responses are of interest. Thank you.
Dr. Denenberg's answer: Hmm. We're not great at high nostril creases. But ...
... there still may be ways to make you happier with your nose. See the Web reference link, below I made a computer morph, and an animation of that morph, of one of your views, showing changes that are possible with a rhinoplasty in truly expert hands.
The nostril crease, if we are using the same terminology, is at the top edge of the little prominence of thick skin where the nostril meets the cheek. It looks like a round prominence of thicker skin. The reason we can't typically tailor that area as we like, is that most of what we do in a rhinoplasty is to work on the bones and cartilages underneath the skin. But that prominence of skin, which we call the alar lobule, is just that thick skin. And we can't just cut it out because it might leave a scar, or a pucker, or some other deformity that would be much, much more problematic.
In the morph, I elevated the bottom edge of the alar lobule, because there is a little debulking of the lobule that can be done, which debulking would typically raise the bottom edge a bit. But I probably wouldn't attempt to lower the position of the crease itself, which would almost certainly cause some distressing scarring.
In the morph, I elevated the tip of the nose, and brought the tip closer to your face. Those changes can make the nose overall look smaller, and might make you happier with your nose, even if the position of the alar crease doesn't necessarily move to your ideal position. That make sense?
1) Proposed before and after:
Here's an animation of those changes. Give it a couple seconds to load:
Does this fit with what you hand in mind for yourself?
2) Click here to comment on those changes, or to ask Dr. Denenberg a follow-up question.
3) Click here to see more rhinoplasty before and afters of patients with combinations of features to correct.
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Plain talk about picking a plastic surgeon for your first-time or revision rhinoplasty.
I do lots and lots of revision rhinoplasties; I'll try to give you some advice here, to maximize the chances that you'll be happy after surgery, and to minimize the chances you'll need a revision.
Important!! How to tell whether your consultation was acceptable:
Photos. If a surgeon doesn't show you before and after photographs, scratch him off of your list. Period. No exceptions. Deal-breaker.
You pick a surgeon primarily from his before and after photos. Diplomas, board certifications, hospital affiliations, academic appointment, and even reputation tell you nothing: a surgeon is never tested for his skill, his artistic eye, the quality of his outcomes, or even whether he cares that his patients are happy.
You must see photos of other patients who had some features similar to your nose. For example, if your nose has a wide and drooping tip, don't accept profile-only photos of patients who had a hump carved down. You can't see the width of the tip on a profile photo.
Revision nose operations are much more difficult than first-time operations, so if you are consulting a surgeon about a revision operation, you must see photos of his revision patients.
If you do see the surgeon's photos, but you don't love them, scratch him off your list. You want to use a surgeon whose work you like. Don't assume that he'll do great on you when he didn't do great on the other people.
Thought experiment: you are going to hire a portrait painter to paint your portrait. Would you really hire the painter if he wouldn't show you any of his other portraits?! No, it would never occur to you to hire him. Well, now you're going to hire a surgeon to change your nose, in the middle of your face, and you aren't going to insist on seeing examples of his work, proof that he knows what he's doing? Think about it. Teach your friends.
Communication. If the doctor treats you disrespectfully, scratch him off your list. If he won't patiently listen to what you want for your nose, same thing. How will he know how to make you happy if he won't hear what you want for your nose?
If he conducts the consultation from behind his desk and doesn't examine your nose, deal-breaker. If it's the nurse and not the surgeon who conducts the consultation, run away fastest. All due respect to the nurse, she doesn't know what's possible and what isn't. If the plan is to see the surgeon for the first time on the morning of surgery, deal-breaker. For sure.
Computer morphing. If the surgeon doesn't do computer morphing of your nose, scratch him off your list. The morphing is crucial, so the surgeon can prove to you that he understands exactly what your goals are. Also, if the surgeon recommends some changes that you hadn't thought of, you need to see the morphs, so you can see whether you like those changes.
Your intuition. If your gut tells you "no," don't use the surgeon. Don't ever use a surgeon only because you know him, or your kids know him, or he lives on your street, or your primary care doctor referred you to him, or he did your breasts, or your tonsils, or your wisdom teeth, or you saw his advertisement, or his awards.
I hear these stories all the time from my revision rhinoplasty patients. You must do your own evaluation of any surgeon you visit. And by "evaluation," again, we're talking mostly about seeing his photos and seeing how well he communicates with you. Don't bother checking the surgeon's licensure and board certification and hospital affiliations and all that; it'll just distract you from what's important.
Conclusion. The fact is, the great majority of plastic surgeons who perform rhinoplasty shouldn't be doing the operation. It's an incredibly difficult procedure, technically demanding, requiring experience, skill, judgment, an artistic eye, an exceptional level of communication and thoughtfulness, and a rare level of empathy and caring for the patient. No hospital board protects you by judging the quality of a surgeon's rhinoplasties and prohibiting him from operating if he's terrible. It's the wild, wild west out there, folks.
More plain talk: should you let your primary surgeon perform your revision?
First, you need to consider whether things didn't turn out great on your first operation because of some unusual circumstance with the surgery or the healing, or whether things went wrong because your doctor was not expert in rhinoplasty in the first place.
Evaluate your surgeon again. Read the section above, on how to evaluate a surgeon for a rhinoplasty. If you saw lots of before and after photos of your surgeon's other patients who got excellent results, in noses at least somewhat similar to yours, then your surgeon probably knows what he is doing, and you can consider letting him perform your revision. Even the very best surgeon has the occasional disappointing result.
However, if, on looking back, you decide that you did not do excellent research on your original surgeon -- perhaps you relied on a referral, or on his board certification, without being able to see his photos -- then you probably should not have him perform the revision. If he couldn't get you close to your goal the first time because of a lack of skill, he will have no chance at all on the second try, and then you'll be in the tough position of looking for a third operation.
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