Crooked noses or deviated noses are among the most challenging to fix. Sometimes they are due to previous trauma, mostly though its just a developmental growth issue.
They often resist good repair and straightening unless the surgeon uses specific techniques. I find I get the best results if I follow these steps:
First as in all noses I analyze. Is the crooked shape or deviation from bone or cartilage or both? Is the deformity external only, or internal as well? If each area that is affected is not addressed then its unlikely to get a good result.
With bony deviations I like to use a “turn the page of a book technique”. What that means is that instead of a routine procedure when one is just trying to narrow the bony width from the outside by bringing the bones together, you have to modify what you do. To explain further, if the nose is deviated off to the right side of the face, I start by releasing the left nasal bone in the middle and then on its outside. This allows me to “turn the page” and rotate the bone from the right side of the face to the center or left of center. I then follow with the same procedure on the left bone which allows me to turn it towards the middle and “close the book” with the nasal bones in the center of the face.
If the cartilage is deviated this is also challenging. Cartilage is flexible and has memory and so will often resisit efforts to straighten it. I often find it necessary to use a variety of techniques to get it to sit straight such as scoring to “break the spring”, adding cartilage as “braces or struts” to splint it in the new shape or camouflage curvatures and different types of suture placements.
Internally the nasal septum is integrally connected to the external profile. If the septum is deviated (often in an opposing direction to the external curve) it must also be corrected. If not the external result will often be compromised. This also holds true when dealing with a nose that initially appears straight. If the surface (dorsum or profile) is reduced or altered and a crooked septum is not addressed the end result may be a crooked nose which had started out straight.
One of the tradeoffs of having to do so much bone and structural work is that the surgery takes a little longer and patients often have more bruising post operatively than routine rhinoplasty. However the bruising goes away and I’ve never had anyone complain about it or longer surgery when the nose is sitting straight. I’ve spent a lot of time consulting with people who’ve gone through procedures and are still frustrated by having a crooked nose. Both of us would rather have spent the extra time in the OR and not talking after.
Like many practices I’m seeing an increase in men seeking facial plastic surgery. By this I’m referring to procedures designed to maintain or restore a youthful and rejuvenated appearance, not correct injuries or deformities.
Both men and women are often concerned about their eyes and want to eliminate or avoid the “tired” or baggy appearance which may develop. In men it is important to pay careful attention to a “heavy brow” which may exaggerate the problem and hamper the result if not addressed. Men are also more often concerned about the lower neck (”turkey neck”) that develops then they are about the cheeks and midface or forehead.
Many men can be well served by procedures designed to address targeted areas as opposed to a “total” facial rejuvenation plan. This allows them to feel refreshed without the fear or sense that they have completley changed their facial appearance.
Other special considerations when treating men relate to hairlines, hairstyles and incision placements. What might be easily hidden or camouflaged by makeup in a woman would be unacceptable for many men.
The good news is that there are a variety of procedures, techniques and approaches that can be specifically tailored for men to address their aging concerns. Many men spend a lot of time and money in the gym, on trainers and supplements. These are all key steps in feeling youthful and healthy. Unfortunately none of these practices will restore a sagging jaw and neckline or hooded eyelids. It’s great to see how many men now recognize this and actively are seeking solutions.
I read a nice article in the Style magazine of this past Sunday’s New York Times. It described the benefits of a “liquid lift” as performed by Dr. Yan Trokel of NYC. Basically it described his approach and technique of using Botox and multiple fillers to restore volume and build a refreshed youthful face. The main advantages being that it was done in the office with local anesthetic, took under 2 hours and had minimal post procedure discomfort or downtime. It was therefore also perfect for patients who are “surgery phobic” as there is no cutting or incisions. I found the article to be accurate and realistic in its descriptions of procedure, results and price.
The problem is I don’t know many “real people” who can afford this or are willing to pay the maintenance for it. As described the procedure costs $4000-$8000. This is for filler and Botox only. All of which disappear anywhere from 6-18 months. The article says it will last for up to one to two years with $2000 worth of touchups. I agree with this description as realistic.
Unless you are a high earning executive or professional model/actor who absolutely can not have down time it’s hard to find the value here. You may be a person who doesn’t want to have a recovery period or are fearful of surgery, but most of us have to allocate the resources we have the best we can. Is no down time and discomfort for an 18 month result vs one to two weeks recovery for a result that will turn the clock back 15 years and last 1o years worth the same $8000?
There are many wonderful techniques and treatments available now for facial rejuvenation. Due to the unique differences in each persons anatomy, lifestyle and aging pattern often a combination of these is the best way to approach the problem. Liquid lifts are great as you long as you understand and choose to accept the limitations on longevity and continued maintenance costs. I always recommend that a patient see a number of well trained and regarded physicians in the field to get some insight before they choose to “fit themselves to a procedure” and not the other way around.
This week I worked on two patients who really illustrated the interface of cosmetic and reconstructive rhinoplasty.
One patient had been asssaulted and had his face smashed with a baseball bat. Having completed restoration of his upper jaw and teeth it was time to rebuild his nose. Unlike routine rhinoplasty where there is bone and cartilage to reshape, everything had been smashed and crushed leaving little to work with. After adding in the resultant scar tissue it left the patient with a collapsed, shapeless and nonfunctional nose. The challenge was met by going to one of our natural spare parts boxes, in this case the patient’s rib cartilage. After harvesting this new supply of firm, supportive cartilage all the building blocks to create an aesthetic and functioning nose were carved and shaped and then implanted and grafted. This is one of the most diificult of all challenges in rhinoplasty.
The second patient presented with what is often called “finesse” rhinoplasty. An attractive young woman who only desired modest refinement of her profile and nasal width. The challenge (and sometimes trap) for the surgeon here is to resist the temptation to do to much. The over zealous surgeon who wants to use all the great (or usual) techniques he knows or does on every patient ends up altering a pretty face when only subtle refinement is needed or has been requested. Such a result can be devastating for a patient.
Each of these cases represent polar opposites in planning, approach and execution to achieve the desired result.The sum of these two cases together remind me why I love doing this procedure-even after twenty years you still are challenged by every patient. It is never routine. You can’t do the same procedure on every patient. You have to be skilled in a wide variety of techniques but only use what’s needed for each individual case. The results will be right out there for everyone to see, not hidden under clothes or makeup. It can only come from you, it’s not an implant or a technology that anyone can buy. Nothing is more rewarding or humbling then being trusted by patients with this responsibility and being able to help them meet their goals.
In this tight economy many people are shopping for Botox cosmetic aggressively by price. Here are some pearls to keep in mind when doing so:
Genuine Botox cosmetic by Allergan is supplied to practitioners in freeze dried bottles of 100 units. Unlike fillers which come in pre filled syringes of set volume, the practitioner mixes and dilutes the strength of the Botox. The stronger the concentration, the less you need. Generally most people either dilute the 100 units with either 2.5ml or 4ml of saline. This yields botox concentration of 4units/0.1ml or 2.5 units/0.1 ml. (some practitioners may dilute it more but it’s not typically recommended to do so)
Why is this important? When you are price shopping are you being quoted a price per unit or a price per area? If its a price per area and is cheaper chances are you are getting a more dilute concentration.
Is this bad? Not necessarily if you are being made aware of it, it’s just that I think you will get a better and longer lasting result with a higher concentration. Also if you don’t get as much result as you like when you pay by the unit you just pay for as many more units that you need, not the whole area again. Pearl: Its OK to ask what concentration and how many units you are receiving.
Second big question to ask when shopping: Who’s doing the injection? Doctor? Nurse? Aesthetician? Why is this important? Botox achieves it’s effect by weakening muscles that cause wrinkles and lines when moving. To be most effective it needs to be injected into the muscle itself. Does the injector have the training, background and familiarlity with the facial muscles to be certain you are getting the most injected into the right place?Remember we are talking about very small volumes and concentrations here. You want to be sure it’s going where it needs to, not the skin or surrounding tissues where it will not have much effect-especially if you are paying per unit.
Bottom line-paying a little more to get injected by a skilled doctor using higher concentration Botox may in the long run save you a lot in satisfaction and longevity of results than a cheaper salon or mall injection.
Last pearl: Just like many other products the more you buy the better chance for additional discounts. Get a group of 3 or 4 friends together and most offices will give you a discount if everyone is getting it together. Plan on the future and negotiate a discount for your next treatment at the time of the current one by making a partial payment towards it. Consider a package combination of Botox and fillers and you can get a discount for multiple treatments done together.
Rhinoplasty
