Raffy Karamanoukian, MD
Rhinoplasty Expert Los Angeles

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Repairing a Previous Nose Job with a Revision Rhinoplasty


Overview of Rhinoplasty Revision and Secondary Rhinoplasty with Dr. Karamanoukian

There are various techniques used to correct the shape and contour of the nose.  Problems with nasal contour can occur as a result of normal growth, family traits, trauma, or a previous nose job.  Revision rhinoplasty procedures are not only performed for cosmetic reasons, but may be required as a result of poor breathing, nasal collapse, nostril retraction, or deviated nose.

Dr. Karamanoukian will examine five major elements of your nose during your consultation.  This comprehensive approach will allow Dr. Karamanoukian to formulate a comprehensive and definitive treatment plan in order for you to improve your airway and your cosmetic appearance.  The nose should be considered both as a functional part of your face (breathing airway) and an important cosmetic component of your face. Correction of only your airway is performed with a
Septoplasty, while correction of your cosmetic appearance is known as a Rhinoplasty.

The five major elements of your nose that will be examined by Dr. Karamanoukian are as follows:

  1. Skin ( There are major differences between individuals with thick porous skin and thin skin).
  2. Airway ( It is important to determine how well you breathe through your nose).
  3. Upper Third ( This is composed of the nasal bone which is the highest portion of your nose).
  4. Middle Third ( The Bridge comprises the area between the bone above and nasal tip below).
  5. Lower Third ( The Lower Third is defined by the nasal tip, nostrils, and base of the nose). 
The techniques used in revision rhinoplasty are complex and multidisciplinary.  Cartilage grafts, bone grafts, composite grafts, alloplastic tissue replacement, and cartilage repostioning can all be used to correct apparent deformities of the nose resulting from trauma, development, or previous rhinoplasty.  For years, rhinoplasties were performed using a 'cookie-cutter' approach that simplified rhinoplasty without an appreciation for the multivaried ethnic differences among noses of different races and backgrounds.  These rhinoplasty procedures destroyed normal ethnic and anatomic variations in the nose in favor of a diminutive ski-slope type nose.  The overall aesthetic objectives were nasal reduction without regard to nasal function or appearance.  Dr. Karamanoukian will carefully evaluate your rhinoplasty results and recommend a customized surgical treatment that will recreate the normal anatomy and function of your nose with rhinoplasty. 

Correcting Problems with the Skin Before and After Rhinoplasty - Rosacea and Large Pores

Many patients do not initially realize that the skin plays an enormous factor in the cosmetic result of the nose.  Patients with very thick skin or overactive oil glands and pores may have bulbous noses that can be partially improved through non-surgical techniques.  Dr. Karamanoukian has been highly successful treating patients with bulbous noses and rhinophyma using a combination of topical treatments, laser, and chemical peels.  Although these techniques do not replace traditional surgery and corrective rhinoplasty, they may play a large role in the correction of an unappealing nose. 

Rosacea is one condition that affects the thickness and appearance of the nose.  Redness, blushing, thickening of the skin, large pores, and tissue overgrowth may occur with rosacea, causing the overlying nose skin to appear bulbous and without definition.  Dr. Karamanoukian uses a combination of treatments, including laser ablation, to destroy the overactive pores and eliminate unecessary bumps and irregularities of the nose.  In more severe cases of rosacea, a condition known as rhinophyma may occur, in which the entire nasal tip has grown disproportionately, causing a bulbous nasal tip and 'glob' of tissue on the nose. 

Improving the Nose with a Cartilage Tip Graft during Rhinoplasty Surgery


A tip graft is one of the most technically difficult techniques used in rhinoplasty and revision rhinoplasty.  Although there are many different types of cartilage tip grafts, Dr. Karamanoukian will use his knowledge to customize a cartilage tip graft that enhances your particular nasal profile in order to acheive harmony between your nasal bridge, nasal tip, and nostrils. These cartilage tip grafts are a mainstay of rhinoplasty and can even be used in ethnic rhinoplasties in order to define the tip of the nose. 

The major goals of a cartilage tip graft are as follows:
  1. Increase and improve tip projection.
  2. Improve nasal tip definition and sculpting.
  3. Adjunctive tip defining technique in ethnic rhinoplasty.
  4. Improve asymmetry of the nasal tip (One side is different than the other).
  5. Lengthen the nasal bridge in patients who have a short nose.

Large Nostrils and Nostril Retraction can be Corrected with a Revision Rhinoplasty Surgery


Nostril Retraction is a difficult problem to correct without surgery.  If you are concerned that you have an exposed or retracted nostril that has excessive show, you may be a candidate for a corrective rhinoplasty procedure. During your consultation, Dr. Karamanoukian will examine your entire nose to determine if your nostrils are truly retracted or exposed, or whether you merely have an undercorrected nasal base (columella).  Expert rhinoplasty diagnosis is essential in choosing the right surgery for your condition. In either case, Dr. Karamanoukian will recommend a suitable surgery to correct the apparent disproportion between your nasal tip and the nostrils. 

During your rhinoplasty surgery, Dr. Karamanoukian will make sure that your cartilage grafts are placed meticulously within the tissue in order to maximize cartilage lifespan and retention, and to minimize the risk of nasal asymmetry and cartilage warping.

Two options for nostril retraction or exposed nostrils are through the use of cartilage grafts.  There are two variations of cartilage grafts that can be used to correct your nostrils, as described below:
  1. Subcutaneous cartilage graft ( A small piece of supportive cartilage is placed underneath the nostril in order to provide structural support for breathing and correction of the cosmetic appearance of the nose).
  2. Composite cartilage graft ( This is a procedure that Dr. Karamanoukian has specialized expertise in.  A composite graft is a combined skin and cartilage graft placed in a hidden location inside the nose).

Building the Bridge of the Nose with Augmentation of the Dorsum - Los Angeles

The bridge of the nose can confer certain facial characteristics that may be appreciated or unwanted. After an unsuccesful rhinoplasty, the bridge of the nose can be sloped, crooked, deviated, humped, shortened, or elongated. The best example is a ethnic male who has received an overagressive rhinoplasty with a 'ski-slope' nose.  In this case, the nose will no longer match the masculinity and strength of a male face because it is concave in appearance.

Dr. Karamanoukian uses his expertise in surgical rhinoplasty techniques to translate your aesthetic desires to a beautiful and well proportioned nose.  The key is to listen to patients and make recommendations that fit one's ethnicity, age, and facial characteristics.  

One of the key reconstructive strategies employed by Dr. Karamanoukian is the technique of dorsal augmentation to rebuild the nasal bridge after over-aggressive rhinoplasty. In our office, we employ techniques that use one's own cartilage and tissue to augment or build the bridge to reshape the nose in a more aesthetic manner.  Revision rhinoplasty techniques to build the nose are designed to:
  1. Build the bridge of the nose ( Resulting from trauma or over-resection during rhinoplasty).
  2. Correct a 'ski-slope' nose.
  3. Correct asymmetry of the nose as a result of rhinoplasty or normal growth.
  4. Improve the relationship between the nasal tip and the bridge.
Although there are many options available for augmenting or building the dorsum of the nose, the best material still remains a cartilage or bone graft.  Goretex mesh, silicone implants, and MedPor implants can provide longterm improvement but pose a greater risk of displacement, extrusion, and infection.  A viable alternative to these types of dorsal augmentation is a technique wherein intercartilaginous sutures are placed in the existing dorsal cartilage and cartilage grafts in order to heighten and project the septal cartilage and nasal tip. 

Breathing problems and Nostril Collapse are reasons for a Revision Rhinoplasty in Beverly Hills

The external nasal valve is closely associated with the nostrils and the terms are used interchangeably to discuss a very disturbing complication of rhinoplasty known as external nasal valve collapse or nostril collapse.  We see this condition after rhinoplasty in a very small segment of patients and it results from a loss of alar (nostril) support caused by a variety of reasons, mostly anatomical. When the nasal tip cartilages are over-reduced, a collapse of the nostril cartilage occurs because there is no obvious support for the nostrils to remain open. 

If there is nostril collapse, then the nostrils shut down on deep inspiration, a condition which necessitates revision rhinoplasty and requires correction.  Most commonly, nostril collapse causes a distinct airway collapse which renders the nostrils useless as a passageway for breathing.  As a rhinoplasty specialist, Dr. Karamanoukian will receive consultations from allergists and sleep specialists who identify problems with airway breathing. Very rarely, nostril collapse will result from normal aging, but this may occur if the tip begins to droop significantly with time.  

You have many options for revision rhinoplasty with Dr. Karamanoukian.  His offices in Beverly Hills and Santa Monica will assist you in your consideration of revision rhinoplasty and can accomodate international clients from Russia, the Middle East, and Asia. 

Correction of nostril scarring and nostril retraction, Beverly Hills Plastic Surgeon for Rhinoplasty

There are many reasons to undergo revision rhinoplasty if you are unhappy with the contour of your nose after surgery.  Patients who have previously undergone rhinoplasty sometimes have a condition known as alar retraction or nostril retraction in which the nostril is elevated and exposed. This leads to overexposure of a significant portion of the inner mucosa.  In other words, nostril retraction shows up when the nostril are lifted to the point where the inside of the nose can be seen by others in an upright position.

 

Nostril retraction can be improved.  The condition known as nostril retraction or alar retraction can be corrected with a very meticulous technique known as composite grafting on the inner mucosa of the nostril.  In this procedure, a small composite graft made up of skin and a small amount of cartilage is meticulously dissected from the outer ear.  The harvest site is then closed with absorbable sutures, which results in no obvious change in the shape or contour of the ear.  A small incision is placed in a hidden location inside the nostril and the scar tissue is dissected free. The small composite graft that contains cartilage is then carefully sewn into the inside of the nose using very fine sutures.

 

Nostril retraction or alar retraction is usually performed under anesthesia in a surgical suite in either Santa Monica or Beverly Hills.  In my experience alar retraction can occur on both sides, but it is usually a unilateral problem caused by excessive scar tissue from over resection of the inner mucosa.

 

I would classify this as a minor revision rhinoplasty in which the contour of the nose has changed due to scar tissue from inside the nose.  Unlike other procedures the nostril retraction requires a small piece of cartilage to lend support to the correction and to obtain definitive long term results with rhinoplasty.  Although retracted nostrils are a subtle characteristic of over-aggressive rhinoplasty, they can cause significant aesthetic deformity and can detract from the overall shape of the nose. 

 

Once the composite graft is placed inside the nose, the healing process is quick with minimal downtime and almost immediate correction of the problem.  The nostrils are a significant and important part of a rhinoplasty procedure and demand attention both in the revision rhinoplasty setting as well as for a first time rhinoplasty.  These revision rhinoplasty procedures can be performed under general anesthesia with very little downtime.

 

Dr. Karamanoukian is available for consultation and for surgery in both Santa Monica and Beverly Hills.  Schedule a consultation for revision rhinoplasty or correction of nostril retraction by calling our office at (310) 998-5533.