Plastic surgeon Dr. Jason Diamond is renowned for the rhinoplasties (nose jobs) that he achieves with a technique that he has perfected over years of experience. In this personal article written by Dr. Diamond himself, he discusses all the intricacies associated with achieving a natural result. Dr. Diamond also lets us know his opinions of famous celebrities who had nose jobs.
By Jason Diamond, MD, FACS
Rhinoplasty is one of my favorite procedures to perform and as most of you may know the nose is considered to be one of the most complex anatomical structures on the face to work on and therefore rhinoplasty is one of the most difficult procedures to master. It took me about 400 rhinoplasty procedures before I really gained an advanced understanding of the finer points of rhinoplasty surgery. The beautiful thing about rhinoplasty surgery is that it is extremely predictable with a very high rate of success if the finer points are understood and understanding these points is what leads to a natural rhinoplasty result. In this article I am going to discuss how to create a natural looking nose that will stand the test of time, based on the structure of the nose’s cartilage, the nose’s overlying skin, and the surgeon’s own aesthetic judgment. I will also explain in detail how I go about making the surgical decisions of what is appropriate for a patient based on the consultation in my office. Finally, I will close by discussing the “non-surgical rhinoplasty” and its limited but useful role in facial plastic surgery.
I will be somewhat anticlimactic here and give away the punch line first and then discuss in greater detail how to arrive at the punch line. THE MOST IMPORTANT FACTOR IN ACHIEVING A NATURAL RHINOPLASTY RESULT IS TO CREATE A NOSE WITH GOOD STRUCTURAL SUPPORT.
In the following example, the patient had two previous rhinoplasty procedures with different plastic surgeons. The nose’s structural foundation was made too weak by trying to reduce the size too drastically. Therefore, the nose collapsed due to the forces of healing over time. After my revision rhinoplasty, I added cartilage to restrengthen the nose, providing the patient with a stronger foundation for a more natural, aesthetically-pleasing appearance. This result, although still swollen (which should resolve over the next few months), it will be a permanent solution, as it will never collapse.
(Top: Before; Bottom: After)
We have all seen those upturned noses that are way too pinched at the tip or ski sloped, those noses that have twisted, those noses that have indented on the bridge, those noses where one or both nostrils have pulled too far upward and those noses where the nostrils collapse down with every breath. These are all very common problems that occur with primary rhinoplasty surgery that are 99% of the time caused by a weakening of the nose and therefore the nose is left without support. All of these problems almost always leave the nose looking unnatural and can be spotted from a mile away as a nose that screams “BAD NOSE JOB.” These negative outcomes usually take a while to develop. Sometimes they occur right away but more often they occur over the coarse of a few years following the rhinoplasty (and I will explain why below). These problems are all completely avoidable with the appropriate analysis of a given nose followed by the appropriate techniques to address that given nose.
Certainly, to create a natural nose, the surgeon must create a nose that fits in harmony with that person’s face, but the reality is that if the nose is left with good structural support then the nose will most likely fit that face in a very natural way. It’s those noses that collapse or change too dramatically in a bad way that usually create the unnatural appearance.
As a surgeon, one of the most important questions to answer prior to deciding to perform a rhinoplasty on a given person is “what is the nasal anatomy like”?
The most important factor that determines if that nose has good or bad support is the inherent strength of the underlying cartilages. A nose with good tip support is a nose that is very springy such that when you press on the tip it will resist forcefully. A tip with poor support will easily be “smooshed” into the face when pushed on with your fingers.
Often times if the tip has good support, then the tip can be refined by simply removing some of the excess and the result will look more refined and still maintain its natural shape. On the other hand, that same technique applied to those tips with poor support will not only make the nose look worse than it did before surgery but it will very likely distort the nose’s appearance more and more as healing occurs over several years.
The reason for the delay in the poor outcome is several fold. The first reason is that the swelling that occurs the minute the nose is operated on is quite significant in its ability to camouflage a problem. It is now fairly, common knowledge that the swelling from a rhinoplasty takes a full year to resolve. This is true, and because of this the potential problems underneath can be hidden by the swelling. More importantly, however, is that as healing progresses a phenomenon called contracture occurs which basically means the forces of healing cause everything to shrink back down and compress. You might think of this like the way you would try to “pack a snowball” where you would take a soft mound of snow and continuously make it tighter and tighter by pressing with your hands around it. The nose will heal as if those hands packing the snowball are compressing the nose. If a lack of support exists, then the nose will not be able to withstand that force and will essentially crumble under the pressure. These healing forces can continue for years after the surgery and sometimes it can take that long for the nose to lose the battle. The nose that has lost the battle will likely look more bulbous than it did before surgery and often times will collapse in such a way that it will become uneven or asymmetric. The nose will often droop and it may likely have breathing problems as well. Therefore, the same technique that seemed so simple and worked great on the first nose could be disastrous for the second.
The way in which we avoid the above problems is to actually strengthen that weak nose. Instead of removing cartilage, we actually may add a little (in the right places) and will use sutures to change the shape of the cartilages into a stronger and thus, more attractive configuration. Usually, a nose with poor tip support will be an unattractive nose to start, since the weak cartilages can not exert enough force on the overlying skin to create a sculpted or defined appearance. Therefore, by strengthening the cartilages we are making a nose that looks more refined and one that will withstand those healing forces for the patient’s entire life. This will be a nose that looks visually pleasing and natural.
The next most important aspect of the patient’s anatomy to assess is the skin thickness. Again, the tip cartilages are inherently very delicate structures that exert their force under the skin to create a scaffold for the skin to lie over. The thicker the skin, the less definition to the nose that exists, and vice versa. For example, imagine you are on your bed with a thick comforter and you stuck your fist up under the comforter and raised it up toward the ceiling. If your blanket was thick, you would not be able to see the definition or even the outline of your knuckles. If you change the blanket for a thin sheet you would be able to see every contour of every knuckle. The skin affects the appearance of the nose in the same exact way. The only way to create more definition to a nose with thick skin is to strengthen the underlying cartilages so that they can push up against the skin. There is no possible way that removing or weakening cartilage under thick skin will lead to a good shape. Therefore, a nose with thick skin requires strengthening of the cartilages in the same way as the nose with a weak tip. Any attempt to weaken or remove cartilage from that nose with thick skin will cause the weight of that overlying skin to essentially crush the underlying cartilage leading to collapse and therefore a very distorted and unnatural appearance. I get asked many times can thick skin be thinned out and the answer is not very effectively.
The following example shows a patient with strong cartilage and and thin skin. Because of the inherent strength of her nose, she required a very minor reduction of the structure of her nose. The nose was slightly weakened so that it could be appropriately re-shaped, but based on its inherent strength, this nose can tolerate this type of procedure.
(Top: Before; Bottom: After)
This next example shows a nose with strong cartilage and medium skin thickness. This patient, due to their inherent strong cartilages, can have their framework reduced slightly and still maintain a good result. The main difference between this patient and the previous example directly above is the level of skin thickness. In this situation, the skin is slightly thicker, so the cartilages have to maintain a slightly stronger shape. Accordingly, you are unable to do as much to this nose as you can to the previously discussed nose above.
(Top: Before; Bottom: After)
There are other very important potential areas of inherent weakness to a nose that may need to be strengthened during rhinoplasty, such as the area known as the keystone region of the bridge (which is where the cartilage meets the bone or 1/3 of the way down from the top of the bridge) as well as others. If these areas are not strengthened (in the nose that has these weaknesses) during rhinoplasty, there will likely be deformities and areas of collapse that will leave an unnatural appearance.
The other essential component to making a nose look natural is to have a finely honed aesthetic eye that will allow for making changes that will create an attractive nose. There are many important well defined measurements and relationships within the nose that most nice noses have in common. They serve as guidelines but they don’t apply to every single case so the surgeon’s aesthetic judgment always takes precedence. The general consensus of what a beautiful nose looks like has changed considerably throughout time. For example, in the 80’s and early 90’s, a tiny scooped nose was in vogue. In the present time, that same scooped nose is now considered to look unnatural and instead, a straighter more substantial nose is far more desirable. The best way to determine what the ideal nose for any given person would be is to use the computer imager to actually see what the changed nose will look like. Often times this not only helps the patient see what they will look like but it can help the surgeon determine if a slight change one way or the other will look best.
The most common mistake that a patient makes when looking to have a rhinoplasty is not understanding what it is that they don’t like about their nose and thinking “IT NEEDS TO BE SMALLER”. Many people do need their nose to be smaller, but very often a person is unhappy with the shape of their nose that actually has more to do with poor cartilage strength or overall nasal/facial relationships rather then cartilage “SIZE”. The most common examples of this are patients who are seeking revision rhinoplasty. Those people who had “bad nose jobs” will have even less definition to their noses after their surgery then they had before and they will often think that the reason for the failure is that “not enough cartilage was removed”. In many of these cases, nothing could farther from the truth. Almost always, the way in which the overly weakened nose collapses makes it look like the nose is too big but the solution is to actually restore the strength to the collapsed area rather then remove more cartilage (which could be disastrous). Michael Jackson is the quintessential example of this.
This next patient is the perfect example of “thinking it needs to be smaller”. Because she is somebody with all of the unfavorable anatomical factors (thick skin and weak cartilage), even though she thinks her nose is too big and that she needs everything cut out, it’s absolutely untrue. Due to the weak cartilage and thick skin, you would have to modify the way you approach this nose. Doing a simple procedure, as discussed in previous examples, would be total disaster. Instead, she needs the nose strengthened. This patient needs cartilage added to the tip to make it strong, so that the cartilage can exert its one force on the heavy overlying skin, creating a nice shape. This will prevent collapse and become a natural, permanent, strong solution.
(Top: Before; Bottom: After)
In this next following pictures, the before picture shows what happens to a patient with thick skin and weak cartilage when you fail to strengthen the cartilage before cutting things out and reshaping those nose. It makes for a very unnatural look. Initially, the patient had a rhinoplasty with a different plastic surgeon, who cut out cartilage, but because of the weights of the heavy skin, and the inherent weakness of the cartilage, it just crumbled under the pressure. The patient came to me, and I added cartilage to make it strong. As you can see in the after picture, the cartilage is now strong enough to hold up and sustain that heavy shape and support the overlying skin.
(Top: Before; Bottom: After)
The next most common mistake that a certain group of patients make when seeking a rhinoplasty is to think that their tip is “too long”. Many people do have overly projected or long noses that need to be reduced, but just as many people don’t. There are very precise measurements that can be made to determine the perfect projection for a given nose. Most commonly, people with weak chins will think that their nose is too long even when the nose may have the perfect length. This is all related to the optical illusion that’s created from the weak chin. This is easily proven to the patient by using the computer imager and it’s always amazing to see their positive reaction when this is revealed. Furthermore, when the tip has poor support and an unpleasing shape, people may think that the nose is too long when in actuality the nose is not long enough. Again, this is easily revealed using the computer imager and these people are equally amazed to see how much better their nose looks with the appropriate projection.
This next patient thought their nose was too long, but in reality their chin was too weak, which makes the chin look longer. After a rhinoplasty (not making the nose shorter) and adding chin implants, everything works together in harmony. It’s important to understand that the nose isn’t always too long.
(Top: Before; Bottom: After)
The other common mistake that I see is when dealing with patients with thick skin. Often times these people think that “removing as much as you can” from the nose will make it look better. As we discussed above, the only way to make those noses look better is to strengthen the cartilage complex rather then weakening it and therefore very little cartilage, if any, should be removed from these people.
I have many rhinoplasty patients who are Asian and African American. These groups of people often are the extreme examples of people with thick skin and weak cartilages. The principles of adding strength to these noses instead of weakening these noses, as discussed above, are essential to creating a natural and pleasing rhinoplasty result. One other common factor to consider when dealing with Asian rhinoplasty is that often times the bridge is low and these noses look better if the bridge is raised. There are many ways to raise a bridge but in my opinion the prefabricated implants are the superior way to do this ( if done right) because the newest implants have the perfect aesthetic shape that is otherwise very difficult if not impossible to replicate with the persons own cartilage.
Rhinoplasty surgery is typically associated with minimal post operative pain despite what it may look like. I do several things to ensure the bruising and swelling will be as minimal as possible. I first start by icing the patient’s nose and eyes even while the surgery is taking place. By starting the icing process before the actual operating begins gives us the best chance of minimizing the bruising. I also recommend arnica preoperatively. This is a well known homeopathic herb that is supposed to minimize bruising and swelling. Does it work? I’m not 100% convinced but it is certainly safe and therefore, worth trying. I believe that postoperative cold compresses are important to help minimize bruising as well. I heard an interesting story from someone who knows the Jackson family very well and was around Michael Jackson for many of his procedures. Apparently, his surgeon came up with this contraption that was like a miniature vice that he would attach to Michael’s nose and then twist the handle to tighten the grip around the nose in an effort to decrease the swelling. I think this in theory may be a good idea but in practice is certainly overkill as the cast and tape that is in place for 1 week is all the compression that is needed.
Being a resident of Beverly Hills I see many celebrities up close and personal. The 2 nose jobs that bother me quite a bit are Deborah Messing’s and Lisa Kudrow’s. Both are obviously beautiful and successful women and most lay people may not even pay close attention to their noses. Upon close inspection both look unnatural and unpleasing to my eye and I consider poor rhinoplasty results.
I will now take you through the brief outline I use when evaluating a patient interested in rhinoplasty. First, I take a full medical history and really listen to what changes and end result the patient wants. As they are talking, I am evaluating the nose to see if there is movement such as the tip plunging downward with smiling, as happens commonly. Then I do a full nasal examination and try to evaluate the strength of the cartilage and thickness of the skin. I also evaluate the septum to see if it is deviated. I then take photos of the patient and put them on the computer imager and review the proposed changes with the patient. This allows me to make sure we have the same aesthetic goals. The approach to surgery then depends on the person’s given anatomy. If the tip is strong and the skin is not too thick then I may use a closed approach to refine the tip. If the tip is weak or the skin is very thick I usually perform an open approach and almost all revision rhinoplasties are performed with an open approach. I always bring the original and the modified photos with me to surgery so that I can match up the final refinements to the images that we agreed upon pre-operatively. The techniques used in surgery are fully customized to each individual case depending on their anatomy. Needless to say that every technique I use is designed to create a natural attractive nose that will be able to withstand the healing forces and maintain its shape permanently.
I would like to also discuss injectables to the nose or what has been termed the “non surgical rhinoplasty”. I believe that there is a role for this procedure and I perform it frequently but its role is very limited. There are several circumstances where fillers into the nose can be a satisfying and successful procedure. The first and probably most successful circumstance is when a person has what is known as a low radix. The radix is the highest point of the bridge of the nose. When the radix is low, an artificial hump will be seen on the profile view when in actuality there really is no bump. By filling in the low radix with filler, the appearance to the nose will improve and no longer look like there is a hump. I have actually done this procedure on a talk show called Life and Style hosted by Jules Eisner as well as a spot on Inside Edition and several local news stations. This procedure can give a nice temporary improvement and I prefer the filler, radiesse, as it lasts about 1 year. Occasionally, patients, who are seeking improvements after having been through rhinoplasty where there are minor post operative irregularities, may be candidates for injectables. If there are small divots, dents, or irregularities, then small amounts of filler can nicely camouflage the problem and save the patient from going through another surgery. Again, I usually use radiesse for this purpose when the irregularity is on the bridge. If the irregularity is on the tip then I prefer restylane as it is a thinner material. Although restylane won’t last as long, it is safer in the tip. Finally, fillers to the tip to increase tip projection can work well for some people to lift the tip slightly. I use restylane for this as well. This usually gives a six month improvement and most people end up opting for the permanent surgical rhinoplasty option after having done this filler once. The reasons for this are that continued filler use is a hassle as it has to be repeated every six months or so to maintain the result and it can be quite a painful procedure. This option also over time leads to a considerable expense for the patient compared to the one-time cost of rhinoplasty. But there are those people who continue to opt for the filler and this is an acceptable option for those people.
In summary, there are many important steps involved in achieving a natural rhinoplasty result. The first step involves knowing what changes you want to make on the nose based on aesthetic judgment and the patient’s desires. The next step involves using the appropriate technique for a given person based on their own unique anatomy. This combination will not only lead to a nose that looks good right off the surgical table but to a nose that will have a permanently, aesthetically pleasing result. In the world of rhinoplasty surgery, it is a known phenomenon that many a surgeon can make a patient look good and be happy with their result for the first few months after surgery. However, the success of a rhinoplasty and the true skill of its surgeon are determined by a long lasting natural result.
Dr. Jason Diamond is a Board Certified facial plastic and reconstructive surgeon. He is also a Board Certified Head & Neck Surgeon, Otolaryngologist, fellow of American College of Surgeons, who received his medical degree from the University of Rochester School of Medicine. After completing his five-year residency, Dr. Diamond chose to hone his skills by learning from top experts in the field. He spent two years seeking out the leading facial plastic surgeons worldwide, studying and operating with them to learn their secrets and perfect his craft. This self-motivated training enabled Dr. Diamond to master an extensive variety of facial enhancement techniques. His broad base of knowledge, combined with his sense of artistry, allows Dr. Diamond to tailor his approach to each individual patient. Dr. Diamond has been recognized by multiple sources including Harpers Bazaar, E Entertainment and NBC as being one of the top facial plastic surgeons in his field.
Dr. Jason Diamond’s Website: www.jasonbdiamond.com
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