Dr. Sam Lam Plastic Surgery Forum

Hello Dr. Lam,

I'm interested in projecting my subnasale (premaxilla) forward and I was wondering if this is something that isn't difficult to do. From what I've seen and heard, it seems that most Asian patients focus mainly on the bridge and somewhat on the tip, but hardly on premaxillary augmentation. My subnasale isn't retrusive by Asian standards and sits slightly behind the pink upper lip when seen from the profile. I want to advance the subnasale (I'm guessing via augmenting the nasal spine) so that it sits slightly forward of the pink upper lip and such that the "pull" of the subnasale creates a "tethered curl" (where the upper lip meets the base of the nose).

In addition to premaxillary nasal spine augmentation, I'm looking for a more defined tip and a more projecting tip. Right now, my lobule is rounded and lacks shape, but want to project my tip forward and also create a sharper tip (perhaps via collumellar strut I'm guessing).

My bridge is probably fine - any higher and it probably wouldn't look natural for an Asian. There might be other tweaks I'd like to do but the aforementioned two points are what I'm mainly looking for - premaxillary nasal spine advancement, and projected and pointed tip. I used a 3-way mirror. I pinched the front of my collumella with my thumb and middle finger and pulled forward. Then, I used my index finger to pinch down on my lobule. I like how this looks. It places the subnasale in front of the pink upper lip, creates a tethered curl at the subnasale, and the index finger pinching down on the lobule creates a pointed tip. Obviously, it is harder to imagine how the front view would look like with my hand in the way but these changes mainly affect the profile anyway.

Sorry for being verbose and wordy but I'm not medically-inclined. I've probably made it sound more complicated than it really is. Are those something you can do in your practice? I imagine a rhinoplasty surgeon with little or no Asian rhinoplasty experience won't have a clue.

Thank you for your time,
Paul

hi paul,
yes, that is very clear. it sounds reasonable but let me clarify my position on each of the following:
1. nasal tip with septal +/- ear graft (most times 95% do not need extra cartilage) to get the tip shape and projection. it also can lengthen the nasal base downward and give you "columellar show" better than a columellar strut can. although i use a strut very very often too. the tip graft gives me the illusion of more subnasale show because it lengthens the base of the nose without really changing the actual premaxilla. that being said...
2. i do cartilage plumping grafts using septal and or ear cartilage to bring the central premaxilla forward as needed. however, these plumping grafts are not as reliable as the silicone and gore-tex blocks that i used to use in this area. the reason that i stopped using them is the discomfort people had when smiling. i took almost all of them out. i think they are too bulky and uncomfortable when they span across the entire base of the nose. if that is what you are looking for, i am not your surgeon. however, if the points 1 and 2 make sense, then i would be happy to visit with you further. thanks for the question.
best,
sml

Hi Dr. Lam,

Thank you very much for your reply. I had some developing questions that I didn't want to write until I was able to consolidate all of them and didn't want you to waste too much of your time replying to every post I make, so hopefully I can get this in one shot. With your corroborating and encouraging feedback, I would have a plan of action and would be worth making the trip all the way from NY to see you in the future, since you're one of the best in the business.

1) I recently had orthognathic le fort I osteotomy done on 11/2009 due to teeth malocclusion and the doctor did a great job. I had told him about my desire to undergo septoplasty/rhinoplasty and he told me I should wait at least 6 months for everything to heal. I told him pretty much everything I had written here and he suggested that I should have a bone graft done on my ANS (anterior nasal spine) to achieve the look of the "tethered pull" at the subnasale and that this is something he can do. He would harvest the part from the chin. The reason for going this route is twofold (correct me if I'm wrong). Firstly, I'm thinking this is the most "natural" way to achieve that "tethered pull" since that new extended ANS would be as if I had one solid piece of bone there without any risk of any implant or cartilage to slip out of place. Secondly, I'm thinking that the septal and ear cartilage a doctor would use to plump up the premaxilla could be reallocated to the tip instead. Someone who is looking for a sharp pointed tip and a strongly projected tip would probably need all the cartilage they can get at their disposal, I assume. This way, none of the scarce cartilage is wasted on the premaxilla and can be used solely for the tip. So the hypothetical plan might be that I have this ANS bone grafting done by my maxillofacial surgeon and then perhaps see a rhinoplasty surgeon like yourself afterward for a rhinoplasty consultation for a strictly nose-only job without worrying about the premaxilla/ANS. Do you agree on the logic of this and does this make sense to you, Dr. Lam?

2) This leads into what I'm looking for from the rhinoplasty. Here are some photos of my profile...

http://farm5.static.flickr.com/4067/447 ... d63c_o.jpg
http://farm3.static.flickr.com/2688/447 ... 2f05_o.jpg
http://farm5.static.flickr.com/4050/447 ... abf6_o.jpg
http://farm5.static.flickr.com/4022/447 ... 34a6_o.jpg

The first shot is how I look like currently. The second shot *might* be how I look like after the ANS bone grafting and I simulated this by pulling my columella forward with my fingers. Note the tethered pull at the subnasale and the slight concavity formed on the entire upper lip. In my opinion, curves and curls in the profile line soften up the appearance and is more aesthetically pleasing (notably - the subnasale, the upper lip concavity, the mentolabial fold, etc). For the third shot, I took the first photo and drew in pencil what I'm looking to achieve with rhinoplasty. The fourth shot is identical to the third shot plus notes. Note the slight elevation at the bridge and the upper dorsum. Didn't want to raise it too much since it would look unnatural on an Asian face. The dorsum should be straight until it gets to the part right above the tip at which point should be a noticeable supratip break. The tip itself should be projected and sharp like how I'd drawn, and should have good tip support. Not only is the tip projected outward but slightly downward too, which would lead to more columella show and decrease my nostril show from the front. I also drew in the tethered pull of the subnasale since that would be there by the time I do the rhinoplasty. So in a nutshell, I want to achieve these goals when viewed from the profile. Is this something you can do? Would I have enough cartilage from my septum and ear to achieve that kind of projection and sharpness, without going the rib route? I might want a slightly more projected tip but what I'd drawn is the minimum amount of projection I'm looking for. What I'd drawn probably has slightly more projection and sharpness than what you do for the average Asian patient. And for the bridge/upper dorsum, I suppose you use gortex or silicone (I or L type)?

3) From the frontal view, I would like to have osteotomy done on the nasal bones to reduce the width of the bridge. Maybe a slight general narrowing of the rest of the dorsum and tip too, but this is not so black/white, will have to see. And lastly, slight alar resection to bring in the alar base. I remember reading that you do alar base reductions and it was refreshing because I've heard many doctors refuse to do this since they lack experience and are worried they will leave massive exterior scarring.

I'm sure all aspects of #3 are easily doable. The main questions I had were if it made good sense to do #1 first and also, if the nasal profile described and shown in #2 is possible with just the septal and ear cartilage or other material at the rhinoplasty surgeon's disposal. With your corroborating and encouraging feedback, I would have a plan of action and would be worth making the trip all the way from NY to see you in the future, since you're one of the best in the business.

Thank you in advance for your feedback and for your time,
Paul

Here are my thoughts:
1. it makes sense that using a bone graft to conserve precious cartilage, which there already is very little in the Asian. however, looking at your premax region, to me it does not look as if you have a deficiency there. nevertheless, you should consult with your OMFS regarding it since i do not do that procedure.
2. as far as nasal tip work is concerned, i believe that a septal cartilage plus or minus ear cartilage graft will help. however, i do not like an overly pointy look that many people want using silicone implants. that is important to know.
3. narrowing the bridge with osteotomies is not feasible in an asian for many reasons. first, it simply does not narrow the bridge. second, it destabilizes the implant, third, it makes the tip larger looking. if you want that done, i may not be the right surgeon, but then again, i think what you want is not achievable.
4. alar base. i don't often do it simply because shape changes are often unfavorable and yes external scarring can be bad. i only do it in the right patient. if you squeeze in your sides, you may see that your nose tip looks more bulbous. unfortunately, many things we want may make our nose worse.
unfortunately, there are as many things that i won't do for you as i would possibly do for you. if you feel that i cannot deliver on those points based on my experience and philosophy, i am sure some surgeon would do it. i personally would not recommend it. honesty is the best front-end policy so that we can maintain a good relationship afterward.
best,
sml

Thanks for your honest answers Dr Lam, and I believe candidness is what makes a great doctor. Replying to your bullets...

1) Yes, I myself don't think I'm deficient in the premaxilla, but I just want to extend the ANS a small amount purely for personal cosmetic reasons. People have said to me that I appear chronically aggressive and angry (no, I'm not an angry person ) so I'm doing what I can to soften my appearance. The longer ANS would create a tethering into the nose and make a slight concavity in the upper lip region. This I believe would improve the aesthetics (again, personal opinion).
2) So are you saying that the pointy sharp tip that I drew is not achievable with just septum/ear cartilage alone, and I would need some kind of an implant in combination with the cartilages? Is it because septum/ear cartilage is insufficient or not strong enough? I guess people who naturally have sharp tips have strong cartilages built-into their tips? If implants are needed in my case, what kind of implant? Or were you just saying that you yourself don't do this pointy sharp implementation for patients because that's not what you do?
3 and 4) Thanks for your feedback.

Thank you,
Paul

1) speak with your OMFS and work with him on what you two believe is right for your premax. i do not want to do that for you but do not want to tell you it is right or wrong since i am not there with you and plus i don't really do the kind of procedure he does. if you do it, give it 3 to 6 months at least so that i can "read" your result and adjust my rhinoplasty (if not longer).
2) the best way to think of the nose tip is like a tentpole analogy. watch this video (http://www.lamfacialplastics.com/galler ... y.flv.html). the only way to make the tip super pointy is with a big silicone implant. i think they look really weird and fake. i rather achieve a softer more natural result with septum. septum plus or minus ear is the most natural way to go. with taping for 6 weeks to 3 months you should see some nice definition changes but the degree of supratip break (which i think looks a bit weird on a guy) and the sharpness with which you drew it looks too strong for my taste to fit your asian features. obviously, definition to a more limited degree is desirable.
best,
sml