Dr. Sam Lam Plastic Surgery Forum

Hi Dr. Lam,

I would really like to narrow the overall look of my nose from a frontal view and am considering doing some alar/nasal sill reduction and tip-plasty. As for the bridge, it is already at a good height (though a bit wide) and I really do not want to have an implant put in if possible, so I was wondering if it's still feasible to reduce the width of my nose with an osteotomy instead.

Thank you.

Great question! When it comes to ethnic rhinoplasty (for example for Asians, Hispanics, and African-Americans) who have a broad nasal tip, the #1 thing you want to avoid is osteotomies if the tip is very wide. Narrowing the nasal bridge will make the nasal tip look significantly bigger.

Remember that balance between the tip and the bridge of the nose is how we perceive the size of a nose. A broad tip will be made to look significantly broader if the bridge is relatively reduced in size.

For Asians and African-Americans, I rarely perform osteotomies. In Hispanics that have more Caucasian features (i.e., nasal hump, etc.) I frequently perform osteotomies. In Hispanics with more African/Asian features, I don't. In Caucasians, I most often perform osteotomies.

Besides narrowing the nasal tip to make the nasal tip look smaller, I generally make the bridge higher (while preserving ethnicity) to make the nose look thinner. How is this possible? Two ways: 1) as mentioned the bridge is now relatively bigger compared with the nasal tip making the tip look smaller, 2) when the bridge is raised it is raised slightly toward the center so that the bridge appears narrower. If you don't understand point#2, think of it this way: imagine a pyramid with the top 1/3 cut off. It looks wide because it is flat. Now, put the cap back on the pyramid, with a narrower cap, the entire pyramid of the bridge looks smaller even though the nose is "larger".

That being said, I do not always need to raise the bridge. All of this requires artistry and judgment, and I would have to see you in person to make that decision. Osteotomies are too often performed for ethnic rhinoplasty and in many cases ostetomies make the situation much worse rather than better.

Best,
SML

Dr Lam,

Is there ways of making a tip narrower and less fleshy looking without performing alarplasty? My doctor told me he sewed the two sides of my nose together (i dont remember exactly) and tip skin thinning that will make my nose narrower. He told me i didnt need alar and i also dont want it done because im scared of a pinched looking nose. But i feel my nostrils are just as wide as before, and my nostrils look somehow more flared than before.

What your doctor has done is what I usually do to narrow the appearance of a nasal tip. I also tend to use cartilage grafts that project the nose forward more. I don't use these grafts on Caucasians in general because their thinner skin predisposes toward showing these grafts over time. In Asians, without them, it is hard to get much narrowing effect in general from just doing a tip narrowing procedure with skin thinning (at least in my opinion). That would be the only other maneuver that might be possible if not already done besides an alarplasty.

Dr. Lam,

How do you decide when to use septal or ear cartilage? Do you make your choice before or during surgery? I've heard from other PS that ear cartilage tends to curl

Thanks.

I prefer septal cartilage for most cases because I try not to use ear cartilage if I don't need to. For a tip graft that projects the tip forward like a diving board, septal cartilage is much more rigid. However, for onlay grafts to the nose, ear cartilage is softer and rounder and not as good for structure but better to match the natural curvature of the lower lateral cartilages. I still try to get septal cartilage as a first desire if it has not been taken as I think it is higher quality cartilage for long-term maintenance.
best,
sml