Dr. Sam Lam Plastic Surgery Forum

Hello Dr Lam!
Hope all is well
I plan to visit you very soon for an African-American rhinoplasty. specifically I would like an alar base reduction ,a bridge implant , a reduction of the nose overall and a refinement to the tip. My questions are as follows:
1. For a nostril reduction do you make the incisons outside by the cheeks, or is it done a the base of the nose hiding visible scars?
2.For creating a nose bridge do you narrow the flat bone around the bridge itself or do you just add an impant. (I ask because the bones on the side of the bridge might still be flat but only the bridge would be raise making the nasal surface uneven.
3. What is your procedure for reshaping a bulbous nose tip and reducting the overall size of the nose?
4. Is Your rhinoplasty techniques usually open or closed? (I know It depends) and are there obvious rhinoplasty scars visible after any procedure?

Thank.

For a lip reduction, are you able to reduce the size of the "round area" in the middle of the upper lip? When the lip is reduced and that area isn't it may protrude out and become more visible.

MY ANSWERS ARE IN ALL CAPS:
1. For a nostril reduction do you make the incisons outside by the cheeks, or is it done a the base of the nose hiding visible scars?
I TEND NOT TO LIKE DOING IT IN MOST CASES BECAUSE THEY CAN MAKE THE NOSE LOOK UNNATURAL. IF I DO IT FROM THE INSIDE, IT WILL NARROW THE NOSE BUT FLARE THE EDGES OUT MORE. I THINK IN YOUR CASE, THE INSIDE APPROACH CONSERVATIVELY SHOULD BE FINE BUT I NEED TO SEE IT. IF I CAN AT ALL AVOID THE OUTSIDE APPROACH, THE BETTER. ANOTHER METHOD THAT I USE TO FIX THE SIDES IS BY ACTUALLY NOT FIXING THEM, THAT IS, IF I BUILD THE CENTRAL TIP FORWARD SLIGHTLY, IT MAKES THE SIDES SMALLER LOOKING. AGAIN, THE RIGHT BALANCE IS GOING TO BE WHAT I SEE IN PERSON.
2.For creating a nose bridge do you narrow the flat bone around the bridge itself or do you just add an impant. (I ask because the bones on the side of the bridge might still be flat but only the bridge would be raise making the nasal surface uneven.
IT DEPENDS ON THE PERSON. I THINK IN THE PHOTO YOU GAVE ME JUST AN IMPLANT. A HUGE REASON AND A HUGE FAILURE IN AFRICAN AMERICANS IS THINKING THAT OSTEOTOMIES (BONE BREAKING) WILL LEAD TO NARROWING OF THE NOSE. IT TYPICALLY DOES NOT FOR 2 REASONS. FIRST, THE INSERTION OF THE BONE TO THE BONY SKULL IS AT A VERY WIDE POSITION TYPICALLY AND THE NARROWNESS DOES NOT OCCUR SIGNIFICANTLY. FORTUNATELY, YOURS DOES NOT LOOK THAT WIDE TO BEGIN WITH BUT AGAIN I NEED TO SEE IT. THE SECOND REASON IS THAT WITH A WIDE NASAL BASE, NARROWING THE NOSE BRIDGE CAN MAKE THE TIP LOOK EVEN MORE DISPROPORTIONATELY FLARED.
3. What is your procedure for reshaping a bulbous nose tip and reducting the overall size of the nose?
GENERALLY, WITH THICKER NASAL SKIN AND WITH A WIDE NASAL BASE, TRADITIONAL CAUCASIAN TECHNIQUES OF DOME BINDING AND NARROWING FAIL FOR TWO REASONS. FIRST, THE THICK SKIN PREVENTS ONE FROM SEEING THE FAVORABLE CHANGES UNDERNEATH. SECOND, IT CAUSES TIP ROTATION MAKING THE NOSTRIL FLARE MORE APPARENT. I TEND TO USE CARTILAGE GRAFTS FROM THE NOSE (WHICH IS TYPICALLY NOT SAFE FOR THE WHITE NOSE BUT IN MY OPINION THE ONLY WAY TO GO IN ABOUT 80% OF AFRICAN AMERICAN PATIENTS) THAT CAN EXTEND A WEAKER COLUMELLA/PREMAXILLA (BOTTOM CENTER OF THE NOSE) AND CREATE A DIFFERENTIAL BETWEEN THE UPPER BULBOUS AND ROUND PART AND MAKE THE TIP MORE DEFINED WHERE TIP DEFINING POINTS SHOULD BE. AT TIMES, I DO NARROW THE UPPER BULBOSITY DEPENDING ON HOW THE SKIN FEELS AND WHETHER I CAN GET A WAY WITH IT. USUALLY I CAN. BUT THAT IS NOT THE CORRECT PRIMARY METHOD TO IMPROVE THE UPPER PART OF THE NASAL TIP.
4. Is Your rhinoplasty techniques usually open or closed? (I know It depends) and are there obvious rhinoplasty scars visible after any procedure?
TYPICALLY OPEN BECAUSE GRAFTING PROCEDURES ARE VERY HARD TO GET DEAD ON RIGHT WITH A CLOSED TECHNIQUE. PUTTING THEM IN IN A BLIND POCKET ALLOWS THEM TO SHIFT AND MAKES IT VERY HARD TO SECURE APPROPRIATELY. I LIKE TO SEE THE IMPLANT, TIP GRAFT, AND CARTILAGE SHAVE ARE ALL AS PERFECT AS I CAN UNDER DIRECT VISION. THE INCISION SHOULD HEAL IMPERCEPTIBLY.
For a lip reduction, are you able to reduce the size of the "round area" in the middle of the upper lip? When the lip is reduced and that area isn't it may protrude out and become more visible.
I CAN REDUCE ALMOST ANY PART OF THE LIP. YES, THE CENTRAL LIP CAN BE REDUCED TO MAKE IT LOOK LESS ROUND AND PROTUBERANT. IT SHOULD NOT MAKE IT PROTRUDE MORE BUT IT SHOULD MAKE IT PROTRUDE LESS.
hope that helps as a start.
best wishes,
sml

Hello again and thanks for your response.
I would have to opt for the incisions to be done on the inside, after all why would anyone want nose job scars lol...it would hard to deny it I also did not follow when you said doing the nostril reduction fron the inside would flare out the edges. what edges?
I would also prefer that the bones around the bridge to be flatened because they are raised.
I mention this becaus i want my nose be the most defined. I fear that if I get just an implant the sides of the nose might still not look separate from the bridge. In short, I want my nose to stand out and look define, and I don't want it to look so "connected"to the sides.
The picture can only depict so much. I am going to come in for a consultation and are you available this summer like July or August? My last concern I have is the nasal tip, and you did explain it well but it is possible to get rid of the bulbousness completly?

Thanks.

hi,
let me see you to decide. i am booked into the summer for consultations so please schedule as soon as you can. as far reducing the bone i really have to see you to see if it is right for you. it is very hard to tell from a photo. an implant btw should not disconnect the sides or the tip. it blends seamlessly. if i draw the sides in from the nasal sill (in the nose) the outer edge of the nose can flare outward a bit more. if you don't understand this, i really have to show you in person. it is very hard to discuss subtle nasal anatomy and techniques in a written forum.
best,
sml