Question 1

What are Dr. Reish's aesthetic preferences for rhinoplasty results?

Accepted Answer

Dr. Reish focuses on achieving natural, refined rhinoplasty results that avoid the 'surgical stigma' of appearing obviously operated on. He cautions against overly defined, pinched, or 'Barbie nose' aesthetics, which he believes often lead to long-term complications such as pointy tips, asymmetry, and blanching cartilaginous spots.

Question 2

What are the long-term risks associated with overly aggressive rhinoplasty techniques or 'Barbie nose' aesthetics?

Accepted Answer

Overly aggressive rhinoplasty, often seen in 'Barbie nose' aesthetics, can lead to significant long-term issues. These include tips that become very pointy and overly pinched, twisting, asymmetric cartilage blanching, and an overall appearance that deteriorates significantly 1-2 years post-op. Once these issues are visible, they are very difficult to fix.

Question 3

What should patients prioritize when selecting a rhinoplasty surgeon?

Accepted Answer

Dr. Reish emphasizes that patients should always prioritize surgeons who provide real, long-term follow-up pictures (1-2 years post-op and beyond) on their website. These pictures should feature standardized lighting and backgrounds, showing all angles. He considers it a major red flag if a surgeon only posts on-table results, splint removal videos, or easily manipulated patient selfies without genuine long-term documentation.

Question 4

What are the expectations for complex revision rhinoplasty, particularly for severe cases like total nasal destruction or saddle nose deformity?

Accepted Answer

For patients with total nasal destruction or severe saddle nose deformity, Dr. Reish is upfront that he never promises complete fixation or a 'perfect' nose. However, significant improvements are possible with great technique. These complex cases often require multiple surgeries over several years to rebuild the entire nasal structure and restore normal function, a process Dr. Reish discusses transparently during the initial consultation.

Question 5

How does Dr. Reish refine a bulbous or over-projected nasal tip?

Accepted Answer

Dr. Reish addresses bulbous or over-projected nasal tips, which can be caused by thick skin or bowing lower lateral cartilages, using a combination of techniques. These often include nasal tip deprojection, lateral crural steal to imbricate tissue medially, and sometimes debulking soft tissue. He uses robust grafting, such as columellar strut grafts and soft fascial tip grafts (sometimes hybrid grafts of crushed cartilage with fascia), to tension and define the tip, achieving a natural, proportional look that is not overly rotated, pinched, or scooped out.

Question 6

How long does it typically take to see the final results of rhinoplasty, and what factors influence long-term stability?

Accepted Answer

While a nose may look great immediately after splint removal, the true long-term results of rhinoplasty, including potential issues like pointiness, asymmetry, over-projection, or blanching cartilage pressure spots, often become apparent 1-2 years after surgery once all swelling has resolved. Dr. Reish emphasizes that long-term results matter most, and the stability of the outcome is heavily influenced by the surgical technique, with approaches that avoid overly aggressive tip definition tending to yield better, more stable results over many years.

Question 7

What are blanching pressure points in the nasal tip after rhinoplasty, and how are they addressed?

Accepted Answer

Blanching pressure points, along with white knuckling cartilages and asymmetric spots in the nasal tip, are common long-term tell-tale signs of a surgical rhinoplasty that typically appear 1-2 years post-op, not immediately or at three months. Once visible, these issues are very difficult to fix. Dr. Reish's revision technique usually involves nasal tip deprojection to shorten the tip length and covering it with a hybrid tip graft (crushed cartilage covered with a fascial graft, sometimes mastoid fascia) to achieve a smoother, better long-term result.

Question 8

How long does it typically take to see the final results of a primary rhinoplasty, and what factors influence long-term stability?

Accepted Answer

While a nose may look great immediately after splint removal, the true long-term results of rhinoplasty, including potential issues like pointiness, asymmetry, over-projection, or blanching cartilage pressure spots, often become apparent 1-2 years after surgery once all swelling has resolved. Dr. Reish emphasizes that long-term results matter most, and the stability of the outcome is heavily influenced by the surgical technique, with approaches that avoid overly aggressive tip definition tending to yield better, more stable results over many years.

Question 9

How do you refine a bulbous nasal tip without making it look 'pinched' or unnatural?

Accepted Answer

Dr. Reish addresses bulbous or over-projected nasal tips, which can be caused by thick skin or bowing lower lateral cartilages, using a combination of techniques. These often include nasal tip deprojection, lateral crural steal to imbricate tissue medially, and sometimes debulking soft tissue. He uses robust grafting, such as columellar strut grafts and soft fascial tip grafts (sometimes hybrid grafts of crushed cartilage with fascia), to tension and define the tip, achieving a natural, proportional look that is not overly rotated, pinched, or scooped out.

Question 10

What are realistic expectations for improvement in a revision rhinoplasty, especially for complex cases?

Accepted Answer

For patients with total nasal destruction or severe saddle nose deformity, Dr. Reish is upfront that he never promises complete fixation or a 'perfect' nose. However, significant improvements are possible with great technique. These complex cases often require multiple surgeries over several years to rebuild the entire nasal structure and restore normal function, a process Dr. Reish discusses transparently during the initial consultation.

Question 11

What exactly is nasal tip deprojection, and who is an ideal candidate for this procedure?

Accepted Answer

Dr. Reish addresses bulbous or over-projected nasal tips, which can be caused by thick skin or bowing lower lateral cartilages, using a combination of techniques. These often include nasal tip deprojection, lateral crural steal to imbricate tissue medially, and sometimes debulking soft tissue. He uses robust grafting, such as columellar strut grafts and soft fascial tip grafts (sometimes hybrid grafts of crushed cartilage with fascia), to tension and define the tip, achieving a natural, proportional look that is not overly rotated, pinched, or scooped out.

Question 12

What causes blanching pressure points after rhinoplasty, and what are the treatment options?

Accepted Answer

Blanching pressure points, along with white knuckling cartilages and asymmetric spots in the nasal tip, are common long-term tell-tale signs of a surgical rhinoplasty that typically appear 1-2 years post-op, not immediately or at three months. Once visible, these issues are very difficult to fix. Dr. Reish's revision technique usually involves nasal tip deprojection to shorten the tip length and covering it with a hybrid tip graft (crushed cartilage covered with a fascial graft, sometimes mastoid fascia) to achieve a smoother, better long-term result.

Question 13

What does Dr. Reish say about their techniques?

Accepted Answer

Usually the technique I will use is a nasal tip deep projection to shorten the actual tip length and cover that with a hybrid tip graft.

Question 14

What does Dr. Reish say about what they specialize in?

Accepted Answer

The practice loves performing complex revision rhinoplasty for patients.

Question 15

What does Dr. Reish say about results?

Accepted Answer

We want to get rid of that surgical stigma of previous surgery where it just looks like a rhinoplasty. That is how I was able to achieve a natural look while still giving definition to the tip. "Barbie noses" tend to look significantly worse over the long term. Unfortunately when your rhinoplasty surgeon takes off your splint, and sometimes we've seen this in all these splint removal videos, and it looks so great, it can turn into a disaster at the one to two year mark.

Dr. Richard G. Reish, MD, FACS

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