Nose Reshaping (Rhinoplasty)
Los Angeles Rhinoplasty Surgeon – Dr. Vladimir Grigoryants
Most of Dr. Vladimir Grigoryants’ Los Angeles plastic surgery practice is dedicated to cosmetic and functional rhinoplasty, including primary and revision rhinoplasty. Dr. Grigoryants performs rhinoplasty surgery every day, Monday through Friday, giving him extensive experience with a wide range of nasal anatomy, cosmetic concerns, breathing problems, and complex revision cases.
Rhinoplasty is one of the most technically demanding procedures in plastic surgery. Changes measured in millimeters can significantly affect not only the appearance of the nose, but also its structural support and the patient’s ability to breathe. For patients searching for the best rhinoplasty surgeon in Los Angeles for their individual needs, important considerations include how frequently the surgeon performs rhinoplasty, the surgeon’s actual before-and-after results, experience with different surgical techniques, and expertise in both the appearance and function of the nose.
Dr. Grigoryants has extensive experience performing both closed and open rhinoplasty, as well as cosmetic and functional nasal surgery. Rather than relying on one approach for every patient, he selects the surgical technique based on each patient’s anatomy, skin thickness, previous surgery, airway, and desired result.
His goal is to create a natural-looking nose that is in better balance with the patient’s face while preserving or improving nasal breathing whenever indicated.
Closed Rhinoplasty and Open Rhinoplasty
The two principal surgical approaches to rhinoplasty are closed rhinoplasty and open rhinoplasty.
Dr. Grigoryants has extensive experience with both.
Closed Rhinoplasty – Scarless Rhinoplasty
Dr. Grigoryants is particularly experienced in closed rhinoplasty, also known as endonasal or “scarless” rhinoplasty.
Importantly, Dr. Grigoryants’ closed rhinoplasty technique should not be confused with older, more limited closed rhinoplasty techniques. Using his approach, Dr. Grigoryants performs detailed nasal tip reshaping, dorsal reshaping, cartilage modification, graft placement, and structural support under direct visualization, just as in open rhinoplasty.
The important difference is that this can often be accomplished without making an external incision across the columella. This avoids a columellar scar, which can be noticeable in some patients and may be particularly undesirable in patients prone to visible or thickened scarring.
During closed rhinoplasty, surgical incisions are placed inside the nostrils. There is therefore no external incision across the columella, the strip of tissue between the nostrils.
Over many years of performing rhinoplasty, Dr. Grigoryants has refined closed rhinoplasty techniques that allow him to perform substantial reshaping of the nasal bridge and tip, as well as functional nasal airway surgery, through internal incisions.
Depending on the patient’s anatomy, closed rhinoplasty can be used for:
- dorsal hump reduction
- nasal bone reshaping and narrowing
- tip narrowing and refinement
- tip elevation or repositioning
- correction of certain nasal asymmetries
- septoplasty
- cartilage grafting
- nasal valve reconstruction
- selected primary and revision rhinoplasty procedures
Open Rhinoplasty
Dr. Grigoryants also performs open rhinoplasty. Open rhinoplasty uses an incision across the columella in addition to internal nasal incisions. This allows exposure of the underlying nasal framework and may be beneficial in certain complex primary rhinoplasty cases and revision procedures involving substantial scar tissue or structural abnormalities.
Because Dr. Grigoryants performs both open and closed rhinoplasty, the operation can be selected according to the patient’s needs rather than requiring every patient to undergo the same surgical approach.
The decision between closed and open rhinoplasty is individualized based on the patient’s anatomy, previous surgery, scar tissue, skin thickness, functional problems, and desired changes.
Cosmetic and Functional Rhinoplasty
Dr. Grigoryants believes that rhinoplasty should address both appearance and function. For this reason, Dr. Grigoryants evaluates the internal nasal airway as well as the external appearance of the nose when planning rhinoplasty.
Dr. Grigoryants frequently performs revision rhinoplasty on patients who underwent previous nasal surgery elsewhere. In some of these cases, he finds substantial septal deviation or other structural issues blocking the airways, which were not addressed in previous surgery.
Depending on the patient’s anatomy and symptoms, functional nasal surgery performed with rhinoplasty may include:
Septoplasty
The nasal septum separates the two nasal passages. A significantly deviated septum can narrow one or both sides of the nose and interfere with breathing. When indicated, Dr. Grigoryants corrects significant septal deviation during rhinoplasty to improve the nasal airway.
Turbinate Reduction
The inferior turbinates are structures along the side walls of the nasal passages. They consist of bone covered by vascular soft tissue and naturally enlarge and shrink. In some patients, enlarged turbinates contribute substantially to nasal obstruction. When appropriate, Dr. Grigoryants reduces the inferior turbinates while avoiding unnecessarily aggressive removal of turbinate tissue.
Nasal Valve Reconstruction and Spreader Grafts
The internal nasal valve is one of the narrowest areas of the nasal airway. Narrowing or weakness of this region can cause significant difficulty breathing. Spreader grafts are strips of the patient’s own cartilage that can be placed alongside the septum to support or reconstruct the internal nasal valve. Spreader grafts may also be used to maintain smooth dorsal aesthetic lines and provide structural support following certain types of nasal bridge reshaping.
Revision Rhinoplasty Surgeon in Los Angeles
Revision rhinoplasty is generally more complex than primary rhinoplasty because previous surgery has already altered the anatomy of the nose.
Revision patients may have:
- scar tissue
- missing or weakened cartilage
- altered nasal support
- persistent asymmetry
- residual dorsal irregularities
- septal deviation
- nasal valve narrowing or collapse
- difficulty breathing
- cosmetic changes they would like corrected
Dr. Grigoryants frequently performs revision rhinoplasty in Los Angeles, treating patients who previously underwent rhinoplasty elsewhere as well as patients who have undergone more than one previous nasal operation.
He performs revision rhinoplasty using both closed and open techniques. Some patients who previously underwent open rhinoplasty can be revised using a closed approach. Other patients, particularly those with extensive scar tissue, multiple previous operations, or complex structural problems, may benefit from open revision rhinoplasty. The approach is selected according to what needs to be corrected.
Rhinoplasty for Patients With Thick Skin
Thick nasal skin presents particular challenges in rhinoplasty. Skin thickness affects how much underlying cartilage definition will ultimately be visible and can limit how small or sharply defined the nasal tip can realistically become.
Patients with thick skin may also experience more prolonged postoperative swelling.Dr. Grigoryants has developed techniques for rhinoplasty in patients with thick nasal skin. His work involving techniques to improve rhinoplasty outcomes in this group of patients was published in Aesthetic Plastic Surgery in 2013.During consultation, Dr. Grigoryants discusses how skin thickness may affect the achievable result and the expected healing process.
Ethnic and Middle Eastern Rhinoplasty in Los Angeles
Dr. Grigoryants treats a diverse rhinoplasty patient population.
His patients have included individuals of Armenian, Iranian, Middle Eastern, Mediterranean, Pakistani, Indian, Afghan, African American, Hispanic, and many other backgrounds. Ethnic rhinoplasty does not mean creating a particular “ethnic nose.” Many patients want to improve certain features while preserving characteristics that are important to their appearance, family resemblance, or ethnic identity. Dr. Grigoryants individualizes rhinoplasty according to each patient’s anatomy, facial proportions, preferences, and desired degree of change.
The objective is a nose that looks natural and harmonious with the patient’s face, rather than one that looks like the same operation has been performed on every patient.
Rhinoplasty Trusted by Physicians and Plastic Surgeons
Dr. Grigoryants’ rhinoplasty patients travel to his Los Angeles-area practice from throughout Southern California, across the United States, and internationally. His rhinoplasty patients have included celebrities, athletes, physicians, and members of physicians’ families. Other physicians and plastic surgeons have also entrusted Dr. Grigoryants with the rhinoplasty care of their close relatives. For a surgeon, being selected to operate on another physician’s or plastic surgeon’s family member represents a particularly meaningful expression of professional confidence.
Dr. Grigoryants was selected as the rhinoplasty surgeon featured on Season 3 of The Real Housewives of Beverly Hills and has appeared on HLN/CNN as a Los Angeles plastic surgery specialist.
Rhinoplasty in a Hospital-Affiliated Surgery Center
Rhinoplasty is elective surgery, but it is still surgery. Dr. Grigoryants believes that the environment in which surgery and anesthesia are performed is an important consideration. Dr. Grigoryants performs his rhinoplasty procedures primarily in a hospital-affiliated surgery center with modern operating-room and anesthesia equipment, experienced surgical personnel, and established patient-safety protocols. Anesthesia is administered and monitored by experienced physician anesthesiologists.
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FREQUENTLY ASKED QUESTIONS ABOUT RHINOPLASTY
What is the process once I have decided to have rhinoplasty?
You would first meet with Dr. Grigoryants for an initial consultation. Dr. Grigoryants believes that for each patient, the rhinoplasty procedure needs to be individualized, as every person has a different nose. During your consultation, Dr. Grigoryants will evaluate your nose and facial features and, together with you, will decide what nose-reshaping changes to produce. The doctor will discuss your goals with you and examine your nose. He will also show you in the mirror, by covering, lifting, and narrowing parts of your nose, what result to anticipate. Dr. Grigoryants will meet with you again for a preoperative visit 2-3 weeks prior to surgery to review the rhinoplasty procedure and give you preoperative and postoperative instructions.
To schedule your rhinoplasty consultation with Dr. Grigoryants, please call our office at 818 396-5551 or email vgplasticsurg@gmail.com . It is best to speak with our office assistant directly or email our office. Please avoid leaving messages on our answering machine, as the messages sometimes are not clear.
Additionally, an initial rhinoplasty consultation can be done virtually. Please email your face pictures (front, side, and bottom views) to Dr. Grigoryants at vladgrigor@gmail.com , and he will reply to you with more information.
Why closed rhinoplasty?
Dr. Grigoryants prefers closed rhinoplasty as it allows to reshape the nose without a visible scar across the columella. Dorsal hump and tip reshaping is done through incisions placed inside the nose. Dr. Grigoryants has improved the closed rhinoplasty techniques, which allow him to perform reshaping of the tip and dorsum and perform functional nasal airway surgery all under direct vision. Furthermore, since the nasal skin is not lifted (as in open rhinoplasty), Dr. Grigoryants finds that closed rhinoplasty results are more predictable and consistent. Healing is easier after closed rhinoplasty than after open rhinoplasty.
In open rhinoplasty, a cut is made across the columella, and the skin of the nose is lifted. The columella scar healing is not always predictable. In many patients, especially patients with thicker skin such as ethnic patients ( e.g., Middle Eastern, Mediterranean, Hispanic, etc.), the columella scar results in a visible notch and thickening of the skin in front of the scar. We see this frequently in patients who come to us for revision rhinoplasty. Revision surgery after open rhinoplasty tends to be more difficult than after closed rhinoplasty. In many patients who underwent previous open rhinoplasty, Dr. Grigoryants will frequently perform revisions using closed techniques. However, in some patients with very scarred tips after several previous surgeries, he would perform open rhinoplasty.
The goals of rhinoplasty
In general, the goals of rhinoplasty are to produce a nose that appears natural and in better balance with the rest of the face, as well as to maintain or improve nasal airways. For each patient, the specific goals will be discussed as to the degree of nasal narrowing, lifting of the tip (if at all), achieving a straight vs. sloped profile (and how sloped), columella position, any possible nostril narrowing, etc.
Will computer imaging be used?
Although Dr. Grigoryants does use computer imaging and Photoshop to show what can be done with the nose, he finds that this method of predicting the surgical outcome is not reliable. Many patients have come to our practice from elsewhere, complaining that their surgical results look nothing like their preoperative imaging. Surgical outcome depends on the surgeon’s skill and experience, the patient’s skin/bone/cartilage thickness, and the forces of postoperative healing. Photoshop does not take into account any of these. It is more important to see the surgeon’s actual results, and as many as possible, to decide what the surgeon may be able to do for you. We believe that a surgeon’s rhinoplasty volume and consistently good surgical results are the two most important factors for achieving a successful outcome.
Patient 1: This patient exemplifies how rhinoplasty techniques need to be customized for each person. Closed rhinoplasty was performed to produce very subtle changes including slight lifting of the tip and minor dorsal hump reduction. This resulted in a natural shape of the nose. Incisions were placed inside the nose (endonasal rhinoplasty), leaving no visible scarring. More drastic nasal reshaping ( which works for many patients) would not be appropriate for this patient.
Where will my surgery be performed?
To assure the highest safety for his patients, Dr. Grigoryants performs surgery primarily at Glendale Adventist Hospital affiliated surgery center. This state-of-the-art facility provides not only the safest possible environment but also caring and friendly staff. Your anesthesia will be performed by experienced anesthesiologists (doctors). In most patients, we use general anesthesia for breast augmentation. However, local analgesia and sedation can be used in some patients.
How long does rhinoplasty surgery last?
This procedure lasts anywhere from 1 – 2.5 hours. Revision rhinoplasty may last longer.
What happens after surgery?
Patients go home the same day after surgery. The next day Dr. Grigoryants will examine you and remove your dressing. The splint on your nose will be removed in 5-6 days after surgery.
Will nasal packing be used?
Dr. Grigoryants does not use nasal packing to avoid any unnecessary discomfort or pain.
When will I see the final result after rhinoplasty?
The nose will look better already as the most noticeable facial swelling will resolve in 10 days to two weeks. Swelling in the upper part of the nose goes away faster. Swelling in the lower half of the nose and tip takes longer to resolve. Typically, swelling will be 80-90% resolved by 12 months, around 90% by 18-24 months, and nearly all by three years after rhinoplasty. Although it is stated in other sources that the final result will be seen in one year, it is almost never true as mid-nasal area and the tip continues to shrink for at least two years after surgery. Patients with thick skin tend to have more pronounced swelling.
Patient 2: This patient underwent closed rhinoplasty to reshape the nose and open nasal airways. The resolution of swelling is evident as the tip appears well refined. It takes 1-2 years after surgery to achieve this type of shape. Visit our rhinoplasty Before and After photo gallery to view front and side views of this patient.
What about pain and bruising after rhinoplasty?
Most of our patients report no pain or only mild discomfort following nose reshaping surgery. Therefore, most patients do not take any pain medications (even though those will be provided for you). Some patients may have bruises which usually resolve within 7-10 days.
When can I start wearing glasses following rhinoplasty?
If reshaping of the bones is performed, then patients can usually resume wearing glasses in about 3- 4 weeks after surgery. However, if only tip reshaping is done, then glasses can be worn in 5-6 days after rhinoplasty.
Does medical insurance cover rhinoplasty?
Cosmetic rhinoplasty is not covered by insurance. Patients who have breathing problems through the nose may be eligible for insurance coverage for the medical or breathing improvement part of surgery. Coverage depends on the type of insurance.
What is done to open nasal airways?
Dr. Grigoryants opens nasal airways in almost every patient presenting for rhinoplasty, especially in patients complaining of nasal airway obstruction. The following important steps are typically taken to open nasal airways:
- Septoplasty. Most people have some degree of septal deviation. Significant septal deviation needs to be corrected surgically.
- Turbinate Reduction. Many patients have enlarged inferior turbinates. The turbinates are long structures on each side of the nose consisting of a bone (concha) covered with soft tissue that can enlarge and shrink. These turbinates enlarge and shrink throughout the day especially when lying down, in people with nasal allergies, or when ill with a cold. Enlarged turbinates frequently cause nasal airway obstruction. During surgery, the inferior turbinates are reduced in size. Aggressive reduction or removal of the turbinates is avoided to prevent the so-called empty nose syndrome (chronic dryness and inability to feel nasal airflow).
- Spreader grafts – Many patients with nasal airway obstruction have a narrow internal nasal valve and spreader grafts are used to reconstruct the internal nasal valve. Spreader grafts are strips of the patient’s own cartilage that are placed on each side of the septum ( between the septum and the side wall). The cartilage for spreader grafts is usually obtained from the patient’s septum. Spreader grafts are very important to prevent midnasal collapse (also known as an internal valve collapse or inverted V deformity) in rhinoplasty.
Furthermore, in nearly all cases when dorsal hump reduction is performed, the spreader grafts must be used to preserve the smooth dorsal aesthetic lines ( smooth lines on each side of the bridge of the nose, from the forehead to the tip) and prevent midnasal collapse. See the patient below.
Can nose reshaping be combined with other procedures?
Yes. Many patients combine rhinoplasty with other plastic surgery procedures such as breast augmentation, liposuction, tummy tuck, eyelid surgery, brow lift, or labiaplasty (labia reduction).
In this patient rhinoplasty and ear reshaping (otoplasty was performed at the same time). The crooked appearance of the nose was improved, deviated septum corrected, the tip narrowed and lifted, the dorsal hump reduced, and the ears reshaped. The patient’s nose and ears appear natural and in a better balance with the rest of the face.
What if I have thick nasal skin?
Patients with thick nasal skin represent a challenging group of rhinoplasty patients. Thick nasal skin limits how much smaller the size of the tip can be made. Dr. Grigoryants introduced some of his own techniques to improve rhinoplasty outcomes in this group of patients. His techniques were published in Aesthetic Plastic Surgery Journal, June, 2013.
Does Dr. Grigoryants perform ethnic rhinoplasty or Middle Eastern rhinoplasty?
Patients come to Dr. Grigoryants for rhinoplasty from various parts of the world and different ethnic backgrounds. Therefore, Dr. Grigoryants has a very diverse mix of rhinoplasty patients. Many patients are ethnic / Middle Eastern including Armenian, Iranian, Pakistani, Indian, Afghan, African American, and others.
Patient 3: Closed rhinoplasty was performed on this Middle Eastern patient. The drooping tip was raised, the dorsal hump removed, and the nostrils narrowed and shortened. Visit our rhinoplasty photo gallery to view additional views of this patient.
Postoperative Instructions
The following instructions are given to Dr. Grigoryants’ patients after rhinoplasty. These instructions may be modified for each patient depending on what was performed during surgery.
First day after surgery: Keep your upper back elevated 30-40 degrees. Apply a cold compress (cloth soaked in cold water or crushed ice in a glove placed over a cloth) during the first 24 hours. Avoid applying anything frozen directly on the skin. Start taking antibiotics (prescribed by Dr. Grigoryants) the same evening and prescribed pain and nausea medications as needed (read instruction labels on the medications).
Facial swelling tends to get worse during the first 3 days after surgery and improves by the fifth day after surgery. Call Dr. Grigoryants’ office to schedule your postoperative appointment 5-7 after surgery.
Starting day 3 : Start cleaning the bottom of the nose gently using cotton balls or facial tissue soaked in warm water. Apply Vaseline on the rims of the nostrils once a day. Do not put Q-tips inside the nose.
Day 5-7: Dr. Grigoryants will remove your splints and sutures if your nostrils were narrowed. Having the nostrils lubricated with vaseline prior to the appointment will make suture removal less uncomfortable. Dr. Grigoryants does not use nasal packing.
– Irrigate the nose with saline spray (also known as Ocean spray). Apply Vaseline inside the nose at night for two weeks using a corner of an open paper napkin rolled into a cylindrical shape (Q-tips are too stiff and may cause injury). Sutures and dry secretions/dry blood will come out. Breathing will improve.
– Tape your nose only at night. Although taping will not affect the final result, it will help minimize swelling that develops overnight during the early postoperative period.
– Avoid alcohol and blood thinners (aspirin, Motrin, Advil, Excedrin, naproxen, ibuprofen, vitamin E, fish oil, omega 3 fatty acids, herbal supplements ) for 2 weeks after surgery.
– Showers, makeup, and facial creams can be restarted.
Nose blowing: Can be started gently 3 weeks after surgery.
Driving: You may drive when facial swelling is not impairing vision and you are no longer taking pain medications.
Exercises: Avoid bending for 2 weeks after surgery. Exercises can be resumed 1 month after surgery.
Swimming: Swimming with a submerged head in the water can be started 2 months after surgery.
Sun exposure: You may be in the sun but avoid prolonged exposure. Use a hat to protect your nose.
Pore strips: May be resumed 3 months after surgery.
Unpleasant smell in the nose: This may occur in some patients after rhinoplasty and will go away over time.
Stiff upper lip and smile: Usually resolves by 2-3 months after surgery.
Flying on airplanes: You may fly 7 days after surgery. Dr. Grigoryants will review special in-flight care instructions with you.
Does Dr. Grigoryants perform revision rhinoplasty?
Revision rhinoplasty is frequently performed by Dr. Grigoryants and his revision rhinoplasty patients come from various parts of the world. Dr. Grigoryants will carefully assess who would benefit from revision rhinoplasty and wether closed or open rhinoplasty techniques would be used.
An example below illustrates a patient who underwent open rhinoplasty elsewhere. She presented to us complaining of a crooked nose, residual dorsal hump, hanging columella. The patient also requested to preserve ethnic nasal features and not make the tip too narrow. Open revision rhinoplasty was performed. The results at 19 months after surgery are shown below.
