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Rational Rhinoplasty ™


Customized Rhinoplasty

The rhinoplasty operation is a highly individualized and specifically customized procedure. Each patient desiring this operation has her or his own unique anatomy. More importantly, each patient has their own specific desires and goals in mind, which may be different from what the surgeon envisions. Therefore, it is essential that the surgeon recognizes the nuances of the anatomic differences among patients. Additionally, the surgeon must listen to the patient’s wishes and goals, often on more than one consultation, and within reason, give the patient the nose she or he desires.

Please find below before and after photos as well descriptions of a variety of male and female rhinoplasties that I performed recently. Each patient had specifically different anatomic features which required customized surgical maneuvers to achieve an excellent result. In addition to the anatomic variances, each patient had specific and individualized concerns and goals to be achieved. It behooves the surgeon to listen carefully, ask questions, look at photos of noses patients like, performing computer imaging, and develop a specific plan with the patient to achieve their cosmetic goal.

It is important to understand that achieving the kind of results you will see below, where each nose is specifically customized, requires years of experience, technical skill, and performing each operation thoughtfully and carefully. Rhinoplasty surgery must be “tailor made” to fit each individual face.  It is not a “cookie cutter”, assembly line type of operation. Rhinoplasty surgery requires extreme skill, years of thoughtful experience, and a caring physician.  These qualities are what Dr. Guida feels allows him to obtain such positive results with his rhinoplasty techniques.

Dr. Guida also has extensive experience achieving excellent results performing revision rhinoplasty. He has performed revision rhinoplasties from patients around the world for over twenty years. Just as with primary rhinoplasty, the revision rhinoplasty operation must be individualized, taking into consideration the patient’s goals, but also understanding as much as possible what transpired during the primary operation. Success in revision rhinoplasty surgery necessitates experience, understanding all aspects of rhinoplasty surgery, and having experience with major nasal reconstruction.




  • Fix traumatic fracture
  • Straighten crooked broken nasal bridge
  • Eliminate pronounced bump to yield a straight and less  projected bridge
  • Closed approach performed

This 20 year-old college student broke his nose in a sporting related injury. As a result, his breathing was much worse on the left side and the bridge of his nose became crooked and off center. Exam revealed a marked deviated nasal septum to the left blocking his breathing, and an in-fracture of the nasal bones on the right side and an out-fracture of the nasal bones on the left causing his nose to look crooked on a front view. On the 3/4 and side view, there was now a prominent, elevated bump which he did not have prior to the accident.

This young man came to see me with his mother and they wanted to fix the fractured nose and correct the breathing problem. Additionally, he wanted to improve the shape of his nose by reducing the overall size. Specifically, we agreed that I would remove the prominent bump, lower the bridge of the nose to reduce the projection, but to keep the bridge straight and masculine.  I would eliminate the “snarl look” or droop which occurred when smiling, but not overly rotate the tip. And I would center the fractured nasal bones and fix the deviated nasal septum to improve his breathing. The goal was to improve form and function but maintain a natural looking, masculine nose. 

Using a closed approach, the nasal bridge was lowered to achieve a straight dorsum, the fractured nasal bones were reset and centered, the deviated septum was straightened, and the nose was set back (less projection) and rotated up slightly to avoid the hook or droop when smiling. He healed very well. Now he breathes better and has a more balanced looking nose, which is still strong and masculine, but fits his facial features more appropriately. 



  • Reduce projection and bump, but leave some of the bump, at the request of patient and his family
  • He requested that no tip work be performed
  • Fix the deviated nasal septum and breathing problem
  • Closed approach utilized

This is an 18 year old gentleman who desired cosmetic and functional improvements to his nose. He wanted the new nose to be customized specifically for his face and he had specific requests. He and his parents did not want the cosmetic change to be much different than his original nose. Specifically, they requested that I do not completely remove the bump or convexity, but simply make it smaller and less pronounced. The patient and his parents did not want the bump completely eliminated.

The patient wanted to eliminate the “droop” when he smiled. He also wanted no change to the tip of his nose.

We met several times before his actual operation and discussed the possible cosmetic changes which were possible. Ultimately, we agreed to leave some of the bump on the bridge of his nose, eliminate the “hook” when smiling, make the overall nose smaller with less projection, and do no cosmetic change to the tip. Simultaneously, I would improve his nasal breathing as well by correcting a deviated nasal septum.

Using a closed approach, the dorsal bump was lowered to the level the patient and I agrees upon preoperatively, with care taken to leave a suggestion of a dorsal bump that was not so prominent. The tip cartilages were left alone so as not to change the appearance of his nose too much.  The hanging end of his septum was shaved to help rotate the tip up and his deviated nasal septum was corrected. 

It is now over a year after surgery and he is extremely pleased with the results, primarily because I took the time to listen to what he and his parents wanted to achieve. Then during the operation, I was able to give him the customized nose job he wanted. This led to a very happy patient and family. 



  • Complicated nasal anatomy with collapsed, concave and symmetric nasal tip cartilages causing bilateral nasal valve collapse
  • Pointy, collapsed, pinched nasal tip
  • Over projected, prominent, fractured, and crooked nasal bones and cartilages
  • Lack of tip support requiring columellar strut using a septal cartilage graft
  • Open approach required

This 33 year old police officer had a nose with complex anatomy requiring several more surgical steps than a routine reduction of a nasal fracture.  His nose had been broken in the past and he suffered from nasal obstruction from a fractured, deviated nasal septum. Additionally, he had congenital collapse and pinching of the nasal tip cartilages causing narrowing of the nasal airway and an unusual, pointy appearance to the tip with indents and shadowing on the sides. He also had very little tip support which caused his nose to droop downwards, even when he was not smiling.

He wanted to improve his nasal airway, reduce the nasal bone fractures, eliminate the bump on his nose, lift and deproject the tip, and to get rid of the pinched collapsed look of the tip cartilages. He wanted to maintain a masculine, strong look to the nose, but to bring it into more balance with the rest of his facial features.

Fixing this gentleman’s nose required an open approach in order to visualize the collapsed tip cartilages in their entirety and to insert a supporting strut of septal cartilage in his columella at the base of his nose to provide long term support.The bump on the bridge of his nose was lowered appropriately. The tip cartilages were fixed to eliminate the collapsed pinched look, the overall nose was lifted and set back, and a supportive strut was inserted to help maintain strength to the nose throughout his lifetime. He is very pleased with his new shape and function of his nose.



  • Over projected bridge and tip
  • Droopy tip that hangs down too much
  • Bulbous wide tip
  • Wide alar base
  • Open approach needed
  • Alar base resection
  • Chin implant

This 33 year-old gentleman felt his nose cosmetically was too big relative to the rest of his facial features. He did not like the round fullness and bulbousity of the nasal tip, the over projection and length of the overall nose, the wide alar base, and the droopiness when he smiled. There were many intertwining anatomic issue causing these cosmetic imbalances. After several discussions and reviewing the computer imaging, we agreed to make the nose smaller and thinner overall, from the bridge of the nose, down through the tip as well as narrowing the alar base. In addition, he wanted significant de-projection of the tip, which can only be achieved through an open approach. He also felt he had a recessed chin and he wanted a chin implant simultaneous to the rhinoplasty. 

An open rhinoplasty approach was used to achieve the above stated goals. The open approach allowed me to obtain better access to the entire tip cartilage to simultaneously deproject and rotate them appropriately. The bridge was lowered to a straight dorsum, eliminating the convexity and droopiness. The bridge and tip were also narrowed and an alar base resection was done, thus achieving a smaller, thinner nose that complemented his facial features better. This was enhanced with a moderately sized chin implant.

Over a year later, this gentleman has healed quite nicely, has a natural and masculine look with more appropriate and attractive facial features.



  • Crooked, widened bridge from traumatic fractured bones
  • Collapsed nasal dorsum
  • Asymmetric and collapsed nasal tip cartilages
  • Required cartilages grafts to reconstruct nasal valve region and depressed nasal bridge
  • Closed approach

This 25 year-old gentleman was a victim of an assault resulting in facial trauma and a broken nose. This causes an asymmetric, crooked nasal bridge, loss of tip support which exaggerated the size and droopiness of the tip cartilages, and a collapse of the lower part of his nose. His nasal septum was broken causing nasal obstruction.

He wanted to me to eliminate any signs of the trauma and broken nose, straighten the crooked bridge and tip, improve the breathing, fix the loss of support to the droopy tip while maintaining a straight, yet smaller and more balanced look to the nose.

A closed approach was utilized and the fractured nasal bones straightened to provide symmetry. The bridge has narrowed and the bump lowered.  The tip cartilages were reshaped providing less bulbousity and less fullness. Septal cartilage grafts were used to support the tip and collapsed lower 2/3 of the nose.

He healed nicely and has a handsomely shaped nose which functions much better as well.



  • Broken nose from several sporting related injuries, including boxing and baseball
  • Deviated and fractured nasal septum causing nasal obstruction
  • eliminate bump from broken nasal bones, fix the breathing, and make the nose smaller relative to his facial features
  • Maintain an natural, masculine look to nose while making bridge straight and overall nose smaller and less projected
  • Closed approach was used

This 16 year-old high school athlete broke his nose several times playing baseball and boxing. Because of the broken nasal bones, he developed a large, elevated bump over the bridge. This caused the nose to extend further from the rest of his facial features and droop a lot when he smiled. He also suffered from progressively worse nasal obstruction and sinus infections due to a fractured and deviated nasal septum.

The patient and his parents wanted the bump to be removed, to eliminate the “droopy tip” when he smiled, and to achieve a straight nasal bridge.  They also wanted the nose to be less projected and to be more proportional to his otherwise balanced nasal features. The key to the operation is achieving all of this while maintaining a straight, strong bridge that had a masculine, natural look and a nose that functioned better.

Using a closed approach, the bump was lower appropriately, the “hooked” look to the nose eliminated, the fractured nasal bones centered, and the deviated nasal septum and sinus passageways were fixed. He and his parents are very happy with the cosmetic and functional results of the surgery.



  • Cosmetically unhappy with the shape of his nose
  • Desires to eliminate the prominent bump on the bridge
  • Wants a shorter nose that does not droop when he smiles
  • Wants the tip elevated and more defined
  • Wants a significant difference, but a natural look

This is a 16 year-old high school student who came to see me with his parents to discuss having a nosejob. He was quite self-conscious about the shape of his nose. The nose was overall too big relative to his other facial features and was quite prominent on his face. There was a large bump on the bridge, a wide droopy tip, and very little support for the lower third of the nose. All of what he did not like about his nose was exaggerated when he smiled.

We performed computer imaging in the office and it became clear he wanted a much smaller, better proportioned nose that was more in balance with the rest of his facial features. He wanted to get rid of the bump completely, lift and narrow the tip, and to be reassured the nose would look great for decades without looking over done.

A closed approach was used and the above stated goals were achieved. The bump was removed, the tip lifted and softened and the nose narrowed.  In addition, a supportive columellar graft was used to prevent the tip from dropping as years went by. His postoperative pictures are a few years later. He is in college now and very happy with the results of his nose job.




  • traumatic break resulting in a prominent bump
  • desired a straight, natural bridge with strong tip support
  • lack of tip support requiring a columellar supportive strut
  • open approach

This 19 year old college student and athlete has a history of trauma to the nose causing a broken nose, elevated and crooked bump, and a very deviated nasal septum which completely blocked her nasal airway. In addition to not being able to breathe through her nose, she was not happy with the shape.  She did not like the prominent bump, the asymmetry of the bridge and tip, and the pronounced droop that occurred when she smiled. She has attractive facial features, but the nasal anatomy was out of balance with her otherwise well balanced facial features.

Exam revealed a palpable and visible nasal bone fractures and bump, a very crooked internal septal deviation, wide asymmetric tip cartilage and off-center, wide bony nasal bridge from the trauma. She also had very little tip support, making the droopy tip much worse with smiling.

Because of the tip asymmetry and lack of support, an open approach was used to achieve symmetry and definition of the tip cartilages and for precise insertion of a septal cartilage columellar strut.  Her dorsal bump was lowered significantly, the tip elevated, the bridge narrowed and the nasal obstruction fixed.

She healed quickly and nicely and has a significantly more balanced look to the facial features as well as a better functioning nose.



  • desired an overall smaller , more delicate nose with a subtle slope to the bridge
  • softer, more defined, and elevated nasal tip
  • closed approach

This is a 17 year-old high school student who did not like the shape of her nose. As she got older, she noticed that the bump was getting bigger and the tip seemed to droop more. It became obvious that the nose was too big for the rest of her facial features. I met several times with her and her parents and through conversations and computer imaging, we determined she would look best with a subtle feminine slope to the nasal bridge, a narrower bridge, and a more defined, narrower and uplifted tip.

Through a closed rhinoplasty approach, I was able to achieve the results the patient wanted. The ¾ and side view demonstrate the gentle, feminine slope to the bridge with appropriate rotation and deprojection. She is much more comfortable when taking photos and smiling and socializing with her friends. She and her family are very happy with results and the more balanced look to her facial features.



  • desired a slight feminine slope
  • had no tip support and requiring a supportive columellar cartilage strut
  • desired refinement and elevation of nasal tip
  • eliminate the “snarl look” or hanging down look of the tip, especially on smiling views
  • open approach

This is a 21 year-old woman who felt her nose was too large relative to the rest of her facial features and that on the front view it looked a bit crooked. She did not like the fact that it was so long and droopy, which became much worse when smiling. She disliked the flat, square look to the tip of her nose, especially on the ¾ view. Additionally, she had a deviated nasal septum blocking her breathing and a history of recurrent sinusitis.

She wanted the hook, bump, and droopiness eliminated and replaced with an elegant, slightly upturned nose. She also wanted a more defined tip and slight feminine slope to the bridge on the ¾ and side view. She also wanted the bridge centered but not too narrow, so as to maintain a natural appearance.

Because her exam revealed relatively weak droopy tip cartilages with little support, I performed an open approach in order to precisely place a supportive columellar strut using her own septal cartilage. Her tip cartilages were made less bulbous and more defined giving her the more elegant appearing tip while maintaining a natural look. The bridge was centered and lowered to a subtle feminine slope and lifted to eliminate her excessively droopy tip. During the operation, I also improved her nasal airway and endoscopically drained her sinus passageways. She is extremely happy with her new look.



  • wanted a much higher and narrower nasal dorsum, tip and alar base
  • requested an implant to achieve her desired look
  • open approach performed
  • alar base resection necessary

This is a 38 year-old Asian woman who did not like the flat, wide dorsum of her nose as well as the flattened, wide nasal tip. She desired a higher, narrower nasal bridge with slightly more definition to the tip and alar base without looking overdone. What bothered her most was the flattened wide look of her nose from the front and 3/4 view.

I expressed that a cartilage grafting from her septum or ear cartilage would not be enough to raise the bridge to the height she desired. The patient was opposed to using her own rib cartilage due to the scarring and painful recovery and she did not like the idea of using cadaver rib. Therefore, the best option was to use a synthetic nasal implant. The risks, limits, alternatives, and potential complications were explained to the patient. In order to achieve the look she wanted, we decided to use the implant, which I have used successfully in mnay other cases.

This procedure was done through an open approach. The implant was soaked in antibiotic solution before insertion. It was carved appropriately to give her the look she wanted. The tip cartilages were narrowed and an alar base resection was performed. This result was exactly what she wanted and she is very pleased with the results.



  • desired an overall smaller , more delicate nose with a subtle feminine slope to the bridge
  • softer, more defined, and elevated nasal tip
  • eliminate the droopy, hanging look to the tip
  • closed approach used

This is a 22 year old woman who did not like the fact that her nose seemed to be getting bigger as she got older. The bump on the bridge and the droopy look to the nasal tip seemed to be getting worse over the last several years. She also felt the bridge and tip were too wide for her otherwise petite nasal features. The features she disliked about her nose worsened when she smiled she became uncomfortable with her picture taken at certain angles.

She expressed that she wanted the bridge to have a slight feminine slope as opposed to a simply straight look. She felt this would give a more delicate look to her nose, and I agreed. She also wanted the bridge and tip to be narrower, though natural looking.

Through a closed approach, the bridge was lowered and narrowed and the tip given more definition. The tip also was rotated up nicely, which eliminated the downward “snarl look” that occurred when she smiled.

Her new nose is smaller, thinner, and fits her delicate petite features in a very attractive and natural manner. 



  • desired complete elimination of the prominent bump
  • wanted a straight nasal bridge with much less projection
  • desired a softer, more defined and narrower tip that looked natural
  • eliminate the “hook” or “snarl look”, especially when smiling
  • closed approach performed

This is a 22 year-old female with a nose that was too large for her facial proportions. It was over projected, extending too far from the rest of her face. There was a prominent bump on the bridge which hanged down even more when she smiled. She wanted a relatively straight nasal bridge, with complete elimination of the prominent bump that was so visible at all angles, especially on the ¾ and side view. Finally she desired more definition and elevation of the nasal tip with a soft, natural appearance.

A closed approach was performed to achieve the above stated goals. The bridge now has a straight, natural appearance that does not droop anymore, even when smiling. Overall the nose is smaller, more attractive, and better proportioned to the rest of her facial features. She is very pleased with the results.



  • traumatic nasal fracture resulting in significant collapse of the nasal bones and nasal airway
  • closed approach was utilized

This 20 year-old woman was a passenger in a car that was involved in a motor vehicle accident. This resulted in forceful fracture of her nasal bones and septum.  As seen in the photos, there was a marked in-fracture of the nasal bones on one side and an out-fracture on the other, giving her a very crooked and unusual look. Inside the nose, the septum was fractured and blocked her nasal airway.

All she wanted was her “old nose back” and for me to fix the fractured bones and cartilages so she looked as pretty as she did prior to the accident.  And she wanted to be able to breathe through her nose again.

Using a closed approach, the displaced and fractured nasal bones and cartilages were reset in the midline. The broken and deviated septum was straightened. She healed very well and is extremely happy with the results.



  • prominent bump on bridge of nose
  • flattened, poorly defined tip
  • closed approach performed

This is a 23 year-old Chinese woman who did not like the prominent bump on the bridge of her nose, which seemed to be getting larger as she got older.  She also did not like the flattened, square look to her tip cartilages which also seem to be widening more with time.

She desired a gentle feminine slope to the nose and more definition to the tip while maintaining a natural appearance.

A closed approach was done to obtain these changes in her nasal anatomy. The bump was lowered appropriately to give her the degree of slope she requested and the tip cartilages were altered to provide refinement without looking overdone. She is very happy with her now, natural looking nose.



  • overall, size of nose too big for her facial petite features
  • large, prominent dorsal bump
  • crooked nasal bridge
  • wide, droopy tip which hooked down more when she smiled
  • closed approach used

This is a 21 year-old female who felt her nose was too large for her facial features and which looked much worse when she smiled. She had a prominent bump on the bridge which was shifted to one side because of a deviated nasal septum. The tip cartilages were wide, lacked definition, and drooped downward when smiling. She wanted a feminine slope to the nose and an uplifted, youthful, more defined tip.

Using a closed approach, the bridge was lowered to give her the slope she wanted and to elevate the tip appropriately. The tip cartilages were given more definition and elevated to fit the new bridge. The deviated nasal septum was fixed to improve her nasal airway. 

She is very happy with her new nose, which has the gentle, feminine slope and tip definition and elevation that she wanted. 



  • overall width of bridge, tip, and nostrils too wide
  • has slight bump on bridge which she wants lowered
  • she wants a natural look that is narrower and more feminine, but not overdone
  • lack of tip support
  • open approach necessary

This is a 25 year-old woman who felt her entire nose was too wide for her facial features. She wanted the bridge, tip and nostrils narrowed and the bump lowered, but she desired a subtle look that was not overdone. She lacked support of the lower part of her nose, which required an open approach with a supportive cartilage strut.

Using an open approach, the bridge was lowered and narrowed appropriately, the tip cartilages were given more definition, a supportive cartilage strut was used between the tip cartilages, and an alar base resection was performed.

The results were exactly what she wanted – a distinct change without being overdone.  She healed nicely and is very happy with the result.



  • flattened, wide nasal bridge, tip, and nostrils
  • lack of tip support and definition
  • lack of projection of bridge and tip
  • required grafting to increase height of the nasal bridge
  • open approach necessary with supportive columellar cartilage struts

This is a 40 year-old woman who was unhappy with the overall shape of her nose. She felt the entire nose was too wide and flat from all views. She wanted to have a higher, narrower bridge and a more defined and narrower nasal tip and nostrils. Though she wanted the new shape to be distinctly different, she did not want to have an obvious, overdone look to the nose.

An open approach was needed for full exposure of the tip cartilages and for precise placement of the columellar support strut. The bridge was augmented with grafts to elevate and narrow the dorsum. The tip cartilages were reshaped to look narrower and an alar base resection was performed.

These multiple steps were done carefully and stepwise to ultimately change the shape of her nose to the new look she desired.  Several years of follow up later revealed a very happy patient.



  • prominence of a nasal bump
  • over projected bridge and tip
  • lack of tip definition  with flattened appearance
  • droopy tip, especially when smiling
  • closed approach used

This 22 year-old female was unhappy with the overall size and proportions of her nose. She disliked the prominent bump on the bridge and the hooked appearance when she smiled. She also did not like the square, flattened look to the nasal tip. She desired and more feminine slope to the bride, more definition and refinement to the tip, feminine rotation of the tip of her nose, and elimination of the “snarl look” when she smiled.

Using a closed approach, her cosmetic goals were achieved. The bridge was lowered to the height she wanted, with a subtle feminine slope. The tip is now more defined and refined without being pointy or pinched. The overall nose is less projected and rotated appropriately. 

This nose looks great now and will age well through the decades of her life, giving her the softer, more feminine look she desired.



  • prominent bump on bridge of nose
  • over projected nasal dorsum and tip
  • wide, bulbous tip
  • recessed chin giving accentuating the “weak appearance” to the face
  • closed approach utilized

This is a 25 year old woman who felt the size of her nose was too large relative to her otherwise delicate facial features.  She did not like the prominent bump, the over projected bridge, and the poorly defined and wide tip.  She desired a smaller and delicate nose with a feminine slope, less projection and more tip rotation.  She also felt her chin was set back too far and desired to have a chin implant.

A closed approach was used to lower and narrow the bridge appropriately, to refine and narrow the tip cartilages, and to adequately deproject rotate the tip and bridge to a more attractive level.  A chin implant was also inserted to balance out her facial features nicely.

Several years of follow up reveal that this patient has healed quite nicely and she is very pleased with her more balanced and proportioned facial features.

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