One of the earliest and most common facial cosmetic procedures, rhinoplasty is the art and science of restructuring the nose. Although it has been commonly referred to as a “nose job” since the 1960s, the term trivializes the difficulty of the procedure, which is widely acknowledged to be the most technically challenging of the facial cosmetic surgeries.
Rhinoplasty can correct deformities of the nose by removing, adding, and reshaping bone and cartilage to form a more pleasing appearance without compromising the function of the nose. While each patient has their own personal reasons for seeking the procedure, common reasons for rhinoplasty include removing bumps, reducing the size or width of the nose, and adjusting the shape of the tip. Deformities due to trauma or congenital defects can also be remedied, as can functional problems like difficulty breathing through the nose.
Since it is such a technically demanding procedure with very visible results, rhinoplasty requires an experienced surgeon. Dr. Bentkover is not only an experienced plastic surgeon but also a trained ear, nose, and throat specialist with a great deal of experience with both severe cosmetic issues and complex functional nasal problems.
Candidates for Rhinoplasty
Whether you are suffering from functional impairment or you’d like to refine your nose to fit your face better or create more definition, you are probably a good candidate for rhinoplasty. Ideally, prospective patients will understand that the goal of the procedure is improvement rather than perfection and that the final outcome of surgery cannot be predicted with absolute certainty. In addition, individual characteristics such as cartilage strength and skin thickness can affect the result.
To determine if you would like to proceed with the procedure, you’ll need to go through a consultation with Dr. Bentkover. This typically lasts from 1½ to 2 hours. To make the most of your time, you’ll want to bring any completed paperwork that we’ve sent you as well as relevant medical documents such as reports from any previous rhinoplasty. During the consultation, we’ll review your medical history and discuss any functional issues in addition to going over your current likes and dislikes about your nose. Dr. Bentkover will thoroughly examine your nose and airway to evaluate the shape and strength of the bones and cartilages.
After the examination, pictures will be taken of your face in order to digitally modify them on a computer so that you can get an idea of what can be achieved through surgery. Once you’ve settled on your goals for your rhinoplasty, Dr. Bentkover will also present diagrams of his plan for the procedure.
Once this part of the consultation is over, you’ll also meet with the aesthetic nurse to discuss concrete details about scheduling, costs, and preparation for surgery. Smoking must be avoided for at least a month before and after surgery to help with healing, and antibiotics will be provided to help avoid infection.
The Rhinoplasty Procedure
Since most rhinoplasties require intravenous sedation or general anesthesia, they are performed in the Day Surgery Unit at Saint Vincent Hospital in Worcester Medical Center in Worcester, MA. Sometimes they are also performed at the Massachusetts Eye and Ear Infirmary. Both facilities are comfortable, patient-friendly, and state-of-the-art, and there are several hotels just across the street for out-of-town patients. Touch-ups are typically done under local anesthesia in the office operating room in our suite at the Worcester Medical Center, Worcester, MA.
The surgery itself may be done with either a closed or open approach depending on the work to be done. While a closed, or endonasal, rhinoplasty requires no external incision, it does not allow the surgeon to see many of the internal structures of the nose, which can lead to an inferior result in complex cases. An open-approach rhinoplasty, in contrast, uses a small incision across the columella between the nostrils to allow full access. In most cases, Dr. Bentkover prefers an open approach, although this will be discussed in full during your consultation.
Once the incisions for either a closed or open rhinoplasty have been made, Dr. Bentkover will carefully reshape the cartilage and bone of your nose to refine its shape. Any augmentations will usually use cartilage from your own nasal septum to strengthen the new shape while preventing issues with your body rejecting the transplant. Once the shape is correct, the incisions will be closed.
Open vs. Closed (Endonasal) Rhinoplasty
The difference between the endonasal and open approaches is mostly structural and philosophical. Dr. Bentkover will choose the approach that he feels will give the best results in his hands. That is what is important. There is not one absolutely right way to do a rhinoplasty.
The incisions for an open rhinoplasty differ from the closed approach incisions only in the small incision that comes across the columella, the skin and cartilage between your nostrils. It is placed about 2/3 of the way down the columella, and is made so that it generally hides very well. It should not be an issue of concern. This is not an area that most people see.
The real difference between the two approaches is what the surgeon can see during the surgery and the how the cartilages and bone of the nose are modified. In most cases, Dr. Bentkover favors the open approach for primary rhinoplasties. If he needs to make a small modification to an operated nose, he may use a closed approach. Usually this is when the goal is just a bit more filing to take the profile down some or perhaps if he wants to add a small piece of cartilage to the tip or sidewall of the nose. Most of the noses he sees for revision (secondary) rhinoplasty, however, require an open approach in order to visualize all the problems in the nose and to replace large amounts of cartilage removed during the first or subsequent procedures.
Before your rhinoplasty, you will be given instructions for before and after the surgery to decrease your risk of bleeding, help alleviate any swelling, and increase your comfort. Most people are able to resume normal activities and resume to work within ten days, but we will monitor your recovery at one day, one week, two weeks and three weeks after surgery.
Immediately after surgery, we will apply a lightweight splint to help protect your nose. Soft silicone splints may also be inserted on either side of the septum and help in place by temporary sutures. Packing is normally unnecessary, and the splints will be removed a week after surgery. Pain is normally moderate and controlled easily with medication, but most patients experience some stuffiness for one to two weeks, but you may not blow your nose for three weeks. We do recommend a saline solution to help with dryness for up to six months after the procedure. Bruising is typically confined to the eye region and will start to fade within a few days, although this depends on your skin type. Other characteristics that affect your healing time include skin thickness, cartilage thickness, and the length of your nasal bones. Smokers also experience much longer healing times. To aid correct healing, patients should avoid cold-weather activities like skiing as well as any unprotected sun exposure for the first year after rhinoplasty.
While rhinoplasty is a safe procedure with very few complications, patients rarely do experience bleeding or infection. There is also a small possibility of loss of sense of smell. Although it has never occurred in Dr. Bentkover’s experience, there is also a very small documented risk of brain abscess and meningitis.
In a few cases, aesthetic complications like scar formation, uneven bone healing, and other bone irregularities can occur. As healing progresses, other patients may find themselves disappointed that the width of their nose has not been reduced or the tip refined as much as they had hoped. These cosmetic issues can be addressed at follow up appointments to determine if a touch up or revision might be in order.
Absolutely. Dr. Bentkover has a deep interest in the procedure and has spent his entire career studying it and refining his skills. In order to fully evaluate his results, he follows his patients for years after surgery and welcomes the most challenging cases. In addition to first time rhinoplasty, he also handles revision cases in patients from all over New England and the rest of the United States.
While perfection is certainly the goal, there are no guarantees in any surgery, so it is important to understand that the most realistic outcome is significant improvement. Prospective patients who will be severely bothered by mild irregularities or asymmetries after surgery are likely not good candidates for any cosmetic surgery. Constantly chasing perfection does not result in happy patients.
Although there are no guarantees with cosmetic surgery, Dr. Bentkover’s goal is always to give a good-looking and natural-looking nose rather than one that has an operated look. We invite you to view the rhinoplasty photos on this website to judge for yourself. During your consultation, you’ll have the opportunity to go over many more photos.
It would be nice, but insurance companies typically cover the surgeon’s fee, hospital fee, and anesthesia fee to correct functional problems only and do not cover voluntary cosmetic changes to the appearance of your nose. Any fees not covered by insurance are the responsibility of the patient.
While bruising is generally gone in a week and work resumed at around ten days after surgery, the swelling will not fully go away for up to six months, although it will not be noticeable to anyone but you and your surgeon. Some slight swelling around the tip of the nose may remain for up to 18 months. Some thinning can continue for two to four years or longer.
No, but 10% or more of performing an actual rhinoplasty procedure is unpredictable, which can cause changes due to scar formation and other factors that could not be predicted. Normally these adjustments are minimal and do not require revision, but a few cases may.
Not at all. A close-approach rhinoplasty leaves no external scars, and even an open-approach rhinoplasty only leaves a tiny mark at the base of the nose between the nostrils. Due to size and location, the scar is practically invisible. To reduce visibility even further, be sure to wear sunscreen when outdoors for at least the first year after surgery to prevent darkening.
Rhinoplasty is the art and science of restructuring the nose so that it looks and works better. It was one of the first facial aesthetic operations and is among those most frequently performed today. In rhinoplasty, deformities of the nose are corrected by removing, adding, rearranging, or reshaping cartilage and/or bone. It is the most complex and challenging of the facial operations. In rhinoplasty, form (appearance, style, the look) is always tied to function (the ability to breathe through the nose). In every rhinoplasty the experienced surgeon must make sure that changes in form do not compromise function and vice versa.
Some people refer to rhinoplasty as a “nose reshaping” or a “nose job”. To call such a sophisticated operation a “nose reshaping” or “nose job” misses the point. A surgeon cannot just “reshape” a nose. The surgeon must also pay attention to the airway and to strengthening the underlying bone and cartilage framework.
Yes. For Dr. Bentkover, Rhinoplasty is a true surgical passion. He as been an innovator in the field and welcomes the most difficult and challenging cases. He does primary (first time) and secondary (revision) rhinoplasty, treating patients from all over New England and other parts of the United States.
The difference between the “closed” and “open” approaches is structural and philosophical. It is not about the incision. The incision should not be an issue of concern. This is not an area that most people see. Usually only you, your surgeon, and perhaps your significant other will see the incision. between the two approaches is what the surgeon can see during the surgery and the how the cartilages of the nose are modified.
In the classic “closed” rhinoplasty, much of the operation is done without actually being able to see the tissues being modified.
Surgeons are taught to remove significant amounts of cartilage to narrow or “thin” the nasal tip. The surgeon may not be able to see pre-existing irregularities of the tip cartilages and bones that could become more apparent after surgery. Also, over time the areas where the cartilage was removed can be replaced by scar tissue that leads to twisting of the nasal tip and difficulty breathing.
The surgeon can see everything that needs to be modified. Also, the basic philosophical difference is that in an “open” rhinoplasty the surgeon usually removes less cartilage and generally adds structure to the nasal tip that strengthens the underlying architecture and prevents twisting and other adverse changes as you age. Most commonly the surgeon uses your own septal cartilage for these shaping and strengthening cartilage grafts.
In most cases, Dr. Bentkover favors the “open” approach. If he needs to make a small modification to an operated nose in a minor revision, he may use a “closed” approach to file the bones down a bit more or perhaps add a small piece of cartilage to fill a small post operative depression. (The reality of revision rhinoplasty, however, is that most often it requires an “open” approach to replace large amounts of cartilage removed during the first procedure.)
Dr. Bentkover’s goal is always to give you a natural looking nose, not a nose that has an operated look. While no surgeon can guarantee how your nose will look, we invite you to review the photos on this website and judge for yourself. We also have many more photos to show you at the time of the consultation. Dr. Bentkover takes great pride in his work and his patients are generally very happy. The art and science of rhinoplasty is a life long pursuit with changes in the field every year. If a surgeon’s results are not generally natural looking, it is very frustrating for the patients and the surgeon. If Dr. Bentkover’s noses consistently had an operated look, he would not be doing this operation.
I heard that if I have trouble breathing my insurance company will cover the cost of the operation. Is that true?
If you are truly have difficulty breathing through your nose, your insurance may cover the surgeon’s fee, hospital fee and anesthesia fee to improve these functional problems only. However, your insurance will not cover any part of the cosmetic rhinoplasty. You will be responsible for the surgeon’s cosmetic rhinoplasty fee, hospital fee and anesthesia fee in addition to what is billed to your insurance company for your functional surgery. As far as your insurance company is concerned, you are essentially having two operations, one functional and one cosmetic. They do not cover any of the costs associated with the cosmetic operation. Also, Dr. Bentkover will only bill your insurance company for functional surgery if you truly have a breathing problem. Unless you have sustained a fairly recent and medically documented injury to your nose that has severely disfigured your nose, your insurance company usually is not concerned about the overall appearance of your nose. They might cover the straightening of your nose within a few weeks of the incident and surgery to improve your breathing, but usually not other changes.
About an hour and a half. Dr. Bentkover will ask you what you do not like about your nose, examine your nose, photograph you himself, and do some simulated surgical planning with you on the computer. He will answer all of your questions. You will also spend some time with our aesthetic nurse. You may return for a second, shorter consultation at no charge, if you have more questions.
Generally, you will be black and blue around your eyes for 7-10 days or so. You can usually go back to work at 10 days. Much of the swelling will be gone in 3-6 weeks, but it takes months for all the swelling to go away. It goes away slowly, and most people you see will not realize your nose is still swollen. The nose is essentially healed at 18 months.
No. However, some surgeons estimate that 10-20% of the outcome of a rhinoplasty is unpredictable. Even the most carefully done rhinoplasty by the most experienced rhinoplasty surgeon may have some changes that, because of scar formation, could not be predicted. These changes are usually so minimal that they do not require revision, but some may (see our webpage on Revision Rhinoplasty).