Rhinoplasty

For Dr. Bentkover, Rhinoplasty is a Passion…

A Short Discussion of Rhinoplasty

What is Rhinoplasty?   Rhinoplasty is the art and science of restructuring the nose. It was one of the first facial aesthetic operations and is among those most frequently performed today. 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. It is arguably the most technically challenging of the facial operations. In rhinoplasty, deformities of the nose are corrected by removing, adding, rearranging, or reshaping cartilage and/or bone. Form (appearance, style, “the look”) is always tied to function (the ability to breathe through the nose). In every rhinoplasty, the experienced surgeon will try to make sure that changes in form do not compromise function and vice versa.

Photo before rhinoplasty
photos

Rhinoplasty is part structural engineering, part architecture and part sculpture. While there are some generally accepted parameters and measurement guidelines to which most facial plastic surgeons agree, each surgeon has his/her own aesthetics and philosophy about this operation. It is important that you and your surgeon agree on an overall approach to the desired look for your nose. Dr. Bentkover will discuss this with you extensively during the consultation.

Should I have a Rhinoplasty?  If you do not like the appearance of your nose and would like some refinement so that it fits your face a bit better, looks a bit softer, or perhaps has a bit more definition, the answer is probably yes.

The answer is “probably yes”, because it is impossible to absolutely predict the appearance of your nose after surgery and whether or not you will like the outcome of the surgery. As with any cosmetic procedure, the realistic goal is improvement. No surgeon can give you a perfect nose, and you cannot pick a nose out of magazine and ask the surgeon to give you that nose. Every person has individual characteristics that can affect healing and, hence, how your nose will look. Factors such as the thickness of your skin, the strength of the cartilages in your nose, and how well you breathe can affect the cosmetic outcome. You are a good candidate for cosmetic surgery if you understand that there is no such thing as a perfect result and understand the relative risks and benefits of the surgery. This is discussed more fully in the rest of this article.

Reasons for Surgery  The reasons for having a rhinoplasty are highly personal but commonly include reducing the size of the nose, removing a bump, narrowing the nose, straightening the nose and refining the shape of the tip. Deformities of the nose may be natural or due to trauma.
Difficulty breathing through your nose can be improved at the time of a rhinoplasty. The wall in the middle of your nose (the nasal septum) may be excessively crooked (a deviated septum). When you breathe in through your nose, you may find that one or both sides of your nose may collapse inward. This is called nasal valve collapse or nasal vestibular stenosis. Both of these conditions can be corrected at the time of a rhinoplasty. Removal of cartilage from the nose to change its shape can make nasal valve collapse worse or create nasal valve collapse. It is important that this be evaluated and discussed before surgery. If it is a real or potential issue, it should be corrected. Dr. Bentkover will carefully check your nasal airway and make recommendations on what might be needed to improve a less than ideal airway or preserve an otherwise reasonable airway. Dr. Bentkover is also trained as an ear, nose and throat specialist. He is very comfortable treating complex functional nasal problems. He gets referrals from other nasal specialists for these problems.

Does Dr. Bentkover specialize in rhinoplasty? Yes. For Dr. Bentkover, Rhinoplasty is a true surgical passion. He has spent his entire career studying this operation and honing his skills. Because he critically evaluates his results, he follows his patients for many years after surgery. Dr. Bentkover 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. By in large, our patients are very pleased with their results and the care they receive in our office. 

What is the difference between open and closed rhinoplasty? I am concerned about the incision.  The difference between the closed and open approaches is mostly structural and philosophical. It is not about the incision. A surgeon will choose the approach that he/she feels will give the best results in his/her hands. That is what is really important. There is not an absolute right way to do a rhinoplasty.

The incision for an open rhinoplasty should not be an issue of concern. It is placed about 2/3 of the way down the columella, the skin and cartilage between your nostrils, and is made so that it generally hides very well. This is not an area that most people see. Usually, only you, your surgeon, and perhaps your significant other will see the incision. Also, in both types of surgery, other small external incisions may be used to help narrow the nostrils or the bones. All of these incisions also usually hide very nicely.

The real difference between the two approaches is what the surgeon can see during the surgery and the how the cartilages of the nose are modified.

In an open approach rhinoplasty, the surgeon can clearly see everything that needs to be modified. Also, surgeons tend to use more “structural” cartilage grafts to strengthen and shape the underlying architecture. This helps prevent twisting and other adverse changes as you age. Most commonly, the surgeon uses cartilage from your own nasal septum for these grafts. Often, less cartilage is removed from the nasal tip than in commonly performed endonasal operations. Also, through an endonasal approach, a surgeon may not be able to see pre-existing irregularities of the tip cartilages and bones as well. These irregularities can become more apparent post operatively with the normal development of scar under the skin. Today, some of the same grafting techniques of open rhinoplasty can be applied to endonasal rhinoplasty. The real issue in choosing an approach to rhinoplasty is the amount of the nasal structure that needs to be visualized for any particular rhinoplasty and the degree to which it the architecture of the nose may need to be modified.

In most cases, Dr. Bentkover favors the open approach for his primary rhinoplasties. If he needs to make a small modification to an operated nose, he may use an endonasal approach. Usually this is when the goal is just a bit more filing to take the profile down some more or perhaps if he wants to add a small piece of cartilage to the tip or sidewall of the nose. Mo
st of the noses referred to Dr. Bentkover 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 procedure.

How long will I be in the office for the consultation? About 1 ½ – 2 hours. To make sure that your time is well spent, you should fill out all of the forms we send you before you come to the office. Time spent filling out paperwork at the time of your consultation will take away from the time you spend with Dr. Bentkover.

If you are considering a revision rhinoplasty, you need to bring along the operative reports from your previous operation(s). Without these reports, your consultation will really be wasted. Dr. Bentkover will not know how the cartilage and bones in your nose were modified. Pre-Operative photos, either from your previous surgeon(s) or your own collection are also very helpful.

You will spend about 1 hour with Dr. Bentkover. You will then spend about ½ hour with our aesthetic nurse. You may return for a shorter, second consultation at no extra cost. We encourage this. Sometimes patients bring a family member or friend to the second consultation.

Dr. Bentkover will check your medical history, ask about any breathing issues, and ask what you like and dislike about your nose. He will thoroughly examine your nose and your entire nasal airway. He will feel your nose to evaluate the relative length, strength and shape of your nasal bones and cartilages. He will examine the inside of your nose before and after spraying the nose with a mixture of a decongestant called phenylepherine and a numbing medicine called lidocaine. This will enable him to see the inside of your nose more clearly. You may have some numbness of your throat for about 30 minutes after the exam; we recommend that you refrain from eating or drinking until the numbness is gone. Sometimes the phenylepherine can also give you a fast heartbeat for a few minutes. He will examine the inside your nose first with a speculum, a small instrument that gently spreads your nostril open. Next he will examine your nose with a flexible fiber-optic nasal endoscope. This can be a bit uncomfortable but is certainly tolerable, and it is quick. This enables him to see all the way to the back of your nose to more thoroughly evaluate your airway. He can also see behind the nose and down to your larynx with this scope. If you have a breathing problem, he will do a complete ear, nose and throat examination.

Dr. Bentkover will take pictures of your nose himself and digitally modify (“morph”) them on a computer. The purpose of this is to help him plan your operation. The computer program is an architectural planning tool. He may also show you a diagram of what he plans to do for your nose. During this exercise he will elicit your opinion so that he can make sure that you agree with what he wants to try to achieve. It would be nice if he could guarantee that your nose will look just like the “morphed” images of his surgical plan. Unfortunately, he cannot. It is impossible to entirely predict how your nose will heal. There are too many variables in how a nose can heal. That said, however, Dr. Bentkover is generally able to achieve most of the goals that he sets for a particular operation on the nose. If he could not, he would not continue doing rhinoplasty. It would be simply too frustrating. Translating the surgical plan into an actual operation is the major challenge of every rhinoplasty, and also half the fun of the operation. The morphed images of your nose do not leave our office.

After your consultation with Dr. Bentkover, you will meet with our aesthetic nurse to go over pre-operative planning, scheduling and costs. You will receive a fee quote and be asked to sign it to confirm that you understand it. She will also give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and medications. If you smoke, we want you to quit for at least 1 month before and after your surgery. Smoking can have a very negative effect on how well you heal. You must stop all anticoagulant medications and some herbal preparations including aspirin, ibuprofen, vitamin E, St. John’s Wart, gingko, garlic pills or ginseng 2 weeks prior to surgery. You will be required to take antibiotics to prevent infection. Make sure you tell us about any medication allergies. You should shampoo your hair and wash your face with an antibacterial soap the night before and the morning of surgery. We sometimes ask you to use Arnica Montana pills and have you drink fresh pineapple juice (contains Bromelein) before and immediately after surgery to help decrease swelling and bruising.

I want the perfect nose. Can Dr. Bentkover make it perfect? While perfection of technique and outcome is certainly Dr. Bentkover’s goal, it is not possible to guarantee you a “perfect nose”. With any cosmetic procedure, before committing to surgery, you must understand that the realistic goal is significant improvement. If you are the type of person who is going to be bothered by mild irregularities or asymmetries after surgery, then you are probably not a good candidate for cosmetic surgery. Above all, we want happy patients.

Even an unoperated nose that looks perfect to you probably has some asymmetry or slight irregularity. Also, no surgeon, even a specialist in rhinoplasty, can predict exactly how your nose will heal. Furthermore, your nose continues to change as you age. In normal aging without surgery, the skin loosens and thins, the tip often droops, and the ligaments holding the cartilages can weaken and stretch. After a rhinoplasty, age will still affect your nose. While the “final” result of a rhinoplasty is usually evident by 18 months after surgery, your nose will continue to change as you age. Part of the art and science of rhinoplasty is to try to predict some of these changes and make alterations to the structure of your nose so that you will have a good looking and well functioning nose for the rest of your life. An area that looks a little wide at 18 months, for example, may look just right 5 years later.

Dr. Bentkover is very “picky” about his outcomes. Even so, the revision rate for his own rhinoplasties, is only about 10%. Also, he will not revise one of his own rhinoplasties if he thinks the goals for that revision are unreasonable or might endanger an otherwise reasonable surgical result. The best chance to get the optimal result in rhinoplasty is with the first operation.

I don’t want a nose that looks like it has been operated on. Can you guarantee that won’t happen?  There are no guarantees or warranties with any type of surgery. Dr. Bentkover’s goal is always to give you a good looking and 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 our website (www.DrBentkover.com) 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.

If I have a breathing problem, how do I know how much my insurance will cover? As much of the functional surgery to improve your breathing as they feel they should cover and none of the cosmetic surgery to improve the appearance of your nose. If you have the necessary referrals and approvals required by your particular insurance company, we will bill your carrier for the functional or reconstructive part of your procedure, as will anesthesia and the hospital. Unfortunately, this will not decrease the cost of your cos
metic surgery. If you have a Massachusetts based insurance plan, Medicare or Medicaid, your insurance carrier has a fee schedule that limits reimbursement to what they decide to pay. We do not know what that reimbursement will be until they pay for it. Other costs for your functional surgery are generally your medications and applicable co-pays or deductibles. You should review and understand your co-pay amount and deductible status before surgery. This is especially true if you just changed insurance plans or if your employer has changed your benefit package.

How is our rhinoplasty fee determined?  Rhinoplasty is a complex operation, and we take it very seriously. Our fees are based on the fact that this is Dr. Bentkover’s specialty and on his career-long devotion to study, innovation and the quality assessment of his results. Also, we consider operating time as a factor in cost. A routine procedure to fix a deviated septum for just an airway problem takes about 45 – 90 minutes depending on the complexity of the problem. If you are also having a cosmetic rhinoplasty at the same time, the procedure can take 2 – 4 hours more. Most of Dr. Bentkover’s septo-rhinoplasties take about 3 ½ hours. A revision rhinoplasty often takes longer. Our cosmetic rhinoplasty fee is just for the cosmetic part of your surgery. Our fee also includes follow up on your cosmetic surgery. Dr. Bentkover follows his rhinoplasties for as long as possible.

We often hear from patients, “I heard that if I have trouble breathing, my insurance company will cover some or all of the cost of my rhinoplasty.” Is this true?  Generally, no.
The two paragraphs that follow hopefully will clarify any possible confusion on this issue.

Dr. Bentkover will only bill your insurance company if you truly have a significant breathing problem prior to surgery that he can verify on his examination. Common reasons for such a finding include: a deviated nasal septum (a wall in the center of your nose that is crooked and causing airway obstruction), nasal valve collapse (also called nasal vestibular stenosis, when the sides of your nose collapse in on hard inspiration), or enlarged (hypertrophied) inferior turbinates (enlargement of the wings of bone and mucous membrane that humidify air in your nose). If you have one of or more of these conditions, insurance may cover the surgeon’s fee, hospital fees and anesthesia fees but only to improve these functional problems. We will bill your insurance company for any functional surgery only if Dr. Bentkover feels it is medically necessary. This is in addition to what you will pay for your cosmetic surgery; it does not affect what you pay for your cosmetic surgery. Your insurance will not cover any part of the cosmetic rhinoplasty…surgeon’s fees, hospital fees, or anesthesia fees… even if you are having functional surgery on the same day. As far as your insurance company is concerned, you are having two separate operations, one functional and one cosmetic. They do not cover any of the costs associated with the cosmetic operation.

There is also a reconstructive (i.e. non cosmetic) rhinoplasty. This is a rhinoplasty done to correct a severe deformity of your nose that is related to trauma, cancer or a functional airway problem. . If you were in a recent accident, have sustained an injury that has severely disfigured your nose, or have skin cancer on your nose, your insurance company might cover the charges for a reconstructive rhinoplasty. With the exception of skin, without a breathing problem, the likelihood of your insurance company covering any of the surgery is much less. Also, some insurance companies might cover just the straightening of your nose and surgery to improve your breathing, but no other changes to the appearance of the nose. Any changes to your nasal tip, for example, would be your responsibility. Rules vary from company to company, and we will request approval for surgery prior to surgery. Even with “prior approval”, however, they sometimes deny payment.

Where is the surgery performed?  Procedures requiring intravenous sedation or general anesthesia (most rhinoplasties) are usually performed in the Day Surgery Unit at Saint Vincent Hospital in Worcester Medical Center, Worcester, MA, or the Massachusetts Eye and Ear Infirmary. We are confident you will find these facilities to be state-of-the-art, comfortable and very patient friendly.

Located in Central Massachusetts, Saint Vincent charges less for cosmetic surgery and anesthesia. Downtown Boston hospitals are generally more expensive. Saint Vincent is located in middle of downtown Worcester and very easy to reach. It is close to I 90, I 290, I 495, I 395, Rt. 9, and Rt. 146. Surgery performed under local anesthesia may be performed in our office operating room in our suite at Worcester Medical Center, Worcester, MA.

We see all our patients the day after surgery to check the nose, clean the nose and change any dressings that need to be changed. If you live more than an hour from Worcester, you might consider staying at one of the reasonably priced hotels just across the street from the hospital.

Recovery: What to Expect  You will be given pre and post operative instructions designed to decrease the risk of bleeding, help alleviate your swelling and optimize your comfort. The recovery takes one to two weeks. Most people resume most of their normal activities and return to work within 10 days. We will advise you on when to resume specific types of exercise. Following surgery, a lightweight splint is applied to help protect the nose. The splint is removed in a week. Soft silicone plastic splints may be inserted on either side of the nasal septum at the time of surgery to protect the septum. These are held in place by temporary sutures and are also removed in a week. Usually, there is no packing in the nose. There is always some stuffiness of the nose for a week or two, especially when work has been done on the nasal septum. Your nose will be a bit dry for 6 months or so. We will recommend a saline spray. Pain is generally moderate and is usually well controlled with medication. Bruising occurs around the eyes, but begins to fade within a few days. Discoloration usually disappears within 10 days to two weeks. If you have an ear cartilage graft or temporalis fascia graft (the outer layer of the muscle above your ear), this area may be a bit more uncomfortable than the nose for the first week or so. The ear stays a bit tender even for months and may be a bit numb. Staples used to close these wounds are usually removed at 10 days or two weeks. Sutures behind the ear usually dissolve on their own, as do the sutures to the incisions in your nose. Most are gone in 10 days or so. Sutures under the skin that hold grafts in place can last 4-6 months. Sometime Dr. Bentkover uses a thin, dissolvable mesh under the skin of the nose. This mesh, Vicryl mesh, usually dissolves in 6 weeks.

What are some factors that can affect how my nose heals?
• Thick nasal skin
• Thin nasal skin
• Thick cartilages in the tip
• Thin cartilages in the tip
• Short nasal bones
• Smoking

What are some of the changes that occur after rhinoplasty that may not be predictable before surgery?

• Bleeding and infection. While rare, bleeding or infection are the most common complications of rhinoplasty. Your nose with ooze some blood from the nostrils for the first 4-5 days, but you should call us if there is rapid bleeding or a lot of blood in your mouth. Increased pain and redness after a few days or even after a week can be a sign of infection. You will be on an antibiotic for 7 days. If you have any concerns, you should call us.
• Other severe but rare complications. The nose and nasal septum attach to the base of your skull. While extremely rare, with any type of nasal surgery, functional or cosmetic, there is the possibility of loss of se
nse of smell, leakage of brain fluid, meningitis or brain abscess. Brain abscess, leakage of brain fluid, and meningitis can be life threatening conditions. Dr. Bentkover is double boarded in Facial Plastic and Reconstructive Surgery and Ear, Nose and Throat surgery (Otolaryngology). He has been operating on noses for over 30 years and has never had any of these complications, but they are well established risks of nasal surgery.
• Persistent swelling and scar formation. As a result of a rhinoplasty, your body forms a thin layer of scar under the skin that adheres to the cartilage and bones below. To some extent, it is the proper formation of this scar that holds in place the changes made to your nose. Depending on your type of skin, you may have persistent swelling in parts of your nose that may require one or more injections with a steroid called triamcinolone (Kenalog) to help the nose heal evenly. These injections are mildly uncomfortable. If you have thick skin or are of Mediterranean decent, you may be more prone to form thick scar tissue under your skin than can lead to some fullness in the profile or width of the nose. The injections usually help alleviate this. If you have external incisions, on rare occasion you may need to have the incision revised. This is usually a 10-15 procedure in the office with local anesthesia.
• Uneven healing of the bones. Especially if your nose is crooked, the bones can trend to drift back to the where they were; because the periosteum (the coating over the bone) is shorter on one side. You may be instructed in compression exercises after the splint comes off to prevent this.
• Irregularities of the bones. Every effort is made at surgery to make sure that the bones are smooth at the end of the procedure. Despite this, there can still be some irregularity of the bones as they heal.
• The height of your nasal profile. As the tip of the nose settles after surgery, sometimes the profile may be a bit higher than desired. If this is a real issue for you and for Dr. Bentkover, he may be able to file the bones a bit more after 18 months.
• Changes in the width of the nose. Imagine your nose as the shape of a long triangular tent. If you take off part of the top of the triangle, the remaining tent is lower, a bit wider and now has an “open roof”. If you then bring the sides of the tent in towards each other and re-attach them to the center horizontal supporting beam of the tent, this closes the roof; but the new top of the tent may still be a bit wider than before. This is a reasonable analogy to what happens when the surgeon reduces a bump on your nose to improve your profile. The surgeon files or trims the bone and cartilage to lower the profile and then cuts the bones to bring the sides in to establish a new height to the profile. The center horizontal supporting beam is your nasal septum. Sometimes, grafts called spreader grafts may be necessary to correct some collapse of the internal nasal valves. These grafts are placed between the side walls of the nose and the septum on each side. They can add 1-1.5 millimeters or so of width to the middle of the nose.
• Changes in tip definition. Dr. Bentkover most commonly uses cartilage grafts from your nasal septum to improve the definition of the tip. It often takes 3-6 months before you can start to appreciate the affect of this type of graft. If you have thick skin in your nose it may not be possible to get the amount of refinement that you picture in your own mind. In normal healing, Realistic expectations are very important.

Skin Changes.

• Your nose will be numb for the better part of a year, and some small spots may stay numb. This is not usually an issue. The middle of your palate may be numb for a few weeks.
• Your skin may be a bit red or have prominent blood vessels in it (telangiectasias) after surgery. This is especially true if you skin tends to form these blood vessels in other areas, like the cheeks and chin. It may also be possible if you have Rosacea. It is more common with revision surgery.
• Smokers are at risk for slough (dying) of some of the skin of the nose. This is rare but can happen.
• Your skin may be thicker over the nose after surgery.
• When you go out in cold weather, your nose may turn a bluish color after surgery. This is especially true during the first year after surgery. It is also especially a possibility if you have Raynaud’s Syndrome,l a condition where your finger tips turn blue in the cold. We do not recommend skiing or extended periods of other cold weather outside activity during the first year after surgery.
• Your nose will be more susceptible to sun burn for at least the first 6 months after surgery. This can adversely affect the outcome of the surgery. We recommend at least an SPF 60 sunscreen when you are outside in bright sunlight for the first year. If you are going to the tropics, we recommend an SPF 85 or higher. Do not let your nose tan or burn. You may get permanent brown discoloration.
• There may be some slight irregularities of the skin. Most usually clear on their own.

In the Before and After section we have posted a few of our patients who have kindly consented to have their photos on our website. We have many more images to show yoin the office.


YOUR RHINOPLASTY PROCEDURE

Where is the surgery performed?  Procedures requiring intravenous sedation or general anesthesia (most rhinoplasties) are usually performed in the Day Surgery Unit at Saint Vincent Hospital in Worcester Medical Center, Worcester, MA, or the Massachusetts Eye and Ear Infirmary. We are confident you will find these facilities to be state-of-the-art, comfortable and very patient friendly.

Located in Central Massachusetts, Saint Vincent charges less for cosmetic surgery and anesthesia. Downtown Boston hospitals are generally more expensive. Saint Vincent is located in middle of downtown Worcester and very easy to reach. It is close to I 90, I 290, I 495, I 395, Rt. 9, and Rt. 146. Surgery performed under local anesthesia may be performed in our office operating room in our suite at Worcester Medical Center, Worcester, MA.

We see all our patients the day after surgery to check the nose, clean the nose and change any dressings that need to be changed. If you live more than an hour from Worcester, you might consider staying at one of the reasonably priced hotels just across the street from the hospital.

Recovery: What to Expect  You will be given pre and post operative instructions designed to decrease the risk of bleeding, help alleviate your swelling and optimize your comfort. The recovery takes one to two weeks. Most people resume most of their normal activities and return to work within 10 days. We will advise you on when to resume specific types of exercise. Following surgery, a lightweight splint is applied to help protect the nose. The splint is removed in a week. Soft silicone plastic splints may be inserted on either side of the nasal septum at the time of surgery to protect the septum. These are held in place by temporary sutures and are also removed in a week. Usually, there is no packing in the nose. There is always some stuffiness of the nose for a week or two, especially when work has been done on the nasal septum. Your nose will be a bit dry for 6 months or so. We will recommend a saline spray. Pain is generally moderate and is usually well controlled with medication. Bruising occurs around the eyes, but begins to fade within a few days. Discoloration usually disappears within 10 days to two weeks. If you have an ear cartilage graft or temporalis fascia graft (the outer layer of the muscle above your ear), this area may be a bit more uncomfortable than the nose for the first week or so. The ear stays a bit tender even for months and may be a bit numb. Staples used to close these wounds are usually removed at 10 days or two weeks. Sutures behind the ear usually dissolve on their own, as do the sutures to the incisions in your nose. Most are gone in 10 days or so. Sutures under the skin that hold grafts in place can last 4-6 months. Sometime Dr. Bentkover uses a thin, dissolvable mesh under the skin of the nose. This mesh, Vicryl mesh, usually dissolves in 6 weeks.

What are some factors that can affect how my nose heals?
• Thick nasal skin
• Thin nasal skin
• Thick cartilages in the tip
• Thin cartilages in the tip
• Short nasal bones
• Smoking

What are some of the changes that occur after rhinoplasty that may not be predictable before surgery?

• Bleeding and infection. While rare, bleeding or infection are the most common complications of rhinoplasty. Your nose with ooze some blood from the nostrils for the first 4-5 days, but you should call us if there is rapid bleeding or a lot of blood in your mouth. Increased pain and redness after a few days or even after a week can be a sign of infection. You will be on an antibiotic for 7 days. If you have any concerns, you should call us.
• Other severe but rare complications. The nose and nasal septum attach to the base of your skull. While extremely rare, with any type of nasal surgery, functional or cosmetic, there is the possibility of loss of sense of smell, leakage of brain fluid, meningitis or brain abscess. Brain abscess, leakage of brain fluid, and meningitis can be life threatening conditions. Dr. Bentkover is double boarded in Facial Plastic and Reconstructive Surgery and Ear, Nose and Throat surgery (Otolaryngology). He has been operating on noses for over 30 years and has never had any of these complications, but they are well established risks of nasal surgery.
• Persistent swelling and scar formation. As a result of a rhinoplasty, your body forms a thin layer of scar under the skin that adheres to the cartilage and bones below. To some extent, it is the proper formation of this scar that holds in place the changes made to your nose. Depending on your type of skin, you may have persistent swelling in parts of your nose that may require one or more injections with a steroid called triamcinolone (Kenalog) to help the nose heal evenly. These injections are mildly uncomfortable. If you have thick skin or are of Mediterranean decent, you may be more prone to form thick scar tissue under your skin than can lead to some fullness in the profile or width of the nose. The injections usually help alleviate this. If you have external incisions, on rare occasion you may need to have the incision revised. This is usually a 10-15 procedure in the office with local anesthesia.
• Uneven healing of the bones. Especially if your nose is crooked, the bones can trend to drift back to the where they were; because the periosteum (the coating over the bone) is shorter on one side. You may be instructed in compression exercises after the splint comes off to prevent this.
• Irregularities of the bones. Every effort is made at surgery to make sure that the bones are smooth at the end of the procedure. Despite this, there can still be some irregularity of the bones as they heal.
• The height of your nasal profile. As the tip of the nose settles after surgery, sometimes the profile may be a bit higher than desired. If this is a real issue for you and for Dr. Bentkover, he may be able to file the bones a bit more after 18 months.
• Changes in the width of the nose. Imagine your nose as the shape of a long triangular tent. If you take off part of the top of the triangle, the remaining tent is lower, a bit wider and now has an “open roof”. If you then bring the sides of the tent in towards each other and re-attach them to the center horizontal supporting beam of the tent, this closes the roof; but the new top of the tent may still be a bit wider than before. This is a reasonable analogy to what happens when the surgeon reduces a bump on your nose to improve your profile. The surgeon files or trims the bone and cartilage to lower the profile and then cuts the bones to bring the sides in to establish a new height to the profile. The center horizontal supporting beam is your nasal septum. Sometimes, grafts called spreader grafts may be necessary to correct some collapse of the internal nasal valves. These grafts are placed between the side walls of the nose and the septum on each side. They can add 1-1.5 millimeters or so of width to the middle of the nose.
• Changes in tip definition. Dr. Bentkover most commonly uses cartilage grafts from your nasal septum to improve the definition of the tip. It often takes 3-6 months before you can start to appreciate the affect of this type of graft. If you have thick skin in your nose it may not be possible to get the amount of refinement that you picture in your own mind. In normal healing, Realistic expectations are very important.

Skin Changes.

• Your nose will be numb for the better part of a year, and some small spots may stay numb. This is not usually an issue. The middle of your palate may be numb for a few weeks.
• Your skin may be a bit red or have prominent blood vessels in it (telangiectasias) after surgery. This is especially true if you skin tends to form these blood vessels in other areas, like the cheeks and chin. It may also be possible if you have Rosacea. It is more common with revision surgery.<
br />• Smokers are at risk for slough (dying) of some of the skin of the nose. This is rare but can happen.
• Your skin may be thicker over the nose after surgery.
• When you go out in cold weather, your nose may turn a bluish color after surgery. This is especially true during the first year after surgery. It is also especially a possibility if you have Raynaud’s Syndrome,l a condition where your finger tips turn blue in the cold. We do not recommend skiing or extended periods of other cold weather outside activity during the first year after surgery.
• Your nose will be more susceptible to sun burn for at least the first 6 months after surgery. This can adversely affect the outcome of the surgery. We recommend at least an SPF 60 sunscreen when you are outside in bright sunlight for the first year. If you are going to the tropics, we recommend an SPF 85 or higher. Do not let your nose tan or burn. You may get permanent brown discoloration.
• There may be some slight irregularities of the skin. Most usually clear on their own.

For the convenience of our patients, we have included our Post Operative Instructions below:

Post Operative Instructions

TO AVOID BLEEDING

  • Do not pick your nose.
  • Do not blow your nose. Dab the nostrils with facial tissues.
  • If you must sneeze, do so with your mouth open.
  • To keep your nasal linings moist and clean: A. Three times daily dab inside the nostrils with a solution of ½ water and ½ hydrogen peroxide and then apply Bacitracin to the same area with a Q-tip in a circular manner. B. Spray saline nose spray, 3 puffs in each nostril at least 5 – 6 times a day.
  • NO SMOKING for 1 month. Basically, give it up.
  • No bending, stooping or straining.
  • Do not strain while having a bowel movement. No alcohol for 7 days.
  • Avoid hot temperature drinks or hot foods.
  • Rest and sleep with your head propped up on 2 – 3 pillows.
  • No aspirin or aspirin related products such as Advil, Nuprin, Motrin, Aleve or ibuprofen should be used for pain relief for 7 days. Use an aspirin substitute, such as Extra-Strength Tylenol or medications prescribed by your physician. Also avoid high doses of vitamin E, gingko biloba, ginseng, garlic tablets and St. John’s wart.

AVOID TRAUMA 

After surgery, the nasal structures may be weaker than before, temporarily in most cases and permanently in some cases. A nasal injury at this time may severely damage your nose.

  • AVOID ACTIVITIES DURING WHICH YOU MAY BUMP YOUR NOSE No active swimming or diving for 6 weeks. You may wade, but watch out for other people’s heads and elbows.
  • If you bump your nose, please call us at (508) 363-6500.
  • No contact sports for at least 5 – 6 months.
  • Avoid vigorous indoor activities for 10 days.
  • IMPORTANT: You may have a small pack or sheet of plastic in your nose for a period of time. If it should fall out or be bothersome, please call us at (508) 363-6500

RHINOPLASTY FAQ

What is Rhinoplasty?

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.

Does Dr. Bentkover specialize in rhinoplasty?

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.

What is the difference between “open” and “closed’ rhinoplasty? I am concerned about the incision.

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  

In an “open” approach rhinoplasty, there are no surprises

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.)

I don’t want a nose that looks like it has been operated on. Can you guarantee that won’t happen?

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?

Generally, no.
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.

How long will I be in your office for the consultation?

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.

How long is the recovery?

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.

Is it true that most rhinoplasties need to be done more than once?

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).

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