A Discussion of Rhinoplasty
This webpage contains a comprehensive discussion of rhinoplasty based from science and experience. We recommend you start you web search by reading the entire page.
What is the rhinoplasty procedure?
Rhinoplasty, the art and science of restructuring the nose, was one of the first facial cosmetic operations; it is among the most frequently performed cosmetic operations today. Many plastic surgeons do not do rhinoplasty because it is also widely recognized as the most challenging of the facial cosmetic procedures.
Is a rhinoplasty the same as a nose job?
Some people refer to rhinoplasty as a “nose job”. To call such a sophisticated operation a “nose job”, a term popularized in the 1960’s, 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, re-arranging, or reshaping cartilage and 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.
Am I a good rhinoplasty candidate?
If you do not like the appearance of your nose and would like to refine the shape so that it better fits your face, looks softer, or perhaps has more definition, the answer is probably yes. The answer is only “probably yes”; because, despite careful planning and excellent surgical skills, it is impossible to predict the appearance of your nose after surgery and whether or not you will like the surgical outcome. As with any cosmetic procedure, the realistic goal is for improvement. No surgeon can give you a perfect nose, picked out of a magazine. 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 will affect the cosmetic outcome. To be a good candidate for any cosmetic surgery, you must first understand that small irregularities and asymmetries after a rhinoplasty are common.
What are the common reasons for having a rhinoplasty?
There are many personal reasons for choosing a rhinoplasty. These commonly include reducing the size of the nose, removing a bump, narrowing the nasal bridge, straightening the nose and refining the shape of the tip. Deformities of the nose may be genetic or occur due to trauma. Difficulty breathing through your nose can also be improved during a rhinoplasty. The nasal septum (wall in the middle of your nose) may be excessively crooked (deviated). One or both sides of your nose may collapse inward. This is referred to as nasal valve collapse or nasal vestibular stenosis. Both of these conditions can be corrected during a rhinoplasty. Removal of the nasal cartilage, in an attempt 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 nasal valve collapse is a real or potential issue, it should be corrected. I 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. I am also trained as an ear, nose and throat specialist; I am comfortable treating complex functional nasal problems, and often get referrals from other nasal specialists for these problems.
What is the difference between open and closed (endonasal) rhinoplasty? Should you be concerned about the incisions?
The difference between the closed (endonasal) and open approaches is both structural and philosophical. There is not one absolutely right way to do a rhinoplasty. What is important is that the surgeon choose the approach that he/she feels will give the best results.
The incisions for an open rhinoplasty differ from the closed approach. The small incision that comes across the columella (the skin and cartilage between your nostrils) is placed about 2/3 of the way down, and is made so that it generally hides very well and should not be an issue of concern. This is not an area that most people normally notice.
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.
The real issue between a closed and open approach to rhinoplasty is the amount of the nasal structure that needs to be visualized, as well as the degree to which the architecture of the nose may need to be modified. In an open approach rhinoplasty, the surgeon has the ability to see everything that needs to be modified.. Often, during an open rhinoplasty, less cartilage is removed from the nasal tip, leaving a stronger, more functional, and more defined nose. Surgeons tend to use more “structural” cartilage grafts, from your own nasal cartilage, to strengthen and shape the underlying architecture. This prevents the twisting and other adverse changes as you age.
Through an endonasal approach, a surgeon is not be able to see pre-existing irregularities of the tip cartilages and bones as well as in the open approach. These irregularities can become more apparent post operatively with the development of scar tissue under the skin. So generally need to be addressed at surgery. Especially in very deviated or twisted noses, it is important to be able to see as much of the nasal cartilages and bone as possible to be able to modify the problem areas.
In most cases, I favor the open approach for primary rhinoplasty. If I need to make a small modification to an operated nose, I 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 I want to add a small piece of cartilage to the tip or sidewall of the nose. Most of the noses I see for revision (secondary) rhinoplasty, however, require an open approach in order to visualize all the problems and to replace the large amounts of cartilage removed during the initial procedure(s).
Does the experience of the surgeon matter?
Absolutely. The ability to achieve the planned goals of the operation is definitely experience driven. Rhinoplasty is an artistic endeavor that is part structural engineering, part architecture, and part sculpture. It is important that you and your surgeon agree on an overall approach to the desired look for your nose. While there are some generally accepted parameters and measurement guidelines to which most rhinoplasty surgeons agree, each physician has his/her own aesthetics and philosophy about this the rhinoplasty. I will discuss this with you extensively during the consultation and will “morph” possible changes on your digital photos as a way of planning an operation with you.
Your Rhinoplasty Consultation
You will be in our office about 1 ½ – 2 hours. We will send you the new patient paperwork electronically. To make sure that your time is well spent, please fill out all of the forms before coming to the office. Time spent filling out paperwork will take away from the time we can spend together during the consultation.
If you are considering a revision rhinoplasty, you need to bring the operative reports from your previous operation(s). Without these reports, your consultation will be wasted, as I will not know how your nose has been 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 me and about ½ hour with our aesthetic nurse, Nancy. You may return for a second consultation at no extra cost. We encourage this visit. Sometimes patients bring a family member or friend to the second consultation.
I will check your medical history, talk about any breathing issues, and ask what you like and dislike about your nose. I will thoroughly examine your nose and your entire nasal airway. I will feel your nose to evaluate the relative length, strength and shape of your nasal bones and cartilages. I 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 me to see the inside of your nose more clearly. Your throat may be numb 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. I will examine the inside your nose first with a speculum, a small instrument that gently spreads your nostrils open. Next I will examine your nose with a flexible fiber-optic nasal endoscope. This can be a bit uncomfortable but is certainly tolerable; it is quick and extremely important. This will enable me to see all the way to the back of the nose to thoroughly evaluate the airway. I can also see behind the nose and down to your larynx with this scope.
I will take pictures of your face and digitally modify (“morph”) them on a computer with your input. The computer program is an architectural planning tool. Its purpose is to help me plan your operation. I will also show you a diagram of what I plan to do for your nose. During this time in my private office, I will explain the plan for your nose and make sure we agree on the surgical goals. It would be nice if I could guarantee that your nose will look just like the “morphed” images, but unfortunately I cannot. It is impossible to entirely predict how your nose will heal; there are too many variables. That said, however, I am generally able to achieve most of the goals that I set for a particular operation on the nose. If I could not, I would not continue doing rhinoplasty; it would be too frustrating. Translating the surgical plan into an actual operation is the real challenge of every rhinoplasty, and also half the fun of the operation. Remember, the morphed images of your nose generally do not leave our office.
After your consultation with me, you will meet with our aesthetic nurse to go over pre-operative planning, scheduling, and costs. You will receive a fee quote that is good for 6 months 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 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 three 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 drink fresh pineapple juice (contains Bromelein) before and immediately after surgery to help decrease swelling and bruising.
Insurance and Rhinoplasty
Insurance does not cover voluntary cosmetic changes to the appearance of your nose. Depending the terms of your policy, deductibles and co-pays, your insurance might cover part or all of the necessary functional surgery to improve your breathing or to correct the affects of recent trauma to your nose only. This surgery might include a septoplasty, nasal valve repair or re-setting of the bones. If you need functional surgery to your nose at the time of a cosmetic rhinoplasty, the cosmetic fee is still the same as without this surgery. We are permitted to bill your insurance company for any necessary functional surgery in addition to our cosmetic charges to you. The also applies to anesthesia and hospital day surgery charges.
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 my specialty and on my career-long devotion to study, innovation and the quality assessment of my results. We also consider operating time as a factor in the cost. A routine procedure, to fix a deviated septum for an airway problem, takes about 45 – 90 minutes depending on the level of correction required. If you are also having a cosmetic rhinoplasty at the same time, the procedure can take 2 – 3 hours more. Most of my septo-rhinoplasties (septoplasty plus rhinoplasty) take about 3-3 ½ hours. Our cosmetic rhinoplasty fee only covers the cosmetic part of your surgery. Our fee also includes all follow-up visits for your cosmetic surgery. To ensure long-term results, I follow my rhinoplasty for as long as possible.
A revision rhinoplasty can be shorter or much longer than the original procedure. Depending on the complexity, it can cost more or less than the original procedure. Major revision changes will usually be more expensive.
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 sometimes at 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. Touch-up surgery may be performed in our office operating room under local anesthesia in our suite at Worcester Medical Center, Worcester, MA. We will see you the day after surgery to check and clean your nose, and instruct you on post-op care. If you live more than an hour from Worcester, we hope you will consider staying at one of the beautiful hotels located across from the hospital.
Recovery: What to Expect after Rhinoplasty Surgery
You will be given pre and post-operative instructions designed to decrease the risk of bleeding, help alleviate your swelling and optimize your comfort. Initial recovery takes 7 – 10 days. Most people resume the majority of their normal activities, as well as return to work, within 10 days after their rhinoplasty. We will see you initially at 1 day, 1 week, 2 weeks and 3 weeks after surgery. 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. You may not blow your nose for 3 weeks, so the purpose of your 2-week post op appointment is to clean the nose, removing crusts that can temporarily obstruct our breathing. Your nose will be a bit dry for up to 6 months or so. We recommend Simply Saline™. Pain is generally moderate and is usually well controlled with medication. Bruising occurs around the eyes, but begins to fade within a few days. Some of the bruising will depend on your skin type. In can spread down towards your jaw. 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 in the scalp above your ear), this area may be more uncomfortable than the nose for the first few weeks. The ear can stay tender for months and may feel slightly numb. The staples used to close the scalp incision for the fascia donation are usually removed at 2 weeks postoperatively. 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. The sutures under the skin, holding grafts in place, can last from 4-6 months. Sometimes I use a thin, dissolvable mesh under the skin of the nose. This mesh, Vicryl® mesh, can cause some swelling under the skin that goes away when it dissolves in about 6 weeks.
What are some factors that can affect how your nose heals?
- Thick nasal skin
- Thin nasal skin
- Thick cartilages in the tip
- Thin cartilages in the tip
- Short nasal bones
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. It is normal for your nose to ooze some blood from the nostrils for the first 3-4 days, but you should call us if there is rapid bleeding or a lot of blood in your mouth. You will be on an antibiotic for 7 days. Increased pain and redness after a few days or even after a week can be a sign of infection. If you have any concerns, you should call us immediately.
- Other severe but rare complications. The nose and nasal septum attach to the base of your skull. While extremely rare, any type of nasal surgery, functional or cosmetic, holds the possibility for 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. I am double Board Certified in Facial Plastic and Reconstructive Surgery and Ear, Nose and Throat surgery (Otolaryngology). I have been performing rhinoplasty for over 30 years and have never had any of these complications, They are, however, well-established risks of nasal surgery in the medical literature.
- Persistent swelling and scar formation. As a result of a rhinoplasty, your body forms a layer of scar tissue under the skin, adhering 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 the steroid 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 the formation of thick scar tissue under the skin. This scar tissue can lead to some fullness in the profile or width of the nose. The Kenalog injections usually help alleviate this situation. If you have external incisions, on rare occasion you may need to have the incision revised. This is usually a short 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 towards where they were before surgery. This is because the periosteum (coating over the bone) is shorter on one side. You will be instructed in compression exercises after the splint comes off to prevent this.
- Irregularities of the bones. During surgery, every effort is made to ensure that the bones are smooth at the end of the procedure. Despite this, some irregularity of the bones ;may still occur as they heal. Also, as the tip of the nose settles after surgery, you may notice the profile to be a bit higher than desired. If this is an issue, 18 months after surgery I will be able to file the bones for an aesthetic improvement.
- Changes in the width of the nose. Imagine your nose in the shape of a long triangular tent. If you take off the top of the triangle, the remaining tent is lower, slightly 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 will still be a bit wider than before. This is an analogy to illustrate what happens as the surgeon improves the profile by reducing a bump on your nose . The surgeon will file or trim the bone and cartilage to lower the profile. He will then cut the bones (called osteotomies) to bring the sides and establish a new height for the profile. The center horizontal supporting beam is known as your nasal septum. Spreader grafts may be necessary to correct a collapse of the internal nasal valves, or to straighten your nasal septum. These grafts are placed between the sidewalls of the nose and the septum They can add 1-2 millimeters of width to the middle of the nose.
- Changes in tip definition. I most commonly use cartilage grafts from the nasal septum to improve the definition of the nose tip. It often takes 3-6 months before you can start to appreciate the affect of this type of graft. If you have thick nasal skin, it may not be possible to get the complete desired amount of refinement. Realistic expectations are very important for satisfactory results.
Skin and Other Unusual Changes.
- Your nose will be numb for the better part of a year, and some small spots may stay numb. This is normal and not usually an issue.
- The middle of your palate may be numb for a few weeks.
- Your skin may be red or have prominent blood vessels (telangiectasias) after surgery. This is especially true if your skin is prone to these blood vessels in other areas, like on the cheeks and chin. It may also be possible if you have Rosacea. Redness and prominent blood vessels are more common with revision surgery.
- Smokers are at risk for the slough (dying) of some on skin the nose. While this is rare, it does still occur.
- Your skin may be thicker after surgery.
- After surgery, your nose may turn a bluish color when going out in cold weather, This is especially true during the first year post operatively. There is a higher instance if you have Raynaud’s Syndrome, a condition where your fingertips and nose have a tendency to turn blue in the cold. We do not recommend skiing or other cold weather outside activities 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 rhinoplasty. We recommend at least an SPF 50 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 of these will usually clear on their own.
In the Before and After gallery we have posted a few of our patients who have kindly consented to let us use their photos online. We have many more images to show you in the office.
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 operations 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 (the structure of the nose) is always tied to function (breathing). In every rhinoplasty the experienced surgeon must make sure that changes in form and function compliment each other. The surgeon must also pay attention to the airway and to strengthening the underlying bone and cartilage framework.
Does Dr. Bentkover specialize in rhinoplasty?
Absolutely. For me, rhinoplasty is a true surgical passion. I have spent my entire career studying this operation and honing my skills. Because I critically evaluate my results, I follow my patients for many years after surgery. I welcome the most difficult and challenging cases. I do primary (first time) and secondary (revision) rhinoplasty, treating patients from all over New England, as well as many 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.
Can a surgeon make my nose perfect?
While perfection of technique and outcome is certainly our 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. You may not be a good candidate for cosmetic surgery if you are not prepared for mild irregularities or asymmetries after surgery,. Above all, we want happy patients.
I do not want a nose that looks like it has been operated on. Can you guarantee that will not happen?
This is always my goal. However, there are no guarantees or warranties with any type of surgery. My goal is always to give you an aesthetically pleasing and natural looking nose; not one that looks ‘operated’ on. We invite you to review the Rhinoplasty Before and After photos on our website and judge for yourself. We also have photos classified by the types of changes on our rhinoplasty only website. At the time of your consultation, Dr. Bentkover will go over more Before and After photos of Rhinoplasty patients.
What is the difference between “open” and “closed’ rhinoplasty? I am concerned about the incision.
The difference between the “closed” and “open” approaches is both structural and philosophical. It is not about the incision; so this should not be an issue of concern. See the full discussion of this top earlier on this page.
I heard that if I have trouble breathing, my insurance company will cover the cost of the operation. Is that true?
This would be nice, but not necessarily the case. If you 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.
How long will I be in your office for my consultation?
You will be in the off for about an hour and a half. We will do a comprehensive evaluation and try to educate you as much as possible on what to expect.
How long is the recovery?
Generally, you will be black and blue around your eyes for 7-10 days. You can usually go back to work after 10 days. Much of the swelling will be gone in 3-6 weeks, but it may take months for all the swelling to resolve in the tip of the nose. This goes away slowly, and will not be perceptible to others. The nose is basically healed at 18 months, but some thinning can continue for 2-4 years or longer.
Is it true that most rhinoplasty procedures will need to be done more than once?
No, this is not true. However, some surgeons estimate that 10-20% of the rhinoplasty outcome 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 normally minimal and do not require revision, although some may (see our webpage on Revision Rhinoplasty).