What is a Rhinoplasty Procedure?
Rhinoplasty, the art and science of restructuring the nose, was one of the first facial cosmetic operations and is among the most frequently performed cosmetic operations today. It is also widely recognized as the most challenging of the facial cosmetic procedures. That is why many plastic surgeons do not do rhinoplasty.
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, kind of 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 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, despite careful planning and excellent surgical skills, 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 must also understand that small irregularities and asymmetries after a rhinoplasty are common. If you are going to be very bothered by small post-op irregularities, you may not be a candidate for any cosmetic surgery.
What are the common reasons for having a Rhinoplasty?
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 of the nose. Deformities of the nose may be natural or due to trauma. Difficulty breathing through your nose can also 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). Also, 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. 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 very comfortable treating complex functional nasal problems. I 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 endonasal and open approaches is mostly structural and philosophical. A surgeon will choose the approach that he/she feels will give the best results in his/her 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.
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 the architecture of the nose may need to be modified. In an open approach rhinoplasty, the surgeon can clearly see everything that needs to be modified in as close to its normal state as possible. Often, 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 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.
Through an endonasal approach, a surgeon may 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 normal development of scar under the skin and 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 rhinoplasties. 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 in the nose and to replace large amounts of cartilage removed during the first or subsequent procedures.
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 surgeon has his/her own aesthetics and philosophy about this operation. 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. 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 we can spend together.
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 really be wasted. I 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 me and about ½ hour with our aesthetic nurse, Nancy. You may return for a second consultation at no extra cost. We encourage this. Sometimes patients bring a family member or friend to the second consultation.
I will check your medical history, ask 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. 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. 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; and it is quick and important. This enables me to see all the way to the back of your nose to more thoroughly evaluate your 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 so that I can make sure that you agree with what I want to try to achieve. 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 in how a nose can heal. 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 simply 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. 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 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 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 have you 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. 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 – 3 hours more. Most of my septo-rhinoplasties (septoplasty plus rhinoplasty) take about 3-3 ½ hours. Our cosmetic rhinoplasty fee is just for the cosmetic part of your surgery. Our fee also includes follow up on your cosmetic surgery. I follow my rhinoplasties 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 performed under local anesthesia may be performed in our office operating room in our suite at Worcester Medical Center, Worcester, MA. We will see you the day after surgery to check your nose, clean it and instruct you post-op care. If you live more than an hour from Worcester, we hope you will 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. Initial recovery takes 7 – 10 days. Most people resume most of their normal activities and return to work within 10 days. 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 part of 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 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 depends 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 a bit more uncomfortable than the nose for the first few weeks. The ear stays a bit tender even for months and may be a bit numb. Staples used to close the scalp incision for the fascia donation are usually removed at 2 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. 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. Your nose will 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. 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. I am double boarded in Facial Plastic and Reconstructive Surgery and Ear, Nose and Throat surgery (Otolaryngology). I have been operating on noses for over 30 years and have never had any of these complications, but they are 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 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 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; 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. Also, 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 me, I 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 (called osteotomies) 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 or straighten your nasal septum. These grafts are placed between the sidewalls of the nose and the septum on each side. They can add 1-2 millimeters or so of width to the middle of the nose.
• Changes in tip definition. I most commonly use 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 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 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 your 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 a bit thicker 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, a condition where your fingertips and nose can 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 surgery. 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 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 you in the office.
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 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.
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. 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.
This is always my goal. There are no guarantees or warranties with any type of surgery. My goal is always to give you a good looking and natural looking nose, not a nose that has an operated look. We invite you to review the rhinoplasty photos on this website and judge for yourself. We have many more photos to show you at the time of the consultation.
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. We have a 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?
Would be nice, wouldn’t it. 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.
About an hour and a half. We do a very comprehensive evaluation and try to educate you as much as possible on what to expect.
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 in the tip of the nose. It goes away slowly, and most people you see will not realize your nose is still swollen. The nose is basically healed at 18 months, but some thinning can continue for 2-4 years and even lifelong.
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).