Rhinoplasty Consultation: How to Do It

If you’re going to ask about a rhinoplasty, some of your best clues about your future treatment come before you meet the plastic surgeon.

Early warnings include:

• An endlessly ringing phone
• A busy signal
• An uninterested, bored phone receptionist

Some rhinoplasty surgeons charge for a first consultation and apply the fee toward the cost of the procedure.

Rhinoplasty is more difficult than you can imagine. You’ll be in far better hands and much more likely to prevent future problems if you use only board-certified plastic surgeons. (More about the difficulty of nose surgery.)

If you’ve found three or four surgeons online in your area you like, try filling out the patient contact forms on their websites.

Explain you are seriously interested in a nose job but working on a limited budget so a consultation fee is out of the question.

It’s okay these days to talk about budgets first!

When you go to the consultation, have the attitude that you are hiring a surgeon.

Ask:

• To see the surgeon’s before and after rhinoplasty pictures
• How many times weekly or monthly the surgeon performs the procedure in which you are interested. The more, the better!
• If you can call former patients

In the consultation, most surgeons hand you a mirror and ask you to point out what bothers you about your nose.

If you’ve had previous nose surgery, if you think your nose is too large, too crooked, too bulbous or too bumpy, say so, being as specific as possible about the change you want.

Try bringing a friend or relative along.

An artistic eye is usually necessary for nose surgery to create a nose balanced with the rest of your face.

Do you see balance and harmony in the surgeon’s before and after rhinoplasty pictures? If your eye does not go immediately to the patients’ eyes in the after pictures, the results are less than desirable.

Do you feel comfortable and reassured with the surgeon?

Remember, he or she wants to please you while making your nose look as good as possible. Why? One happy patient brings in five others!

If you decide to go ahead, ask for a firm quote on the total cost of the surgery. That includes:

• Surgeon’s fee
• Anesthesiologist fee
• Charge for operating room
• Recovery garments
• Medications

Rhinoplasty: How Long Does It Last?

The short answer: given capable, trained hands of the plastic surgeon, rhinoplasty is intended to be permanent.

Because the changes in nasal surgery are often made to bone or cartilage, the procedure usually lasts a lifetime.

After a rhinoplasty, patients look in the mirror, see a bruised face and swollen nose and naturally wonder if they must go through it again.

Perhaps three months will go by and the tip of your nose may still be swollen. Bear in mind, it can take a year before the final appearance of a rhinoplasty can reveal itself.

The bridge of the nose can be swollen for about six months while the region of the nose where glasses sit can remain swollen for periods up to a year.

However, a newly refined nose is still subject to aging and gravity so a few minor changes occur as the years roll by.

Facial muscles also can influence exactly how your nose is going to look.

For instance, in some people, the facial muscles used in smiling will also make the nose widen on the outer part of the lower nostrils. Or the tip may point down slightly.

But there could be other considerations about how long your rhinoplasty will last.

For instance, was your nose job performed 15, 20 or more years ago? Surgeons back then often took away too much skin and too much of the nose’s internal structures.

All that could lead to serious drooping or even collapse of the nose. Also, quite a few plastic surgeons from several decades ago learned how to do one type of rhinoplasty so that most of that surgeon’s patients had the same basic nose.

But today’s surgeons do much more to conserve the structures inside your nose and create a unique nose that naturally fits your face and flatters your profile.

Many rhinoplasty patients stay in touch with their surgeons and return after some years have gone by for minor touchups.

Most surgeons actually enjoy – and learn from – seeing their older rhinoplasty patients because they want to know how the nose has progressed over time.

Why? Mother Nature’s healing process is often the third party in the patient-surgeon relationship.

But minor touchups do not equal your original cost of rhinoplasty, nor are they as time consuming as was the healing process of the first nose job.

Rhinoplasty and Microsurgery

If you have read our bio, you already know we trained for a year in microsurgery so that micro-vascular surgery is one of our specialties.

What does it do? Short answer: makes repairs on very tiny things in the body.

Recently, there was a case in Minot, North Dakota, in which a man’s nose was torn from his face in a motorcycle accident.

Coming to the victim’s aid was not a plastic surgeon, but Dr. Juan Ulloa, a dentist with four years training in oral and maxillofacial surgery. (Read more about the rhinoplasty reattachment.)

As you might guess from the name, microsurgery is performing surgery under a microscope.

Dr. Ulloa was under the gun because the past has shown that he has about two hours to reattach a nose and stand a reasonable chance of it remaining alive on the patient’s face.

Just how tiny are the items involved in microsurgery?

The thread used to reattached blood vessels is ten times thinner than a human hair. So, your first guess is correct. The surgeon absolutely needs a microscope or ultra high bionic lenses on his or her glasses to see the work.

Before reattaching,  blood vessels must have clean, not ragged, edges so they will grow back together.

Dr. Juan Ulloa and patient

The work is extremely exacting: the blood vessels and nerves on which the surgeon works can be as small as two to four millimeters.  (One millimeter equals the width of the period at the end of this
sentence.)

The facial transplants that took place at the Cleveland Clinic required reconnecting multiple areas of the face with microsurgery.

According to news reports, Dr. Ulloa reattached the patient’s nose by finding the severed ends of his nasal arteries and veins and sutured them together. He then reattached the nasal tissue and splinted his nose to keep the bones in place.

“Cartilage in the nose is very soft and it’s difficult to get an acceptable result in such a case,” said Dr. Ulla who was holding his breath about the outcome.

But the patient had about the best outcome that could be hoped for.

While infection is always a possibility in cases like these, good aftercare resulted in the patient having a nose that looks normal, has sensation and – last, but certainly not least – one that he can breathe through.

Rhinoplasty and Turbinate Woes

Patients sometimes see rhinoplasty specialists because they have breathing problems and may require surgery inside the nose.

Typical breathing problems are usually caused by one of two things:

• A deviated septum, the wall that separates the nostrils
• Imperfect turbinates

Turbinates are long, narrow structures made of spongy bone inside the nose. Also known as nasal concha, turbinates have a number of functions, including:

• Good breathing
• Playing a role in immunological defense
• Keeping the olfactory receptors (for your sense of smell) working

But if the turbinates swell too much, your breathing may be blocked. The swelling can be caused by:

• Allergies
• Irritants in the environment
• Persistent infection in the sinuses
• Disease

The actual function of turbinates is to swell and subside many times  during the day to change the size of the air pathway.  Turbinates even cause you to roll over in your sleep!

In some cases, nasal surgery on the turbinates is done. But due to their role in breathing, only small amounts should be removed.

However, if the surgeon is too aggressive, a separate condition known as “empty nose syndrome” can be created.

Results?

Affected patients frequently complain about chronic dryness, stuffiness and a congested feeling in the nose, along with breathing difficulties and, sometimes, a feeling of not being able to get enough air into their lungs.

Others complain of burning, crusting and pain inside the nose.

Difficulties sleeping may crop up, too.

Empty Nose Syndrome (ENS) happens often enough that a self-help website, EmptyNoseSyndrome.org, was created in 2005.

The website offers a forum for Empty Nose sufferers along with information from plastic surgeons who specialize in the condition. And yes, treatments do exist for ENS.

We’ve often said that rhinoplasty is one of the most difficult surgeries for surgeons to learn and master due to the complexity of the human nose.

So checking your surgeon’s training, credentials and certification is more important than ever.

ENS is just one example of why.
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Rhinoplasty Reconstruction

A very advanced form of nose surgery is Rhinoplasty reconstruction.

Usually, some terrible accident or injury has smashed the bones in the nose and they need to be replaced.

The best framework for a reconstructed nose is bone and cartilage taken from the ribs. In some cases, ears can contribute small pieces of cartilage.

In a recent case in Mumbai, India, a ten-year-old girl got a rare but powerful microbial infection known as Noma (caused by the organisms Fusobactgerium necrophorum or Prevotella intermedia.) Both are due to living in conditions of poor hygiene.

Results? Because the infection is attracted to soft flesh, it ate away her nose and left ear. The unfortunate child was left with two nostril holes in the middle of her face.

Although the child came from a very poor family, she was able to attend school and was making good progress. But as her nose disappeared, the teasing and ridiculing eventually became too much and she quit.

Even though plastic surgeons were able to build a proper nose framework, they need the girl’s own skin to wrap and cover the bony nose structure.

Solution? Tissue expanders are often used in cosmetic breast reconstruction, are inserted under the skin and gradually filled with saline. That forces more skin to grow over time.

The same technique was used to grow extra skin to cover the girl’s nose.

A silicone balloon was inserted through a tiny incision in her forehead and then slowly expanded for four weeks. That provided enough skin to cover her nose. Presumably, the surgeons also made sure the girl could breathe through her nose.

The young patient told the Mumbai Mirror: “I feel very happy when I see myself in a mirror; people can’t make fun of me anymore..” Plus, she is back in school.

The nose is so important because it is the central focal point of the face.

When a nose has more-or-less normal parameters, the eye sees the face and profile in balance ; few people ever actually notice a normal nose. Instead, the eye usually deflects its attention to the eyes.

But when a nose is too large, misshapen, crooked, humped or drooping, observers’ eyes tend drag down from the subject’s eyes, concentrating more on the nose. The result is the eyes seem smaller.

Her partial ear can be covered by hair until more surgery can take place.

Rhinoplasty and Surgery on the Older Nose

Nose jobs are appropriate for people in their teens to senior citizens. But there are some special considerations in plastic surgery on the older nose. As we age – and with the help of gravity – many older noses also droop and appear longer and less attractive.

Those noses also tend to develop humps on the middle part of the nose.

So the surgeon must carefully consider the following about older rhinoplasty patients:

• Current medical problems
• Medications taken
• The patient’s expectations from surgery

Writes Rod Rohrich, M.D. a Texas board-certified plastic surgeon who has authored technical articles on performing the mature rhinoplasty: “Less is indeed more; mature patients do not want the big changes wanted by younger patients.”

Dr. Rohrich was president of the American Society of Plastic Surgery from 2003 to 2004 and is professor and chairman, department of plastic surgery at the University of Texas Southwestern Medical Center.

It’s an important topic because the first of the huge numbers of baby boomers (everybody born between 1946 and 1964) will fill doctors’ offices in two years. Perhaps you’ve read that baby boomers are not retiring like previous generations and often take up new careers.

Facial makeovers to look more energetic, rested and refreshed are often part of that boomers new career.

Nonetheless, all that energy and ambition is contained in a 65-year-old body!

Sometimes, the rhinoplasty surgeon finds, as the nose droops and grows longer, the internal nasal valve is also pinched, restricting breathing.

Solution? The surgeon uses a technique known as spreader grafts to safeguard the airway.

A piece of donor cartilage is inserted in the middle part of the nose to prop the nostrils open.

The surgeon also must carefully consider how the passing decades and gravity have affected changes in the patient’s skin, cartilage and the bony framework inside the nose.

To make the older nose look better the surgeon usually must:

• Bring up and straighten the tip
• Lengthen the columella, the strip of skin between the nostrils

Experts also say older patients heal more slowly and might have bruising and tenderness longer than younger patients.

If the patient is really concerned about his or her appearance, a neck lift or chin augmentation might also help improve the person’s facial profile.

Another bright idea: find a surgeon who has done many older noses!

Rhinoplasty’s Most Common Questions

Most patients ask common questions. The first is usually, “Will my nose be broken?”

Well, yes and no.

It’s not so much a brutal breaking or fracturing of bones as it is a controlled repositioning of the nasal bones. About 90 percent of nose job patients undergo a repositioning of the nasal bones.

How Every Rhinoplasty Patient Sees Her Own Nose

At least 90 percent of patients ask what can be done about a hump on the nose. The old way was using  a hammer and chisel during surgery to remove some cartilage and bone in one piece. But a better way, known to physicians as the component technique, prevents a common undesirable side effect in rhinoplasty.

Think of the nasal bones from a point between the eyes to the tip of the nose as a covered bridge. If a surgeon just removes the hump with a hammer and chisel, he or she may create more problems in the three-dimensional structure of the nose. The effect would be the covered bridge losing the peak of its roof line.

Working under the skin of course, the component technique separates – not cuts – that length of nose cartilage and bone and gently folds one side over the other so that the patient still has a nose that is like a covered bridge. But the bridge now has a straighter roof line, with no hump.

Other common questions to plastic surgeons from potential rhinoplasty patients include:

I can’t breathe through my nose!

Actually, part of the rhinoplasty surgeon’s mandate is creating an attractive nose that fits the rest of the face and is functional so you can breathe well through it.

Must I stay in the hospital and be put to sleep?

Rhinoplasty is usually done on an outpatient basis, most often in a certified surgical center with a board-certified anesthesiologist. Rhinoplasty is very, very exacting with tolerances measured in millimeters. So it’s best for the results if the patient lies still like a statute under general anesthesia.

How much time is lost from the job?

You should take a week off work. Some bruising is usually still visible by day 10 but can be covered by camouflage makeup. You should be presentable in about two weeks.

Will insurance pay for it?

For breathing woes, most insurance companies will cover the functional part. But they may not cover the cosmetic aspect.

Rhinoplasty and The Sense of Smell

When you first inquire about nose surgery, your plastic surgeon will tell you about the various risks of rhinoplasty.

Because the nose is so complicated and because healing highly influences the way your final result appears, rhinoplasty has one of the highest rates of revision, a secondary repair procedure.

So, your success rate is increased by choosing a board-certified plastic surgeon. (Read our previous post about certification in plastic surgery.)

Your surgeon will also tell you about the usual complications of nose surgery. They range from the serious like infections, excessive bleeding and bad reactions from anesthesia to swelling, bleeding and scar tissue formation inside the nose.

One complication you rarely hear much about – loss of smell – was studied by a plastic surgeon in Iran and reported in the March, 2009, issue of BMC Ear, Nose and Throat Disorders, a professional journal for physicians.

Dr. Hashem Shemshadi, M.D. a plastic surgeon and three associates studied a group of 40 men and women rhinoplasty patients who had open rhinoplasty. (See a 3D animation of open nose surgery.)

Before surgery, the researchers gave the patients a smell test with 40 familiar scents; they all passed with flying colors.

Then, one week after surgery, the doctors tested the same 40 odors on the patients again.

Results? 87.5 percent could not smell while the others had at least moderate degrees of smell impairment. But it wasn’t permanent.

At the six week point after surgery, 85 percent of the patients reported only a mild to moderate decline in their ability to smell.
At the six month point, the smell i.d. test was given yet again. The researchers found the subjects’ olfactory function was just as good as before surgery.

While this group needed six months to regain their complete sense of smell, others patients may take a little longer.

Why the loss of smell after rhinoplasty?

The delicate and complicated human nose senses odors because, as you breathe, air swirls around inside the nose in eddies on its way to your lungs. Certain regions of the nose, along with some in the mouth, have nerve endings to detect odors.

Swelling goes hand-in-hand with most nose surgery. So the air that carries scent molecules simply cannot get to the right nerve endings.

When the swelling subsides, the problem is solved.

Nose Surgery for Teens: A Good Thing?

The American Society of Plastic Surgeons (ASPS) just released its annual plastic surgery statistics for 2008.

According to the ASPS survey, 38,136 teens had rhinoplasty during ‘08.

Like most surgeons, I prefer to wait until a patient is at least 18, when the nose is fully developed, before performing cosmetic nose surgery.

Of course, there are some exceptions, like when the condition of the patient’s nose is affecting his or her daily life or if the patient is unable to function in public due to the appearance or condition of the nose.

The youngest rhinoplasty patient I’ve had was 17.

I’m sure many of those 38,000 nose surgeries on teens under 18 are due to a functional problem inside the nose that restricts normal breathing. Many others are probably related to accidents and other injuries.

But, even with older teens, the plastic surgeon wants to know a few things before going ahead with the procedure.

For instance, does the teen:

• Want surgery for him-or-herself alone?

During the initial consultation, I carefully watch to make sure the desire for surgery is coming entirely from the patient, and not parents or friends. Plastic surgeons also watch for young people who unrealistically want the features of rock or movie stars. And is the desire for rhinoplasty a fad? Was it breast augmentation last week and liposuction the week before that?

• Understand the after care involved?

Having nose surgery is not the end of the process. The teen must be mature enough to realize that certain after care must be taken for a freshly rejuvenated nose.

I also want to see that the patient appreciates and understands the small risks that exist with any surgical procedure.

• Have realistic expectations?

Even if the procedure is cosmetic, is the teen mature enough to understand that a more attractive nose won’t solve all of life’s problems?

A better looking nose does give a person more self-confidence but it won’t make a young person a rock star, captain of the football team or the head cheerleader.

• Have allergies?

Plastic surgeons need to know if the patient has allergies because pollen, dust, pet dander and other substances can be breathed in through the nose to swell passageways and close off the nostrils.

Rhinoplasty? Is That With – or Without Surgery?

If you read rhinoplasty advertisements, you’ll see many that promote a procedure widely known as non-surgical rhinoplasty.

Non-surgical nose surgery is the process of making a nose look better by injecting semi-permanent fillers such as:

• Juvederm
• Restylane
• Radiesse

What the ads don’t say:  non-surgical nose surgery is primarily for noses that need only minimal augmentation or small touch-ups.

Consequently, rhinoplasty sans surgery accounts for less than five percent of nose shaping procedures. Plus, the fillers last only about a year or less.

In any case, you should probably consider health before beauty. Many surgical rhinoplasty surgeries also improve breathing.

Then, you might want to consider the cost of non-surgical rhinoplasty.

Because the soft tissue fillers like Restylane are injected deep into the nose and because the human nose is extremely complicated, patients get the best results after seeing a board-certified plastic surgeon or head and neck surgeon who has as lot of practice giving those injections.

(Look for certifications by the board of plastic surgery or the board of otolaryngology, for head and neck surgeons.)

The average cost for non-surgical nose surgery is around $1000.
Rhinoplasty injections are actually used only on a very few places on the nose, including:

• Around small nasal bumps
• To fill in the depression on a boxer’s nose, something your surgeon knows as a saddle nose deformity
• Ski slope noses
• Small pits or depressions on the sides of the nose
• The depressed area between the top lip and nose

However, you would need invasive rhinoplasty to improve the appearance of very large noses, for tip reductions and large humps.

Many Asian and African-American patients, who have a flat bridge, ask for facial fillers to build up that part of the nose.

In some cases, silicone – instead of facial fillers — is injected into the nose. I personally don’t recommend silicone due to the high chances of developing lumps and bumps, or granulation, just under the skin and due to the possibility of infection.

What would you like to do to your nose? Feel free to leave a comment!