(The same technique can be applied to breast augmentation. Read our blog post about breast enlargement with fat.)

If the technique should become more widespread, that would mean some nose surgery techniques could be done, not with scalpels, but with needles.

Here’s how it works:

The plastic surgeon takes some of your own fat from areas where you can spare it – perhaps your tummy or thighs. In plastic surgery, it’s a fairly new and growing specialty known as autologous fat transfer.

The fat is then carefully prepared.

It goes into a centrifuge, a device that whirls the fat around in a circle to separate blood, anesthetic and other fluids from the donated fat; it’s known to cosmetic surgeons and plastic surgeons as lipoaspirate.

Next, the surgeon gives the patient a local anesthetic and fills his syringe with the prepared fat cells. The surgeon can then:

• Flatten bumps on the nose
• Make crooked noses appear straighter
• Widen tiny noses
• Fill depressions on the nose

However, large noses cannot be made smaller. Only nose surgery can do that.

Plastic surgeons can also perform the same treatments with fillers like Juvederm, Radiesse and Restylane although those substances are absorbed by the body in 12 to 18 months. While the body may absorb some fat, most is permanent.

Unlike rhinoplasty in which bone or cartilage is added, moved or rearranged with the patent asleep under a general anesthesia, injection nose surgery offers:

• Less cost
• Quicker recovery
• Minimal bruising
• A return to work in several days for patients

Nose-job with fat patients must not touch their noses or wear spectacles for seven days.

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

In New York, plastic surgeons have taken on the case of 24-year-old Brandy Elias who lost her nose to gunfire in Guyana, her homeland.

In Africa, Brandy had about two dozen surgeries on her face which became a mask of scar tissue; her appearance forced her to wear a gauze mask where her nose once was.

The novel surgical approach of creating a new nose is allowing it to grow and develop a blood supply by placing the fledging nose on her forearm. The bridge of the new nose is actually a piece of arm bone with the blood vessels attached.

According to Dr. Minas Constantinides of NYU Medical Center, Brandy will be able to breath and smell after the fledgling nose is moved from her arm to her face.

Exclaimed Brandy “I can’t wait to stop wearing the bandage (over my face) so people will stop staring and asking a lot of questions!”

Watch the KABC New York video about Brandy’s nose surgery.

The technique was done at least once before in Aberdeen, Scotland, in 2001, when 25-year-old Madina Yussuff  showed up, explaining she lost her nose as a child in Nigeria.

A gangrenous, flesh-eating disease known as Noma destroyed her lip and one eyelid along with her nose.

Consequently, Madina has spent most of her life in hospitals.

Scottish surgeons used Madina’s own ribs and thin slices of her skull to build the framework of a nose which was then implanted into her forearm.

Her skin in that area of her arm was expanded to provide a covering for the new nose.

Once a blood supply was well developed, the nose and its blood vessels were be moved to her face.

Various charities have donated 30,000 British pounds (US$49,470) while medical staff donated their time and skills.

According to the National Health Service in Aberdeen, Madina returned to her homeland and had some additional touch up surgery to increase her mouth and nose openings and was planning on starting a business with the money that been donated by big-hearted people in the U.K.

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.

But, at the same time, some of these people do not have black eyes or purple bruising on their faces.

The amount of bruising actually all depends on the type of nose surgery a patient has undergone.

The rule of thumb: If your nasal bones were not broken during surgery, you will probably see a clearing of whatever bruising exists within three days to a week.

Ditto if your plastic surgeon only shaved or filed down a bump on your nose,

Breaking the nose bones, though, causes more bruising which could require one to two weeks to heal.

Ask if your surgeon uses open or closed rhinoplasty.

Closed rhinoplasty creates swelling that takes anywhere from one to six weeks to subside.

But in an open rhinoplasty — the procedure in which the skin of the nose is peeled back from the bony framework of the nose – swelling takes longer to go down. It could be from one to six months.

(Nobody can give you a more exact answer because every nose job is unique.)

At first, you’ll probably feel like your whole face is swollen and that you have a minor headache.

But the prescription pain medications prescribed by your doctor should help; it’s a good idea to just chill out and stay in bed the day after surgery, with your head elevated. Keep some ice on hand to better control swelling and bruising.

Schedule at least a week off from work just for recovery. Continue sleeping with your head elevated for the first few nights after surgery. The idea is to prevent swelling that fluid accumulation brings.

And consider keeping some camouflage make up on hand in case you still have some bruising when you return to work.

Depending on the procedure, you may have a lot of nasal stuffiness, too. Nonetheless, your surgeon will probably tell you not to blow your nose.

Nasal packing usually comes out after two days while dressings, splints and bandages will be gone in about two weeks.

Things you want to avoid on and to your nose for one to three weeks include:

• Sunburns
• Any blow or strike
• Caution when face washing
• Anything that increases your blood pressure

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.

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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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.

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!

• The open, or external, technique

The surgeon makes a small incision in the strip of skin that separates your two nostrils and pulls the skin back to reveal the architecture of the nose. Imagine opening the hood of a very tiny car.

• The closed technique

The surgeon operates through your nostrils. Some surgeons, including the ones at California Surgical Institute, favor this approach although it requires extra training and is more demanding due to the small tolerances in the nose.

Also known as the endonasal approach, the closed technique offers some advantages, including allowing the surgeon to immediately see what the final result is going to look like.

But if the surgeon is using the open technique, the nose skin must first be pulled back into place over the nose framework to get an idea of the nose’s final outcome.

The closed approach can heal faster. When the nasal skin is peeled back, the lymphatic drainage system is interrupted; that also causes more swelling.

Most surgeons who use the closed technique learn it from an older, more experienced plastic surgeon and that might require a year-long fellowship.

Of course, there are exceptions: if the surgeon is doing a repair of a previous nose job – a revision rhinoplasty — there may be too much scar tissue to allow the surgeon to get to the area where he needs to work. He may then switch to the open approach.

Or, if the surgeon is not getting the results wanted, he or she may go ahead and open the nose up for better visibility.

However, if the surgeon starts with an open, he or she can’t go back to a closed and enjoy its particular benefits.

A closed may be best for removing a nasal hump while changes in the tip of the nose may require an open.

Which is best?

If you like the quicker healing of the closed approach, do the next logical thing and look at the surgeon’s before and after rhinoplasty pictures and make sure all the noses you see look natural and fit well within the faces shown.