Managing Swelling in the Nose After Rhinoplasty


Rhinoplasty surgery is certainly a complex and complicated procedure to perform. Small maneuvers can result in big changes and unintended consequences. It certainly helps to have a surgeon working on you that knows what they are doing.  Unlike most plastic surgery procedures, nose reshaping takes longer to heal and deliver a final result.  Of all the procedures I perform, rhinoplasty easily requires the closest patient management to get the best results.

Because healing from nose surgery can take up to a year, it is best for patients to exercise a bit of patience to avoid going crazy over those 12 months. Aside from asymmetry, one thing that most patients fret over is swelling in the nose after surgery. Having answered 100’s of questions on, one theme that pops up a bunch has to do with prolonged swelling after rhinoplasty. In general, it doesn’t seem like nose surgeons are doing a great job in preparing their patients for recovery after surgery. Many prefer to take the auto-pilot approach and let time determine the final outcome.

In my opinion, that’s nonsense! An exceptional rhinoplasty surgeon will take the time necessary to educate their patient before and after surgery to make sure that there is a healthy partnership that ensures optimal results. I am great proponent of a hands-on approach to after surgery management of nasal healing and make sure that my patients are taught all they can do to get the best results. To manage swelling after surgery, here are a few things to consider.


Being nutritionally sound prior to surgery will definitely help reduce recovery times after surgery. I am a big proponent of a high protein diet and use of certain supplements for several days before and after surgery. My favorite supplements are Arnica Montana, Bromelain, and Vitamin C. Each supplement has an important roll in healing after surgery.


One of the biggest causes of post-surgical swelling after surgery is inadequate control of bleeding while the patient is on the operative table. Time spent on controlling bleeding in the O.R. will benefit the patient after.


After surgery, the race is on. Patients are so busy trying to get back to their regular lives that they don’t realize they have a big part to play in reducing swelling. I require icing and head of bed elevation to control the major swelling that occurs during the first five days after surgery. In addition, a nasal splint is applied for both protection of the nose and to reduce swelling, pain, and bruising. While patients hate packing in the nose, it is a great way to tamponade bleeding and cut down on bruising and swelling.

Patients groan when they learn of the many things that can increase swelling after surgery. When I remove the splint at one week after surgery, patients are so excited by the results. However, soon that excitement turns to caution as they watch their now uncontained nose swell. This is where patient behavior and compliance with teaching become critical. At the day of splint removal, I teach patients how to tape their noses at night and how to gently mold the nose using pressure several times a day. This helps guide nasal shaping in my opinion.

Patients often remark on how every day they have a new nose because of the ebb and flow of swelling they see. Over time this stops and the nose shapes up quite nicely. Patients in Denver love to be active but this can make recovery slow after nose surgery. Anything that increases your heart rate or blood pressure will increase the swelling in your nose. Extra icing after workouts can help in this situation.

Excess salt or alcohol in the diet can cause swelling. Low protein intake can cause swelling. Excess heat exposure can cause swelling. Sunburn that injures the delicate nasal skin after surgery can cause swelling. Re-traumatizing too early after surgery can increase scar and worsen swelling. So many things can cause swelling. Often the difference between a successful rhinoplasty and a mediocre one is how well the patient managed swelling after surgery.

If swelling doesn’t seem to be resolving despite the patient being compliant with aftercare, the problem may be scar in the nasal skin. This scar can block lymphatic drainage causing a backup of soft-tissue fluid under the skin. A go-to for me in this situation is the use of low dose steroid injections. Steroids shut down inflammation, thereby reducing fluid accumulation.

A final trick that works well is to make sure that the pores of the nose are clean and dry. Anything that plugs the pores will make the skin boggy. Patients with aggressive T-zones have more swollen nasal skin after rhinoplasty than those whose T-zones are small. Pore strips or charcoal waxes that pull out blackheads are very helpful. Nightly hydrogen peroxide cleansing of the nasal tip skin also helps by killing the bacteria in the pores that make the blackheads. Reduced blackhead formation leads to cleaner, less porous skin.

The video below shows my technique taught to patients for managing the swelling that occurs the first 2 months after surgery:

Ultrasonic Rhinoplasty – It’s time for a change!


For the past 100 years rhinoplasty, or nasal reshaping, surgery has been performed in pretty much the same way. There have been minor alterations, here and there, in technique: open vs. closed approach, graft vs. no graft, alloplastic vs. autologous grafts, hand-held rasps/chisels vs. powered rasps/chisels, etc. What all techniques have had in common is that the tools used were fairly simple in what they could do to reshape the nasal bones to create elegant lines and shapes. With social media driving an increasing number of patients to the offices of plastic surgeons around the world, it hasn’t escaped notice that patients are seeking even greater refinement of their features.

Most people are familiar with ultrasound if they’ve ever had children. All parents remember the joy created by getting to see the ultrasound pictures of their unborn children. Ultrasound has been used for decades in radiology to detect lesions and masses of all kinds. More recently, dentists have been using ultrasonic equipment to gently clean teeth and help them with delicate dental bone surgery. The technology uses high speed sound waves to power tiny tools to vibrate ever so gently to perform removal of surface tissues like plaque and bone.

In the world of plastic surgery, ultrasound technology has also been used, primarily for body contouring and fat reduction. For example, the VASER device is a tool used by liposuction specialists, like Dr. Shah, to gently melt fat with sound waves before regular liposuction techniques are used to remove excess fat. Ultrasound is also used in some devices like Ulthera to melt fat of the face and tighten skin to perform nonsurgical face rejuvenation.

In the last couple of years, the world of rhinoplasty has been turned on it’s head with the introduction of ultrasonic rhinoplasty tools that allow the expert nasal surgeon to perform more delicate alterations to the nose than was previously possible with traditional tools. Dr. Manish Shah, a Denver board-certified plastic surgeon who specializes in advance rhinoplasty techniques, has introduced the first ultrasonic rhinoplasty device to the Mountain West region of the United States. There are only a few devices available to patients in the country.

Social media and nasal contouring make-up techniques have driven an interest in more sculpted nasal shaping. With this new device, Dr. Shah has been able to create more elegant results for his rhinoplasty and revision rhinoplasty patients. The device has a number of ultrasonic tips available to perform varying technical maneuvers.


Dr. Shah has the Expert Tip Set that allows him the greatest variety of tools to work with during difficult rhinoplasty cases.

The device that Dr. Shah uses is made by Comeg Medical, a European company that excels in the manufacture of ultrasonic medical equipment. Because the device uses high speed sound to gently vibrate the tips, Dr. Shah is able to create less trauma during surgery to surrounding tissues, focusing most of the trauma only on the nasal bones themselves. This results in less swelling, pain, and recovery time.

The young woman below had an ultrasonic rhinoplasty, and it is easy to see how natural her nose looks.


While most rhinoplasty surgeons around the world continue to use the simple rasp and chisel to perform their nasal reshaping, whether manual or powered, the more savvy surgeon wanting greater outcomes for their patients has moved into the arena of ultrasonic surgery. Dr. Shah keeps rasps on his back table during rhinoplasty surgery, still using them when appropriate, but he is quite satisfied with the change his rhinoplasty practice has seen in terms of enhance patient satisfaction since the introduction of the ultrasonic rhinoplasty device.

For more information about Ultrasonic Rhinoplasty, please visit Dr. Shah’s website.




Deviated Septum and Weight Gain


Did you know that having a deviated septum can lead to weight gain? No? Well it can!  If you are asking yourself what a deviated septum is, let me explain it to you. The septum is a cartilaginous divider between the right and left halves of the nose. When the septum is straight, it provides laminar, or smooth, airflow equally to the nasal passageways and sinuses. When there is a bend or distortion of the normally straight septum, then airflow becomes turbulent, leading to all kinds of problems. The picture below shows a young man who has a significant septal deviation before and after correction.



Deviated septum can be caused by many things. Some people born with significant facial asymmetries tend to have deviated septa. Also, deviated septa can be caused by nasal and mid-facial trauma. In fact, after any nasal or mid-facial trauma, it is important to evaluate the nasal septum to confirm that it is intact. A missed hematoma (blood clot) of the septum can lead to septal perforation (hole in the septum) and weakening of the septal integrity and nasal collapse.

So, what is the mechanism of action by which a deviated septum causes weight gain? Well, it is multi-factorial. The first thing that a patient with a deviated septum notices, while awake, is difficulty breathing through the nose, especially when trying to exercise, making cardio more difficult to perform without mouth breathing. With advanced deviation, they may feel this restricted nasal breathing at rest. With reduced airflow comes reduced exercise capacity. This can lead to weight gain.

As intranasal airflow stays turbulent, specialized structures known as the turbinates are affected causing them to enlarge. This further blocks airflow, especially on the more open side of the nose. This is known as compensatory hypertrophy. The reason this occurs is that feedback loops inside the nose and sinuses are trying to compensate for asymmetric airflow, drying, and particulate matter exposure. In the end, the nose is trying to re-equalize airflow.

Another thing that most patients with deviated septa experience is snoring when asleep. The mechanism for this has to do with the fact that turbulent nasal airflow due to a bent septum forces people to breath with their mouths open when asleep. While asleep the tongue relaxes and falls to the back of the throat vibrating off the soft palate, making the distinctive snoring noise.

As this combination of effects adds up, excess fat that is gained is partially gained around the airway, narrowing it a bit and making the effect of a relaxed tongue with sleep more powerful. Eventually snoring leads to disordered sleep for the patient and often for their bed partners. In advanced cases, patients can develop sleep apnea which is a potentially life threatening obstructive breathing problem.

It is well-known that folks that have trouble sleeping develop certain types of hormone imbalances in substances like insulin, ghrelin, and leptin. This can lead to increased hunger, especially for carbohydrates, and disordered insulin function. High carbohydrate diets have been associated with significant weight gain. Another hormone that increases with poor sleep is cortisol. Cortisol is a stress hormone that in excessive amounts further deranges insulin function and carbohydrate metabolism, causing further weight gain. This cycle continues causing further sleep disturbances, weight gain, and more snoring. If you aren’t already convinced that getting good sleep is of the utmost importance, check out this article on the long-term effects of sleep deprivation.

The diagram below shows the basic cycle of problems caused by septal deviation:


If you happen to have a deviated septum and suffer from weight gain, you may want to consider being seen by a nasal surgery specialist for an evaluation. It may even help to get a sleep study to see how advanced your sleep deprivation is and to determine if you have sleep apnea. While a septoplasty procedure can help correct septal airway deformities, a diagnosis of sleep apnea requires a multi-pronged approach for management. Dr. Manish Shah is a Denver, Colorado area nasal surgery and rhinoplasty specialist who has a greater than 98% breathing reconstruction success rate. In fact, Dr. Shah had a septoplasty procedure as a teenager, and is currently the father of 3 high school students, so he intimately understands the importance of getting a good night’s sleep.

Teens and Rhinoplasty

young-1922401_1920Teenage cosmetic surgery is still not very common. But, when teens seek cosmetic surgery, a nose reshaping is the most common cosmetic surgery requested. It’s usually performed as an outpatient procedure under general anesthesia. This means you go to the surgery facility and then go home the same day. Getting a “nose job,” which doctors call a rhinoplasty, can be very simple or very complex. When done correctly by an experienced rhinoplasty surgeon, it can make a big difference in how a person looks and feels about themselves.

Some questions we’ll explore the answers to in this blog article are:

  • When Can Teens Have Rhinoplasty?
  • What Can You Change with Rhinoplasty?
  • What Are the Risks of Rhinoplasty?
  • How to Choose a Surgeon

When Can Teens Have Rhinoplasty?

Teens should not have a nose job until the nose has reached its adult size. This normally happens at about age 14 to 15 for girls. For boys, it is usually no earlier than age 17. If surgery is performed before the mid-face is fully grown, there may be alteration in the aesthetics and function of the upper jaw.

What Can You Change with Rhinoplasty?

Rhinoplasty can be performed for cosmetic and/or reconstructive reasons. Reconstructive reasons usually include the need to fix breathing problems due to a deviated septum and/or inferior turbinate hypertrophy. Cosmetic reasons for rhinoplasty include:

  • Removing a hump on the nose
  • Straightening the bridge
  • Reshaping the nose’s tip
  • Increasing or decreasing the size of the nostrils
  • Making the nose bigger or smaller
  • Improve the appearance and/or function of the nose after trauma

Health insurance may cover the costs for the reconstructive portion of a rhinoplasty procedure. Inquire with your health insurance provider for the terms of your policy.

What Are the Risks of Rhinoplasty?

Any type of surgery has risks. These include bleeding, infection, and allergic reaction to anesthesia. Risks of rhinoplasty include:

  • Numbness
  • Nosebleeds
  • Scarring
  • Nasal obstruction
  • Wound healing problems
  • Bursting of small blood vessels on the skin’s surface
  • Swelling
  • Permanent nerve damage
  • Septal perforation
  • Saddle nose deformity
  • Dissatisfaction with the cosmetic and/or functional outcome
  • Need for a revision operation

Many plastic surgeons take a lot of time to talk with teens before doing surgery. They want to make sure the teen is mature enough to handle it, is doing it for the correct reasons, and has realistic expectations about the results. For instance, thinking that changing your nose will change your whole life and make you more popular is not being realistic.

Before getting a nose job, teens and their parents or guardians should talk extensively with the surgeon and weigh all of the risks and benefits. Honest communication between you, your parents, and the surgeon is very important to the success of the operation. It is very important to understand why a teen might seek to change the appearance of their nose. Bullying, self-image problems, history of nasal trauma due to sports injury, etc. are some valid reasons teens seek rhinoplasty surgery.

After a nose job, recovery takes patience and support from family and friends. You will need to keep your head elevated for 7 days after the operation. And there will be some pain and swelling (which can be managed with pain medication and cold compresses). Some people become discouraged with the swelling and how they look immediately after the operation. But when the swelling goes down, the redness disappears and the nose fully heals. This can take weeks, but most people like the results. The upper 2/3’s of the nose heals in the first 2-3 months. The tip of the nose takes until the 10th to 12th month to completely heal. If the surgery is a revision operation, it could take twice as long to recover.

Look for a surgeon who is experienced in plastic surgery of the nose and who has a reputation for achieving patient satisfaction. The American Board of Plastic Surgery (ABPS) and the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS) are the most common bodies that certifies rhinoplasty surgeons. Make sure you read both the good and bad reviews about the surgeon to get the most accurate impression about them.

It’s best to have the procedure done in an accredited facility. If you have a complication, an experienced surgeon working with a well-trained team will be able to assess and correct the situation.

When you consult with a rhinoplasty specialist, they will evaluate your nose in the office. They will assess shape and function of the nose to determine the surgical plan. They will take photographs and perform rhinoplasty simulations to better understand your cosmetic goals.

You should talk to your surgeon in detail to describe your goals and learn about the risks and benefits of a rhinoplasty surgery. You should also ask your surgeon for information on what it will cost. Cost estimates are typically given at the time of consultation. For insurance cases, cost estimates are more difficult to assess.  If you have health insurance, talk to your health insurance company so you’re clear on what will be covered and what you will pay for. Health insurance companies usually don’t pay for plastic surgery unless there’s a medical reason for the operation.

Check out this video on choosing a plastic surgeon…

If you want to recover quickly after surgery, you should do these 7 things!


While plastic surgery procedures vary in complexity and anticipated recovery times, it is pretty widely known that everyone is ultimately looking to heal faster and minimize downtime after a procedure. It is important to consider these 7 things you can do to ensure a fast recovery.  It is vital that you plan ahead so that there are no surprises while you are recovering after surgery. In conjunction with proper sleeping habits, the food you eat can heavily influence your recovery as good nutritional choices can promote faster wound healing and return to activity.  Facial surgery in particular, such as rhinoplasty, has more obvious social downtime associated with it and an optimized recovery is always welcomed!

1. Drink Plenty of Water

Proper hydration is very important in terms of daily nutrition, and even more so when recovering from surgery. Adequate water intake flushes impurities (including surgery drugs) out of your system, stabilizes your metabolism, reduces joint pain, and helps combat fatigue. Leading up to your surgery date, increase your water consumption to 8-10 glasses of water per day, and gradually work your way back up to that intake rate after the procedure. Adequate water intake protects your kidneys and helps maintain your blood pressure during and after surgery.

2. Consider Adding Vitamin Supplements

For those concerned about adequate post-op nutrition, vitamin supplements are available and worth considering. Discuss with your surgeon what supplements are right for you and your recovery plan. If you are taking any special medications, be sure to ask your doctor if any foods are off-limits while you recover. My favorite post-surgery supplements are Arnica montana, Bromelain, Astaxanthin, and Vitamin K. I have found that their use in preparation for surgery and recovery after surgery has resulted in quicker resolution of swelling and bruising.

3. Don’t Skip the Protein

During surgery, various body tissue types are damaged and in need of repair. Adequate protein intake helps your system rebuild these body tissues. Vegetarians and vegans should seek protein through almonds, tofu, tempeh, and seitan. If eating meat isn’t a problem, opt for lean meats such as chicken, pork, and seafood.  Protein supplementation with a flavorful whey protein drink is also desirable.

4. Be Sure To Eat Even if You Don’t Want to Eat

This may sound obvious, but don’t forget to eat. Depending on the location of your surgery, eating may become painful or inconvenient – since your metabolism is up after surgery, now is not the time to swear off food. Your body needs healthy calories when it is in a state of self-repair, and denying your system important nutrients could result in delayed wound healing. Medication like narcotics and antibiotics can upset the stomach, so stick to simpler meals that are easier to keep down. If eating proves painful or uncomfortable but otherwise digestible, opt for calorically denser foods. Make sure you have a selection of foods you like easily available. Get your grocery shopping done well in advance of surgery.

5. Add Fiber to Keep Things Moving

High-fiber foods help stabilize your digestive processes, and reduce the risk of constipation, a relatively common side effect of surgery. Popular foods include whole grain breads, fruit, vegetables, beans, and certain fiber-rich cereals. If concerned about constipation, avoid dehydrated or processed foods, dairy products, red meats, and sweets. Adding a stool softener or fiber supplement may be necessary.

6. All Hail Vitamin A

Adequate Vitamin A intake promotes epithelial and bone formation, as well as boosts general immune function. For high vitamin concentrations, try leafy greens such as kale and spinach. Other viable sources include yams, carrots, squash, and bell peppers. Vitamin A is fat soluble, meaning that it must be consumed with fat for optimal absorption, so considering preparing your cooked kale with a serving of extra virgin olive oil. Patients who are on oral steroids for chronic medical conditions especially benefit from Vitamin A supplementation.

7. New Collagen Requires Vitamin C

Collagen regeneration is required to restore structural proteins in the skin, a vital element of recovery after surgery. In addition to boosting collagen formation, Vitamin C promotes immune function, and acts as a tissue antioxidant, blocking the harmful effects of free radicals in your system. The vitamin is water soluble and requires a continuous supply, as residual amounts of Vitamin C are expelled from the body in our urine. Vitamin C rich foods include citrus fruits, kiwi, mango, broccoli, and potatoes. Add orange juice to your whey protein to make a power shake!


Taking the time to plan for your recovery will ensure that things go as smoothly as possible. Proper nutrition is key to this. Ask your surgeon about their particular nutritional optimization program so that you are both on the same page when it comes to having a successful surgery. Good luck!

Flying after Rhinoplasty surgery – Is it safe to do?

When deciding on having rhinoplasty surgery, working with the best doctor for your needs should be your top priority. After doing your homework, you may determine that the best surgeon for your situation does not practice in your city.  This is especially true when thinking about having revision rhinoplasty.



If a patient is given the go ahead to travel a few days following their rhinoplasty surgery, there is the possibility that they experience some discomfort while in the air. An increase in sinus pressure could result depending on your procedure, however using a saline spray may help alleviate the discomfort.


There is a discontinuity in the skin of the surgical site during the first week until scar formation occurs. The pressure fluctuation inside the plane could make you more susceptible to minor bleeding during this time due to circulatory pressure changes. Though this is rare, the major concern would be the limited access to medical care if a vessel were to begin to bleed.


Following surgery, the discontinuity in the skin increases your susceptibility to injury and infection. Avoid traveling in tightly packed compartments such as in the subway trains during peak traffic. As well, swimming, baths, pools and hot tubs are not safe for any surgical incision which isn’t completely closed and this does have a limiting factor on many people’s ideal vacation plans so it is important to understand what activity is allowed while healing. Avoid direct sun exposure till at least six weeks or until the incision heals as sunburns can damage traumatize the new skin and prolong the healing. Be sure to plan out your traveling schedule to give yourself enough time to recover.

Blood Clots

Most elective surgeries performed under general anesthesia carry a slight risk of blood clot formation. This is more of a concern for older patients, those who smoke or are obese and those who are taking hormone supplements or medication. A history of deep vein thrombosis or clots would put you at a slightly higher risk of experiencing this issue. In the early days after surgery, patients are encouraged to be immediately mobile, walk around slowly and reduce these risks. These precautions are typically more than adequate to ensure healthy circulation in the legs post operatively, however pressure changes and long periods of sitting still on a plane or lengthy drive would again, elevate those risks. For this reason, depending on the patient’s whole health picture, the surgeon will advise a required amount of time to pass before flying is considered safe. Dr. Shah usually recommends that on long flights or road trips that patients routinely get up and move around or get out of the car for a quick stretch.


As mentioned before, lowered cabin pressure relative to blood pressure causes ankles to swell while sitting in an airplane. The nose can swell as well, because after surgery, it is susceptible to pressure related changes in nasal shape.

Patients are traveling more than ever now for both elective and non-elective surgery. Access to the internet and social media have made it so that patients can attempt to be their own best guide in finding the right doctor for their concerns. Often times, that doctor isn’t close to home. Most drive to find their surgeon, but some may have to fly. For those that have to fly it is important that they know the facts that will help them ensure a safe and successful experience.

Planning for a Successful Rhinoplasty Surgery Procedure – What You Can Expect and What You Should Do


Planning for a rhinoplasty procedure is something that all patients seeking nose surgery should take seriously. Rhinoplasty, or nose job, surgery is the most difficult of all cosmetic surgery procedures. With revision rates as high as 30-50%, you must make sure to do all of your homework ahead of your visit with your plastic surgeon.

Researching the procedure before your visit

It is important that you take some time to read up on rhinoplasty surgery to familiarize yourself with the procedure and what it entails before you go and have a consultation with a board-certified plastic surgeon or facial plastic surgeon who specializes in rhinoplasty. The most obvious source for information on just about anything these days is the Internet. The problem with the Internet is that while there’s lots of great information about any subject you might care to learn more about, there’s also lots of junk information. Below is a list of reputable sources of information about rhinoplasty (besides this blog of course!):


Researching your plastic surgeon to make sure you pick a good one

Once you’ve familiarized yourself with the rhinoplasty procedure, it is time to choose one or a few surgeons to consult with, or interview, to both learn more about the procedure and to see if you like their style and temperament. There are basically two types of surgeons who perform rhinoplasty: board-certified plastic surgeons and board-certified facial plastic surgeons. Avoid anyone else who does not come from this medical training background as they either dabble in the procedure (do not truly specialize) or are wholly unqualified to perform this procedure! Below is a little tutorial I put together on how to choose a plastic surgeon:


What happens on the day of the consultation?

Once you’ve chosen the surgeon(s) you plan to consult with, go ahead and call their office(s) to get on the schedule to meet them. Be aware that many plastic surgeons charge a consultation fee to consult with them. Do not let something like a consultation fee scare you off from visiting the best surgeon for you. I say this because some surgeons don’t charge a consultation fee because they are afraid patients won’t pay to come see them if they do. Your face is nothing to mess with, so don’t let the fact, that a surgeon you are interested in charges a consultation fee, dissuade you from seeing them.

On the day of your consultation, make sure to bring a list of your questions for the doctor. Also bring any “wish pics” you have of noses that you like. This will help your surgeon better understand your aesthetic mindset.

The consultation typically starts with the surgeon or their patient coordinator evaluating your medical history. It is absolutely vital for you to tell the truth on your medical history forms. Concealing any pertinent health information could jeopardize your physical safety, especially on the day of surgery. Once the health review is completed, your surgeon will examine your nose and ask questions about your concerns.

Skilled rhinoplasty specialists will evaluate your face from several angles to see how your preoperative nose fits in with the rest of the face. They will check the skin of the nose, the cartilage strength and position, and the bony anatomy and contour. An internal exam of the nose will be performed to evaluate for a deviated septum, septal perforations, airway obstruction, nasal valve function, and to look for any nasal masses. Based on the starting anatomy and your aesthetic/functional concerns, your surgeon can develop an operative plan.

Most rhinoplasty specialists will typically take a series of photos of the nose after they’ve completed a physical exam of your nose. These pictures serve to educate the patient on their starting anatomy, including all the normal asymmetries of the face not typically recognized by the average person. With these photos your surgeon can perform rhinoplasty simulations. Simulations are used to educate a patient about realistic possible outcomes from surgery. Simulations are not, however, a warranty or guarantee, of a particular outcome. Remember that many patients need a little touchup procedure after the nose completely heals.

At this point it is time for you to ask questions of the surgeon to make sure you both are on the same page. Check out my blog article Top 10 Questions to Ask a Rhinoplasty Surgeon to see what I think makes a good list of questions to ask your surgeon.


How am I going to pay for my surgery?

Rhinoplasty surgery can be either elective cosmetic surgery or can be covered by your health insurance policy. If you don’t like the look of your nose and are wanting to improve it for the sake of it’s look, this is considered to be a cosmetic reason for the surgery. Health insurance companies will not pay for these types of surgeries. Your surgeon will often offer several forms of financing to cover the cost of the surgery, anesthesia, and facility charges. Of course cash, checks, and credit cards will always be welcomed.

If you have problems with nasal obstruction or other types of breathing problems due to anatomic problems with your nose, whether congenital or due to trauma, your health insurance will often cover the cost to fix these problems. Your surgeon, however, has to prove medical necessity first. To do this, they will often try to manage your nasal obstruction concerns using medication, and other nonsurgical methods, for 4-6 weeks. If this fails, it is often due to a fixed anatomic deformity that can only be improved upon with surgery.


I’ve arranged my form of payment for my surgery and have scheduled the surgery date

At this point you have made arrangements to pay for the surgery and have a surgery date scheduled on the calendar. Most patients will want to take 1 week off of work to have enough time for a successful recuperation period after surgery. To prepare for the surgery, your surgeon will typically schedule you for a preoperative appointment 2-4 weeks prior to surgery. During this appointment, your surgeon and their staff will finalize the surgical plan and go over your simulations to make sure that you still agree with the plan and the cosmetic goals. You will sign your surgical consent forms and the office staff will start the process of your medical clearance (if medically indicated). Medical clearance is a process in which you have blood work obtained and an EKG (electrocardiogram) performed to make sure that you have the best chance for a successful and safe surgery. If you have particular medical issues, your surgeon will also want to communicate with your general doctor to make sure you are truly safe to move forward with surgery. If it is safe to do so, you will typically stop all unnecessary medications and supplements that would increase your chances of bleeding during surgery. These might include aspirin, ibuprofen, fish oil, garlic, vitamin E, weight-loss supplements, etc. Your surgeon will have a list for you to read over. Also this would be a great time to stop smoking as well. Nicotine in tobacco cigarettes is a poison that effects the blood supply to the nose and continued smoking could cause tissue loss in your nose.


The day of your surgery

On the day of surgery, you come to the surgery center with someone who will be able to take care of you for 24 hours after surgery. Most patients will need general anesthesia to have their procedure performed. Sometimes the procedure can be performed using only local anesthesia, or IV sedation. Either way, you will want a responsible adult with you to help you in the first day after the procedure.

You will be greeted by the nursing staff and your belongings secured. You will change out of your street clothes and into one of those drafty patient gowns. The preoperative nurse will ask you some questions including when you ate last. It is important to have an empty stomach prior to IV sedation or general anesthesia procedures. If you are having surgery using only local anesthesia, you are typically allowed to eat something before the procedure. After the question, the nurses will go ahead and start an IV and get you situated on the bed with a warming blanket. If you are female of childbearing capability, you will have a pregnancy test administered. If you happen to be pregnant, your selective surgery will be cancelled for the safety of the fetus.

At this point, your anesthesiologist will come and speak with you. He/she will ask you pertinent questions about past anesthesia experiences, etc. They will examine your mouth and your neck to determine how easy or difficult of an airway you might have. They will then have you sign anesthesia consent forms after you’ve had a chance to ask any questions you might have about anesthesia.

Your surgeon will be the last person to see you before you go back to the operating room to have your procedure. This is a great time for you to ask any last minute questions. It is a great time to review the surgical goals and plan with you one last time. Make sure you get your desires across.


The operating room

At this point, you have been given a little IV cocktail of sedatives to relax you and help you drift off gently to sleep for surgery. The surgical team will wheel your gurney back into the operating room and place it next to the surgical table. While you will feel drunk, you are still able to move. The surgical nurse will help you move over onto the surgical table. The gurney is then removed from the room. You will be secured on the table and warm blankets will be placed over your body. Operating rooms are notoriously cold for sterility purposes. Special massaging socks will start squeezing your calves. These help prevent blood clots.

The anesthesiologist will then add more medications to your IV while making you breathe 100% oxygen to pre-oxygenate your lungs. One of the medications you are given is a short-acting paralytic drug that relaxes your muscles for a short period of time so that the anesthesiologist can go ahead and safely intubate you. Intubation consists of placing a tiny tube into your mouth, across your vocal cords, and into the upper part of your tracheal airway. A little cuff on the tube is inflated to avoid the loss of anesthetic gases used to keep you asleep during surgery. Your endotracheal tube is then secured to your face with special tape to keep it from dislodging.



Every surgeon will perform your surgery slightly differently. Issues like anatomy, medical history, and desired outcome play into the path a surgeon will take with your nose. It is always recommended that you discuss this in detail with your surgeon prior to surgery. There are commonalities for most patients, ever. Most patients will have sutures if they’ve had an open rhinoplasty procedure. Most surgeons prefer this procedure because it allows better visualization of the nasal anatomy. Many patient may have intranasal packing or airway splints to control postoperative bleeding and help shape the healing nasal airways. Finally, the majority of patients will have some type of splint/cast on the outside of their nose to smooth the skin back down and control swelling of the nose.

Bruising is to be expected and will last 7-10 days. In my practice, we use a Rapid Recovery Protocol to minimize the bruising and swelling my patients experience.


Your recovery

Rhinoplasty is the procedure that takes the longest to heal from. Primary rhinoplasty patients can expect their final results to take a year to manifest. Secondary or revision rhinoplasty patients may need 18-24 months to see their final results. The extra recovery time is due to the scarring and blood supply alteration created during the first rhinoplasty procedure.

The first week after your surgery, you will be taking it easy. You will sleep with the head of your bed elevated to decrease swelling and control blood pressure to your head to reduce bruising. Aggressive icing around the nose and eye will help this out tremendously. You might need a little cotton dressing at your nostril to catch any draining blood. Because your nose will feel stuffy, you will probably breath open mouthed, or even snore after surgery. I highly recommend the use of a cool mist humidifier to soothe your throat. Nasal packing is removed 2-3 days postoperatively.

You will keep the splint on your nose for about 6-7 days. At the time of external splint removal, your surgeon will remove any external stitches. Internal airway splints may be removed 7-21 days postoperatively, depending on the situation. In my practice, this is the time I provide a patient with their second phase of rhinoplasty recovery instructions. In my practice, I teach patients night time taping and daily soft tissue molding exercises. Your nose will definitely swell after the splint is removed, so I like to control this process.

The upper 2/3’s of your nose will stay swollen for 2-3 months before recovering. If your nasal bones were reshaped or narrowed, they will be fully healed by this time. You definitely want to protect your nose from any other trauma until this time. After this period, most patients don’t notice significant changes in the nose until the 9th month when the tip itself starts to soften. By 12 months, healing is typically complete.

If you are concerned with the pace of your healing, I highly recommend sticking close to your surgeon and their team. Aggressive swelling can be managed with taping and massage, but may occasionally require steroid injections to control. Besides, your surgeon has as much invested in the success of your rhinoplasty as you do. I can tell you that I have an extremely high satisfaction rate with both primary and revision rhinoplasty surgeries, and I believe it has to do with both my technical skills and the very close care we provide to each patient. While I want my patients to be happy, I also want to be happy with the noses I create or fix.

Check out this video I made regarding recovering from rhinoplasty:


Now that you have a better understanding of rhinoplasty surgery and the recovery process, you can confidently go forward with your own rhinoplasty journey. As always, I encourage you to do your homework and make sure you pick the best surgeon for you. If you have any questions for me or want to consult with me about rhinoplasty surgery, please call (303) 708-8234, or email me at my Contact Us page.

Revision Rhinoplasty – The Cure for a Botched Nose Job?


Revision rhinoplasty is a term used to describe a nose surgery procedure to correct problems or deformities that are the result of a previous rhinoplasty. There are many reasons a rhinoplasty may fail to produce the desired results,  but in any case it can be an exceptionally traumatic event to face.

Manish H. Shah, MD, FACS is a specialist in revision rhinoplasty in Denver, Colorado.  His fellowship at the Manhattan Eye, Ear and Throat Hospital in New York City, allowed him to work with his mentor, Dr. Tabbal.  Dr. Tabbal is one of the best revision rhinoplasty surgeons in the world and Dr. Shah was able to learn many advanced techniques to help patients with post-operative nasal deformities.  Revision rhinoplasty makes up at least 30% of the rhinoplasty operations he performs each year.  Patients from Colorado and surrounding  states consult with him to correct their noses after failed primary rhinoplasty procedures.  Revision rhinoplasty is generally considered the hardest procedure amongst all cosmetic surgeries.  This is due to the fact that once a nose has been operated on, there are multiple soft tissue types that are now scarred.  Skin, mucosal lining, cartilage, fat, and bone are all damaged in the process of performing the initial rhinoplasty.  Blood supply to the nose is altered and is usually diminished.  

Oftentimes, damaged cartilage will need to be virtually rebuilt from scratch to create the new nasal skeleton.  Sometimes, too much cartilage was removed at the first surgery and now needs to be put back to fix the nose and improve its support.  To build a new nasal skeleton, graft material, or cartilage, may be harvested from one of three areas of the body: the nasal septum (septal) cartilage, ear (conchal) cartilage, or the rib (costal) cartilage.  In extreme cases, Dr. Shah has taken split calvarial (skull) bone to rebuild noses.  These particular cases require the use of titanium hardware to fix the bone in place. There are pros and cons to the use of each of these materials, which should be discussed between you and Dr. Shah. In some cases the damage may be too severe so synthetic tissue may be used instead.   Various synthetic tissues include silicone, e-PTFE, and Gore-tex. Another possibility is that all of the above materials may be used, both the natural and synthetic.  If at all possible, Dr. Shah prefers the use of natural materials over synthetic ones.  They are less likely to cause long-term complications like infection, rejection, skin erosion, palpability, capsular contraction, and malposition.  A recent favorite of Dr. Shah’s is the DCF (diced cartilage-fascia) graft for rebuilding a bridge that has been over-reduced or over-resected. He has even perfected his own version of the operation known as the SCF (shaved cartilage-fascia) graft procedure.

The soft tissues of the nose are prone to inflammation after having plastic surgery.  The inflammatory changes result in scarring that increases the stiffness of the tissues.  When patients have had several revision rhinoplasty surgeries, it can feel like you are operating on cement.  It can take much longer just to remove all the scar to see what the “normal” anatomy looks like.  When scar that is obstructing function has to be removed, new tissue in the form  of skin grafts or mucosal grafts may need to be used.  Due to all these various reasons, revision rhinoplasty takes much longer to perform in the operating room. Postoperatively there is a longer recovery time also. Recovery time might be anywhere from 6 months to 2 years depending on the severity of the damage and the health of the skin. 

Check out Dr. Shah’s video page in which he discusses Revision Rhinoplasty!

The most important thing for revision rhinoplasty patients to understand is that each time their nose gets operated on, the outcome of a “perfect” nose becomes harder to achieve. Be patient and have realistic goals.  The lesson is that it is best to get it right the first time. But that is not always possible.  If you need revision rhinoplasty in Denver, Colorado, make sure you see a rhinoplasty specialist like Dr. Manish H. Shah.

Primary Rhinoplasty – What Can You Expect?

Primary rhinoplasty is a procedure designed to cosmetically improve the nose…


The term Primary Rhinoplasty is used to describe a nose surgery procedure which is done purely for cosmetic reasons.  In essence, it is a first time nose operation.  It is typically not performed to correct functional issues in the nose or reconstructive issues resulting from trauma. There are many reasons a person may choose to undergo a Primary Rhinoplasty in Denver, Colorado. Some of the issues that people use rhinoplasty surgery to correct or improve are to change the shape of the tip of the nose, to improve the nasal profile by removing bumps or indentations, to change the angle of the nose as it relates to the mouth, to change the shape or size of the nostrils and to improve overall facial harmony.

A Primary Rhinoplasty procedure is most ideal for patients who’ve completed their mid facial growth period, generally considered to be after 14 years of age in females and after 17 years of age in males. Patients should be in good health and should only be considering rhinoplasty for their own personal benefit and not to please anyone else. Patients should also have realistic goals and expectations. Rhinoplasty procedures can affect a great deal of improvement in a nose, but it is generally not recommended to try to change the nose drastically.  Consulting with a skilled board-certified plastic surgeon who specializes in facial plastic surgery procedures, such as Dr. Manish H. Shah, is the best way to determine if your goals are achievable.

Your consultation with Dr. Shah will allow for a physical examination of your nose after discussing your relevant pre-history.  Dr. Shah will then typically take multiple pictures of your nose from various angles.  He then takes these digital photos and puts them into Rhinoplasty simulation software.  With this software he can simulate various changes to your nose to give you an approximate idea about your possible outcomes.  It is important to note that Rhinoplasty simulations are not a guarantee or warranty of any particular outcome.  Dr. Shah uses the simulations to help educate you, the patient, about what is possible and what is not possible.  Complications from rhinoplasty surgery are quite rare but they can include the following: bleeding, infection, scarring, wound healing problems, asymmetry, numbness, soft tissue loss, breathing problems, septal perforation, dorsal saddle nose deformity, stiffness, need for revision surgery, dissatisfaction with the cosmetic outcome, reactions to medications and anesthesia, heart problems, lung problems, brain problems, and death.  While this might sound scary, rest assured that actual risks are quite rare.  Safety should always be a priority!

Primary Rhinoplasty procedures are typically performed in fully-accredited outpatient surgery centers, and in certain situations, in hospital.  Dr. Shah uses board-certified M.D. Anesthesiologists.  Dr. Shah prefers to use full general anesthesia because he believes it allows for better control of the patient’s airway.  This maximizes safety!  No one, but Dr. Shah, touches the patient.  Dr. Shah, though he loves to teach, is the only person who will be operating on your nose.  Most patients typically experience very little bleeding or post-operative bruising.  Postoperative nausea and vomiting are also fairly rare.  Pain control is fairly easily established, and most patients stop their narcotics by post-operative day # 2. A patient will rarely wake up with nasal packing.  If extensive work is done to straighten a deviated nose, Dr. Shah will often leave temporary internal splints to help mold the airway and insure that breathing will ultimately be improved.  All patients have an external molding splint left on for at least seven days after surgery.  This helps stabilize the skin and keep any surgically fractured nasal bones in place.

The first week is typically the hardest week for the patient.  They will be sleeping with their head elevated.  They will be applying ice packs to reduce bruising and swelling.  They are not allowed to get their faces wet, so hair washing is a bit difficult to do.  Dr. Shah recommends bathing during this first week.  A cool mist humidifier at the bedside is very soothing for the face and throat.  After this week, you will typically have your external splint and any external sutures removed.  External sutures are used only if you are having an open rhinoplasty and/or you are having your nostrils narrowed.  If the rhinoplasty is a closed procedure (endonasal approach) then all the incisions are hidden inside the nose and there will be no sutures to remove.

At this point, you will be taught the second phase of your care.  You will be allowed to rinse out your nose with saline spray and use oral decongestants to unclog your airways.  You will be taught night-time taping techniques and soft tissue massage to help mold your nose.  You will not be able to use eyeglasses, sunglasses, or ski goggles for two months to avoid shifting fractured nasal bones.  Your nose may swell after the splint is removed, but with time it will decongest.  The upper part of the nose settles in after about three months. The bones are at their hardest at this point.  For the next five to six months after this, most patients don’t notice big changes.  Finally, around months ten to twelve after surgery, the tip of the nose finalizes its cosmetic outcome.  Patients must realize that patience is mandatory because it will be at least one year before they see how their Rhinoplasty surgery turned out!

Top 10 Questions to Ask a Rhinoplasty Surgeon

Arm yourself with the facts that will help you make the best decision possible…

The questionnaire

Rhinoplasty is the most difficult cosmetic surgery procedure to perform.  For this reason, it is essential that someone looking to have this surgery performed be well-educated and armed with the information they need to make a good decision.  As a board-certified plastic surgeon specializing in rhinoplasty surgery here in Denver, I feel that it is important for patients to ask questions of me when they consult with me about their choice for rhinoplasty.

Here are my Top 10 Questions to Ask a Rhinoplasty Surgeon…

1. “Are you board-certified?”

Board certification by the American Board of Plastic Surgery and/or the American Board of Facial Plastic and Reconstructive Surgery shows that your surgeon has completed accredited training in an ACGME accredited residency program and has passed both a rigorous written exam and an oral exam that tests them on their actual patients clinical care and outcomes.  Maintenance of Certification status further acknowledges that your surgeon continues to stay at the forefront of knowledge in their specialty.

2. “Is rhinoplasty a significant part of your cosmetic surgery practice?”

There are lots of different procedures that a plastic surgeon can perform.  While every surgeon claims that they perform rhinoplasty, the fact is that this procedure is not all that common in most practices.  Breast surgery and liposuction are more common procedures to ask for, and so surgeons are more commonly performing those procedures.  Rhinoplasty is not something you dabble in.  For the greatest chance of success with your rhinoplasty, I always recommend that you consult with a rhinoplasty specialist.  Rhinoplasty makes up roughly 25-30% of my practice.

3. “How many rhinoplasty procedures do you perform each year?”

In the U.S. the average ASAPS (American Society of Aesthetic Plastic Surgery) member performs between 6-12 rhinoplasty procedures/year.  I am an ASAPS member and I average around 50 rhinoplasty procedures/year.

4. “What is your revision rate?”

Rhinoplasty surgery is a very complex operation.  Some patients have more difficult noses than others.  For this reason, there is always a chance that a revision operation might be necessary after a nose heals from an initial surgery.  Most patients getting revision surgery really are getting touch-up or finesse surgery to get the best result possible.  A smaller percentage of patients have revision surgery because the initial procedure did not turn out well.  Nationally, in the U.S., you can expect a 30-50% revision rate in primary rhinoplasty. Amongst rhinoplasty specialists, the average revision rate is closer to 10%.  My primary revision rate is in line with this.

5. “What is your preferred technique for performing rhinoplasty?”

Rhinoplasty surgery can be performed either as a closed or an open operation.  A closed rhinoplasty operation only has incisions inside the nose.  It tends to be a method that reduces trauma to the nose and lends itself to a quicker recovery.  However, in less experienced hands, this technique doesn’t allow for as much visualization of the surgical field making the risk of a suboptimal outcome higher.  That being said, those surgeons who prefer this method and have a lot of experience using it make beautiful noses.

An open rhinoplasty operation involves intranasal incisions and an incision across the columella (the fleshy divider of the nostrils). This technique allows for better visualization of the surgical field but does cause more trauma to the tissues and takes longer to recover from.  In modern rhinoplasty, more surgeons are adopting the open technique.

In my practice over 80% of rhinoplasty procedures use the open technique.  I reserve the closed technique for more minor rhinoplasty cases and some revision rhinoplasty procedures.

6. “What happens if I need a revision after one year?”

Luckily for you, your chances for revision surgery in the hands of a skilled rhinoplasty specialist are fairly low.  Most surgeons stand by their work.  If a patient isn’t happy and has reasonable expectations, a reputable surgeon will often not charge for touch-up surgery.  Patients may be required to cover the costs of anesthesia and facility charges.  It is best to enquire about your surgeon’s revision policy before you have surgery.  The same goes for having realistic expectations.

7. “Do you perform rhinoplasty  simulations?”

Rhinoplasty simulations are computer generated morphs of the pictures of your nose taken by a rhinoplasty surgeon at consultation.  They are used to help educate patients about possible changes that might be expected after rhinoplasty.  They aren’t a guarantee or warranty for a particular outcome, but they are helping in guiding your surgeon to the best outcome possible.  It is important that you remain realistic about your outcomes as simulations can be made to look like anything.

8. “Can I see before and after pictures of patients of yours?”

A surgeon’s before and after gallery is a portfolio of their work.  It should have a cross section of patient types to show that the surgeon has a broad range of rhinoplasty skills.  Though it is rare to see a patient matching your description, you might see someone who looks like you.  That being said, individual results will vary.  Don’t expect that your nose after surgery will look like anyone else’s, especially celebrity noses.

9. “What societies do you belong to?”

Medical society membership shows that a surgeon is interested in staying at the cutting edge of their field.  Continuing medical education is necessary to learn advanced techniques and apply evidenced based data to the practice of rhinoplasty surgery.  I am a member of the ASPS (American Society of Plastic Surgeons), ASAPS, ISAPS (International Society of Aesthetic Plastic Surgery), the Rhinoplasty Society, and the Royal Society of Medicine.  I have published in peer-reviewed journals, been interviewed for television and for online publications, and lectured nationally and internationally.

Other important societies include the AAFPRS (American Academy of Facial Plastic and Reconstructive Surgery) and the AACS (American Academy of Cosmetic Surgery).

Make sure that your rhinoplasty surgeon has similar qualifications.

10. “Doctor, are my goals realistic?”

This is a loaded question but an extremely important one.  The first rule of the Hippocratic Oath is “Do no harm.”  Patient safety, both from a medical and an outcomes-based point of view, requires that a surgeon be realistic when counseling a patient, especially with cosmetic surgery.  There is a lot of money to be made in cosmetic surgery so there has been a sharp rise in non-qualified practitioners offering cosmetic surgery procedures.  Patients get lured into having surgery often with devastating consequences.  I have no problem turning a patient away if I can’t deliver the results they are looking for.  What I have found is that these patient’s have expectations that no one will actually ever be able to fulfill.


Well, I hope you’ve enjoyed my thoughts on the questions to ask a rhinoplasty specialist at the time of your consultation.  If you have any questions, you can always contact me at (303) 708-8234 or drop me an email at


Dr. Shah

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