This blog gives you all the information you might want about the most difficult procedure in cosmetic surgery, written by Manish H. Shah, MD, FACS, a specialist in rhinoplasty, revision rhinoplasty, and ethnic rhinoplasty surgery located in Denver, Colorado. Please call (720) 730-9548 for more information about Dr. Shah and his rhinoplasty practice.
I recently attended the first American Preservation Rhinoplasty meeting held on Saturday November 16, 2019 in beautiful Newport Beach, California. It was an intensive one day teaching course and live cadaver dissection session to demonstrate to only 50 surgeons from around the world the rhinoplasty technique known as Preservation Rhinoplasty. Our wonderful hosts were Drs. Aaron Kosins, Rollin Daniels, Abdulkadir Goksel (from Turkey), and Dino Elyassnia. It was easily one of the best high-level technical meetings I’ve ever attended. It impressed upon me the need to bring the benefits of Preservation Rhinoplasty to Denver, Colorado.
What is Preservation Rhinoplasty? I think the best way to answer the question is to describe what it is not. It is a technique for nasal reshaping that doesn’t rely on the traditional destructive rhinoplasty techniques normally used in cosmetic nasal surgery. These techniques typically include removal of the nasal hump by excision and multiple floating nasal bone fractures that can create complications later on during healing. The technique was originally used in the late 1800’s, but it has been enjoying a resurgence in popularity over the last several years. There is a big fan base for the procedure amongst surgeons in Europe. Expert rhinoplasty surgeons looking to create a safer operation brought Preservation Rhinoplasty back into the spotlight.
In the graphic above, from a paper by Yves Saban and Rollin Daniels, et al. from 2018 in the Aesthetic Surgery Journal (ASJ), you can see that there are two types of procedures that can be performed with Preservation Rhinoplasty. In a “Push Down” type procedure, the nasal bones are disconnected from the facial skeleton in one single piece, and a strip of cartilage is removed from the septum underneath the nasal bone complex. Removing the strip of cartilage makes a space that the surgeon can push the nasal bones down into, hiding the bony hump without removing it. The nasal bones settle onto a solid surface and there aren’t multiple mobile pieces to shift out of place. In a “Let Down” type procedure, not only is a strip of cartilage removed from the septum, but a triangular sliver of bone is removed from the right and left nasal bones, creating a gap that the nasal bone complex falls down into. With either procedure, the beauty lies in the fact that the nasal bones, while disconnected, are in a single piece and more stable. The photos below from the same ASJ article show the anatomy more clearly.
Who is a good candidate for Preservation Rhinoplasty? Several criteria are evaluated when trying to choose the right candidate for this procedure, as listed below:
The dorsal nasal lines are already quite good
The caudal septum in between the nostrils is straight
The patient has a small to medium sized hump
There is no need to modify the radix
The dorsal hump is mostly cartilaginous
The nasal bones are V-shaped, not S-shaped
Many patients in my rhinoplasty present with this type of anatomy. This makes them good candidates for Preservation Rhinoplasty.
What are the advantages of performing Preservation Rhinoplasty? Because the technique is designed to avoid radical alterations in the nasal anatomy, the nose ends up having a more natural dorsum and intact keystone area. This enhances long-term stability. Using subperichondrial dissection techniques to perform the procedure leads to less long-term thinning of the soft tissue envelope. After the procedure, there is much less bruising and less swelling because it is less destructive. Finally, even if a revision procedure is necessary, it tends to be mild and easier to accomplish.
I am looking forward to providing this procedure to my patients and will be critically evaluating Preservation Rhinoplasty in my rhinoplasty practice. I have recently acquired a textbook by Dr. Baris Cakir from Turkey on using closed techniques to perform Preservation Rhinoplasty. He is a huge proponent of the procedure and I’ve heard him speak several times. His results are outstanding! I look forward to furthering my education…
Anyone who has had rhinoplasty surgery knows that the risk of needing a revision surgery is quite real. National revision runs are felt to be as high as 30-50%. In my practice, the overall 15 year revision rate is less than 9%. Additionally this rate reflects only the need for minor touch-up or optimization procedures. My patients can tell you that I’m never satisfied with my results, so I always strive to make them better.
In patients who have already had multiple revision surgeries or traumatic injuries to the nose, they often present with a particular set of difficulties. They have reduced blood supply, subcutaneous scarring, and skin quality problems that make revision surgery quite difficult. Often the damaged skin is thin and of poor quality for trying to make a natural, soft, pliable nose. The risk for wound healing problems and poor outcomes is high.
In the last couple of years, there has been interest shown in the use of nanofat injections to the nose to rehabilitate the tissue conditions to make revision surgery a more successful process for patients already devastated by poor outcomes. When discussing fat transfer, it is important to understand the types of fat transfer and what they are used for. For my patients, I break down fat transfer into 3 basic types:
Macrofat transfer is performed by using traditional liposuction techniques to harvest large molecules of fat for fat transfer to the breast, buttocks, and body. The large molecules provide the best lift and fill. Microfat transfer is performed by using liposuction with smaller cannula diameters to get smaller molecules of fat that can be used for facial and hand augmentation. The smaller molecules provide for more natural, less lumpy results that match the needs of the smaller compartments of the face and hands. The lift and fill capabilities are also less to avoid bulging outcomes.
Nanofat transfer is the newest type of fat transfer. Using special tiny cannulas, small molecule fat is harvested. This fat is then first passed through a series of smaller and smaller separators, followed by one pass through a nanofat mesh. The result is that you obtain 400 micrometer (0.4mm) size fat molecules along with Adipose Derived Stem Cells (ADSC). Nanofat cells are so tiny, they can be injected using a tiny Botox needle. The magic, however, lies in the power of the ADSC.
Stem cells are a particular type of cell that aid in tissue regeneration. ADSC are what are known as pluripotent stem cells. This means that they can behave differently based on the type of tissue they are exposed to. When injected into skin, they control local processes that can improve both the vascularity and characteristics of skin. I started using nanofat in my practice in December of 2018 and have seen good results so far with no complications. As a busy rhinoplasty and facial plastic surgeon, I have had a handful of patients who’ve had minor scarring issues after surgery. Using nanofat, these scars have definitely gotten softer and blended better into the surround normal skin.
From this experience, I decided to try nanofat injections to treat tear-trough deformities of the lower eyelids. We normally used hyaluronic acid fillers like Restylane and Belotero in the past, but patients often complained of swelling and dark circles. With nanofat, we’ve seen none of these problems. Check out the results below on a woman in her 40’s who had both microfat and nanofat injections to the lower eyelid hollows:
It is clear that the science of nanofat and tissue regeneration continues to advance. As this advancement moves along, patients will continue to benefit from better and greater numbers of options for cosmetic self-improvement.
Recently Dr. Shah was featured on the national TV show Daily Blast Live with his lovely patient Megan. She was having Dr. Shah perform a primary rhinoplasty to improve the look and function of her nose. Watch her go through her consultation, have her surgery, and then see the big reveal! You won’t be disappointed…
For more information about Dr. Shah’s rhinoplasty services please CLICK HERE.
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 RealSelf.com, 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.
CARE TAKEN BEFORE SURGERY
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.
CARE TAKEN DURING 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.
PATIENT ISSUES AFTER SURGERY
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:
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.
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.
Teenage 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:
Wound healing problems
Bursting of small blood vessels on the skin’s surface
Permanent nerve damage
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.
How to Choose a Surgeon
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…
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.
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 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.
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.