Rhinoplasty and Cosmetic Surgery

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"A woman on the operating table starts a rhinoplalsty"

Starting Rhinoplasty

We often hear anecdotes from potential nose job patients about other cosmetic plastic surgeons and how they work.  Most recently,  we’ve heard from several patients undergoing revision rhinoplasties  (the procedure to correct a failed, first rhinoplasty) about a first nose job done elsewhere that takes three to five hours. 

Even more dismaying, most of those long, long nose job operations produced only a disappointed patient who still had an unattractive nose. We find that dismaying in the extreme.

When we ask those patients some questions, we find that nose operations consume so much time because the first surgeon spent more time than normal grafting and transplanting nose tissue. Certainly, there are cases like accidents or previous nose surgery that ruined some of the patient’s nose tissue.  But the unusually longer time issues remain.

We are not sure why these nose surgeries take so long. Our basic reaction is that some some surgeons make the procedure more complicated and involved that any need to be.

Here’s what happens in most first rhinoplasties: if the surgeon needs to perform transplantation or grafting inside the nose, adequate tissue is found inside the nose. Doing so makes the procedure very economical and efficient to harvest nose tissue because it’s available in the same area the surgeon is working on.

Frequently, we use cartilage and/or bone from the nasal septum, that paper-thin section of bone and cartilage that divides your nose into two channels. In cases of deviated septum — in which breathing is blocked by a bent or misaligned septum — we are taking it out anyhow to improve the patient’s airway and to correct situations that could lead to sinusitis or other complications.

Cartilage for the nose can come from patients’ ears in rare cases. But now, I’ve been hearing of first rhinoplasties in which rib cartilage or even rib bone is used inside the nose — despite the fact that those tissue can bend and curl. But the point is: using ear or rib cartilage makes for one long, complicated and involved procedure because yet another surgical site must be opened.

However, we perform virtually all our nose surgeries from inside the nose and use hidden incisions.  We close with absorbable stitches. (It’s known as a “closed rhinoplasty.”)

But the other method, the “open rhinoplasty” requires the surgeon to peel back the tip of the nose to reveal the inside of the nose. Some compare it to opening a car hood to work on the engine. The  “Open” technique also requires an external incision on the nose . But we have not see that much need for it in the 5,000-plus nose surgeries we have completed during a 40-year career.

Yet another issue: Some surgeons are just not efficient. It simply takes them too long to do the job. Why? I would personally attribute that to less-than-optimal training in the rhinoplasty residency programs as well as inexperience.

Generally, inexperienced surgeons are slower than veteran surgeons. The “occasional nasal surgeon”, is the doctor who spends more time doing other cosmetic plastic surgeries like:

  •    Breast augmentation
  •    Tummy tuck
  •    Breast reduction
  •    Liposuction

So he or she just doesn’t develop the facility for rhinoplasty because that doctor doesn’t operate on the nose often enough. That cosmetic surgeon cannot become a master nasal surgeon.

In my experience, most cosmetic nasal surgeries or rhinoplasty procedures could be done within an hour. If you need to add on the functional or breathing operation, another 20-30 minutes can be added onto the total time in the operating room, including going to sleep and waking up from the anesthetic. So total time should rarely be more than two hours.

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