The #1 Nose Surgery Guide for Patients
By Rhinoplasty Surgeon Dr. Kotler
Rhinoplasty is an operation that changes the shape and appearance of the external nose. Often, internal surgery to improve breating or sinus conditions are done at the same time but those are not components of a rhinoplasty or “ nose job” a purely cosmetic operation.
The rhinoplasty operation is indicated when the nose is too large, the tip is too bulbous, there is a bump or hump on the bridge. The nose may requiring straightening because it is crooked, often subsequent to an injury. A common, unsatisfactory feature, particularly in the age of head-on cell phone “ selfie” photos is that the tip depresses with smile. In such photos, the nose looks longer and often the tip appears widened.
Rhinoplasty is right for you if you do not like the appearance of your nose. It’s that simple. In some cases, patients seek revision rhinoplasty. Luckily, unlike other Nature-delivered body factors, such as being too tall or too short, the rhinoplasty operation can solve the problem. And, remember, it is not about what others think, it’s your nose, on your face. You are the only decision-maker.
THE COMMON IMPERFECTIONS FOR WHICH PATIENTS SEEK Rhinoplasty:
- Bump or Hump: Peak-like in the mid-portion of the nose. May be from injury or heredity. The most common imperfection:
- Bulbous tip: A round, spherical, ball-like tip or front-most portion of the nose:
- Droopy tip: The tip of the nose hangs down and may be unsatisfactorily too close to the upper lip:
- Abnormally wide nostril floor or sill: Describes the unsatisfactory width of the base of the nostril. This is at the top of the upper lip. See correction images from front profile below:
- Tip depresses with smile : The Depressor Septi muscle when overactive will pull the tip down with smile:
Common rhinoplasty issues:
- Wide bridge : The nasal bones are too wide. Usually, this sets the standard for the mid-portion of the nose causing unsatisfactory wideness of that portion also.
- Low root of the nose: Visible on profile and angled views only. The upper- most portion of the nose, below the eyebrow level, is too low
- Nostril ala or wings: The outer or lateral wall of the nostril. Attaches to the cheek and lip.
- Columella: From the Latin,“ little column”. The vertical bar that separates the two nostrils. Runs from top of upper lip to tip of nose.
types of rhinoplasty
WHAT TO EXPECT BEFORE, DURING, AND AFTER RHINOPLASTY (HOW IS A NOSE JOB DONE)
What to expect before rhinoplasty
Discussing expectations is supremely important. Unquestionably, the single most important element of the consultation. The wise and experienced rhinoplasty surgeon goes through the patients’ checklist of their dislikes. Then, computer imaging is the indispensable tool for doctor-patient agreement on what changes are amenable to change and whether or not they match the patient’s desire. This meeting of the mind is the best way to avoid dissatisfaction and disappointment. The aim is for doctor to be comfortable that he can deliver what is shown and for the patient to agree that the illustrated end-result would be acceptable. Then, all are on the same page and success is anticipated.
A PHYSICAL EXAMINATION
A proper consultation includes a thorough examination of the outside structure of the nose, with attention to strength of cartilage, thickness of the skin, activity of the facial muscles as exerted upon the nose with smile. Analysis of the distance between nose and lip. Discerning the junction between nose and lip. What about the chin and cheeks? Are such other facial features imperfect and in conjunction an unsatisfactory nose contributing to an unhappy appearance in the mirror? All elements of facial structure must be considered. Harmony between nose and face is key. Even the size of skull and facial bones must be taken into account in judging what can be done to improve appearance. Sometimes improvement has limitations based on anatomy adjacent to the nose. Is the patient tall? Short? This must be considered. And, men and women have different ideal esthetics. A small nose on a tall gentleman? Whoa! Guaranteed to disappoint.
An internal exam must be done to evaluate the internal passageways. Is the breathing satisfactory through each nostril? If there is diminished breathing and thus some reason, why the blockage? Is the vertical partition the septum off center and compromising air flow? Are the turbinates, internal structures important to filtering, warming and humidifying incoming air unduly enlarged? Are there nasal polyps, non-cancerous growths, emanated from the sinuses, present and perhaps blocking air flow? Any evidence of sinus infection?
MEDICAL HISTORY DISCUSSION
All superior surgeons should be excellent physicians first. By that, they need to exert medical knowledge in arenas beyond their specialities as to best serve the patient. At the time of consultation, the examination is always accompanied by reviewing the patient’s history. Is there a history of prior surgery? Any complications? Anything noteworthy about the surgery? Any undue bleeding? Reaction to drugs? Other questions such as allergies to medications, other questions include what medications the patient is taking. Also a thorough history in regard to issues regarding breathing. Has there been postnasal drip or pus coming from the nose? There is an entire checklist of questions that should be asked such that the surgeon does not miss any underlying condition that could adversely affect the results of the cosmetic surgery. It all begins with a complete history and physical with the physical, of course, just limited to the internal and external nose.
Today, particularly because of issues with the COVID virus, it is considered prudent to have the patient see their own personal physician and have a “medical clearance.” That examination would ask the question if the patient is fit for surgery. The examining physician would order all of the appropriate lab tests so that the patient is presented for surgery well “worked up” and all medical issues that might present themselves have been discussed.
HOW TO PREPARE FOR A NOSE JOB
In preparation for a nose job, our practice is to have a very thorough preoperative questionnaire of our patients. We need to know about the prescription medications, as well as non-prescription medications they are taking and that includes vitamins and supplements, as well as drug allergies. Often unbeknownst to patients, what they are taking for whatever condition they seek to have improved may have side effects that are undesirable for people having surgery. For example, ginger and garlic have medicinal value but if taken in significant doses may interfere with blood clotting; for that reason, patients are asked to refrain from ingesting them for a period of 10 days prior to surgery. Other life habits, such as drinking, smoking, and the use of other recreational drugs must be presented for reply by the patient. The preoperative questionnaire is extremely important and the purpose is to leave no stone unturned so that the patient may have a safe anesthetic and a prompt and complication-free recovery.
There are no specific prohibitions regarding diet prior to surgery. Patients can have a dinner of their choice the evening before. When the anesthesiologist calls the patient the night before, he will remind them not to have anything to drink after 11 p.m.
All of our patients are given a prescription for an appropriate pain medication, as well as a particular antibiotic that is effective in reducing the chances of infection, and particularly a MRSA infection. This antibiotic is placed into the nose beginning 5 days prior to surgery such that we expect when the patient comes to surgery there will be no bacteria growing inside the nasal vestibule where the hair grows, which is a typical refuge for bacteria that might be capable of causing a postoperative infection.
What to expect during rhinoplasty
During rhinoplasty, you can expect to be asleep during your rhinoplasty with no pain and no awareness. That is the mission of the anesthesiologist; to provide a safe, light anesthetic which is essentially complimentary and supportive of the local anesthetic that I inject immediately after you go to sleep from the first intravenous blast of propofol. It is an ideal combination of a light general anesthetic and complete protection against pain. The protection against pain overlaps even into the recovery room and perhaps early hour of recovery at home.
The expectations for surgical rhinoplasty vs liquid rhinoplasty will differ. We feel the preparation for the actual anesthetic is very important in that we want patients to be free of elevated pulse and blood pressure, which is a product of preoperative anxiety. When a patient arrives at the surgery center and is placed in a proper gown and tucked into the holding area bed, they are given an appropriate dose of Valium. Valium is a marvelous sedative and relaxant and creates an ideal state for the initiation of the anesthetic.
The anesthesia itself is based on intravenous propofol, which takes 3 seconds from the time of injection to hit the brain and that is the cue for my injection of the local anesthetic. During the rest of the case the maintenance anesthetic is propofol with additional drugs such that the drugs are reversed in anticipation of the end of the operation. It is quite elegant for the anesthesiologist to time the so-called “landing time,” meaning the end of the operation akin to an airplane touching down such that as the operation is just completed and the dressings in place, the patient will begin to wake up.
POST NOSE JOB: WHAT TO EXPECT AFTER RHINOPLASTY
- How do you feel?
- Any nausea or vomiting?
- Are you eating and drinking well?
- Any difficulties with bathroom activities?
- If you are having pain, are you sustaining adequate relief from either Extra Strength Tylenol or the prescription medication that we provided?
- Is your management of the breathing tubes going well? You should be able to breath clearly and it is important to flush with tap water to keep the tubes from clogging with mucus.
- Are you icing? Ice over the eyes and cheeks is very important to reduce postoperative swelling and bruising.
Rhinoplasty has three recovery phases. The first is the five day period afterwards during which time the external protector is in place. During that same period, if major internal nasal reconstruction was performed, e.g. nasal septoplasty, turbinate resection to improve breathing and prevent sinus problems, the medication-soak tampon is in place and so is the KOTLER NASAL AIRWAY, which provides for clear breathing while the tampon-packing is in place. The next five day period is the period in which everything is “ off and out”, meaning no packing, no airway and no external protector in place. Since we perform the closed rhinoplasty, there is no pink, visible and ripening external scar as a “ tip-off” that surgery has been performed. The external and internal swelling is receding rapidly from day five to ten. Usually, by day ten nearly all the swelling and bruising is gone and you like what you see in the mirror. The final recovery phase begins at day ten. Now, there are no longer restrictions on strenuous exercise; you can return to your usual workout routine. No limits on your physical activity except, obviously, contact sports such as soccer, football, rugby. This third phase is called the “ripening phase”: the nose’s appearance gets better and better and better. Akin to the maturation of fine wine; Nature makes it even better. That third phase typically lasts to the 100 day-after-surgery. Approximately three months, which is also the magic number for all operations, anywhere on the body. While there may be some further refine in the next nine months until the one-year anniversary is reached, the nose looks excellent at that three- month period.
The important thing to remember is that unlike other operations on hidden portions of the body, such as tummy-tuck or even chest surgery, the rhinoplasty’s evolution is visible. As you look into the mirror each day, as all do, for the first two phases, up to day ten, you wonder “ When will the swelling and bruising go away?” Well, it is going away but hard to discern on a day-by-day basis. Count on Nature; it’s reliable. The sun rises and the sun sets at predicted times. Nature will take over and do a good job following our surgery.
- Delayed healing.
REVISION RHINOPLASTY RISKSRevision rhinoplasty may have a slightly higher risk of infection or bleeding because of the technical difficulties of operating through scar tissues. It is not a significant difference compared to a primary rhinoplasty. While not considered a “complication” or risk per se, revision surgeries always carry a higher percentage of failure to achieve the result. This is just the reality of re-operating on previously operated tissue and the greater likelihood of some unindicated effect on the result. This is why the decision to have a revision rhinoplasty must be weighed very carefully. When one is considering a surgical revision rhinoplasty there must be brought into consideration permanent non-surgical rhinoplasty.
RHINOPLASTY pain symptomsAfter any surgical procedure, even removal of a superficial skin tumor, there is some discomfort. The number one rule of “ pain after surgery” is that each patient has an inherently different toleration for pain. Recognizing that, at consultation, we raise that issue, even if the patient does not. We ask if there has been any prior surgery and the level of pain and how it was controlled. ?What medication or medications did the job for you?” That is a helpful clue as to what pain medication should be prescribed and it varies with each patient. Recently, after some study of the subject, based on our surveying our patients, we have added a very safe and practical partner to the pain medication. The drug is a venerable, safe and successful tranquilizer which also has an additional benefit of “ potentiating” the power of the pain pill. It makes that pain medicine stronger and therefore often can reduce the strength of that pain pill such that there are fewer side effects. That drug is Phenergan and it is taken simultaneously with the pain medication. One of the reasons I call the patient at home the evening of surgery, around 8-9 PM is that I need to hear, firsthand, how well the pain pill and its companion are performing. If not holding the pain at bay or causing unhappy side effects, there is still time to phone in a replacement pain medication to your pharmacy. Pain must be controlled to allow sleep, extremely important for your wellbeing and healing. The other important reason is that uncontrolled pain raises blood pressure automatically. Elevated blood pressure is our mortal enemy because we do not want you to have a nosebleed nor additional swelling and bruising.
NOSE JOB RESULTS
Nose job results are the product of a timeline. On the fifth day when the plastic protectors are removed from the bridge of the nose, the patient has a view of an already improved nose. The bump is gone, the tip shows some narrowing. However, nature now takes weeks and then months to perfect the work that we performed. It is natural to have swelling, which does not appear overnight. Both surgeon and patient can anticipate a 3- to 4-month period during which the nose gets only better and better and better. It ripens, just like wine. While the nose will look quite good at seven to ten days, by which time the bruising and swelling is gone; by two weeks it looks even better and in a month it looks better. At two months it looks better and at three months it looks very good. It should be noted at three to four months is typically when we take the postoperative photographs. Note, however, that even over the period of the next eight to ten months there will be further improvement such that at the one-year mark the nose is even better, more refined and carrying an optimal appearance, even compared to several months before.
FINDING A NOSE SURGEON
- Superior residency training.
- Fellowship training beyond residency.
- Long rhinoplasty surgery experience.
- Demonstration of superior results based on the before and after photo gallery.
- Surgeon whose life focus is centered around nasal surgery. That surgeon will be an innovator in the field. They may well be an author of articles or books about rhinoplasty and they may have invented devices and created techniques within the specialty.
QUESTIONS TO ASK YOUR NOSE SURGEON
The consultation is extremely important. Consider it a matchmaker. Two matches must be made. The first is that you feel comfortable with the doctor and his or her office staff. Every element of service and patient care should “ feel right”. It begins with the first call or e-mail contact with the office. You can sense if the staff is first class: knowledgeable, helpful and courteous. A strong service mentality is the mark of the great practices. When you arrive for consultation, your time is to be valued so no hours in a waiting room. No, that’s a bad sign. Because while delays in any medical office can occur, you must be notified in advance of your arrival time. Very important now since there are limitation on how many people can occupy the reception area. If the office is running late, if you know that you can stay at work or whatever and be productive. At the consultation, two major factors must be in place.
First, you must have computer imaging. That answers the number one question every patient harbors: “Doctor, what will I look like? I wonder about the result.” That’s why a consultation without computer imaging, to me, is worthless. If the cosmetic surgery cannot share his vision of what is proper, natural and achievable, how can you make a decision to go forward? Contrary to common sense. If you commissioned an architect or interior designer to improve your home, would you sign the contract without a computer rendering of the result of their work? And, remember, at the imaging session, you desires and thoughts to into the computer rendering. You need to be comfortable with the image of the “ new you” the doctor is presenting. The doctor must be frank about his or her ability to deliver such a result. There must be a meeting of the minds. That’s why computer imaging is the super-important second match.
There is one more feature of a superior consultation that revolves around questions you may have. The key to having proper and meaningful answers is time with the doctor. One on one. Not rushed. Any question is fair game. The sequel to my first book, SECRETS OF A BEVERLY HILLS COSMETIC SURGERY, The Expert’s Guide to Safe, Successful Surgery, was a Cliff’s Notes for the consultation. A workbook with all the smart questions to ask. That book, also quite popular on Amazon, was The Essential Cosmetic Surgery Companion, Don’t Consult a Cosmetic Surgeon Without This Book! For cosmetic surgery procedure, it listed the savvy questions to ask. It even had diagrams and blank spaces for notes. Feel free to download, from this website, a free PDF copy. It covers preparation, anesthesia, recovery, medications and will keep the consultation on track. Remember, you must have EVERY question answered. Apart from fees and scheduling, your answers must come from your doctor. Of all the staff in the office, the one member you should spend the most time with is : the doctor.
It is safe to get a nose job if you have no significant medical problem. This is ascertained, of course, through a detailed history and physical and, of course, consultation with your own personal physician.
Nose Surgery FAQ
WHAT IS RHINOPLASTY
Rhinoplasty is an operation performed either through external or internal incisions to change the shape of the nose.
How Much Is Rhinoplasty?
The cost of rhinoplasty is dependent on the number of imperfections that need correction, the time necessary in the operating room to achieve a proper result, and the expertise of the surgeon. Generally, the most experienced and accomplished surgeons, the superspecialists, actually are efficient in their work such that the expense for the operating room and anesthesia doctor are less than those of less experienced, less specialized doctors who typically take much longer to perform their surgery.
Does Rhinoplasty Hurt?
All surgical procedures will have some element of postoperative pain. The answer to postoperative pain is medication. Surgeons anticipate the proper level of medication for the condition and should the pain medicine not be satisfactory the surgeon should be available to substitute a more appropriate medication immediately.
Does Insurance Cover Nose Surgery Costs?
Insurance does not cover a cosmetic procedure such as rhinoplasty. Insurance does cover a breathing or sinus operation, which may be done at the same time. Such operations are correction of a deviated septum, reduction of enlarged turbinates which cause airway blockage and perhaps opening of the sinuses, which have had previous infections. It is efficient to perform both the functional and cosmetic surgery at the same surgical sitting. The economy is that of time, and therefore dollars. Likewise, one anesthetic and one recovery. You want to check with the doctor’s office regarding their participation with insurance company programs and how a claim for insurance will be submitted on your behalf.
In our practice, we stand with the patient and provide all administrative support for the billing of an insurance company, when appropriate, for a functional operation. The patient need not complete any forms that the insurance company requires, as we have specialists that provide that service. We will also participate in an insurance company appeal should the payment be improperly processed.
What’s the Difference Between Rhinoplasty and Septoplasty?
Rhinoplasty is the operation performed on the external nose. It may include any or all of the following: Changing the shape and position of the nasal bones, straightening deformed nasal bones and cartilage, narrowing the tip, elevating the nose from the lip, releasing the muscle that causes undue downward rotation of the tip of the nose.
Nasal septoplasty is an internal nasal operation to straighten an imperfect or crooked partition that separates the left and right nasal passages and may be responsible for obstructed breathing.
Is It Safe To Get a Nose Job?
It is safe to get a nose job if you have no significant medical problem. This is ascertained, of course, through a detailed history and physical and, of course, consultation with your own personal physician.
Can I Get A Nose Job Done Without Surgery?
Yes, many people are better served by having a permanent, non-surgical rhinoplasty. A non-surgical rhinoplasty is not a substitute for safer surgery because it is not capable of changing all of the things that surgery can. However, for many patients, depending on their points of dissatisfaction it is an excellent alternative to surgery because it is an office procedure, has no down-time, and is a fraction of the cost of surgery.