Of all the operations in the field of plastic surgery, rhinoplasty is considered the most difficult. It’s not that the of a nose job involves more bleeding, dissection or physical exertion; it’s that rhinoplasty is exacting and unforgiving.
The precise configuration of the tip cartilages is not always known until the tissues are freed up and decisions must be made on the spot. Any change in the amount or shape of the cartilage initiates a process that causes further changes to take place long after the operation is over. And because the nose is in the center of the face small imperfections can have large consequences.
Many people seeking rhinoplasty or revision rhinoplasty in Beverly Hills have significant problems breathing through the nose. Additionally, any aesthetic changes might effect the function of the nose. It is for this reason that the rhinoplasty surgeon be well versed at functional surgery of the nose. I am board certified in both ENT (Otolaryngology-Head and Neck Surgery) and Facial Plastic and Reconstructive Surgery and have over 20 years experience fixing nasal airways with septoplasties, turbinate reductions, perforation repairs, nasal valve adjustments and various other nose job methods.
Many surgeons do not want to perform rhinoplasty except for the most simple of cases such as reducing a dorsal hump. In contrast, I welcome the challenge that nasal surgery poses and have developed a passion for it. Over the years I have performed thousands of rhinoplasties in Beverly Hills and I still find each case unique and educational. By critically analyzing my results I am constantly improving on the way I approach things. My patients in Beverly Hills have become more discerning and specific about what they hope to achieve and their expectations are higher than ever. While unrealistic expectations are certainly a source for concern, reasonable goals from sophisticated patients motivate me to “raise the bar”.
Types Of Rhinoplasty
It is rare that any individual’s nose can be categorized into a neat “cookie cutter” type of operation that is done similarly on all patients. There are many factors that dictate what would render an optimal nose for each patient. Despite this, it is convenient for the purposes of discussion to “name” these operations as if they were separate entities. It is important to note that there is probably a surgical technique to handle any issue (no matter how large or small) that someone might complain about.
Historically the most common method for performing rhinoplasty was to reduce it’s overall size (reduction rhinoplaty). While this is still often the case, today more emphasis is placed on achieving a well-balanced nose that fits harmoniously with the other features of the face, ethnicity, and size of the individual. The most common complaint in people who wish to undergo nasal reshaping is that their nose is too ‘big’. More accurately, the size of their nose is disproportionately too large for their face. Specifically, one or more of the following may be too large: nasal length, nasal width or nasal projection (how far the nose sticks out from the face). In addition many people with big noses tend to have a ‘hump deformity’ of the nasal bridge. State of the art reduction rhinoplasty aims to reshape the nose rather than simply remove underlying structure so that it does not change drastically over time and become pinched or non functional. During reduction rhinoplasty it is important to pay attention to other unattractive features that need to be improved such as asymmetry, nostril shape and tip definition.
The ideal nose has subtle features which make it attractive. Even if the length, width and projection are acceptable, other elements will influence nasal aesthetics. Important considerations include tip definition, contour irregularities, asymmetry and the brow-tip nasal aesthetic line. A well defined tip is adequately narrow with properly positioned tip-defining points and has appropriately shaped and sized lobules with smooth contours. A poorly defined tip is either too wide, boxy or bulbous. A poorly defined tip is usually the result of thick skin or weak underlying cartilages. In such cases it’s best to create a more robust framework that can “push out” against the skin to provide greater definition.
Revision rhinoplasty refers to nasal reshaping surgery performed in an individual who has undergone one or more previous rhinoplasty procedures. Revision rhinoplasty can range from a simple procedure to remove some residual excess bone or cartilage in the nasal bridge to a very complicated complete overhaul of the nose. Revision rhinoplasty in an individual who has had the misfortune of having too much tissue removed and has severe residual deformity is generally considered the most difficult type of rhinoplasty. Such surgeries are usually long and complicated affairs that require the use of tissue grafts harvested from the ear, rib or temple region to restore the necessary cartilage, bone and fascia that may be necessary. In addition the skin and soft tissue envelope is often a significant limitation on the outcome due to scarring, resistance to expansion and surface irregularities. In major revision rhinoplasty cases, one needs to be realistic about the result that can ultimately be achieved.
Hello Dr. Frankel.
I wanted to let you know how much I love my nose. Most people don't even know that I had anything done, the change is so subtle. And it's exactly what I wanted. I wanted to look like me but a bit improved. I am so happy with the result and it's getting better every day. My recovery was easy and I barely had any bruising. I am so grateful for your artistry.
Thank you so much for everything.
Following surgery to remove cancer or occasionally following facial trauma, the nose may be left severely disfigured due to the lack of tissue that has been removed or lost. Reconstructive rhinoplasty refers to surgery required to restore tissue that is absent or has been damaged beyond repair. Tissue replacement is usually thought of in terms of replacing the three layers of the nose: 1) the outer skin-soft tissue envelope including skin, subcutaneous tissue and fascia, 2) the middle foundation layer or bone-cartilage framework and 3) the inner mucosal lining. Surgical repair requires the use of grafts and flaps from various parts of the body to restore the missing component tissues. The overall reconstructive process typically requires multiple staged surgical procedures. Again, both the surgeon and patient need to understand the limitations in the final outcome that such deformities are associated with.
Each ethnic background has characteristic nasal features. People from the Middle East typically have longer noses with less distance between the base of the nose and the upper lip. People of Asian or African descent tend to show a wider nose with less projection than Caucasian noses. Hispanic individuals fall somewhere in between. Ethnic rhinoplasty involves modifying the non-Caucasian nose to improve the overall appearance while retaining the features unique to each ethnic background. Years ago people often desired a nose that looked more “caucasian” so that they could assimilate. That behavior has changed and in more recent times people tend to want to retain their ethnic look. The surgeon and prospective patient need to carefully consider the impacts that specific changes in the nose will have on the overall facial appearance and how they will affect the ‘ethnicity’ of the final look.
The human body continues to grow until adolescence is complete, usually 15-16 years in girls and 17-18 years in boys. If nasal surgery is undertaken at a point in time when substantial growth has yet to occur, then the remaining growth may adversely affect the outcome or worse yet, the surgery may stunt remaining growth. For these reasons, it is recommended that nasal surgery be postponed until after growth is completed. However in many young teens an unattractive nose can be the source of significant anxiety and self-consciousness. This is a time when their social networking is of paramount importance and they wish to look their best.
A closer look at facial growth relative to overall body growth shows that it proceeds at a more rapid rate than other areas. Specifically, growth in the midface region where the nose is located is usually 95% completed by age 12 in girls and age 14 in boys. IT IS THEREFORE POSSIBLE TO SAFELY PERFORM RHINOPLASTY IN GIRLS BY THE AGE OF 13-14 AND IN BOYS by 15-16 YEARS. Several controlled studies have demonstrated the safety and predictability of rhinoplasty in adolescent individuals. One safeguard is to wait until at least two years following a girl’s first menstrual period before performing surgery. Perhaps a more important factor to consider is that adoescents may not truly know what they want for an outcome. At such a young and impressionable age they might ask for a result that they later find to be unsuitable. For this reason adolescents should be compelled to sit with their desire for some time before embarking on surgery.
The aging process results in typical changes in the nose similar to other areas of the face. These include a drooping tip, a more bulbous and less defined nasal tip and a more prominent hump over the bridge of the nose. The goal of aging rhinoplasty is to reverse these time-related changes. Aging rhinoplasty can be combined with aging face surgery of the eyelids and face as well such as blepharoplasty and face lifting.
FAQs about Rhinoplasty
Most people know rhinoplasty by the more common term “nose job”. It is a surgical procedure that reshapes the nose for aesthetic or functional reasons. Men and women undergo rhinoplasty to alter the width of their nose, change the shape, remove a bump, make it easier to breathe, or make the bridge, tip, or nostrils smaller.
Men and women are both suitable for rhinoplasty. It’s also okay for teens once they’ve gone through their growth spurt. Doctors look for patients who are in good physical and emotional health. Patients must understand that a nose job is meant t to improve the nose’s shape and will not always be able to create a perfect nose.
Rhinoplasty surgery starts with an incision made either at the bottom of the nose or inside the nose. The skin on the nose is separated from the bone and underlying cartilage. Bone and cartilage is trimmed to create the desired shape. The incisions are then closed. As a final step, the doctor puts a splint in place to support the new shape while it heals.
After a rhinoplasty, you’ll have swelling that may subside quickly or last for months. You should not engage in any strenuous activities for two or three weeks, but you can return to work in a week or two.
Because rhinoplasty is a surgical procedure, there is some risk. For most people, the risk is minimal. However, bleeding, infection, and adverse reaction to the anesthesia do occur in rare occasions.
Once a rhinoplasty is performed, expect the results to last a lifetime. The only changes you’ll experience are due to the natural process of aging.
Revision rhinoplasty is a surgical procedure designed to repair problems of form and function of the nose that have resulted from previous rhinoplasty procedures.
Men and women who are physically healthy, realistic in their expectations and looking to improve the results of a previous rhinoplasty procedure may be good candidates for revision rhinoplasty.
Rhinoplasty is best postponed on young patients until the nose has completed its growth. In general, this tends to occur around the age of fourteen or fifteen for girls and a bit later for boys.
During consultation, there will be in-depth discussion with the patient about their desires and previous procedure(s). There will also be a pre-operative evaluation of the nose and the overall facial balance. Computer imaging may also be used.
Revision rhinoplasty often takes place in a free-standing ambulatory surgery center or a surgeon’s office-based facility. Some cases may be performed in a hospital.
Revision rhinoplasty is usually performed with either general anesthesia or a combination of local anesthesia and sedation.
Once the anesthesia is administered, the incisions are made and this skin of the nose is separated from the underlying bone and cartilage. Depending upon the particular case, cartilage may be repositioned or missing structures may be replaced. When the desired shape is achieved, the skin is pulled back down and the incisions are closed.
Primary rhinoplasty tends to take between one and two hours to perform and revision rhinoplasty typically takes longer.
For revision rhinoplasty, the incisions may be confined solely to the inside of the nose or an additional small incision may be made under the tip of the nose. When the incisions are confined to the inside of the nose the procedure is referred to as ‘closed rhinoplasty’, whereas procedures involving an incision under the tip of the nose are referred to as ‘open rhinoplasty’.
With closed rhinoplasty procedures, in which the incisions are confined to the inside of the nose, there will be no visible scarring. With open rhinoplasty, in which an additional small incision is made under the tip of the nose, a small, fine-line scar will result though it is well-concealed and will fade with time.
Revision rhinoplasty tends to involve less pain, as well as less bruising, than primary rhinoplasty procedures. Patients can be prescribed pain medication to help alleviate any discomfort that they may feel.
You will need to have a family member or friend drive you home.
It’s often a good idea to have a family member or friend accompany you to surgery and to your home or your place of recovery for the evening.
Revision rhinoplasty is usually a less painful procedure than primary rhinoplasty and often involves less bruising as well. Most of the bruising that patients experience will have faded by about the tenth day. Swelling is also common and this can takes months to fully fade. The splint and stitches will be removed within about six to seven days. Patients are typically able to return to work within about a week, though strenuous activities will need to be postponed for about two to three weeks. Patients should also avoid bumping or jarring the nose or getting a sunburn for eight weeks.
Patients are typically able to return to work within about a week after their revision rhinoplasty procedure.
Exercise and more strenuous activities can usually be resumed within about two to three weeks, though any activities which may bump or jar the nose or risk sunburn to the nose should be avoided for eight weeks.
The stitches are usually removed within about six to seven days after revision rhinoplasty.
Some of the potential complications associated with revision rhinoplasty may include adverse anesthesia reactions, excessive scarring, prolonged swelling, pulling of the nose to one side, small burst blood vessels, and the need for additional surgery.
Procedures which are performed to repair functions of the nose, such as breathing, may be covered to some degree. However, procedures which are solely cosmetic are typically not covered by insurance.
Many plastic surgery procedures are eligible for financing.
As with any surgery, there are certain medications, vitamins and herbs that should be avoided beforehand as they can cause you to bleed more than normal. These should generally be stopped two weeks prior to surgery and you doctor should provide you with a list of these medications.