Richard E. Davis, MD FACS - The Center for Facial Restoration in Miramar, Florida

Frequently Asked Questions About Rhinoplasty

Below are answers to some of the questions most frequently asked in my practice by prospective primary and revision rhinoplasty patients.

I'm very unhappy with the outcome of my first rhinoplasty and I want revision surgery. Do I need to wait an entire year before undergoing further surgery?

In general, it is best not to re-operate in the first several months after a failed rhinoplasty since the tissues are still inflamed and less likely to heal favorably. However, the traditional recommendation to wait one year before undergoing revision rhinoplasty is a generalization that applies mostly to thick-skinned patients. Assuming that the nasal framework is sturdy, properly aligned and well-proportioned, waiting 12–18 months in thick-skinned patients is often beneficial since a favorable cosmetic outcome is usually evident once the swelling and inflammation resolve. On the other hand, many post-surgical deformities will not improve over time and may even worsen in the first year after surgery and make correction even more challenging. Obvious post-surgical deformities of the nasal framework, such as severe twisting, pinching, collapse or retraction, are all problems that are unlikely to fully resolve once swelling and inflammation subside. In those patients prone to progressive scar contracture, these deformities often steadily worsen over time, making definitive treatment increasingly more difficult or even impossible. Hence, prolonged treatment delays may be detrimental in select patients. Nevertheless, because re-operating on acutely inflamed tissue is far less precise and much less predictable, most patients are advised to postpone revision surgery at least until the acute swelling and inflammation have resolved, which varies considerably from patient to patient.

In summary, each case is different, and although waiting for the nose to fully heal is generally wise, postponing revision surgery for 12 months is not always justified. The decision to re-operate should be made jointly between patient and surgeon after careful consideration of the risk factors and prospects for improvement. I have revised many suitable patients in the first 4–6 months following a failed rhinoplasty with excellent surgical results. On the other hand, I have also discouraged others from a hasty and impulsive attempt at a quick revision, only to eventually confirm that further surgery was unnecessary. A knowledgeable and experienced revision rhinoplasty surgeon can usually determine the appropriate time for a successful revision rhinoplasty.

I recently underwent rhinoplasty and I now have a graft showing on the tip of my nose. I've read on the internet that rhinoplasty can be performed without grafts. Why do some doctors still insist on using grafts?

Two essential ingredients are needed to produce a successful rhinoplasty outcome: a cosmetically pleasing skeletal contour and durable skeletal support to maintain that contour over time. Both of these goals typically require the rearrangement and/or reinforcement of the existing nasal framework with cartilage grafts. For instance, a wide and droopy nasal tip must be lifted and narrowed to achieve a more attractive nasal contour. By elongating and strengthening the existing tip cartilage using additional cartilage tissue, a sturdy and elegant contour is achieved. However, seamlessly incorporating cartilage grafts into the existing nasal tip framework is an art form that takes years to master and requires an adequate supply of healthy donor cartilage. Although an improperly shaped or malpositioned graft may occasionally spoil the cosmetic outcome, cartilage grafting is an indispensable tool in cosmetic nasal surgery and nearly all accomplished nasal surgeons employ cartilage grafts on a routine basis. In fact, cartilage grafts are almost always required in revision rhinoplasty to replace damaged or lost components of the nasal skeleton.

I'm interested in having rhinoplasty, but I've been told I have extremely thin nasal skin. Will my ultra-thin nasal skin keep me from achieving a satisfactory cosmetic result?

In patients with nasal skin of average thickness, small imperfections in the underlying nasal skeleton remain hidden and are difficult to detect. However, in patients with ultra-thin nasal skin, even small skeletal imperfections can become visible and spoil the cosmetic outcome. For this reason, the thin-skinned rhinoplasty patient is regarded as among the most challenging in cosmetic nasal surgery. However, that's not to say that the thin-skinned patient can't achieve a satisfactory cosmetic result. With meticulous and precise contouring of the nasal framework, coupled with secure placement of carefully sculpted cartilage grafts, a glassy smooth and well-proportioned nasal framework can ensue. In severe cases, soft tissue overlay grafts such as fascia, perichondrium, or dermis can also be placed beneath the skin to increase thickness, improve camouflage, and enhance the cosmetic result. However, thin-skinned noses are typically not for beginners. Patients with thin nasal skin should select an accomplished rhinoplasty surgeon familiar with the nuances and pitfalls of this challenging anatomic variant. See also: The Importance of Nasal Skin in Rhinoplasty

I've heard there are two types of rhinoplasty, "open" and "closed". I want the best possible outcome, but I don't want an unnecessary scar. Which type of rhinoplasty is the right one for me?

"Closed" rhinoplasty refers to a form of limited surgical access in which all of the surgical incisions are hidden within the nostril. Although some surgeons prefer the closed approach since it avoids a potentially visible scar, it also significantly limits the surgical exposure, making it difficult or even impossible to utilize many of today's most effective rhinoplasty techniques. As a result, many surgeons prefer the "open" rhinoplasty approach, which connects the nostril incisions at the columella to dramatically improve surgical exposure. Direct visualization of the nasal skeleton not only facilitates diagnostic accuracy, it also enables the surgeon to modify and strengthen the skeletal framework without interference from the overlying soft tissues. This approach is particularly useful with challenging nasal anatomy, such as a complex revision rhinoplasty where the tissues have been previously altered. Although the columellar incision is initially visible, when carefully re-approximated, it seldom results in an objectionable nasal scar and it often fades completely in the months following surgery. For the overwhelming majority of individuals, the advantages gained by the open approach are well worth the limited risk of an unsightly columellar scar. By the same token, avoidance of a potential scar is little consolation if the rhinoplasty result is compromised by poor exposure. See also: Open vs. Closed Rhinoplasty

I've decided to undergo rhinoplasty, but I'm afraid of having anesthesia. What are my options?

Minor touch-up procedures excepted, rhinoplasty is almost always performed with one of two forms of deep body-wide anesthesia: intravenous sedation or general anesthesia. Various factors, including comfort, safety, cost and technical logistics, must be considered when selecting a rhinoplasty anesthetic.

In my opinion, general anesthesia is superior to intravenous sedation (IV sedation) in all respects. In most hospitals, the cost is equivalent. But unlike IV sedation where patients may endure unpleasant sights, sounds or even surgical pain, with general anesthesia there is no conscious awareness and comfort is unsurpassed. Because all of my patients receive their general anesthetic in a fully-accredited hospital facility with a board-certified MD anesthesiologist present for the entire operation, safety is also optimized. Although both anesthetic options require drugs to induce unconsciousness, in the case of IV sedation, the anesthesiologist (or nurse anesthetist) must walk a fine line — too much anesthesia and the patient may stop breathing; too little anesthesia and the patient may experience pain or become confused, uncooperative or even combative during surgery. In contrast, with general anesthesia, a breathing tube and ventilator allows the anesthesiologist to more easily maintain a steady level of deep anesthesia in the patient, without the risks of awareness, sudden movements or an unprotected airway. In addition, non-narcotic general anesthetic protocols developed specifically for nasal surgery are seldom associated with post-operative nausea or other common anesthetic side effects.

However, perhaps the biggest advantage of general anesthesia is superior blood pressure control. By maintaining a comparatively low "resting" blood pressure throughout the entire operation, bleeding is minimized and post-operative swelling, inflammation and bruising are all significantly reduced. Although many office-based facilities recommend nurse-administered IV sedation as a cheaper and safer alternative to general anesthesia, in my medical opinion, a properly administered general anesthetic is far better suited to the surgical needs, safety and comfort of the rhinoplasty patient. See also: IV Sedation vs. General Anesthesia

I dislike hospitals. May I go home immediately following my rhinoplasty?

In addition to proper surgical technique and accommodating tissues, a good rhinoplasty outcome requires a favorable healing response. Prolonged inflammation and excessive soft tissue swelling complicate the healing response and may ultimately lessen the cosmetic result. Therefore, controlling post-operative swelling and inflammation is paramount.

While some surgical swelling and inflammation is unavoidable, good aftercare can minimize the inflammatory effects of rhinoplasty and optimize the cosmetic outcome. Without question, good aftercare is most beneficial in the early hours after surgery when injured tissues are most susceptible to elevations in blood pressure. Whether carrying a suitcase, climbing a flight of stairs, experiencing pain, vomiting or suffering anxiety, elevations in blood pressure will increase the bruising, swelling and inflammation beyond what is already present. Because in-hospital care offers the advantage of intravenous medication administration and round-the-clock nursing support, prevention of nausea and control of blood pressure, pain, anxiety and infection are all enhanced over what can be provided at home. Consequently, I prefer to keep all of my rhinoplasty patients hospitalized overnight. Overnight hospitalization in a private room offers a controlled environment to optimize healing in the critical early stages of recovery. In my opinion, the few extra hours spent in the hospital are well worth the investment. See also: Memorial Hospital Miramar

Can my breathing be improved during rhinoplasty?

A good rhinoplasty surgeon will maintain adequate nasal breathing following cosmetic rhinoplasty, and adequate nasal function should never be intentionally sacrificed for cosmetic improvement. Although nasal obstruction is a potential risk of any rhinoplasty, in competent hands, nasal breathing is seldom compromised. Moreover, certain breathing problems (such as a crooked or pinched nose) are also responsible for cosmetic abnormalities and appropriate treatment can improve both appearance and function. Surgeons who are trained in both cosmetic and functional nasal surgery are far less likely to impair nasal breathing and are often able to achieve a smaller and more attractive nose while simultaneously improving nasal function. See also: Functional Rhinoplasty

I have heard that many surgeons use steroid injections such as Kenalog to improve cosmetic results following rhinoplasty. Is Kenalog treatment safe?

Triamcinolone acetonide, sold under the brand name KenalogĀ®, is a powerful cortisone-type steroid formulated for soft tissue injection. When administered in high doses, potential complications such as thinning of the skin, spider veins, fat atrophy, infection or cartilage resorption may occur and taint the cosmetic outcome. Hence the dose, timing and frequency of Kenalog administration are critical in avoiding potential complications of steroid treatment. However, the same properties that may produce complications in high doses may also be used safely to reduce stubborn swelling, prevent subcutaneous scar formation, or prevent scar contracture. When used sparingly in an appropriate manner, low-dose Kenalog can significantly improve the cosmetic outcome in select patients. While any drug can cause complications when used inappropriately, in my experience, the conservative use of low-dose Kenalog is seldom associated with unwanted complications and can substantially improve the cosmetic result in scar-prone individuals.

How old must I be to undergo rhinoplasty?

Technically speaking, cosmetic rhinoplasty can be performed any time after nasal growth is complete. Nasal growth is usually complete in girls by age 15 and complete in boys by age 16. However, an emotionally mature and cooperative patient is also an essential requirement for a successful rhinoplasty. In rare cases, surgery may be performed at younger ages when severe functional impairment or other medical indications dictate.

Am I ever too old for rhinoplasty?

Cosmetic rhinoplasty becomes increasingly more challenging with age. All other factors being equal, the best time to perform cosmetic rhinoplasty is in mid-to-late adolescence or early adulthood. By the fourth decade of life, the cosmetic outcome is sometimes less favorable, and purely cosmetic rhinoplasty is often best avoided beyond age 60 due to poor healing responses and a much higher incidence of disappointing cosmetic results. However, functional rhinoplasty is often necessary in later life to prevent adverse health manifestations of chronic nasal obstruction. Adequate anesthetic tolerance is also necessary for elective nasal surgery, regardless of age. The decision to perform rhinoplasty at any age is best made after a thorough rhinoplasty assessment and a frank discussion with your surgeon regarding the risks and benefits of cosmetic nasal surgery.

How long will I be out of work following rhinoplasty?

Rest and relaxation are strongly advised during the first week after surgery to hasten recovery and minimize bruising and swelling. Although some bruising may be evident upon bandage removal one week after surgery, patients with sedentary jobs (desk work) may safely return to the workplace at this time. Those whose jobs require physical exertion (athletes, firefighters, etc.) may need 2–3 additional weeks before returning to full work activity. In every case, avoiding exercise or unnecessary exertion is recommended for at least one month after surgery to avoid prolonged swelling.

Should I use herbal remedies such as Arnica or Bromelain to assist healing?

I would be hard-pressed to argue that all plant-derived substances have no medical value, but few herbal remedies such as Arnica or Bromelain have scientifically-proven medical benefits. Moreover, since herbal supplements fall outside of FDA scrutiny, their safety and purity are also unregulated. The studies I have read regarding Arnica have shown no clear-cut reductions in swelling, bruising or recovery time, and studies with Bromelain are lacking altogether. Since I am ultimately responsible for the welfare and safety of my patients and since unforeseen drug interactions may complicate patient care, I prefer to avoid most herbal supplements before and after surgery. However, since Arnica and Bromelain are unlikely to interfere with healing in the post-operative period, patients are permitted to use these herbals supplements as desired once anesthesia is complete.

How much does rhinoplasty cost?

The cost of rhinoplasty varies considerably according to surgeon skill, geographic area, surgical setting, and the complexity or extent of surgical treatment. Nasal surgery intended for the correction of breathing dysfunction is often eligible for insurance coverage, but purely cosmetic changes are never covered by any health insurance plan. A straightforward tip refinement is far less expensive than a complete rhinoplasty, and revision surgery is almost always more costly, especially when ear or rib cartilage grafts are required. The addition of septal, turbinate or sinus procedures further increases the cost of surgery, even when covered by health insurance.

In my practice, cosmetic surgery fees are based upon the predicted length of anesthesia and the anticipated complexity of surgical treatment. Primary rhinoplasty starts at $12,000 and revision rhinoplasty starts at $20,000. For purely cosmetic patients, the facility fee, MD-administered general anesthesia fee, overnight hospitalization fee, and surgeon fee are all bundled into a single package price. However, health insurance is accepted and may defray some of the out-of-pocket expense for approved procedures. Our staff will assist eligible patients in estimating the out-of-pocket costs derived from insurance coverage such as copayments, deductibles, and other coinsurance fees.

I recognize that surgical skill plays a key role in the quality of a rhinoplasty outcome. How do I select a good rhinoplasty surgeon?

Surveys have shown that many people choose their surgeon based solely upon convenience. While the doctor closest to home may be a talented rhinoplasty surgeon, chances are he/she won't be. Few if any cosmetic rhinoplasty surgeons excel at rhinoplasty unless they devote a majority of their practice to this demanding specialty, and accomplished rhinoplasty surgeons are uncommon. Although surgeons from a variety of medical specialties perform rhinoplasty, the overwhelming majority of cosmetic nasal surgery is performed by plastic surgeons, facial plastic surgeons, or ear, nose, and throat (ENT) surgeons; and board certification in any of these respective specialties also indicates certification in cosmetic nasal surgery. Moreover, surgeons board certified in ENT (otolaryngology) can also claim board certification in sinus and functional nasal airway surgery. Regardless of the surgeon's specialty credentials, board certification alone is an unreliable indicator of rhinoplasty skill and experience. While board certification indicates that a practitioner has surpassed the knowledge-based examination requirements for a particular specialty, including problem solving and medical decision making, it by no means guarantees satisfactory technical competence, artistic skill, clinical experience, ongoing training, or personal integrity. Although there is no 100% foolproof means of assessing a particular practitioner, several key parameters can be used collectively to assess competence in rhinoplasty surgery. These include:

  • A good reputation among colleagues and former patients
  • Preferably greater than 100 cosmetic nasal surgeries performed per year
  • Few if any malpractice claims
  • A personal portfolio of satisfactory "before and after" rhinoplasty photos
  • Recognition of clinical excellence by fellow rhinoplasty surgeons (lecturer, board examiner, etc.)
  • Contributions to peer-reviewed rhinoplasty literature
  • Board certification by an official certifying agency in the field in which the procedure is being performed
  • Specialization by the surgeon in the procedure being considered
  • The ability to establish good communication with your doctor
  • Accredited operating room facilities where your procedure will be performed
  • And perhaps most importantly, confidence that your surgeon will perform your procedure with skill and good judgment

See also: Selecting a Rhinoplasty Surgeon