Rhinoplasty Explained [video]

The following is a transcript with limited edits for ease of readability. 

What is a Rhinoplasty?

Rhinoplasty is basically nose reshaping.

Often times I’m asked about what the best way for my nose to look and you know, of all the surgeries I do it’s the most artistic of all. And rhinoplasty is sometimes in some patients who don’t want a huge change and want to just look like themselves but a better nose, you just end up refining their nose, removing the deformities associated with the nose.

There’s typically a dorsal hump, a bump on the nose or a bulbils tip, under-projecting nose, over-projecting nose.
Those are the things that are the most straightforward easy rhinoplasty is crooked nose is a little harder. But those are the things that like for some people that’s all they want and that’s kind your basic rhinoplasty.

As an art form, it takes years and years to master it. You need to have done hundreds and hundreds of noses to be an excellent rhinoplasty surgeon, and it’s a lifelong commitment and I’ve committed to that. And so the issue is there are some noses that really require a whole rearranging of the bony and cartilaginous structures.

There’s about 18 to 20 maneuvers that you can do to change the nose. You have to be well versed in all of those types of maneuvers and comfortable with those maneuvers to get your best result. And not every nose is the same and not every outcome is the same: the skin quality is different, the bone is differently and so and then what the patient wants out of their nose.

So for your rhinoplasty, having an experienced rhinoplasty surgeon is really important so you get the best result. You really want your most experienced surgeon doing it so you get one rhinoplasty done right.

I do so many revisionary rhinoplasties, and those rhinoplasties oftentimes you can just tell that they weren’t done by professionals, by a master, by someone who really understood rhinoplasty. And so they have some, what I call a half-assing, some removal of cartilage here and there but they don’t do a comprehensive nose. And sometimes I find that I’m either doing completion rhinoplasty finishing what they didn’t finish. Or having the confidence to take the hump down more so that what they had done or give it some more structure.

Those are the kinds of things that cause the need for a revisionary rhinoplasty – you don’t want to go to a rhinoplasty thinking you may have to a revision.

What are the Most Common Rhinoplasty Maneuvers?

What type of things do you do in a rhinoplasty?

Obviously, the most common is a dorsal hump, a hump on the nose, that’s the most common.

Oftentimes I would say that’s probably the most common where we shave down the bone and then we shave down the cartilage. Oftentimes that can be associated with an under-projecting tip. And an under-projecting tip is a tip that doesn’t match even if when you bring the dorsal down, the tip is still under-projecting. And sometimes we can elevate the tip by use of suturing or cartilage grafts.

The next is a bulbous tip.

A bulbous tip is just a bulky looking nose, a wide tip and that can be improved again by suturing and or grafts. And the final determination of those and how it looks is real-time in surgery. You know, a lot of rhinoplasties is artistic in rasping a little bit more, tightening a little more, maybe I’m going to try a tip graft. Place a tip graft and see how that looks.
It really comes down to the art of your surgeon.

So then we have you know, other types of noses. We have over-projecting tips, where we have to take the tip down. We have to pull the tip in by dividing the cartilage and suturing those together to shorten the tip of the nose.

Some people have a drooping tip which is pretty common and you really want to shorten the nose and so sometimes we have to shorten the nose.

Those are the most common, and occasionally we get crooked noses.

Crooked noses are pretty tough, we have to open up the nose, we have to remove the spring of the septum cartilage and put basically braces on each side of the cartilage called spreader grafts to straighten the nose. And that’s a very important aspect of nose straightening, and I think a lot of surgeons don’t really get that and understand that really to get a fix a crooked nose – it takes a very specific type of maneuver.

As I mentioned before, there’s about 18 to 20 of these type of [rhinoplasty] maneuvers that you have to be really well versed in, in order to create an artistic, attractive beautiful nose.

What happens if I have a really prominent nostril (also called a hanging columella).

The part of this central part of the nose sometimes looks drooping. And that’s part of the comprehensive rhinoplasty which we see very commonly. Oftentimes we’ll shorten the columella this part of the nose that you see. And there’s maneuvers which are called [caudal septal] a doctor term for just removing about two or three millimeters of the bottom of the septum and that raises up the columella.

The next maneuver sometimes is lowering the alar rim, so that the rim right here sometimes can patch up and be very prominent and you can see your nostrils. And so a lot of times we will place a alar contour graft which is again a doctor term for just placing a matchstick piece of cartilage just along the rim to straighten that.

Sometimes I have to go the next level and the next level is that the columella still is bowing down too much. I’ll actually divide the cartilage in half and then suture it together, sometimes over a strut graft I get from the septum. And I’m talking technically, these are things that I do. But each portion of the nose has it’s few maneuvers that I can change, and you have to have the confidence and have done hundreds of procedures to be able to confidently improve those areas.

They are very improvable, in other words, the hanging columella, the prominent nostril, those are fixable very much but you have to have experience in doing this.

How to prepare for rhinoplasty surgery.

There’s no specific things for rhinoplasty that you need to prepare. I would you know, obviously avoid aspirin or any non-steroidal anti-inflammatory medications. I tell everybody globally if you do cardio prior to surgery, you’re going to recover much quicker, even in two weeks of doing cardio a half hour getting your heart rate up. This real cardio I mean, like sweating cardio, makes a big difference in your overall post-operative recovery. But other than that there’s no other real major issues you need to deal with prior to your rhinoplasty.

What to expect on the day of surgery for rhinoplasty:

And what I’d like to do is I’d like to meet with the patient to re-discuss their goals and what they want their nose to look like. At that time they meet with anesthesiologist because we do put people to sleep for rhinoplasty surgery. Typically, a rhinoplasty surgery is about an hour and a half to two hours long. In today’s world they really don’t have a lot of pain or discomfort after surgery, they will have some packet which will come out the next day. Usually, we operate on rhinoplasty patients on Tuesdays and Wednesdays so that the following Monday, which is a clinic day for me, I can take out the splint and take out the sutures. By then the nose looks pretty good and usually, they have a little bit of bruising and other than that most people by eight-nine days really look quite good with a little makeup.

A question I was asked is after rhinoplasty are there any post-procedure adjustments or things that you need to have done?

And yes, rhinoplasty is an art form but a lot of times the skin end below wants to go back to the old skin, it has memory. It’s not uncommon to thick skin individuals for me, to put steroids in their super tip area maybe a month or two months out. Sometimes we need to build up a little area. That’s part of rhinoplasty. The more and longer I’ve been doing rhinoplasty surgery the more I realize that the post-operative care is just as important as the surgery itself.

What is a non-surgical rhinoplasty?

Sometimes there are patients who have previous rhinoplasties or not. That a simple filler can make a big difference in the appearance of the nose, if their nose is too scooped out, if they have a certain bump. Sometimes, you can just use fillers around the nose to expand the skin envelope and it can make the nose look better. I often times can use a non-surgical rhinoplasty after rhinoplasty to go from good to great. Or sometimes, some people don’t even need a rhinoplasty and all they need is a little bit of filler. So that’s when you’re talking about non-surgical rhinoplasty, you’re talking about filler using. Something like Juvederm or I even use silicon oil which works really well in the nose.