Why does my nose look so much worse after 4 weeks, than when the doctor took the cast off?

The cast usually helps to suppress the swelling. The first
few weeks are the “ugly month” as the nose is beginning to settle down. The
nose can change daily and swelling can move around the nose for up to many
months as the nose slowly begins to take shape. It is best to discuss your
swelling concerns with your surgeon.

I agree with the other respondents. Hopefully you are continuing to see your surgeon on a regular basis and assessing your progress. Also there is the ability for the swelling to expand a bit after the cast is off. Over time (even a year) this will go down and your will see real and gradual change

When your surgeon removed your nasal cast or splint, the nose had been held in the desired shape by the splint (cast), and this also helped to keep swelling at a minimum as the skin re-adhered and began to heal.The minute the splint was removed, your nose began to swell, and scar tissue beneath the skin where all the work was done also was forming. The underlying shape is now obscured by both swelling and scar tissue.As we continue to say here and in our patient consultations, scar tissue takes 6-12 months to fully soften and mature, which is why it takes noses (and all operated areas, actually) up to a full year to settle and develop their "final" appearance. And also why any consideration of (or request for) revisionary surgery should be delayed for 6-12 months.Excessive swelling or scar formation can sometimes be favorably influenced by judicious and skilled low-dose steroid injection(s) to soften and reduce these things that can affect your nose appearance. I typically wait for 6-8 weeks before considering steroid injection, start with very low dose and low concentration, and wait two months between injections to assess effectiveness. I'd rather creep up on effectiveness slowly and carefully than use too strong a concentration or too high a dose and end up with a dent! So slow and easy if this route is taken. Yes, you ARE swollen, and this can obscure your result. Scar tissue has not yet matured either, so see your surgeon and see if steroid treatment is recommended. In the meantime, relax and let the time pass before you become concerned too much. This is indeed normal in the vast majority of rhinoplasty patients. Best wishes! Dr. Tholen