The art of sculpting the nose

by

BORIS M. ACKERMAN, M. D.
PUBLISHED BY SKIN DEEP WORLD

The art of sculpting the nose

Noses that are too large, too small or those that are crooked have unwanted bumps and humps or those that have been damaged by physical trauma can be corrected through a surgical procedure known as rhinoplasty. "Rhinos" is the Greek word for nose and "plastikos" means to shape. So, literally rhinoplasty means to "shape the nose." Without a doubt, the nose is the most defining facial characteristic. Therefore, a slight nasal alteration can greatly improve one's appearance. A rhinoplasty is ideal for patients who wish to enhance the aesthetics of their nose. Rhinoplasty can reduce or increase the size of the nose. It can change the shape of the nasal tip or bridge. It can narrow the span of the nostrils or change the angle located between the nose and upper lip.

Who should consider Rhinoplasty?

Generally, a rhinoplasty patient is a person who has been moderately unhappy with a specific characteristic of his or her nose. This person has usually been unhappy for a period of time. Candidates for rhinoplasty surgery include men, women, adolescents, teenagers, adults and seniors.

Few people realize it, but as we age, the cartilage within our nose enlarges. The nose grows bigger and it can significantly droop or become irregular in shape. One of the signs of facial aging in some people is the alteration of nasal appearance. It is not uncommon for me to perform a rhinoplasty at the same time as a facelift in a patient whose primary reason for wanting surgery is to look younger.

In general, patients who come to me for cosmetic rhinoplasty complain about noses that are:

Too thick at the bridge or tip
Too long
Have a hump or bump
Are crooked or hooked
Or those that have other deformities
A rhinoplasty is the procedure of choice for patients who have difficulty breathing. This procedure may help them breathe more normally. Troubled breathing can be caused by a traumatic nasal fracture or by functional deformities. Health insurance usually covers rhinoplasty procedures for those cases because they are viewed as being medically necessary. A specific type of rhinoplasty used to treat functional nasal breathing deformity problems is called the septo-rhinoplasty. This procedure involves the removal of any internal obstructions. A septo-rhinoplasty also involves the correction of any functional abnormalities that may block nasal breathing as well as those abnormalities which allow too much air to enter the nasal cavity.

Most rhinoplasty procedures, however, are performed for cosmetic reasons and are therefore not eligible for insurance reimbursement. Cosmetic procedures are not covered by health insurance. Even so, I have found that these procedures are still prized and desired by patients. This accompanying change in appearance often results in an increase in self-confidence and in overall patient happiness and satisfaction.

About half of cosmetic rhinoplasties require functional correction at the same time. If a septoplasty or internal valvular reconstruction is not performed at the time of cosmetic rhinoplasty, and it is indicated, then these patients, who might have had marginal breathing before surgery, will have impaired nasal breathing after cosmetic rhinoplasty.

It is not uncommon for me to see a boy or a girl in their mid-teens, brought in by their parents, requesting nasal surgery. A large or otherwise unattractive nose can be quite debilitating for the personality of a young person. This facial characteristic can even create a social recluse. In these patients, a rhinoplasty can be a life-altering procedure. The surgery can transform an awkward, social recluse into a more outgoing, self-confident and overall happier teen.

There Is No Substitute for an Experienced Board-Certified Plastic Surgeon

Unfortunately, along with the rise in popularity of rhino-plasty, there has been an increase in the number of inexperienced surgeons that perform this procedure. According to a recent New York Times article, there has been a corresponding increase in the need for, and the number of corrective revision surgeries or "re-dos."

The point to take home with you is that surgical experience with nasal surgery really counts with this type of surgery. In the hands of experienced, Board-Certified plastic surgeons and ENT surgeons, the overwhelming majority of rhinoplasty procedures can result in an improved appearance as well as in improved nasal breathing. Unfortunately, the same cannot be said for procedures performed by less experienced or less talented surgeons. That's why, if you want the best chances for success, it is better for prospective patients to chose a Board-Certified plastic surgeon, one who has the experience, technical skills, and innate artistic vision to achieve the desired result.

After all, you are entrusting your face to your plastic surgeon. You owe it to yourself to hire the surgeon who is most experienced and most qualified. To find that paragon, patients should ask for referrals from their family physician or internist. Try to get referrals from friends and relatives who have had successful rhinoplasty procedures. Patients should then get second or even third opinions from Board-Certified plastic surgeons regarding the necessity and extent of the nasal surgery needed in your case.

Once you are in the surgeon's office, don't be shy about asking questions. Ask to look at "before and after" photos of the surgeon's former patients. Ask the office for the names and phone numbers of former patients who have agreed to talk about their surgical experiences. When you speak with these former patients, explain that you are considering having "a nose job" and that you would appreciate their opinion. Don't be reluctant to ask about whether their expectations were met by the surgeon who did their surgeries. Ask these former patients to share their thoughts and feelings with you from everything to the initial consultation to their post-operative care.

And, before you make your final decision to hire a plastic surgeon, check to determine if he or she is Board-Certified by the American Board of Plastic Surgery. This "Stamp of Approval" indicates that the surgeon has gone through a rigorous training, education and testing process. This certification also indicates that the surgeon's case results have been reviewed and approved of by her Board-Certified peers.

What about revision surgery?

If you are a member of the small, but growing percentage of patients who need a "redo," consider hiring another specialist. . . one who is skilled at what is called revision rhinoplasty surgery. A small group of extremely skilled and talented plastic surgeons are now focusing a larger part of their attention and skills on helping such patients. Don't be afraid to ask the surgeon to whom you have been referred whether he or she has extensive experience in revision nasal surgery.

The most common reasons for a revision rhinoplasty include poor tip definition, contour irregularities in the tip or dor-sum, overall esthetic imbalance. When I perform revision nasal surgeries that require the addition of native tissue, I use cartilage grafts obtained from the septum, ear or rib cartilage.

Realistic expectations are key to patient satisfaction

Personally, I perform a lot of rhinoplasty revision surgeries on patients who have been referred to me. I have found that one key to the success of a rhinoplasty, especially a rhinoplasty revision surgery, is the initial discussion with the patient about what outcome is expected. Inexperienced surgeons often don't realize the importance of this factor. Oftentimes, they don't take the necessary time to consult with their patients regarding expectations. On the other hand, the most talented and experienced of all plastic surgeons may not recognize the importance of taking the time to understand their patients' desired outcomes.

In fact, experienced plastic surgeons can help their patients develop realistic outcome expectations. They do that in several ways. One way is by discussing with the patients their vision of how they want their nose to look like after the surgery. This pre-operative discussion hones in on specifics, not generalities.

I also help my patients visualize the best possible outcomes that are possible by taking digital photos of their faces. Next, I use computerized software to manipulate the photos to develop a series of images that show how their post-surgical nose can look.

Preoperative photograph:
this patient has a poorly defined nasal tip as well as disharmony of all of the nasal parts.

Post-operative photograph:
she had a rhinoplasty performed with repositioning of all nasal elements in such a way as to create a beautiful, more natural appearance. This patient also had neck liposuction performed.
 

Rhinoplasty is a relatively painless out-patient procedure

Almost every rhinoplasty patient asks how much pain and discomfort he or she should expect. I explain that rhinoplasty operations are generally out-patient procedures which, if done properly, cause little pain, swelling, or discomfort. Proper care includes a thorough pre-surgical assessment of the patient's general physical health and preoperative laboratory studies.

Patients who smoke, former smokers and those with diabetes or cardiovascular problems present unique problems. Generally, these types of patients can have rhinoplasty operations if they are still in good health, but the surgeon must be aware of and capable of recognizing and dealing with potential problems associated with the risk factors involved.

Precautions should be taken. Smokers, for example, should be encouraged to quit or at least reduce the number of cigarettes consumed. This precautionary step can significantly help reduce postoperative coughing and bleeding. Diabetic patients should make sure their blood sugar levels are within normal levels. Their blood sugar levels should be monitored before and after the operative procedure.

Every patient must be warned that no food or liquids should be consumed within six hours prior to the surgical procedure. A patient is not to drink water, eat candy or to even chew gum. This is because if there are stomach contents present, the complication rate can increase. Another precaution is the cautionary warning regarding avoiding aspirin and all blood thinners. None of these blood thinners should be taken within 10 to 14 days prior to surgery because they will encourage bleeding and bruising. Since many over-the-counter products contain aspirin or blood thinners, it is important to check all medications carefully. Even multi-vitamins are off-limits because of the presence of Vitamin E (a potent blood-thinner) in most multi-vitamins.

Other drugs to be avoided include non-steroidal anti-inflammatory medications (such as Advil, Motrin, and Naprosyn). These medications should not be taken within ten to fourteen days of a rhinoplasty. If you are in doubt ¡X if you have any questions regarding the medications that you take, please call your plastic surgeon's office or consult your pharmacist

In my hands the rhinoplasty surgical procedure usually takes one to two hours, depending on the complexity of the case. It is usually performed at an outpatient surgery center. No overnight stays are required. An anesthesiologist is present to monitor vital functions throughout the procedure. Usually, the anesthesiologist calls the patient the night before surgery to review the patient's medical history.

Rhinoplasty can be performed under a general or local anesthetic, depending on the patient's or surgeon's preference. Because of the need for anesthesia, I always insist that someone else drive the patient home after the procedure and encourage the patient to have someone stay overnight the day of surgery in the event of unforeseen complications. Post-rhinoplasty (after rhinoplasty) complications are quite uncommon. The plastic surgeon must be capable to recognize any potential complications and be competent to treat them. Some of the known complications of rhinoplasty surgery include nasal bleeding, infection, breathing difficulties and external (located outside) visible nasal irregularities. Cosmetically, the most common complications after a rhinoplasty are poor tip definition and supratip scarring which yields an overall poorly defined nose.

One of the fears expressed by potential rhinoplasty patients is that their noses will have to be uncomfortably packed with gauze to prevent post-operative bleeding. I quiet such patient fears by placing specific sutures inside the nose which prevents excessive bleeding and therefore makes gauze packing unnecessary.

As part of our usual post-operative care, rhinoplasty patients wear a small nasal splint for five-to-seven days after the procedure. Since the splint acts as a support as well as a protective structure, it actually enhances patient comfort. Some swelling and bruising is common, although it should be mild.

Most patients report that their post-operative discomfort is usually mild. I prescribe rather mild medication for pain relief. Some patients take only Tylenol.

Complete healing and the settling of the nose into its final desired form typically takes from between six to nine months. In my experience, most patients look presentable and can return to work without pain or discomfort within 7 to 10 days after the procedure. Most patients return to some moderate form of exercise within 10 days after surgery. I allow contact sports after about 2 months. By that time, the nasal structures have healed enough to withstand any accidental injury.



Preoperative photograph:
this patient has a relatively small nose to start with. She also has fine facial features.

Post-operative photograph:
subtle alterations of her nose created more nasal definition and improved nasal proportions. The procedure resulted in an overall more pleasing appearance.
 

In summary, a successful rhinoplasty requires a skilled, talented and experienced Board Certified plastic surgeon that can accurately assess an individual patient's anatomy as well as the patients expectations. Hopefully this same surgeon will be capable of producing the desired aesthetic result



BORIS M. ACKERMAN, M.D.
PRIVATE PRACTITIONER
BOARD CERTIFIED PLASTIC SURGEON
AMERICAN BOARD OF PLASTIC SURGERY
NEWPORT BEACH, CALIFORNIA
 

Article by
Newport Beach Plastic Surgeon