Getting a minor dorsal hump reduction, but my surgeon insists I won’t need osteotomies. Can I trust him? (Photos)

Question

I (23F) am scheduled for a septoplasty/rhinoplasty + turbinate reduction in a month. I have a minor dorsal hump I would like reduced to be rather straight. I also would like a slight supratip break to mitigate a lengthened appearance and drooping of the tip. I have very thin skin which I know is a risk factor inverted V deformity. I really like how I look from straight on. I have a thin, straight dorsum and a nice tip. I don’t want to look much different from the front. My surgeon is a double board certified ENT and plastic surgeon. I want to keep my thin dorsum as much as possible, but instead he insists that osteotomies are only for large/moderate dorsal humps and he has instead proposed the use of spreader grafts. He has only one before and after photo on his website for rhinoplasty. The results are alright, not amazing, but I can’t make a fair judgement because the patient is just 10 weeks post-op and still has swelling. I’m wondering if I can trust him with this surgery? Will the results be aesthetically pleasing enough to go through with such an invasive, risky, and cosmetically uncertain procedure? I start medical school in a few months (I am also interested in facial plastics!) and I would like to breathe better, but I know that many surgeons harvest grafts from the septum. If it’s better to do both the septoplasty and rhinoplasty in tandem, should I just wait a few years being a bit uncomfortable with my breathing in order to find a different surgeon?

Andrew Miller, MD · Answer

Based on your photos, you are a great candidate for rhinoplasty. In a nose that's done properly, osteotomies are almost always done to avoid an open roof deformity and judging by your photos, you are no different. Not to question anyone's abilities, but if I were undergoing rhinoplasty, I would want to see many before/after photos and confirm that the surgeon is performing rhinoplasty weekly. It is definitely better to do both the septoplasty and rhinoplasty at the same time. The septal cartilage is used to strengthen your droopy tip and give it better definition. Be sure to see a rhinoplasty expert for consultation that does computer imaging at the same time.

Gianfranco Frojo, MD · Answer

I would be highly cautious about a surgeon with one before and after photo that is at only at 10 weeks. Rhinoplasty results should show a minimum of at least 12 months follow up, ideally 24 months (especially in revisionary cases). If things do not feel right, usually things are not right. Trust your gut when it comes to choosing someone that is going to operate on the central point of the face. I would recommend seeing an American Board of Plastic Surgery certified surgeon with experience in rhinoplasty, ideally one that is a member of the Aesthetic Society as well.

Kadir Berat Oyur, MD · Answer

Since you are about to embark on your own medical journey, you likely already sense that the most critical element in any surgical outcome is the alignment between the patient’s anatomical goals and the surgeon’s technical philosophy. While your surgeon’s double board certification is a strong credential, the combination of very thin skin and a desire to maintain a narrow frontal profile requires a high degree of precision; spreader grafts are excellent for preserving the internal nasal valve and preventing an inverted-V deformity especially after hump reduction but they can occasionally widen the mid-vault, which seems to be your primary concern. Given that you only have one clinical example to reference and are feeling significant hesitation regarding his aesthetic approach, it is entirely reasonable to postpone the procedure. In the world of facial plastics, "measure twice and cut once" applies to the consultation process as much as the surgery itself; waiting a few years to find a surgeon whose aesthetic portfolio consistently mirrors your specific goals is a far better path than rushing into a primary surgery that may require a complex revision later.

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. Based on your photographs, you are a great candidate for rhinoplasty. Maneuvers for your surgery would include dorsal hump reduction, tip refinement, nasal tip deprojection, tip elevation, among other maneuvers. Make sure you are going to a surgeon with hundreds of long-term before and after pictures on their website with standardized lighting and standardized backgrounds. With good surgical technique, you could have an outstanding result. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Steven M. Denenberg, MD · Answer

I would keep looking for another surgeon. I understand I'm working with limited information -- just what you wrote here and the pics you posted, but I'll tell you what comes to mind, in no particular order.

You like your *thin* dorsum. Lowering a bump on the bridge pretty much always makes the bridge look wider. If the bump is small-ish then the bridge would only look a small amount wider, and osteotomies can correct that small widening. Osteotomies are a *very* minor part of a rhinoplasty, and there's very very little downside to doing them if they're done well, so I don't see a reason to avoid them.

But you mentioned he would be using spreader grafts, too. Spreader grafts typically make the dorsum look *substantially* wider, so if you reported your desire to keep a thin dorsum, in my opinion, spreaders shouldn't be under consideration at all.

You mentioned you wanted a "slight supratip break to mitigate a lengthened appearance and drooping of the tip. A supratip break doesn't mitigate or correct a drooping tip. Your nose is rather long, especially visible on the 3/4 view, and if the bump is taken down, your nose will look longer still. To my eye, you would benefit from having the tip elevated a not-insignificant amount. This is something that you should have figured out with morphs before considering going with the doctor. Morphs are crucial, because otherwise how do you know what he's picturing as a final result for your nose?

Having only one photo--and a 10-week result, too--on the website is a big problem. It's true that every surgeon has to start out with none (I did!!), but *you* don't have to use those beginning surgeons. Without before and after photos, you just have no evidence that the doctor understands the operation or what your nose needs or whether he can accomplish what you want. And as I mentioned already, if there are no morphs, the two of you haven't really agreed on a goal yet. The board certification exams, by the way, do not test for skill in this area.

Accomplishing surgically what your nose needs, especially the decreasing of the length, requires skills that most rhinoplasty surgeons do not possess with expertise, and many don't possess those skills at all. I think you should live with your breathing issues and start your search over for a surgeon to do your rhinoplasty. Having an unsatisfactory operation is much, much worse than having no operation at all.

Gautham Ullas, BMBS, BMedSci, FRCS (ORL-HNS) · Answer

Hopefully I will see you as a colleague in the future.Osteotomies are not always necessary with modern hump reduction techniques. If the surgeon is planning a structural septorhinoplasty then component reduction technique is used by filing down the bone or cartilage. The osteotomy is only needed if an open roof deformity is created. You do not necessarily create an open roof with component reduction. In practice, its difficult to know with absolute certainty whether osteotomy is needed or not. If mostly cartilaginous hump then spreader graft or autospreader flap is enough.

Ronald J. Edelson, MD · Answer

If you go to 10 different plastic surgeons you will get 10 different answers so there’s really no right or wrong answer. Personally I think your nose needs to be reduced significantly more than you think.  Therefore  I would perform osteotomies. Some surgeons are more conservative than others.  If you’re unsure get other opinions.

Gary M. Horndeski, MD · Answer

If all you want is minor dorsal hump reduction then that can be done with a file and will not result in an open roof deformity and will not need osteotomies. However, you would benefit from a rhinoplasty and a chin implant. The nasal columella angle is less than 90 degrees and it should be at 110 degrees. The nose is too long and your tip need to be refined.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Zoran Potparic, MD · Answer

It is in your best interest to collect as much information about your condition and a surgeon as you can. Dallas has many excellent nose surgeons and I am sure it would not be a problem to have one or two second opinion consults. There are very few procedures in plastic surgery that require such an expertise as a rhinoplasty. Good luck.

Kyle Kimura, MD · Answer

Thank you for your questions and photos! 
I think the most important question that you have to answer for yourself is are you comfortable with your rhinoplasty surgeon? This comes from a wide number of factors that include how they interacted with you during your initial consultation, did they answer your questions or did you feel like they rushed through things quickly, did they explain thoroughly what surgery entails and the recovery process as well as the risks of surgery, did they push you to sign up for surgery right away or did they give you time to process and consider your options. Their results and online presence can also be a factor and ideally you want to good long-term results. Word of mouth and asking around can also be helpful in determining their reputation. And if there are ever concerns, getting a second opinion is never the wrong decision. Ultimately the most important thing is that you feel comfortable with your surgeon and the plan because this is a life long decision and you want to make a decision you are happy with. 
Hope this helps and best of luck!Kyle Kimura, MD

Getting a minor dorsal hump reduction, but my surgeon insists I won’t need osteotomies. Can I trust him? (Photos)

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