Nose and jaw are both tilted, which should I fix first?

Question

I am an Asian, 34 years old. I have an S-shaped deviated septum and my nose is tilted to one side; I also have jaw alignment and protrusion issues. My face is very asymmetrical due to these issues, but I don't know what type of doctor to go to, and which issue should be fixed first?

Jacqueline T. Cheng, MD · Answer

Hello and thank you for your question about rhinoplasty, septoplasty and maxillofacial surgery. Without pictures, it is not possible to make specific recommendations. However, a septoplasty procedure can help straighten a deviated septum; and a rhinoplasty procedure can help straighten your nose using either bone, cartilage grafts, or a combination of the two. Maxillofacial surgery may also be able to address your jaw alignment issues. To treat these symptoms, you will first require a full examination and diagnosis. Schedule an in-person consultation with a board-certified facial plastic surgeon and have an examination to discuss a possible treatment plan and the order in which to have your procedures. Good luck! 
- Jacqueline T. Cheng, MD

Ronald J. Edelson, MD · Answer

I’mNot sure which should be done first but before any surgery you might want to consult an orthodontist or oral surgeon to determine what possibly needs to be don with your jaw.  The jaw surgery can be quite complicated but you should find out how bad your situation is and if it even needs correction.once you see the dentist you will be better able to make an informed choice.

Mark Murphy, MD · Answer

Thank you for your question. If you have nasal asymmetry due to a crooked nose, thenrhinoplasty can address your cosmetic concerns and improve the symmetry of your face. Adeviated septum can only be corrected using a septoplasty procedure, which is commonlyperformed alongside rhinoplasty.
Your jaw alignment and protrusion issues may be corrected using orthognathic surgery or otherprocedures. I would advise seeing an oromaxillofacial specialist to determine how to correctyour jawline before moving forward with rhinoplasty and septoplasty. When you are ready, besure to schedule a consultation with a board-certified facial plastic surgeon to discussrhinoplasty and septoplasty. Best of luck.

Robert Kotler, MD, FACS · Answer

Dear labcat1019 in Irvine, CA:
          If there are jaw issues, it is best to get those corrected since there may be some influence on the conduct and safety of anesthesia.  The choice of which to go to first is not absolutely critical, but you need to have consultation from two very highly-specialized people.    Today’s oral surgeons are extremely talented in the work that they do.  Often, they work with orthodontists and other dental specialists to achieve the best results.  I would start there.  Another reason is if they can realign the lower jaw, then that becomes a help in terms of the alignment of the nose to match the other facial features.  
  
     Do your homework before consultation. Prepare well for your consultation.  When you search, look for rhinoplasty super-specialists. There are other super-specialists for every procedure, e.g. revision breast augmentation, or body sculpting.  Impossible for any one MD to be the master of ten or 15 cosmetic procedures.  Look for surgeons whose practice is the majority or entirely devoted to rhinoplasty, septoplasty, and associated procedures.  This would include both primary and revision rhinoplasty surgery.  Why not have the most specialized talent in your service?  Consider how much experience the surgeon has doing the procedure you are considering. We all get better at what we do with time and so those surgeons who have a long run of experience are the ones who have learned the most from experience. Residency and fellowship are where the learning begins, but for all of us, time and experience is where the talent and wisdom are amplified. 
  
Part of your preparation for consultation should be preparing a list of questions beforehand.  Bring a notepad, or I-pad or laptop, with you and take notes as the surgeon answers the question you are asking.  You should spend more time with the surgeon than with the office staff, because you need to get a sense of whether you are comfortable with the doctor.  You should not feel rushed such that you are on a consultation conveyer belt.  If the presentation by the office staff seems a bit to “sales-ie”, that’s also a yellow or red light. Take a friend or relative along since two heads are better than one in gaining information and understanding.  In the end, the purpose of the consultation is for you to be educated, not to be “sold”.  Ask yourself two key questions: “Is this surgeon teaching me or selling?” And secondly, “Can I put my face ― and my life ― into this doctor’s hands? Can I completely trust him/her?”
  
There are excellent books out there that you can read and use to study up. It is worth the homework time you put in up front so that you make the right decision with respect to choosing a surgeon who has the talent, experience, and degree of super-specialization that you certainly want to have. You want to do it right the first time. 
  
When you visit doctor’s websites, the most important feature on the site is the before and after gallery.  If there are just a few examples of rhinoplasty or revision rhinoplasty, you wonder how much experience the surgeon has performing such surgeries.  You need to see dozens examples.  The more examples there are, the more likely you will see one or more that demonstrate situations similar to yours.  Look closely at the photos for natural results.  That is what you want.  Nobody wants to carry a sign saying “I have had a rhinoplasty.” You also need to see the computer imaging section of the site. See how closely the actual “after” matches the computer-generated after. Nothing better displays a doctor’s artistic and surgical talent.                                      
  
Reviews, particularly right here, on RealSelf, are very important and should be carefully digested. The larger the number of reviews, the better.  A consensus is generally correct. 
  
A consultation without computer imaging is, in my opinion, of much less value.  Why shouldn’t you see the predicted result of the procedure the doctor is proposing?  At consultation, photos are taken of you and loaded into a computer system that morphs your present appearance into the anticipated “after” based on your and the nasal surgeon’s input.  Imaging is an incomparable learning tool because it provides a forum for doctor and patient agreement on what would satisfy the patient and what is, based on the doctor’s talent and comfort zone, achievable.  After all, cosmetic surgery is 100% visual.  It is about appearance. So, without a visual evidence of what is planned, how can you make a decision as to whether or not you might be satisfied?  Talking about what your result will look like is worthless and confusing.  To anticipate a successful outcome, there must be a visual meeting of the minds between surgeon and patient. When you shop for clothing, you usually try on the outfit, right. How else can you tell if you would be satisfied?
  
 
  
     Best wishes,
  
 
  
Robert Kotler, MD, FACS 
  
Over 4,500 nasal procedures performed

Samir Shureih, MD · Answer

Provided your own evaluation is correct.An evaluation by a Cranio-facial surgeon or Maxillo-facial surgeon for evaluation of the bite and the mandible and maxilla.Once that is corrected then the nose can be re-evaluated by a surgeon or a plastic surgeon working with the other surgeons to achieve the facial symmetry

William Portuese, MD · Answer

If there is a deviated septum present along with a twisted nose, probably best to seek out a consultation with a double board certified ENT/facial plastic surgeon to accomplish straightening the internal and external component of the nose. If the jaw is tilted, an oral surgeon would probably be the best person for that. To straighten the crooked nose appearance is considered rhinoplasty, and to make the diagnosis of a deviated septum requires internal examination of the nose. A septoplasty is only performed for breathing improvement, and is considered functional for medical necessity. A rhinoplasty is usually paid for by the patient, while a septoplasty is billed to medical insurance once the medical necessity and preauthorization has occurred. Both procedures can be performed together when needed, which allows one anesthesia and one recovery period.

Frederic H. Corbin, MD (license restricted) · Answer

Thank you for the question and I would see an orthodontist first and have your bite etc evaluated first and he may then refer you to an oral surgeon if surgery for your teeth/mandible is needed.  After that si corrected you can get your nose fixed Dr Corbin

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