Rhinoplasty and TMJ: Scared of rhino because I have bad TMJ.

Hello and thank you for your question. Based on your
photograph, you may benefit from a tip refining rhinoplasty.  You may also benefit from a cephalic rotation
of your tip to turn up your tip slightly and a conservative dorsal hump
reduction. In order optimize safety and results, I prefer general anesthesia administered by a board-certified MD anesthesiologist.  I do not place packing inside the nose after surgery.  If you have hypertrophy of your maseter muscle, you may want to also consider botox injected into the maseter which may help your TMJ.   Make sure you specifically look at
before and after pictures of real patients who have had this surgery performed
by your surgeon and not just a computer animation system.
The most important aspect is to find a surgeon you are comfortable with. I
recommend that you seek consultation with a qualified board-certified plastic
surgeon who can evaluate you in person.
Best wishes and good luck.
Richard G. Reish, M.D. FACS
Harvard-trained plastic surgeon

As a physician, you understand the need to explain all possible, albeit unlikely complications arising from surgery.  That said, I have never seen TMJ exacerbations from TMJ and none of my patients go home with nasal packing.  I don't think that should be the "rate-limiting" decison for your surgery.  Finding a board-certified Facial Plastic or Plastic Surgeon experienced in rhinoplasty that you feel comfortable discussing this should be the next step.  Best of luck.

Click on the "Learn more" link, just below my response, or go here:
FacialSurgery.com/RealSelf/RealSelf_firstrimer.html
I made a computer morph of your nose, and an animation of the morph, to show the changes that are possible for your nose in truly expert hands.You didn't say just what you wanted changed about your nose, but what I did was to lower the bump and elevate the tip just a bit. You can probably see it best in the animation. When a bump is lowered, it can make the nose *look* longer, which is one reason we often elevate the tip a bit.I (and many doctors -- you have to ask) don't use any packing at all in the nose, so the patient can usually breathe through the nose during the week after surgery, when the splint is in place.General anesthesia isn't needed. This operation is done fine with IV sedation. I never use GA. TMJ is not an impediment.Filler on your nose would be awful. It would make your nose look bigger, and to my eye at least, most people with your nose, if they were considering surgery, would want the nose smaller!
You should understand that the changes I demonstrated in the morph require advanced techniques, techniques that most plastic surgeons cannot handle.  Be sure to read the section in the "Learn more" link on how to stay out of trouble while searching for a rhinoplasty surgeon. Rhinoplasty is an exquisitely difficult operation to get right, and you should only have surgery if you are able to make yourself very confident in your surgeon's skills. Read that page very carefully. Most plastic surgeons are quite poor at this operation, and I believe my advice will go a long way toward keeping you safe.
I'd love to hear what you think of the morph. Did it seem to address your main concerns? I could modify the morph to your taste if you wish.
Your nose is also a good example of why computer imaging is mandatory in rhinoplasty. You need to know exactly what the surgeon is planning to accomplish -- what features he thinks he can change, and by how much he thinks he can change them. When you see his goals, you'll know whether he has an eye for an attractive nose, and whether he shares your opinion of what constitutes an attractive nose. You'll also know whether the changes he proposes are enough to be meaningful to you, and whether he understands your wishes enough to address all of your priorities. But remember, you're not hiring him for his skills with the computer. The doctor must then show you his before and after photos to prove that he can actually accomplish what he draws on the computer.
In your case in particular, you need to find a surgeon who understands all of the issues I mentioned, and how they fit together, and who can actually accomplish them in surgery. 

In my experience improving nasal breathing can help significantly with TMJ disorder symptoms in the long run.  In fact, I work with many dentists to improve the nasal airway for just this purpose.  This improvement happens because you sleep better with less obstructions which means a less stressful sleep.  This decreases bruxism (clenching) and therefore pain in the joint.  The nasal surgery itself can trigger a short term worsening of pain due to the reduced breathing postop.  This can happen even if the nose isn't packed, because of swelling.  Cosmetic goals can be accomplished during the same surgery to improve your health.  
Of course if the surgery is cosmetic only, then surgery could be limited and the postop swelling limited.  The decision of open vs endonasal is more of a conversation of what you want to accomplish and how comfortable the surgeon is with doing those techniques.  GA vs sedation will really not affect the postop swelling.  
I would see a ENT/ facial plastic surgeon to not only evaluate the outside, but the airway as well.  IMO, patients are never happy with the appearance if they can't breathe. 
I do not believe that a non-operative rhinoplasty would accomplish your goals.  
All the best

 When performing a rhinoplasty procedure, it's important to have a controlled airway so that blood does not pool in the back of the nose and go into the trachea. In our practice, we do not perform rhinoplasty procedures under IV sedation, since osteotomies must be performed in the nasal bones to narrow them after the dorsal hump removal. TMJ should not be a problem, since we place a laryngeal mask airway in place and  patients are not fully  intubated with an ET tube. The dorsal hump removal and narrowing the  bridge line can be accomplished  with a closed rhinoplasty approach with all the incisions placed on the inside of the nose. No  painful intranasal packing is required. In our practice, we do not recommend nonsurgical rhinoplasty due to the fact that it is only temporary, is not FDA approved that application, and can have significant complications such as skin Necrosis. Rhinoplasty is a very difficult endeavor, so choose your surgeon wisely based on extensive experience producing natural results consistently. Digital computer imaging would also be helpful to understand what can be accomplished with your nose upon your facial features. This can be performed at the time of the consultation, or online. For many examples of close rhinoplasty, please see the link and the video below

You are a great candidate for rhinoplasty.  The amount of mouth opening you need to breathe through your mouth is minimal and very unlikely to exacerbate your TMJ.  In addition, you may not have any issues with breathing out of your nose after surgery regardless.  I would discourage doing a rhinoplasty under sedation.  In my opinion, a properly performed rhinoplasty for your case requires your comfort, and protection of the airway during surgery.  This is best achieved with general anesthesia.

You present two issues that you might have to endure for lifetime --a TMJ problem which may or may not be resolved, and a nasal issue which you are unhappy with and can be resolved.  I'm not sure that rhinoplasty and mouth breathing because of packing will aggravate your TMJ, but if it does, it will be temporary --some surgeons place tubes through the packing to keep some nasal air passage open--- However, Not all rhinoplasty surgeries require packing  --but you should know that if there is no packing placed, post -op swelling can also obstruct the nasal passages.. Whatever the experience, [and there is some discomfort and annoyance with all rhinoplastic surgery], you will have addressed and dispensed with one of the two mentioned issues affecting you--  ---About the other questions you raise, I do all rhinoplasties with local anesthesia and sedation ..... some surgeons prefer general anesthesia  -which is not wrong, but just not my preference for many reasons... The advantage of an endo approach is that there is no external scar ---in the right hands of a surgeon well versed in this technique [I do 90 primary rhinoplasties this way], it is a great technique... open rhinoplasty is perfectly fine however and I would advise you to follow the advise of the surgeon you finally trust to do the procedure.
Armand Simone, MD  FACS
Board Certified Plastic Surgeon,   New York, NY