What Is A Rhinoplasty?
Rhinoplasty, or nose job, refers to the surgical reshaping of internal and external nasal structures either to restore breathing, alter appearance, or both. This may include changing the shape, width, angles of the nose, in addition to adding structural support to improve the nasal airway.
Who Performs A Nose Job?
Rhinoplasty is typically performed by facial plastic surgeons with a background in Otolaryngology – Head and Neck Surgery or commonly referred to as ENTs. These surgeons complete a 5-year training in all aspects of head and neck surgery including surgery of the nose. After this, these surgeons typically complete an added year of Fellowship by the American Academy of Facial Plastics and Reconstructive Surgery (AAFPRS) where they fine-tune their skills to be able to provide the highest quality care when dealing with surgeries of the nose. Other surgeons include Plastic Surgeons. These surgeons spend about 5 years getting General Surgery Training, after which they pursue a fellowship in Plastic Surgery. Unlike AAFPRS fellowships, plastic surgeons spend time training and fine-tuning their skills in all areas of cosmetic surgery of the full body (breast augmentation, tummy lifts, mommy makeovers etc).
What Is A Septoplasty, and Do I Need One With A Rhinoplasty?
A septoplasty refers to the surgical alteration of the cartilage on the inside of the nose that divides the left side from the right side. Septoplasty may be required during rhinoplasty, as often times it is crooked and contributing to breathing issues. This cartilage can also be used for the rhinoplasty portion of the procedure, providing free grafts (link to free grafts) to help contour and restructure the nose.
Who Are The Ideal Candidates For A Rhinoplasty?
Patients that are dissatisfied with the external appearance of their nose may benefit from surgery. Common complaints include deviations of the nose, crookedness, large humps, nasal tip drooping, misshapen or bulbous nasal tip, large noses, and enlarged nostrils. These patients may have completely normal breathing but would like to change the external appearance of the nose. It is important to have an extensive conversation with your surgeon to define exactly what it is that you don’t like about your nose. Also, changing the external appearance of your nose may alter the internal structure, and it is important to maintain your ability to breathe. Your surgeon should have the skills necessary to make the requested changes without altering or limiting your ability to breathe properly.
Sometimes patients may complain of the inability to breathe from either side or both sides of their nose. Often times this is due to a history of trauma that may be recent or in the distant past. Also, as we grow older the structures of the nose internally and externally begin to change. The cartilage and bones weaken as we age. Continued growth as we grow older may also happen. As the cartilages grow, they may grow in a crooked fashion also worsening our ability to breathe. These issues may also be made worse by other problems such as allergies, recurrent sinus infections, or other underlying medical issues. It is important to discuss with your surgeon all possible causes of your nasal issues so that you can understand which issues may be fixed with surgery, while others with medications or lifestyle changes. Patients with functional complaints may also have aesthetic complaints that can also be fixed at the time of surgery.
History of Rhinoplasty with Poor Results
Patients with a history of Rhinoplasty may also suffer from a combination of functional and aesthetic complaints. Often times, depending on what was done during the original surgery, the internal and external parts of the nose may be altered and compromised. This compromise may be due to scar tissue formation that progresses over time, misshaping the nose, altering its appearance. This scar tissue may also cause nasal airway issues. Surgeries that involved removal or “cartilage cutting” techniques, from a different era, also tend to result in issues as time progresses. By removing key components of the nose, the nose begins to lose structural support and weaken with time. This alters the appearance and function of the nose. Sometimes, patients just have low satisfaction with their previous surgeries and would like specific alterations.
These patients undergo what is termed a revision rhinoplasty. It is important to seek an expert with experience in this area. Revision rhinoplasty is traditionally more challenging because of the nature of operating in a field that has been previously altered by surgery. There is a higher risk of complications such as bleeding, infection, and skin loss. Also, depending on what was done in the previous surgeries, limited options may exist for reconstruction of the nose. Absent cartilage may need to be reinforced with free grafts (link to free grafts) or rib grafts (link to rib grafts). Be sure you are aware of the limitations of revision rhinoplasty and seek treatment from an expert in this area.
Preparation For A Rhinoplasty
You will meet with Dr. Mourad where he usually spends an hour going over everything related to your nose. He will evaluate and make sure that he can specifically tailor a custom care plan to your exact needs. During the consultation, Dr. Mourad will determine the exact nature of your complaints and the exact causes. He may prescribe medications that will assist in your complaints. You will also have the opportunity to demonstrate exactly what it is you don’t like about your nose. He may examine the inside of your nose through a painless in-office procedure using a small camera. This will allow Dr. Mourad to visually map out all of the internal structures of the nose to create the best surgical plan. Once a tailored plan is made, Dr. Mourad and his staff will take you through all the necessary information needed to make sure that your surgery happens without issue. We take care of the details so that you can have the most enjoyable experience.
Dr. Mourad views treating his patients to be nothing short of a privilege and an honor and enjoys taking the time to get to know his patients and fully understand their issues. Dr. Mourad’s office provides a boutique experience that takes you out of the mindset of being at the doctor’s office. It is a warm, comfortable environment, providing a bespoke experience.
How Is A Rhinoplasty Performed?
Depending on the type of surgery, the procedure is usually performed under general anesthesia at a surgicenter. You go home the same day, after surgery. The morning of surgery you will meet Dr. Mourad in the surgical area. He will great you along with any accompanying friends or family. He will go over all the questions that you may have, in addition to summarizing all aspects of the procedures, finalizing the details. This type of communication is important. You need to rest assured that you are in good hands, with the plan in place that you agreed upon previously. Next, you will go in for the procedure, saying goodbye to anyone accompanying you. There it’s a short nap for you, and you will awaken in the recovery room. Dr. Mourad will be there to greet you and go over any issues or concerns you may have and inform you of how the procedure went. You will spend a short time in recovery to make sure that you have no issues with anesthesia or pain control. When you are cleared to go home by the anesthesiologist, Dr. Mourad will give you a goodie bag that will contain all of the necessary things you will need on your road to recovery. Contents include nasal sprays, creams, and ointments that will help you with your recovery.
This type of procedure is performed with a small incision on the undersurface of the nose. The surgery involves exposing all of the internal structures of the nose and provides access to the nasal tip, bridge, and bones. This is the most extensive surgery that allows for the most alterations. Depending on your complaints, whether aesthetic or functional, this type of surgery is reserved for those with significant issues requiring more extensive work. Patients with crooked, enlarged, misshapen, or disfigured noses may benefit the most from an open approach. Patients with extensive breathing issues may also benefit from this type of surgery.
Incisions for this procedure are hidden. This type of surgery allows for making smaller modifications to the nose, including the nasal tip. Surgeons use this approach to change the tip projection, rotation, and shape. This type of surgery is suited for those type of patients with minor breathing complaints, or minor aesthetic complaints centered around the tip of the nose.
This type of rhinoplasty involves the use of injections and fillers to modify the shape of the nose. These often times are temporary with gradual degeneration of time. Although Dr. Mourad is trained and aware of these types of procedures he does not endorse them. These modifications are temporary and may cause issues (e.g. local reactions, tissue loss, and necrosis). Furthermore, the use of such techniques may negatively impact future, long-standing, and more permanent interventions.
After Surgery and Recovery
Depending on the type of surgery you have, you will likely have nasal packing/splints in your nose. These are placed by Dr. Mourad to allow for proper healing of the internal nasal structures, like an “internal cast” for the nose. These typically are removed at your first postoperative visit, one week later. You will also likely have a nasal cast on the outside of the nose. This also helps reduce swelling and keep everything in place. This remains on the nose also for 1 week following surgery. Depending on your work, Dr. Mourad typically recommends taking a minimum of 3 days off before returning to work. He also discourages his patients from any heavy lifting as this can alter the structure of the nose through straining. If you wear glasses, you may require some alterations as to not provide pressure on the nasal bones. Dr. Mourad will provide you with pain medications, ointments, nasal sprays, all to help maximize your results.
You will see Dr. Mourad one week after surgery where he will remove all casting materials and splints. Your nose may be swollen for a temporary period of time, so don’t stress! The nose is a small area, and all that surgery causes swelling that eventually is reduced with time. Depending on the patient this swelling typically lasts for 2-3 weeks but can last up to two months in rare circumstances. To help reduce the swelling Dr. Mourad will re-apply tape to the nose that will be there until your second post-operative visit. This pressure dressing reduces the amount of swelling. The second postoperative visit will involve removing all the tape. Dr. Mourad will then see you in visitations two weeks later, and then one month after that. Dr. Mourad enjoys the continued visitation of his patients and will see them in follow up for many years thereafter.
- Anesthesia: Depending on the type of anesthesia administered, patients may have a reaction. This is exceedingly rare, and it is important to discuss your personal risk with your anesthesiologist.
- Infection: In rare circumstances patients may develop an infection following rhinoplasty procedures. These are usually managed with intraoperative and postoperative antibiotics.
- Bleeding: Although rare, patients may have bleeding episodes following nasal surgery. Your surgeon will likely order blood work to make sure you are healthy enough to undergo the procedure. Your surgeon should also go over all medications and supplements that you take to minimizing bleeding risk.
- Need for secondary and revision surgeries: Depending on the complexity of the surgery, sometimes multiple surgeries are required to ensure the best aesthetic and functional outcomes.
- Scarring and Poor wound healing: Some patients with underlying medical conditions or more prone to poor wound healing and scarring. It is important to understand these risks prior to embarking on a treatment strategy.
- Local Reactions: Sometimes you may experience local reactions to the ointments, sutures, taping material, and nasal packing used during surgery and postoperatively. This is rarely seen, but may occur. If you have any allergies to certain materials or adhesives you should discuss with your surgeon.
- Changes in nasal sensation: Patients may experience altered sensations in their nose (pain or numbness). This is exceedingly rare, and if it occurs it is most often temporary.
- Persistent, New, or Recurrent Nasal Airway Obstruction: Altering the nose may result in changes to breathing. Sometimes patients may develop new, persistent or recurrent airway problems. This is rare, but oftentimes is due to poor wound healing or scarring (see above). This may require secondary surgeries to optimize outcomes.
- Continued need for medical therapies: If you have breathing complaints related to medical causes (e.g. allergies), then you may continue to require medical nasal therapies (e.g. nasal steroids and sprays).
- Swelling: Swelling is a common part of the healing process. Sometimes this swelling may persist for a prolonged period of time.
- Poor Aesthetic Outcome: Although the goal of rhinoplasty is to enhance the aesthetics of the nose, sometimes patients may have an unsatisfactory result. This may occur due to poor communication and understanding of the goals by the surgeon. Other times, it may be due to poor wound healing, scarring, and swelling (see above). It is important that you spend a significant amount of time with your surgeon in order to outline the exact goals and desires of surgery to minimize the chance of a poor outcome.
- Nasal Septal Perforation: A hole in the septum may develop. Oftentimes these do not cause any problems. Other times however, they may cause crusting, bleeding, and breathing difficulties. These require secondary surgeries for repair.
Will Dr. Mourad Perform A Rhinoplasty On A Teenager or Child?
Rhinoplasty should typically not be performed in people under the age of 16. This is because the nose continues to grow throughout our lives, with the most amount of growth in our youth and adolescent years. Surgically altering the nose as it grows at a young age may result in abnormal growth patterns and deformities. The nose is like a tent, with internal and external support structures. If you remove some of those critical components too early, the tent may collapse as it grows. Some teenagers and children may be candidates for surgical procedures in very specific circumstances. It is important to understand the limitations and potential for performing rhinoplasty in younger patients and seek counsel from an expert in that area. Dr. Mourad does see younger patients and can take you and your family through the process.
Select Relevant Publications
Kadakia S, Mourad MW, and Ducic Y. Supraclavicular Flap Reconstruction of Cutaneous Defects Has Lower Complication Rate than Mucosal Defects. Journal of Reconstructive Microsurgery. 2017 May; 33(4):275-280. Link to Article.