Rhinoplasty 101 (Ep. 11)

Dr. Hall: When I first started this podcast, doing an episode on rhinoplasty was one of the first episodes that I actually, kind of, sketched out. And here we are, we’re in the double digits now of episodes, and I’m just getting down to putting this out there. And part of that was because it’s something that I really care about. I mean, I really care about all the procedures that we talk about, and really, I love doing all of them, but there’s something about the rhinoplasty episode that I really wanted to make sure I nailed it.

And I had written this whole big thing about the history of rhinoplasty and getting down and detailed with where that came from and where it started. And that may be something that we do in the future, but I was trying to do the single perfect rhinoplasty episode, and what I realized is that I really need for you, the listener, and the potential patient out there, is that I need to get some good information out there, and then I can work on the rest of it later. And so without further ado, here is our rhinoplasty episode. Let me know if there’s anything else that you are interested in listening to, but there will certainly be more rhinoplasty talk and rhinoplasty surgeons that talk on this show in coming months.

Welcome to The Trillium Show, where we help you make the changes you want to see in your body, in your mind, and in your life. I’m your host, Dr. Jason Hall.

Welcome back to The Trillium Show. Today we’re going to talk about one of my favorite operations which is cosmetic rhinoplasty. Rhinoplasty is really one of the operations that started the field of plastic surgery and is a good example of how cosmetic surgery can change people’s view of themselves simply by changing the appearance of a single physical feature. Today, there are three things that we want to get across in this podcast.

One is that a prominent nose can draw unwanted attention and throw off the delicate balance of a face; two is that cosmetic rhinoplasty helps to reshape the nose and restore or give balance to facial features, and then three—and this is a really cool aspect of it is that we no longer quote “Break bones” during rhinoplasty. The focus of this operation is on preserving the delicate framework of the nose. And piezosurgery, or ultrasound technology, helps to do that and we’ll talk about that later on in the show.

So, let’s talk about what cosmetic rhinoplasty is and how it fits into plastic surgery as a whole. Now, cosmetic rhinoplasty is consistently one of the most popular cosmetic surgery procedures in the United States. In 2020, which is the last year we have full statistics for, it was the number one cosmetic surgery procedure in the country—ahead of facelift, ahead of eyelid surgery, ahead of breast augmentation—with over 350,000 rhinoplasties performed in that year. And certainly for me, before I got into plastic surgery and this became my career was under the impression that the people who got rhinoplasty surgery were typically girls that were just out of high school, in college, or just out of college, and that it was an operation for 20-something women, and that really couldn’t be further from the truth.

Rhinoplasty surgery is done across all age groups, and three-quarters of rhinoplasty patients range in age between 30 and 70. So, this is not an operation just for 20-year-old women. The purpose of this show is to review rhinoplasty surgery, review the preoperative indications, surgery, recovery, and then discuss how to go about planning a rhinoplasty operation.

So, first let’s, kind of, talk about why. And the definition of really what needs to be done in rhinoplasty is difficult. There is an old saying in plastic surgery that the eye only sees what the mind knows, and a lot of times when I’m seeing people in consultation, this is very true. The in-vogue nasal shape these days is this Turkish nose, the petite upturned ski slope tip with very defined tip cartilages, and things like that because that is really popular on social media. And while that is arguably an attractive nose that doesn’t necessarily fit everyone’s face.

And the important thing to remember about rhinoplasty, and something that I learned from a mentor of mine a long time ago, is that a good rhinoplasty makes the nose disappear from the face. Think for a second about Jennifer Aniston. Can you picture her nose in your mind? Now, go back and look at a picture of her from She’s the One, which is her first movie, or Office Space, which is personally one of my favorites; she’s a different person than she is today because of what I think is a cosmetic rhinoplasty.

Now, plastic surgeons like to do interesting studies that make you kind of scratch your head as to what they were thinking when they came up with this idea, and one of the things that they’ve done is a study of non-surgeons looking at people’s faces using eye-tracking technology, and they’ve shown—very interestingly—that the focal points of the face are the eyes, the nose, and the mouth. A well-performed rhinoplasty really reorients that focus away from the nose so that the nose is not the focal point of the face, which serves to underscore the fact that facial balance is really the goal of any rhinoplasty surgery. When we’re evaluating patients, we divide the face into thirds vertically. So, if you think about that, from your hairline to your eyebrows, eyebrows to the bottom part of your nose, and the bottom part of the nose to the chin, are each roughly equal vertical thirds of the face with their own associated prominent features. If one of those thirds is out of balance, then it can throw off the balance of the rest of the face.

And that’s why when we’re consulting with people about rhinoplasty—certainly during my consultations—we sometimes talk about chin surgery, or forehead reduction surgery as a part of rhinoplasty, not to try and upsell procedures but because we want to restore overall facial balance. Getting ready for the consultation, there’s a lot of things that we need to discuss to make sure that we’re all, kind of, speaking the same language. The first thing to know is there are two main types of rhinoplasty: The open and the closed. And this really relates to how your surgeon, how I, access the underlying cartilage and bone framework of the nose. Whether we make an incision on the outside—which is what happens with an open rhinoplasty—you have an incision through the columella, which is that little bridge of skin on the underside of your nose between your nostrils—or not, which is the case with a closed rhinoplasty where all incisions are on the inside.

Now, open rhinoplasty is a far more common operation and is more common because the visualization of what’s underneath is so much better. You can see everything right there in front of you, if you’re the surgeon, as opposed to trying to deliver the cartilages through small incisions on the inside of the nose and then look up through a small tunnel to see the bridge and things like that. The downside to an open rhinoplasty is that the swelling from a rhinoplasty, which is really one of the things that we talk about extensively during consultation, can really last longer with open rhinoplasty than closed rhinoplasty. I don’t think the incisions really are that big a deal—actually in open rhinoplasty, there are typically fewer incisions because the visualization is better—but you do have an external incision. For the vast majority of patients, that incision is not something to worry about. It’s not a scar that really heals very visibly at all, and if it is, it’s very easily revised and made to be almost invisible.

Closed rhinoplasty, on the other hand, you have more incisions but they’re on the inside. They’re invisible, essentially, to everybody. It is a more technically demanding operation. The learning curve for that is a whole lot longer than with open rhinoplasty, but swelling tends to go away a lot faster. A closed rhinoplasty is not a good operation for everybody, and there are many candidates for rhinoplasty surgery who are not candidates for closed rhinoplasty, and that’s something that we discuss during a consultation.

Next, I want to get into the lingo and what we’ll be talking about during your consultation. So, there are a couple of definitions to know. One is ‘projection,’ ‘length,’ and then ‘shape.’ So, projection in rhinoplasty surgery refers to how far your nose sticks out from your face. That’s from, kind of, your upper lip to the tip of your nose going straight out.

Length, on the other hand, is the distance from between your eyes to the tip of your nose. So, the bridge of your nose. That’s what we talk about when we talk about length. So typically, people will talk about having a long nose and they think about Pinocchio where the nose sticks way out. And that’s really—we refer to that as being over projected.

Those two things are just good definitions to have in your mind. The last is all of the shape things that we talked about. So, dorsal hump or a bump on the bridge of your nose; tip shapes being boxy, or bulbous, or asymmetric. And then lastly, we need to talk about septal deviation. And your septum is this cartilage—mostly cartilage; cartilage and bone—wall that separates the right and left sides of your nose on the inside. It’s responsible for the shape of the bridge of your nose, and is a major cause of airway obstruction, although there are others that we’ll get to during a consultation.

Septal deviations can be visible, which means you can see them—the bridge of your nose is twisted one way or the other, the tip of your nose is twisted one way or the other—or it can be invisible. Everything on the outside is straight, but then your septum is this C shape or S shape or zigzag on the inside, causing airflow problems. Septal deviations, it’s really important that these are identified during the consultation so that they can be corrected at the time of a cosmetic rhinoplasty. It’s very difficult to undergo cosmetic rhinoplasty after septoplasty because part of that deviated septum has been removed, and then we don’t have that cartilage that we need to work with to help reshape and support the nose during a cosmetic rhinoplasty, and by doing those two operations separately, the support for a bridge that’s got a hump on it can be destroyed. And it means we have to use cartilage or bone from other places to help support that and it just makes that operation much more difficult if we try and split the septum part and the rhinoplasty part into different operations.

Lastly, we need to discuss the role that skin plays in rhinoplasty surgery. And skin, like with any other plastic surgery procedure, is really important when we are considering where we want to end up results-wise after an operation. I like to use an analogy of a bed sheet or quilt when we’re talking about how skin affects the results of a rhinoplasty. So, all of the support and all of the shape that we gained from rhinoplasty surgery is from the underlying bone and cartilage framework which gets reshaped during surgery; the skin just acts as a covering. And if you think about laying in bed in the summertime on your back, covered with a very thin sheet and you look down and look at your toes, you can almost count every single one of your toes through that bedsheet.

Now, in the wintertime, you do the same thing with a big bulky quilt on, and it’s hard. Not only can you not see your toes, it’s hard to even tell where one foot stops and the other foot starts. The same kind of thing happens in rhinoplasty. If you’re very thin nasal skin, all of the detail that gets created during that rhinoplasty surgery is visible. And you get a very nice, kind of, detailed appearance to the bridge and tip of your nose.

In contrast, if you have very thick skin, very oily skin, certain ethnicities are prone to this, that underlying cartilage framework gets covered up by this thick skin and you lack the detail at the end of the surgery that you would if you had thinner skin. Now, there are things that we can do to help thin the skin either before or after surgery, main things there being either Accutane or laser, but it’s important to really talk about these things before surgery so we’re not trying to come in on the back end and correct something that we could have anticipated would have been a problem from the start.

So, let’s move on to the consultation. The purpose of the consultation, like it is with anything in medicine, is to establish a proper diagnosis, to figure out what’s wrong, what your goals are so that then we can establish a treatment plan that helps to accomplish those goals. Age is important with rhinoplasty because we want to make sure that your nose has finished growing and that your facial growth is complete. For women that happens at about 16 years old, for guys a little bit later, 17 or 18. But especially for elective procedures, we have to make sure that facial growth is complete before we start talking about rhinoplasty surgery.

Secondly, it’s important to know if there’s a history of trauma—have you broken your nose, or gotten injured in sports, or previous car wrecks?—a history of previous nasal surgery or history of chronic sinus problems. These are all important for surgical planning. Sinus problems and the management of chronic sinus problems has really changed recently, in that now most endoscopic sinus surgeries can be done in-office. And this really is convenient for you the patient because it avoids having to try and coordinate surgical schedules between two surgeons.

We send patients to our EMT colleagues, they get their sinus procedures done in the office, and then we can proceed with the cosmetic portions of surgery in an operating room setting separate from that. Once we’ve done the [historical 00:16:36] part, a good internal and external physical exam is needed to identify all the things we talked about earlier. And then after that is where I like to perform 3D surgical simulations. The surgical simulation is not for me to do your surgery on the computer, give you a copy of a picture to take home, and then you look at your picture and say “Okay, that’s exactly what I’m going to look like at the end.”

The simulation actually serves two goals. One is to make sure that you and I—you the patient, me the surgeon—are on the same page as to where we’re going, that my idea of balancing your face based on experience and knowing what is going to look good related to your other facial features is the same thing that you’re looking to accomplish and that we agree on our final goal. The other thing where this is really helpful is in the recovery phase. Having any facial surgery, any facial cosmetic surgery is psychologically a little challenging because you’re changing what you see when you look in the mirror, you’re changing your definition of yourself. And having a simulated picture of you to go and look at and get used to before surgery really helps ease some of that minor panic that you see when you look in the mirror in the first week after surgery so that you’re not freaking out that you’ve looked different because you’ve been looking at pictures that are very similar that and get used to that over time before you choose to have surgery.

Those two reasons—that we’re on the same page and you’re kind of getting used to your postoperative appearance—are where surgical simulations really shine in the consultation process. Now, let’s talk about surgery. And it’s important to note here that we’re really talking about open rhinoplasty. I do all of my surgeries in our surgery center, which is right down below us. I use a general anesthetic primarily for airway protection but also for comfort even though minor corrections and minor things we can do either under local anesthesia or local anesthesia with a little bit of sedation.

In the beginning of the podcast, we talked about the advances in surgical technology, which have really helped improve not only results but recovery, and this is where piezosurgery or ultrasonic surgery really comes into play. Especially when we’re fixing a deviated nose or taking down a large hump, the bones of the nose need to be cut and moved to help narrow the base, help close the bridge of the nose so that there’s not a divot there. And this is where ultrasonic surgery comes into play. I can use the piezosurgery equipment to cut those bones very precisely with no trauma to the soft tissue, which means minimal bleeding, which means less swelling and less pain, and faster healing. And I’ve seen the healing time and certainly the bruising and discomfort from rhinoplasty cut down immensely, just by adding this piece of equipment to my standard rhinoplasty surgery.

From a time standpoint, to kind of shift gears again, rhinoplasty surgery takes between two and three hours. You go home the same day, you have a small cast and some tape on your nose, sometimes we’ll use some silicone airway splints to help keep your nasal passages open and avoid them swelling shut right after surgery, in that week after surgery, and this is really used if work on the septum has been done. Those are things you can’t see, you don’t really know they’re there, your nose feels a little bit stuffy, but is not something—it’s not like you’ve got tubes hanging out at the end of your nose. Immediately after surgery, you’re going to want to keep your head elevated, you’re going to want to lay or sit at between 30 and 45-degree angle, head a little bit higher than your heart. That’s going to help with the swelling, help with some of the discomfort.

And I encourage all of my patients to stay on a scheduled pain management plan for the first 48 to 72 hours after surgery. What you don’t want to do is fall behind with your pain medicine and then have to try and play catch-up. From a hygiene standpoint, I’ll have you irrigate your nose with some saline spray you can just get to the drugstore for a few bucks to help keep the inside of your nose clean and moistened, and then clean the incisions themselves with some half-strength hydrogen peroxide on little Q-tip and then apply a thin layer of antibiotic ointment. That helps to keep those incisions clean, helps keep the, kind of, gunk from collecting on them, and makes suture removal, which happens at a week, much easier. So, at that one-week mark, the sutures come out, the splint comes off the airway tubes—if they’re inside—come out, and then put some tape on the outside of your nose, which again, just helps with some of that early swelling.

It’s important to plan on avoiding contact sports, avoiding glasses, things like that, for the first six weeks after surgery to let those bones that we’ve moved heal because even something as innocuous and minor as a pair of sunglasses can cause those bones to shift and mean revision surgery down the road.

One common recovery question that we get and have to deal with every surgery is when can you go back to work. And typically what I tell patients is that you can return to work after about a week when the cast and all of that comes off. You’ll still be swollen, but are able to return to work. Now, if you can work remotely or if you have a job where you’re not in front of people, really the only requirement for that is that you’re sober. And most patients after about 72 hours, are able to get to a point during the day where they’re alternating back and forth between Tylenol and Motrin and don’t need narcotic pain medicine during the day but is still helpful at night.

And so, for that kind of work, I would say three, four days, but budget a week just to be safe. The other big question is swelling. And rhinoplasty is kind of notorious for swelling after surgery, and that really is the biggest hurdle that rhinoplasty patients have to deal with in the post-surgical time period. The majority of the significant swelling—that’s swelling that other people are going to be able to notice—resolves in the first two to three weeks after surgery, but you will still have some degree of swelling which is palpable—or swelling that you’re able to feel—for the first year after surgery. And this is where people come in six months down the road and say, “You know, my nose still feels hard, it still feels numb at the tip.”

This is more a problem again, with open rhinoplasty than closed; the swelling tends to go away a little bit quicker, but a good rule of thumb is rhinoplasty swelling takes a year for things to kind of settle into what they’re going to look like long-term. The way that the swelling resolves is kind of top to bottom. So, starting in between your eyes—it’s a good rule of thumb is to divide the nose into quarters and the swelling between your eyes typically is gone within the first three months; the quarter below that, six months; the quarter below that, nine months, and then the tip itself resolves at about a year. So, just know going into a rhinoplasty that it does take time for that minor, that last 10% of the swelling to go away for that final result to really be visible.

If you’ve listened to other podcasts of mine talking about surgical procedures, you know, we always can’t talk about a surgical procedure without talking about potential complications. And the disclaimer here is that this is not an exhaustive list of complications. There are specific complications that can be related to your anatomy, your individual surgery—and whether it’s with me or with another surgeon—you need to make sure you have a discussion of potential complications with your surgeon before surgery. So, one thing to know with rhinoplasty is that the revision rate for rhinoplasty—this is all comers, all surgeons, all patients—is about 10%. So, one in ten patients who undergo rhinoplasty are going to want or need some type of revision.

Fortunately, most of these are minor and can usually be done in the office, and oftentimes—and this is a relatively new advent in rhinoplasty surgery—is that they’re things that we can touch up with a little bit of injectable soft tissue filler. So, in terms of what happens if you’re one of those patients who need revision surgery after rhinoplasty, well, assuming that we can agree on the problem, I fix my own revision cases and I don’t charge a revision fee for those. That’s part of the initial surgery, but you will have to pay for the operating room time. That’s not something that we can control. We also because of what we talked about with the swelling, it’s important that we wait a full 12 to 18 months in the vast majority of cases to allow that tissue, that skin, the cartilage, the lining of the nose, and all of that to heal fully before we can make an accurate assessment of what needs to be revised, and then plan an operation that is going to fix the problem and be durable.

We don’t want to go diving into an area where there’s a lot of scar tissue; that is going to be complicated, it’s going to make the surgery harder, increase the complication rate, and will make a final result less predictable. So, waiting a year if a revision is needed is really, really important. You also know that if you’ve listened to other episodes, that I kind of divide complications into problems with a small p and problems with a capital P, and we’ll do the same here.

So, small p problems with rhinoplasty include things like minor contour irregularities. And again, these can oftentimes be fixed with some small amount of filler in the office, other times will require a small office procedure under local anesthesia to correct. Anybody who has a twisted nose or their noses deviated, your soft tissue skin, mucosal lining of the nose, even the cartilage itself has memory, just like a fishing line. And you know, if you ever tried to unspool fishing line, it curls right back up the way it was wound and your tissue does the same thing; it wants to go back to that twisted, deviated state that it was in before surgery. And so part of our operation is building a framework in the nose to resist that, but a small amount of relapse may occur, and that’s something that we have to understand both as surgeon and patient going into it.

A little bit of deviation is in the realm of acceptable, a lot of deviation is going to need surgery to correct. Then that kind of brings us to the large P problems, things like bleeding right after surgery, major contour irregularities, airway obstructions, septal perforations. All of these things, fortunately, are rare, and many of those things will require a second operation to treat. Again before deciding on revision surgery, it’s best to wait that full year to let things heal, let the inflammation and scar resolve to make surgery safer and more predictable. Fortunately, though, major complications, revision surgery rates are relatively uncommon in rhinoplasty surgery. Again, filler makes a lot of our minor revisions things that we’re able to correct with an injection in the office and not require second surgery.

And filler in the nose, because they’re such small amounts, tends to be a fairly durable solution. And as your body is degrading that filler, it’s laying down some of its own collagen which helps to fill in any little contour irregularity, and sometimes one injection is all we need to do; we fix the problem and everybody is happy.

This kind of comes to the end of the rhinoplasty show. I hope this has been beneficial. If you’re curious about rhinoplasty, if you’re interested in having a rhinoplasty, it is a favorite surgery of mine, and it’s one of those foundational operations in the specialty of plastic surgery. Indeed, plastic surgery grew out of rhinoplasty surgery.

So, to recap our three points from today. A prominent nose can certainly draw unwanted attention and throw off that delicate balance of the face. A rhinoplasty is really designed to help reshape the nose but more to help rebalance facial features so that the focus of people’s gaze is on eyes and mouth. And lastly that ultrasonic surgery, piezosurgery, is really changing rhinoplasty specifically in terms of the precision with which we can do some bony work and minimizing the bruising, swelling, and discomfort that go along with rhinoplasty recovery.

Please shoot us a message if you’ve got any questions, and as always, thanks for listening.

Dr. Hall: Thanks for listening to The Trillium Show. You can keep up with the latest on the podcast at jhallmd.com. Be sure to follow us on Spotify, Apple Podcasts, or wherever you listen to podcasts. If you want to connect with us on social media, you can find us at @jhallmd on Instagram and Twitter and @DrHallPlasticSurgery on Facebook. Remember, be the change you wish to see in the world.