Rhinoplasty, nose reshaping, is a general term used to describe procedures that change the appearance of the nose. Although most commonly used for cosmetic reasons, functional nasal issues such as difficulty breathing can often also be addressed. Current rhinoplasty is very different from the past when procedures were often very obvious. Today, rhinoplasty experts have otolaryngology training (ear, nose, and throat) in addition to fellowships in facial plastic and reconstructive surgery (double board-certified) and can offer much more advanced techniques. Not only are natural, predictable results the rule, but recovery is quicker both cosmetically and functionally.
Your surgeon’s philosophy is important. “If it looks like you had it, it’s not worth having”. Noses can be smaller, but do not have to be small to be beautiful and enhance one’s facial appearance. But philosophy alone cannot overcome the training and ability of a particular surgeon. Overall, our nose should not be noticed when someone views our face. The majority of one’s beauty is centered on their eyes, cheekbones, and facial contour; our nose should fit our face, have aesthetically pleasing angles, and most often go unnoticed on our face. Often great rhinoplasty causes the effect of bringing an observer’s gaze to our eyes and not our nose. Comments on the beauty of your eyes are often the most significant compliment in sophisticated rhinoplasty.
Noses are individualized procedures that are designed based on the specific imperfections in the nose as well as the degree of the nasal imperfection. This is then balanced with how the nose fits into the overall aesthetic of the face. One nose may look fine on one face and not another. A rhinoplasty specialist can be predictive, before any commitment to a procedure, of the degree of outcome that can be achieved, while still maintaining a natural, un-operated upon appearance.
We Can Classify Degrees of Imperfections in This Manner
In these cases, the individual may not appear attractive to themselves or others due to larger degrees of imperfections of their nose. Size and shape are both usually problems. The nose dominates the face and doesn’t allow the viewer to “see-through” to their other attractive features. Refinement of the facial feature will not produce enough of a result to be considered satisfying to the individual. In these cases, the goal is to eliminate the prominence and the attention created by the nose and bring out the “buried” facial features.
In most situations by eliminating the aesthetic nasal issues, while respecting the shapes and angles of the “natural nose”, the face becomes attractive based on the underlying, already existing facial features. Although the cosmetic results are often striking and very significant, if the nose retains natural angles, appearance and fits the face, new facial beauty is seen by others with the majority not knowing it was due to a rhinoplasty.
In these cases, the attractiveness of the individual is evident despite an imperfect nose. They may have both size and/or shape issues, but if they never choose to change their nose they will always be considered attractive.
The goal in these cases is the refinement of the facial structure. Their result creates the best version of their nose and will not make them look different, but will make them look much better. Often friends and family do not know the procedure was done, yet the before and after photos reveal a significant change.
In revision or secondary rhinoplasty (a person who has had a rhinoplasty before) being evaluated by a nose, a specialist carries the greatest importance.
There are many reasons why a person may be dissatisfied with their rhinoplasty, and a nose expert can be predictive of whether the changes the person requests are consistent with the outcome that can be obtained.
Noses can be imbalanced, over-done, or under-done; each will have different solutions and levels of predictability. Commonly, improvement can predictively be made to their nose, in certain cases, all issues can be reversed, and in some advice may be to not undergo further procedures.
Open Vs Closed Technique
The goal in rhinoplasty is to change the size and/or shape of the bone (upper third) and/or cartilage (lower 2/3 thirds) which constitute the infrastructure of the nose, creating its shape. In most situations, the soft tissue (skin and underlying layers) is not affected or is minimally addressed. There are two techniques used in rhinoplasty to accomplish this, open and closed.
Understanding the difference is important. The older technique is closed rhinoplasty where all incisions are done internally. Since there are no external incisions the cartilage and bone cannot be appropriately visualized by the surgeon. When altering a segment of the nose, the cartilage must be distorted from its natural appearance to access it through the nostril. Predictions of symmetry and the details of how these internal structures relate to one another must be assumed since they cannot be seen. Besides, nasal asymmetries, not always apparent from the outside, were often made worse. This technique was most ineffective in noses with “tip” cosmetic issues and revision (secondary) rhinoplasties. Because the cartilage and bone cannot be visualized in their native state, often the same maneuvers were done regardless of the initial external appearance. This explains why for many decades rhinoplasty produced an unnatural, operated-upon appearance, as well as the “same nose” being produced over and over by a particular surgeon.
First used in revision or difficult rhinoplasties, open rhinoplasty adds one very small incision hidden in the base (columella) of the nose. The advantage of this incision is that now the nose can be “opened” and the internal structures, cartilage, and bone are visualized in their native state. Subtle differences between sides and how the structures interact, which are not seen from the outside, can be seen in their natural state and much more accurate changes can be made to predictably alter nasal shape and size. The small incision fades quickly and is not an issue but the advantage provided by actually seeing the structures you want to alter is invaluable.
Once surgeons started “opening” noses the outcomes in rhinoplasties became much more natural-appearing. Individual nose designs could be created and the “done”, “operated-upon” rhinoplasty began to disappear.
A useful analogy is to imagine needing to work on the engine of your car. In closed rhinoplasty, you would need to reach through and under the grill and blindly feel around to make the adjustments to the engine. In open rhinoplasty, you can open the hood of the car, see the engine and make accurate adjustments.
VIEW THE PROCESS
The first part of the process is defining whether you are a candidate. Rhinoplasty is accomplished on people of all ages, the age criteria for younger candidates is based on when someone has reached certain stages of physical maturity since the nose completes growth during puberty.
Besides the actual procedure, the consult is probably the most important part of the process. This is the best opportunity to communicate your thoughts on what you don’t like about your feature, express your desires as well as any concerns. The surgeon should communicate to you how they view your nose and make you feel comfortable with them as a doctor and as a person. Details such as what internal structures will be treated and what can you expect as an outcome should be thoroughly discussed. You should not feel rushed during this process.
We chose not to use computer imaging because it is not real. It does not predict how your nose will behave or that you will receive the image as a real outcome. We always want to focus on what occurs and viewing your surgeon’s cosmetic outcomes is the most predictive of what result you can expect.
The majority of procedures are done at New England Surgical Center, a private, state-of-the-art, state-licensed, fully accredited outpatient surgical facility at The Retreat at Split Rock. Since the facility specializes in plastic surgery, infections are prevented and comfort and privacy are expertly provided.
Rhinoplasty is an elective procedure so there is no timetable for someone to commit. Successful surgeons want potential patients to take their time and feel comfortable in their decision. Most patients will be both excited and nervous during the entire before period. Once someone decides to move forward they select a date and schedule another pre-procedure appointment. Patients who are traveling to us can often have this appointment virtually or by phone. During this appointment, logistical issues will be discussed as well as what you will experience throughout the process. Every patient will speak to the surgeon at least twice and, also, to patient coordinators, departments of nursing, and anesthesia before any procedure.
Since we do not pack noses (place 6 feet of gauze inside each nostril), rarely are noses perceived as painful. The most common description is the “feeling like I have a bad head cold”. Uncomfortable rather than painful. Appropriate comfort medication is used as needed. Follow-up office visits are scheduled for after days 4 and 7. The external splint is removed after the day 7 visit and the majority of patients can be back to social or professional commitments in the immediate period after this appointment. Further aftercare is defined by the type of nose you have and logistics. Nasal taping, exercises, and massage are some of the individual treatments; these can be done regardless of your location. All patients are invited to follow-up visits for as long as they desire.
BEFORE AND AFTER PHOTOS
It is extremely important to view before and after photos of the outcomes from any surgeon you are considering.
Often patterns will emerge, such as all the noses appear the same, or operated upon, or the opposite, different faces have different cosmetic results and all the noses appear natural regardless of the initial appearance. A surgeon who does rhinoplasties regularly should be able to show you many different outcomes that are similar to your cosmetic issues; as well as outcomes that may not be your situation but illustrate their ability to do many types of noses.
This will form a basis of communication between you and the surgeon and provide valuable information.
Our practice does not publish before and after photographs on the internet for several reasons.
The main reason is privacy. Photographs on the internet can be used by people for other non-authorized purposes and no one can control this behavior. We cater to the high-end consumer and appreciate that many allow us to use their photographs, so in respect for that privilege, we will not publish photographs when we cannot control who has access to them and their ultimate use. Also, sophisticated rhinoplasty is individually designed, and before and after results shown on most websites are not necessarily reflective of your specific type of nose or the outcome you could expect. The consult environment is best to view other patients’ results in direct relation to your specific anatomy, goals, and desires.