Beverly Hills Rhinoplasty Surgery Blog

Many modern day gym-aholics want to get back to pilates, lifting weights, or pounding the treadmill or spin class as soon as possible after rhinoplasty. Many are told that they shouldn’t exercise for a month or longer after surgery. The good news is that you may not have to wait as long as you think.

We recommend our patients wait 2 weeks before going back to heavy exercise, head-down yoga positions, or generally any activity that is likely to get the heart racing and push blood flow up into the face. Light activity like walking is fine and so is intimacy so long as you go a bit easy and avoid smacking your nose! For any activity that involves prolonged submersion in water, major pressure changes such as diving, or potential contact to the nose, you generally should wait about a month to six weeks. Flying is OK a week after surgery and we have patients regularly take long flights home at this stage. The pressurized cabin will not create problems although you might notice a bit more swelling the next day.

Why avoid exercise right after surgery? We’re not so much worried about bleeding as the risk for any serious bleeding is very low and unlikely more than several days after surgery. What we do want to prevent is swelling. Most noticeable swelling is gone within one week, and light activity such as walking is helpful in mobilizing this fluid and helping it to drain away faster. But, too vigorous activity too soon after surgery will drive more fluid to the area and make you appear more swollen. As time goes by and drainage pathways start to normalize, this is not as much of an issue.

We recently had a consult where, despite all efforts by everyone, we just couldn’t seem to find ourselves on the same page with regard to the imaged result. This young woman wanted a very dramatic change and we thought we had projected a significant and meaningful narrowing and refinement on the imaging. Yet, she just didn’t feel like she was seeing enough of a change.

And, then, we finally realized what was the cause of the communication problem. Makeup. We were imaging a photo in which she was wearing makeup. The patient had very artfully learned to contour her nose with makeup to artificially create a dramatically more defined look. When she removed her makeup, the difference in apparent bridge and tip definition was astonishing.

Below are two photos of her nose taken a few minutes apart and shown side by side, with and without makeup. You can imagine that we had a much easier time doing computer imaging on the photo on the right. The lesson for us is that it is best to come to consultation without makeup to convey a realistic view of the potential surgical result. And, for those of you considering rhinoplasty, when you see that perfect nose on the red carpet or the runway, remember the power of makeup and good lighting in creating that image.

How makeup can be used to contour the nose to create more definition

Recently, we have seen a number of patients who have had a filler- juvederm, perlane, artefill, radiesse, restylane- placed in their nose. Some of these patients have never had previous surgery while some have had previous rhinoplasty and were using the filler to further revise/correct the nose thereafter.
Universally, the patients that we have seen who had nonsurgical rhinoplasty felt that the procedure was causing their nose to look bigger. Now, in fairness, we are seeing those patients who are unhappy with their results and there are likely to be many patients who are perfectly happy after having done an injection rhinoplasty.

If you have had a filler placed in your nose, the important questions we want to know before considering surgery are:

1. Which filler was used?
a. As you can imagine there is a big difference in approach for someone who had juvederm/ restylane placed in the nose- which generally last about 6-9 months- vs someone who had artefill or silicone- which are permanent fillers.

2. How much was injected?
a. Again, if only a small amount of filler- say 0.1 cc was injected to fill in a single depressed space we can move forward with surgery sooner that with someone who has had 2 or 3 cc of fillers injected during multiple visits at multiple different sites.

3. How long ago was the filler injected?
a. Again depending on which filler was used that will help us determine when it would be best to proceed with surgery.

The reason these details are important is because as we all know rhinoplasty is a procedure of millimeters and the details of how long ago and how much filler was placed are crucial toward the final goal. The last thing we want to do is assume all the filler is gone and go in to do surgery only to find many months later that more filler dissipated and now the nose is smaller than we had intended.

As a result, we do not have a blanket approach toward when to proceed with surgery. These details are all individualized to each patient and the details of the procedures they had undergone.

All this being said, we have operated on patients who have had restylane, juvederm, perlane, radiesse, artefill and silicone and had fantastic success by individualizing each patients treatment plan.

At the start of the new year, we want to take the opportunity to thank you, our readers and patients, for your ongoing support of our practice. Last year was an exciting year for us at Profiles. We celebrated our 5-year anniversary in practice together. And, 2012 saw the launch of our new skin care line, JolieMD Metamorphosis. We’re looking forward to seeing what 2013 will bring.

We want to wish you much happiness and success in the coming year. Whether you are actively considering rhinoplasty or facial rejuvenation surgery, or just in the information gathering phase, we hope you find our blog helpful and informative. We are always looking for new and interesting topics of discussion, so please feel free to post questions or comments. If you are interested in a surgical procedure at Profiles, please contact us on our practice website. All our best to you for 2013.

In general, it is best not to massage your nose after rhinoplasty as it is possible, although unlikely, that vigorous rubbing or manipulation in the first few weeks could pop a delicate stitch and disturb the corrections made or affect the cosmetic result. Some people habitually rub the tips of their noses. Recognize that this will not likely ruin the result but may cause more irritation and swelling.

That being said, your nose is not glass after surgery. In fact, it can often feel quite stiff and wooden for a period of several months after surgery. Rolling over onto your nose during sleep or lightly bumping your nose will not make it end up on the side of your head. So, you don’t have to walk around in a bubble after surgery.

After about a month, the skin starts to wrap around the cartilage, and the bone is pretty much set, so contact to your nose is less likely to cause any shift or problems with healing. Likewise, a small rind of fibrous tissue or scar has started to form that will likely hold the cartilage in place even if a stitch were to loosen at this stage.

Some surgeons recommend ‘nasal exercises’ which essentially amount to light lymphatic drainage. These will not be harmful but may not do much either. Instead, we ask patients to tape the nose at night for the first month to help skin contract and push out swelling. If you have any questions about nasal massage, ask your surgeon for his or her preferred routine after surgery.

We often see patients who present to us with a crooked appearing nose as well as breathing problems. Many of our patients are confused about what the difference is between septoplasty and rhinoplasty and when either procedure is recommended.

To begin with the septum is the piece of cartilage and bone that separates one side of the nose from the other. Normally, the septum is straight and allows normal airflow. If the septum is crooked, either normally or arising after an accident or trauma, it is termed a deviated nasal septum. A deviated septum can decrease or block the nasal passage and cause nasal obstruction.

Correction of a deviated septum with a septoplasy is generally done by making an incision on the inside of the nose. The mucosa covering the septum is lifted off the cartilage and bone and the deviated portion(s) of the septum is either removed or reshaped to make the breathing passages more open. While septoplasty will correct breathing significantly when the septum is significantly deviated, if there are other factors contributing to nasal obstruction arising from the nasal bones or the upper lateral cartilages having problems, those issues will still continue to exist and breathing may still not be perfect. For patients who do not have a significantly crooked external nose and who do not want to change the appearance of their nose for any other reason, a septoplasty is a great procedure that can significantly enhance your breathing with relatively minimal downtime, no bruising or swelling. And if you have health insurance, this procedure is covered by insurance.

If you not only have a deviated septum but also notice that your nose itself, externally, is crooked and/ or you have a desire to change the actual appearance of the nose, then the procedure that we would recommend is a septorhinoplasty (rhinoplasty or nose job for short). This procedure would then not only take care of the septum but would then also address the causes of the crooked nose, the nasal bones, the nasal tip, and or the upper lateral cartilages. This can be done via an open or closed procedure depending on what your goals are. More information regarding this can be found on our blog about how to treat a broken nose

There are two questions at the forefront of most people’s minds when considering rhinoplasty. When will I look good enough to go back to work, school, or social activities? And, when will I see the result I want?

The first answer is easy. Swelling and bruising should be gone in the vast majority of patients within one week after surgery. At one week, most everyone is comfortable going back to normal social and work activities. That being said, your nose will still feel a little strange at that time. It will probably be a little numb and stiff, and your smile may feel tight or awkward. No else will notice this but you will be aware of it. It’s extremely rare for anyone to notice what’s different about you unless you’re announcing your impending surgery to friends or to the whole workplace. Most of our patients tell us they here statements like “Hey, you look good”, or rarely “There’s something different but I can’t put my finger on it”. The reason is that there is not an immediate dramatic change. In most cases, the change is gradual enough that it is seen only when we focus on the nose.

On the second question, you should be seeing a real and meaningful positive change in your appearance even within a week or two after surgery. But, at this stage, you may only be about halfway to the imaged or desired result. We are talking here about detail or refinement. The skin has been lifted and changes made to cartilage and bone underneath, and it takes weeks and months for the skin to contract around the bone and cartilage. Until then, the skin can feel a little ‘loose’ or spongy. As the skin contracts, it ’shrink wraps’ onto the change structure allowing more detail to show through.

Some factors can affect this timing. Thicker, more oily skin can often take longer to contract. If the nose was made smaller or narrower, it will take more time for the skin to contract to that level. On the flipside, if the tip was projected or the bridge raised and augmented, you will generally see more definition sooner after surgery. Revisions can sometimes be slower to heal although not always. If a large amount of scar was taken out during a revision and cartilage resupported, the skin will likely be able to drape better more quickly.

Of course, there is some individual variation here. Some patients look fantastic after 3 months and healing is essentially done. Others may have some fluctuating puffiness and continued improvement well over a year or longer after surgery. Your surgeon will be able to give you a sense of your expected course of healing during your pre-op visit. Things can also be done along the way to help swelling go down and have you looking and feeling great as quickly as possible.

Check out another one of our blogs on healing after rhinoplasty.

For many of our African American patients there is some real confusion as to what rhinoplasty can accomplish. The problem is that after having seen a number of different surgeons for consultation they are repeatedly told that in order to accomplish any “real” change they need to have the bridge of their nose built up.
The problem is that for most of you, it is not the profile view that has ever bothered you- it’s how wide your nose looks on front view that made you feel like your nose does not quite fit.

Unfortunately, many surgeons are not comfortable in dealing with the excessive width of the tip and nostrils and will instead focus on building up the bridge to make it look narrower. Again, while this treats part of the problem it does not address the tip and as a result your nose can still feel excessively wide. Moreover, because the surgeon often uses your septal cartilage in order to build the bridge it makes revision of the tip much more difficult.

In our experience, traditional reduction rhinoplasty generally does not work very well for African American patients. The reasons for this have been addressed in previous blogs on the topic, but suffice it to say that in most African American patients there is a layer of fibrofatty tissue that underlies the skin that covers the tip and makes the tip excessively wide and undefined. In order to create more tip definition and make it look more refined, this fibrofatty tissue often has to be dealt with during surgery and at least partially removed so that the skin can then contract down to the cartilage.

When we then couple this with suture techniques to help refine the tip and do alar base surgery (nostril narrowing) that addresses both the flare of the nostril as well as the width of the nostril (sill width) you can really tailor the procedure to address your goals in a very natural way. By combining all of this we have found that our patients are able to address the excessive width of the their nose and end up with a nose that is natural and stable so that they no longer have to think about their nose any more.

The open rhinoplasty approach offers unquestioned advantages when operating on the nasal tip. But, what if you just want to reduce a nasal bump? Should it be done closed or open?

The answer, in our opinions, depends on the extent and location of the bump. Some people have a bump that is mostly isolated to the bony part of the bridge. If the bump is mostly bony and in the upper third of your nose, it is perfectly suitable to go through a closed approach. The bony bump can be rasped or shaved down and then osteotomies can be done to narrow or straighten the bones as needed.

For many people, however, the bump is not just in the bony part of the bridge, but is more of a curve that goes all the way from the forehead down to the tip. In these cases, the bump involves the middle portion of the nose which we call the mid-vault. This area, made up of cartilage sidewalls attached to the septum in the middle of your nose, is a vital part of the nasal airway. For this reason, we prefer an open approach when addressing these types of bumps.

The reason we prefer an open approach is that it is critical to re-support these sidewalls to preserve breathing after a bump is taken down in the mid-vault. In a closed approach, the cartilage sidewalls are often reduced along with the bump and the normal connections between the sidewalls and septum are released and left unattached. If left to heal this way, the sidewalls can lose support and fall in or collapse, leading to breathing problems or apparent crookedness, something we call internal valve collapse. The advantage of an open approach is that it provides the access and visibility for the connections between the sidewalls and septum to be more easily and more accurately sutured back together, minimizing chances for poor healing. In a closed approach, reaching this area with a suture from underneath the skin is both less precise and more difficult to accomplish. As a result, some surgeons who prefer a closed approach do not do this, increasing the risk for mid-vault collapse in the long-term. By re-supporting the nasal sidewalls through an open approach, the chances for breathing issues after rhinoplasty can be kept to a minimum.

Whether your nose is operated from an open vs closed technique should honestly not be the dominating question. What is important is that the surgeon you choose has a lot of experience with rhinoplasty and can choose the best approach for your nose in order to optimize your chances for a great result and minimize chances for risks from the procedure.