A Patient's Guide to a Nose Job or Rhinoplasty

Interviewer: Today we delve into the world of cosmetic rhinoplasty, as well as some of the considerations you should have before you consider a nose job. Today, we are joined by Dr. Sarah Akkina, the Director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology.

Reasons for Considering Rhinoplasty: Function and Appearance

Now, Dr. Akkina, what are some of the reasons that people might consider a rhinoplasty, more commonly known as a nose job?

Dr. Akkina: So the main reasons that people consider rhinoplasty are either for function or for appearance or cosmetics, or often in many cases for both.

For function, we can really help people breathe better if certain parts of their nose, like their septum, or that middle part of the nose, or the nasal valves, basically the side parts of the nose, are collapsing or constricted when they're breathing. So we can surgically improve both those aspects from a functional standpoint.

From a cosmetic standpoint, there are many appearance changes that we can make to the nose, including making it look straighter, taking the bumps off the top of the nose or the dorsal hump, or improving the tip position, rotation, and overall definition.

So those are some examples of why people might want to pursue a nose job or rhinoplasty.

Open vs. Closed Rhinoplasty

Interviewer: Understood. And so when someone is first looking into it, whether it be functional or cosmetic, what are some of the different aspects, or the different types of surgeries that they should be aware of when they first start looking for a surgeon?

Dr. Akkina: The main approaches to rhinoplasty are what we call an open approach or a closed approach. With an open approach, a surgeon typically makes an incision along the columella, or the bottom part of the nose, and the rest of the incisions are inside the nose. But there's that key lower incision that is how we define an open rhinoplasty.

In that procedure, essentially the skin envelope of the nose is lifted up so that the surgeon can access the cartilages and other structures of the nose to improve both the form and the function.

There are also techniques called closed rhinoplasty in which all of the incisions are inside the nose. So there are no external visible incisions. Many providers can do very similar techniques to an open approach with that approach. It's really a difference of training and the patient and what their preferences are in terms of which approach is used.

Interviewer: Now, just briefly, because this is a conversation really best for the surgeon that you'll be working with, but what are some of the differences or benefits that come from an open versus a closed procedure?

Dr. Akkina: The main benefit of an open procedure is that everything is visible. It's kind of the difference of opening the trunk of a car and seeing everything that you can essentially take out or put back in, versus maybe just opening a side window and having to tunnel under the side to be able to do the same maneuvers.

Ultimately, I think there are wonderful surgeons who do both approaches. So the approach itself is probably less important than the surgeon and the patient having a really in-depth conversation about what the patient's goals are.

Recovering from Rhinoplasty

Interviewer: Regardless of what kind of open or closed they choose to have, what is the typical recovery time for a procedure like this?

Dr. Akkina: For one week typically after rhinoplasty, patients have tape and a cast on top of their nose. That's to help prevent some of the initial swelling from surgery.

Sometimes surgeons will also use permanent sutures on some of the outer incisions if those are made, and those may need to be taken out after one week. That one-week period is really critical to, again, allow some of the swelling to improve and for the initial incisions to start healing themselves.

After that period, it really depends on what was done in the rhinoplasty. For instance, if any bony work was done, then often surgeons will recommend patients take it pretty easy for six to eight weeks and not put any pressure on the top or bony parts of the nose, as that could risk shifting some of the bones.

We generally also recommend avoiding any sort of contact sports or any other activities where the nose can get hit during that really critical initial six- to eight-week period.

A lot of the swelling from the rhinoplasty, while it improves within the first few weeks, can hang on, especially at the tip of the nose, for up to a year after surgery. So while the initial recovery period is a several-week span after surgery, all of the swelling and healing takes that full year often for it to be more finalized, as we say.

Realistic Expectations and Long-Term Results

Interviewer: What can they expect with those results, understanding that it can take up to a year for all that swelling and the final thing to go? What kinds of things do we need a patient to understand about realistic expectations and what kinds of results they can expect?

Dr. Akkina: The most important thing is understanding that the swelling around the nose really does hang on. The definition of what was done to the nasal dorsum, or top of the nose, and especially the tip takes some time to come through.

So it's really important to allow your body to heal after this type of surgery and to ideally not focus on any subtle asymmetries, things like that, as many of those things may improve as the swelling improves.

The other important thing to know is typically for a few weeks after surgery, one way to help the swelling stay as low as it can be is to keep your activities very calm and easy.

Certainly, walking is great and encouraged to help prevent blood clots after surgery. There's really a recommendation against doing heavy cardio activities or anything where you're bending over, because those things will increase the swelling in the nose and also the potential bleeding risk after surgery.

So those are small things that can help reduce the swelling and help, ultimately, the definition of the nose present itself maybe a little bit sooner.

Risks Considerations Before Rhinoplasty

Interviewer: Well, it seems to me as a layperson that a nose job is something that we see on TV, it's pretty straightforward, pretty standard, but what are some of the risks that can be involved with this kind of surgery? And is its commonality a misconception?

Dr. Akkina: Sure. So risks of rhinoplasty that I always review with my patients include the following. There's always a risk of bleeding after surgery, and that is also why we recommend reduced activity overall for the first few weeks.

There's a risk of infection with any surgery that we do. Thankfully with this surgery, the risk is relatively low compared to other surgeries, but it certainly still exists. Many surgeons will give patients antibiotics during surgery and potentially after surgery to help prophylax against infection.

Other risks involve damage to the septum, which is the middle part of the nose. So there's a risk that you could develop something called a septal perforation, or a hole in the septum. Many patients are asymptomatic from that if it does occur. But of course, since it can happen, I always discuss it.

Other things that can happen are change of smell. Hopefully, if patients are undergoing rhinoplasty for functional reasons, their smell may improve as the airflow in the nose improves. But, it can be difficult to predict as some of the postoperative swelling can also affect the smell.

Other small things that can happen are the upper teeth and the upper lip might be numb after surgery for a period of a few days to a few weeks, and rarely that could be permanent. That's because the sensation nerves of the nose are in the same areas as the sensation nerves for the teeth and the lip at the top.

So, just things to be aware of for all patients undergoing these surgeries.

Choosing the Right Rhinoplasty Surgeon for You

Interviewer: With any surgery, we know from other interviews that we've had that the surgeon that you choose, the relationship that you have with them is one of the most important decisions you can make. What sorts of things should a patient be looking for when it comes to certifications, experience, etc., to help them choose the right surgeon for a rhinoplasty?

Dr. Akkina: Yeah, so looking at board certification is always an important aspect of your surgical team. Our surgeons can be certified either through the American Board of Otolaryngology, the American Board of Plastic Surgery, or additionally the American Academy of Facial Plastic Surgery. So there are a number of overall national boards that certify certain surgeons based on additional qualifications and experience. So those are always great things to look for.

And in general, these days there are many patient reviews and other aspects that you can see of a specific surgeon.

When you meet with a surgeon, it's a great idea to ask them as well if they have before-and-after photos that are available or patients who have spoken out about their results from that surgeon. That can be very helpful as well.

The other risk, of course, of this type of surgery is that the appearance of the nose might not be exactly what a patient expects. Any surgery itself can introduce other either asymmetries or changes to the nose that may be favorable or unfavorable.

So it's important to come into this type of surgery with the understanding that ideally a surgeon will do, of course, his or her best, but unexpected things can happen. And making sure that you're comfortable with your surgeon and being able to work through those outcomes with them is incredibly important.

Interviewer: Say a patient is curious about either the aesthetic or functional benefits that they could maybe have with a procedure like this. What's the first step they should take?

Dr. Akkina: The first step is to meet with a rhinoplasty provider. We can talk about all the general aspects of rhinoplasty, but every patient is so individual and their concerns, their nose itself is so different from anyone else's. So it's so important to be able to meet in person with a provider and be able to learn more about yourself and the procedure itself.