Frequently Asked Questions
Non-surgical rhinoplasty is a term used for modification of the external contour of the nose using soft tissue filler materials. This may be hyaluronic acid (HA) based materials, like Juvederm®, or calcium hydroxyapatite (Radiesse®). Small, precise placement of these products can make a bump on the bridge look more smooth, can add projection to the tip of the nose, and can make the nose look a bit more rotated (up-turned). Non-surgical rhinoplasty is appropriate for many patients, generally with smaller noses. It does not make a larger nose smaller and is not used for functional improvements to the nose or breathing passages. The duration of the effect depends on the filler and each patient’s unique metabolism. This is generally 9 months to a year and can be repeated at that time.
A “forehead flap” (paramedian forehead flap reconstruction) is a two-stage surgical procedure that is used to close large soft tissue defects of the nose. It is particularly useful when a substantial portion of the tip of the nose has been removed. The first stage of the reconstruction involves elevating a flap of skin from the middle of the forehead which is attached to a blood vessel that emanates from the medial brow region. This skin is turned inferiorly, trimmed to shape, and sutured into the nasal defect. It is left attached to the brow region for a period of about 3 weeks, and then the second stage is performed. At this time, the connection to the brow is severed and the flap is tailored at both ends – resulting in complete closure of the brow region and the nasal reconstruction. The entire process takes about a month to complete. Healing depends on the nature of the defect and individual patient factors, and in some cases, secondary procedures are used to give the best cosmetic result possible.
When a Mohs procedure is done to remove skin cancers from the nose or other parts of the face, your dermatologist may refer you to a facial plastic surgeon for repair of the resulting defect. Depending on the size, shape, and exact location, the reconstructive surgery may involve different procedures. In most cases, local flap reconstruction methods are preferred. This involves using carefully planned rearrangements of nearby skin to close the defect. By taking advantage of areas of relative laxity and borders between parts of the face, Dr. Ransom is able to hide the incisions and give a natural-appearing result. In some cases, structural support is needed and this is often cartilage borrowed from the ear or the septum.
Sometimes a severely deviated septum will result in an external deformity of the nose (crookedness). In most cases, however, a crooked nose is multi-factorial – it may be related to the septum as well as asymmetry in the tip cartilages, deviation of the nose bones, etc. Nasal airway problems can be caused by a deviated septum (the cartilage between the two sides of the nose) but are also caused by the overall anatomy of the air passages and the structural support of the nose cartilages. Certain types of functional nasal surgery may be covered by your insurance, including septoplasty and nasal valve repair (making the breathing passage wider). This requires pre-authorization and proof of medical necessity.
When a bump is removed from the bridge of the nose, and the nose bones are subsequently repositioned to close the “open roof,” the breathing passages inside the nose necessarily get smaller or narrower. In most cases, this is not a problem. For very large bumps, however, it is necessary to place some cartilage grafts (“spreader grafts”) to maintain an open air passage. These are generally borrowed from the septum. Dr. Ransom will discuss this with you during your consultation.
Blunt nasal trauma may cause a nosebleed, a broken nose, or a fractured septum – or all three. Generally, with a broken nose, there is a visible external deformity. In most cases, one side of the bridge collapses in and the other side is pushed outward. There will be bruising and swelling across the bridge and around the eyes (“raccoon eyes”). When the skin is touched, you may hear or feel crackling (“Rice Krispies”) which results from air getting trapped under the skin after the bones break. Finally, it is possible to fracture the septum without breaking the nasal bones. If you experience significant pain or nasal obstruction after blunt trauma, you should have your nose examined to make sure that you don’t have a septal hematoma. This collection of blood in the septum can have significant functional and cosmetic consequences if not treated urgently.
This is a common question in Asian or ethnic rhinoplasty. Cartilage grafts and other soft tissues are frequently used to build up (add height) to the bridge of the nose. In some cases, the tip of the nose can be reshaped with suture techniques and modifications of the existing tip cartilages. For patients who have a very flat tip of the nose, cartilage grafts may be needed to add height and match the contour of the bridge. These decisions are often made during the surgery, based on a plan that is formulated during your consultation.
The shape of the nose is among the most closely associated features of ethnicity. Many people seek changes to their nose to reduce this association. It is less common to do the opposite, but this certainly comes up in consultations. There are limited techniques to make the nose flatter or wider, and the potential utility for each of these depends on the anatomy of the patient. This could include cartilage or other soft tissue grafts, or, in some cases, osteotomies to realign the nasal bones.
For people with small or flat noses who desire more projection or an improved profile, I prefer to use soft tissue grafts borrowed from your own body. In many cases, the primary graft material comes from the nasal septal cartilage. This is often wrapped in fascia, which may be taken from the temple region behind the hairline. When a larger amount of graft material is needed, rib cartilage can be harvested through a small incision under the breast or pectoral area.
Making the choice about the doctor for a revision surgery has many complex issues. First, and perhaps most importantly, do you have a good relationship with your surgeon? Do you trust their judgment and skills? Do you have an open line of communication? Second, you should consider the training and practice of the surgeon. Revision rhinoplasty is a very complex operation and is typically best performed by a surgeon who specializes in this procedure. Lastly, it seems from the conversation that you had, that your surgeon has some specific techniques in mind. It is worth inquiring as to why these were chosen and why they are more appropriate for your revision surgery and weren’t performed the first time. It is crucial that you understand the plan and reasoning behind this in order to avoid disappointment again.
Modification of the nostril shape can be performed during rhinoplasty. This is performed to make the base of the nose narrower and the nostrils more shapely. In terms of making the opening of the nostril bigger, this depends on the specific anatomy of the tip and base of the nose. Often, nostrils are collapsed due to poor support. This can be addressed with cartilage grafts to add structure. In addition, changes to the tip (to add projection or make it less bulbous) also affect the nostril shape and orientation. When the nasal ala or base is surgically modified, the incisions are hidden in the grooves around the nostril to make sure that it looks natural after healing.
Years ago, after nasal surgery, the nose was packed with a ribbon gauze material. This was meant to decrease bleeding after the surgery. In modern rhinoplasty and septoplasty, this is not commonly used. In my practice, we do not use nasal packing – which makes the post-operative recovery significantly more comfortable. In a minority of cases where the septum is very crooked, temporary splints made of silicone are used in the nose. These are removed one week after the surgery.
Refinement of the nasal tip is most commonly performed with precise shaving of the tip cartilages and the use of suture techniques to reshape them. In some cases, a graft (generally from the septum) is used to add height or projection to the tip. In certain types of noses, these grafts can also be used to increase the definition of the tip shape. In patients with thin skin, however, I try to avoid grafts in the tip region if at all possible. These patients are more likely to have visible edges of the grafted cartilage and late complications such as bossae. When a graft is essential for the desired result, I round the edges of the graft and gently crush the cartilage to make it softer.
The recovery process after rhinoplasty has basically three phases. First, the sutures, bandages, and cast on the bridge are removed throughout the week after the procedure. The bruising should be resolving by the time the cast is taken off, but swelling persists. Patients typically feel comfortable going out in public at this time, though there are still some restrictions on exercise. The second phase is over the next two weeks or so, during which the swelling goes down substantially. The final phase is the slow resolution of the remaining 10-20% of the swelling (particularly in the tip region) and the settling of the bones and cartilage. The final result of a rhinoplasty is generally said to be around 9 months to a year from the surgery. Dr. Ransom works closely with his patients during this time to make sure that the best result possible is achieved.
Dr. Evan Ransom is an Ivy League-educated and Ivy League trained Facial Plastic and Reconstructive Surgeon. He is a Double Board Certified Head and Neck Surgeon and Facial Plastic and Reconstructive Surgery and fellowship-trained in facial plastic, reconstructive, and laser surgery. His practice is in the San Francisco Bay Area, serving patients from San Francisco, Oakland, Marin County, Palo Alto, Silicon Valley, Walnut Creek, the East Bay, and all over Northern California.