Deemed one of the most challenging procedures in plastic surgery—one where “millimeters and symmetry really matter,” notes Philadelphia facial plastic surgeon Jason Bloom, MD— rhinoplasty (the “nose job”) can reduce or enhance the size of the nose, smooth away humps and bumps, tweak the shape and orientation of the tip, raise or lower the bridge, and relieve breathing problems. “Our aim is not just to make the smallest nose we can,” Dr. Bloom adds, “but to balance the tip and nostril size with nasal function and support”—objectives often achieved by using grafts (made of the body’s own cartilage and fascia) to change the framework of the nose. Done right, the high-impact procedure can bring overall balance to the face, and in many cases, make patients look younger. By “enhancing the supporting structures and making the link between the tip and other parts of the nose stronger, we assure that the nose won’t be as susceptible to dramatic gravity forces and the droopiness that occurs to every nose with age,” says Cleveland plastic surgeon Bahman Guyuron, MD.
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Along with a slew of technical upgrades, an evolved aesthetic has helped make the surgery a 21st-century staple. “The goal of any rhinoplasty is a natural, un-operated look—never the scooped-out slope with pointy, turned-up tip,” says Dallas plastic surgeon Rod Rohrich, MD. Meeting expectations starts at consultation, when you and your surgeon will map out your new nose—typically with the help of 3-D imaging, which lets you glimpse every angle, and tweak accordingly—and discuss the surgical maneuvers that may be required to create it, or at least come close (as doctors can’t guarantee your final result will be an exact replica of the computer-generated image).
Two Approaches to Rhinoplasty
This 27-year-old patient felt her nose was out of balance with her face. Raleigh, NC facial plastic surgeon Adam Stein, MD, performed an open rhinoplasty to correct the overprojection of her nose.
Open
“While closed rhinoplasty is the classic approach to the nose, open rhinoplasty rose to popularity in the early ’80s, and became the more common method for teaching residents in training, as the operating surgeon was able to point out the anatomy with the nasal skin elevated,” explains Los Angeles plastic surgeon Geoffrey Keyes, MD.
Closed
The closed, or endonasal, approach is sometimes dubbed “scarless rhinoplasty” because incisions are hidden inside the nose. Despite the name, Dr. Bloom says, “We can still see everything we need to. We’re taking the still-attached cartilages out of the nose through the nostrils, suturing them, modifying them, and putting them back.”
Key Questions to Ask During Your Consultation
Are You Board-Certified?
Your doctor should be certified by the American Board of Plastic Surgery (ABPS) or the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS).
How Many Rhinoplasties Do You Perform Weekly?
While there is a select lot of rhinoplasty specialists who operate on multiple noses daily, Dr. Rohrich says a true expert should do three to five rhinoplasties a week, and have at least 10 years of experience.
May I See Before-and-After Images of My Specific Problem?
“At the end of the consult, when we’re looking at before-and-afters, most of my patients will say, ‘Her nose looks like mine!’ during our review. And that’s my goal: to show patients I can address their particular issues,’ notes Dr. Bloom. Ask to see 10 or more relatable B&A photos. And beware of cookie-cutter results: “Older techniques called for removal or interruption of too much cartilage, which resulted in prototype noses—everyone had the same nose,” says Dr. Guyuron.
What Approach Would You Use for My Nose, and Why?
When it comes to open or closed, one method isn’t superior, but ideally, your surgeon will be proficient in both, so he or she “can match the approach with the complexity of your case,” says Dr. Bloom. “You want the surgeon to be comfortable with the approach they choose, not adapt their style to fit your requests.
What to Expect
Average Procedure Time
One to three hours
Average Recovery Time
Six to nine days before patients are comfortable in public; two to three weeks before they can resume full physical activity; and up to a year for swelling to totally subside, revealing final results. Stitches and splints are typically removed between a week and 12 days later.
Minimal Discomfort
Upon waking from surgery, your nose will be splinted and packed (to diminish blood oozing). You’ll feel congested, like you have a bad cold, but “rhinoplasty, when performed correctly, is not painful,” says Dr. Keyes. “There’s some discomfort from swelling, but very little real pain.” Bruising around the eyes and cheeks generally lingers for two weeks.
Results Are Permanent, but…
If done properly, your rhinoplasty should last for life. As you age, though, your nose, like the rest of your face, may sag due to the pull of gravity. Revision surgeries are sometimes recommended. But neurotoxins, like Botox, injected at the base of the nose, can also subtly boost droopy tips for three to four months.
Nasal Bones May Be Cut or Broken During Surgery
The controlled surgical cutting of a bone is what’s known as an osteotomy. Surgeons perform osteotomies when they need to reposition the nasal bones. Although they can create under-eye swelling and bruising, they’re an essential part of rhinoplasty. “Bruising should never be the driving concern of a patient seeking rhinoplasty,” says Dr. Keyes. “Bruises fade and can be camouflaged with makeup.”
A Natural Result
Unlike in the ‘70s and ‘80s, surgeons’ aesthetic choices are now guided by hard science, not individual taste alone. “We use the principles of cephalometric analysis to match the nose to the face, and allow science to dictate how much we remove to avoid an overdone, surgical look,” explains Dr. Guyuron.
What Can a Nose Job Fix?
Princeton, NJ plastic surgeon Adam Hamawy, MD performed a rhinoplasty to bring down the hump on this 34-year-old patient’s nasal bridge, which straightened her nose to give her the shape she desired.
A Bumpy Bridge
Surgeons erase bumps by filing down excess bone and/or cartilage. According to Dr. Rohrich, it’s rare to just take down a hump, even if that’s the patient’s only concern, because there’s usually a domino effect in play: Fixing the hump can cause the tip to droop or look out of balance, thereby necessitating a subtle tip reshaping to achieve an natural and harmonious look— a straight nose that’s not overly dainty, scooped or projected.
A Drooping Tip
As the support mechanisms of the nose weaken with age, the “tip begins to droop, making the nose appear longer than it actually is, especially when smiling, as some of the muscles involved exert a downward pull,” explains Dr. Bloom. By lifting the tip and adding support, surgeons can restore it to a more youthful position and help keep it from relapsing.
A Bulbous Tip
To refine the tip, cartilage may be narrowed, sutured or otherwise augmented with grafts. Tip refinement may also include the creation of what doctors call the supratip break: “Right above the tip, there should be a minor level difference that isolates the tip and makes it more aesthetically pleasing and defined,” says Dr. Guyuron.
Irregular Nostrils
“Selfie nation has caused people to really look more carefully at their nostrils, so we’re doing a lot more nostril modifications these days,” says Beverly Hills, CA plastic surgeon Jay Calvert, MD. Surgeons can do any number of things to create a complementary set, “from moving the septum and adding cartilage to the rim of the nostrils, to moving the alar base and tucking up the mucosal lining of the nostrils,” says Dr. Calvert. Some of these tweaks can even be done in the office under local anesthesia.
Over-Projection
An over-projected nose has one or more aspects that protrude too far from the face—usually due to an abundance of cartilage at the tip or septum—dwarfing or otherwise detracting from features like the chin, cheeks and lips. Surgeons can shave down the bridge to bring it in, or retract a tip by removing tissue or cartilage in that area.
A Nose That’s Too Small
Surgeons can use grafts to add length or build up the bridge of a nose so it better fits the face. “The best graft, by far, is the patient’s own septum,” says Dr. Rohrich. In revision cases, where the septum has been taken out, doctors may use ear or rib cartilage.
A Crooked Nose
Typically caused by a deviated septum or an injury, a crooked nose is often accompanied by breathing problems. To straighten it, bones need to be moved and are often reduced before being reshaped.
To correct a deviated septum, this 26-year-old patient underwent a rhinoplasty with Wayne, NJ facial plastic surgeon Jeffrey B. Wise, MD, which fixed her breathing issues and created a smoother-looking nasal bridge.
Breathing Problems
The airway can be compromised by trauma, previous surgery, a deviated septum, collapse of the internal valves, or swelling of the inferior turbinates. “Surgeons must never sacrifice function for aesthetic appearance,” says Dr. Rohrich.
What’s New in Nose Jobs?
The innovations and trends rhinoplasty surgeons are buzzing about.
Hot Tool
Powered by ultrasonic vibrations, piezoelectric instrumentation is being studied globally for its role in rhinoplasty. Claiming to deliver less bruising, the device, which is “best used with the open technique,” says Dr. Keyes, “allows for refining of the nasal bones and precise fracturing of the nasal bones.” It’s not yet widely used in the U.S., however, and surgeons are split over its potential. According to Dr. Guyuron, “piezo can be an excellent tool for removing a hump, but the tool’s tips need to be adjusted to make it more usable and less cumbersome.” Skeptics cite other downsides, including its exorbitant price and the extent of undermining required to use the tool. “You have to de-glove the skin from the nasal bones significantly, which can destabilize your bony nasal framework,” says Dr. Rohrich. Aggressive undermining also means more time under anesthesia, notes Dr. Calvert: “It takes an additional 20 minutes to do what I do in about two minutes.” Most surgeons agree that studies are needed to bear out piezo’s true benefits.
Groundbreaking Grafts
“Diced cartilage and fascia grafts have really changed the game in terms of controlling dorsal aesthetic lines—the shadows that make the bridge—and also the smoothness in reconstruction with secondary rhinoplasties,” says Dr. Calvert, referring to the process of wrapping minced rib cartilage, burrito-style, inside a membrane borrowed from the patient’s temporalis muscles on the sides of the head, and then using it to line the bridge of the nose in situations where it needs to be built up. While procuring rib cartilage used to mean harvesting it directly from the patient, “we now have an alternative to autologous rib: fresh-frozen cadaver rib grafts,” says Dr. Rohrich, who’s been using them for more than five years, primarily in revision cases. “My patients love it, because it obviates the need for a second procedure, another scar, and the pain and risk associated with the rib harvest.”
Controversial Move
First espoused in the 1950s as a way to maintain one’s original bridge, preservation or “let-down” rhinoplasty is having a resurgence, primarily abroad. Only a handful of U.S. surgeons have fully adopted the technique, but one who has, San Francisco plastic surgeon Dino Elyassnia, MD, describes it as a “more holistic approach to rhinoplasty.” Instead of taking off the top of the bridge to remove a dorsal hump, surgeons first make space below the bridge, then weaken the joint between the bone and cartilage comprising the bridge, and push it down to the straighten the nose. According to Dr. Elyassnia, the larger goal is to spare ligaments, cartilage, septum and soft tissue—all via a closed approach—to make recovery and potential revisions easier. “It’s a promising technique,” adds Dr. Rohrich, “but we need more published long-term outcomes.”
Is Nonsurgical Rhinoplasty Right for Me?
Using Restylane Lyft to perform a nonsurgical rhinoplasty, Scottsdale, AZ facial plastic surgeon James Bouzoukis, MD lifted the drooping tip on this 47-year-old patient’s nose.
For those who can’t manage the recovery of a surgical rhinoplasty, or simply want to test-drive a new nose before going under the knife, hyaluronic acid fillers, like Restylane, can temporarily give the look of a straighter bridge or more refined tip. (Never use permanent fillers in the nose.) While fillers can’t physically change the structure or shape of the nose, they can create the illusion of a smoother profile by camouflaging bumps and dips. Bear in mind, “a filler rhinoplasty is an additive rhinoplasty,” says Dr. Rohrich—“filler can only make the nose bigger, not smaller.” Because the nose is considered a high-risk area—injecting into or compressing a vessel can lead to skin necrosis or blindness in rare cases—trust only board-certified doctors practicing in scope to perform nonsurgical nose jobs. “All of the vessels in the area are superficial and off to the sides of the nose,” notes Dr. Rohrich, so injecting deep and only in the midline of the nose is key to a safe outcome.
