Nose Surgery / Rhinoplasty - Consultation

We have outlined below what you can expect from your rhinoplasty consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to your plastic surgeon what you want to accomplish.

• Health History

All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used but also applies to local anesthesia. Rhinoplasty may be done under general or local anesthesia depending what needs to be done and on the preference of both the plastic surgeon and the patient. Prior to meeting with your plastic surgeon you will be given a health history questionnaire to fill out in the waiting area. There are 5 areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.

• General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are: high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What will Dr. Cruise do if I have medical problems?

In short, he will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating you are able to tolerate surgery.

If you are not able to tolerate general anesthesia it may be possible for your procedure to be done under local anesthesia, with or without sedation. This must be discussed with Dr. Cruise.

• Past Surgical History

On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With rhinoplasty it is especially important to mention all previous nasal or sinus surgeries. Previous trauma to the nose is important. If you have traumatic changes to your nose it is helpful to bring in pictures of what you looked like before your injury.

• Medications

Be sure to list all medications you take including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least two weeks before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.

• Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.

• Smoking, Drinking, and Drug Use

These 3 will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and Liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.

• Specific Nose Issues

During your consultation you must be very accurate with nasal problems. Of particular concern is a history of breathing problems, sinus problems, nasal drug use, nasal trauma, and any previous nasal surgery. If you had previous nasal surgery, call the surgeons office and have them fax over the operative note. Bring this operative note to your consultation. This is very helpful so that your plastic surgeon can see what has been done. Revision rhinoplasties are challenging because of the scar tissue left by the first operation.

• Physical Exam

The key to the nasal physical exam is to determine exactly what is causing the problem. Rhinoplasty is a high finesse procedure and requires that the plastic surgeon knows exactly what you want. If there is a particular nasal characteristic that you like, it is helpful to bring in a picture of someone with this particular feature. Obviously, this look will not be duplicated but it helps convey your wishes.

• Dorsum

When looking at the nasal dorsum, there should be a continuous curvilinear line that begins within the eye brow, joins harmoniously with the radix of the nose, and continues to the tip. When the dorsum is too big or too wide this continuity is broken and the nose appears out of place or too big

Nasal osteotomies usually cause bruising around the eyes that lasts about 17 days.

The image on the left outlines the typical location of the osteotomy. After the nasal bones are "broken" they are then repositioned medially to narrow the nasal vault.

This repositioning is one of the methods Dr. Cruise uses to improve the balance between the eye brow and the nasal tip as described above.

Nasal deviation can occur anywhere in the nose from the bridge to the tip. It is a very difficult problem to completely correct but can usually be improved tremendously. The treatment depends on the cause. The cause may be within the nasal bones, the upper nasal cartilages, the lower nasal cartilages, the septum, or all of the above. Usually, the nasal bones will need to be broken and repositioned.

The cartilages will also need to be repositioned. If one's nose has a concavity on one side it may be necessary to fill this gap with a cartilage graft. This cartilage is usually obtained from the nasal septum inside the nose.

Postoperatively, after an osteotomy or deviation correction, one will need to wear a nasal splint for 1 to 2 weeks. Complete bone healing takes about 6 weeks. Swelling of the nasal dorsum lasts up to 6 months but the majority is gone by 6 weeks. This is quicker than the tip, which takes a year for the final result to be evident. Once again, the majority of the swelling is gone by 6 weeks.

Tip

The tip should be a smooth continuity of the dorsum. Too large of a tip will cause people to focus on it. An attractive tip does not draw attention. A large or deviated tip causes the observer to immediately focus on this area. Nasal harmony with the rest of the face is disrupted.

The most common cause of a large, bulbous tip is a large, rounded lower lateral cartilage. This can be reduced and a sharper tip created if the overlying skin is not excessively thick.

Long noses are often caused by long septums. Shortening the nasal septum will correct this.

Droopy nasal tips are usually caused by poor tip support. Correction can be obtained by adding support and bringing the tip upward.

Short noses have a pushed up appearance and/or can have an irregular contour. Correction can be achieved by lengthening the nose using cartilage grafts.

Airway

Airway obstruction is a significant problem and the causes are numerous. Airway obstruction that can be relieved during rhinoplasty fall into two categories.

The most common is enlarged turbinates. Turbinates are three mounds of mucosa on the inside on each nares. They are called the superior turbinate, middle turbinate, and the inferior turbinate. They humidify the air as it travels to your lungs and help trap foreign particles. Enlarged turbinates may impede airflow. Correction involves reducing the size of the turbinates by either cauterizing them or excising them.

The other common cause is nasal deviation. A deviated septum will cause turbulent airflow with each breath and make breathing much more difficult. This will often be markedly improved or resolved when the deviated septum is repositioned or removed.

Chin

Evaluation of the nose would be incomplete without mentioning the importance of the chin. Einstein was right even when it comes to facial proportions. Everything is relative. A small chin makes the nose appear larger.

A strong chin gives a more authoritative look to men and a more attractive triangular shape to women. Ideally, the chin should project forward to the level of the lower lip in woman and slightly farther in men.

For more information on the chin evaluation see the section chin implant.