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The size and shape of the nose is often considered to be the most defining characteristic of the face. So, it’s easy to see why nose surgery (rhinoplasty) is one of the most common cosmetic procedures performed in the U.S. Every year, approximately 300,000 people in the United States elect to improve the appearance and/or function of their nose through nasal surgery. Some people would like to improve the size or shape of the nose; others wish to repair damage caused by an injury, and some would simply like to breathe more easily. Rhinoplasty is designed to improve imperfections in the nose, whether they are inherited, present from birth, or acquired as a result of trauma. The operation is performed to repair asymmetries, to make certain nasal features more delicate, or to create a nose that is more harmonious with the rest of the face. |
Rhinoplasty is perhaps the most complex and the most artistic of any facial plastic and reconstructive surgical procedure. Since the nose provides a focal point of balance for other facial characteristics, it cannot be viewed alone. It is sometimes advisable to create a stronger chin (mentoplasty) to correct what appears to be an excessively large nose, or to create the impression of a shortened nasal tip. In your pre-surgery consultation with Dr. Macdonald, he will study and assess the particular intricacies of your face and advise you how best to achieve the harmonious look you desire.
Rhinoplasty can be combined with the surgical repair of the nasal septum (septoplasty). The septum is the structure that sits in the middle of the nose separating one side from the other. Often, twists and deflections may be present which obstruct breathing. A septoplasty improves or eliminates this problem. Addressing any nasal airway problems associated with the adjacent intranasal turbinates may also be required and included in this procedure.
Occasionally, revision rhinoplasty surgery is required for a variety of reasons…. Dr. Macdonald is considered one of the San Francisco Bay Area’s premier revision nose surgery experts and receives numerous referrals for revision rhinoplasty cases from many of his fellow plastic surgeon colleagues because of the extreme complexity of these surgeries and his respected expertise and artistry in this area.
Procedure Information
Dr. Macdonald most commonly performs rhinoplasty under monitored Intravenous (IV) Sedation, also referred to as “Twilight Sleep Anesthesia”, at a private surgery center in San Francisco. Patient benefits of this method versus general anesthesia are further described in the section entitled Patient Care Philosophy. Alternatively, general anesthesia and/or surgery in a hospital setting are available in both San Francisco and Oakland, if desired or if indicated by a pre-existing condition. The patient experiences no pain during the surgery and remembers very little from the time the IV is started. Surgery generally lasts about 1-3 hours.
In the preoperative consultation with Dr. Macdonald, a detailed and uniquely individualized surgical plan is prepared. A careful analysis is tailored to each patient’s goals, both in terms of aesthetics and function. This analysis and planning takes into consideration the patient’s skin thickness, their nasal airway function, and a number of aesthetic parameters including: nasal projection (away from the face), rotation (is it “turned up” or does it appear to be “hanging”), apparent length, tip mobility, tip contour, dorsal width and curvature, and the presence of any dorsal hump or contour irregularity.
Access to the bony and cartilaginous framework of the nose is achieved either through an intranasal or “closed” approach, with no visible scars, or less commonly, through an “open” approach with a small scar on the nasal collumella (just above the base of the nostrils). The nasal framework is then recontoured to achieve the desired outcome. Cartilage may be borrowed from the septum or elsewhere to aid in recontouring, suture techniques may be used, or occasionally the size or shape of the nose may be augmented. Dr. Macdonald’s ultimate goal is always to produce a result that is uniquely suited to each patient both in terms of form and function.
At completion of the surgery, nasal packing is rarely required. Tape and a splint are applied to the outside of the nose to stabilize and maintain the positioning achieved surgically.
Recovery Information
The tape and splint are left on for approximately 7 days. A gauze pad is taped below the nose to catch any drips of blood following the procedure. This “drip pad” may be used for 3-4 days post operatively, as needed. Any non-dissolving stitches are removed in 7-10 days.
Patients usually experience very little discomfort after rhinoplasty. Dr. Macdonald does, however, prescribe pain medication should the need arise. Because patients often feel only slight discomfort, they are tempted to become too active too quickly. Dr. Macdonald cautions his patients to “take it slow” at least for a couple of days to minimize post-operative bruising and swelling.
During the first week of healing, the patient should:
- sleep with his/her head elevated
- try not to bend over during this time
- avoid exercise, straining, or lifting
- avoid bumping the nose
Patients often love their result immediately (1-2 weeks post surgery), but sometimes it also takes awhile to adjust to the look of their new reflection in the mirror. It will take 6-12 months as the healing process progresses for the final results of rhinoplasty surgery to become fully apparent.
View Nose Surgery Before & After Photos
Revision Nose Surgery
What if your rhinoplasty didn’t turn out the way you hoped or expected? What if in the first several weeks after surgery your nose looks great, but subsequently it changes in ways you don’t expect or like? Or what if you aren’t able to breathe as well following surgery? Perhaps you need a revision rhinoplasty, a procedure to refine your initial result. With any cosmetic procedure, a touch-up or revision procedure is sometimes necessary.
Even in the hands of the best surgeon, the need for revision sometimes occurs. Because rhinoplasty is a complex operation, it has a higher revision rate than other cosmetic procedures, with 5-12% of patients across the U.S. that undergo rhinoplasty needing a revision of some kind, whether it’s major or minor. As such, it is critical to choose a seasoned rhinoplasty surgeon because the high level of specialized experience they possess in analysis, judgment, techniques, complication management, and volume of successful cases helps them to circumvent potential pitfalls of this most challenging facial plastic surgical procedure.
In primary rhinoplasty surgery, the key to preventing complications is the pre-diagnosis of potential anatomic and functional abnormalities. In revision nasal surgery, the surgeon is tasked with the work of repairing the complications caused by the abnormalities that were not identified in the initial rhinoplasty preoperative evaluation. Dr. Macdonald identifies the problems and potential complications and studies the preoperative photographs in creating a comprehensive revision surgical plan that allows for and prepares him for potentially necessary adjustments in approach at the time of surgery. After developing a detailed history of your prior rhinoplasty surgery and healing experience, Dr. Macdonald listens to your desires and determines if your expectations are realistic. He seeks to understand precisely what you are unhappy with – a pinched tip, a “Polly beak” deformity, etc. – to determine if he can help you and you are indeed a good candidate for revision surgery.
The reasons why you may choose to have revision rhinoplasty fall into one of two categories: form – dissatisfaction with the way your nose looks, or function – dissatisfaction with the way your nose functions and how well you can breathe.
Common “form” reasons for seeking revision rhinoplasty include:
- Asymmetry: This may occur due to no fault of your surgeon. Post-operative scarring within the nose can cause it to appear uneven from one side to the other. The nose is a three-dimensional object that can heal in unpredictable ways.
- Callous or bump: A small callous or bump may appear on the dorsum up to one year following your procedure. The cause of this is often unknown, but if it occurs, it can usually be removed in a minor procedure.
- Polly beak: Sometimes called a “parrot beak,” this can occur when a hump on the bridge of the nose isn’t sufficiently reduced in the area just behind the tip or when there’s a build-up of scar tissue. Correction requires revision rhinoplasty.
- Pinched tip: When the tip of the nose appears pinched, it’s often because too much tip cartilage was removed or the cartilage didn’t heal well and collapsed. To correct this, cartilage is usually added to the nasal tip in a revision rhinoplasty procedure.
- Inverted V: When a hump is reduced, sometimes the middle vault of the nose collapses inward, causing an “inverted V” appearance. This may be corrected with the placement of grafts in a revision rhinoplasty procedure.
- Post-operative changes: In general, following primary rhinoplasty, the nose changes every year. These changes can be unpredictable, and you may not like the way these changes look.
- Disappointment with results: Despite your surgeon’s best efforts, it’s possible that you may be disappointed with your results. Disappointment may be due to unrealistic expectations on your part, unclear communication of your goals, surgical aesthetic misjudgment, or complications during the healing process.
Nasal “function” may be an issue even though you’re completely satisfied with how your nose looks. It is possible to experience a nasal obstruction that makes it more difficult to breathe through your nose. Most nasal obstructions can be corrected with revision rhinoplasty. If your breathing is hindered in any way, you may want to consult with your surgeon about a follow-up procedure to alleviate the problem.
As mentioned earlier, rhinoplasty is a complex cosmetic surgical procedure, and revision rhinoplasty is even more challenging. Scar tissue builds up within the nose following surgery, making it more difficult to sculpt the underlying structures. The nasal skin becomes thinner with revision surgery and tends to contract more tightly around the underlying structures, creating a “shrink wrap” effect. To avoid having the underlying structures become visible under the skin, soft-tissue grafts are often necessary. Without a doubt, this is the most difficult facial cosmetic procedure performed.
When do you undergo a revision procedure? No matter what your reasons are, you’ll need to wait an average of one year following your initial procedure. It’s important to wait until all the swelling from your first surgery has subsided, especially if you think your reshaped nose is too big. Revisions may be performed a few months beyond one year, a few years or even decades after the initial rhinoplasty surgery.
Please call or contact us online at any time to further discuss your rhinoplasty surgery options and questions. Or, visit our cosmetic surgery offices in the Union Square district of San Francisco, California. Our offices are conveniently located for easy accessibility from the entire San Francisco Bay area.
Dr. Macdonald is a RealSelf contributor on rhinoplasty.
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