Every year, half a million people who are interested in improving the appearance of their nose seek consultation with Los Angeles Facial Plastic Surgeons. Some are unhappy with the nose they were born with, and some with the way aging has changed their nose. For others, breathing may be a problem, or an injury may have distorted the nose. A slight alteration of the nose can greatly improve one’s appearance. Rhinoplasty (reshaping the nose), could improve one’s looks, self-confidence or health. As with all facial plastic surgery, good health and realistic expectations are prerequisites. The goal of rhinoplasty is to improve the nose aesthetically (without creating a “surgical” look) in order to create harmony with other facial features. Additionally, many patients have a chin augmentation in conjunction with rhinoplasty to create a better balance of features. Rhinoplasty is usually performed with local injections of anesthesia with intravenous sedation, or in some cases, under general anesthesia.

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In Los Angeles rhinoplasty, the majority of incisions are made inside the nose, where they are invisible. In some cases, an incision is made in the area of skin separating the nostrils. Certain amounts of bone and cartilage are then removed or rearranged to provide a newly shaped nose. If the patient has a deviated septum (cartilage and/or bone causing obstruction inside the nose), septal surgery, called septoplasty, is simultaneously performed. The incision is placed entirely inside the nose. The septoplasty removes portions of cartilage and/or bone that are causing the obstruction. The incisions are then closed with fine suture, followed by placement of a splint to the outside of the nose. The splint helps retain the new shape while the nose heals.

If packing is placed inside the nose during surgery, it is removed the next morning following Los Angeles surgery. The nasal splint is usually removed seven days after surgery. At that time, tape is applied to the nose for another seven days and then removed. The majority of the bruising and swelling usually resolve two weeks after surgery. Cold compresses are used to help reduce the bruising and discomfort. A short course of post-operative antibiotics and steroids are given to help prevent infection and excess swelling. Although discomfort is minimal, pain medication is available if required. Vigorous activity is avoided for four weeks following surgery. Sun exposure and risk of injury must be avoided. If you wear glasses, tape is used to avoid putting stress on the nose.

During your evaluation, Dr. Nassif will discuss factors that may influence the outcome of the surgery, such as skin type, ethnic background, age and degree of nasal deformity.

Beverly Hills Revision Rhinoplasty Expert

POST-OPERATIVE INSTRUCTIONS RHINOPLASTY

These instructions should be carefully read and followed. They are designed to answer the most commonly asked questions regarding post-operative care.

Activity: The First Week

Limit your activity sharply during the first week following Beverly Hills surgery. You are encouraged to walk about the house, but avoid bending at the waist or picking up heavy objects. If you overexert yourself, bleeding may result. When you rest or sleep, keep your head elevated on 2-3 pillows and try to avoid turning on your side. Keep your emotions under control. It is not unusual to feel a bit depressed for a few days after surgery. This quickly passes as you begin to look and feel better. Anger or crying will only add to the swelling or initiate bleeding. Restrict your diet to plenty of fluids and easily chewable foods. Hard to chew foods (like steak) should be avoided for one week.

You may carefully clean around the nostrils with a Q - tip and hydrogen peroxide three times a day. Immediately afterwards, place a bit of pure Vaseline or antibiotic ointment around the nostrils to keep them from drying out. Swelling for at least two weeks will obstruct your nasal passages. A humidifier may help you sleep by allowing you to breathe through your mouth more comfortably.

Do not blow your nose or sniff excessively as this will only irritate the healing tissues. If you must sneeze, open your mouth. Also, avoid picking up babies, small children or pets; a flailing little arm may strike your nose. You probably will hit your nose one or more times during the first week. This will hurt, but will cause no problem unless the force is excessive.

With assistance, you may bathe in a tub, showering is allowed on the second post-operative day. Cover the nasal cast so that it remains dry. If the cast becomes wet, use a blow dryer to help dry it. It is all right to carefully wash your face with a mild soap and a clean washcloth or cotton balls.

Avoid cigarette smoking or even being in an area of excessive smoke as this irritates the nasal tissue and impedes healing. Also, avoid alcoholic beverages the first two weeks following surgery as this may increase your chances of bleeding.

Activity: The Second Week

It takes six weeks for the nasal bones to fully heal. Slowly resume your Beverly Hills activity. After the first week, let your body tell you how much to do. Strenuous exercise may be resumed in 5-6 weeks. Build up to this level slowly. Semi-contact sports are to be avoided for four to six months. Swimming is allowed after six weeks.

Do not let your nose become sunburned for six months after surgery. This may result in prolonged swelling and erythema (redness). When outside, wear sunscreen with a SPF of at least 15.

Pain, Swelling, Bruising, or Bleeding

The first day or two, you will have some bleeding. Do not swallow the blood, as it will make you nauseated. Most patients complain more of discomfort from nasal and sinus congestion than from pain. Any pain should be controlled with the prescribed medication. After the first day, the pain may subside enough so that plain Tylenol or Extra Strength Tylenol may be sufficient. If not, call our office and we will prescribe a stronger medication. Swelling and bruising about the eyes and cheeks is variable. Swelling maximizes at about two days then subsides over the next week. An ice pack to the eyes for the first 48 hours may help decrease the swelling about the eyes and cheeks. This will clear completely and will not adversely affect the result. Bruising (discoloration) may persist a few days longer. Remember, this will all subside in time and has no bearing on your final result.

Bleeding

It is normal to have bleeding over the first 12 hours after surgery. It may be necessary to change the gauze a dozen or so times over this period. It is normal to have a pinkish-reddish discharge from your nose and throat for the first 3-4 days. This will gradually subside. If you have profuse nasal bleeding after this time, immediately lie down with your head elevated on 3-4 pillows. Iced washcloths on the back of the neck and over the eyes may help. Using nasal decongestants (such as Afrin) as directed will often help with bleeding. Please call our office if these measures do not suffice.

Medications

Avoid medications such as Vitamin E, aspirin or ibuprofen for 2-3 weeks. Pain medication will be prescribed. Take it as needed. Please remember that pain medication may impair your reactions. Avoid driving or performing hazardous activities while taking this medication. If the prescribed medication does not control your symptoms, please let us know. Nausea may occasionally be related to the above medication. Taking the medication with food may help alleviate the nausea. After the first 24 hours, Extra-Strength or regular Tylenol may be sufficient.

Infections

Infection in unusual after rhinoplasty, but occasionally occurs. Fever over 100 ° F, excessive pain and swelling with redness may signify a developing nasal infection and should be reported. Infections generally clear up quickly with appropriate antibiotic treatment.

Post-Operative Visits

The nasal packs will be removed on the next morning after surgery. The cast and any sutures will be removed after one week. Brown paper tape will then be applied to your nose. Dr. Nassif will remove the tape in one week. When the cast is removed, the nose will be quite swollen and the nasal tip will be turned up. This will settle down over the next few weeks, then more gradually thereafter. Nasal "exercises" are then demonstrated, if necessary. These are done to keep the sides of the nose narrow and in proper alignment. They should be preformed 15-20 times per day and held for 30 seconds. They are to be continued for about six weeks. Remember that the nose does not assume its final shape until many months after surgery, depending upon the type of nasal skin you have. It will probably look better than prior to the operation within two or three weeks, but the final result takes longer. Be patient. Occasionally, an injection is necessary to reduce the swelling in one area. Any touch up surgery that may be necessary is not preformed for at least six months.

WHAT TO EXPECT FOLLOWING NASAL SURGERY

Certain physical changes are expected following nasal surgery. Some individuals experience all of the following and others only some. The degree to which each person is affected is variable and unpredictable. You may experience changes that are not included in this list.

Bleeding

Bloody drainage is common in the first 48 hours after surgery. Blood-tinged nasal discharge may persist for 1-2 weeks following surgery. Profuse bleeding is unusual. Should this occur, pinch your nostrils together firmly for 10 minutes without interruptions. If this does not stop the bleeding, call our office immediately.

Swelling

Nasal swelling is expected and may not be readily noticeable until after the splint is removed. Most of the swelling subsides in 4-6 weeks, but subtle swelling may persist for 6-12 months. In certain situations, the doctor may inject a small amount of steroid into your nose to help reduce the swelling.

Bruising

Bruises following nasal surgery usually manifests as "black eyes". Most bruising will resolve in 2-3 weeks and may be concealed with makeup if desired.

Breathing

Nasal breathing may be difficult for 2-3 weeks after surgery due to swelling inside the nose. This "stuffiness" will subside gradually and IS NOT improved with nasal sprays. Decongestive nasal sprays may actually cause damage to the nose and impair healing.

Discharge

As noted above, blood-tinged nasal discharge is common following surgery and may persists for 1-2 weeks.

Itching/Numbness

Itching, numbness and a "wooden feeling" to the nose are common. All of these do subside, although, it may take months for your nose to feel completely "normal".




Caution:  Some of the rhinoplasty medical photographs that you will view in this section are graphic in nature.

Figure 1	Figure 2
Figure 3	Figure 4
Figure 5	Figure 6a Before
Figure 6b After	Figure 7a Pre-operative
Figure 7b Post-operative view	Figure 8a Pre-operative view
Figure 8b Post-operative view following dorsal augmentation with Goretex and crushed cartilage and tip deprojection	Figure 9a Basal View - Before
Figure 9b Basal View - After, following reconstruction	Figure 10a Basal View - Before
Figure 10b Basal View - After Post-operative view following bilateral lateral crural strut reconstruction.	Figure 11a Before
Figure 11b Post-operative view following tip reconstruction.	Figure 12a Before
Figure 12b After	Figure 13
Figure 14a	Figure 14b
Figure 14c	Figure 14d
Figure 14e Columellar Strut Graft	Figure 14f Shield Graft
Figure 14g Lateral Crural Strut Graft	Figure 14h Alar Batten Grafts
Figure 14i Basal View - Before Lateral Crural Strut Reconstruction	Figure 14j Basal View - After Lateral Crural Strut Reconstruction
Figure 15a	Figure 15b
Figure 15c	Figure 15d
Figure 16a	Figure 16b
Figure 16c Spreader Graft	Figure 16c2 Spreader Graft
Figure 16d Deep Temporalis Fascia
Figure 16e Frontal View - Before	Figure 16f Frontal View - After
Figure 16g Basal View - Before	Figure 16h Basal View - After
Figure 16i Basal View - Intra-op
Figure 17a Composite Graft taken from left ear	Figure 17b Composite Grafts
Figure 17c Graft site stitched together.	Figure 17d Full Thickness Skin Graft inserted into defect
Figure 17e Behind ear where Full Thickness Skin Graft is Taken
Figure 18a Cephalically-oriented Lower Lateral Cartilages with collapsing ala.	Figure 18b Buckled or weak lateral alar cartilage causing external valve collapse.
Figure 18c Lower Lateral Cartilage Release with Columellar Strut	Figure 18d Repositioned Lower Lateral Cartilage with Lateral Crural Strut Grafts.

As a patient, you wonder why this is happening to me. You wonder why do I need a revision rhinoplasty 9 months following my initial surgery. You wonder why everything looked great and the next thing you notice is pinched nostrils and progressive nasal obstruction. Well, you are not alone. Whether it’s the result of aggressive surgery or scar contracture with the healing process, unfortunately this problem is not that rare. Nationally, approximately 5 –12% of patients that undergo rhinoplasty need a revision of some kind, whether it is major or minor. Even in the hands of the best rhinoplasty surgeons across the country, the need for revision sometimes occurs. Without a doubt, revision rhinoplasty surgery is the most challenging procedure that we, Facial Plastic & Reconstructive Surgeons perform.

Perfecting surgery with this three-dimensional structure (the nose) takes years to master and continues to improve. Little did we know that rhinoplasty maneuvers that were used three years ago could cause disastrous results today. Rhinoplasty surgery is forever evolving! My fellowship director, J. Regan Thomas, MD, told me something that I’ll never forget – “you haven’t learned anything about rhinoplasty until you’ve performed at least a thousand procedures and followed them for many years”. This statement epitomizes why fellowships are so valuable. Some of the needed experience and potential pitfalls are circumvented by first hand observing and learning the analysis, judgment, techniques, complication management and most importantly, results from a seasoned rhinoplasty surgeon. This is why I super-specialized in rhinoplasty surgery during my fellowship in Facial Plastic & Reconstructive Surgery. The training catapults you years ahead of many other surgeons that aren’t fortunate to have post-graduate training. Many cosmetic surgeons are taught that aggressive cartilage removal is a procedure of the past. Today’s concept is “less is more”. Less cartilage excision, cartilage repositioning, camouflage techniques, structural grafting and suturing techniques are being taught in most rhinoplasty courses and at our national meetings.

In primary rhinoplasty surgery, the key to preventing complications is the pre-diagnosis of potential anatomical and functional abnormalities. For example, you desire a hump reduction and I identify short nasal bones and a narrow middle vault. My thorough evaluation will warn me that you are at risk for upper lateral cartilage subluxation from the nasal bones (inverted V deformity) (Figure 1) and internal valve collapse. In revision nasal surgery, the previous surgeon missed these telltale potential anatomical abnormalities and now we’re in charge of repairing the complication. We always perform a detailed anatomic and functional evaluation of the nose followed by a diagnosis of the post-operative nasal deformities and/or nasal obstruction. The incidence of post-operative nasal obstruction is approximately 10%¹. After the problems and potential complications are identified, we create a surgical plan while studying the preoperative photographs and prepare to use everything in our surgical armamentarium since we must always prepare for the unexpected.

Below is my algorithm for a revision rhinoplasty consultation, which is approximately 60% of my practice. When the appointment is made, you are asked to bring a copy of your medical records and operative reports from your rhinoplasty surgery or surgeries, in addition to photographs of your nose prior to surgery. If email is an option, we have you send your photos and comments to us before your consultation. Initially, I’ll review your notes and photos while you are discussing surgery with my patient care coordinator, Eve or Sonya. Next, I perform a detailed history while listening very carefully to your desires. I will interpret from our conversation if you have realistic expectations. This is by far one of the most important details that I need to attain from your history. What are you unhappy with – a pinched tip (Figures 2–4) or Polly beak deformity (under-resection of the hump just behind the tip) (Figures 5 and 6a - Before, 6b - After )? My goal is to find out if I can help you and to see if you are a good candidate for revision surgery.

Another important detail is to ascertain if you have nasal obstruction. I will determine if the nasal obstruction was present preoperatively. If the obstruction is a result of the surgery, a number of questions need to be answered. Did you have reductive rhinoplasty surgery? I will have you point out where the obstruction is. Is it static or dynamic? Present with normal or deep inspiration? What alleviates and worsens the nasal obstruction? What are the characteristics of the nasal obstruction? Was septal surgery performed? With these important questions answered I am now ready to perform the physical examination.

For the physical exam, I use a detailed nasal analysis worksheet. I will perform a detailed visual and tactile evaluation of the nose. For the bony dorsum, I will examine the osteotomies, presence of open roof deformity or rocker deformity, and hump under- or over- resection (Figures 7a - Before, 7b - After and 8a - Before, 8b - After). Then I will examine the middle part of your nose, called the middle vault. I will look for middle vault abnormalities such as a narrow middle vault, inverted V deformity or under-resection of the caudal cartilaginous dorsum (Polly beak deformity). For the tip, I will examine tip projection, rotation, support, alar and columellar retraction, over aggressive Weir incisions, and lower lateral crural characteristics such as over-resection, cephalically oriented or bossae formation (Figures 9a - Before & 9b - After, 10a - Before, 10b - After). Over-resection of the lower lateral cartilage complex in patients with a heavy sebaceous skin-soft tissue envelope can cause tip ptosis and nasal obstruction (Figures 11a - Before, 11b - After & 12a - Before, 12b - After ). This problem often occurs in Hispanic, Asian, Middle Eastern and African-American patients. A deviated cartilaginous dorsum and tip can signify a deviated septum. This is only a partial list of anatomical problems that I need to identify in nasal analysis.

For patients with nasal obstruction, I’ll observe you performing normal and deep inspiration on frontal and basal views. Often, the diagnosis is easily identifiable as supra-alar, alar and/or rim collapse or slit-like nostrils during static or dynamic states. External Valve Collapse (lower lateral cartilage pathology) can be evaluated with the soft end of a cotton swab while plugging the contra-lateral nostril. The cotton swab elevates the area of obstruction whether it’s the alar rim, lower lateral crura or supra-alar region. I will see if the nasal obstruction is alleviated by elevating the nasal tip in patients with ptosis of the nasal tip. I will perform the Cottle maneuver (pulling laterally on the cheek) to check for internal valve collapse. Although this test is generally non-specific, internal nasal valve pathology caused by supra-alar pinching or a narrowed angle between the upper lateral cartilage and septum can be diagnosed. On basal view, I’ll examine the medial crura to identify if they are impinging into the nasal airway. Following a thorough external nasal evaluation, I will examine the inside of your nose. I will examine your nose with a nasal speculum and check the nasal septum for perforations, persistent deviation (Figure 13) and for any remaining cartilaginous remnants to be used for grafting. Other causes of nasal obstruction to identify are: hypertrophic inferior turbinates, synechiae (scar bands) between the lateral nasal wall and septum, nasal masses and middle turbinate abnormalities (concha bullosa).

As I'm examining you, I will create a mental list with solutions followed by documentation on your nasal analysis sheet, such as: 1. External valve collapse secondary to over-resected lower lateral crura with a plan of open rhinoplasty with lateral crural strut grafts ( Figure 14a, b, c, d, e, f, g, h, i - Before, j - After ) using conchal (ear) cartilage ( Figure 15a, b, c, d ), Figure 15d shows a post-operative photo of the ear and ear scar after cartilage has been removed, 2. Internal nasal valve collapse secondary to a narrowed middle vault and supra-alar pinching with moderate inspiration with a plan of bilateral spreader grafts ( Figure 16a, b, c, c2) and supra-alar batten grafts using conchal cartilage, and 3. Bilateral alar retraction with a plan of bilateral conchal composite grafts (See Next Section) . If structural grafting is necessary, I will discuss with you what material may be used, such as remaining septal, ear cartilage or alloplastic grafts (Goretex, Porcine skin or Alloderm). If a blanket of tissue is needed to cover the structural grafting, such as a shield graft, or to add a thin layer of dorsal augmentation, deep temporalis fascia (fig 16d) is an excellent tissue that is easily harvested from a small incision made in the hairline.  If ear cartilage is needed, a well-hidden incision is made inside your ear or on the back of your ear with minimal to no post-operative deformities. Before and after photos of frontal views ( Figures 16e- Before, 16f - After )and basal views ( Figures 16g - Before, 16i - Intra-op, 16h - After ), complete internal and external valve reconstruction using bilateral spreader grafts and bilateral lateral strut grafts.

Composite grafts are a combination of skin and cartilage taken from your ear ( Figure 17A) . This graft ( Figure 17B) is then added to the inside of your nose to help correct retracted or notched ala. In simpler terms, the nostrils may pull up following rhinoplasty surgery which will reveal the nostril openings and show too much of your columella. This is a common finding in revision or secondary rhinoplasty surgery. Once the graft is taken from the ear, either the defect (area where the skin/cartilage has been removed) is stitched together (Figure 17C), or in some cases a piece of skin (Full Thickness Skin Graft) is taken from behind your ear and then placed in the defect ( Figure 17D) where your composite graft was removed. This usually heals with minimal to no visible scar ( Figure 17E) . The grafts are inserted into the nostril and with time, will heal and become part of your ala/nostril. Occasionally, the grafts can become swollen up to approximately 3 months and there is a small risk that the graft will not survive for one reason or another.

Prior to undergoing rhinoplasty, the orientation of the lower lateral cartilage has to be examined to determine if it's cephalically- or vertically-positioned ( Figure 18A ). This is often called a parenthesis deformity. The tip cartilage is directed towards the inside corner of the eye instead of the more natural position towards the outer corner of the eye. This malpositioning doesn't give enough support for the ala which can cause buckling or pinching of the ala ( Figure 18B ) which may lead to nasal obstruction. If tip cartilage is removed in rhinoplasty surgery with a parenthesis deformity, the tip will lose its natural contour and the nostrils will probably collapse and cause nasal obstruction. To prevent these problems, the tip cartilage has to be released ( Figure 18C ) and then repositioned ( Figure 18D ) to a more horizontal position and reinforced with lateral crural strut grafts.

This is only my initial plan as I’m creating your algorithm for surgery. Guaranteed, it will change as we get closer to surgery. Photo imaging is usually performed which can be extremely useful if you understand that the final image is NOT A GUARANTEE of results. Occasionally, I can identify if you have unrealistic expectations when a conservative image is generated by me and you desire a radical change. If this is the case, I’ll discuss this issue with you and explain why your thoughts may be considered unrealistic. Finally, I will use the computer image as a goal in surgery. Often times, patients will bring photos (models, movie stars, etc.) of what they feel their nose should look like. My goal is to take what you have and make a moderate, and sometimes, significant difference in the appearance and function of your nose, creating an aesthetically pleasing, natural nose.

Following surgery, the majority of patients have minimal pain. I will ask you to clean your incisions and the inside of your nose approximately twice a day. You will be instructed to spray salt water (saline) into your nose with a spray bottle and a baby bulb syringe. Your cast and the stitches will be removed in one week (assuming that you are having an open revision rhinoplasty). For the second week, your nose will be taped. Following the second week, if needed, I will instruct you on how to tape your nose nightly to help reduce the swelling. The most important attribute that you, the patient, can possess following revision nasal surgery is PATIENCE. It may well take one year for the swelling to completely resolve. I can promise you that I will do the best job possible to improve the health of your nose and your spirit.

¹Beekhuis GJ: Nasal obstruction after rhinoplasty: Etiology, and techniques for correction. Laryngoscope 86:540, 1976.

Paul S. Nassif, M.D., F.A.C.S. is a world-renowned facial plastic and reconstructive surgeon whose work has been featured on numerous international and national television and print media. He has been featured on such programs as NBC World Nightly News with Tom Brokaw, ABC World News Tonight with Peter Jennings, CBS’ The Early Show, CNN, MSNBC, E!, EXTRA!, VH1, BBC, The Learning Channel and Discovery Health. Dr. Nassif has also been quoted in such publications as the New York Times, Associated Press (world-wide), The Wall Street Journal, USA Today, and Los Angeles Times among others. For a complete list of his media work, go to the Media section.

Beverly Hills rhinoplasty and Los Angeles nose jobs.