What To Ask Before Rhinoplasty

February 21, 2020
Both male and female patients have been highly pleased with their results from Dr. Markey.

The more a patient knows about his or her surgery beforehand, the smoother the recovery afterward.

It is essential that each patient visiting Dr. Markey is able to have all his or her questions answered before deciding to undergo rhinoplasty surgery. The following five questions are a good place to start.

1. Why should I have a rhinoplasty?  

The reasons to undergo a rhinoplasty essentially fall into two camps.  The first reason is “I wish my nose looked differently”.  The second is “I wish I could breathe better”.  These reasons are not mutually exclusive. For example, Dr. Markey would not improve the appearance of a patient’s nose while reducing their ability to breath. Dr. Markey would also never adversely change the appearance of a patient’s nose to help it breath better.  The art of rhinoplasty is all about balance. Every patient should love the way their nose looks, and every patient should be able to easily breathe through their nose.  

Dr. Markey understands that choosing to have a rhinoplasty is a personal decision.  Each person that visits the Facial Plastic & Reconstructive Surgery clinic will have his or her own reasons for seeking surgery.  

Many patients that are hoping to improve the appearance of their nose have one or two specific qualities they hope to change. Many patients have a full or rounded appearance to the dorsum of their nose when viewing it from the side, leading to a “hooked” appearance.  Other patients find the tip of their nose too wide, or bulbous.  Some patients believe the tip of their nose sags downward, especially when smiling.  Still others have a flat appearance and they’re hoping for more definition or to lengthen their nose.  Every reason is slightly different, but the end goal is the same: to create a nose that each patient loves.

2. What’s my recovery after a rhinoplasty like?

The recovery can vary depending on the changes to the nose agreed upon before surgery.  Some patients hoping for more extensive structural changes will require an open rhinoplasty. This involves a narrow incision in the skin between the nostrils, the columella, and usually requires more time to heal.  Other patients will undergo a closed, or endonasal, rhinoplasty.  These patients will often have fewer changes to the nose, and will heal a little faster.

[Read more about Dr. Markey’s rhinoplasty technique here]

Regardless of whether it is closed or open, the recovery involves many similar concepts.  After the surgery, most patients awake with their nose taped with paper tape (with a gentler adhesive for patients with sensitive skin).  Atop this tape is a plastic “cast” that’s used to maintain the nose’s shape while it heals.  This stays in place for 4-9 days after the rhinoplasty, and helps to protect the nose in case it’s accidentally bumped at home after surgery. Patients can also wear their glasses as normal when the cast is in place.

Most patients describe considerable congestion after rhinoplasty.  This may involve the left, right or both nostrils and is a result of normal postoperative swelling within the nose.  Using the salt-water nasal rinses that Dr. Markey will provide can be helpful in keeping the nasal airways open. This lasts for anywhere from 3 days to 2 weeks, depending on the surgery.  When patients breathe through their mouths during this period some dry mouth may be experienced – so it’s good to have some water and oral rinses on hand.

Discomfort after any procedure, on the nose or elsewhere, is not unusual – but most patients don’t describe especially bothersome aches and pains.   Acetaminophen (Tylenol®) and Ibuprofen (Advil®, Motrin®) can be alternated every 3 hours and usually does the trick.  But sometimes Dr. Markey and the Facial Plastic & Reconstructive Surgery office will prescribe a stronger pain medicine like Norco® (hydrocodone-acetaminophen) to manage any additional discomfort.

As soon as the surgery is complete and the tape and “cast” are in place, it’s a team effort with the patient and Dr. Markey vs. the swelling.  Most of the recovery instructions given to each patient (found here and here) are designed to prevent excessive swelling.  Some postoperative swelling is unavoidable.  Just as when you notice swelling after you bump your elbow, swelling is the body’s way of healing.  The only true treatment is time. But Dr. Markey, as detailed in his instructions, has some tricks that can help reduce the swelling and get each patient to the final result faster and safer.  These include icing, keeping the nose elevated at night, reducing strenuous workouts, taking anti-inflammatory medication, applying anti-bruising and swelling topical ointments, rinsing the nose, and massaging the nose once the cast is removed 4-9 days after surgery.  

It varies as to how much time one can expect for the swelling to subside.  During an open rhinoplasty, a good rule of thumb is that your friends and coworkers may notice the swelling for 3 weeks or so after surgery, you may notice the swelling for 2-3 months, and Dr. Markey may notice the swelling for 6-12 months. It’s true –following some surgeries it may take a full year for the nose to completely heal.  However during a closed rhinoplasty the swelling may subside much faster.

Lastly, the incisions required for a rhinoplasty require daily care after surgery. As mentioned, during a closed rhinoplasty these are all hidden inside the nose and during an open rhinoplasty an incision is necessary in the columella.  During the first 3 weeks the wounds need to be cleaned with hydrogen peroxide and ointment should be applied.  After this, the incision needs to be kept out of the sun for 4-6 months and a silicone gel ointment can be applied to hurry up the healing process.

3. What should I do to be prepared for a rhinoplasty?

Dr. Markey and the Facial Plastic & Reconstructive Surgery clinic will ensure that each patient has all the instructions and postoperative medications available prior to the day of surgery.  In the days leading up to the procedure, a few logistical considerations will be helpful to ensure a smooth recovery.   Patients should eat a robust, healthy meal the night before surgery as they cannot eat or drink anything (including water and chewing gum) within 8 hours of the surgery time.  Female patients are asked to not wear makeup to the operating room the day of surgery. Male patients are not required to change their shaving routine before the procedure.  Antibiotics aren’t required prior to surgery, but some patients (especially those that work in the healthcare field) are asked to apply mupirocin (Bactroban®) ointment to their nostrils for three days before surgery.  

Each patient should have hydrogen peroxide, Vaseline® or another petrolatum based ointment, ice packs, pain medicine (Norco®, Tylenol®, ibuprofen), and extra pillows on hand for the days after surgery.  Specific instructions can be found in the rhinoplasty postoperative instructions on the website. Patients need to schedule a ride home for after the procedure.  All patients are given an additional copy of the postoperative instructions and any necessary medications are refilled the day of the procedure.  Most importantly, patients should have their Netflix queue updated and their couch cleared for 2-3 days of downtime after the rhinoplasty.  

4. When should I have a rhinoplasty done?

This answer will vary for each patient.  Younger patients undergoing rhinoplasty that are still in school often opt for the summer months or immediately following the holidays.  Most adult choose a time in which a gap in their work schedule allows adequate recovery time.  Everyone’s schedule will vary, but each patient should choose a time that’s most convenient.  

For children, depending on how necessary the nasal surgery may be, it is often helpful to wait until the child is almost fully grown before opting to perform rhinoplasty.  A good rule of thumb is 14-16 years old for females and 16-18 years old for males.  However if there was a recent nasal injury, or if there is a clear deformity, Dr. Markey may opt to operate on patients younger than these criteria.

For patients undergoing rhinoplasty for nasal obstruction, there may be reason to trial topical and oral medications before proceeding to surgery. Nasal obstruction results from anatomic factors including internal or external valve collapse, septal deviation, enlarged inferior turbinates and/or hypertrophy of the adenoid tonsils.  Nasal congestion is often experienced during a cold, or when exposed to an allergen like dust, pollen, animal dander, along with many others.  If nasal congestion is the chief culprit then using a steroid nasal spray or trying an oral antihistamine medication may be helpful.  However, nasal obstruction won’t often improve with these treatments alone.  Some patient try breathing devices at night, including BreatheRite® strips, nasal cones, or even taping their nose.  If these are ineffective or only partially helpful, surgery may be the best best.  Time alone will not improve obstructed nasal breathing.  

5. How is the rhinoplasty performed?

As mentioned, the two major types of rhinoplasty are closed and open.  Closed rhinoplasty is performed often for functional cases (to alleviate nasal obstruction), to improve any deviation in the upper two-thirds of the nasal anatomy, and for some cosmetic cases where the nasal tip requires little adjustment.  This is performed by making targeted incisions inside the nose.  These incisions allow for Dr. Markey to carefully remove deviated cartilage from the upper and lower lateral cartilages and the septal cartilage and to add cartilage to areas that are deficient. The closed technique usually allows for faster healing times and avoids an incision on the outside of the nose.

The open rhinoplasty technique provides Dr. Markey with the ability to clearly see the cartilage that defines the shape of the nose.  This technique involves the narrow incision described earlier and then the underlying tissues are gently lifted off of the cartilage and nasal bones below.  Dr. Markey is then able to make fine adjustments to these cartilages to narrow the tip, smooth a large and rounded dorsum, lengthen or shorten the nose, bring the tip further or closer from the face, and a variety of other changes to the nasal shape.  This approach is necessary when the patient has a drastic deviation from the midline or desires subtle cosmetic changes to the nasal tip.  The open approach usually requires some additional time for the swelling to completely subside.  However the incision normally heals imperceptibly with time, and final result enjoys a high rate of patient satisfaction.  

Regardless of the approach, the goal of surgery is to achieve a symmetric, appealing nose that breathes without difficulty.