By its very nature, Rhinoplasty is one of the most personal of Plastic Surgical procedures. Many people define the way they look and reflect their ethnicity on their noses and any changes anticipated must be fully discussed pre-operatively. To do this the patient must have a firm and unwavering commitment to facial change as well as an honest and realistic expectation about the nose they wish to have. This may start with a look through today’s fashion magazines to see what the “beautiful people” look like. While it is rarely possible to recreate another’s nose, it does provide a starting point and does give the Plastic Surgeon a general idea of what the patient wants. The process can then begin to alter the patient’s expectations to something nearer to reality. Every patient should expect to have a more attractive nose that also breathes well, but not every patient can have the perfect little turned-up nose seen in so many of our current movie actresses. Once the Plastic Surgeon gets a general idea of what the patient desires, then he/she can begin discussion of the details of the operation and what may or may not be possible. During this part of the consultation, drawing expected results on the pre-operative photos or utilizing computer imaging is essential. The only caveat regarding computer imaging is that it is always better if the operating surgeon does the imaging so that the imaged results are as close to realistic as possible.
Explaining the details of the procedure is important as the possibility of complications is hidden in these details. For instance, describing a dorsal hump reduction should lead to the possibility of a small elevation at the bone-cartilage junction and in large reductions leads to a discussion of osteotomies and supra-tip problems. We usually perform a septoplasty as straightening the outside of the nose can incur septal deviations that cause breathing difficulties if no septoplasty is performed. Additionally, the sub-mucous resection of the septal cartilage can be replaced (banked) for possible future use or used to help define a nasal tip or to open an internal valve or straighten the cartilaginous dorsal septum.
The thickness or thinness of the skin needs to be addressed as each can affect the visualized result; thick skin will camouflage tip contouring while thin skin may show the tip architecture created in the finest detail. Therefore, in a thin skinned patient more discussion of tip detail is crucial. Explaining planes, cartilage breaks, and light reflexes may then become important.
The most important pre-operative information that must be understood clearly by the patient is that it takes at least 6 months and usually up to a year before the final result is realized and that any necessary revisions should wait at least 6 months in most circumstances. It is important to not over-sale the cosmetic rhinoplasty.
From the Plastic Surgeon’s point-of-view, reconstructive and even cosmetic rhinoplasty is challenging and has a “steep learning curve” which means it takes a lot of cases to become facile with the instruments and the operation. I personally was trained by one the best rhinoplasty surgeons ever (see: Rhinoplasty Tetralogy by D. Ralph Millard, Jr., MD). My early practice encompassed a lot of broken noses due to automobile or physical trauma. Then I gained a reputation for cleft lip and palate as well as the most difficult rhinoplasties on infants and children. After 20 years of experience I now only concentrate on teenage and adult cleft lip rhinoplasties, complex rhinoplasty due to trauma and most cosmetic rhinoplasty. After an extensive 26 year experience, I still find rhinoplasty to be the most taxing and the most rewarding operation that I perform.
The use of complimentary or alternative medicines such as those found in herbal or homeopathic preparations has increased from 20% of our patient population to more than 60% of our patients. The fascination of herbals, teas, and homeopathic products exists because people believe these medicines to be “natural” and therefore perceived to be “safe.” Only recently have these products been scrutinized carefully by the medical community to determine how safe they actually are. In preparing for plastic surgery, safety issues are being addressed due to the fact that there are an increasing number of reports describing bleeding
complications due to herbal remedies. We now know the chemistry of most herbals so we can now identify the substances within each herbal preparation that are likely to cause bleeding problems. To date, the only documented sequelae of herbals that effects plastic surgery is the increased risk of peri-operative and post-operative bleeding which usually manifests as more swelling and bruising than one would normally see. In more severe cases, these homeopathic medications may even cause significant bleeding and hematomas.
A partial list of common herbal supplements that are known to cause bleeding problems is provided:
Oil of Wintergreen
Red Chili Pepper
Other dietary supplements known to effect healing or cause bleeding:
Chondroitin & Glucosamine
As a general rule of thumb, any herbal supplement which is known to cause or have any pharmaceutical activity should be discontinued 2 weeks prior to a general anesthetic or outpatient surgery under local or sedation. Since many herbal or homeopathic formulations contain numerous plant extracts, it is best to stop all homeopathic remedies including herbal teas a full 2 weeks before surgery. Patients may renew taking their supplements once uncomplicated healing has progressed for at least one week post-operatively. It is probably in the patient’s best interest to assume all homeopathic supplements have the potential to effect healing and should be discontinued 2 weeks prior to surgery.
There is a certain subset of patients who, by genetics or trauma, will require a true septo-rhinoplasty to correct breathing problems and to straighten an injured nasal pyramid. There is a much larger group of patients who have relatively minor cosmetic nasal problems, usually confined to the tip or the bridge of the nose. It is a well-known that the tip of the nose tends to lose its support as we age causing the nose to tilt over the upper lip and gives the impression of a longer nose. Minor nasal tip cartilage problems can create the impression of a “boxy” tip or even a “pointy” nose. Minor bridge problems can be addressed with small operations.
The use of filler in the nose has only recently become popular. There are a few situations where fillers may improve the nose without surgery. Small discrepancies of the nasal bones usually due to trauma and certain small tip and bridge asymmetries may be improved with the judicious use of fillers. To this point in time the “perfect filler” is still your own fat. Harvested and processed fat is long-lasting and usually does not require secondary procedures.
The nasal refining procedures do not require general anesthesia and are not covered by insurance. These procedures are for refining the nose and as such do not change to overall ethnicity of your nose. Think of your same nose yet more refined, elegant, and at a greatly reduced price. For some people a major nasal reconstruction may be necessary due to trauma, for those who want a completely new nose, or those with significant nasal breathing problems.