Rhinoplasty, which is cosmetic plastic surgery of the nose, has long been staple in Hollywood.
The reason is that Hollywood thrives on showing the world beautiful faces and it is impossible to have a truly beautiful face without a satisfactorily-shaped nose.

Some people are lucky and are born with a nose that is proportional and is pleasing to the eye.  Elizabeth Taylor comes to mind.  Likewise Grace Kelly and Catherine Deneuve. 

Those who have not had luck on their side with respect to receiving a “good nose”, have always had the option of having the rhinoplasty surgery. Of all the procedures that a younger person can do to improve their appearance, rhinoplasty ranks number one.  It is more important and more commonly requested than chin augmentation or blepharoplasty.

Remember, also, that many people have the rhinoplasty surgery at the same time as they have nasal septoplasty and turbinate resection to improve the airway or correct a sinus problem. This “double need” is more common in men than women, of course.

Marilyn Monroe had rhinoplasty.  Comedian Milton Berle and actor Dean Martin also had rhinoplasty.  

Years ago when I was researching for my book, Secrets of a Beverly Hills Cosmetic Surgeon, I visisted a photo archives facility in Venice, California.  It was fascinating to leaf through the drawers and recognize that many familiar faces had indeed had rhinoplasty surgery at some point in their life. 

Incidentally, some people go to great lengths to conceal the fact that they are having such surgery.  If you ever saw Barbara Streisand in the movie Funny Girl, you would know that it was the story of comedienne Fanny Brice.   In the 1930s, Fanny had a rhinoplasty performed in a hotel suite.  She felt that was the best way of keeping it a secret.

Today, rhinoplasties are not performed in hotel suites and, frankly, they are rarely performed in hospitals.  It is appropriate to perform such a procedure in a credentialed outpatient surgery center or a duly qualified physician’s office surgical suite. 

I have been thinking a lot about men’s rhinoplasty or cosmetic plastic surgery of the nose, the last several days.  In the last two days we performed nasal cosmetic and reconstructive surgery on two gentlemen.

The first was a middle-aged businessman who had difficulty breathing, but who also was motivated by the fact that he felt his “nose was growing”.   The nose, in fact, doesn’t grow, but the tissues within the nose, the loosen, the tip drops and the nose appears more bulbous and longer.  The gentleman’s motivation for that cosmetic enhancement was proper.  Likewise, the desire to breathe was very reasonable and the patient’s deviated septum and enlarged turbinates were causing blockage such that snoring and poor sleep quality was the result.  So it all made sense. 

In the case of that middle-aged gentleman it was very important to fully understand the man’s wishes.  He expressed on several consultation visits the need to have a natural looking nose that would not look artificial, “done” or drastically different from that which his face had carried for many years.  A surgeon needs to listen carefully to these words and understand the mission.  Any miscommunication could result in an unsatisfactory result and an unhappy patient.  That is not what a conscientious and competent cosmetic facial surgeon wants.

The second nasal case involved a young man who had had two prior nasal surgeries, one for breathing and one for appearance.  The former, the nasal septoplasty, was accompanied by reduction of the turbinates.  The turbinate reduction was quite satisfactory but the septum was still deviated to one side, meaning he had internal nasal blockage because of the shift of the septum which is the vertical partition that separates the two nasal passages.  Those “ revision septoplasty operations are not easy because typically some of the cartilage has been taken out of the septum and there is quite a bit of scar tissue underneath the internal lining of the nose.  It does call for considerable experience, expertise and judgment.

The young man’s other wish was to have his nose appear less long.  Indeed the nose was too long for his face and, as he ages, the length would have only increased.  Apparently the original operating surgeon did not heed the patient’s advice and the result did not match the patient’s wishes.

At this young man’s surgery, very conservative elevation of the nose was done such that it no longer looked too long as if it would touch his lip when he smiled.  And indeed, regarding smile, part of the problem was that he had a very strong muscle which, upon smiling, would depress the tip of the nose further.  The breathing problem was corrected by straightening the septum and some other relatively routine internal procedures, and we were able to lift the nose off the lip, release the muscle which had been exerting its downward force on the lip and give him a natural looking nose which was not radically different from what he had before. But certainly better and in keeping with his desires.

It is very important for surgeons to listen to patients, to get a good sense of what they want.  Also, in my opinion, it’s important have computer imaging available so that the perspective patients can see the predicted results of the procedure that the surgeon deems achievable and reasonable.  A meeting of the minds should take place at the computer imaging session such that the patient and the doctor are on the same page based on that computer visualization of the end result of the cosmetic rhinoplasty.

We have used computer imaging in our practice since 1989. It is helpful and important to patients who need the comfort of seeing the projected outcome.

Consulting Affirmed

We have been big fans of consulting with patients long distance by using Skype.  We have used it to consult with patients both in the United States and overseas.  It gives us a chance to get a good sense of the patient’s request and problem if a new patient and also the ability to follow the progress of our postoperative patients. 

There was an article in The New York Times on Sunday, May 30, entitled, The Doctor Will See You Now, Please Log On.

The article discussed the advances in technology and the increasing popularity of what has now been labeled “telemedicine.”  The paper noted “spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry.”

The article further stated “the technology has improved to the point where the experience of both the doctor and the patient are close to the same as in-person visits and in some cases better.”

I don’t agree with that statement because nothing beats a face-to-face meeting.  However, we have to accept some imperfections in indirect communication. If we do not have the chance to see the patient in the office to look, to feel and evaluate, certainly consultation via Skype is a second best.

The article brought to my mind the fact that three days prior to this article, on Thursday, May 27, we operated on a 15-year-old girl who came to us from Texas to have both rhinoplasty and functional nasal surgery including septoplasty and turbinate resection.  She also had placement of our post-operative nasal airway system to ensure breathing post-operatively. 

We had originally been contacted by the patient after she had visited our web site to learn more about the nasal surgery.  Following exchange of e-mails and phone conversations with our patient consultant, a Skype consultation was arranged. We had a good session the teen and her mother.  We also had the opportunity to provide, for the patient’s benefit, computer imaging to show the predicted result of the surgery since the patient was able to supply us with digital front and profile photos.

That Skype consultation went into very deep detail as much as we would in the office with regard to the patient history including the difficulty breathing, clogged ears and some of the medical issues.  We always ask about allergies, medications being taken, past history, so there is no short-cutting in the history and there is no reason not to address all issues past and present.  The only faculty we don’t have available is touch. 

Based on our long-distance consultation, computer imaging and Skype session, the patient came here prepared for surgery.  Her history and physical and all laboratories were done at home in Texas and she arrived the day before.

At the “pre-surgery” visit, I had a chance to examine the patient’s nasal airway and affirm that which I had learned from the history and also from reviewing the x-rays that were taken of the nasal passages and sinuses in her home town.   I also took further digital photographs that I could use to study before surgery and all questions were answered that had been posed by the patient and her mother.

As is routine for all our patients, whether local or national or international, all arrangements had been made for the patient to have her post-operative medications filled by our local pharmacy.  The patient’s post-operative kit was at hand so that she could start some of the medications that night prior to surgery.  The office had also assisted the patient’s mom in making hotel arrangements.

Certainly, technology is giving us a leg up on better pre and post-operative care and allows patients from afar to make contact with us and have meaningful conversations and consultations from nearly anywhere in the world. 

Blocked air passages are extremely common.  Common causes include deviated septum, nasal allergy, enlarged turbinates (turbinates are normal, shelf-like structures within the nasal passages).  Some blocked noses are permanent due to abnormal architecture.  For example, after a broken nose, the bones and cartilages may be shifted out of position and, therefore, compromise the airway.

Sometimes nasal blockage is temporary such as during a common cold or an allergy attack.

Regardless of whether the problem is intermittent or constant or whether or not it is caused by allergy or architectural issues, blocked noses can be helped.  For nearly 100 years, a very successful operation has been performed totally within the nasal interior to straighten the deviated septum which is the most prominent player in causing the blockage and reducing the size of enlarged turbinates. 

Internal nasal surgery to correct a deviated septum is called septoplasty.  The root words are “septum” which means partition and “plasty” which means changing form or shape.

The object of a nasal septoplasty is to correct a deformed, crooked or perhaps broken nasal septum which is blocking the airway.  The end game is to make it straighter with fewer curves, baffles, angles, all of which contribute to blocking the airflow. 

It takes considerable skill and dexterity to do an operation entirely through the nostrils.  One has to conduct the operation with the same steps that are done in any operation:  There is an incision, there is work that has to be done, then the wound has to be closed and stitches placed to assure satisfactory healing.  Yet all this must be done through the nostrils; as if the surgeon is operating through a keyhole.  Often the nasal septoplasty is accompanied by reduction of the turbinates.  The turbinates, numbering three within each nasal passage, add to the surface area of the nasal interior and, therefore, multiply the humidification, purification, and warming functions of the inside of the nose.  Some turbinates become too large, particularly the inferior turbinate, or lowest turbinate, and when the turbinate becomes enlarged from allergy or even other unknown stimuli, it is necessary to reduce the size.  This can be done by many means, including standard surgical excision or laser treatment or other means to reduce the bulk. 

Since airflow through the nose is related to the fourth power of the radius of the air passage (Poiseuille’s law, well known to students of physics), a slight increase in the functional diameter of the nose by relieving the blockages yields a huge differential increase in air flow.

It behooves the patient who is consulting for cosmetic nasal surgery to ask the surgeon to evaluate the breathing.  It makes sense to correct the blocked nose at the same time that one is having cosmetic nasal surgery or rhinoplasty.   Why not have two operations at the same sitting with one anesthetic and have the economy of one recovery period and, often, you can save considerable money since the second and third procedures when added on to the primary procedure are generally significantly discounted by the surgeon’s office.

Unfortunately, the sinuses are the much maligned and much blamed subjects of advertisements for decongestant and allergic nose sprays, pills and an assortment of over-the-counter medications.  The reality is that the sinuses are dependent on the nose function. They need to be filled with air that flows into them from the nose. So it is the nose that really deserves our attention.  Consider the sinuses as anterooms that sit astride the nasal passage as a hallway.  You cannot get into your room if the hallway is blocked.   So if the nasal passages are blocked, you cannot expect the sinuses to function normally.

What happens in the case of abnormal nasal architecture such as the presence of a deviated septum (the vertical partition that separates the right and left nasal passage) is that the airflow is inadequate.  When the airflow is inadequate, then the sinuses do not aerate properly.  They may begin to fill with fluid and ultimately cause symptoms.  The symptoms of true sinus infections are hard to ignore:  headache or facial and tooth pain.  The signs are thick and often pus-like drainage from the nose into the throat. Sometimes bleeding.  Patients have a temperature and even nausea and vomiting. A sickness far worse than a “head cold”.

The best way to keep the sinuses healthy and out of trouble is to not smoke and make sure that your air passages are functioning well.  This calls for an examination by a specialist.  It may be that only allergies need treatment with a prescription steroid or cortisone nasal spray.  But for some patients, surgery is necessary.  The surgery takes less than an hour, has been done for over 100 years and is very well established.  The definitive operation is nasal septoplasty to correct the deviated, crooked or broken nasal septum as well as trimming of the inferior turbinates which are normal outpouchings inside the nasal cavity subject to enlargement either from allergy or other stimulations.

Finally, when patients tell me that they have “three to four sinus infections every year” I know they need help. That is not a normal condition.  True sinus infections should be very rare.

There are some people who almost have no need for their nose.  They are not using it to breathe.  But if so, something is wrong.  Nature gave us a nose for a reason.  We are not supposed to bring air into our bodies through the mouth; the nose is the preferred route.  Long ago, it was established in laboratory experiments, that lung function improves when the air is delivered to the lungs through the nose rather than through the mouth. 

So what are the reasons for this complete nose blockage?  There are a limited number of reasons why the nose does not allow enough air through it.  The first is that the passages are blocked from a previous injury.  When the nose is injured, the support structures cave in, become crooked and become an impediment to airflow. The nasal septum is broken, crooked, deviated. Often the injuries occur when we are young and so the adult patient has no knowledge of “normal breathing.”  They have only known complete nasal obstruction.

Another common reason is nasal allergy, particularly when it is superimposed upon an architectural deformity such as uncorrected broken nose.  The lining of the nose is very sensitive to certain allergens in the air.  For some people in springtime it is grass and trees.  For others it is indoor mold.   Others have very specific sensitivity to ragweed pollen which only grows in certain parts of the country.  But whatever the offending allergens, the nose blocks up because the lining swells.  Two normal structures within the nasal passages called the inferior turbinates are particularly subject to this.   The two inferior turbinates are larger than the four other turbinates can expand to nearly twice normal size.  Such a blockage within the nasal passages has dire consequences for breathing.

If you combine a deviated nasal septum as part of an uncorrected nasal fracture or just because one was born with it, with nasal allergies causing swelling of the lining and particularly thickening of the inferior turbinates, you have the setting for very poor breathing.

There is good new about this sad story, however.  Modern techniques of surgical correction sometimes in concert with certain simple medications can make a huge difference.  One of the most rewarding things for a surgeon is to give a patient his breathing back.  And, incidentally, when you give the breathing back, you also give the sense of smell back.  Because if air does not enter the nose, the smell receptors high in the nasal passages are not activated and the sense of smell is non-functional.  People think that taste comes from the tongue in the mouth but the reality is that the tongue has very primitive sensors that detect only salt, sweet and bitter.  But the actual aroma of food, for example, comes when air passes through the nose and stimulates the olfactory nerve which carries the sensation of smell to the brain.  Now you know why “food does not taste very good” when you have a cold.  Colds are temporary.  Think about those people who have permanent blockage and never have the pleasure of smelling a blooming rose or even a great dinner dish.

I am hearing some amazing stories from patients. While we always learn from listening to our patients, I am not only learning but becoming a bit dismayed with respect to what I am hearing about nasal cosmetic plastic surgery. Patients report operations taking three, four and even five hours that ultimately were unsatisfactory for the patient. It seems the operations become longer as more grafting and transplantation of tissue takes place. Now certainly there are indications for adding on tissue into the nose, particularly if there has been previous surgery or if there has been an accident that has destroyed some of the tissue. But, even if that is the case, why are these operations taking so long? I am not sure of the answer, except, my sense is that some surgeons are making the operation much more complicated and complex than need be. For many of the grafting or transplanting needs, there is adequate tissue inside the nose itself. This of course makes it very economical and efficient to be able to harvest the tissue since it is coming right from the area that we are working on. Often, we use cartilage and bone from the nasal septum because we are taking it out anyway to correct the deviated nasal septum and improve the airway, and correct problems that might lead to sinusitis and other serious complications. While only very rarely is it necessary to take cartilage from the ear, I am now hearing stories of almost routine harvesting of rib cartilage and even rib bone to be place inside the nose, and of course, that makes for a very involved, complicated and long duration operation since other surgical sites besides the nose must be operated upon. I guess I am just from the old school. We do nearly all our surgeries from inside the nose using completely hidden incisions, closed with absorbable stitches. That is called a “closed rhinoplasty“. The “open rhinoplasty” requires an external incision, and I just don’t see the need for that very often. And I have done over 4,000 cases in my career which now spans nearly forty years. The other issue is that some surgeons are not efficient. It just takes them too long to get the job done. I would attribute that to less-than-optimal training in the residency programs as well as inexperience. Generally, inexperienced surgeons are slower than veteran surgeons. The “occasional nasal surgeon”, the doctor who spends more time doing other cosmetic plastic surgeries such as breast augmentation, tummy tuck, breast reduction and liposuction just doesn’t develop the facility for rhinoplasty because he doesn’t operate on the nose often enough. He cannot become a master nasal surgeon. In my experience, most cosmetic nasal surgery or rhinoplasty procedures could be done within an hour. If you need to add on the functional or breathing operation, that adds another 20-30 minutes. The total time in the operating room, including going to sleep and waking up from the anesthetic, should rarely be more than two hours.

The recession has affected nearly every business, industry and profession in the United States – including Beverly Hills.  While Beverly Hills remains a cosmetic plastic surgery destination for many people from the United States and throughout the world, the reality is that in a recessionary environment, fees are reduced.

However, it is important to understand that a low fee by itself should not be the decision-making factor when considering having cosmetic plastic nasal surgery.  The price range of rhinoplasty encompasses both the less experienced, younger practitioners and the veteran superstars and super specialists of the cosmetic surgery world.

 It is accepted that young doctors, eager to build their practices will charge less for their services and hope to attract patients in that manner.  For patients, there sit risks.  Because, often, the younger surgeons do not have the talent and long line of experience to handle anything but the most simple case.
But, few nasal plastic surgery cases are simple. Often, there are breathing or sinus problems that should be corrected. Nasal septoplasty and turbinate resection to improve the airway should be considered in such cases. Does the young surgeon have the training, talent and experience to handle all those issues?

 The reality is that rhinoplasty fees in Beverly Hills may be higher than they are in Omaha, Nebraska or Oshkosh, Wisconsin, but of course, that reflects the cost of doing business including rent, salaries, etc.

One should always inquire from the office as to what the cost of the rhinoplasty is and to ask if, in fact, there are some ways to be granted a courtesy.  Don’t expect to get a courtesy reduction in the fee just for asking, however, because that is not likely.  What will help you get a reduction in the fee is being able to schedule your case at the time that is convenient for the outpatient surgery center and the surgeon’s office.  That is the most common and proper reason for fees to be reduced.

Remember that rhinoplasty prices also reflect the complexity of the case and the time involved in performing the surgery. Particularly, if you need revision rhinoplasty in addition to that septoplasty and turbinate resection to help you breather, the fee will be higher than that for just shaving a bulbous tip.

                     – patient consulting for nasal cosmetic plastic surgery

This is a very important statement. If a prospective patient believes that the majority of patients who have cosmetic nasal surgery are likely to wind up with breathing problems, then our specialty has a problem.

Difficulty breathing after rhinoplasty should not necessarily occur. The competent cosmetic plastic nasal surgeons are trained in the evaluation of the internal nasal structure and the correction thereof.  They need to know if there is a breathing problem before any surgery.  Often, patients are not even aware they have a breathing problem.  It is very easy to check because you ask the patient to close one nostril and with lips closed breathe through their right nostril and then shift the focus to the left nostril as the right nostril is closed.  Very quickly, one gets the airflow picture.

Once the diagnosis of airway obstruction is established, it is incumbent upon the operating surgeon to figure out why.   The most common reasons are that there is a deviated septum which is a crookedness of the internal vertical partition that separates the two nasal passages.  For many patients, particularly those with allergies, there is also the issue of enlarged turbinates, particularly the inferior turbinate.  Turbinates are the three shelf-like extensions that fill a portion of the nasal passages, on each side, to increase the surface area so there is further warmth, humidification and filtering of the incoming air in preparation for inhalation into the lungs. 

If the surgeon diagnoses a breathing problem or such borderline breathing that it is possible that narrowing of the nose as a result of the cosmetic nasal plastic surgery, or rhinoplasty, might throw the patient’s breathing over the edge, it is incumbent upon that surgeon to plan to deal with the blockage and correct it.

My sense is that perhaps a fair number of surgeons who are willing to take on rhinoplasty cases may not be trained in the functional and reconstructive surgery. 

If the doctor’s ego will allow it, when facing an airway problem that he feels he cannot address, the doctor can always call in a consulting surgeon with the “inside” skills to perform that portion of the operation.  After all, it is not unique to cosmetic and reconstructive nasal plastic surgery to have a team instead of a solo surgeon.  It certainly occurs in heart surgery and liver and kidney transplants, etc. It is all for the patient’s benefit.

The recent edition of The New York Times happened to address that very issue whereby some surgeons conceded that it is “normal” to have a breathing problem after some cosmetic nasal surgeries.  I think that is a very damning comment and represents a lack of concern for the patient’s interest.  Steps must be taken to correct the breathing problem at the same time as the cosmetic plastic nasal surgery.