Rhinoplasty is the science & art of Aesthetic Nasal Surgery, which remains the most popular cosmetic surgery across all cultures, races, sexes and ages. The history of nasal surgery dates back thousands of years to ancient India where the skillful and compassionate surgeon, Sushruta, devised “cutting edge techniques” using forehead tissue as a “flap” to reconstruct women’s noses that had been cut off as a sign and punishment for adultery! We have fortunately come a long way since those cruel and inhumane times. However some of the techniques used and described by those pioneering ancient reconstructive surgeons are still valid and used today for reconstruction of the nose after trauma, cancer or dog bite injuries. In fact, slight modifications of these ancient techniques gave rise to the Para-median Forehead Flap, which is the cornerstone of all significant nasal reconstruction.
History of Rhinoplasty
The history of Plastic Surgery and its milestones are tightly interwoven with the history and progress in Rhinoplasty. In the 16th century, the Italian surgeon, Gasparo Tagliacozzi, who is considered by most as one of the forefathers of Plastic Surgery, devised a clever “flap” using skin from the arm of a patient to reconstruct the nose by attaching the arm to the nose for a period of time until the arm skin developed its own blood supply from the nose. Although by today’s standards, such a procedure seems gross and primitive, this concept of a “distal flap” is one of the cornerstones of modern reconstructive techniques for very large total nasal defects using methods such as a “Radial Forearm Flap.”
The father of modern Plastic Surgery, John Orlando Roe, who was an Otolaryngologist (ENT) from Rochester, New York, is accurately given credit for performing the first endonasal or “closed” Rhinoplasty and for being the father of aesthetic Rhinoplasty. Later on Jacques Joseph, from Berlin, used this technique to help a young man who was so embarrassed by his overly large nose that he had avoided appearing in public.
During the “taboo period” of plastic surgery when the field was seen as superfluous and was not taken seriously by most surgeons, cosmetic surgery and Rhinoplasty where merely available to the select few of wealth and advantage. However, today more than ever before in history, cosmetic surgery is in the spotlight. It has gained wide acceptance as a valid field of medicine and the rewards of self-improvement, and increased self-confidence, and wellbeing are available for the first time to the general public.
This new “birth” of cosmetic surgery has also resulted in a “flooding” of the market by devices, procedures, and promises that are not always grounded in science and medicine but more so in “marketing” and “hype.” Plastic Surgery is being “sold” today in an alarming rate to the public, in the media and in cosmetic surgeons’ offices.
Fortunately, the field of Rhinoplasty and aesthetic surgery of the nose has by enlarge been shielded from such hype and exposure; (with the few exceptions of the doctors offering “no-downtime-rhinoplasty” by injecting fillers like Radiesse into the nasal bridge in order to create a straighter profile). Overall, Rhinoplasty has evolved properly and stepwise over the last several hundred years into the safe, effective and impressive surgery that it is today when performed by the true “Rhinoplastic surgeon.”
Rhinoplasty is widely considered by all kinds of surgeons to be the most difficult of all surgeries. Hence, the Rhinoplastic Surgeon is considered to be the most meticulous, skilled and exquisite of all plastic surgeons. Aesthetic surgery of the nose is a three dimensional operation of millimeters. The successful Rhinoplasty requires skill, artistry and a complete understand of the nose, its architecture, as well as its functional physiology.
Trust a Facial Plastic Surgeon
Facial Plastic Surgeons who by training are specialists of the nose are inherently better equipped to deal with these issues. The five to six years of surgical training focusing specifically on the face and nose results in unparalleled skill and expertise.
Dr. Naderi, belongs to an even more sought after and specialized group of Facial Plastic Surgeons with specific training and expertise in Revision Rhinoplasty or Secondary Rhinoplasty. Dr. Naderi spends a large portion of his time correcting the work done by other plastic surgeons. Some of his patients may have had 2 to 6 unsatisfactory surgeries before being referred to him for help. He has authored chapters on this topic in major medical text books used by other surgeons around the world. Dr. Naderi has held a position at Indiana University School of Medicine as a Clinical Assistant Professor of Facial Plastic Surgery where he has taught many surgical residents the proper techniques of Rhinoplasty for both aesthetic and functional purposes. Furthermore, Virginia Plastic Surgeons quite often refer their “tough noses” to Dr. Naderi, favoring his expertise and skills.
As the centerpiece of the face, the nose can draw significant attention to itself. Given all the intricacies of Rhinoplasty and Revision Rhinoplasty and the skill and experience required, you can rest assured with Dr. Naderi’s unrivalled expertise in the greater Washington D.C. and Northern Virginia area.
Dr. Naderi takes the time to go over all of your options with the aid of the cutting edge “digital computer imaging” to show you what you may look like after surgery. He confidently encourages all his patients to seek several other surgeon’s opinions so they can feel totally comfortable with their ultimate decision to undergo Rhinoplasty or Revision Rhinoplasty as well as with their choice of surgeon.
Patients who choose Dr. Naderi as their Rhinoplasty Specialist Surgeon do so based on the carefully calculated decision and wise desire to trust a “specialist” with their face and nose. Dr. Naderi is a Board Certified Facial Plastic Surgeon (exclusively performs Plastic Surgery on the face only) but above and beyond this, his busy surgical practice is focused practically completely on the nose (Rhinoplasty and Revision Rhinoplasty). Patients who choose Dr. Naderi do not do it based on price. He is not inexpensive! He takes excellent, skillful, artistic, and compassionate care of his patients and their noses. While no one can guarantee a “perfect” nose, his multitude of happy and grateful patients from all over the world are testimony to his skill. Do not choose Dr. Naderi if you are seeking a bargain. Choose Dr. Naderi if you want a surgeon who has the specialized skill and high ethics to take excellent care of you or your loved one.
Cost of Nose Job Surgery
“Average rhinoplasty total price” is around $7,000 to $10,000 with Dr. Naderi. Dr. Naderi’s Primary Rhinoplasty total cost can range from around $4,500 – $10,000 or above, and this price includes the cost of Anesthesia and Hospital Fees. “Average revision rhinoplasty price” is around $10,000-$12,000 with Dr. Naderi. For Revision Rhinoplasty Dr. Naderi’s total cost ranges from around $9500 to $17,000 or above, which includes the cost of Anesthesia and Hospital fees. Effective January 1st 2016 all primary rhinoplasty consult fees are still $100.
Anesthesia Options Virginia
Various types of Anesthesia can be used for rhinoplasty. The most commonly used types of anesthesia for a nasal reshaping operation are General Anesthesia and IV Sedation Anesthesia. Some doctors prefer using Local Anesthesia. All anesthesia forms have risks just like all surgeries have risks but risk is greatly minimized in the proper setting when short-cuts are not taken, and proper equipment and properly trained board certified anesthesiologists are used. Here are the major differences:
- Usually done at hospitals or major surgery centers
- Rhinoplasty patient is totally asleep and feels no pain and has no major memory of rhinoplasty surgery
- Airway is protected with an endotracheal (breathing) tube
- Breathing machine breaths for patient
- Patient must me medically in great shape to tolerate general anesthesia
IV Sedation Anesthesia:
- Also known as “twilight anesthesia”
- There is no breathing tube
- Rhinoplasty Patient breaths on their own
- Tough to control proper sedation level so patient can be “too awake” or “too asleep” which can affect the plastic surgeon’s work
- Patient can move and talk or act inappropriately which can all affect plastic surgeon’s work
- No good way of protecting the airway from blood dripping down the back of the throat onto the airway
Oral Sedation Anesthesia:
- An Oral Sedative like Valium may be used to lightly sedate the patient
- Typically oral sedation is used for minor office procedures like Lip Implants
- With local anesthesia the rhinoplasty patient is totally awake
- Numbing fluid (lidocaine) is injected into the nose to numb the nose
- Numbing fluid is also used with other types of anesthesia but with local anesthesia, the numbing injections are the only method for numbing and pain control
- Relatively safer than other forms of anesthesia but uncomfortable and impractical for most Rhinoplasties.
- Patients can become tired or cramped for during longer cases
- Difficult to numb the nasal bones
Augmentative & Reductive Rhinoplasty Virginia
Rhinoplasty or Nasal Reshaping is not simply a matter of removing cartilage and bone. This was the mistake of the Plastic Surgeons doing Rhinoplasty 20 or 30 years ago, and unfortunately still repeated by some Cosmetic Surgeons today. Rhinoplasty may involve removal of cartilage, bone or nostril skin but may also involve addition of cartilage, bone or fascia. Many times, a Rhinoplasty Specialist will rearrange cartilage during Rhinoplasty or reshape cartilage, using sutures.
However, you can group some nose jobs into #Reductive Rhinoplasty# where the size of the nose needs to be reduced overall. Or a nose job can be classified as an #Augmentative Rhinoplasty# if the size of the nose needs to be increased overall. For example, many Middle Eastern, Jewish, and Mediterranean patients undergo Reductive Rhinoplasty while some Asian patients undergo Augmentative Rhinoplasty.
Best Age for Rhinoplasty
One of the most common questions on the mind of younger patients, their parents as well as much older patients is, “what is the best age for a nose job?”
There is no upper age limit for Rhinoplasty as long as older patients are healthy and in good medical condition for Rhinoplasty. Nose jobs on a patient in his or her 70’s can actually make them look younger by correcting a droopy “ptotic” tip or a “hanging” long nose. Often times a much older Rhinoplasty patient will look more rested and youthful as if they underwent a facelift by just improving their nose. There are plenty of older patients who have wanted a nose job for many years but for one reason or another were not able to accomplish their goals till later in life. These patients are often extremely grateful and appreciative after a successful nasal reshaping by a Rhinoplasty Specialist.
The youngest age for Rhinoplasty is usually 16. Some surgeons will not perform Rhinoplasty on anyone younger than 18 so that the patient can sign the surgery consents as an adult. This approach is not fair to younger patients especially since the typical age for Otoplasty (ear pinning) is around 4 to 6 years of age. What is more important than legal age is mental and physical age. Occasionally on rare instances, a Rhinoplasty Surgeon will consider performing a nose job on a teenager as young as 14 if the patient has essentially completed their physical growth. For example, if the teenage Rhinoplasty patient is 5’3″ tall but both parents are 6 feet tall then more time should be given for the teenage growth spurt and completion of physical development. However, if the teenage nose job patient is relatively the same height as his or her parents, then it may be safe to assume further drastic changes in growth will not occur.
But more important than physical growth and maturity is mental and emotional maturity. While there are some 14 year olds that have the proper attitude and mental outlook towards Rhinoplasty, there are some 40 year olds that do not possess such mental strength and emotional maturity to undergo elective nasal reshaping surgery. We sometimes see teenage nose job patients who are much more mature and realistic than their own parents.
The most important factor with teenage Rhinoplasty is to make sure the desire for changing one’s nose is internally driven and not forced on the teenage patient by the parents. It’s also as important to make sure the patient has realistic goals about the outcome. All things being equal, a successful Rhinoplasty can increase the self-confidence of any patient, especially the teenager who is self-conscience about his or her nose.
Complications in Rhinoplasty Virginia
As in any other surgery, there are risks and possibilities of complications and adverse outcomes after any Rhinoplasty and all prospective patients must be educated on the facts. Risks are minimized if the nasal reshaping surgery is performed by an experienced Plastic Surgeon, in the proper hospital setting, with Board Certified Anesthesiologists, and the patient is relatively healthy, with normal pre-operative work up and lab tests. However, cutting corners to save cost may lead to poor functional and cosmetic outcome or even life threatening complications such as meningitis or death. The old saying of “bargain shop for shoes not for your nose” is wise advice.
The risks must be outweighed against the benefits. This is why a safe and ethical surgeon like Dr. Naderi will tell you that if the goal of improving a certain part of the nose is not at the very least 20% then Rhinoplasty should be avoided. Improving a nose 5% is not worth the risks of any surgery. Put another way, if the area of the nose being addressed will at least improve 20% or more, then the benefits outweigh the risks. Sometime a nose can improve 100% by just improving the bump on the bridge or a bulbous tip and sometimes a nose that has undergone 5 or 6 bad previous rhinoplasties can be improved 100% by revising the entire nose. It’s all about goals and expectations.
Many patients unfortunately think Rhinoplasty is a simple procedure. Many patients think that Rhinoplasty is about simply removing a hump or reducing a “meaty tip” or lifting a droopy tip. While the end result may be just that, the skills required to accomplish that are unrivalled by other specialists in the field of Plastic Surgery. In fact Rhinoplasty is the most complex and intricate of all cosmetic surgeries. There are few other surgeries that affect a 3 dimensional structure (i.e. the nose), or that are performed in a 3 dimensional fashion. There are few surgeries where removing as little as 2mm, or a little over 1/16th of an inch, can result in major cosmetic and/or functional changes. Seldom do other operations’ results change for years to come due to healing and molding of scar tissue. In Rhinoplasty all of these issues must be understood and accounted by the plastic surgeon.
Not a patient of Dr. Naderi. This is a patient of another world famous and well-respected Plastic Surgeon with nose tip necrosis (the skin died off, requiring major reconstruction). Courtesy: www.nosejobgonebad.com
Not a patient of Dr. Naderi. Patient of another plastic surgeon who had an implant in her nose instead of cartilage. Implant got infected. Courtesy: www.plasticsurgerypractice.com
Changing one aspect of the nose will usually change other aspects as well and the skilled Rhinoplasty Specialist Surgeon must be able to diagnose these issues and discuss these with the patient before surgery and be able to diagnose and deal with these issues during surgery. The seemingly “simple hump removal” or “simple Rhinoplasty” can be done in a very elegant and natural fashion with fantastic results, or an unskilled plastic surgeon can end up destroying an otherwise decent nose and creating much more harm than good. We routinely see patients who come in for Revision Rhinoplasty consultations who went elsewhere with noses that were in need of refinement but noses that nevertheless were not terrible by any means, yet an irresponsible cosmetic surgeon took on much more than he or she was capable of handling and ended up ruining the nose and the patient’s life as a result of a bad nose job.
(3-a, b, & c) Pictures of a patient who went to another famous plastic surgeon with poor judgment in rhinoplasty, who over aggressively reduced her nose resulting in extreme deformity. Such gross mistakes should practically never occur in the hands of a skillful Rhinoplasty Specialist.
Yet in the best-case scenario there are still risks that each prospective Rhinoplasty patient must be aware. The most common risks are post-operative nosebleeds, mild infections, and healing asymmetries. To put things in perspective, in our practice, post op nosebleeds occur once every 2-3 years or even less. However, we believe preparing patients for worse case scenarios leads to happier post-op patients who can easily deal with minimal complications should they arise. Thankfully, such complications at The Naderi Center are extremely rare.
Nevertheless, you can read the standard American Society of Plastic Surgery Rhinoplasty Consent Form below, which discusses many of the potential post Rhinoplasty complications that can or have ever occurred anywhere in the world.
Informed Consent: Cosmetic & Functional Nasal Surgery –
(Rhinoplasty; Revision Rhinoplasty; Septoplasty; Turbinate Reduction;
Nasal Trauma Repair)
This is an informed-consent document that has been prepared to help inform you about Cosmetic & Functional Nasal Surgery, its risks, and alternative treatments.
It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your facial plastic surgeon.
Surgery of the nose (Cosmetic & Functional Nasal Surgery) is an operation frequently performed by facial plastic surgeons. This surgical procedure can produce changes in the appearance, structure, and function of the nose. Cosmetic & Functional Nasal Surgery can reduce or increase the size of the nose, change the shape of the tip, narrow the width of the nostrils, or change the angle between the nose and the upper lip. This operation can help correct birth defects, nasal injuries, and help relieve some breathing problems.
There is not a universal type of Cosmetic & Functional Nasal Surgery that will meet the needs of every patient. Cosmetic & Functional Nasal Surgery is customized for each patient, depending on his or her needs. Incisions may be made within the nose or concealed in inconspicuous locations of the nose in the “open” Cosmetic & Functional Nasal Surgery procedure. In some situations, cartilage grafts, taken from within the nose or from other areas of the body (ear, ribs, frozen rib, etc) may be recommended in order to help reshape the structure of the nose. Fascia or Alloderm may also be needed during surgery. Internal nasal surgery to improve nasal breathing can be performed at the time of the Cosmetic Nasal Surgery.
The best candidates for this type of surgery are individuals who are looking for improvement, not perfection, in the appearance and function of their nose. In addition to realistic expectations, good health and psychological stability are important qualities for a patient considering Cosmetic & Functional Nasal Surgery. Cosmetic & Functional Nasal Surgery can be performed in conjunction with other surgeries.
Alternative forms of management consist of not undergoing the Cosmetic & Functional Nasal Surgery. Certain internal nasal airway disorders may not require surgery on the exterior of the nose. Risks and potential complications are associated with alternative surgical forms of treatment. Occasionally fillers may be injected to the nose for a “Non-surgical Rhinoplasty.” Medical management of sinus disorders and allergies may be necessary by your general Otolaryngologist or Primary Care doctor.
RISKS OF COSMETIC & FUNCTIONAL NASAL SURGERY SURGERY
Every surgical procedure involves a certain amount of risk and it is important that you understand these risks and the possible complications associated with them. In addition, every procedure has limitations. An individual’s choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience the following complications, you should discuss each of them with your facial plastic surgeon to make sure you understand the risks, potential complications, and consequences of Cosmetic & Functional Nasal Surgery.
Bleeding- It is possible, though unusual, to experience a bleeding episode during or after surgery. Intra-operative blood transfusions may be required. Should post-operative bleeding occur, it may require an emergency treatment to drain the accumulated blood or blood transfusion. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or after surgery. Accumulations of blood under the skin may delay healing and cause scarring. Do not take any aspirin or anti-inflammatory medications for ten days before or after surgery, as this may increase the risk of bleeding. Non-prescription “herbs” and dietary supplements and drinks can increase the risk of surgical bleeding. Hematoma can occur at any time following injury. If blood transfusions are necessary to treat blood loss, there is the risk of blood-related infections such as hepatitis and HIV (AIDS). Heparin & Coumadin and Plavix medications that are used to prevent blood clots in veins can produce bleeding and decreased blood platelets. Control of bleeding may require packing, cauterization, embolization or further surgical treatments.
Infection- Infection is unusual after surgery. Should an infection occur, additional treatment including antibiotics, hospitalization, or additional surgery may be necessary. Toxic Shock is a very rare type of life threatening infection, usually as a result of Nasal Packing.
Scarring– All surgery creates and leaves scars, some more visible than others. Although good wound healing after a surgical procedure is expected, abnormal scars may occur within the skin and deeper tissues. Your body creates scar tissue. Scars may be unattractive and of different color than the surrounding skin tone. Scar appearance may also vary within the same scar. Scars may be asymmetrical. There is the possibility of visible marks in the skin from sutures. In some cases scars may require surgical revision or treatment. Scars are permanent.
Damage to Deeper Structures- There is the potential for injury to deeper structures including nerves, tear ducts, blood vessels, muscles, brain, and lungs (pneumothorax) during any surgical procedure. The potential for this to occur varies according to the type of Cosmetic & Functional Nasal Surgery procedure being performed. Injury to deeper structures may be temporary or permanent &/or life threatening.
Change in Skin Sensation– It is common to experience diminished (or loss) of skin sensation in areas that have had surgery. There is the potential for permanent numbness within the nasal skin after Cosmetic & Functional Nasal Surgery. The occurrence of this is not predictable. Diminished (or loss) of skin sensation in the nasal area may not totally resolve after Cosmetic & Functional Nasal Surgery.
Asymmetry– The human face is normally asymmetrical. There can be a variation from one side to the other in the results obtained from Cosmetic & Functional Nasal Surgery. Additional surgery may be necessary to attempt to revise asymmetry but perfect symmetry is often unrealistic and impossible. Your body will create scar tissue, which will change the symmetry of the nose with time.
Skin Discoloration / Swelling- Some bruising and swelling normally occurs following Cosmetic & Functional Nasal Surgery. The skin in or near the surgical site can appear either lighter or darker than surrounding skin. Although uncommon, swelling and skin discoloration may persist for long periods of time and, in rare situations, may be permanent.
Seroma– Fluid accumulations infrequently occur in between the skin and the underlying tissues. Should this problem occur, it may require additional procedures for drainage of fluid.
Pain- You will experience pain after your surgery. Pain of varying intensity and duration may occur and persist after Cosmetic & Functional Nasal Surgery. Chronic permanent pain may occur very infrequently from nerves becoming trapped in scar tissue.
Allergic Reactions- In rare cases, local allergies to tape, suture materials and glues, blood products, topical preparations or injected agents have been reported. Serious life threatening systemic reactions including shock (anaphylaxis) may occur to drugs used during surgery and prescription medications. Allergic reactions may require additional treatment.
Delayed Healing– Fracture disruption or delayed wound healing is possible. Some areas of the nose may not heal normally and may take a long time to heal. Areas of skin may die or necrose. This may require frequent dressing changes or further surgery to remove the non-healed tissue. Smokers and Revision patients have a greater risk of skin loss and wound healing complications.
Skin Sensitivity- Itching, tenderness, or exaggerated responses to hot or cold temperatures may occur after surgery. Usually this resolves during healing, but in rare situations it may be chronic.
Nasal Septal Perforation– Infrequently, a hole in the nasal septum will develop. The occurrence of this is rare. Additional surgical treatment may be necessary to repair the nasal septum. In some cases, it may be impossible to correct this complication. Crusting, whistling or nasal collapse may occur with varying side holes.
Nasal Airway Alterations– Changes may occur after a Cosmetic &/or Functional Nasal Surgery that may interfere with normal passage of air through the nose. “Runny nose” or “dry nose” may be a side effect of nasal surgery. Sometimes these problems become psychologically and physically overbearing.
Surgical Anesthesia– Both local and general anesthesia involve risk. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation.
Substance Abuse Disorders– Individuals with substance abuse problems that involve the inhalation of vaso-constrictive drugs such as cocaine or Afrin are at risk for major complications including poor healing and nasal septal perforation.
Skin Contour Irregularities– Contour irregularities may occur. Residual skin irregularities at the ends of the incisions or “dog ears” are always a possibility and may require additional surgery. This may improve with time, or it can be surgically corrected. Occasionally this is permanent.
Sutures– Most surgical techniques use deep sutures. You may notice these sutures after your surgery. Sutures may spontaneously poke through the skin, become visible or produce irritation that requires removal. “Permanent sutures” may need to be removed surgically.
Unsatisfactory Result– Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. You, &/or your friends and family, may be disappointed with the results of your Cosmetic &/or Functional Nasal Surgery. This would include risks such as asymmetry, loss of function, structural malposition, unacceptable visible or tactile deformities, unsatisfactory surgical scar location, poor healing, wound disruption, and loss of sensation. It may be necessary to perform additional surgery to attempt to improve your results.
Shock– In rare circumstances, your surgical procedure can cause severe trauma, particularly when multiple or extensive procedures are performed. Although serious complications are infrequent, infections or excessive fluid loss can lead to severe illness and even death. If surgical shock occurs, hospitalization and additional treatment would be necessary.
Cardiac and Pulmonary Complications- Surgery, especially longer procedures, may be associated with the formation of, or increase in, blood clots in the venous system. Pulmonary complications may occur secondarily to both blood clots (pulmonary emboli), fat deposits (fat emboli) or partial collapse of the lungs after general anesthesia. Pulmonary and fat emboli can be life-threatening or fatal in some circumstances. Air travel, inactivity and other conditions may increase the incidence of blood clots traveling to the lungs causing a major blood clot that may result in death. It is important to discuss with your physician any past history of blood clots or swollen legs that may contribute to this condition. Cardiac complications are a risk with any surgery and anesthesia, even in patients without symptoms. If you experience shortness of breath, chest pains, or unusual heart beats, seek medical attention immediately. Should any of these life threatening complications occur, you may require hospitalization and additional treatment. A dropped lung can occur as a risk of anesthesia &/or rib harvest from your chest wall.
GRAFTS, etc- During Cosmetic & Functional Nasal Surgery the surgeon may require additional graft material. Septal cartilage is usually the first choice but ear cartilage, rib cartilage, Frozen rib cartilage, Temporalis fascia, Alloderm, etc, are some other potentially necessary grafts or materials for your surgery. Additional scars, risks and costs may be associated with these but they are used only if needed for the best possible results.
Skin Disorders / Skin Cancer– Cosmetic & Functional Nasal Surgery is a surgical procedure to reshape of both internal and/or external structure of the nose. Skin disorders and skin cancer may occur independently of a Cosmetic & Functional Nasal Surgery.
Long-Term Results– Subsequent alterations in nasal appearance do occur as the result of healing after Cosmetic & Functional Nasal Surgery, or as a result of aging, weight loss or gain, sun exposure, exercise, pregnancy, menopause, or other circumstances not related to Cosmetic & Functional Nasal Surgery. Future surgery or other treatments may be necessary.
Female Patient Information- It is important to inform your facial plastic surgeon if you use birth control pills, estrogen replacement, or if you believe you may be pregnant. Many medications including antibiotics may neutralize the preventive effect of birth control pills, allowing for conception and pregnancy.
Intimate Relations After Surgery– Surgery involves coagulating of blood vessels and increased activity of any kind may open these vessels leading to a bleed, or hematoma. Activity that increases your pulse or heart rate may cause additional bruising, swelling, and the need for return to surgery and control bleeding. It is wise to refrain from sexual activity until your physician states it is safe.
Smoking, Second-Hand Smoke Exposure, Nicotine Products (Patch, Gum, Nasal Spray)-
Patients who are currently smoking, use tobacco products, or nicotine products (patch, gum, or nasal spray) are at a greater risk for significant surgical complications of skin dying, delayed healing, and additional scarring. Individuals exposed to second-hand smoke are also at potential risk for similar complications attributable to nicotine exposure. Additionally, smoking may have a significant negative effect on anesthesia and recovery from anesthesia, with coughing and possibly increased bleeding. Individuals who are not exposed to tobacco smoke or nicotine-containing products have a significantly lower risk of this type of complication. Please indicate your current status regarding these items below:
- I am a non-smoker and do not use nicotine products. I understand the risk of second- hand smoke exposure causing surgical complications.
- I am a smoker or use tobacco / nicotine products. I understand the risk of surgical complications due to smoking or use of nicotine products.
It is important to refrain from smoking at least 6 weeks before surgery and until your physician states it is safe to return, if desired.
Mental Health Disorders and Elective Surgery- It is important that all patients seeking to undergo elective surgery have realistic expectations that focus on improvement rather than perfection. Complications or less than satisfactory results are sometimes unavoidable, may require additional surgery and often are stressful. Please openly discuss with your surgeon, prior to surgery, any history that you may have of significant emotional depression or mental health disorders. Although many individuals may benefit psychologically from the results of elective surgery, effects on mental health cannot be accurately predicted. Happy and optimistic patients often do better after elective surgery.
MEDICATIONS- There are many adverse reactions that occur as the result of taking over-the- counter, herbal, and/or prescription medications. Be sure to check with your physician about any drug interactions that may exist with medications which you are already taking. If you have an adverse reaction, stop the drugs immediately and call your doctor for further instructions. If the reaction is severe, go immediately to the nearest emergency room. When taking the prescribed pain medications after surgery, realize that they can affect your thought process and coordination. Do not drive, do not operate complex equipment, do not make any important decisions, and do not drink any alcohol while taking these medications. Be sure to take your prescribed medication only as directed. Patients who are or have taken Accutane for treatment of acne or any other reason cannot undergo elective surgery for at least 6-12 months after stopping the medication. Serious scarring may result otherwise.
Follow all physician instructions carefully; this is essential for the success of your outcome. It is important that the surgical incisions are not subjected to excessive force, swelling, abrasion, or motion during the time of healing. Personal and vocational activity needs to be restricted. Protective dressings and splints should not be removed unless instructed by your facial plastic surgeon. Successful post-operative function and outcome depends on both surgical technique, your body’s healing course, and subsequent care. Physical activity that increases your pulse or heart rate may cause bruising, swelling, scar tissue, fluid accumulation and the need for return to surgery. It is wise to refrain from intimate physical activities &/or exercise after surgery until your physician states it is safe. It is important that you participate in follow-up care, return for aftercare, and promote your recovery after surgery. It is important to discuss your concerns with your surgeon rather than ignore them, or discuss them with others who do not know the details of your surgery and intra-operative findings.
Most health insurance companies exclude coverage for cosmetic surgical operations or any complications that might occur from cosmetic surgery. If the procedure corrects a breathing problem or marked deformity after a nasal fracture, a portion may be covered. Many insurance plans exclude coverage for secondary or revisionary surgery. Please carefully review your health insurance subscriber-information pamphlet. You may be responsible for fees not covered by your insurance.
The cost of surgery involves several charges for the services provided. The total includes fees charged by your doctor, the cost of surgical supplies, anesthesia, laboratory tests, and hospital charges, depending on where the surgery is performed. Depending on whether the cost of surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. Additional costs may occur should complications develop from the surgery. Secondary surgery or hospital day surgery charges involved with revisionary surgery would also be your responsibility. Your facial plastic surgeon or his/her practice is not responsible for any such fees.
ADDITIONAL SURGERY NECESSARY
There are many variable conditions that may influence the long-term result from Cosmetic & Functional Nasal Surgery. Secondary surgery may be necessary to obtain improved results. Should complications occur, additional surgery or other treatments may be necessary. Even though risks and complications occur infrequently, the risks cited are particularly associated with Cosmetic & Functional Nasal Surgery. Other complications and risks can occur but are even more uncommon. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied, on the results that may be obtained. In some situations, it may not be possible to achieve optimal results with a single or even multiple surgical procedure. Your body’s healing is out of your or your surgeon’s control and contributes significantly to your final outcome.
Informed-consent documents are used to communicate information about the proposed surgical treatment of a disease or condition along with disclosure of risks and alternative forms of treatment(s), including no surgery. The informed-consent process attempts to define principles of risk disclosure that should generally meet the needs of most patients in most circumstances.
However, informed-consent documents should not be considered all inclusive in defining other methods of care and risks encountered. Your facial plastic surgeon may provide you with additional or different information, which is based on all the facts in your particular case and the current state of medical knowledge.
Informed-consent documents are not intended to define or serve as the standard of medical care. Standards of medical care are determined on the basis of all of the facts involved in an individual case and are subject to change as scientific knowledge and technology advance and as practice patterns evolve.
It is important that you read the above information carefully and have all of your questions answered before signing the consent on the next page.
Computer Imaging & Rhinoplasty Consultation Virginia
The importance of digital computer imaging for Rhinoplasty patients cannot be stressed enough. IT IS EXTREMELY IMPORTANT. The imaging is not a guarantee of the outcome but it’s the only accurate method of dialogue between the plastic surgeon and the Rhinoplasty patient. Computer morphing or imaging is the best way of ensuring that the plastic surgeon and the Rhinoplasty patient have similar goals and expectations and plans for the nose job. Computer imaging is a “road map” for the plastic surgeon. The road map is planned out during the Rhinoplasty consultation and then the “road trip” is carried out by the plastic surgeon bearing the goals of the computer imaging in mind during the surgery.
The computer-imaging should be performed by the surgeon doing the surgery. His nurse or tech or another imaging performed by another plastic surgeon or one performed online or by a friend or even by the patient is never as accurate as the computer imaging performed by the actual surgeon. However, imaging or photo-shopped pictures can be shown to the surgeon to relay desires and fears.
The reason computer imaging is so crucial is that there is no other way for the patient to visualize his or her new nose and new face before surgery, before going through a Rhinoplasty and before it’s too late! The time of nose splint or cast removal should not reveal a total surprise! More importantly the images should be fairly accurate and representative of the goals of the surgery and fairly realistic.
(1 a, b, c, & d) Samples of Dr. Naderi’s actual patients with pictures of their “before rhinoplasty” “computer imaging” and “actual after rhinoplasty” showing how close and realistic his results often are. But it is important to realize computer imaging is a “road map” and a tool for dialogue and not an exact promise of Rhinoplasty outcome.
For example, a patient with a “simple dorsal hump” who wants the hump removed may see several plastic surgeons. Obviously they all plan on removing the hump, but the degree or aggressiveness of reduction determines if a small residual hump remains or if the profile will be straight, slightly curved, or completely ski-sloped! Seeing the surgeon’s plans on the large computer screen before Rhinoplasty will allow the patient to discuss and adjust the surgical plans before it’s too late. Of course we are discussing a best-case scenario where the plastic surgeon is actually experienced and skilled but may not be “on the same page” as with the patient – if computer imaging is not used. If the surgeon is a bad surgeon or does not understand noses or his actual results and his computer imaging are totally different then all bets are off and you are better off looking for another plastic surgeon.
Cost and Role of Insurance in Nasal Reshaping Virginia
One of the most important aspects of each patient’s decision-making process is the cost of Rhinoplasty. The other issues patients are concerned with are the type of Anesthesia (general or sedation), the location of surgery (office or hospital), the skill of the surgeon (Rhinoplasty Specialist or General Plastic Surgeon), and the goal of the surgery and “the fear of ending up looking like Michael Jackson.” We have addressed these concerns in their own respective secti
ons in this online textbook of Rhinoplasty but here we will discuss cost.
Cost varies significantly based on geographic location. For example, while there are cosmetic surgeons in New York City charging up to $30,000 for a Revision Rhinoplasty, as far as we know there is no one in South Dakota that charges even 1/3rd of that fee. Cost also varies based on the skill and specialization of the plastic surgeon and the demand on his time and expertise. For example, while there are general ENT surgeons performing nose jobs for an additional $1000-3000 above what insurance will pay for a Septoplasty, there are no Rhinoplasty Specialists who will perform such an intricate and complex surgery for that amount. Most times, (but not always), you get what you pay for.
The “average cost of Rhinoplasty” in the United States is about $5000-7000 total while the average cost of a revision Rhinoplasty in the U.S. is about $6000-9000. But these numbers are just averages and there are significant variations in the cost of anesthesia and hospital fees even in the same city. The data from the American Society for Aesthetic Plastic Surgery revealed that the average plastic surgeon in the United States performs only 12 Rhinoplasties per year. That is one per month! Most Rhinoplasty specialist surgeons perform 10 times that number and hence understand the nose better.
Patients who choose Dr. Naderi as their Rhinoplasty Specialist Surgeon do so based on the carefully calculated decision and wise desire to trust a “specialist” with their face and nose. Dr. Naderi is a Board Certified Facial Plastic Surgeon (exclusively performs Plastic Surgery on the face only) but above and beyond this, his busy surgical practice is focused practically completely on the nose (Rhinoplasty and Revision Rhinoplasty). Patients who choose Dr. Naderi do not do it based on price. He is not inexpensive. But he is reasonable and fair. He takes excellent, skillful, artistic, and compassionate care of his patients and their noses. He is ethical and he talks 20-30% of his patients out of undergoing unnecessary Rhinoplasty! While no one can guarantee a “perfect” nose, his multitude of happy and grateful patients from all over the world are testimony to his skill. Do not choose Dr. Naderi if you are seeking a bargain. Choose Dr. Naderi if you want a surgeon who has the specialized skill and high ethics to take excellent care of you and your loved ones during and after surgery. Dr. Naderi’;s Primary Rhinoplasty total cost ranges from around $8500 – $10,000 or above, which includes the cost of Anesthesia and Hospital Fees. For Revision Rhinoplasty Dr. Naderi’;s total cost ranges from around $9500 to $17,000 or above, which again includes the cost of Anesthesia and Hospital fees.
Down-time, Healing & Facts Virginia
Each patient has a somewhat different experience after his or her Rhinoplasty but there are some usual trends. For example, if your Plastic Surgeon does not pack your nose then post-operative pain after Rhinoplasty is rare. Dr. Naderi does not routinely pack the nose of his patients and so many of his patients do not take any pain medication after their surgery. If your Plastic Surgeon uses excellent technique then bruising and swelling will be minimized. Shorter operative durations (surgery time) will also usually translate to less post Rhinoplasty swelling. The less bruising and swelling patients have, the quicker they will recover. Typically Dr. Naderi’s Rhinoplasty patients will have about one week of down time. This down time is often due to the desire for privacy. Patients will be required to wear a very small cast on their nose for 5 to 7 days. Most patients will stay home during this period in order not to be seen by friends, classmates, or co-workers. Some patients who are not concerned about such privacy issues will go back to work or school as early as 2 to 3 days after their Rhinoplasty. Typically Dr. Naderi sees his post-operative patients the very next day and then in 4 to 6 days later to take off their nose cast (and sutures if their surgery was an open Rhinoplasty). At that point most patients can head back to work or school with the aid of a little cover-up makeup if there are some light bruises still lingering. Dr. Naderi asks his patients not to exercise in the gym for a total of 2-3 weeks to prevent nosebleeds and minimize swelling. Heavy exercise will increase swelling. Excess heat, changes in altitude, and other factors can also adversely affect swelling. But for most patients, their “true down time” is only the first 5 to 7 days with the tiny cast on their nose. Dr. Naderi asks his nose job patients not to wear glasses or partake in contact sports for a total 1 to 3 months after their Rhinoplasty if their bones were broken and need to set. While it’s a fact that healing after Rhinoplasty takes years, the down time for most patients is about a week for all practical purposes. But the nose will continue to change for weeks and months and even years. Most patients are surprised to see how their noses continue to refine and get more definition even 2, 3 or 5 years later and so on.
Rhinoplasty Surgery Aftercare
Grafts & Sutures In Rhinoplasty
In the old days of purely “reductive” Closed Rhinoplasty, Plastic Surgeons would do an entire Rhinoplasty in about half an hour, by simply removing cartilage, removing bone and thereby narrowing and shrinking the nose. The results were often great in the first few months, to even the first few years, but with the passage of time, shrink-wrapping of the skin and soft tissue envelope, and the unpredictable nature of scar tissue contracture, would end up distorting many of these noses. Pinched tips, alar notching and retraction, collapsed nasal bridges and some of the telltale signs of a “bad” nose job were unavoidable.
With the pendulum swing from the predominantly closed Rhinoplasty to the open structure Rhinoplasty, more grafts and more sutures (stitches) entered the tool belt of the Rhinoplasty Surgeon. The use of more conservative reductive maneuvers replaced aggressive, reckless, excisions. (For example, judicious narrowing of the lateral segment of the Lower Lateral Cartilages replaced the complete amputation of this segment: “Cephalic Trim” vs. “Complete Strip”). Rearrangement of tissue and reshaping of tissue, with sutures, as well as addition of support grafts, replaced simply removing tissue. Cartilage grafts, soft tissue grafts, and suture manipulations, have developed significantly over the last ten to fifteen years. We have learned which sutures are safe and which sutures should be avoided due to their higher risk of infection or extrusion.
The knowledge gained as result of open structure Rhinoplasty has spilled over into the closed Rhinoplasty technique in order to achieve more predictable, and stable, long lasting result. The skillful Rhinoplasty surgeon should be able to achieve great results with either open Rhinoplasty (External Rhinoplasty) or closed Rhinoplasty (Endonasal Rhinoplasty). While the open Rhinoplasty is the approach of choice for total nasal reconstruction in severely deformed Revision Rhinoplasty cases, as well as complex Primary Rhinoplasty cases, the closed Rhinoplasty remains an excellent approach and an art that is becoming extinct, due to its teaching complexity, and steep learning curve. Both are great approaches and both approaches can be done well or done poorly. These are merely tools in a plastic surgeon’s hands and the nose job results depend on how well the tools are used!
GRAFTS IN RHINOPLASTY:
Columellar Strut Grafts: About a 4mm x 2cm cartilage graft that sits between the medial crura of the Lower Lateral Cartilages (LLC) and provides support to the tip. Sizes can vary. May be sutured in open Rhinoplasty or placed into a precise pocket in closed Rhinoplasty. Positioning and shape can affect rotation of the tip and projection as well as shape of columella. Very strong columellar struts can be fashioned from rib cartilage to allow building of the tip in revision Rhinoplasty or in significantly short & under-projected noses such as Asian Rhinoplasty.
Plumping Grafts: Pieces of cartilage placed at the naso-labial junction, usually beneath a columellar strut to “open up” the naso-labial angle in patients with ptotic (droopy nasal tips)
Pre-maxillary Grafts: Larger sheet of cartilage or fascia or implants placed at the naso-labial junction as the foundation for the base of the nose, in patients with severely under developed pre-maxillas. Usually used in Hispanic or Indian Rhinoplasty patients.
Shield Type Tip Grafts: Cartilage grafts in various shapes, widths, and lengths (typically resembling a medieval armored shield) placed over the medial crura of the Lower Lateral Lartilages (LLC) extending to the domes or even above. Used to modify the tip and create new and better “tip defining points.” Can be used to increase projection if the graft extends above the domes of the LLC. Can be used to create a more refined and narrow tip. Can be used in a layered or stacked manner to de-rotate the tip in short, upturned noses and to lengthen the nose. Edges must be beveled to prevent showing through the skin. Must be used in extreme care in thin skin Rhinoplasty patients. Very commonly used in thick skin Rhinoplasty patients to create better tip definition. Secured with sutures in open or “closed-delivery Rhinoplasty;” or placed in a precise pocket in “closed-non-delivery Rhinoplasty.”
Cap Grafts: Small oval shaped grafts placed over the domes of the lower lateral cartilages or placed over the upper portion of shield type tip grafts for added projection or length to the tip
Blocking Grafts: Small oval shaped cartilage grafts placed on the back part of the upper portion of an extended shield type tip graft to add support and prevent the upper end of the shield graft from bending backward. Used in cases where extended shield grafts are used above the lower lateral cartilage domes for added projection and length.
Alar Batten Grafts: Large oval shaped cartilage grafts placed over or under the lateral portion of the lower lateral cartilages and extending to above the pyriform aperture bone. Used to support the lateral ala (nostrils) and prevent pinching or collapse. Can be used for cosmetic purposes but often used for functional purposes to prevent dynamic alar collapse during forceful inspiration.
Alar Strut Grafts: Rectangular cartilage grafts placed above or below the lateral segment of the lower lateral cartilages to provide shape and support. Often used for replacement or reconstruction of the LLC’s in revision Rhinoplasty when the LLC’s have been over aggressively excised. Also used to bend a convex lateral LLC into a more favorable straight segment to reduce bulbosity of the tip.
Rim Grafts: These are usually 2mm x 1.5cm cartilage grafts placed at the alar (nostril) rims to provide support and prevent pinching or collapse in Rhinoplasty patients with thin nostril skin. May be used to correct minimally retracted alar margins. These may flare the nostrils on base view.
Composite Grafts: Usually cartilage grafts harvested from the ears with the skin remaining attached to the cartilage. These are used to correct vestibular stenosis as well as correct moderate to severely retracted or notched alar margins.
Spreader Grafts: These are usually 4mm x 2-3cm cartilage grafts placed between the upper lateral cartilages and the dorsal septum. Very useful grafts in prevention of some post-operative Rhinoplasty deformities as well as correction during revision Rhinoplasty. Sutured into place in open rhinoplasty or placed into a precise pocket in closed rhinoplasty. Cosmetically spreader grafts can be used to:
- Help straighten a crooked nose
- Open a pinched middle vault and fix an “hour glass shaped” nose
- Help de-rotate an over rotated nose when used as a D.A.R.T.
- Lengthen a short nose when extended beyond the caudal septum
- Prevent “inverted V deformities” post Rhinoplasty
- Create nice “brow-tip aesthetic lines”
- Functionally spreader grafts may improve breathing by opening the internal valve area between the dorsal septum and the upper lateral cartilages.
- These grafts can create noses that look too wide from front view
Onlay Grafts: Cartilage or fascia grafts placed over the middle vault, or dorsum to add bulk, width, or height. Can be crushed or morselized cartilage. Not “functional” grafts usually but mostly cosmetic.
Radix Grafts: Cartilage, diced cartilage, or fascia grafts placed at the radix to increase the height of the radix and the “nasal starting point.” These grafts may show their edges in thin skinned Rhinoplasty patients.
Caudal Septal Extension Grafts: Very useful and powerful grafts placed to increase the length of the septum and nose. Used in ethnic patients with short noses or in Revision Rhinoplasty cases. Usually this graft is taken from rib cartilage but thick septum or double layer ear cartilages can also be used.
Lateral Wall Grafts: Cartilage grafts to replace over aggressively reduced Upper Lateral Cartilages in Revision Rhinoplasty.
Temporalis Fascia Graft: Soft tissue graft used in patient with very thin skin to help camouflage and create a smoother nose. Can be used at the tip, dorsum or radix. Alloderm, which is a cadaveric a-cellular dermal graft, can also be used as an easier, but more expensive alternative.
GRAFT MATERIAL IN RHINOPLASTY:
Septal cartilage: A large portion of the Septal Quadrangular Cartilage can be harvested and used during Rhinoplasty. “An L-strut” must be left to support the nose. This L-strut must be at least 1.5cm in width to support the bridge and tip. The remainder of the cartilage can be removed and used for Rhinoplasty. In Revision Rhinoplasty, this cartilage is often missing and unavailable, as it may have been used during the previous Rhinoplasty surgeries. Septal perforation (hole) is a risk of septal cartilage harvest or septoplasty. This cartilage is often missing and destroyed in patients who have been struck to the nose very hard (boxers) as well as patients with history of Cocaine abuse or autoimmune diseases.
“Cartilage is to a Rhinoplasty Surgeon what wood is to a carpenter.”
Most Rhinoplasties require some form of cartilage grafts – from minimal use to extensive use. Typically septal cartilage is the first choice of cartilage for most Facial Plastic Surgeons while many Plastic Surgeons prefer ear cartilage due to lack of comfort and training in operating inside the nose.
Septal bone: A portion of the perpendicular plate of the Ethmoid bone, at the back-top end of the septum, can be used for graft material although not ideal.
Ear (Auricular) cartilage: A greatly versatile source of cartilage for grafts. Incisions can be placed in front or behind the ear(s). Cartilage can be harvested from various parts of the ear and used in Rhinoplasty and Revision Rhinoplasty. Under skillful hands, no major cosmetic deficits should be noticed with the ears after surgery.
Ear composite graft: Powerful grafts taken from the ear including cartilage and its overlying attached skin. Used to correct “soft tissue triangle defects” as well as retracted nostrils and vestibular stenosis. Very technically challenging grafts to place and do not always survive.
Post Auricular Fascia: Soft tissue taken from behind the ear to help camouflage areas, in thin skinned Rhinoplasty patients.
Temporalis Fascia: Strong soft tissue layer covering the Temporalis Muscle, used to camouflage areas in Rhinoplasty patients with thin skin. It can also be used to augment the radix. Alloderm can substitute for Temporalis fascia.
Rib (Costal) Cartilage: Large, strong cartilages harvested from the ribs 5,6,8,9,or 10. Used when abundant cartilage and building material is needed in Rhinoplasty or Revision Rhinoplasty. Often used to build up the bridge or lengthen the tip. Frozen or Irradiated cadaver rib may also be used. When carved properly concentrically, these cartilages have a minimal risk of warping.
Bone: Bone from the ribs, skull, scapula or hips can be used in major reconstructive cases.
IMPLANT & ALLOPLASTIC GRAFTS USED IN RHINOPLASTY
Mersilene Mesh: Permanent implant that resembles “cheese cloth.” Often used in general surgery to fix hernias. Can be layered and used nicely as a chin implant. Not a good option in the nose due to risk of acute or delayed infection but some plastic surgeons do use this in the nose.
Gore-Tex (PTFE): Permanent white leathery soft plastic implants. Comes in sheets or in pre-formed strut type implants. Not a first option in the nose due to risk of acute or delayed infection but used commonly by many plastic surgeons.
Silastic (Silicone): Pre-made implants in different shapes and sizes. Very commonly used for Asian Rhinoplasty. Not a good option in the nose due to risk of acute or delayed infection as well as shifting and extrusion.
Medpor: Pre-made implants in different shapes and sizes. Very commonly used for Asian Rhinoplasty. Not a good option in the nose due to risk of acute or delayed infection as well as shifting. Very difficult to remove once it’s been in place for a few weeks. May also extrude through the nasal skin, leaving bad scars.
Surgicel: Cellulose sheets used for hemostasis. Used abroad for radix grafts as a “Turkish Delight” which is diced cartilage wrapped in Surgicel. Temporalis Fascia is a much better alternative.
SUTURE MATERIAL IN RHINOPLASTY:
Vicryl: An absorbable braided suture that can be used in Rhinoplasty but not the best choice. It can cause inflammation, infection, or extrusion (spitting of the suture).
Monocryl: A fantastic mono-filament (non-braided) absorbable suture that can be used in Rhinoplasty. Often used in a 5.0 size for dome defining sutures.
PDS: A fantastic mono-filament (non-braided) absorbable suture that can be used in Rhinoplasty. Often used in a 5.0 size as dome defining sutures, or 6.0 for securing tip grafts. Takes a few weeks to months longer than Monocryl to absorb.
Plain Gut & Fast Absorbing Gut: Quickly absorbing sutures used in Rhinoplasty to close internal incisions. Fast Absorbing Gut dissolves quicker than Plain Gut but the two are very similar. Used in 3.0, 4.0, 5.0 and 6.0 sizes.
Chromic and Mild Chromic: Quickly absorbing sutures used in Rhinoplasty to close internal incisions. Alternative to Gut.
Prolene: Permanent mono-filament suture that can be used in certain areas of the nose during Rhinoplasty. It is often unnecessary and can be substituted with PDS. The suture is not removed if used internally.
Nylon: Permanent mono-filament suture that is often used in a 6.0 or 7.0 size to close external Rhinoplasty columella incisions. The suture is removed in 3-7 days if used externally.
Ethibond: Permanent braided Polyester suture used by some Plastic Surgeons in Rhinoplasty. High risk of infection and post Rhinoplasty problems.
SUTURE TECHNIQUES IN RHINOPLASTY:
Single Dome Stitch: Mattress type stitch placed at the dome of the Lower Lateral Cartilage to bend the dome into the desired, more defined shape. The suture material most commonly used are 5.0 PDS, 5.0 Monocryl, 5.0 Clear Prolene, or 5.0 Clear Nylon. May cause alar retraction.
Double Dome Stitch: Mattress or simple type stitch placed between the two domes of the two Lower Lateral Cartilages to bring them together and create more symmetry and support. Plastic Surgeons must be careful to avoid cinching the suture down too tight to prevent a “uni-tip” appearance.
Alar Spanning Stitch: Simple type stitch placed between the cephalic, lateral aspects of the Lower Lateral Cartilages to reduce tip convexity. Must be used carefully as it can create significant alar rim retraction.
Wright Stitch: Suture placed to correct a deviated caudal septum. It essentially pulls the deviated septum to the other side of the anterior nasal spine and secures it there
Septal-Columellar Stitch: Suture placed to position the tip in relationship to the rest of the nose by placing a suture from the caudal septum to the columella. It is also used in “Tongue-In-Groove” maneuvers to suspend a “hanging columella” and shorten the nose.
- There are many other stitches used in Rhinoplasty to attach grafts or bend and manipulate cartilages. There are also other less commonly used grafts and suture materials in Rhinoplasty and Revision Rhinoplasty that can be used in certain situations. Your Rhinoplasty Surgeon should be familiar and comfortable with multiple grafts and sutures in order to have all the necessary tools to achieve the best possible Rhinoplasty results.
Nasal Analysis & Anatomy
External Nasal Anatomy Profile View
External Nasal Anatomy Base View
External Nasal Anatomy 3/4 View
Internal Midline Nasal Anatomy Side View
External Nasal Anatomy Front View
To reduce your risk of requiring a Revision Rhinoplasty, you should read the following facts very carefully. Rhinoplasty is a surgical procedure. That may sound obvious but there is a very important message in that simple phrase. All surgeries are forms of treatment, whether elective or otherwise. Surgery is meant to correct a problem. But what many Plastic Surgeons fail to carry out is the crucial steps prior to the actual treatment – the diagnosis of the precise cause of each nose problem. Too often Plastic Surgeons perform a “routine” or “cookie cutter” Rhinoplasty. Sometimes this approach leads to a nice outcome but often the end point is disappointing results. Each nose is unique. Each problem is different and many times correction of one issue may lead to creation of another one that has to be predicted, and accounted for, and treated. Plastic Surgeons must stop focusing on “open Rhinoplasty” versus “closed Rhinoplasty” and stop worrying about “selling” the procedure to their patients, and instead spend time thoroughly analyzing the nose and pinpointing exactly what needs to be fixed, as well as discussing what should be left alone. This approach yields satisfying results and happy patients.
For an analogy, your family doctor has to first diagnose the cause of high blood sugar before treating it with the proper medication. In the same way, your Plastic Surgeon has to first precisely diagnose the cause of a nasal “deformity” before treating it with Rhinoplasty. A patient’s complaint of a “droopy tip” can be due to a variety of factors such as an extra-long caudal septum, or weak tip support, or an over developed anterior septal angle or due to dynamic muscle forces during smiling or the “droopy tip” may be an illusion due to a large dorsal hump. The proper cause has to be diagnosed because the various surgical techniques used during a Rhinoplasty to correct each problem, are very different. If the proper cause is not diagnosed initially, the Rhinoplasty treatment will not only fail to correct the problem but very likely may create a whole new set of problems which will require a reconstructive Revision Rhinoplasty down the line.
So the take home massage is the initial key to a successful Rhinoplasty or Revision Rhinoplasty is accurate analysis and diagnosis. Good surgical technique, complete understanding of the nose and its anatomy, as well as a thorough doctor-patient dialogue using digital computer imaging, are other keys to success. But too often analysis and diagnosis are neglected by the novice Plastic Surgeon. A Rhinoplasty Surgeon, who has dedicated his or her entire career to Rhinoplasty and Revision Rhinoplasty, understands the importance of these key factors. For me, nasal analysis begins either in person, during the in-office consultation, or online by reviewing photos of out of town patients desiring phone consultation. Analysis of the nose starts with analysis of the entire face, body and even behavior. The nose does not sit in a vacuum. The nose has to fit everything else. Here are some general rules but please note that there are plenty of exceptions to these rules, which makes computer imaging so important during the consultation dialogue. We will discuss these issues in depth under specific sections in this online textbook of Rhinoplasty.
- The sex and age of each patient as well as their ethnicity will influence what changes will best fit their face with a Rhinoplasty or Revision Rhinoplasty. For example, an older African-American male patient will require a different looking nose, and a different surgical approach than a teenage Caucasian female patient. As the end goals are different so are the surgical maneuvers. Yet, the essential desire for a more improved, beautiful, and natural looking nose that “fits” is universally shared.
- In general, men, as well as patients above 50 years of age, often benefit from less drastic changes; with a more conservative surgical plan.
- The height and sex of the patient must be taken into account when planning changes to the nasal length, bridge contour, as well as tip rotation. Male Rhinoplasty patients and taller patients require stronger and more natural nose bridges with less upturned tips. The shorter the patient, the “cutesier” the nose can be with slightly more tip rotation during a Rhinoplasty. A “Barbie doll nose” may fit on a 5’1” blond female but will never look good on a 6’3” Italian male.
- Patients with larger, rounder faces need noses that are “softer” compared to patients with chiseled, angular, or thin faces.
- Facial asymmetries and portions must be taken into consideration. 85% of people have significant facial asymmetry. The base-view-photograph best demonstrates these variations from side to side. It is almost universal for the left and right mid-face, cheek and eyes to be in different positions on the face. These asymmetries are very common and do not always create unappealing faces. But it is important to note these asymmetries. Many of the most popular and beautiful actors and celebrities have significant facial asymmetry. The nose, a midline structure, located in the dividing line between two uneven surfaces, cannot always be perfectly straight nor should it be. For an analogy, a house built on uneven grounds will be tilted unless the foundation is corrected. Again, computer imaging is crucial to demonstrate these issues during the consultation. Computer imaging is not just a “cool gadget” but an absolute necessity for Rhinoplasty and Revision Rhinoplasty operative planning. Digital computer imaging is the road map for Rhinoplasty.
- The various relationships between the chin projection, mento-labial sulcus, lower lip, upper lip, pre-maxillary eminence, mid-face position, naso-frontal angle, forehead slope, and nose shape are critical. A certain beautiful nose on one person may look out-of-place on another. While the nose can be changed to match the other variables, most of the other anatomic structures, unique to each face, cannot be easily changed. Therefore, the ultimate nose after a Rhinoplasty must “fit” the unique face for each individual patient. For example, a forehead that is sloped significantly backward will make a nose look more projected or protruding. The same applies to a weak or retro-positioned chin. But, while a chin implant can bring more balance and harmony to the face and make a nose look less protruding, no changes to the forehead can or should be done. These issues can be clearly demonstrated using computer imaging and a true Rhinoplasty Surgeon can help each patient decide on the “best nose for their own unique face.”
- Nasal Analysis starts with visual inspection. Seeing how light reflects off of the various parts of the nose provides important information about the underlying structural anatomy. Light and shadows create proper or improper nasal aesthetics. For example, a light reflex off of the area just above the tip (supra tip) can raise the suspicion that the anterior septal angle cartilage is too high (or there is too much scar tissue in a Revision Rhinoplasty). In such cases, natural ambient light hits this highest point, instead of the normal tip defining points. However, this is just one piece of the diagnostic information. By itself, a naïve Plastic Surgeon may shave this “extra high” anterior septal angle cartilage down, but with proper nasal analysis, an experienced Rhinoplasty Surgeon may have accurately realized that in fact, the anterior septal angle appears high because the tip is under projected! Therefore the proper Rhinoplasty technique would have been to re-establish the proper nasal tip position by increasing projection of the tip and moving the tip cartilages ahead of the anterior septal angle, for the proper balance and light reflex. In the latter case, you would end up with a beautiful nose, but in the former case you end up with a nose that is too small and visibly out-of-balance on the face. The 3-Dimensional nature of Rhinoplasty and its uniqueness amongst all forms of surgery is seen in such cases.
- The next step in analysis is watching dynamic movement. Seeing how the nose moves during speech and with smiling is very important.
- Watching a patient’s behavior, self confidence or lack thereof, will reveal key issues about their mental capacity to undergo an elective surgical procedure.
- Physical examination is not something that can be substituted by pictures or mere online consultation. Computer imaging must not be done before actually examining the nose. The Rhinoplasty Surgeon must feel the nose. The skin, cartilages, bones must be examined by touch. A thick skinned patient requires a different variation in Rhinoplasty technique than a thin skinned patient and these issues must be diagnosed and discussed with the patient prior to the Rhinoplasty surgery. Palpation allows for determination of the nasal bone length. The shorter the nasal bones and the longer the upper lateral cartilages, the more need for spreader grafts. Only diagnosis via physical examination will accurately provide this information; although in patients with thin skin, visualization may also reveal these relationships. Tip support and cartilage strength must be diagnosed prior to Rhinoplasty by pushing on the tip.
- The inside of the nose, septum, external nasal valve, internal nasal valve, pyriform aperture, and turbinates must all be examined. This is a key area where usually most Facial Plastic Surgeons excel compared to their Plastic Surgeon counterparts, due to their extra years of training specifically in Head and Neck surgery. The inside of the nose and the outside are intimately connected and related. A Plastic Surgeon cannot successfully straighten a crooked nose without straightening its crooked septum and vice versa.
- Examination of the septum as a source of cartilage as well as the ears or ribs is also important. Cartilage is to a Rhinoplasty Surgeon what wood is to a Carpenter!
- I will further discuss specifics as they relate to different sexes, ages, ethnicities, and nasal types in the respective chapters in this online textbook of Rhinoplasty.
Psychological Issues Virginia
While the majority of patient seeking and undergoing Rhinoplasty are well adjusted mentally and have positive outcome after surgery, there are some important exceptions that must be noted. The information below is a combination of simple observations and scientific facts, none of which are meant to judge or degrade any patients. These are just some pearls and a collection of random points that should be understood by all patients who have undergone or plan to undergo a Cosmetic Rhinoplasty.
Rhinoplasty has sometimes had a certain secrecy or taboo associate with it. In certain people’s eyes, it is somehow more acceptable for patients to undergo a facelift or a tummy tuck, since these are aimed at reversing signs of aging. This way of looking at cosmetic surgery seems to justify a surgery that “reverses aging” over a surgery aimed at “changing or modifying” someone’s look. We see this kind of phenomenon occasionally with patients who have no problem getting Botox shots in a Spa but “are not ready” to get Botox shots in an actual Plastic Surgeon’s office. In the patient’s mind, one seems to be a “spa treatment” while the other seems to be “Plastic Surgery!”
Several decades ago there was much attention given to the male Rhinoplasty patient after psychological “experts” published scientific papers claiming male Rhinoplasty patients suffered from gender identity issues and that the nose represented a phallic symbol that was being altered!
There are also plenty of patients who have had nose jobs in the past but will call it a “Septoplasty” or “sinus surgery” even when providing their past medical and surgical history to their own doctors. Some will go through enormous lengths in order not to reveal their “secret” to their own family or spouses.
Some patients will refuse to be seen in public with the nose cast after surgery while others will not go in public until the swelling has completely resolved. Some will retreat, become depressed and introverted and “live” on Plastic Surgery chat rooms online, if there is even the least minor of asymmetries or aesthetic issues; while others will be perfectly fine, happy and extroverted, leading perfectly productive lives even with the worse “botched nose jobs.”
Body Dysmorphic Disorder (BDD) is one of the most common psychological diagnoses amongst Rhinoplasty patients. Depression is also a common presenting symptom with patient seeking Rhinoplasty or Revision Rhinoplasty. While a patient with BDD should almost never be offered a cosmetic Rhinoplasty, depression is usually not a pure contraindication to getting a Rhinoplasty.
With all of the taboo and underlying psychological issues that may be present with Rhinoplasty, it is extremely important for the Rhinoplasty Specialist to get to know the patient seeking a nose job. A nose job is not a “simple procedure.” A nose job is not reversible like Botox; it does not wear off in a few months. It’s not like getting a hair cut; it won’t grow back.
Therefore it is very important for the Plastic Surgeon to understand the underlying motivations or rationale for the patient seeking Rhinoplasty. Regrettably, sometimes we see Plastic Surgeons who place their own financial motivations before their patients’ well being. More often we see Plastic Surgeons who just simply do not take the time to diagnose such nuances of Rhinoplasty. And sometimes even the sharpest and best well-intentioned Plastic Surgeon may be fooled or may fail to pick up warning signs of a problematic patient. As the old saying goes, “you cannot please all the people all the time,” but it’s important to identify such patients who will potentially be unhappy with even the best of Rhinoplasty results.
Unfortunately, too often we see parents who are extremely critical of their children. These parents often grab their teenage child’s face in a rough manner and point to its flaws harshly. Many times these parents have had Rhinoplasty themselves and may have had parents who did the same to them.
Sometimes, we see teenagers that have been teased badly in school by their peers or bullied on social websites such as facebook or youtube or twitter. Many times their parents add to the stress by ridiculing their desire for improvement of their nose instead of participating in a healthy dialogue.
But we often see that it is much better to have a situation with a parent who does not think their child needs a nose job than a scenario where the parent is the primary driving force behind pushing their child towards an early nose job. Parent’s role should focus on providing support and enhancing their children’s emotional self confidence, rather than tearing down the self confidence of their children by pointing out physical flaws.
At times older patients in their 30’s, 40’s or 50’s come in for Rhinoplasty and break down in tears recalling how their parents or friends teased them and treated them harshly when they were younger. These old comments have left deep psychological scars that can become refreshed by certain social triggers.
The parents, friends and relatives of a patient can provide a good support network but they can also be very detrimental to the patient by not understanding the facts and providing untimely negative comments.
Sex change or transgender patients often seek changes in their nose to fit their more feminine or masculine goals. With proper screening and counseling, these patients many times have very successful outcome.
Certain patients come in with evidence of lack of attention to the rest of their visage or appearance. Some times these patients are morbidly obese, have not taken care of their bodies or faces and may not be wearing presentable or even clean clothing but for some unexplainable reason, they are focused on their nose and want that “perfect nose.”
Some patients have already had 4, 6 or even more “successful” previous Rhinoplasties by some of the top Rhinoplasty Specialists in the world but they continue to be unhappy and seek that “perfect unachievable nose.”
The ideal Rhinoplasty patient is a healthy patient, both mentally and physically, who wants to improvetheir nose and does not expect the new nose to change their life drastically. The goal of a nose job should not be to get a better job or a better spouse or to change one’s face from “self perceived ugly” to “beautiful.”
The goal of a nose job should be to improve the nose and balance the face. That’s it!
However, we do see time after time, how a good outcome after a Rhinoplasty can improve the self confidence of a patient and their “quality of life.” A successful Revision Rhinoplasty can help heal some of the emotional scars left behind by a previous plastic surgeon’s negligent scalpel.
These are all complex matters that require careful thought and attention by the Rhinoplasty Specialist, as well as his staff, who get to witness each patient’s behavior from the initial phone call onwards.
Teenage Rhinoplasty Virginia
The youngest age for Rhinoplasty is usually 16. Some surgeons will not perform Rhinoplasty on anyone younger than 18 so that the patient can sign the surgery consents as an adult. This approach is not fair to younger patients especially since the typical age for Otoplasty (ear pinning) is around 4 to 6 years of age. What is more important than legal age is mental and physical age. Occasionally on rare instances, a Rhinoplasty Surgeon will consider performing a nose job on a teenager as young as 14 if the patient has essentially completed their physical growth. For example, if the teenage Rhinoplasty patient is 5’3” tall but both parents are 6 feet tall then more time should be given for the teenage growth spurt and completion of physical development. However, if the teenage nose job patient is relatively the same height as his or her parents, then it may be safe to assume further drastic changes in growth will not occur.
But more important than physical growth and maturity is mental and emotional maturity. While there are some 14 year olds that have the proper attitude and mental outlook towards Rhinoplasty, there are some 40 year olds that do not possess such mental strength and emotional maturity to undergo elective nasal reshaping surgery. We sometimes see teenage nose job patients who are much more mature and realistic than their own parents.
The most important factor with teenage Rhinoplasty is to make sure the desire for changing one’s nose is internally driven and not forced on the teenage patient by the parents. It’s also as important to make sure the patient has realistic goals about the outcome. All things being equal, a successful Rhinoplasty can increase the self-confidence of any patient, especially the teenager who is self-conscience about his or her nose.
Thin Skinned vs Thick Skinned Rhinoplasty Virginia
Rhinoplasty involves meticulous, precisely planned out maneuvers, on the nasal skeletal architecture – beneath the nasal skin. These maneuvers involve reduction, augmentation, or rearrangement of the cartilage and/or bony framework. These precise Rhinoplasty techniques on the nasal framework are done in order to see the final results through the skin. “All the surgical work during Rhinoplasty is usually done beneath the skin, but the results are seen by the patient and the world from above the skin.” The only exception is nostril reduction where the surgery is directly on the nostril skin.
Now imagine “fixing your bed” at home. If you have a thick, heavy, Down Comforter covering everything as the final “layer,” then wrinkles in the actual bed sheet will not be seen. Even a walnut or a ping-pong ball, under this heavy, thick comforter may not “show!” But if instead of a heavy, thick comforter, you used a thin, Linen bed cover, as the final “layer,” then any small imperfections in the mattress or bed sheet would be readily “visible” beneath this thin Linen sheet.
Now imagine going camping and “pitching a tent.” If your tent is made of a very heavy, thick canvas then you need a strong tent pole in order to hold it up and have a nice shape to the tent. The thick, heavy fabric will weigh down a weak tent pole, and you will not be able to give your tent proper definition and shape. On the contrary, a much less sturdy tent pole can hold up a thin fabric. If anything, the tent pole may actually be “too visible” through the thin fabric. This analogy applies to thick and thin skinned nose job patients. Basically in thick skinned nose job patients, cartilage and structure needs to be added in order to create a more refined nose with definition, while in thin skinned nose job patients cartilage is removed to create refinement and definition.
Here are some general rules for Rhinoplasty patients with thin skin and Rhinoplasty patients with thick skin:
THIN SKIN RHINOPLASTY:
- Very small surgical maneuvers will show as significant visible changes in thin skinned patients
- Rhinoplasty patients with thin skin do not have a significant subcutaneous fatty layer beneath their skin. Therefore, post-operative steroid injections to prevent excess scar tissue development are usually not necessary or even advisable in Rhinoplasty patients with thin skin.
- Rhinoplasty patients with thin skin often do not have as much post-op edema or swelling.
- Extremely meticulous surgical technique must be used in Rhinoplasty patients with thin skin to prevent asymmetries or irregularities from “showing through” the thin skin after surgery. There is no room for less than stellar surgical technique. Even with best techniques, some slight asymmetry post rhinoplasty is inevitable.
- Temporalis fascia or Alloderm may be added beneath the thin skin as a small “camouflage blanket” to create smoother post-op results.
- Tip grafts are usually avoided in thin skinned Rhinoplasty patients to avoid edges from showing during healing.
- Open Rhinoplasty technique or closed delivery Rhinoplasty techniques are often used in patients with thin skin.
- Very beautiful results are achievable in Rhinoplasty patients with thin skin when the proper Rhinoplasty techniques are used.
- Typically Rhinoplasty patients with very thin skin tend to be of northern European decent or Caucasian.
Patient of Dr. Naderi who had an original Rhinoplasty many years ago by another surgeon resulting in contour irregularities and harsh shrink wrapping of her thin skin to the underlying cartilage and bone. Dr. Naderi did her Revision Rhinoplasty and reconstructed the nasal cartilages then used Alloderm to “soften” the appearance of her skin for a more pleasant nose.
THICK SKIN RHINOPLASTY:
- Minute or average “bread and butter” nose job surgical maneuvers may not show as significant visible changes in thick-skinned patients.
- Rhinoplasty patients with thick skin have a significant subcutaneous fatty layer beneath the skin and this layer can hold swelling fluids (edema) for a very long time.
- Rhinoplasty patients with thick skin can develop post-op scar tissue beneath the skin as the post-op edema lifts and creates a “potential space” under the skin and above the cartilages and bone. This “space” can fill with scar tissue. Post-operative steroid injections are usually indicated in Rhinoplasty patients with thick skin to prevent soft tissue polly beaks.
- An experienced Rhinoplasty Specialist may very gently thin this subcutaneous layer out to slightly think the skin in a thick sebaceous skinned patient. However, extreme caution must be used to avoid compromising the blood flow to the skin in order to prevent skin necrosis. This is a very advanced technique that must be used conservatively. Some plastic surgeons, outside of the United States, use pre-operative Accutane to thin the skin. However, the risks of Accutane are too high to be justifiable for elective surgery and I do not recommend this risky medication for this purpose.
- “Structural Rhinoplasty” techniques with the use of sutures and cartilage grafts must often be used in Rhinoplasty patients with thick skin. (Think back to the camping and tent analogy: a strong tent pole must be used to create a nice defined tent.) In Rhinoplasty patients with thick skin, additional cartilage in the form of grafts are often used to create the definition and narrowing desired at the tip and along the bridge. This may be a counterintuitive concept at first for patients (and unfortunately for many inexperienced Plastic Surgeons). While in Rhinoplasty patients with thin skin, cartilage and bone is removed to create more definition and refinement, in Rhinoplasty patients with thick skin, cartilage is added to create the desired definition and refinement. Removal of excess cartilage in Rhinoplasty patients with thick skin will create a “potential space” which can fill with scar tissue. Scar tissue has no definition and appears as an amorphous blob making the nose worse that prior to Rhinoplasty!
- Sutures can also be used to bend and reshape the cartilages in Rhinoplasty patients with thick skin into a more desirable shape without removal of cartilage.
- Often Rhinoplasty patients with thick skin also have very weak cartilages. This is an unfavorable situation that will not lend to nice aesthetic Rhinoplasty results unless additional adequate structural graft material is harvested from the septum, ears or ribs. I do not advocate the use of “man made” or artificial implant materials due to a high risk of infection and extrusion.
- Very beautiful results are achievable in Rhinoplasty patients with thick skin when the proper Rhinoplasty techniques are used.
- Open Rhinoplasty technique or closed-delivery Rhinoplasty techniques are often used in patients with thick skin.
- Typically Rhinoplasty patients with thick skin tend to be of African, South East Asian or Hispanic decent.
Patient of Dr. Naderi with thick oily skin and a heavy ptotic droopy tip who underwent primary male Rhinoplasty with tip grafts to create a very nice natural looking masculine nose.
Board Certification and Specialization Virginia
BOARD CERTIFICATION AND SPECIALIZATION IN RHINOPLASTY (Washington DC, Virginia & Chevy Chase Maryland)
Patients often wonder who is the best type of cosmetic surgeon for a Rhinoplasty? There are so many specialties now a day with so many “Boards” that have arisen out of the popularity and lucrative prestige of cosmetic surgery. Separating the truth from deceptive marketing can be difficult. Filtering out the constant mudslinging between different specialties and Boards can become a headache. So here are the facts:
1) The larger overall governing body in the United States is the American Board of Medical Specialties (ABMS).
2) There are 24 medical specialty boards under the ABMS.
3) The ABPS (American Board of Plastic Surgery) is one of the main boards overseeing the training and qualifications of Plastic Surgeons
4) The ASPS (American Society of Plastic Surgery) and the ASEPS (American Society of Aesthetic Plastic Surgery) are the two main societies of Plastic Surgeons.
5) Boards are not the same as Societies or Academies. Boards are the governing bodies responsible for examination and training qualifications as well as the politics and “turf wars.” Academies and Societies are merely membership groups or clubs concentrating more on educational meetings as well as marketing, media.
6) The members of ABPS, ASPS, ASEPS are Plastic Surgeons are also known as general plastic surgeons. These are usually made up of surgeons who have finished 5 years of general surgery training concentrating on abdominal surgery followed by 2 years of plastic surgery covering the entire body. It is not rare to spend only 4-6 months out of the entire 7 years on cosmetic surgery of the face. They can then become certified by the ABPS and can then join the ASPS &/or the ASEPS.
7) ONLY THE ABPS, ASPS, ASEPS which are closely related groups and made up of general plastic surgeons insist on making sure that your plastic surgeon is certified by the ABPS or a member of the ASPS. They have used this “catch phrase” or slogan for decades.
8.) The fact is that the field of Plastic Surgery dates back to head and neck surgeons (Otolaryngologists) who created and coined the field and performed the very first closed rhinoplasty: Dr. John Orlando Roe. Later on an Orthopedic Surgeon, Dr. Jacques Joseph, also performed a Rhinoplasty and these two men are known as the fathers of modern plastic surgery.
9) The fact is that the prestigious American Board of Otolaryngology (ABO) and all of its members are actually certified by the American Board of Medical Specialties (ABMS) in the EXACT same manner as the American Board of Plastic Surgery. The difference is that ABO does not advertise or market itself due to its bylaws. All Board Certified ENT Surgeons or Head & Neck Surgeons have the exact same level of authority under the American Board of Medical Specialties (The parent board of all boards) to perform plastic surgeon on the face, head and neck. In fact, most ENT surgery residents have done many more facelifts and nose jobs and eyelid lifts by the end of their residency training than most plastic surgery residents have! This is an undisputable fact that was actually published by the Plastic Surgery department of the world famous Cleveland Clinic.
10) The fact is that the only two ABMS boards (out of 24 member boards) certifying its members to perform “Plastic Surgery” are the American Board of Plastic Surgery and the American Board of Otolaryngology. Oral Surgeons, Oculoplastic Surgeons, Maxillofacial Surgeons and “cosmetic surgeons” are certified by their own boards that are not recognized by the ABMS and there is ongoing debate as to their validity. However these are all experts in their own respective fields with their own area of focus and specialization.
11) The American Board of Plastic Surgery certifies its members to perform plastic surgery on the entire body under the authority of the ABMS.
12) The American Board of Otolaryngology certifies its members to perform plastic surgery only on the head and neck and face (Facial plastic surgery) under the authority of the ABMS. Some ENT surgeons will go beyond the boundaries of their certification and training and will advertise and perform body plastic surgery. This is against the rules of the Board.
13) A minority of Board Certified Head & Neck Surgeons train beyond their initial residency and board certification and complete an accredited fellowship under the governance of the American Academy of Facial Plastic & Reconstructive Surgery (AAFPRS) and then can try to obtain their second board certification under the prestigious American Board of Facial Plastic & Reconstructive Surgery (ABFPRS).
14) The AAFPRS is the Facial Plastic Surgeon’s society similar to the ASPS for Plastic Surgeons.
15) The ABFPRS is a sub-specialty Board under the governance of the ABO.
16) Members of the ABFPRS have to have completed and maintained certification by the ABO or the ABPS before being able to sit for the grueling 2-day ABFPRS examination and submit their surgery case logs for certification. Only Board Certified Head & Neck Surgeons or Board Certified Plastic Surgeons can take the exam for the American Board of Facial Plastic Surgery and hope to become Board Certified Facial Plastic Surgeons. Some Board Certified Plastic Surgeons in practice seek to become triple board certified, recognizing the value of being certified by the American Board of Facial Plastic & Reconstructive Surgery.
17) Facial Plastic Surgeons have completed a 5 year head and neck surgery residency followed by a one year fellowship exclusively in Facial Plastic Surgery.
18.) Here is the difference:
19) There are other boards as well such as the American Board of Cosmetic Surgery (ABCS) and American Academy of Cosmetic Surgery (AACS), American Board of Laser Surgery, etc but these are not under the ABMS and are not validated by a single state in the U.S.
20) Only the ABPS and ABO (and its sub-specialty board ABFPRS) are responsible for maintaining high standards and safety criteria for their members performing plastic surgery on the entire body and face respectively.
21) Only the ABPS and ASPS recommend that your surgeon be certified only by them. The fact is that if you are seeking body plastic surgery then they are correct and your surgeon should be certified by them. However, if you are seeking Facial Plastic Surgery then your surgeon can be certified by the ABPS/ASPS or the ABO/ABFPRS.
Here is the training difference again:
22) There are amazing surgeons certified by both societies and boards. Unfortunately, there are also some very lousy surgeons certified by these governing bodies as well. Just because your surgeon is “board certified” it does not guarantee a safe and successful outcome. But it is the most basic and minimal criteria to start with. The rest depends on training, skill, experience, judgment, talent, ethics, etc. Taking a test and becoming Board Certified is not that hard. But taking excellent care of your patients and not losing site of the fact that you are a physician sworn to “do no harm,” is a life long learning process.
23) Rhinoplasty Specialist Surgeons are a very small subgroup of Facial Plastic Surgeons or Plastic Surgeons who have dedicated the vast majority of their training and practice to the understanding and improvement of aesthetic nasal surgery. Most major cities have one or two such specialists at the most and that is why so many patients fly or drive in from far locations seeking the expertise of Rhinoplasty Specialist Surgeons like Dr. Naderi.
Frequent Rhinoplasty Questions
What is rhinoplasty?
Rhinoplasty, also referred to as nose reshaping surgery (nose job) or aesthetic nasal surgery, is a plastic surgery procedure which can improve the appearance of the nose and correct some underlying medical problems. Aesthetic problems which may be corrected include an increase or decrease in the overall size, the removal of a hump, a decrease in the width of the nostrils, reshaping of the tip or bridge, and a change in the angle between the nose and upper lip. Problems which may affect breathing can also be corrected.
What is functional rhinoplasty?
Functional rhinoplasty is aesthetic nasal surgery with the main goal of improving breathing. There are a variety of techniques for improving nasal airway obstruction including septoplasty, valvuloplasty, vestibuloplasty, turbinate reduction, and osteotomies. As a Facial Plastic Surgeon, Dr. Naderi?s background training and Board Certification is in both Plastic Surgery of the face as well as ENT (Ear, Nose & Throat) surgery, making his understanding of the nose and its anatomy and function unique amongst cosmetic surgeons.
Is rhinoplasty right for me?
If you are healthy, over the age of sixteen, and have realistic goals for the improvement of your nose, you may be a good candidate for rhinoplasty.
Are there any age restrictions for undergoing rhinoplasty?
Dr. Naderi performs rhinoplasty on patients who are over the age of sixteen although occasionally some patients as young as 14 who show mental maturity and completion of their growth spurts may be candidates.
What does a consultation for rhinoplasty entail?
During a consultation for rhinoplasty, Dr. Naderi will examine the structure of your nose and face, take a thorough medical history, and discuss your goals. He then takes your digital high resolution photographs and performs ?computer imaging? so that you can have an accurate dialogue and understanding of what your nose may look like after surgery by being able to visualize these changes on a computer screen. All aspects of the rhinoplasty procedure will be explained including the technique (open or closed), the anesthesia, the facility, the recovery, the risks, the costs and so on.
Where is rhinoplasty performed?
Dr. Naderi performs rhinoplasty at INOVA system hospitals which include Fair Oaks Hospital, Loudoun Hospital, and Fairfax Hospital.
What type of anesthesia is used for rhinoplasty?
Extremely safe general anesthesia administered by Board Certified Anesthesiologists is commonly used for Rhinoplasty. Occasionally the procedure can be done under local or mild sedation if the patient is willing to undergo the awake localization process.
How is rhinoplasty performed?
Dr. Naderi is unique in that he commonly uses open as well as closed techniques and their variations. He plans the proper and best approach for each individual patient. For closed (endonasal) Rhinoplasty incisions are made on the inside of the nose with no scars on the outside. For open (external) Rhinoplasty, incisions are mainly on the inside much like the closed technique but an additional small incision is on the outside of the nose on the skin separating the nostrils (columella). The nose is then gracefully reshaped by removing, replacing or rearranging certain amounts of bone and cartilage. When the desired shape is achieved, the incisions are closed and a splint is applied to the nose.
How long does rhinoplasty take to perform?
Rhinoplasty usually takes about one to three hours to perform with most cases taking about 2 hours. More complex cases needing external grafts such as ear or rib cartilage can certainly take longer to complete. The goal is not to perform the surgery fast but rather to perform is meticulously and precisely.
Where are the incisions made for rhinoplasty?
Incisions may be confined to the inside of the nose which is known as endonasal or closed rhinoplasty. In some cases, incisions may be made on the inside of the nose along with a small incision made on the skin separating the nostrils, which is known as external or open rhinoplasty. About 70% of aesthetic rhinoplasty cases and 30% of functional rhinoplasty cases are performed as endonasal procedures.
Does rhinoplasty leave scars?
Endonasal rhinoplasty results in no visible scarring as the incisions are located on the inside of the nose. External rhinoplasty does result in a small, fine-line scar that is well concealed on the underside of the nose between the nostrils. This scar becomes practically invisible in the vast majority of patients.
Does rhinoplasty involve much pain?
Patients may experience a dull headache and the nose may ache but this is not a typically painful surgery. Medication can help to control any discomfort that patients experience.
What is the recovery like after rhinoplasty?
The face may appear pale and puffy right after surgery, and swelling and bruising may occur around the eyes. Though some unnoticeable swelling can last for up to a year, the majority of swelling fades in about two weeks. Dressings and splints are usually removed in one week. Most patients return to work or school a week after their nasal reshaping surgery.
When will I be able to return to work after undergoing rhinoplasty?
Patients can usually return to work abut a week after rhinoplasty.
How soon will I be able to exercise after my rhinoplasty procedure?
Patients will need to wait at least two weeks before partaking in strenuous activities and exercise.
When will my stitches be removed after my rhinoplasty procedure?
External sutures are removed in three to five days after the rhinoplasty procedure. Endonasal sutures need not be removed as they are all absorbable and on the inside of the nose.
What are the risks or complications associated with rhinoplasty?
All surgery carries potential risks. Those associated with rhinoplasty may include nose bleed (1-3%) &/or the need for minor revision (5%).
Is rhinoplasty covered by insurance?
Rhinoplasty procedures performed for cosmetic purposes only are typically not covered by insurance, though some degree of coverage may be available when used to correct breathing problems. Patients should check with their own insurance company.
Can I finance my rhinoplasty procedure?
Financing is available for Rhinoplasty procedures.