More than any other cosmetic procedure being performed today, rhinoplasties continue to be one of the most transformational both physically and emotionally. For recent rhinoplasty patient Monica F. of West Palm Beach, FL, the decision at age 44 to finally have the hump on the bridge of her nose taken down is one she has been contemplating since high school. So, why now? “I decided to do it now because I think no one will see me or even notice. So many people are home and we aren’t socializing as much. Plus, I can hide behind this,” she says, pointing to her face mask.
“I’ve never liked my side profile,” she explains a few weeks after surgery. “Every time I took a picture, it had to be straight-on. And when I didn’t like how it looked, I used the FaceTune app to edit my nose. I never went through with the surgery before because I was worried someone would notice. Then the pandemic happened, and it changed everything.”
The mask mandates in response to COVID-19 made it somewhat easier for patients like Monica to heal virtually undetected. “Wearing a mask will help conceal the majority of nasal swelling that occurs two weeks after the procedure,” says New York facial plastic surgeon Matthew White, MD. “Additionally, a tremendous amount of the population is working from home now, which makes it easier for them to recover.”
How Our Noses Change as We Age
While often thought of as a coming-of-age procedure, more and more adults in their 30s and 40s are finally getting the noses they’ve always wanted. Age-related changes that make the nose appear to be growing, or look bigger or wider as we get older, may also factor into the decision to undergo a rhinoplasty. “The bottom two-thirds of the nose comprises cartilage with ligaments attaching to adjacent structures,” explains New York facial plastic surgeon Edward S. Kwak, MD. “The effects of time and gravity cause these ligamentous attachments to lengthen and loosen.” As a result, Dr. Kwak says the cartilage in the nasal tip loses support, which can give the appearance of a “droopy tip”— splaying of the tip cartilages can also make the nose look larger.
This 26-year-old patient was unhappy with the look of her dorsal hump, but was not yet ready for surgery. Dr. Wise de-emphasized the hump using filler in the radix of the nose, and Botox Cosmetic and filler, off-label, to raise the tip.
Nonsurgical Nose Jobs
For patients who want a noncommittal testrun, nonsurgical nose jobs with hyaluronic acid fillers can be effective for some cases, but it’s important to note that injections cannot replace surgical results. “Today, there is an increased interest in minimally invasive options,” explains New York facial plastic surgeon Lee Ann M. Klausner, MD. “But, filler injections in the nose must be done with caution and only be performed by a board-certified plastic surgeon or dermatologist who is skilled in managing a potential vascular complication.”
According to Wayne, NJ facial plastic surgeon Jeffrey B. Wise, MD, nonsurgical nose jobs can hide minor imperfections, but they can’t do everything a traditional rhinoplasty can do. “By adding filler, you can camouflage a bump, make the nose narrower, add dorsal height, and rotate the tip.” However, injectables cannot make the nose appear smaller or fix functional nasal issues like a deviated septum.
A rhinoplasty consists of, “changing the framework of the nose, which is made up of cartilage and bone, then redraping the skin on the newly formed structure,” explains Dr. Kwak. “Surgeons may utilize sutures or cartilage grafts to reshape.”
SURGICAL APPROACHES Open: A small bridging incision is made across the columella, which connects the right and left nostril incisions. The skin can then be folded upward to allow a better view inside the nose. “This approach gives many options for reshaping, adding tip projection, using grafts, and bone narrowing,” says Eugene, OR plastic surgeon Mark Jewell, MD.
Closed: In a closed rhinoplasty, surgical incisions are positioned inside the nostrils. While parallel incisions surround nearly half of the nostril lining, the incision cannot be seen externally, which results in no visible scar. “More important than the approach is the experience and artistry of the surgeon and your comfort level and confidence in that individual,” notes La Jolla, CA plastic surgeon Robert Singer, MD.
Rhinoplasty Step by Step
01. Pre-Planning: “Is it too long or too short? Is it crooked or straight? Is the bridge too high or too low? Is the tip too wide, turned up or droopy? Can I breathe well through my nose?” asks Dr. Klausner. “Communicating with your surgeon is important in making sure results match expectations.”
02. Breaking Bones: An osteotomy is the technical term for “breaking the nose.” This is necessary in some cases, but not all, to narrow or straighten the bone. It is typically done on patients who have crooked noses or large nasal humps.
03. Skin Contraction: A newer rhinoplasty trend is paying greater attention to the skin and how it contracts after surgery. “Individuals with thicker skin need extra consideration of how to encourage optimal skin contraction in the months after rhinoplasty,” adds Dr. Klausner.
04. Swelling: Choosing the right time for surgery is vital, so as not to be under any pressure to heal. The initial swelling period is within the first 10 days to two weeks, but more subtle swelling resolves very gradually over the next 12 to 18 months.
This 28-year-old patient said she felt she had a “wide bridge and a bulbous nose.” Dr. Kwak performed a rhinoplasty to make her nose smaller, refine her tip, and fix breathing issues caused by a septum deviation.
Other Types of Rhinoplasties
Today, there is an increased focus on patients preserving their identifiable ethnic features when undergoing facial procedures. More doctors and patients are making conservative aesthetic choices in order to preserve their natural characteristics. “When we say ethnic rhinoplasty, we’re referring to African American, Asian and Hispanic patients, and patients of Mediterranean and Middle Eastern descent,” explains New York facial plastic surgeon Alexander Ovchinsky, MD.
“For example, African American patients usually have very wide nasal tips that are bulbous and not as defined, and very shallow nasal dorsums,” he says. “Typically, those patients request narrowing of the dorsum, possibly increasing the dorsal height, refining the nasal tip, and sometimes, reducing the size of the nostrils.”
Another example, adds Dr. Kwak, are East Asian patients who want to address a low dorsal height, an under-projected nasal tip or an overall short length. “However, the Southeast Asian rhinoplasty usually addresses a dorsal hump, a wide tip and an underprojected tip. In general, all these noses tend to have thicker skin and softer and thinner tip cartilages with poor tip support.”
Dr. Ovchinsky says his Hispanic patients are most concerned about a dorsal hump and wide nasal tip. “They tend to want hump reduction and tip refinement, where we lift the tip up by increasing tip rotation.”
While these are just some generalizations of the patients these surgeons commonly treat, doctors are also careful to remind their patients that a wide variation of nose shapes exists within each ethnic group.
Dr. Ovchinsky performed an ethnic rhinoplasty on this 43-year-old patient who wanted to reshape her nose and reduce nostril size without altering her appearance.
“If there are notable asymmetries, irregularities or deviations after a rhinoplasty, correction of these cosmetic issues may require revision surgery,” says Dr. Kwak. “Always go to your original surgeon first to explain why you are unhappy before seeking a second opinion or surgery.” A revision procedure is best performed after the nose is completely healed from the original surgery, which “occurs at the six-month point and preferably one year after surgery,” notes Dr. White. “It is critical to perform the revision after swelling has completely resolved in order to ensure the best possible result.”
Ultrasonic rhinoplasty is a new technique that employs a handheld device called a piezotome which is used to remove bone without breaking it. Boca Raton, FL facial plastic surgeon Jacob Steiger, MD says it uses high-frequency sound waves to vibrate tiny cutting and shaving tip inserts. “This allows me to precisely sculpt the nasal bones without causing any trauma to surrounding tissue. I’ve seen a reduction in the amount of bleeding, bruising and swelling,” he explains. Doctors who perform this procedure must also be experienced and skilled in traditional rhinoplasties to ensure the best outcome based on the patient’s anatomy, he cautions. “The piezotome is just a tool, and a small component of surgery. A surgeon must be chosen based on their experience and results.”