How fast you heal after rhinoplasty is a major question on everyone’s mind, whether it’s your first surgery or a revision. No matter how careful or meticulous your surgeon, there will still be some swelling afterwards. Your nose will not look exactly like the computer-imaged ‘after’ picture as soon as the splint comes off. It will take some time for your skin to contract and ’shrink wrap’ down onto the new structure underneath to really give your nose a lot of definition. Of course, the goal is to get you feeling good about your nose as soon as possible and we do whatever we can to make sure that happens. We want you to skip the puffy stage and move straight on to liking your nose…really liking it. That’s why we are fans of asking patients to tape their noses at night after surgery and of using steroid medication, both during and after surgery, to speed up healing.

There are a number of studies that have supported the use of steroids in rhinoplasty to reduce swelling, bruising, and discomfort from surgery. We offer most of our patients a short course of oral steroids after surgery. When the splint comes off 6 days later, we find it makes the difference between “Wow! I love it already!” with steroids and “I can see it’s gonna be great but it’s puffy right now” without steroids. Beyond the first month, we find judicious use of steroid injections to be enormously helpful in reducing swelling in certain stubborn areas of the nose like just above the tip where the skin is thicker.

To accomplish this, we rely heavily on suture techniques that draw the tip cartilages into exactly the shape we want rather than relying too much on older techniques that involve removal of strips of cartilage from the tip in order to make it smaller. The advantage of our approach is an extraordinary degree of reliability and predictability that can do away with potential problems like pinching of the tip, loss of tip support, and breathing issues.

One other consideration in evaluating bulbous tips is the need to address any other contributing factors. Many bulbous tips are not just wide — they are too prominent in all dimensions including being overprojected, or pointing out too far away from the face. Often, and especially in ethnic patients, the fatty tissue overlying the tip cartilage is also thick and needs to be dealt with if we hope to get the best possible result. The open technique is by far the superior approach for dealing with both of these issues because the cartilage and fatty tissue can be addressed directly as opposed to using indirect methods to deproject the tip that potentially weaken tip support. This allows us to create a tip that is symmetrical, smooth, and strong enough to hold up for a lifetime.

The patient below is shown before and 1 year after open rhinoplasty for refinement of a bulbous tip. Note how the boxy appearance has been transformed into a more triangular contour while remaining smooth and without looking pinched.

Quite frankly, we were a little surprised by this recommendation. The beauty of surgery is that it is not an exact science and there are many ways to arrive at the desired goal. However, the concern that tip rhinoplasty and nostril narrowing, when done together, might compromise the blood supply to the tip skin is really unfounded. In fact, most surgeons who make rhinoplasty a focus of their practice will tell you that they routinely perform these procedures together without issue. That has been our experience.

Some surgeons also advocate waiting to do nostril narrowing as a second procedure so that they can better assess how much narrowing is needed. To the contrary, we have found that we can very readily assess at the time of the initial tip work how much nostril reduction is needed if at all. To our minds, the initial surgery is the best time at which to make these desired changes to create a tip that is balanced and harmonious by reducing nostril width, flare, and asymmetry. We leave this part of the procedure to the very end so we can best determine how much nostril width and flare is still an issue after the other tip enhancements have been achieved. In experienced hands, the minimal swelling that occurs during surgery is not a factor.

There’s no real harm in waiting, of course, other than having to go through a second procedure later on. It can be done fairly easily under local anesthesia. In rare cases, when we feel that someone is very borderline in terms of need for nostril narrowing, we’ll wait. We almost always find later on that indeed it was not necessary. But, our overriding philosophy is that we want our patients’ first rhinoplasty with us to also be the last time they need anything done for their noses. So, when alar base reduction would be beneficial, we want to take care of it at the same time.

Ethnic rhinoplasty depends more on cartilage grafting (using your own cartilage to create definition where it is lacking) than does traditional rhinoplasty. So, you should see a rhinoplasty expert who has experience in ethnic rhinoplasty to ensure your chances at a great result. We have found that a combination of tip cartilage suturing/grafting and soft tissue thinning, along with augmentation of your bridge and nostril narrowing, if required, can produce a beautiful and natural result. You’ll see some examples of the results you can achieve on our website.

The photo above gives you a peek inside at the anatomy of a boxy tip. For many years, the standard technique for tip narrowing was thinning of the upper edge of the tip cartilages, what we call a cephalic trim or cephalic margin resection shown below. When an excessively wide and thick tip cartilage is contributing to a boxy tip, this maneuver is helpful, but it’s very important that the surgeon doesn’t do so much thinning that the tip cartilages are destabilized.

The diagram below shows a reasonable amount of cartilage thinning (shown in red) that will preserve structural integrity and prevent collapse over time. This is especially important in thicker-skinned patients where stronger cartilage is necessary to support the thicker skin. Sadly, we continue to see potential revision patients every day where most or all of the tip cartilage was removed in this area resulting in predictable collapse over time.

Suture techniques for tip narrowing and refinement

 You can see from the above real patient photos that these techniques can produce a dramatic improvement. We need to be careful to preserve just the right angle between these cartilages so that light will reflect favorably on your new tip. An inexperienced or careless surgeon may draw the cartilages too close together or may introduce asymmetries that show up later on, or he may not account for skin thickness and other factors. But, in the right hands, suture techniques provide a powerful way to safely provide the refinement and narrowing you are looking for without compromising breathing. In a future post, we’ll show you how we address tips that are too overprojected.

While we recognize that there is tremendous variability in every parameter of the African American noses: including nostril shape and flare, nasal length, skin thickness, columella length, nasal projection, and bridge height; numerous studies have shown that African American patients, on average, tend to have:

1.      Weak, Short Tip Cartilages- results in tip looking short and droopy

2.      Wider, Bulbous Nasal Tips

3.      Wider Variability in Nostril Shape

4.      Greater Nostril Flare (bigger nostril curvature)- makes tip look wide

5.      Acute Nasolabial Angle- again can make tip look droopy

6.      Thin, Weak Septal Cartilage- harder to support and refine nose

7.      Wider, Lower Nasal Bridges- makes nose look wide and washed out

8.      Thicker Skin- makes it more difficult to add tip definition and refinement

9.      Excess Tissue in the Nasal Tip- resulting in poor tip definition

With all of this being said, over the years we have found that the most challenging part in African American rhinoplasty is correcting the deficiency in tip projection in the face of a bulbous, amorphic tip with thick skin.  In other words, the nose is at once short and wide.

As a result, in this type of nose it is important to build up and add to the tip structure in order to not only provide adequate support but also to give lasting tip definition and refinement. And at the same tip we must recognize that most of our patients are seeking a thinner, more refined nasal tip that is not built up too much. So as you can see in our example below a balance must be created between appropriate refinement without excessive projection.

This professional African American presented after noticing that over time his nose had started to droop and widen. You will note that even 3 months after surgery the improvement in tip definition and refinement is significant.

Above you can see the typical shape of a nasal L-strut implant. This particular one happens to made of Medpor which can be a real problem to revise…but that’s another story.

We were recently asked about revision of an L-shaped implant that gave this particular patient’s nose a pointy, unnatural appearance. She had been happy with her natural tip but the surgeon recommended an L-strut anyways. Now, she didn’t like the look and was also starting to notice some redness of her tip 3 months after her surgery.

Let us say first off that we’re not big fans. We much prefer your own cartilage for augmenting or rebuilding the nose, whether it is from the septum, ear, or rib, or even sometimes irradiated rib.

The concerns mentioned can sometimes arise after use of a nasal implant, and that’s part of the reason we’re not big fans. An L-strut lays over the entire bridge and extends down under the tip to the base of the columella. It gives the tip definition by placing a fair bit of pressure over a small area of skin to tent the skin out. It cannot reproduce or retain the natural shape of your tip. As a result, it can look a little too pointy and unnatural.Sometimes, this pressure on the skin can become too much for the skin to bear. If you are noticing redness at your tip after an implant, you should see your surgeon or another rhinoplasty expert early to determine the cause. If the skin is under too much tension, this would be a good reason to intervene early with a revision procedure to avoid injury to the skin.

The other problem with an L-shaped implant is the possibility that it will twist or move over time and cause your nasal contour to appear crooked. These problems are less likely with an I-shaped implant that stops just above your tip because the forces of healing and skin contraction do not act on it in the same way. An I-shaped implant really justs rests on your bridge without providing the same type of structural support that an L-shaped implant is intended to give. Still, an I-shaped implant can look bulky, blocky, and unnatural. Your own natural nose is not one continuous block of cartilage…so a long, bulky, continuous implant does not make sense to us. We should replace your own lost or deficient tissues with similar tissues.

Our preference for ethnic augmentation rhinoplasty is to use your own cartilage for augmentation. If you are happy with your natural tip, you should be able to keep that roundness. Augmentation of your bridge can be done by itself to balance with your tip and other features. If you continue to be unsatisfied with a nasal implant, rest assured that you can achieve a refined but natural nose.

While most people go abroad thinking they can have surgery done cheaper in some exotic location, the problem is you really cannot be sure what you will get in terms of surgeon or facility once you get there. The truth is that facilities in the US are held to a standard that is not matched by many of the destination countries people look to when thinking about surgery abroad. Moreover, in case of an infection or other complication, there is little patients can do since they usually have not planned to stay more than the few days they thought would be necessary. And all this is not too mention the problems of a long flight after long surgery which can result in a blod clot or more serious problems.

This problem becomes especially important to us because rhinoplasty is more complex than some other procedures and the potential for long term poor outcomes is much higher. We address this because whether your Asian and considering augmentation rhinoplasty or if you are Persian and think that you can have surgery done in Iran, the decision on who to have do your surgery should not be based on cost.

That being said, we are not saying that the most expensive is the best, we know that that is not true either. Rather we advocate for choosing a doctor who you can speak to, whose results you can see, and who takes the time to understand what you want to achieve. If you go abroad, this may be difficult if you and the doctor don’t speak the same language.

In the old days, the short, upturned, ‘cutesy’ nose was the only way a rhinoplasty was done. Sadly, this is sometimes still the case today, but those days should really be gone. We like to say that the object of a successful rhinoplasty should be to give you the nose you were meant to be born with. It is not meant to radically change the way you look. The results should look totally natural and completely in balance with your other features.

When done properly, your nose should blend into the background and no longer be a focus of attention. When done poorly, a rhinoplasty can really change your look in a way you may not have wanted, so you are absolutely right to explore these questions. Check out our previous blog on the topic for more info. Your rhinoplasty should be tailored individually to your features and goals, and should never rob you of your character.

If you find yourself having similar mixed feelings about your nose, there is nothing wrong with asking your surgeon to preserve certain aspects of your nose while changing others. You should recognize that every aspect of your nose is tied in to every other aspect so a change in one part will have a certain effect on the whole. But, in most cases, your goals and desires will turn out to be very reasonable and achievable in the hands of a rhinoplasty specialist.

If you have a longer and narrower face to match your longer nose, you may decide to keep the length; it will look good on you and give a sophisticated, elegant look. Your surgeon should be able to help you tease out what can be accomplished using computer imaging. Remember, this is an operation of millimeters. It is not and should not be an all-or-nothing procedure.