Beverly Hills Rhinoplasty Surgery Blog

We are often asked how long it takes to heal after a nose job. Patients are suitably concerned about when they can show up back to work, go on a date, see friends, or worse, go to a family wedding or reunion, without looking alien.

We often tell people that within two to three weeks after surgery, no one but themselves and any one else in on the truth should know that anything happened at all. Most patients are comfortable returning to work even after one week. Bruising and swelling should be minimal if present at all.

But, there is still some healing to go after the first few weeks. If you read about healing after rhinoplasty, you will see the phrase 1 year often thrown around like some magic number. It’s not that you wake up on your 365th day after surgery and your nose miraculously appears different.

But, it really does take time for the skin to shrink down and wrap around the new structure underneath. For those with thin skin, this may largely happen within a couple of months. For some with very thick skin, revision patients, or if your nose was reduced significantly in size, it can sometimes take even more than a year. So, there is some individual variation in healing based on your skin type, healing characteristics, degree of previous nasal injury, and the type and amount of work done during your procedure.

If you don’t believe us , check out the photos below to see the progress of our recovery nurse after her revision rhinoplasty.

Our recovery room nurse is shown before (left), 10 days (middle), and 4 months (right) after revision rhinoplasty to treat a scooped out, overprojected nose. Notice how even at 10 days, she can return to activities without worry. But, you can see the reduction in swelling above and below the tip that continues to happen over several months after the procedure.

Here is another one from the Q&A file that can be a source of concern for people soon after a rhinoplasty. We were recently asked about vertical lines/shadows showing up after rhinoplasty on either side of the bridge. What was more worrisome for this person was the fact that she was able to feel small gaps when she pressed on the area.

The lines you may feel at the sides of the bridge are most likely fracture lines in the bones that were created to narrow or straighten them. If your bones were wide or crooked, then the surgeon must create these cuts in the bones in order to manipulate them to the desired shape.

If there was a lot of narrowing accomplished, you can sometimes feel a little gap in this area which can be perceived as a small ’step-off’ in appearance.

Don’t worry too much, though. If this is noticeable at all (and most people will not notice this), it will not last long. The bones will heal and the apparent gap should diminish in most situations. This rarely ever becomes a long-term problem, and usually only when the bony cuts were made too high near the bridge. If you are having a similar concern, you have reason to be reassured.

We were recently asked this question by someone who was understandably worried about these persistent symptoms about one year after a revision rhinoplasty. She wondered whether steroid injection would still work at this stage.

While discoloration is admittedly unusual at this stage, the key to this question is fluctuation. If swelling and redness were persistent and not getting better, we would be concerned about a possible low grade infection or chronic inflammatory condition, especially if there were a graft of foreign material placed in the nose. When swelling or discoloration fluctuates between being present and then going away, we are not nearly as concerned.

Whenever rhinoplasty is performed, the surgeon is lifting the skin and soft tissues of your nose to alter the cartilage and bony framework. By definition, this process involves disrupting the little nerves that provide sensation to some areas of skin and the little vessels that allow normal drainage of fluid from your skin. Thankfully, this ‘injury’ heals and all goes back to normal. With each successive surgery though, this healing can take longer and it is uncommon, but not abnormal, to have some of the symptoms being talked about even at one year after a revision.

These symptoms are definitely annoying, but the fluctuating nature of these symptoms is really a good sign. That means that there is still some healing to go and things will continue to improve. Some people pass this stage at 9 months. For others, it may sometimes take another six months or, rarely, longer until you see this go away completely. Steroid injections are meant to help you get there faster and can still help at your stage of healing.

Until then, it is normal to have flushing of the skin in hot environments, bluish discoloration in colder temperatures, and fluctuating swelling and congestion, especially when laying down for long periods or when exercising or doing any activity where fluid collects in the area.

The marker of healing is fluctuation. As time goes by, the swings from ’swollen’ to ‘happy’ days will start to narrow and the fluctuation will eventually stop. That’s when you know you’ve reached a near-final result.

So, what is a pollybeak deformity? Well, that’s the unpleasant and unkind name we give to a nose in which the area just above the tip is too full. Normally, there should be a little dip or depression just above your nasal tip that defines the transition from your bridge to your tip on profile. When that area is high or filled in, we call it a pollybeak.

When it is very full, it can even make the nose look down-turned like a parrot’s beak, thus the name. The reason for this is that the area above the tip often becomes the part of your nose that sticks out or projects the most from your face. This is not the way it should be. Your tip should be the most projecting point of your nose.

Check out the photo below to see a pollybeak deformity indicated by the arrows.

OK, what causes a pollybeak deformity?

Well, a few things can and they are all preventable. First, a surgeon may not reduce the cartilage enough in the area above your tip. Second, the surgeon may be overaggressive in reducing that area too much in someone with thick skin. In this case, the skin doesn’t contract and flatten out as much as it should and, instead, the area fills in with thick scar tissue. Finally, a surgeon may not provide enough support to your nasal tip. Over time, your tip may droop and make the area above the tip look too full.

Look below to see the plan for fixing this pollybeak deformity. The green area is the area of the bridge that was built up in the last blog post. The blue shaded area shows the cartilage that has to be shaved down to correct this appearance. Notice how the tip itself also has to be deprojected or brought in closer to the face.

See the two photos below for a simulation of this correction. On the left, only the pollybeak was taken down but the tip was not brought in so it looks too high and too pointy. This is not a good look but it is something we also see a lot after first-time rhinoplasty because tip correction is harder to do. On the right, you can see how much more balanced the tip looks now.

This is by no means a final image. Even the picture on the right doesn’t look right yet because we haven’t addressed the other problems with this nasal tip. It still looks pulled down and rounded and the nostrils have to be addressed. Tune in to our next post to see us pull together the final imaged picture.

Want to know the most significant complaint we hear about after Rhinoplasty surgery?

It’s not pain, pressure, headache, or even discomfort. In fact, rhinoplasty is rarely very painful.

The symptom we hear about most is nasal congestion.

The picture above shows one technique that some surgeons still use to pack the nose. Most surgeons still use some form of packing or splint, which can either be merocel, gauze, xeroform or a variety of other forms. The end result unfortunately is more discomfort for the patient.

While not being able to breathe through your nose is not earth-shattering, it is extremely annoying. Think of it like a bad head cold that lasts. So, anything we can do to prevent this symptom is meaningful to you, and therefore important to us. And the biggest thing we can do to help, is to avoid nasal packing.

Packing is routinely used by some to help prevent excessive bleeding or dripping. We find we almost never need it. By handling tissues exceedingly carefully and gently, we find that we can generally keep bleeding, bruising, and swelling to an absolute minimum…and the benefit to you is an earlier return to breathing through your nose, less blockage from the beginning, and no painful removal of crusted packing.

We really have a passion for rhinoplasty, and we do all we can to help make your experience with us the best it can be… so we encourage you to come in and experience the difference.

Your concerns are valid and it is important to discuss your history of poor scarring whenever you undergo any type of surgery. You should note however that different parts of the body will heal differently. The simple answer is that keloids rarely develop in the central face and we here at Profiles have never seen a keloid develop after we have done rhinoplasty.

A more in depth explanation begins with an explanation of scarring. First, we need to help you in understanding the difference between a hypertrophic scar and a keloid. Clinically, hypertrophic scars are enlarged scars that stabilize or shrink with time. Keloids, however, initially develop as hypertrophic scars but later extend beyond the original injury area. They rarely regress on their own and have a propensity for recurrence after excision.

Keloids may affect virtually any surface on the body with the central chest, deltoid/shoulder region, and back having the highest frequency. And this has led some doctors to speculate that motion and tension play a large role in causing keloids to develop. While this may be true to some extent, the earlobes, which are one of the most frequent sites affected, are obviously subject to minimal motion or tension forces.

This African American patient demonstrates a typical example of a large keloid scar of the earlobe that was removed in one session with flap reconstruction of the back of the ear. The After photo to the right shows her postoperative result over 6 months after the procedure.

All this being said, while you should explore this issue with your doctor before surgery, you should feel some comfort in knowing that the nose is rarely a site for keloid development after rhinoplasty or nasal surgery. In fact, we did a literature review to check on your answer and were unable to find any papers which could point to a case of a keloid after rhinoplasty.

First and foremost, do not panic.

Early changes after Rhinoplasty are influenced by swelling and do not necessarily reflect the end result nor what was done during your operation. Trust your instincts and talk to your doctor about your concerns. There may be a perfectly good explanation for what you’re seeing. Sometimes, reassurance is all that is needed.

Once the cast comes off your nose, the natural tendency is to stare in the mirror for far too long- looking for the smallest of changes. This is precisely the most harmful thing to do because it will not change your healing and will only make you more nervous.

You will find that you are more swollen in the morning, when you are more active, or after lying down for long periods of time. This is because blood and fluid pools in the area of your nose and cheeks. Aside from that, healing happens in drips and drabs. You may not notice any changes for a few days, and then suddenly see a big reduction in swelling. There is a range of ‘normal’ healing. Don’t be alarmed if you are on the edge of that range. Your surgeon should let you know if anything unexpected is happening. If you are still unhappy at six months or a year, it may be time to talk about your options for improvement.

Your original surgeon is still the best place to start with this conversation, if he or she still has your trust. If not, consult a surgeon who has an experienced practice in Revision Rhinoplasty to see if this is a good option for you.

If you have any questions, please feel free to give us a call or send an email.

Skin quality and thickness is one of the most important factors in determining your final Rhinoplasty result. And it can also be one of the hardest to predict. When we perform Rhinoplasty, most of what we do involves altering the cartilage and bone that makes up the nasal skeleton. We shape the cartilage and bone in many ways to take on the new desired contour. During the healing period for many months after surgery, the skin and soft tissue that lays over this skeleton must contract inwards and ’shrink wrap’ onto this altered framework for the desired changes to become noticeable. That’s why you don’t see real definition for weeks to months after surgery while the skin and soft tissue is swollen.

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We find that the decision to tell friends and family is a very personal one that largely depends on you and your relationships. For most of our patients we find the question of telling friends and family is very simple and they find that the added support helps in making the entire process easier.

Occasionally, however we have some patients who feel that they have family or friends who simply will not accept their decision to proceed with surgery. Occasionally, these patients want to remove some family defining characteristic such as a nasal hump that they feel their family would want them to keep. For other patients, especially those who are still in school, we will wait to have surgery over the winter or summer break so that changes are not quite so obvious to classmates. Overall, however we have found that the social stigma that used to be associated with plastic surgery is no longer really an issue and in general when our patients discuss their reasons for wanting to pursue surgery, their families and friends are generally much more supportive throughout the process than you may otherwise expect.

In those cases, when our patients are from out of town or when they do not have support, at PROFILES we have developed a comprehensive team and program to help take care of all your postoperative needs and to make you feel comfortable every step of the way.

We recently received a question from a patient who had underwent rhinoplasty elsewhere and noted that a few days later her nose was very itchy. Upon removal of the cast she had red, swollen skin with multiple tiny pustules. She wrote to us in a panic wondering what had happened.

Of course without an evaluation, we told her that we would only be speculating. But we did note that on rare occasions, there are people who have allergic reactions to the adhesive on the tape that is used on the bridge of the nose after surgery. The tape and splint are intended to help keep pressure on the skin in order to help reduce swelling and to prevent the nasal bones from moving after surgery.

When an allergic reaction occurs, most patients generally report in hindsight that they noted some itchiness starting as soon as the day after surgery but that it only became intolerable after a few days. Of course once the tape is removed the allergen- the thing that is causing the allergic reaction- is gone but it generally takes days for the swollen, red, itchy skin to return to normal. The long term consequences of this are generally negligible outside of the transient initial itchiness and discomfort, but it does occasionally mean that it will take a while longer for you to see the final results of your surgery.

Depending on the severity of the reaction, some surgeons will provide anything from a topical to an oral steroid to help in treating your itchiness as well as in helping to reduce the swelling and inflammation. Hope this helps.