Beverly Hills Rhinoplasty Surgery Blog

Please note: We are happy to see that our blog is of some help to many of you who are considering or recovering from rhinoplasty. While we would like to address your concerns directly, we are not able to dispense medical advice over the internet. Your own surgeon is your best resource in the first weeks and months after surgery. If, after 5-6 months, you continue to feel unhappy with your result, feel free to contact us via our practice site www.beverlyhillsprofiles.com and we can arrange time to discuss your concerns. All the best for a happy outcome.

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.

A bulbous nasal tip is one of the most common reasons for patients to seek rhinoplasty. A bulbous tip, often called a boxy tip, refers to a tip that is too wide and prominent in proportion to the rest of the nose and other facial features. The key focus in our approach to bulbous tips is in emphasizing creation of a sense of tip refinement and definition rather than excessive narrowing.

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.

You often hear that it can take a year or longer after a nose job before you’ll see the final result. Many of you may be skeptical and a small number of you probably roll your eyes when you hear a statement like this. Does it really take that long to see results or are surgeons just telling you that so they can buy time in case you’re not seeing what you want to see after surgery?

The answer is that surgeons aren’t just feeding you a line. It really does take time for the skin to shrink down and wrap onto the new structure underneath. That’s not to say that you’ll be miserable for months. Our patients generally bound into the office for their 3 month visit ecstatic about their noses. Still, when we take photos, we can see that there is still some swelling that needs to settle so that more definition can show through. The photos below are a perfect example of just how much your nose changes over the first year after rhinoplasty. In cases of revision rhinoplasty, thick skin, or when the nose has been deprojected or brought in significantly, this process happens even more gradually.

Looking at these photos, you can understand why we tell our patients that it matters far more to us how their noses look at 1, 2, or 10 years after surgery than it does at 2 weeks after surgery. At 2 weeks, your nose will look good but puffy. If a surgeon is showing you photos that look absolutely perfect 2 weeks after surgery, be very wary. You can bet that those same perfectly cute noses at 2 weeks will probably look scooped and overdone at 2 years once the skin contracts. It’s important to make sure your prospective surgeon is showing you long-term results.  

The young woman below underwent primary open septorhinoplasty with us at Profiles Surgery Center. Photos below (from left) show her pre-op, at 3 months, and 1 year after her surgery. Note how her 3-month photos still show some fullness and rounding while at 1 year we see a lot more definition.

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.