Rhinoplasty (Nose Job)

The word “Rhinoplasty” derives from the Greek term rhis (nose) and plassein (to shape). Nose job surgery involves making changes to the skeleton of the nose for improved breathing and/or appearance. Rhinoplasty can use open or closed approaches, which are explained below. The procedure can be combined with a septoplasty, which is called a septorhinoplasty. A primary nose job refers to an operation in a previously unoperated nose. Secondary (or revision) rhinoplasty is a procedure for patients who had at least one prior rhinoplasty.

The singular goal of cosmetic rhinoplasty was to create a smaller nose no matter the consequences. Noses would overtime appear pinched and scooped and created breathing problems leaving many patients as nasal cripples. Recently, rhinoplasty surgeons have moved to a more sophisticated approach as a global community. We now recognize the need to preserve the function of the nose and balance the aesthetics with the rest of the face. We also consider ethnic preferences while performing the procedure.

Rhinoplasty is a category of plastic surgery involving alterations to the nose. While cosmetic changes are associated with a nose job, functional improvements can also be made. Nose surgery for aesthetic and functional changes is complex. It is vital that both the form and function are considered. Because of cartilage in the nose structure, too many procedures can cause complications or weakening of the nasal passages. For those that want both functional and cosmetic alterations, Manhattan rhinoplasty specialist, Dr. Linkov advises performing both types of rhinoplasty at one time.

There are many types of rhinoplasty procedures to reshape and improve nasal function. Some that Dr. Linkov performs at our City Facial Plastics in Manhattan, NY include:

Nose job surgery can address several issues at once. Breathing or sinus issues are improved with septoplasty, or deviated septum repair, during a cosmetic transformation. When performed by a talented surgical artist like Dr. Linkov, the results are beautiful and improve health for the patient.

While there are many techniques to reshape and improve nasal function, newer and advanced methods used by Dr. Linkov has been shown to be more effective. Dr. Linkov has completed special training and has treated many patients successfully. Come visit our clinic in New York City if you are looking for the most natural aesthetic and functional rhinoplasty results.

There are certain key nasal structures, made of bone, cartilage, skin, soft tissue, and blood vessels. They must be considered when performing a nose rhinoplasty, including:

• Bone: There are several most important bony structures that define the nose. These are the nasal bones at the top, the ethmoid bone at the back, and the maxilla at the bottom. Each of these areas is encountered during rhinoplasty. They serve as the support for the cartilage and soft tissue.
• Cartilage: Much of what we see when looking at a person’s nose is the cartilages. These include the upper lateral (midvault) and lower lateral (nasal tip) cartilages. The septum, mostly composed of cartilage, is the partition between the two sides of the nose. The strength and straightness of the septum are paramount for a strong and beautiful nose.
• Skin and soft tissue: This layer that envelops the underlying bony-cartilaginous framework of the nose is very important. Some people have thin skin in this area which can reveal underlying imperfections but also tends to swell less after surgery. Other people have thick skin which has prolonged swelling after surgery but can mask any underlying imperfections. It may be difficult to reveal the fine shapes and details of cartilage, in particular when dealing with thick skin.
• Blood supply: The rich blood supply to the nose comes from several sources. These entail the internal and external carotid arteries. Precautions need to be taken before, during, and after surgery to minimize bleeding. The surgeon needs to understand where the blood vessels travel to avoid complications of the surgery, such as skin loss.

There are two ways to approach the nose for a rhinoplasty, including:

• Closed rhinoplasty (endonasal approach): This technique involves no external, visible incisions. The incisions are made on the inside of the nose and are used to access the necessary areas. Because of the limited visibility for the surgeon, this technique has become less popular. This makes it more challenging to learn the techniques and to execute certain rhinoplasty maneuvers. Advocates of this approach believe that one can better judge the outcome during the surgery because the nasal skin remains in place. There is still nasal tip swelling after closed rhinoplasty if the tip is manipulated.
• Open rhinoplasty: This external approach is great for visibility and more complex reconstruction. A small incision is made at the mid-columella, close to the base of the nose, in addition to a few internal incisions. The nasal skin/soft tissue envelope is carefully peeled off of the underlying bone and cartilage to reveal all structures. Once the structural work is complete, the skin/soft tissue envelope is laid back down and the skin is sutured closed. The advantage is better visibility and control over the structures. But there may be more swelling after surgery. Also, there is a risk of poor scarring at the external incision site. However, this is rare and the incision is typically not noticeable even at close proximity.

There is no correct approach. The best rhinoplasty approach depends on the preferences of the doctor and the patient. Many surgeons are comfortable with both approaches and select the best one based on a particular case. NYC rhinoplasty surgeon, Dr. Linkov carefully examines every patient and discusses if more complex nose reconstruction is required.

Prior to committing to rhinoplasty in New York, Dr. Gary Linkov schedules two initial consultations accounting for not less than 12 hours in total. The consultation phase is typically split into two appointments.

First Consultation

During your first rhinoplasty consultation, the two of you will cover a wide range of topics that might potentially affect your candidacy. These include:

• Your health history
• Medications that you currently take
• Your health disorders (if such exist)

Second Consultation

During your second appointment, you will need to explicitly outline your goals for surgery, and voice any cosmetic or functional imperfections you would like to address. To accept your complaints as acceptable or realistic, Dr. Linkov conducts an in-depth facial evaluation that includes an assessment of the six parameters of the nose.

Once Dr. Linkov combines all the information, you will be informed if it is possible to achieve the desired results with rhinoplasty. An integral part of the preparation process is the patient’s photographs. During this stage, the nose is photographed at eight different angles and the possible after surgery look of the nose is displayed to the patient in 3D simulation. Pre and post-operative pictures are vital for result monitoring and are indispensable from a legal-medico point of view.

Computer software for digital imagining is widely available and used by most plastic surgeons. But as a world-class rhinoplasty surgeon in New York City, Dr. Linkov clearly discloses the chances of fully achieving or coming close to the simulated result. To avoid a strong mental fixation of the projected outcome in the patient, preoperative simulated images will not be handed out to the patient before surgery.

Nose plastic surgery is usually performed under general anesthesia with the patient intubated. This is done for several reasons, including:

• Patient comfort
• Limiting patient movement
• Protecting the airway from blood and aspiration

Major Steps of Surgery

1. Exposing the underlying structures

The first major step of the procedure is to expose the cartilage and bone that will be further manipulated. This is done to achieve the goals set forth by the surgeon and the patient. This starts with choosing a surgical approach, open or closed, as discussed earlier. The doctor then makes certain incisions and exposes the necessary cartilage and/or bone in a safe manner. It is done without disrupting the blood supply and without injuring these underlying structures.

2. Sourcing of Cartilage and other Building Materials

Advanced NYC rhinoplasty procedure involves providing adequate structural support for optimal form and function of the nose. Hence, your surgeon must decide where to get this material from. Materials used in the nose can be divided into four groups: autografts (same person), homografts (another person), xenografts (another species), and alloplasts (synthetic).

The building material, which is primarily cartilage, typically comes from your own body. It can be harvested from the nose itself (septal cartilage), the ear (conchal cartilage), or the rib (costal cartilage). Other potential materials such as cadaveric rib cartilage or synthetic materials such as high-density polyethylene (Medpor) can also be used. In general, infection rates are lower and the stability of grafts is higher if your own body tissues are used.

3. Grafting 

Once the underlying structures are exposed and the grafting material is selected, the necessary grafts are carved and placed.

There are many types of nasal grafts used, including:

There are various grafts that your surgeon needs to be familiar with and adept at using depending on the specific situation. During your consultation, you should be comfortable asking your nose surgery doctor which rhinoplasty grafts he/she plans on using.

4. Bony work

Manipulating the bones of the nose, or adjacent structures happens throughout the rhinoplasty NYC procedure. Osteotomies are bony cuts made in the nasal bones and parts of the cheek bones. Some people refer to this as “breaking the nose”. But it is really controlled cuts in the bone that allow resetting of structures. These cuts can be useful to straighten the nose since the cartilage is attached to the bone and often can be difficult to correct without altering the nasal bones. Also, there may be a crooked bony base to the nose along the floor. This area can be corrected during the septoplasty portion of the surgery.

5. Closing up

Once all required changes to the bones and cartilages are made, the skin and soft tissue envelope is put back (redraped) and sutured closed. This is done with a combination of dissolvable and non-dissolvable sutures. Packing and splints are explained below.

Once you have decided to undergo nose surgery, Dr. Linkov will discuss in detail how to prepare for your surgery. There are a few steps you should take before the procedure to get the best results. These steps include:

• Avoiding certain medications and supplements that may thin the blood, such as:
  • NSAIDS – ibuprofen (Motrin) and naproxen
  • Aspirin
  • Vitamin E
  • Garlic, Ginger, Ginseng, St. John’s Wort, Ginkgo, Black Cohosh
• Stop smoking at least 2 weeks before surgery, as tobacco products can decrease blood flow to the skin and compromise the healing of the surgical site
• Stop all nasal sprays 2 weeks before surgery, except for saline which you can continue
• Pick up medications at the pharmacy, as you will be prescribed certain medications to take after surgery, such as:
  • An antibiotic
  • Pain medication
• Arrange someone to accompany you home and stay with you at least the first night

On the day of your nose job surgery, it is important not to eat or drink 6 hours before the procedure. Surgery is performed under general anesthesia with an anesthesiologist. Hence, there will be no pain during the surgery and you will have no recollection of the procedure. You will be asked to change into a surgical gown and women of child-bearing age will need to take a pregnancy test. The intake process can take about an hour. The surgery usually takes 2-4 hours, and recovery will take another hour.

Recovery after the procedure varies from person to person. A short-term healing phase occurs in the first few days to weeks following the surgery. A long term healing phase occurs in the weeks to months after surgery. How long you will spend in each phase depends on a variety of personal factors.

The short term healing phase

The short term healing phase occurs in the first few days to weeks after the rhinoplasty NYC procedure. Common, anticipated aspects of healing in the short term phase include:

• Bruising – Most patients will experience some degree of bruising. For some, the bruising is minimal, and for others, it is more pronounced. Bruising typically improves in the first few days after surgery but can last for up to 2 weeks.
• Redness – It is normal for there to be some redness at the surgical incision if an external incision is made. Redness gradually improves but can linger for up to 12 weeks.
• Swelling – All patients will experience some degree of swelling. The amount of swelling also varies from person to person. Swelling gradually improves but can last at the nasal tip for up to 1 year.
• Bleeding – It is common to have oozing from the nose for the first 48 hours after surgery. A drip pad taped under the nose can help catch the blood. More extensive bleeding can occur but is rare.
• Nasal obstruction – Stuffiness is normal after surgery and will gradually improve over the first few weeks.
• Pain – There is usually some degree of pain in the first few days which gradually improves. Pain medications are given to help ease the discomfort.

There are several precautions you should take during the short term healing phase to ensure the best result and minimize bleeding. Some of these precautions include:

• Using antibiotic ointment then scar gel as advised by your doctor for the external incision if necessary
• Avoiding vigorous exercise for at least 1-week postoperatively
• Not blowing your nose
• Sneezing with your mouth open to avoid excessive bleeding
• Practicing good nasal hygiene with nasal saline spray five times daily, starting 48 hours after surgery
• Rrefraining from participating in contact sports for at least six weeks to prevent nasal injury
• Attending your follow up appointment for suture, nasal splint, and cast removal at about 1 week postoperatively.
• Making sure not to wet the external cast or it will fall off sooner.

The long term healing phase

The long term healing phase occurs in the weeks to months following your rhinoplasty surgery in NYC. The duration each person spends in this phase depends on the individual’s health characteristics and the extent of the surgery that was performed. In general, you can expect to see final results about 1 year post-operatively. Your doctor will schedule your follow-up appointments to monitor your progress. The part of the nose that requires the most patience to see swelling improve is in the nasal tip. Sometimes, steroid injections are used to help control the swelling.

It depends on the techniques used during your surgery. Some techniques are more durable than others. Another factor that can impact long-term rhinoplasty results is the aging process. It causes a weakening of the nasal tip and as a result a droopy tip in some patients. There are methods of more permanently securing the nasal tip during surgery that limits its ability to drop over time (septal extension graft and tongue-in-groove suturing).

Dr. Gary Link is among a few rhinoplasty doctors who can ensure the effectiveness of the procedure at the same time making sure that no complications occur. The most common risk and complications include:

As you can see, many issues can arise from a rhinoplasty. It is important to choose a surgeon who understands these potential problems and has strategies in place to avoid such complications.

Some patients should not have a rhinoplasty nose job. These include patients with the following:

• Blood thinners that cannot be stopped
• Medical conditions not suitable for general anesthesia
• Not enough donor supply of cartilage
• Very poor overlying nasal skin
• Active vasculitis (Wegener’s) affecting the nose
• Unrealistic expectations

Changing the appearance of your nose is a major decision. When done with artistry, it can create balance in the facial features and help you feel more confident in your appearance. Candidates for rhinoplasty are in good health and non-smokers who want to look their best. Adults and teens whose nose has matured (around age 16) may benefit from cosmetic nose reshaping when performed by an experienced facial plastic surgeon.

Complete reshaping of the nose is done under twilight or general anesthesia. Some simpler procedures, like nostril reduction, can be performed with local anesthesia only. The recovery time depends on the extent of the rhinoplasty. More complicated surgeries require two to three weeks of recovery while the swelling and bruising subside. Dr. Linkov goes over all the details of what to expect during his consultations and pre-operative visits with potential nose job NYC patients.

The cost of a nose job surgery in NYC is a combination of several factors, including a surgeon’s fee, facility fee, and anesthesia fee. These are sometimes reported as a combined fee in certain offices. In other cases, these are broken down into their components. The surgeon’s fee can range from $5000 to $25000, plus the additional fees for the operating room and anesthesia.

Revision rhinoplasty costs are typically 20% to 30% higher for the surgeon’s fee. The cost of a nose job will vary by:

• Location
• Experience of the surgeon
• Demand for the surgeon
• The anticipated complexity of the surgery

Insurance companies are making it more and more difficult to have a rhinoplasty nose job covered. There may be a three-month waiting period to even get a decision from the insurance company. Often, doctors’ appeals are necessary to secure coverage. Cosmetic improvements are never covered by insurance while breathing issues may be.

Photos often need to be sent to the insurance companies to justify the need for a functional nose job. Many New York rhinoplasty surgeons are strictly out-of-network, including Dr. Linkov. It means that patients would need to have out-of-network benefits to get any reimbursement for a nose surgery from their insurance carrier. And often surgeon fees are still taken upfront before the surgery.

Satisfaction
According to a “Patient Satisfaction After Rhinoplasty” study published on PubMed, the overall rhinoplasty satisfaction rate is around 83.6%. Out of 2326 cases (294 males and 2032 females), the satisfaction rate distribution among genders was as follows:

• 87.6% of females were satisfied
• 56.1% of males were satisfied

Statistics
Another retrospective study on “Cosmetic Rhinoplasty” published on PubMed shows that out of 369 consecutive cosmetic nose job procedures, during the study period, 279 (72.7%) were done with an open approach. According to the research, out of all the surgeries performed:

• The complication rate was 7.9%
• The dissatisfaction rate was 15.4%
• The revision rate was 9.8%

Given the complexity of the procedure and potentially unrealistic patient expectations, only a few rhinoplasty surgeons in New York have a high success rate of a nose job and Dr. Linkov is proud to be one of them. His extensive experience in the field of plastic surgery allows him to perform a nose job surgery with the highest caliber of quality leading to a success rate of over 90%.

As an alternative to surgical rhinoplasty, some patients choose to undergo a liquid rhinoplasty, which refers to using a filler (such as Restylane) to add volume to parts of the nose to create certain cosmetic changes. These results are temporary and limited in what can be achieved.

Not exactly. It is possible to do a rhinoplasty alone, a septoplasty, or a septorhinoplasty together. The most common scenario is that they are done together since the septum is the most common source of cartilage for a nose job and often the septum needs to be addressed for cosmetic and functional concerns.

The literature reported satisfaction rates after rhinoplasty in NYC are in the 80-90% range. The rates are lower in men compared to women. These results underscore the difficulty of nose job surgery and the need to find the best rhinoplasty surgeon who performs many of these surgeries every year.

When evaluating a patient for rhinoplasty, it is important to also assess the proportions of the rest of the face. Specifically, a recessed (under projected) chin can make the nose look bigger and more projected. Dr. Linkov counsels all of his patients on the possibility of chin augmentation, including an implant, should they meet criteria.

Some rhinoplasty surgeons, including Dr. Linkov, use computer renderings of what the nose might look like after surgery to help guide patient decision making. The most important utility of this process is for the doctor and patient to truly be on the same page about what the aesthetic goals are.

Please keep in mind that the computer image is not a guarantee of what will result after surgery, but rather a framework for the surgeon to work off of during surgery. It is extremely important that your surgeon is honest with the rendering and does not give in to just any digital manipulation, as the digital change must be possible to produce on the live nose.

Rhinoplasty is the technical term for a nose job. A nose job is a blanket term for any surgery involving the nose but typically is used to indicate a rhinoplasty or septorhinoplasty. The term “nose job” does not capture the full breadth of surgeries that can be performed on the nose.

For example, nasal reconstruction can be performed after the skin cancer is removed, and septoplasty surgery can be performed separately to address a deviated septum, without involving any other nasal structures. Rhinoplasty specifically describes nose plastic surgery that alters the bone, upper lateral cartilages, and/or lower cartilages of the nose.

There is no ideal age for a rhinoplasty. Rhinoplasty can be performed as early as teenage or adolescent years, assuming full parental consent under age 18. The key is to operate on noses that are fully matured and on patients who can understand the full risks and benefits of the procedure. Girls should be at least 15 or 16 years old before having a rhinoplasty and boys should be at least 17 or 18 years old. There is no age maximum for a rhinoplasty, assuming that a person is medically and emotionally able to proceed with a surgical procedure.