Rhinoplasty (Nose Job Surgery)

The word “Rhinoplasty” derives from the Greek term rhis (nose) and plassein (to shape). Rhinoplasty surgery, also known as 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. Rhinoplasty is often combined with a septoplasty, which is called a septorhinoplasty. Primary nose job refers to an operation in a previously unoperated nose, whereas the term secondary (or revision) is used to describe a surgery for patients who had at least one prior rhinoplasty.

The singular goal of cosmetic rhinoplasty used to be 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. In recent decades, 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 to balance the aesthetics with the rest of the face, as well as consider ethnic preferences, while performing nose plastic surgery.

Rhinoplasty is a category of plastic surgery involving alterations to the nose. While cosmetic changes are often associated with 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. Due to the limited amount 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, Dr. Linkov, the best-rated Manhattan rhinoplasty doctor advises to perform 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, a best in class Midtown NYC rhinoplasty specialist 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.

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

• Bone: The most important bony structures that define the nose are the nasal bones at the top, the ethmoid bone at the back, and the maxilla at the bottom. Each of these areas is often encountered during rhinoplasty and help 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, including the internal and external carotid arteries. Precautions need to be taken before, during, and after surgery to minimize bleeding. Also, the surgeon needs to understand where the blood vessels travel to avoid complications of the surgery, such as skin loss.

Broadly speaking, there are two ways to approach the nose for a rhinoplasty, these include:

• Closed rhinoplasty: Sometimes referred to as an 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. This technique was once the most popular approach but has become less popular over time due to limited visibility for the surgeon. 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 and 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, though 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 surgeon and the patient. Many surgeons are comfortable with both approaches and select the best one based on a particular case. When you come in to see Dr. Linkov, the rhinoplasty NYC specialist, he will examine you and discuss if more complex nose reconstruction is required.

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

2. Sourcing of Cartilage and other Building Materials

Since modern-day NYC rhinoplasty procedure involves providing adequate structural support for optimal form and function of the nose, 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 can be used such as cadaveric rib cartilage or synthetic materials such as high-density polyethylene (Medpor). 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 different types of nasal grafts used, including:

As you can see there are many grafts that your rhinoplasty 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 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 and this area can be corrected during the septoplasty portion of the surgery to straighten the septum and therefore the external appearance of the nose.

5. Closing up

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

Once you have decided to undergo a nose surgery, Dr. Linkov, top rated NYC rhinoplasty doctor will discuss in detail how to prepare for your surgery. There are a few steps you should take before your rhinoplasty in order 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
• Identify an escort home, as you will need 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 your scheduled rhinoplasty surgery in NYC.

This nose cosmetic surgery is performed under general anesthesia with an anesthesiologist, so 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 be about another hour.

Recovery after rhinoplasty surgery varies from person to person. There is a short-term healing phase that occurs in the first few days to weeks following the surgery, and a long term healing phase that 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
• Avoid rigorous exercise for at least 1-week postoperatively
• Do not blow your nose and please sneeze with your mouth open to avoid excessive bleeding
• Practice good nasal hygiene with nasal saline spray five times daily, starting 48 hours after surgery
• You should refrain from participating in contact sports for at least six weeks to prevent nasal injury
• Attend your follow up appointment for suture, nasal splint, and cast removal at about 1 week postoperatively. Make 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 amount of time each person will spend in the long term healing phase also varies 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. Occasionally, steroid injections are used to help control the swelling.

The answer to this depends in part on which techniques were used during your nose job NYC surgery. Some techniques are more durable than others. Another factor that can impact long-term rhinoplasty results is the aging process, which causes a weakening of the nasal tip and subsequently 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).

The risks and complications of this nose cosmetic surgery 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 (usually around age 16) may benefit from cosmetic nose reshaping when it is carefully performed by an experienced facial plastic surgeon.

Complete reshaping of the nose is usually performed under twilight or general anesthesia. Some simpler procedures, like nostril reduction, can be performed with only local anesthesia. 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.

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.

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.

The cost of a nose job surgery in NYC is a combination of a surgeon’s fee, facility fee, and anesthesia fee. These are sometimes reported as a combined fee in certain offices and other times broken down into their components in other offices. 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 costs of a nose job will vary by location, surgeon experience, and demand, along with 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, and often surgeon 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 rhinoplasty to improve nasal function. Many New York rhinoplasty surgeons are strictly out-of-network, including Dr. Linkov, which 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.

The best rhinoplasty plastic surgeon in NYC is the surgeon with whom you feel the most comfortable and confident. Your surgeon should be a doctor who is board-certified in plastic surgery or facial plastic surgery. You and your rhinoplasty surgeon should be in agreement with your surgical goals and desired appearance. You should feel comfortable that your nose job surgeon will guide you through the recovery stages and be there for you should any complications arise.

Dr. Gary Linkov is a board-certified and among the best NYC nose job doctors, with extensive experience treating all conditions of the nose. He is the Chief of Otolaryngology and Facial Plastic Surgery for the Veterans Hospital in Brooklyn, NY, where he operates on complex nasal deformities, serving our country’s veterans.

Dr. Linkov’s private practice on Manhattan’s Upper East Side in New York City focuses on cosmetic and functional rhinoplasty. You can view before and after photos of the rhinoplasty procedure below: