Behind the Double Doors: The 10 Questions Everyone Asks About Rhinoplasty

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Houston facial plastic surgeon Dr. Taylor DeBusk answers the top 10 rhinoplasty questions people ask most often to help you feel more confident about the procedure.

He covers everything you need to know, from how it’s done and the differences between open and closed rhinoplasty to important topics like risks, age considerations, recovery timelines, and costs.

Find out when rib cartilage is used for support, how long it takes to see your final results (patience is key!), what rhinoplasty can and can’t do, and more.

Read more about Houston facial plastic surgeon Dr. Taylor DeBusk

See rhinoplasty before and after photos

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Transcript

Dr. DeBusk (00:11):
So today we’re going to talk about the top 10 questions people ask about rhinoplasty. So what specific changes can be made to my nose and what can’t be changed? So this is a common question we get with pretty much every rhinoplasty consultation. And when we look at the nose, things that can be changed are the bridge of the nose, which is one of the most common reasons people are interested in a rhinoplasty if they have that nasal hump or too much of a convexity over the bridge. Those are things that we can bring down by shaving down the bone or shaving down the cartilage. Other things that can be changed is the shape of the tip. That’s pretty much the second most common reason people want or are interested in rhinoplasty having a very round tip or asymmetric tip. These things we could augment or change the shape of the cartilages to give you much more symmetric shape or more defined contour.

(01:02):
You can also change the width of the nose by narrowing the nostrils. So most of the anatomic things can be augmented or changed to better fit the patient’s ideal aesthetic. One thing that can’t be changed or is hard to manage is the thickness of the skin. So with a lot of rhinoplasty patients, this can be a limiting factor in regards to the type of definition that you can get with the nasal tip and the nasal tip contour. There are some things that we’ve been using, some medications that have previously been used or most commonly used for acne like Accutane. These things can kind of thin out the skin a little bit to try and improve the contours or the shapes of the nasal tip, but again, one of the limiting factors with rhinoplasty surgery is just the overall thickness of the patient’s skin. What are the risks of rhinoplasty?

(01:50):
Well, I mean, rhinoplasty is a surgical procedure, so the typical risk of any surgical procedure like infection, bleeding, those are low risks, but again, those are inherent risks with surgical procedures. One of the most common risks that we see with rhinoplasty surgery is just the undesired cosmetic outcome. And that can be due to the surgeon not being well versed or very comfortable with rhinoplasty or comfortable with the specific changes that you’re trying to achieve. Other risks can be loss of cartilage and that can be due again to over resection of cartilage during the surgery. That can really result in the dreaded saddle nose deformity or excising too much of the cartilage at the bridge of the nose. Other risks with rhinoplasty surgery can be, again, one is asymmetries. Asymmetries can be controlled only so much by the surgeon and their techniques because every patient will heal differently when the soft tissue around the bone and the cartilage heals.

(02:56):
Some patients can develop thinness, or thinning of the skin over certain parts of the nose. And if your skin is too thin in certain areas, specifically over the bone, you can have subtle irregularities specifically at the top of the bridge of the nose. Same thing with the tip, the nasal tip. If patients have weak cartilage, as the skin heals with time, the cartilage can buckle or create again, visible irregularities at the nasal tip. These are all things that your rhinoplasty surgeon should really discuss with you, review with you and change kind of their approach or grafting techniques to minimize those types of risks. How old do you have to be to have a rhinoplasty? So typically with females, we say the youngest age, or I say the youngest age, for rhinoplasty surgery is going to be about the age of 17, and men or males need to be about the age of 18.

(03:49):
Now that’s just pretty standard across the board. If patients have had severe nasal trauma or have severe breathing issues, then we can make exceptions to that and perform rhinoplasty surgery on these patients at a younger age. Again, mostly for functional reasons. Usually patients are a little bit older, mid twenties, thirties or beyond because they’ve been thinking about having a rhinoplasty for quite a long time. The nose doesn’t really take its full shape until after puberty has hit, so most people don’t start to become aware of the irregularities or the overall shape of the nose until they’re really in their later teens or early twenties after your nose is completely developed. Now, on the opposite end of the spectrum with age in regards to rhinoplasty, older patients, as you get to sixties, seventies, eighties and beyond, things that you have to take into account again is the thickness of skin.

(04:43):
Because as we age, we start to lose a lot of collagen and elastin in our skin and the skin becomes very thin. And that’s important to be aware of specifically again around the nasal bones and as well as around the nasal tip and the skin around the cartilages of the nasal tip. If the skin is very thin, we have to counsel the patient on the potential for irregularities or contour issues, but a lot of times you can take that into account and use grafts such as fascia that we take from above the ear to maximize our ability to camouflage these potential irregularities. What is the difference between an open and a closed rhinoplasty? So an open rhinoplasty, the majority of the incisions are made on the inside of the nose, and then there’s about a five millimeter incision made on the bottom of the nose called the columella.

(05:29):
Whereas with the closed rhinoplasty, all the incisions are inside the nose. One of the benefits of doing an open rhinoplasty is that you get much better visualization of all the cartilages, specifically the cartilages of the nasal tip. For me, I prefer open rhinoplasty because I have much more control over the tip shape and a much better idea and understanding of the final outcome or product of the rhinoplasty. A closed rhinoplasty, again, most of those incisions or all of the incisions are on the inside of the nose. You’re still doing all of the same surgical maneuvers and techniques, but you have less visibility. One of the benefits of closed rhinoplasty, other than lack of that five millimeter incision, is that there can be less swelling specifically along the nasal tip, but neither one of these procedures has better long-term or worse long-term outcomes. Again, for me, I prefer open rhinoplasty because it gives me much more visibility and much better control of the nasal framework. When are rib cartilage or other types of grass used in primary rhinoplasty.

(06:34):
So I use cartilage often in both primary and always in secondary rhinoplasty. So with primary rhinoplasty, if the patient has a severely deviated septum has a history of nasal fracture or injury to the nose or to the nasal septum or ethnic rhinoplasty. So in non-Caucasian noses, oftentimes what we can see is there’s a deficient amount of cartilage or the cartilage can be very thin and weak. In those cases, I always want to have a backup plan because whenever we do a rhinoplasty, my primary focus is on building a strong foundation inside the nose so that when we make our contour changes, we know that the nose is going to be rigid, going to withstand time, and it won’t develop any nasal or breathing issues. I typically prefer to use rib grafts, and that can either be rib from the patient themselves or oftentimes in more often nowadays I use donor rib, which is cartilage that has been irradiated or washed free of all cellular debris.

(07:36):
It’s basically just a scaffold. It looks like rib, but there’s no proteins in it, so we can cut it up, use it as rib, and the patients actually grow into the rib or the rib becomes their own tissue with time. Other places that we take cartilage can be from the ear. I don’t use it as much these days for two reasons. One, because the ear cartilage has a very concave shape. It’s hard to get those pieces of cartilage to be very straight, which in rhinoplasty more often than not, we want our cartilage grafts to be as straight as possible to give us the best outcome. Also, the ear cartilage tends to resorb more. So what we’ve been seeing is that when we use ear cartilage, oftentimes some of that ear cartilage can disintegrate or disappear within the nose, and if that happens, then we tend to see contour irregularities or asymmetries 12, 18, 24 months down the line.

(08:32):
Another type of graft that I use often is fascia. So fascia is a thin layer of tissue that’s over a muscle. I typically take it from the muscle that’s above the ear, and what’s one of my favorite types of graft to use, again, because it is so thin that you don’t see it in the nose externally after you heal from your rhinoplasty, but it is very good at creating smooth contours specifically over the nasal bridge or over the nasal tip, especially when somebody has very thin skin. One of the benefits of using donor rib is that number one, you don’t have to harvest the rib from the patient themselves, so it decreases the surgical risks because you’re not making a separate incision in the chest, and it also improves the patient’s recovery by using donor rib because can be very painful to remove a patient’s rib because it’s in the chest, there’s a lot of musculature that you have to dissect around to harvest that piece of cartilage, and when you make those incisions and manipulate those muscles, it can cause a lot of discomfort or pain when patients breathe or move around. So that’s why most people these days tend to prefer using the donor rib because it shortens the surgical procedure and it decreases surgical risk. Will there be visible scarring after the surgery? And rhinoplasty scars, how do we take care of them? So with an open rhinoplasty, again, the incision is about a five millimeter incision at the bottom of the nose. These incisions heal remarkably well. The vast majority of patients, once you hit that 12, 18 month timeframe, those incisions are hard for me to even find. That being said, you want to optimize the healing so that you minimize that scar visibility. And one of the things that have all patients do within those first three to four weeks is just use Aquaphor or Vaseline a light amount to keep that incision very moist because moist incisions heal the best.

(10:17):
And then once we hit that four week timeframe, actually start them on a silicone based ointment again to even further improve the visibility of that scar. All the other incisions for rhinoplasty are all inside the nose, so those are not visible. The way I have patients manage those incisions the first couple of weeks after surgery is using a light amount of Aquaphor on a Q-tip and wiping it on the inside of the nose just to keep those incisions moist. But usually once you hit that three to four week timeframe, most patients have no issues whatsoever with any of those incisions on the inside of the nose. One of the most important parts though, in regards to post rhinoplasty care is making sure that the inside of the nose stays very moist. I recommend that every patient consistently use nasal saline sprays because that keeps the mucosa on the inside of the nose extremely moist and healthy.

(11:07):
It reduces crusting, increases the amount of airflow that we get through the nose. So it really just maximizes the patient’s comfort as well as maximizing the patient’s ability to heal in that postoperative setting. How long is the recovery period, and when can I resume normal activities, and how long will I have swelling after surgery? Now, I would say this is the most common question that I get in our consultations, and I think it’s probably the most important topic that we discuss during the consultation because rhinoplasty, one of the main things people have to be aware of is the recovery period. So what I tell everybody, typically at one week after surgery, we’ll see you back. We take the cast off the nose, take the splints out of the inside the nose if you have splints. At that point, you have a very swollen nose. You’re not going to like the tip shape, but you’ll see the improvements at a week.

(11:57):
But again, due to the swelling of the soft tissue, it honestly looks nothing like the final product at a month. So four weeks after surgery, a lot of that initial swelling has improved. You’re really starting to see the shape of the nasal bridge. When you walk down the street. Nobody will have any idea you had surgery, but every time the patient looks in the mirror, what they see is kind of the tip is still pretty swollen or still kind of round. Once we get to that third and fourth month, we’re really starting to see the shape of the tip. You still have some residual swelling and edema of the soft tissue, but you’re really starting to see those contours and the improvement of the tip shape relative to where we were before surgery. Then from month four, all the way to month 12 into month 18, you still continue to have that soft tissue contracture of the skin around the cartilage and bone, but the progress is much slower, again from month four into month 12 or in month 18.

(12:56):
So I tell every patient, you have to be very patient with respect to the healing. Ideally, once you get to that third, fourth month after surgery, you’re really likened the shape of the nose, but you still have to be kind of patient until you get to that month 12, month 18, until we say that you’re kind of a hundred percent healed. Does rhinoplasty fix breathing problems and are there benefits of rhinoplasty outside of aesthetics, allergies, breathing, sleep apnea, snoring? So yes. So with every rhinoplasty I do, the initial or primary goal is to make a structurally sound nose and a structurally functioning nose. So what I mean by that is that even though patients may not have breathing problems as a reason to get a rhinoplasty, the goal with after rhinoplasties to always have a straight septum or as straight as humanly possible and keep those nasal passages open, because it doesn’t matter how good looking or how cute your nose is, if you can’t breathe out of it, you’re not going to like it.

(13:54):
So for me, again, my primary goal is to always have a structurally strong structurally sound nose that breathe extremely well. When can you resume your normal activity? So with patients, I typically say that first week after surgery, we really want you to relax. I want you up moving around, but I don’t want you to overexerting yourself or getting your blood pressure up. After that first week when we get the splints out, quality of life dramatically improves because you’re able to breathe through your nose beautifully. We still, want you at about 25 to 50% of your normal activity, after that third week, you can go back up to a hundred percent your normal exercising, running, weightlifting. We still recommend using a lot of nasal saline spray to keep the inside of that nose very moist because after rhinoplasty surgery, you’re going to have a lot more airflow through the nose.

(14:41):
Even though you didn’t have necessarily breathing problems before, you’re still going to have a much more open nasal passages after rhinoplasty. So because of that, because you have more airflow, you’re going to end up having more drying or crusting on the inside of the nose those first couple weeks, even couple months. So it’s really important as you get back to a hundred percent your physical activity, you still stay pretty religious with using nasal saline spray on a daily basis. Allergies, you know rhinoplasty is not necessarily going to improve a patient’s underlying allergic issues or concerns, but what it can do is open the nasal passages allow you to have much more ability to administer your steroid nasal sprays, your antihistamine nasal sprays, which in turn can help to improve your response to those medications. Sleep apnea, the data out there says that obstructive sleep apnea is not necessarily indication for a rhinoplasty, but what I can say anecdotally is I’ve had a lot of patients, even, even for strictly functional rhinoplasties who have been diagnosed with obstructive sleep apnea and require a C PAP device nightly, after they’ve had a functional rhinoplasty, patients tell me that their quality of sleep has dramatically improved. They start dreaming in, they actually don’t even feel like they need their C PAP anymore. That being said, I don’t tell patients that a rhinoplasty is going to fix your sleep apnea, but what I can say is that if you have nasal breathing issues because of a deviated septum and you have sleep apnea, by fixing that septum, your compliance or your ability to wear that mask will dramatically improve, which in turn will dramatically improve your sleep. So rhinoplasty in regards to snoring, again, snoring is typically not because of the nose. Snoring typically originates at the back of the nose at the palate. But if you have a very deviated septum, what that can create is very turbulent airflow in the nose, which in turn can result in snoring or causing a lot of turbulent airflow along the soft palate.

(16:44):
Now, by opening the nose, making that septum a lot straighter, getting laminar or more streamlined airflow through the nose can reduce that turbulence and thus improve snoring or reduce patient snoring. How long does the rhinoplasty procedure take? Now, this is again a question we get or I get honestly with every consultation, and that really depends on the patient. Number one, their baseline nasal anatomy, the shape of the nose, how deviated the septum is, if they’ve had trauma, and the types of changes that patients want to make. If patients just want the hump of the nose taken down, then it may take two to three hours. If they want the hump down and the tip reshaped or contoured, it could take three up to four hours. If they’ve had severe nasal trauma and they have very poor septal cartilage, then it can take potentially even longer.

(17:38):
So I try not to give a specific time for rhinoplasty for each patient. What I do tell them is that this may take a little bit longer due to the desired that you want to make, or it may take longer due to your nasal anatomy. But that being said, most rhinoplasty surgeries for me take about three to four hours. What type of anesthesia is used for rhinoplasty surgery? So I do all my surgeries under general anesthesia. The reason I like that is because number one, we put breathing tubes in the patient. So because there’s a breathing tube, it protects the patient’s airway. Rhinoplasty surgeries aren’t necessarily bloody surgeries in the grand scheme of things. That being said, if you do bleed in the nose and it trickles down the airway, it gives me a lot of comfort knowing that the patient’s safe by having an endotracheal tube or a breathing tube in the airway.

(18:29):
Also, patients are much more comfortable. In my experience, having a rhinoplasty surgery under general anesthesia and general anesthesia is safe. We have phenomenal anesthesiologists that work with us here in our surgery center. As a rhinoplasty surgeon, I’m very particular about the anesthesia, especially about how the patient wakes up from anesthesia because I don’t want patients waking up aggressively or waking up and having any pain. So our anesthesiologists here wake patients up deeply. So what that means is basically, once they remove the breathing tube, patients are breathing on their own, but they’re still very drowsy, though their airway is safe. And that does two things. One, it reduces patients waking up that are a little bit grouchy or patients moving around as they wake up. And the two, it also maintains the blood pressure at a reasonable level so that we don’t increase the blood pressure, increase risk for bleeding under the skin, which in turn can affect the long-term results of the rhinoplasty.

(19:28):
How much does rhinoplasty cost and can I finance? So rhinoplasty again depends on what the patient’s desire goals are, whether or not we need to use cartilage or fascia to achieve those goals. But typically, rhinoplasty, including anesthesia and facility fees are going to cost around 12 to $14,000. Most often patients do finance. Some patients pay everything upfront, but I’d say the majority of our patients will finance the expense of the rhinoplasty. And there are several financing options with 0% interest over several months. And these things our office can give you much more specific information on. But we can work with every patient, their financial situation, in order to make the rhinoplasty happen.

Announcer (20:17):
Basu Plastic Surgery is located in Northwest Houston, in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That’s BASU Plastic Surgery. Behind the Double Doors is a production of The Axis, theaxis.io.