Rhinoplasty for small nose can mean a lot of things. Does the patient want to augment the bridge of his/her nose? Or does he/she want to correct the upturned tip, a feature that can make the nose appear too short or small in relation to the face?
The before photo shows the patient having very visible nostrils due to her over-rotated tip. By counter-rotating the tip with the use of cartilage graft, the nose now appears more proportionate to her face as shown in the after pic.
To achieve results that will satisfy the patient long term, leading Los Angeles plastic surgeon Dr. Tarick Smiley highlights the importance of candid discussion with a rhinoplastic surgeon.
Dr. Smiley says the right candidate for rhinoplasty, or nose job in layman’s term, is someone who can explain his/her goals in detail, adding that vague or generalized description is a big no-no for this surgery in which the success or failure is determined by a few millimeters.
To further shed light on the issues involving rhinoplasty for small nose, the renowned plastic surgeon explains the two most common goals of patients.
- Augment the dorsum or bridge
Some ethnic patients ask for rhinoplasty augmentation to make their nose appear more proportionate to their face. The goal is to create results that are ethnically consistent with the face and so over-augmentation must be avoided.
To augment the dorsum, most surgeons prefer autologous cartilage graft, meaning the patient’s own tissue is used instead of synthetic materials such as silicone or silastic. Possible “sources” include the nose itself, ear, hips, and ribs.
Patients having their primary rhinoplasty (no previous nose surgery) and are only seeking for a conservative amount of augmentation are generally good candidates for autologous cartilage graft, therefore avoiding the potential risks that come with artificial implants.
- Correct the over-rotated [upturned] nose
Sometimes referred to as Miss Piggy (in reference to the Muppet character), an overly rotated or upturned nose can make it appear too short for the face. Some people have this as an inherited feature, while in some cases it occurs from trauma or a botched nose surgery.
To correct the short and over-rotated appearance, the most important thing is to create a strong support to the tip, allowing it to maintain its counter-rotated position.
Because the tip requires significant reinforcement, most surgeons use septal cartilage, which is collected from the nose itself. Rib cartilage is also a good option to create a strong support and to lengthen “visible” wall of tissue between the nostrils. Ear cartilage, meanwhile, is rarely used in this surgical maneuver due to its insufficient strength.
Septoplasty insurance coverage might be possible provided that the patient and his doctor are able to prove that this type of nose surgery aims to improve breathing functions. For this reason, proper medical documentation is of critical importance.
While septoplasty is commonly combined with rhinoplasty, or more commonly referred to as nose job, its only aim is to improve the function of the nose—not its outside appearance or “aesthetics.”
Septoplasty primarily “aligns” the deviated septum, which is the strip or wall of tissue between the nostrils, ultimately eliminating the “obstruction” of airflow. In general, it has no or very little effect on the outside appearance of the nose, according to California Surgical Institute website.
Should the patient and his doctor are able to demonstrate that septoplasty is a medically warranted procedure, health insurance is possible. Many surgeons these days have well-trained staff who can verify insurance coverage and possibly help individuals secure proper medical documentations.
Nonetheless, septoplasty insurance coverage typically means that the patient will still pay for the deductibles, copays, etc.
It is not uncommon to combine septoplasty and rhinoplasty in one surgery. Should the insurance agree to cover the cost of the “reconstructive part” of the operation, the patient will still have to pay for the anesthesia “time” associated with the cosmetic aspect of the procedure.
It is almost always ideal to combine septoplasty and rhinoplasty (should the patient wish for cosmetic improvements as well) instead of performing them separately. With combo procedure, he will only experience recovery once and possibly lower the overall cost of the surgery.
Doing them together also gives the surgeon more “options” and better control over the aesthetic aspect of the nose. For instance, instead of throwing away the removed [excess] septal cartilage, which contributes to the abnormal airflow, he is able to re-use it to refine the tip and/or create a stronger structural support.
As of this writing, the average cost of septoplasty combined with rhinoplasty varies from $5,000 to $8,000.
A revision rhinoplasty on thick skin poses certain challenges. First and foremost, the overlying skin makes it difficult, or sometimes impossible, to show a high level of refinement.
Nonetheless, most patients can still expect a great deal of improvement after a revision rhinoplasty or corrective nose job.
To achieve good results, primary and revision rhinoplasties should ensure that the overlying skin can “shrink wrap” around the altered bony and cartilaginous framework. For this reason, over-reduction and over-narrowing will not provide any real benefits to patients with thick nasal skin.
Leading Beverly Hills plastic surgeon Dr. Karan Dhir warns that a thick nasal skin will not redrape well over the altered framework after an over-aggressive surgical maneuver, leading to an amorphous-looking tip.
Having a thick skin also results in longer recovery and more postop swelling and bruising. But regardless of skin thickness, most patients will look socially presentable at 2-3 weeks since the external swelling tends to dissipate quicker as compared with the internal swelling.
Despite the challenges brought on by thick skin, it is good at concealing minor irregularities that could easily show through a markedly thin skin.
Aside from skin thickness, the number of nose surgeries can also influence the length of recovery. In general, a person who has had multiple revisions should expect longer healing period.
Revision rhinoplasty on thick skin is inherently challenging because the baseline of the nose has already been altered, and the presence of scar tissue makes the skin harder to work with.
Aside from careful placement of incisions, steroid injections after a revision surgery can also minimize scarring. In addition, this treatment is known to control the amount of swelling especially at the tip, leading to quicker recovery.
A good revision rhinoplastic doctor will make every effort to avoid additional scarring, which can alter the way the nose heals and settles.
To achieve good definition and preserve the structural integrity of the nose, adding cartilage grafts—which are natural tissues from donor sites such as the septum (wall between the nostrils), ribs, and bowl of the ear—is common in revision rhinoplasty.
Preserving the structural integrity of the nose also ensures that the results can last a lifetime, look natural relative to the rest of the facial features, and less susceptible to the effects of aging, which are the main goals of any sensible surgeon.
A revision rhinoplasty surgery, or “nose job,” poses some unique challenges due to the presence of scar tissue that makes the skin harder to work with. Also, surgeons often deal with patients who are confused and deeply disappointed in the initial results, further adding to their predicament.
Nonetheless, great results or at least a good amount of improvement can be still achieved with proper patient selection and careful surgical planning.
Photo: A patient happy with the results of her ethnic rhinoplasty
The success rate of revision rhinoplasty also lies in the plastic surgeon’s experience, training, and level of artistic skills, which can be assessed by looking at his before-and-after photo gallery.
A revision rhinoplasty might pose more challenges when performed in ethnic patients, who in general have thicker skin and weaker underlying framework—i.e., small bones and floppy cartilage—than Caucasians.
One of the most common reasons why ethnic patients ask for revisions is the ethnically inconsistent result. Inexperienced and imprudent doctors do not recognize and respect the cultural and racial standards of beauty, and use techniques that are only suitable for Caucasians.
Too much augmentation and excessive tip narrowing often destroy the ethnic features, much to the disappointment of patients. To address these problems, a competent doctor will assess the underlying anatomies, the facial features and their distance from one other, and the patient’s cosmetic goals.
Oftentimes, grafts harvested from the septum or wall between the nostrils, bowl of the ear, or ribs are needed for structural support and improved contour. Compared with synthetic implants, they are better tolerated by the body and have a significantly lower risk of protrusion and adverse reaction.
Nonetheless, the thick skin of ethnic patients means that they are less susceptible to implant visibility, while Caucasians are generally advised to stay away from synthetic materials because their thin skin can easily show what is underneath.
In general, revisions result in longer recovery and more swelling and bruising compared with primary surgeries, although the degree of intervention (breaking bones and disruption of tissue) will still largely determine the downtime.
In revisions performed in patients with markedly thick skin and who require extensive work, the final result could even take up to two years. However, most will see a significant improvement at six months or sometimes earlier if the swelling has been controlled.
Since prolonged swelling is common among revision rhinoplasty patients and those with markedly thick skin, some doctors recommend them to have a small amount of steroid injection (Kenalog) to improve healing.
The thickness and elasticity of nasal skin will have a large effect on the results of rhinoplasty surgery, or “nose job.” Other factors that also play a crucial role include the patient’s gender, ethnicity, facial features, and amount and quality of the bone and cartilage.
A rhinoplasty procedure reshapes, files, or removes a small portion of the nose’s underlying framework—the cartilage, which is a flexible connective tissue found in the lower half of the structure, and the bone, which comprises the upper half. Meanwhile, the skin is not touched.
The overlying skin must be able to shrink down to the new framework, lest the results will appear amorphous or ill defined particularly at the tip.
The advantage of thin skin is that it can redrape better than thick skin due to its elastic nature. And for this reason, patients with this anatomy can tolerate more downsizing without having to worry too much about the risk of amorphous tip, explains leading Beverly Hills plastic surgeon Dr. Karan Dhir.
And due to the innate elasticity of thin skin, Dr. Dhir says it heals faster and experiences less bruising and swelling than thicker skin. Simply put, it leads to quicker social recovery, or about 10 to 14 days.
Meanwhile, patients whose nasal skin is markedly thick may have to wait a little longer before they look presentable in public.
And while full healing—i.e., the skin has “stabilized” or has redraped to the new contour—takes nine months to a year for patients with thin skin, complete recovery for someone with thick skin could take up to two years.
Due to persistent swelling experienced by ethnic patients who generally have thick nasal skin, it is not uncommon for their surgeons to recommend steroid injections especially into their supra tip (slightly above the actual tip or “end” of the nose) to eliminate or at least reduce the postop fullness.
Meanwhile, thin skin rarely requires the use of steroid injections, which must be used judiciously to avoid normal tissue atrophy (shrinkage). To prevent this type of problem, prudent surgeons typically dilute the drug and only use it during the first 3-6 months of rhinoplasty recovery.
However, thin skin has also its disadvantages. For instance, it could slightly increase the risk of minor revision to correct irregularities especially in the nasal bridge.
Any minor imperfection that is easily camouflaged by moderate or thick skin could show through thin skin.