Head and Neck Surgery Consultations
Terence M. Davidson, M.D.

Appointments: (619) 543-6631

This consultation is part of a series of consultations with Head and Neck Surgery specialists at the University of California, San Diego. The case is a hypothetical patient chosen to represent a composite of the usual and most common patients with this specific disorder. Where gender, age or race make a difference, these will be specifically cited. Where they do not make a difference, they may be omitted. The consultation is presented for purposes of general information. Specifics about an individual case and specific treatment must be discussed between the patient and the treating physician.

Patients presenting for septorhinoplasty have both gender and cultural differences. It is virtually impossible to cover all the nuances of septorhinoplasty in a single consultation. However, the principles and concepts should be similar. For purposes of demonstration a 24-year-old woman is chosen.

Doctor: Good morning. What can I do for you today?

Patient: I have been thinking about having a rhinoplasty for many years. I have heard that you are very good and have finally saved the money, gotten my notes together, and decided to explore what might be involved.

Doctor: What do you see when you look in the mirror, and what changes would you like to see as a result of this surgery?

Patient: When I look in the mirror I see a nose that is disproportionately large for my face. It has this big bump on the top and the tip just seems too broad, and also too big.

Doctor: How would you like to see that changed?

Patient: Well, I certainly do not want one of those cute little Hollywood noses, but I would like a nose that is smaller and more proportionate to my face.

Doctor: Do you have a sense of how much smaller you want it?

Patient: I know that I want it smaller. I do not know how best to describe it, and I am not even sure that I know what would be best for me. What do you think?

Doctor: While I would agree that removing the bump and reducing the bulbosity of your tip are very appropriate goals, it has been my experience that women today like bigger noses than they have in the past. Women are professionals. They work and compete in the business environment. Small, cutesy, submissive noses do not seem popular with today’s movie stars, and certainly not with today’s professional woman.

Patient: I understand and appreciate that. I do plan to work as a professional and so appreciate the comment.

Doctor: Have you thought about the dorsal line? By this I mean, in your profile, would you like there to be a smaller bump, a straight line, or a small depression?

Patient: Well, I certainly do not want a little ski jump. I would think a straight line would look good. What do you think?

Doctor: Given that a perfectly straight line is impossible to achieve, I think a straight dorsal profile would look good on you. I ask the question in part because I like to perform my surgeries conservatively, and if your preference were for a scoop, then I would tend to err on the scoop side. Conversely, if your preference were for a small bump, then we tend to err on that side.

Patient: Would it help you if I brought pictures of noses that I like?

Doctor: Generally, this is not helpful, because most of the pictures are taken in oblique views and it is very hard to separate the nose from the face. I think it is more important that we spend our time talking about your face and your aesthetic goals.

Patient: I understand some physicians like computers to show their patients what their nose will look like.

Doctor: I realize that many surgeons use computers. I personally find them to be very misleading. It is one thing to use a computer mouse and draw a straight line to erase a bump. It is a totally different thing to sculpt this on the operating table. The computer drawing, therefore becomes extremely misleading. In the front view, meaning what one sees face on, the computer is even less accurate, for it simply changes the shading, and by this implies changes that the surgeon must make by carefully sculpting the cartilages. For these reasons, I simply neither like nor use computers for cosmetic surgery evaluations.

Patient: How exactly is the surgery done?

Doctor: There are different approaches to nasal surgery. For the operation that you need, the best approach will be with small incisions all made inside your nose. External incisions are neither necessary nor to your advantage.

Patient: How can you work through such a small incision, and yet do what you have to do accurately?

Doctor: Well, this is part of the skill of rhinoplasty. We have trained, practiced, developed techniques and developed instruments that allow us to perform the surgery through very small incisions.

Patient: Do you need to break my nasal bones?

Doctor: As we take the bump off  your nose, you will end up with a somewhat flat appearance across the nasal dorsum. To correct this, we need to narrow the nasal bones, and to do that, very fine chisel cuts are made in selected spots and then the nasal bones push together. This leaves you a thinner nose postoperatively and one that is in balance with the reduced nasal dorsum.

Patient: Will I get black-and-blue eyes?

Doctor: Well, not everyone gets black-and-blue eyes. It is common to have some blood extravasate into the tissues. That is what gives the black-and-blue appearance. This typically dissipates in the 10 to 14 days following surgery.

Patient: Will there be much pain?

Doctor: Well, the surgery is performed with you asleep so that there is no discomfort during the surgery itself. Postoperatively, you may experience some mild discomfort and some mild pressure in and around your nose. This typically lasts for a day or two, and then dissipates rapidly.

Patient: Do you need to use packing? I have heard that it is the packing that is the worst part of the nasal surgery.

Doctor: While it is true that in the past we did use nasal packing, and it was uncomfortable, today’s nasal surgery no longer requires this kind of packing and the patient no longer incurs the discomfort of past surgeries.

Patient: How long will I be out of work?

Doctor: You will need to be out of work for two or three days. However, it is my preference that you actually take a week off. This is a major undertaking. It is important for you that it heals well. The human body heals best when it is relaxed and free to nap, sleep and be without the stresses of everyday life and work. It is therefore my preference that you do take a week off. If your work is such that you can do some at home and you enjoy that, it is fine by me. You are certainly welcome to go for a walk in the park, go to the movies, or participate in these kinds of activities. I just do not want you under the pressures of an 8-hour work day in a way where you can not take a nap, in a place where you can not relax, in a place where you can not recover.

Patient: Will my insurance pay for this surgery?

Doctor: The majority of insurance companies today no longer cover cosmetic surgery. If you had problems like a crooked septum with difficulties breathing or a broken nose with an external nasal deformity, then your insurance company would cover some or all of the surgery.

Patient: Well, can’t we just say that I have a crooked septum?

Doctor: While I know that some have done this in the past, insurance companies often require second opinions, and in any case, that would be dishonest on my part. I have chosen to be honest with you and honest with the insurance companies, and given that your septum is relatively straight, this is a breach of etiquette I choose not to make.

Patient: I need to tell you I have consulted with another facial plastic surgeon. How does one choose between surgeons?

Doctor: This is a good question, and one which is difficult to answer. It is difficult for you to know which surgeon is better-trained or better-skilled to perform your surgery. Certainly, knowing others who have had surgery by the surgeon and have had good experiences and positive outcomes is supportive. Ultimately, you simply need to decide that this is a surgeon whom you believe understands what you want, has the skill to provide it, and is the kind of individual you like, and if problems arise, is the kind of individual who will stick by you and work with you through both the good and the bad.

Patient: Well, what kind of problems could I have?

Doctor: Complications for nasal surgery include infection, bleeding, scarring and failure to achieve the result you wanted. Infection and bleeding are uncommon, and if they occur, they are generally easy to treat. Scarring is not typically a problem with rhinoplasty, although it potentially can be. The biggest complication or the biggest problem is whether my surgery can meet your expectations. Generally speaking, cosmetic surgery such as rhinoplasty makes significant improvement. It never reaches perfection. If your expectations are a perfect nose, a perfect face, and a perfect life all as a benefit of this surgery, then your expectations exceed that which I can deliver and you would ultimately be disappointed. Conversely, if your expectations are that your nose will somehow be a little smaller, it will be in better balance with your face, it will be more aesthetic, then these are very reasonable expectations, and assuming no unexpected occurrences either during or after the surgery, you should have a good result.

Patient: Will my friends be able to know that I had a rhinoplasty?

Doctor: It is very interesting, but very often friends who do not know that you are going to have surgery are very insensitive to cosmetic change. Your mother would know. Those who are close to you and know that you are having nasal surgery will say that they see a change. One of the best compliments a patient can give me is to undergo rhinoplasty, return to work, and have their coworker say, "Gee, Ms. ________, you sure look good. Did you have a vacation?" What we’re doing in rhinoplasty is making small, subtle changes. You will see them and you will appreciate them, but these are not dramatic changes. This is not a whole new face for you. This is the same face, albeit with a slightly smaller nose.

At this point, the patient elected to undergo the rhinoplasty.

An open and honest discussion about the expense was carried on. A preoperative history and physical was performed and a surgery date was set.

Nurse: Dr. Davidson tells me you have decided to have a rhinoplasty.

Patient: Yes, I have, and I am looking forward to this.

Nurse: Let me go over some of the things that are important, some of the things that will happen, and some of the things that you need to know. First and foremost, it is very important that you not take any aspirin-containing compounds, any nonsteroidal antiinflammatory agents, or any blood-thinning compounds. All of these reduce your ability to form a blood clot and they put you at significant risk for bleeding during or after surgery. If you have any discomfort for the week or two before surgery, you should take Tylenol. If for some reason that is not sufficient, you will need to call and we can discuss other medications.

Patient: Do I wear makeup the day of surgery?

Nurse: You should take a shower and shampoo the night before surgery. The morning of surgery you can wear light makeup or no makeup. Heavy makeup would have to be washed away. It is also important that you have a normal dinner and a good night's sleep; however, the day of surgery you are neither to drink any fluids nor eat any foods, for if you have anything in your stomach, the anesthesiologist cannot put you to sleep, and the surgery would have to be postponed and rescheduled.

Patient: I assume that I can not drive myself home.

Nurse: That is correct. After surgery and when you awaken from the anesthesia, they will put you in a recovery room where you will be watched for a period of 2 hours. When you are fully awake and ready to go home, then a friend or relative will be expected to drive you home. Since you have had anesthetic, it would be unsafe for you to drive yourself. It is also nice if a friend can spend that afternoon and evening with you. Problems do not normally arise, but is nice to have someone get you a glass of water and it is certainly nice to have someone there in case problems arise and you feel that you need to return to the hospital or something like that.

The patient underwent her rhinoplasty.

The surgery went well. The recovery went well, and the patient is now back in the office 4 days later.

Doctor: How have you been doing?

Patient: It actually was quite easy. I had a little stuffiness and discomfort the evening of surgery and into the next day; however, this was easily managed with Tylenol and one or two of those codeine tablets you gave me. My eyes are slightly black and blue, but certainly not as bad as I had feared. It is strange, but I can breathe through my nose, so I have not had much discomfort in that regard, and right now I am looking forward to having this cast taken off and seeing what my new nose looks like.

At this point the doctor removes the cast and the tape.

The patient looks in the mirror, nods with approval, and says, "I like what I see."

Physician: I think that your surgery went well. I, too, like what I see. Keep in mind, however, that your nose is swollen and that it will get smaller with time. And it is not really until 6 or 12 weeks later that you will know how your nose will heal. There are some little splints in your nose. They have little silicone straws in them which is why you can breathe. They help support the interior of your nose, and you will need to come back in 4 days to have those removed.

Patient: Is that going to be uncomfortable?

Doctor: No. People always worry because they have heard about packing, but removing the splints will not be uncomfortable. The fact of the matter is, they do not stick to the mucosa, they are not very big, and they are not uncomfortable to remove.

Six weeks later, the patient returns. Postoperative photographs are taken.

Doctor: And how are you doing?

Patient: I am doing spectacular. I can breathe through my nose like I have never breathed before, and I very much like the changes that you have made and the appearance that I have.

Doctor: Have your friends commented?

Patient: You know, it is interesting. It is just like you said. They don’t know that I’ve had a rhinoplasty. They keep looking at me. They somehow know that I am different, but not a single one of them has said, "Gee, have you had your nose done, or why is it that you look different?" Now, I didn’t tell my mother that I was going to have the surgery, and I didn’t see her until last week, when all of the bruising was gone and all of the swelling was gone. I walked in, she took one look at me and said, "You’ve had your nose done." I said, "Yes, I did." Fortunately, she likes it as much as I do.

Doctor: I would like to see you back at 3 months, 6 months and a year. If problems or questions arise, I would want to see you sooner. There is no charge for any of the postoperative visits.

Patient: I’ll be back in 6 weeks. I don’t know how to thank you for what you’ve done. I just want you to know how much I appreciate it.

Doctor: It has been my pleasure.