Rhinoplasty

Who is a good candidate

You're likely a good candidate if you want to change how your nose looks or breathes, and you:

• Have finished most of your facial growth, usually between 15 and 18. A good rule of thumb: your shoe size and height haven't changed meaningfully in the past year.
• Are generally healthy, since surgery is done under at least light sedation and usually general anesthesia.
• Have realistic expectations. If you can't say specifically what bothers you about your nose, or you're hoping to replicate a celebrity's nose, rhinoplasty may not be the right fit.

Rhinoplasty for men

Masculine noses tend to be more projected, wider at the base, less upturned, thicker-skinned, and often have more of a hump. The first step is a clear understanding of your goals. Taking a hump down too far can feminize the nose with a sloped look, and over-rotating a tip that has drooped with age can look unbalanced. Most men who come in don't want an “operated-on” look. They want a natural change to the one thing that bothers them, most often crookedness, a large hump, or a drooping tip.

Primary and functional rhinoplasty

The main distinctions are whether the nose has been operated on before, whether the goal is breathing, appearance, or both, and the anatomy and goals each person brings.

Primary rhinoplasty

Surgery on a nose that has never been operated on. The tissue planes are more straightforward, there are rarely surprises unless there was prior trauma, and, most importantly, the septum is almost always intact. That matters because the septum is a valuable source of graft material for reshaping the rest of the nose.

Functional rhinoplasty

Surgery to improve airflow. Blockage may come from weak cartilage on the sides of the nose that collapses when you breathe in, naturally narrow nasal valves, or deviated nasal bones that push on the septum, whether from injury, previous surgery, or genetics. Cartilage grafts, often from the septum, reinforce and rebuild the structure. Appearance can often be improved at the same time; the two go hand in hand.

The inferior turbinates are often reduced too. These are normal structures inside the nose that warm, humidify, and filter the air, and in some people, including those with allergies, they are enlarged. They are reduced “submucosally,” debulking the tissue underneath their surface so their natural function is preserved.

Will a cosmetic rhinoplasty change my breathing? In most patients, breathing improves, especially if it was a problem before. If you want the nose made much smaller, breathing can get worse, depending on how much cartilage is removed.

Revision rhinoplasty

Surgery to fix a cosmetic or breathing problem that remains or returns after a previous nose surgery. It is more complex than a first rhinoplasty, and healing is harder to predict.

Surgery for a cosmetic or breathing concern that persists or returns after a previous nasal surgery. It is more complex because of scar tissue, altered cartilage, and possibly too little septal cartilage left for grafting. It also carries a higher chance of needing further revision. One review found revision rates of about 3% after primary rhinoplasty and 11% after revision rhinoplasty; another reported rates of up to 10% and 20%. A surgeon can optimize every condition in the operating room, but it is very difficult to predict exactly how a nose will heal and scar, especially when scar tissue is already present.

Heilbronn et al., 2020; Hacker et al., 2021.

Ethnic rhinoplasty

Your plan respects your heritage and your goals. Nasal anatomy and cultural preferences differ across ethnicities, and both shape what surgery should, and shouldn't, change.

Nasal anatomy and cultural preferences differ across ethnicities. Patients of Asian and African descent often share thicker skin, relatively weak cartilage, a low bridge, a less projected, rounder tip, and a wider base, but priorities often differ: building up the area between the eyes (the radix) is more common for patients of Asian descent, while narrowing the base or reducing flare is more common for patients of African descent. All of this is weighed when planning how to meet your goals.

When there isn't enough strong cartilage for grafting, it has to come from elsewhere, most often donor rib cartilage or your own rib cartilage. Each has pros and cons, and the choice depends on your comfort with the risks of each relative to the structural changes needed.

Open or closed?

The difference is where the incisions go. Dr. Kinkhabwala performs both and chooses case by case. Neither is better; they are simply different.

The choice is very surgeon-dependent: some internationally respected surgeons do only open surgery, others only closed.

Preservation (“ultrasonic”) rhinoplasty

A way of lowering a hump without cutting it off. Dr. Kinkhabwala prefers it for hump removal, especially when the nasal bones are also slightly crooked.

How it works

Traditionally, a hump is removed by separating the side cartilages from the septum (so they aren't cut, which would hurt breathing), trimming the hump, and suturing the cartilages back to the middle. For moderate to large humps, bone cuts are also needed to narrow the nose and avoid a flat-topped “open roof” look.

In preservation rhinoplasty, cuts are made in the septum and bone while the side cartilages are left intact, so the hump comes down more naturally. The technique was first described in 1899 and briefly popularized in 1946, but the international movement really took off in the last 10 to 15 years. Dr. Kinkhabwala uses an ultrasonic (piezo) device for extremely precise bone cuts, which is why the technique is often marketed as “ultrasonic rhinoplasty.”

Rhinoplasty vs. septoplasty

Both change the framework of the nose. The difference is which part. They are often combined, called a septorhinoplasty, when someone wants both better breathing and a change in appearance.

The day of surgery

Surgery is done in the practice's own operating room with a licensed anesthesiologist, usually under general anesthesia. You go home the same day with a cast on the outside of your nose and, usually, two soft splints inside.

What happens, in detail

Anesthesia is most often given with a flexible laryngeal mask airway (LMA), and sometimes a traditional breathing tube. Antibiotics are given during surgery to reduce infection risk, along with tranexamic acid (TXA), which numerous studies show reduces bleeding during surgery and bruising afterward.

In recovery, you receive a bag with your medications (including pain medication), a nasal spray, and a water-based ointment. The cast reduces swelling; the splints hold the septum in place and lower the risk of a blood collection (hematoma). Both come out at 1 week.

Recovery, week by week

The first week is the hardest. By 1 month, most strangers can't tell you've had surgery. The final result takes about a year, longer for a revision.

Is it painful? It can be, particularly in the first few days. The most common complaint Dr. Kinkhabwala hears afterward, though, is a clogged nose: the splints get clogged with crust. Saline spray throughout the day keeps them open.

Going back to work: for light work without much lifting, many people go back in 1–2 weeks. For manual labor, you'll need a note to avoid heavy lifting for closer to a month.