More on Rhinoplasty and Cosmetic Plastic Surgery Do-Over

NO face-lift stops time, so as aging continues, even a satisfied patient may choose to have another one a decade later. But what if your face-lift never pleased you, not because of complications or monstrous scars, but because of aesthetics pure and simple? Perhaps your first surgeon’s technique resulted not only in a tighter jaw line, but also a flat wind-swept cheek and a stretched mouth. Or your nose no longer has an unsightly bump, but now, postsurgery, is asymmetrical.

These days, there’s such a critical mass of plastic surgery patients dissatisfied with their results that many doctors market secondary surgeries, or re-dos. It’s not hard to find surgeons’ Web sites that describe in detail how an asymmetrical nose job or an unsatisfactory face-lift can be righted. Last month, Dr. Sam T. Hamra, a plastic surgeon in Dallas, published “The Facelift Letdown: When Results Don’t Meet Expectations” to arm patients with information so they can better articulate their desires to their doctors and avoid postsurgery discontent.

No organization tracks how many procedures are done to correct cosmetic work. (Muddying the situation is the fact that some doctors tweak their own work if it falls short of the patient’s goals and that some complications call for immediate reoperation, like a hematoma, or a collection of pooled blood, beneath a closed incision.)

In this still-shaky economy, cosmetic surgery is down, and revisions for unhappy patients are included in that slump. But doctors who do a lot of revision face-lifts and nose jobs (two common redos) say demand for those operations is still strong.

Reasons vary, depending on the procedure. Rhinoplasty, for instance, is tricky because surgeons can’t control healing or how good the building materials are. Cartilage can be too thick or too flimsy; skin draped over a newly fashioned nose structure might not shrink to the shape the surgeon wants.

“It’s a difficult operation with a lot of variables,” said Dr. James C. Grotting, the editor of the textbook “Reoperative Aesthetic and Reconstructive Plastic Surgery.” “So even in the best of hands, people who only do rhinoplasty,” he said, there is still “a revision rate of up to 20 percent.” Some of the best fix-it nose doctors are sober about the limitations. Dr. Mark B. Constantian, a nose specialist in Nashua, N.H., whose practice is 75 percent revisions, said rhinoplasty is unique in that “you can lose ground every time.” With other kinds of plastic surgery, patients “are not worse off than when they started.”

Some doctors refuse to tackle secondary or tertiary rhinoplasties, and sometimes patients seeking these operations get unfairly labeled as “a fussy neurotic group,” Dr. Constantian said.

He pinpointed four reasons for dissatisfaction: breathing is worse, which can happen if a doctor doesn’t compensate for aesthetic changes; postoperative deformity that patients don’t like (perhaps removing a bump leaves the patient’s nose crooked); the patient never reached the original goal; and last, the patient got the requested change but now finds it unacceptable. “After, they feel they lost a familial or ethnic characteristic, and ask, ‘Can you do something to put my nose back to what it was?’ ” he said.

One of Dr. Constantian’s revision patients, a nurse in New Hampshire, got her first rhinoplasty in 2004 to fix her nose’s too-wide tip and a hanging columella, the tissue on the underside between the nostrils. As the post-operation swelling subsided, “Everyday I would look and wait for changes,” said the nurse, who asked to remain anonymous. But the nose tip “was still wide” and the columella didn’t look “touched at all.” She searched on Google for nose specialists and found Dr. Constantian. Today her profile is straight, her columella no longer hangs, and she breathes better. “My breathing was never a problem until after the first surgery,” the nurse said.

Sometimes earnest miscommunication between patient and doctor is at the heart of the matter. “What the patient is seeing in their mind is hard to describe to the doctor,” said Dr. Jack P. Gunter, who devotes 40 percent of his nasal-surgery practice in Dallas to redos. “Patients will say, ‘I just want a little taken off.’ How much is a little?” Other doctors sweet-talk patients into thinking the perfect nose or face-lift is within reach, leading to discontent. “People are marketing things they cannot achieve,” Dr. Gunter said.

These days advertising creates unrealistic expectations, said Dr. Grotting, whose practice is in Birmingham, Ala. The idea that a procedure can be quick, simple, painless, “all of these catchphrases are heavily marketed to plastic surgery patients,” he said.

When it comes to plastic surgery, Dr. Hamra said, the “customer is always right.” A gynecology patient isn’t the one to determine if she wishes to spend less money to remove fewer of her uterine fibroids. A plastic surgery patient, however, can choose a minimally invasive face-lift instead of a more complete one, said Dr. Hamra, who favors comprehensive face-lifts that address upper cheeks and foreheads. If one surgeon won’t give him what he wants, the patient finds one who will.

Celebrity cases of too many face-lifts overshadow a common problem these days: paying thousands for small improvements that don’t last.

“In face-lifts, you see undercorrections,” said Dr. James M. Stuzin, a plastic surgeon who specializes in face-lifts in Miami and does a “big volume of redos.” Mini face-lifts, he said, require “little recovery,” but have “little longevity.” He also cautions that some surgeons who do only occasional face-lifting “don’t reconstruct the internal anatomy, and that has more longevity.”

In other words, you get what you pay for. “I’m seeing more people who have gone to clinics where price is a major concern for them going there, and often they are dissatisfied with the result,” said Dr. Stuzin, a past president of the American Society for Aesthetic Plastic Surgery. “Instead of muscle work, they are oversuctioning the neck, so the neck looks skeletal.”

Furthermore, not every plastic surgeon tailors his work to each face, but instead “do it the same way every day, and that doesn’t work for faces,” said Dr. Mark E. Richards, a plastic surgeon in the Washington, D.C., area. Patients have sought out Dr. Richards for revision face-lifts ever since Linda Tripp announced on TV that he redid her botched face-lift in 2000.

Other experts caution to be wary of the doctor whose technique is stuck in the dark ages. “There are still a lot of surgeons who just redrape the skin — that’s it,” Dr. Grotting said.

For decades, doing face-lifts hasn’t been about simply pulling the skin toward the ear. At the very least, underlying layers of tissue and fat should be repositioned; some doctors also try to restore the curves and volume lost to aging.

Lately, Dr. Richards says that he has found that many of his unhappy patients are missing “cheek curves.” Pulling the connective and fatty tissue layers just below the skin “doesn’t make an attractive face,” he said. “It just makes a tight face.”

Surgeons’ philosophies vary widely, so it’s crucial to meet with a few to ascertain which one will best achieve your goals. Some love a high full cheek or use transplanted fat to fill out that area. Others think a face-lift that doesn’t address the eye area is incomplete. And some aim to deliver simply a tight neck and a defined jaw line. Dr. Hamra’s guide advocates the composite face-lift, a fairly aggressive surgery that also addresses hollow eyes and lifts cheeks vertically. (If readers can get past the book’s dollops of self-promotion, its descriptions of post face-lift issues prove useful.)

Dr. Constantian, for his part, wrote a new textbook “Rhinoplasty: Craft and Magic” because he feels the “basic ideas of how to fix a nose aren’t correct.” Two misconceptions get surgeons started on the wrong foot, he said. First, the mistaken notion that if a surgeon fashions a good-looking skeletal shape, skin draped over it will “take on the nose shape.”

Not so. The skin of the lower nose “won’t necessarily shrink to the shape the surgeon wants,” Dr. Constantian said.

“We were taught if you just change one area in the nose, nothing else changes,” he added. But “if you reduce the tip cartilage to make it prettier, you can also weaken the ability of the cartilage to support the nostrils,” he said. So he compensates for that weakness.

But some surgeons think impaired breathing is an acceptable trade-off for aesthetic improvement. “Breathing worse after a rhinoplasty is so common that I’ve heard surgeons say on panels at meetings that they expect it to happen, they tell their patients it will happen,” Dr. Constantian said. “I don’t think it should ever happen.”

Dr. Joseph M. Gryskiewicz, the vice president of the Rhinoplasty Society, a nonprofit educational organization for surgeons, wrote in an e-mail message, “Only a sadist would say breathing compromise is O.K.”


This article is from www.nytimes.com By CATHERINE SAINT LOUIS
Published: October 28, 2009

Rhinoplasty Costs

The cost of rhinoplasty varies depending on the surgeon's skill, the geographic area where the surgery is performed, and the type of structural and cosmetic changes made to the nose. Cost cannot be predicted accurately until the surgeon performs an examination and develops a surgical plan.

Rhinoplasty costs range from $3,000 to $8,000. The cost comprises three fees: surgical fee, anesthesia fee, and facility fee. The anesthesia fee ranges from $600 to $1,000, the facility fee ranges from $700 to $1,100, and the rest of the cost is the surgeon's fee.

The most costly aspect of rhinoplasty is the surgeon's fee. This cost is the most difficult to estimate, since the fee can vary greatly depending on the surgeon's training, skill, experience, and other factors. You can learn more about fees from our table of average surgeon fees.

Skill and Training Affects Rhinoplasty Cost

It's important to choose a board-certified plastic surgeon from the American Board of Plastic Surgery, who has extensive, specific rhinoplasty experience, as well as expertise in all areas of facial plastic surgery. Board certification requires specific and rigorous surgical education and training. More highly qualified, board-certified surgeons command higher fees, but they can also help ensure that you receive the most appropriate treatment for your condition, employ the most appropriate techniques, increase your odds of success, and reduce the risk of complications.

The type of certification is also important. There are more than 150 self-designated boards, but only a handful that are designated by the American Board of Medical Specialties (ABMS), such as the American Board of Plastic Surgery. Be sure to ask your surgeon about surgical training and board certification when you investigate the cost for rhinoplasty.

Extent of Rhinoplasty Procedure

The extent of the surgery makes a cost difference. For example, a slight surgical modification or reduction to the point of the nose requires less surgical time than narrowing the bridge or a complete change of shape. The type of rhinoplasty procedure, open or closed, also affects surgical time and cost.

Payments for Rhinoplasty

Some of the cost of rhinoplasty can be covered by insurance if the rhinoplasty procedure is related to modifying the nasal passage to aid in breathing, or another medical necessity. You can ask your surgeon about filing for insurance. Rhinoplasty for purely cosmetic reasons is not covered by insurance.

If the cost for rhinoplasty is too much to pay at once, ask your surgeon about monthly payments. For financing options and tips, continue reading about Patient Financing.

SOURCE

Reconstructive Rhinoplasty

Reconstructive rhinoplasty refers to restoring the normal shape and function of the nose following damage from: traumatic accident, autoimmune disorder, intra-nasal drug abuse, previous injudicious cosmetic surgery, cancer involvement, or congenital abnormality. Rhinoplasty can restore skin coverage; recreate normal contours, and re-establish nasal airflow.

Rhinoplasty for traumatic deformity: Traumatic accidents are the commonest cause of nasal deformity. Typically the nasal bones are broken and displaced. Occasionally, the nasal cartilages are disrupted or displaced, and in the worst cases the nasal dorsum is collapsed. Rhinoplasty allows shaving of the displaced bony humps, and re-alignment of the nasal bones after they are cut. When cartilage is disrupted, stitching of the cartilage for re-suspension, or use of cartilage grafts to camouflage depressions allows re-establishment of normal nasal contour. When the dorsum is collapsed, grafts of rib cartilage, ear cartilage, or cranial bone can be used to restore continuity to the dorsum. Although synthetic implants are also available for augmenting the nasal dorsum, cartilage or bone graft from the patient’s own body poses fewer risks of infection or rejection.

Rhinoplasty for collapsed nose due to septum perforation: Autoimmune problems such as Wegener’s Granulomatosis, Sarcoidosis, Churg-Strauss Syndrome, and Relapsing Polychondritis can lead to creation of a hole in the nasal septum, and loss of support in the dorsum leading to a saddle nose deformity. Intra nasal use of drugs such as cocaine, or extreme abuse of nasal decongestant sprays can similarly cause septum perforation and nasal dorsum collapse. Dorsum reconstruction is accomplished through the use of rib cartilage or bone grafts.

Rhinoplasty to correct nasal obstruction following injudicious cosmetic surgery: Reconstructive rhinoplasty after injudicious cosmetic surgery allows the restoration of normal breathing. When nasal cartilages are over-aggressively trimmed during rhinoplasty, the nose can appear pinched and nasal potency compromised. Patients complain of nasal blockage that is worsened by attempts at deep inspiration. Internal cartilage grafts to support the nasal tip (batton grafts) or widen the middle vault of the nose (spreader grafts) can be quite effective in restoring normal breathing. These grafting techniques will increase the size of the nasal tip and widen the dorsum. Khosh et al.

Rhinoplasty for skin cancer excision: Excision of skin cancers from the nose can lead to loss of internal support as well as external skin coverage. Skin cancer excision in the nose is commonly accomplished via the Mohs’ technique. Once the cancer is removed, reconstructive rhinoplasty aims to provide skin coverage utilizing techniques such as skin graft, local skin flaps, or pedicle flaps. If cancer resection leads to loss of tissue in the area of the nasal tip, cartilage grafts are utilized to maintain support and prevent long-term distortion, by the force of scar contracture.

Rhinoplasty for Rhinophyma: Rhinophyma is the late stage manifestation of a skin condition known as Rosacea, where the skin is infected with acne roseacea. The skin in the area of the nasal tip becomes red, thickened, and enlarged as exemplified by W C Fields. Although known acne treatments such as antibiotics and Acutane can halt the progression of this disease, thickening of the skin and obscuring of the nasal tip landmarks can only be remedied by surgical correction. Currently, laser excision of thickened abnormal skin represents the best option in rhinoplasty for Rhinophyma. The CO2 laser and the Erbium YAG laser are the most effective types of laser for this disorder.

Rhinoplasty for congenital nasal deformity: Vascular malformations and cleft lip anomalies are relatively common causes of congenital nasal deformities. In vascular malformations, the disease process can cause distortions of the skin and underlying structure of the nose. In cleft palate abnormalities, the size, position, and orientation of the nasal tip cartilages may be distorted. Rhinoplasty for reconstruction of vascular malformations can involve laser treatment of the skin and possible surgical excision. When the underlying cartilage structure is disturbed, cartilage grafts and stitching of the native nasal cartilages can help improve nasal appearance. In cleft lip patients, reconstructive rhinoplasty allows re-orientation of the nasal tip cartilages. Additional refinements with cartilage grafts to the tip are also frequently employed.


SOURCE

Rhinoplasty: Definition and History

Rhinoplasty (Greek: Rhinos, "Nose" + Plassein, "to shape") is a surgical procedure which is usually performed by either an otolaryngologist-head and neck surgeon, maxillofacial surgeon, or plastic surgeon in order to improve the function (reconstructive surgery) and/or the appearance (cosmetic surgery) of a human nose. Rhinoplasty is also commonly called a "nose reshaping" or "nose job". Rhinoplasty can be performed to meet aesthetic goals or for reconstructive purposes to correct trauma, birth defects or breathing problems. It can be combined with other surgical procedures such as chin augmentation to enhance the aesthetic results.

Rhinoplasty was first developed by Sushruta, an important physician (often regarded as the "father of plastic surgery") who lived in ancient India circa 500 BC, which he first described in his text Sushruta Samhita. He and his later students and disciples used rhinoplasty to reconstruct noses that were amputated as a punishment for crimes. The techniques of forehead flap rhinoplasty he developed are practiced almost unchanged to this day. This knowledge of plastic surgery existed in India up to the late 18th century as can be seen from the reports published in Gentleman's Magazine (October, 1794).
Patient, three days post-op. Procedures included dorsal bone reduction and re-setting and refinement of nasal tip cartilage. The typical orbital discoloration is also present due to trauma and disruption of blood vessels around the eyes. Also present is a splint.

The first intranasal rhinoplasty in the West was performed by John Orlando Roe in 1887. It was later used for cosmetic purposes by Jacques Joseph (b. Jakob Lewin Joseph) in 1898 to help a patient who felt that the shape or size of his nose caused embarrassment and social discomfort. Joseph's first rhinoplasty patient was a young man whose large nose caused him such embarrassment that he felt unable to appear in public. He approached Joseph because he had heard of a previous successful otoplasty, or "ear reshaping," which the surgeon had performed.

Rhinoplasty can be performed under a general anesthetic, sedation, or with local anesthetic. Initially, local anesthesia which is a mixture of lidocaine and epinephrine is injected to numb the area, and temporarily reduce vascularity. There are two possible approaches to the nose: closed approach and open approach. In closed rhinoplasty, incisions are made inside the nostrils. In open rhynoplasty, an additional inconspicuous incision is made across the columella, the bit of skin that separates the nostrils. The surgeon first separates the skin and soft tissues of the nose from the underlying structures. Reshapes the cartilage and bone, and then sutures the incisions closed. Some surgeons use a stent or packin inside the nose, followed by tape or stent on the outside.

The patient returns home after the surgery. Most surgeons recommend antibiotics, pain medications, and steroid medication after surgery. Most people choose to remain home for a week, although it is safe to be outdoors. If there are external sutures, they are usually removed 4 to 5 days after surgery. The external cast is removed at one week. If there are internal stents, they are usually removed at four days to two weeks. The periorbital bruising usually lasts two weeks. Due to wound healing, there is moderate shifting and settling of the nose over the first year.

In some cases, the surgeon may shape a small piece of the patient's own cartilage or bone, as a graft, to strengthen or change the shape of the nose. Usually the cartilage is harvested from the septum. If there isn't enough septum cartilage, which can occur in revision rhinoplasty, cartilage can be harvested from the concha of the ear or the ribs. In the rare case where bone is required, it is harvested from the cranium, the hip, or the ribs. Sometimes a synthetic implant may be used to augment the bridge of the nose.
The lower lateral cartilage (greater alar cartilage) exposed through the left nostril for modification during a rhinoplasty.

To improve nasal breathing function, a septoplasty may also be performed. If there is turbinate hypertrophy, an inferior turbinectomy can be done.

Although rhinoplasty is usually considered to be safe and successful, several complications can arise. Post operative bleeding is uncommon and often resolves without needing treatment. Infection is rare and can occasionally progress to an abscess that requires surgical drainage under general anesthetic. Adhesions, which are scars that form to bridge across the nasal cavity from the septum to the turbinates, are also rare but cause nasal obstruction to breathing and usually need to be cut away. A hole can be inadvertently made at the time of surgery in the septum, called a septal perforation. This can cause chronic nose bleeding, crusting, difficult breathing and whistling with breathing.

If too much of the underlying structure of the nose (cartilage and/or bone) is removed, this can cause the overlying nasal skin to have little shape resulting in a "polly beak" deformity. Likewise if the septum is not supported, the bridge of the nose can sink resulting in a "saddle nose" deformity. The tip of the nose can be over-rotated causing the nostrils to be too visible and creating a pig-like look. If the cartilages of the tip of the nose are over-resected, this can cause a pinched look to the tip. If an incision is made across the collumella (open approach rhinoplasty) there can be variable degree of numbness to the nose that may take months to resolve.

The cost of rhinoplasty varies regionally and between surgeons. If it is for functional reasons, like breathing correction, it can be covered by many health plans. For example in 2006 in Ontario, Canada the provincial health insurance carrier paid $480, while the cost for cosmetic rhinoplasty varied between $1,000 and $10,000.

SOURCE