Rhinoplasty (nose reshaping), nasal cosmetic surgery, is performed to improve the nose aesthetically - making it harmonize better with the other facial features - while maintaining or improving function. Because it is the most defining feature of the face, the size and shape of the nose has a significant impact on a person's appearance. Dr. Lopez’s goal in rhinoplasty is to minimize the attention that is given to the nose in order to accentuate the beauty of the eyes.

Some patients want their nose to be straight, others want the nostrils narrowed, and others say their nose sticks out too far from their face. Because the nasal tip loses support as we age, some patients are surprised to realize how significantly rhinoplasty contributes to a more youthful appearance. Dr. Lopez shapes the nose to blend into the face, so that the eyes become more of the focus of attention.

When discussing rejuvenation procedures the best place to start is by looking at before and after photos to see just what can be accomplished. As you will see in the photos, patients often ask to combine a rhinoplasty with other cosmetic surgery. Eyelid lift, chin implants, facelift, otoplasty (ear surgery) and lip surgery can also be performed in conjunction with a rhinoplasty.

When patients come to see Dr. Lopez seeking facial plastic surgery, it's not uncommon for them to focus on a single aspect of their appearance rather than the overall picture. One of the most common concerns we hear from patients seeking rhinoplasty is that they do not want a “Michael Jackson” nose.  Fortunately reduction rhinoplasty is becoming less common.  Fewer surgeons are stripping the nose of vital cartilage that supports the function of the nose.  Dr. Lopez believes that form follows function, meaning that a good looking nose is a nose that breathes well.  Dr. Lopez would never compromise nasal function for an improved aesthetic result.

As Dr. Lopez is a board certified facial plastic surgeon, trained to perform plastic surgery exclusively on faces and necks, he knows that his responsibility is to evaluate not only the areas of concern but also the motivation behind the requests. Some patients are not ready for cosmetic surgery and are better served with conservative measures, such as Botox for fine lines and wrinkles or fillers for deeper wrinkles. Patients who educate themselves about facial rejuvenation know when and if the time is right to proceed. Your understanding of the procedures and postoperative routines is essential to a successful final result.

Although the preoperative and postoperative instructions for revision rhinoplasty are the same as for the primary (first-time) rhinoplasty patient, revision rhinoplasty has its own set of special considerations. If you are a patient seeking revision rhinoplasty, please review special considerations for revision rhinoplasty.

Facial plastic surgeons (board certified reconstructive and cosmetic surgeons that concentrate exclusively on the face and neck) are specialty trained to perform rhinoplasty, the most challenging of all cosmetic surgery. Not every cosmetic surgeon is trained in rhinoplasty and not all surgeons have the skill to perform rhinoplasty. More than any other cosmetic surgery, Dr. Lopez highly recommends that you do your homework in selecting a surgeon that specializes in rhinoplasty.

BEFORE RHINOPLASTY SURGERY

At your preoperative appointment Dr. Lopez will provide all the instructions for you to follow before and after surgery. Rhinoplasty takes about 1-3 hours depending on the structure and amount of change you are seeking. Revision rhinoplasty generally takes longer.  Also, if you are having a combination of procedures your surgery will take longer. Recovery time from the anesthetic takes about an hour and you will be discharged about four to five hours from the time of admission.

PREOPERATIVE RHINOPLASTY INSTRUCTIONS

AFTER RHINOPLASTY SURGERY

After surgery your nose will be packed with soft nasal packing. A nasal cast will be on your nose and you will have gauze taped under your nose.  There will be silastic splints along each side of your septum (divider of the inside of the nose). Splints reinforce the newly shaped cartilage. You may notice that tears run down your cheeks. This is due to swelling and will subside during the first week following surgery.

The nasal packing will prevent breathing through your nose so you will have to breathe through your mouth. Your mouth will become very dry. Please drink as much fluid as you can which will help you from becoming dehydrated. Drinks at the bedside along with a humidifier (cool or warm) may help.

Following nasal surgery, mucous membranes can produce extra mucous. Draining of red-tinged mucous through your packs onto your drip pad is normal. You can change your drip pad as often as necessary.

Following your procedure the nurses will ask you to meet the discharge criteria: to drink liquids, walk with a steady gait, void, manage your discomfort, and to have your nasal drainage under control. The nurses will teach you how to change the drip pad under your nose, which you will need for about 24-48 hours.

You will be asked to see Dr. Lopez 1-2 days after surgery for packing removal. Although removal of nasal packing has been described by most patients as discomfort rather than pain, you are encouraged to take your pain medication about an hour prior to packing removal. Packing removal will help relieve some of the pressure. However, due to swelling, you will not be able to breathe well through your nose for two weeks.  You will return to see Dr. Lopez 6-8 days after surgery for cast and suture removal.  Two weeks after surgery Dr. Lopez will remove the silastic splints.

POSTOPERATIVE RHINOPLASTY INSTRUCTIONS

Activity

Sleep with head of the bed elevated or use two to three pillows. Sneeze with your mouth open and do not blow your nose or sniff for seven days. Absolutely no bending, lifting or straining. If you have little children, bend at the knees or sit on the floor and let them climb on to your lap. One week off work is recommended following rhinoplasty. Avoid long steamy showers for one week postoperatively or the cast may become loose. Ensure that care is taken to keep the cast dry while bathing.

Diet

Advance diet from liquids to soft food to your regular diet as tolerated. In the immediate postoperative period, avoid extremely hot liquids or foods if you experience temporary numbness on the roof of your mouth.

Wound care

Medications

Nasal congestion, facial fullness, headache and disrupted sleep are very normal postoperative symptoms and will decrease as the healing process occurs. It is not uncommon to have numbness on the roof of the mouth (palate) behind the front teeth. Therefore avoid extremely hot liquids or food in the immediate postoperative period.

Final Result

Following a rhinoplasty, it takes time for the swelling to subside and for the skin to heal. Most patients return to work one to two weeks following surgery, depending on the degree of privacy one is trying to maintain. At three weeks postoperatively, swelling and bruising may be apparent to you but not to many of your coworkers and closest friends.

Final results following a rhinoplasty are not apparent for one full year following surgery. Dr. Lopez will want to see you 3, 6 and 12 months after the surgery to ensure that you are healing as anticipated.

REVISION RHINOPLASTY - NASAL RESHAPING

Revision rhinoplasty is more challenging than primary rhinoplasty for several reasons. First is the altered "geography" of the nose. At the time of the primary rhinoplasty, distorted cartilage was removed to make the nose straight and restore function. Therefore, in revision rhinoplasty, the cartilage needed for reconstruction is no longer available. Depending on the amount of cartilage that remains, the need to borrow cartilage from behind one ear (an auricular graft) or even from a rib (costal cartilage graft) to restore nasal form and function is not uncommon.  Although the ear incision is camouflaged well and does not change the shape, size, form or function of the donor ear, and the incision for the rib is hidden under a bra/bikini, the need to borrow neighboring cartilage means an extra incision. Dr. Lopez will determine if cartilage is necessary to restore your nose to a more natural form as well as where the cartilage should come from.  Dr. Lopez does not use synthetic implants when performing rhinoplasty.  There are situations where Dr. Lopez will use irradiated rib cartilage, for instance in older patients where ear cartilage will not provide sufficient support.

Nasal lining that has undergone surgery is also subject to scar tissue, which increases the complexity of revision surgery. Therefore, the amount of surgical time required to perform revision rhinoplasty typically is longer than primary rhinoplasty.

Revision rhinoplasty may have its own set of special considerations but it also can be the most rewarding. If you are considering revision rhinoplasty (regardless of where you elect to have the surgery performed) it is essential that you consider a board certified facial plastic surgeon. Why? Because facial plastic surgeons have unique board certifications in both head and neck surgery and cosmetic and reconstructive surgery.  Dr. Lopez has an extensive experience in revision rhinoplasty.  He has patients that travel from all over the country to seek out his expertise.

FREQUENTLY ASKED QUESTIONS

1) I want my nose to look like Brad Pitt's?
Your nose is very specific to your face.  Dr. Lopez’s goal with rhinoplasty is to create a nose that blends into your face and does not take attention away from the beauty of your eyes.  Therefore, Brad Pitt’s nose may not look right on your face.  Dr. Lopez will thoroughly evaluate your nose and discuss with you the your optimal rhinoplasty result..

2) I have a large hump on my nose, can that be fixed?
The hump (convexity) on your nose is usually made of bone and cartilage. Dr. Lopez is able to lower both the cartilage and bone if necessary. Again, your nose must be in harmony with your face as well as the rest of your body.  Tall individuals look better with a small convexity or straight profile rather than a scooped out appearance.  Shorter individuals can look better with a bit of scoop to the nose.  Men in general also look better with a bit of a convexity, i.e. the “Grecian Nose”.

3) If my nose is made smaller, where does the extra skin go?
Over time the skin will contract and take the shape of the underlying bony/cartilaginous structure.

4) My nose is crooked, can that be fixed?
A crooked nose can be because the bone has been broken and is no longer in the midline, or because the cartilage in the middle of the nose (middle vault) has a concavity or both are off.  To fix crooked nasal bones, Dr. Lopez makes cuts in the bones to reset the bones in the midline.  In order to straighten out the middle part of the nose, Dr. Lopez may need to use cartilage to fix the concavity.

5) My nose ticks out too far and I have a weak chin, will fixing my nose make my chin look stronger?
In general no.   A weak chin that does not project out enough usually can be made to look much better with a chin implant.  This will also improve the rhinoplasty result as the face will be in better harmony.

6) Will I still look like "me" after surgery?
Many of my patients report that when they return to their normal life, their friends comment, “You look great. Are you getting more sleep?" or "You look less stressed and tired”.  Dr. Lopez will not drastically change the way you look, just enhance it.

7) Where are the incisions for a rhinoplasty?
In an open rhinoplasty Dr. Lopez makes a very small incision in the skin at the base of the nose in the midline.  This incision heals extremely well and is nearly imperceptible once healed.  The remainder of the incisions are within the nose.

8) What is an open (external) rhinoplasty?
An open (external) rhinoplasty involves making a small inverted V-shaped skin incision in order to raise the nasal tip skin up and be able to visualize the tip cartilages.  The advantage of the open approach is the increased exposure that Dr. Lopez is able to get in order to produce your optimal result.  The disadvantage is that the nose will be swollen longer when compared to the closed (endonasal) approach.

9) What is a closed (endonasal) rhinoplasty?
In a closed (external) rhinoplasty there are no external skin incisions. Dr. Lopez will use this technique when a lot of work does not need to be done to the tip or middle vault.  The advantage of the closed approach is that the swelling subsides quicker.  The disadvantage is the decreased exposure the surgeon attains when trying to manipulate the middle vault or tip.

10) How much pain will I have?
Most patients who have a rhinoplasty say how surprised they are that the pain is less than they anticipated. Understandably, after any surgical procedure, some discomfort can be expected. All patients are provided with prescriptions for pain medication. Patients sometimes use the prescription medication two to three days after surgery and then switch to Extra Strength Tylenol.

11) Will I be awake during surgery?
Patients are asleep during the surgery with general anesthesia. Patients do not hear or feel anything and are comfortable during the operation. Patients wake up very soon after the surgery is completed. All patients must have a responsible adult to stay with them through the night following surgery. Patients may not drive for following their procedure if they are taking pain medicine or their vision is impaired.

12) Do I go home after surgery?
Most rhinoplasties are done on an outpatient basis. Because you will go home after receiving sedation, you will need to make arrangements for a responsible adult to drive you home, to stay with you overnight and to drive you to our office for your first postoperative appointment. Patients having surgery must stay in the immediate San Antonio area overnight.

13) Will I bruise and swell afterwards and how long will it last last?
Unfortunately it is impossible to do surgery without causing swelling.  Dr. Lopez does everything possible to minimize the amount of swelling that occurs.  Generally, postoperative swelling begins to resolve at the end of the first week.  Bruising is extremely variable.  Patients that have a tendency to bruise will generally bruise for about 10 days.  Patients that don’t tend to bruise may have minimal if any bruising.   Complete resolution of bruising and swelling may take two to three weeks. However, bruises may be camouflaged fairly easily at seven to ten days with a concealer stick.

14) How long should I stay in San Antonio following surgery?
Most patients stay in San Antonio about seven to ten days following surgery. After that it's ok to fly or travel long distances.

15) When can I return to work?
Most of Dr. Lopez’s patients take about two weeks off of work. After two weeks, most of the residual bruising and swelling can easily be camouflaged with make-up.

16) When can I exercise?
Dr. Lopez prefers that aerobic activities be avoided for two weeks after surgery.  In addition, heavy weight lifting or more strenuous workouts should be avoided for three weeks postoperatively. It is extremely important to avoid bending, lifting or straining during the early postoperative period as these activities can increase swelling and delay healing.

17) At what age can I have a rhinoplasty?
You should not have a rhinoplasty until your face and nose have stopped growing.  Usually the age is around 16 for a female and 17-18 for a male.  Once your shoe size has been stable for a year, that is a good indication that you can have a rhinoplasty.

18) When can I have a revision rhinoplasty?
Dr. Lopez performs a lot or revision rhinoplasty operations to correct or enhance the work of the previous surgeon.  In general the nose will continue to change over the first year following a rhinoplasty, so Dr. Lopez prefers that patients wait a year after their original surgery to have a revision.

19) Is revision rhinoplasty more difficult?
In general yes.  Once the nose has been worked on scar tissue distorts the normal tissue planes.  In addition, grafting material such as the nasal septum may have already been used.  Often times ear cartilage or even rib cartilage is necessary to correct the deformity.  Make sure that the surgeon you choose has a lot of experience with revision rhinoplasty.

20) What is the septum?
The nasal septum is a cartilaginous and bony structure that divides the nose into two nasal cavities.  Dr. Lopez often uses the septal cartilage to strengthen the nose and improve the appearance and function of the nose.

21) If you take ear cartilage will that change the shape of my ear?
Dr. Lopez uses ear cartilage often and it does not change the shape of your ear or the function of your ear.  At 6 months from surgery even with your hair up nobody will know that you had ear surgery.

RHINOPLASTY PREOPERATIVE INSTRUCTIONS

22) Should I do anything before to prepare for surgery?
You will have a preoperative appointment with Dr. Lopez and his staff to go over the preoperative instructions.

23) Why do I need a preoperative appointment?
This is an essential appointment to prepare you for your upcoming surgery.  Dr. Lopez will take preoperative photographs at the visit as well as go over the procedure again to ensure that everyone is on the same page.  All questions that you have will be answered on that visit as well.  You will often times be given your prescriptions on the preoperative visit day.

24) What else can I do to do to prepare for surgery?
Dr. Lopez likes to have patients that have well controlled blood sugar to drink three eight ounce glasses of pineapple juice for at least one week before surgery.  Pineapple juice can help minimize the postoperative swelling. Patients that use tobacco will be asked to stop for six weeks before and six weeks following surgery. Tobacco has properties that impede wounds from healing.  Dr. Lopez will encourage tobacco users to not resume smoking at all after surgery; in fact many of his patients have used the surgery as their impetus to quit smoking.

25) What about my daily medications before surgery?
In general you will be allowed to take most of your daily medications.  Medications that thin the blood such as ibuprofen, vitamin E, and herbal supplements need to be stopped two weeks before surgery.   You can continue to take a multivitamin.  Aspirin needs to be stopped three weeks before surgery.  Dr. Lopez will provide a "Medication List" that reviews all medications and supplements to avoid prior to surgery.

26) Do I need any special prescriptions before surgery?
Dr. Lopez will generally give you a prescription for an antibiotic, a pain medicine, antibiotic ointment, as well as an anti-swelling medication.. Dr. Lopez does prefer patients to start Arnica, a natural herbal substance, the day before surgery in order to minimize bruising. He also asks you to start Vitamin C before surgery.

RHINOPLASTY POSTOPERATIVE INSTRUCTIONS

27) What does it feel like when I wake up from surgery?
When you wake up you will have a small cast on your nose and small packs within your nose.  The packs will not allow you to breathe through your nose. We will make sure you are not nauseated or queasy. Our nurses will be right there with you as you wake up from surgery.

28) What medications do I take following surgery?
Dr. Lopez will ask you to take the following medications starting the day of surgery:
  1- An antibiotic- generally Keflex for one week
  2- Pain medicince- vicodin or percocet to take as needed
  3- Antibiotic ointment- to place on the incision sites at least three times a day.
  4- Antiswelling medication-  for patients that are not diabetic a medrol dosepak will be given.
  5- Vitamin C 1 gram for 1 week before and two weeks following surgery to promote healing.
  6- Arnica- place under the tongue three tabs three times a day before meals for two weeks.

29) When do I begin taking the medications?
Patients take their pain medication as needed. Begin taking vitamin C one week before surgery.  You can begin taking Arnica the day before surgery.  The antibiotic and swelling medications begin when you arrive home following surgery. Unless you are notified otherwise, resume all daily medications when you arrive home from surgery.

30) Are there any foods to avoid following surgery?
No. Dr. Lopez encourages you to eat a well-balanced diet.  You may notice that saltier foods can cause you to swell for a longer period of time.

31) When can I shower?
You can shower once the second dressing is removed.  Make sure that you pat dry the incisions well after the shower and apply the antibiotic ointment.

32) When is my first postoperative appointment?
You will be asked to see Dr. Lopez on the second day following your rhinoplasty.  At that appointment Dr. Lopez will remove the nasal packing.  Some patients describe the packing removal as a mild discomfort, but Dr. Lopez still recommends taking a pain pill 1 hour before your appointment. You will need someone to drive you to this appointment.

33) What happens after the first postoperative visit?
After your first visit, take your medications as directed and keep your incision clean and moist.  We will ask you to use a Q-tip to cleanse them with peroxide once a day and apply an antibiotic ointment three times a day to keep the sutures soft.  Dr. Lopez will want to see you 6-8 days after the surgery for removal of the cast and suture removal.  Suture removal may be uncomfortable, so Dr. Lopez recommends taking a pain pill 1 hour before your appointment. You will need someone to drive you to this appointment if you are taking pain medication.

34) Are there any instructions about regular daily activities?
Sleep with head of the bed elevated or use two to three pillows for one week. Facial fullness, headache and disrupted sleep are very normal postoperative symptoms and will decrease as the healing process occurs. Absolutely no bending, lifting or straining. If you have little children, bend at the knees or sit on the floor and let them climb on to your lap.

35) When can I blow my nose?
You are not allowed to blow your nose for one week. Avoiding nose blowing minimizes bleeding and swelling following surgery.

36) Can I wear my glasses or contacts after rhinoplasty?
It's best to allow a day or so before using your contact lenses following rhinoplasty. It's not uncommon for patients to tell us that giving their eyes a temporary rest from the contact lenses feels good for the first two to three days following rhinoplasty. It's OK to rest your glasses on the nasal cast. However, one week following rhinoplasty the cast is removed. At that time we will show you how to use the Frame-Ups® to prevent your eyewear from resting directly on your nose. We strongly recommend that you use the frame-ups for postoperative week #2 - which is the week following cast removal.

37) How long does the healing take?
Healing and evaluation of the final result takes one full year. However, after three months, most patients have about 90% of their final result.

38) How can I minimize the swelling and bruising?
Most of Dr. Lopez’s patients will have a little bruising. He minimizes bruising by having patients stop all blood thinners well ahead of surgery as well as using Arnica before and after the procedure. The cold packs around the eyes should be used every 20 minutes while awake after surgery to help prevent swelling and bruising.  The cold packs should be used for the first 72 hours.  You do not need to wake up to use the cold packs.  A good night’s sleep is vital to healthy healing.  Patients are also asked to sleep with their head at least at 45 degrees to minimize the swelling.

39) When will I look normal?
You will be presentable at two to three weeks. You will look great at six weeks and even better at six months as things settle and expressions become more natural. At three weeks you know you are well on the way to recovery and most patients resume routine activities around two to three weeks following surgery. Final results are evaluated at one year.

40) How often do I need to return for postoperative visits?
Dr. Lopez likes to see his patients 3, 6, and 12 months after the procedure to ensure that the healing is going as expected.