Manuel A. Lopez, MD, FACS

Board Certified Facial Plastic Surgeon

(210) 495-5771 (LPS1)
(210) 495-2367          
Lopez Plastic Surgery
1314 E. Sonterra Blvd, Suite 5104
San Antonio, Texas 78258

Nose Reshaping

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
Please avoid any aspirin, aspirin-containing products, or ibuprofen (Advil, Aleve, etc.) for two weeks prior to and two weeks following your surgery. See our “Medication List” for products to avoid prior to surgery. If you are on any medications that affect bleeding (such as coumadin or warfarin) please notify the office immediately.

Please refrain from tobacco products for six weeks and alcohol for one week prior and three weeks following surgery. Along with delayed wound healing, persistent skin redness and other complications may persist when tobacco and alcohol are not discontinued.

Please notify us of all routine medications and significant health history. We ask that you remain on your daily medications unless instructed otherwise. At the preoperative appointment you will be told which daily medications to take with just a sip of water on the morning of surgery.

At your preoperative appointment you will be given prescriptions for use following surgery including an oral antibiotic, anti-swelling medication, antibiotic ointment and pain medications. Please obtain these prescription medications before your surgery so you will have them ready for use when you return home after surgery.

We will ask you to take Arnica, a natural herb that significantly decreases bruising, before and after surgery. We will also ask you to take Vitamin C (ascorbic acid), which helps promote healing, before and after surgery.

You may not eat or drink after midnight the evening before the procedure unless instructed otherwise. You may brush your teeth. Your procedure will be cancelled if you do not follow these instructions.

Remove all make-up and nail polish before arriving for your procedure.

Someone will need to drive you home after your surgery and stay with you that evening.

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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
Keep cold packs on eyes until bedtime, changing pads every 20-30 minutes. It is the weight of the cold pack as well as the temperature that helps minimize bruising. A small bag of frozen peas or corn may also be used. Make sure the bag is not placed directly on the skin. Use a washcloth or towel between the bag and your skin.

You will have a gauze drip pad placed beneath your nose. Change this as needed for the first 24 hours following surgery. It is not uncommon to change this every 15 minutes for the first several hours following rhinoplasty. Ice packs to the forehead and/or back of the neck may help decrease bleeding. Do not place ice packs directly on your skin. Do not swallow any drainage from your nose as it may make you nauseated. Cough it up and spit it out.

Following removal of the packing, the drainage will eventually subside and the drip pad will no longer be required. Do not use saline nasal spray until the night following packing removal.

The cast must remain on your nose for one week. It must be kept dry or it could become loose.

Medications
Most patients complain of pressure from swelling and congestion more than pain. Use pain medication (most commonly Vicodin) as directed/as needed. Vicodin contains Tylenol. Do not take additional Tylenol or acetaminophen while taking Vicodin. Do not drive or drink alcohol while taking pain medication. Side effects of pain medications can include nausea and constipation. Taking pain medication with food can minimize nausea. Over-the-counter laxatives are indicated if constipation persists.

Although packing removal has been described as pressure rather than pain, we recommend taking pain medication about one hour before coming to the office for packing removal.

Start your antibiotic (Keflex) when you arrive home following the procedure. During your surgery you received antibiotics through your IV. Take antibiotics as directed until gone. It is not uncommon to have a low-grade fever for 24 hours following surgery.

The evening following packing removal, start using the antibiotic ointment (most commonly bacitracin) three times a day inside the base of each nostril and on the incision. Insert only the cotton part of the Q-tip into your nose.

Following nasal packing removal, start your saltwater rinses in the evening. Salt water rinsing is very important for your postoperative healing. The salt water moisturizes, cleanses and facilitates healing.

You can make your own salt water by mixing one tablespoon of sea salt (not table salt) and 12-16 oz. lukewarm water in a small plant mister bottle. Place the tip of the mister gently near the opening of the nose and spray your nose. If you prefer you can purchase saline spray in your drugstore without a prescription. Please rinse your nose with salt water five to six times per day until your splints are removed. You may then decrease your rinsing to three times per day.

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.

 

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