The nose is a funny thing – from an evolutionary, aesthetic point of view, anyway. Unlike the eyes or lips, it has very little to do with attracting or keeping a mate; whether short, broad, narrow, bulbous, rounded or pointy, it does not symbolize or even allude to sexual interest, availability, virility, or lack thereof.
And yet nose jobs remain one of the most common cosmetic procedures in the world. It stands to reason, then, that changing your nose is less about how you would like the world to see you and more about how you would like to see yourself.
Whether you’d like to get one or are merely curious about what it’s like, as I am, it never hurts to have the right information; so I got on the phone with Dr. Stafford Broumand, one of the world’s foremost experts on plastic surgery practicing out of New York’s Mt. Sinai Hospital, with a couple of questions. Here’s what he had to say.
How common are nose jobs these days?
It’s way more common than you think. There’s more in the press about it now, and technology’s improved so much that you can improve the shape of your nose by doing so much less. It’s not a traumatic procedure, like it was in the 70s. Now everything is tailored to the patients and customized to their issues and complaints.
How much can rhinoplasty be customized?
Well, there are several components to a nose, but the way they interact is very delicate. There’s a lot of subtlety involved, and you have to be very careful with how you work with the structure of the nose. It’s important to listen to the patient and figure out what’s really bothering them. Sometimes it’s an aesthetic issue, and sometimes it’s a functional issue, like if they have an issue with their breathing. Your doctor then puts together a game plan to see what can be done to make your nose better and address your concerns.
On the other hand, no surgery is sometimes the right answer, and a good doctor should have the wisdom to know when those instances are.
When is it not a good idea?
If someone believes that they need to have their airway passage improved but their nose is actually straight, it could just be that they need medication or nasal spray. Or if they have certain aesthetic concerns that are too drastic and might take away from the actual support structure of the nose and lead it to collapse, that’s a problem too. You have to understand the patient’s psychology behind it – if they’re hoping to look like another ethnicity, for instance, or if you can tell that they’re xx, rhinoplasty might not be able to help.
On the other hand if you come in and say, “The tip of my nose is too broad or it’s too boxy,” or “I’ve got this bump that I’ve never liked,” we can do things to address that. To put it simply, rhinoplasty is a combination of working on the tip of the nose, which is the lower half, and the bump of the nose, which is the upper half.
If someone wants a really subtle change, then that’s not a case for rhinoplasty either. That’s the third aspect of it – you have the upper nose, the lower nose, and then something called liquid rhinoplasty, where your doctor strategically places small amounts of an injectable fluid, like Juvaderm, which can make the nose look better, more symmetrical. So certain changes can be addressed without any surgery at all.
Is it permanent?
It is, but it’s not unlike building a house. The foundation can shift a little over time, things can move around a bit, just like with your regular nose. I don’t generally do this, but there are some surgeons who still use a procedure from the 70s and 80s called a cartilage graft, where pieces of cartilage from the septum, ribs or ear were put into the nose to try and shape it. With surgeries like those, the cartilage will shift over time.
Does it help to go in with a photograph of your ideal nose?
Half the time, patients come in with a photograph and it is helpful for me to see what they perceive as the ‘ideal’ nose, sure. I haven’t known all my patients for a lifetime, so I’m trying to gather as much information about them as I can. If it’s possible to achieve something similar, I’ll try, but if the end result is too disparate from their original nose, I let them know. The goal shouldn’t be to look like someone else, but for your nose to work best for you. This varies – you have to look at the whole proportion of the face; the position of the brow, the distance between the bottom of the nose and the upper lip, how promiment their jawline, cheekbones and even eyeballs are. All these things come into play.
What’s the process like?
Once a patient comes in and we’ve determined that they are a reasonable candidate, I ask them what they want, face to face, with a mirror in their hand. I examine the different components of their nose and do an internal examination to see what their septum is like. Once they’ve told me what they want, we might take some pictures and do a bit of imaging of their nose so they know what I propose to do with it.
So can you see what the end result will look like before the procedure?
Again, it’s like building a house. You can look at the renderings, and those will give you a pretty good idea.
The actual surgery depends on what we’re changing. If they’re concerned about the lower half of their nose and we’re working on only that, it’s called a tip rhinoplasty.
Does that involve breaking the nose?
No, that’s to do with the upper half of the nose, and if we’re working on that, it’s called a dorsal rhinoplasty. Dorsal, like the fin on a whale. Think of a gabled roof on a house. Imagine shaving off the gabled top from the outside – then you’ve got what we call an open roof, where you’ve got one edge not touching the other edge. Now you have to move the side walls in, so that the tops of walls touch each other. That involves ‘breaking the nose’, although the technical term is an in-fracture. We break the bone in a very, very controlled way, with a fine little blade that cuts into the bone. You take the bump out and move the walls so that it becomes more compact, straighter, and smaller.
Most rhinoplasties entail both, the top and the tip of the nose.
I’ve heard of an open rhinoplasty – what is that?
Well, now that you’ve decided whether you’re working on the top or lower half of the nose or both, there are two ways to approach the surgery. There’s an open approach, where we make a very discreet incision in the middle part of your nose, the thin area between your nostirls – and elevate the skin from that point all the way up, and look at the nose with the skin peeled back. It’s like peeling back the lid on a sardine can, and then putting it back.
The other approach is a closed approach, where you make a little incision inside the nose and work on it from there. It’s a one-person operation, because no one can see what you’re seeing.
Which one’s better?
The closed approach is how I was trained to do it. It makes perfectly good sense, and my feeling is that it leaves the support structures intact. An open approach is like taking the whole car apart to replace the spark plug and then putting it back together, whereas a closed approach is like opening up the hood, finding the spark plug, replacing it and then closing the hood. It keeps the support structure of the nose more intact.
The open approach is favoured among doctors who are operating on patients who are having a second or third surgery, or doctors who teaching younger plastic surgeons because they can see everything. It leaves a faint little scar underneath the nose, between the nose and the lip.
If it’s a very straightforward procedure, I’ll do a closed one, and if it’s a more complicated procedure or if I’m teaching my students at the hospital, I’ll do an open one.
Should you be asking your doctor which one you’ll be having?
Of course you should. I don’t think many people are told which one they’re getting. Doctors who routinely do open surgeries will say, “Oh, the scar’s not a problem.” But it can be. Not generally, but it can happen. I always tell my patients which one I’ll be performing.
About the actual surgery – how long does it take, how long will you be under anesthesia, and how much does it hurt?
Anywhere between an hour to two hours, depending on whether you’re doing the upper or lower part of the nose or both. We’ve got the anesthesia down to a system in my office. My anaesthesia group is the Mt. Sinai Hospital in New York, and we have it so the patient wakes up as soon as the procedure is over. They walk to the recover room, stay for an hour, and go home.
In reality, it doesn’t hurt that much at all, if any. A tip rhinoplasty shouldn’t hurt, and a dorsal rhinoplasty will have a splint on for 5-7 days and because of the splint, it shouldn’t hurt. It’s like when you break a bone – once the cast is on, it doesn’t hurt anymore. It’s not a very painful operation at all – you could take a Tylenol for the first day for discomfort, and that’s it.
How long does it take to heal?
If it’s a dorsal surgery, we’ll put a little, flesh-coloured plastic splint to hold the nose in position for about 5-7 days, and if it’s a tip surgery, they’ll just have little tapes to keep the swelling down for 5-7 days. 99% of the time, we don’t pack the nose – you shouldn’t have to.
Before, doctors would take the entire nose apart from A-Z and they’d have to put packing in to hold all the tissues together. You should look for a doctor that’s very strategic about what they’re doing, so that the whole process is tidy and far less traumatic to the nose and requires no packing after.
What else should you look for in a doctor?
A board certified plastic surgeon is the most important thing. Find someone who’s been in practice for a fair amount of time – a decade, at least. You don’t come out of medical school knowing how to do a great rhinoplasty. It’s like someone who’s a painter, or a chef or an architect – they get better as they do more, and become more facile and understand the complexities of what they do far better.
You want to make sure that you have a rapport with the physician and that they understand exactly what you want, and that you understand exactly what’s going to happen. Look at their work on their website or lookbook. If it’s not something you like, find someone else. See who’s administering the anaesthesia, and find out what their experience is. Maybe speak to their past patients. And if their office doesn’t seem to have their act together, that could be a reflection of how the doctor is, too.
It is a complete art; it’s the art of plastic surgery and the science of beauty. There’s a science to making people beautiful, and it’s a combination of understanding aesthetics, physiology and anatomy, and understanding the interaction of all three. You’ve got to find someone with a good aesthetic sense.
As told to Komal Basith.
Eniko Mihalik photographed by Robbie Fimmano for Flair.