Your Questions

Q: Dr. Eppley, I recently had rhinoplasty (4 weeks ago) and I am extremely unhappy with the result. I asked my surgeon to remove the bump on my nose but it is still there and also my nose looks extremely wide. I was wondering if this could still be due to swelling- and if so, how much can I hope for it to go down, and if not, how soon do you think I could get a revision – I really want to be able to feel comfortable with myself before I go to back to school in September. I’ve attached some photos – as you can see my bridge is very wide and there is still a noticeable bump- could these just be caused by swelling, is there a chance they could go down completely/a lot?

A: In trying to answer your questions, I am at a significant disadvantage. I do not know what your nose looked like originally and know no details of how your rhinoplasty was done. These pieces of information are critical to know as to whether the eventual resolution of swelling will produce a favorable outcome or not.

But let us assume that the outcome of your primary rhinoplasty is not favorable, the timing of any revision rhinoplasty would depend on what needed to be done. This would not be before three months at the minimum and likely six months after the original rhinoplasty procedure. The nasal tissues need time to heal and have all the swelling fully subside.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to thin out my large African-American nose, add a defined bridge and still look “natural”? How long does surgery take and how long is recovery?

A: Thank you for your inquiry and sending your pictures. The African-American rhinoplasty is unique  because of the very thick overlying skin and lack of a strong bone or cartilage framework underneath it. You are correct in your description of how to approach the broader and flatter nasal structure by dorsal augmentation (usually with an implant), increasing tip projection with definition with columellar strut and tip cartilage grafts and nostril narrowing. I have done some computer imaging to show some of the potential outcomes with are highly controlled by the thickness of the overlying skin and how well it can contract down over a new supporting framework. The first  imaging prediction is based on the least amount of change (thinning) that can occur while the second imaging prediction is based on what I believe to be the maximum change that can occur in a single rhinoplasty procedure. You did not provide a side view image so how that would be affected will require a profile picture. I will let the images speak to your assessment of whether such a result would be natural in appearance.

This typical African-American rhinoplasty usually takes about 2 1/2 hours to perform under general anesthesia as an outpatient procedure. Since internal breathing work does not need to be done (I am assuming) nor do nasal osteotomies or a rib graft harvest (since an implant would be used), there should be minimal pain afterward and no bruising. Recovery is more about how you look having to wear external nasal tapes and a splint for a week after surgery. Once that comes off there are no physical restrictions and one’s appearance should be socially acceptable. While the final results of a rhinoplasty can take six months to fully appreciate (maximal skin contraction and thinning), one should be reasonably comfortable returning to work and socializing again in 10 to 14 days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, What’s the recovery time for a rhinoplasty? How soon could I return to work and look somewhat “normal”

A: The recovery time for a rhinoplasty is usually no more than 10 to 14 days at worst. This is not the total time that it takes for the nose to achieve its final shape, as that takes months, but until it really looks ‘non-surgical’. I have seen some patients who actually look pretty good when the tapes and splint is removed at one week but it would be safe to use the time period of 10 days for returning to work, etc. Normal is defined when one can walk around in public and not look like they have had surgery. Often the key determinant is when the bruising under the eyes will go away provided that one has had nasal bone osteotomies as part of their rhinoplasty. For those rhinoplasties in which the nasal bones do not need to be manipulated, the recovery in appearance is sooner.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am two months after having a rhinoplasty. Th swelling has gone down considerably and my doctor said that about 75% of it is gone. But my tip is still rock hard. It is so stiff that it barely moves and the tip is very numb. I have not had a significant other since my operation, but am afraid my very stiff  nose will affect kissing. Will my tip ever soften or am I stuck with a hard numb tip?

A: Hardness of the nasal tip after rhinoplasty is very common. It initially occurs due to swelling but persists much longer after the swelling has subsided due to scar tissue and what was done to the tip cartilages during surgery. In most rhinoplasty surgeries the tip is narrowed, lifted and strengthened with sutures and cartilage grafts. This helps give it a new shape but also prevents it from shifting or changing shape after it has healed. This causes protracted stiffness of the nose for up to nine months to one year after surgery. It will eventually be much softer and can be moved around normally again but it is an issue of more healing time. As the stiffness finally goes away, normal feeling to the tip skin will return.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley I have a question. I did open rhinoplasty and now I’m 3 months post op. I have stopped taping my nose but now I feel like my tip is more bulbous than it used to be. When I was taping it was more rounded and big. Now it feels firm with slight pain if I try to move it. Is that swelling? Will this shape change with time? I’m so confuced and I don’t want to  undergo a revision.

A: Your questions are the most common concerns that most patients have after rhinoplasty. While I obviously don’t know anything about before surgery nose or what exact rhinoplasty maneuver were done, I can make some general comments. If you have read my four phases of rhinoplasty recovery blog, you will see that you are currently entering phase 3. Tip swelling is very common in this phase and often the tip may even appear bigger than before. The fact that it is firm and slightly painful indicates that you still have significant tip swelling. What you can know for sure is that the tip is going to get smaller. How much smaller and whether it will end up better than before surgery remains to be seen. You will know that all the tip swelling is gone when it feels soft again and can be freely moved without discomfort. The consideration of a potential rhinoplasty revision is a long way off and you must wait a year after surgery to be certain you are really looking at the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I recently underwent a rhinoplasty on September 19th. I found the results to be disappointing so far, it seems that my nose is twisted.  Is this normal, and will the swelling go down to create a much better result? Where may I send you a before and after picture for an evaluation?

A:  One of the most challenging aspects of a rhinoplasty for many patients after surgery is that the final and expected result can take a long time to see . Of any plastic surgery procedure that I have ever done, I find that a rhinoplasty takes the longest to achieve the final result. The skin of the nose can swell considerably, masking any changes that have been done to the underlying osteocartilaginous framework. And since those changes are ultimately what will make the nose look different, not seeing them for a long time can be disappointing and the wait can be frustrating.

It is important to remember that the results of a rhinoplasty are not a ‘TV moment’. Unlike the way it is frequently presented, the final results are not when the splint and take (bandages) come off. In some patients, some of the changes are immediately seen. But in many patients, particularly those with thick nasal skin or who have had relatively minor changes done, the swelling will mask any changes done and it may even look worse for some time.

This is why it is important to try and ignore what you are seeing right now. Swelling always creates distortions, many of whom may go away as the swelling subsides. Six weeks after a rhinoplasty understandably seems like an eternity to you but, in the rhinoplasty world, this is just a small fraction of time. What you are see at six months after rhinoplasty surgery is more relevant as this gets into a time period when revisional surgery can start to be considered if significant deformities/asymmetries persist.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  It has been 2 months since my rhinoplasty. Everything is going down very nicely. I had my bump removed and narrowed and my tip raised a little. I had a droopy profile. Sometimes when I look at my profile I see a slight hump still when I smile. That is driving me crazy, not so much on my right side but my left side. When it gets down to the tip, it goes in slightly and goes up the tip very little. My question is I was very swollen when cast was taken off. My nose was taped right away and the tip of my nose is still swollen. Could it be that this slight hump is still swollen and when the swelling comes down so will the hump and the swelling in the tip the swelling on both sides of my nose went down dramatically but I’m just concerned about the profile.  Thank you.

A: One of the hardest things in undergoing rhinoplasty is to have patience. The shape and appearance of the nose can take months to fully appear after surgery. Final results in most cases can not be fully judged for up to one year after surgery. I believe you have answered your own question already. While some swelling has gone down, it is far from being completely resolved. Whether your dorsum and the pre-existing hump will be completely gone is not yet known. If you feel that there is still some tip swelling (which there undoubtably is), then there is still some dorsal swelling which may account for a pseudohump appearance. Don’t get out the critical eye until 6 months after surgery. If the hump is still there, then it is no longer just swelling and revisional rhinoplasty may be considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had rhinoplastic surgery two months ago to remove the hump present on my nose. Day before yesterday again I found a big hump on my nose. Please suggest to me what I should do now.

A: Removing a bump on the nose, known as dorsal hump reduction, is one of the most common changes done as part of many rhinoplasties. The size of the hump varies in different patients and the type of rhinoplasty technique used to take it down and make the dorsal line smooth varies accordingly. In small humps, a simple rasping or filing down may be all that is needed. In humps of more significance, greater than 1 or 2 mms, an actual osteotomy technique is needed. While in rhinoplasty days gone by, many humps were converted to a ‘ski slope’ appearance which created an over reduced look. Today, a higher dorsal line is more aesthetically pleasing and a lot of better for maintaining good nasal airflow exchange.

Because of swelling, it may not be possible to fully appreciate if a small hump has been adequately reduced for weeks to months after rhinoplasty surgery. However at two months after surgery, it would be fair to say that the hump reduction achieved should be visible. I don’t think the ‘hump reappeared’ or reformed, it is just that all the swelling may now be gone and the shape of the dorsum is fully apparent again.

While revisional surgery is not generally performed for at least 6 months after surgery, it is reasonable to ask your plastic surgeon about your concerns at this point. He or she can give you better insight as to where you are now in your postoperative recovery compared to your preoperative nasal shape.   

Dr. Barry Eppley

Indianapolis Indiana

Q: I had rhinoplasty surgery one week ago today. Ever since the surgery my nose has been very congested and I can only really breathe through my mouth. It runs all the time and I constantly have to wipe it. My concern is whether this is normal? What can I do to make my breathing better?

A: Such nasal congestion after a full septorhinoplasty is very common and almost the norm for the first week after surgery. Even though most plastic surgeons today don’t use nasal packing, often some form or resorbable or dissolveable packing may be used. This takes a week or two to go away. This combined with the swelling of the nasal linings, clots and reactive production of nasal secretions can make for a difficult first week. Yours sounds like a very typical one for many more complete rhinoplasties.

While time will improve the nasal congestion substantially, it make take up to 10 to 14 days until it is really better. Complete resolution of the congestion and drainage will be seen by three to four weeks after surgery.

The use of hot showers or a dehumidifier in your bedroom at night and the liberal spraying of your nose with Afrin (decongestant) and saline nasal sprays will reduce the swelling in the nose and help loosen obstructive clots. During your first postoperative visit to your plastic surgeon, those clots that are easily visible and not too painful to remove can be cleared.

Dr. Barry Eppley

Indianapolis, Indiana