West Orange, Facial Plastic Surgeon Among Top Influencers in Rhinoplasty Surgery

West Orange, NJ – March 27, 2017 – Local physician Eric M. Joseph, MD is one of 100 doctors worldwide to receive the RealSelf 100 Award, a prestigious award honoring the top influencers on RealSelf—the most trusted online destination to get informed about elective cosmetic procedures and to find and connect with doctors and clinics.

In 2016, more than 82 million people visited RealSelf to research cosmetic treatments and connect with local medical professionals. The RealSelf 100 Award, now in its seventh year, honors the top rated and most engaged board-certified aesthetic doctors who consistently demonstrated a commitment to patient education and positive patient outcomes throughout 2016. This elite group of 100 doctors have excelled at sharing their expertise, free of charge, with tens of millions of RealSelf community members actively searching for information and the right provider, and together contributed 25 percent of the half a million total answers posted on RealSelf in 2016.

Dr. Joseph’s expertise and passion for Rhinoplasty Surgery has helped his patients live with greater confidence. Each nose is uniquely sculpted to achieve a more pleasing and natural looking facial appearance. For more than 17 years, Dr. Joseph has performed functional and cosmetic Rhinoplasty. He has received an unsurpassed number of positive reviews from his patients about their experiences and results.

“The RealSelf 100 represents an exclusive group of doctors who embody both excellent patient service and an ongoing commitment to educating consumers shopping in the aesthetics market,” said Tom Seery, Founder and CEO of RealSelf. “Our research shows that more than 95 percent of patients expect a practice to engage with them online. These doctors are leading the way in terms of their online engagement and focus on empowering patients with good information.”

Eric M. Joseph, MD is an expert contributor to RealSelf, and to date has posted 3,259 answers to questions on RealSelf. Dr Joseph also maintains a patient star rating of 4.9 out of five stars in RealSelf reviews. For more information on Dr Joseph, please visit EricMJoseph.com and for the full list of RealSelf 100 Award winners, visit http://www.realself.com/RS100.

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We performed a rewarding rhinoplasty surgery on a patient taking Pentasa for Crohn’s disease, and there was no excessive bleeding. The patient stopped Pentasa four days preoperative after hematology consultation, but anti-inflammatory medications that inhibitb platelet function typically thin the blood for well over seven days. As of today, there are no guidelines regarding Pentasa and the perioperative patient, and I wanted to share this to help others. Thank you.

http://www.ericmjoseph.com/teen-ethnic-revision-rhinoplasty-nj

Eric M. Joseph, M.D. Wins RealSelf 100 Award for five consecutive years.
West Orange, NJ Rhinoplasty Specialist Recognized as Top Social Influencer in facial plastic surgery.
West Orange, NJ –February 18, 2016 – Local physician Eric M. Joseph, M.D. is one of 100 doctors in the nation to receive the prestigious RealSelf 100 Award, out of nearly 13,000 board certified specialists with a presence on RealSelf—the leading online community helping people make confident choices in elective cosmetic procedures.

In a time when 1 in 4 U.S. adults share their health experiences on social media channels, the medical professionals that made the 2015 RealSelf 100 are recognized both for having an outstanding record of consumer feedback and for providing credible, valuable insights in response to consumer questions about elective cosmetic treatments, plastic surgery, dentistry and more.

Eric M. Joseph has a private practice for seventeen years in West Orange, NJ specializing in Rhinoplasty, Teen Rhinoplasty, Ethnic Rhinoplasty, Revision Rhinoplasty, and Non-Surgical Rhinoplasty. He is also one of the few area surgeons experienced in the serial puncture, microdroplet technique of Silikon-1000 administration for nos-surgical permanent facial rejuvenation, and permanent Non-Surgical Rhinoplasty procedures.

“The doctors receiving this award were among the top 1% of our 13,000-member doctor community in 2015,” said Tom Seery, RealSelf founder and CEO. “When I started RealSelf, many doctors questioned why they should ‘give away’ their expertise ‘for free’ on the web. Now, eight years later — and with over one million doctor answers on our platform — we are proud of the standard this select group has set. They’re leading the way by empowering millions of consumers to gain access to the information they need to make smart and confident health and beauty decisions.”

Eric M. Joseph, M.D. is an expert contributor to RealSelf, and to date has posted 2,500 answers to questions on RealSelf. Each month people from all over world ask important aesthetic-related questions, such as Rhinoplasty, Teen Rhinoplasty, Ethnic Rhinoplasty, Revision Rhinoplasty, and Non-Surgical Rhinoplasty. Dr. Joseph also maintains a patient star rating of five out of five stars in RealSelf reviews. For more information on Eric M. Joseph, M.D., please visit ericmjoseph.com, and for the full list of RealSelf 100 Award winners, visit http://www.realself.com/RS100.

Thank you.

Authors: Lee J. Kaplowitz, M.D. and Eric M. Joseph M.D.

Introduction

Otolaryngology residency training programs have a long tradition of educating junior physicians in nasal surgical anatomy, nasal function, and in surgical techniques for treating disorders of the nose and paranasal sinuses. Patients who wish to alter their nasal appearances with rhinoplasty surgery may benefit from the skills of an otolaryngologist since many prospective rhinoplasty patients require concomitant otolaryngologologic procedures such as major septal repair, turbinate reduction, internal and external nasal valve repair, and endoscopic sinus surgery. The patient and surgeon both benefit when functional  and cosmetic nasal concerns are addressed at a single operation. For these reasons, rhinoplasty surgery is a facial plastic surgical procedure well suited for otolaryngology residents to integrate in their training and surgical practices.

The resident may begin the educational process by studying nasal functional anatomy, and questioning current rhinoplasty techniques while training to perform  septoplasty, sub-mucous resection of septal cartilage, open reduction of naso-septal fractures, repair of obstructed nasal valves, endoscopic sinus surgery, management of naso-facial trauma, and control of epistaxis.

Otolaryngology residents may enhance their learning experience by spending time in the offices of their attendings, observing the care of rhinoplasty surgical patients, which starts at their initial consultation and continues through their fifth postoperative visit, around one year after surgery. Senior residents should additionally observe rhinoplasty surgeries during their training, and schedule post-traumatic nasoseptal-reconstruction clinic cases for surgical repair with their attendings.  Observing many cases, and scheduling clinic cases, may allow a resident to learn to treat some of the most common causes of nasal dissatisfaction – a dorsal hump, a long nose, and a droopy, bulbous tip. The orderly sequence of events in rhinoplasty surgery may be mastered, and the maneuvers necessary for effecting change may be learned.

History of Current Rhinoplasty Techniques

Current rhinoplasty techniques were largely conceived in the latter half of the 20th century. But, rhinoplasty was being performed for millennia prior. One of the first written accounts of rhinoplasty was recorded around the time that the pyramids were being built (around 2500 B.C.). Translated from hieroglyphics, the Edwin Smith Papyrus gave detailed instructions for performing closed nasal reduction for nasal fracture (reference Edwin Smith Papyrus). The Egyptians were not the only early civilization making advancements in rhinoplasty techniques. Indian physician Sushruta developed staged pedicled flap for reconstruction of the nose which principles are in use today(reference Sushruta).

Since the time of antiquity until today, the techniques employed have dramatically changed, but the anatomy has essentially stayed the same. Over the past 60 years, advances in our knowledge, technology, communication and anesthesia lead to the flourishment of our understanding and capabilities today.

Jacques Joseph was a German plastic surgeon credited with developing the modern rhinoplasty. He was born in 1865 as Jakob Lewin Joseph. In 1904 He was the first to publish an endonasal technique of removing a dorsal hump. He became head of the department of facial plastic surgery at a prominent Prussian hospital in 1916. While there, surgeons from around the world came to observe him perform rhinoplasty. He died in 1934 from a heart attack.

There are several notable surgeons who were also developing rhinoplasty techniques around the same time as Joseph. Slightly before Joseph’s time was a surgeon named Johann Friedrich Dieffenbach (1792-1847). He published a paper describing nose reduction using external incisions. Robert F. Weir (1838-1927) was a professor of surgery in New York City who in 1885 claimed to have performed a nasal reduction (named rhinomiosis totalis). In 1887 the Rochester, New York surgeon named John Orlando Roe (1848-1915) published a paper on intranasal rhinoplasty technique and then went on to publish another paper describing an endonasal dorsal hump removal technique.

Joseph had a steady flow of rhinoplasty patients after gaining notoriety across Europe. Additionally World War I left many soldiers with complex nasal injuries in need of repair. In the 1930’s one particular surgeon named Samuel Foman traveled to Europe to observe and learn from Dr. Joseph. Foman  gained a lot from the experience while treating Dr. Joseph’s unique patient population. Foman brought this experience with him to New York City. Similar to his mentor Dr. Joseph, he went on to teach a rhinoplasty course in New York City. Among his students were two named Maurice Cottle and Irving Goldman. These two surgeons were instrumental in disseminating rhinoplasty techniques in the United States.

Maurice Cottle (1898-1981) was born in England and immigrated to the United States from France in 1913. He settled in Chicago. He learned from Dr. Foman and also contributed to the field with his advancements in rhinometry. He taught hundreds of doctors in Chicago. He went on to found the American Rhinological Society in 1954.

Irving Goldman (1898-1975) was born in New York City. He was a prominent figure in New York City. He cared for notable celebrities such as Dean Martin and Frank Sinatra. He was also an avid boxer. He was one of the first people who performed rhinoplasty in New York City and was instrumental in the formation of the American Academy of Facial Plastic and Reconstructive Surgery in addition to serving as the academy’s first president.

As time went on, Foman, Cottle and Goldman each taught their own courses and had a loyal following of plastic surgeons. Each would teach their specific techniques. The three would eventually go on to form their own societies with affiliated surgeons giving their courses. In 1964 the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) was formed as the union of the Foman Society, Goldman Society, American Medical Association and American Academy of Otolaryngology. Cottle chose to remain separate at the last minute and later gave rise to the the American Rhinological Society.

The AAFPRS organized the rhinoplasty community. Summarizing from the mission statement of the academy, it serves to promote education of doctors and the public, defines facial plastic surgery as a specialty, represents the community to legislative and regulatory bodies, and assists members to provide the best care possible.

  • Basic Technique Variations

Though united under AAFPRS, there still remains a lot of variation in rhinoplasty techniques, based on the experience, preference and training of the surgeon. There exists a large family tree accompanied by different techniques for solving the same problems.

The first distinction in rhinoplasty techniques involves the surgical approach to the underlying nasal anatomy. –  a closed, or endonasal approach), versus an open, or external approach. An endonasal approach may combine a transfixion incisions, inter-cartilaginous incisions, and marginal incisions to expose and deliver the alar cartilages for visualization and repair.  An open rhinoplasty approach involves making a transcollumellar incision and carrying it out along both caudal margins of the lower lateral cartilages. The skin and superficial muscular aponeurotic system (SMAS) overlying the nasal tip and dorsum is separated from the framework of the nose providing wide exposure when the degloved soft tissue flap is retracted superiorly. When executed properly, either approach may lead to an improved aesthetic and functional nasal result.

The next distinction in modern rhinoplasty techniques involves the treatment of the nasal tip. Anderson and Simmons popularized dividing the alar cartilages anteriorly, suturing and altering the anterior medial crura, and altering the lateral crura for a desired tip configuration. This is commonly referred to as the “tripod theory” (schematic photo of the tripod from Anderson’s paper). Other surgeons (Pastorek, Kridel) leave the crural arches intact and use intradomal and interdomal sutures to achieve tip refinement…

Demographics of prospective rhinoplasty patients 

The majority of patients seeking rhinoplasty surgery are healthy young adults, typically under thirty five years, or adolescents who have have dissatisfaction with the appearance and function of their noses.  The majority of prospective patients are females are in their second to fourth decades, and they may describe dissatisfaction with their nasal appearances since middle school or high school. Rhinoplasty may be offered to girls when they have reached their full growth potential, as early as thirteen years.  At that time, many girls who develop large, distracting, and often masculine nasal appearances, may become bothered, and begin discussing rhinoplasty with their parents. Boys tend to mature both physically and psychologically later than girls, and rhinoplasty surgery is rarely offered before seventeen years in boys.

Patients in their second to fourth decade may request rhinoplasty surgery during a time of transition – before commencing high school, college, or a new work environment.

The facial aging process is multifactorial, and the effects of gravity on facial aging do not spare the nose, and some patients present in their fifth to seventh decades requesting rhinoplasty. With the passage of time time, the tip of the nose tends to droop several millimeters which may exacerbate the appearance of a dorsal hump. Rhinoplasty surgery to achieve tip rotation and hump removal may lead to a more youthful and desirable nasal appearance.

Others present for rhinoplasty when it is economically feasible, since fees associated with many cosmetic and functional rhinoplasty surgeries may be the responsibility of the patient.

Learn reproducible techniques for treating the most common causes of aesthetic nasal dissatisfaction.

The number of techniques described for performing rhinoplasty over the last thirty years is a testament to the fact that there is no superior method of rhinoplasty surgery associated with the highest level of patient satisfaction. The patient and surgeon are the arbiters of a successful outcome, and successful rhinoplasty is dependent upon establishing realistic goals with the patient, and achieving them within millimeters.

Otolaryngology residents may enhance their learning from the practical teachings of rhinoplastic surgical attendings. The resident’s initial goal is to learn the orderly sequence of rhinoplasty surgery.  For example, exposure, septoplasty with harvest, tip work, bony work, refinement, closure, taping and splinting. If allowable, an intraoperative video may be a  resource for future review of the sequence, common surgical maneuvers, and proper hand positioning. Repetitive rhinoplasty surgical exposure may enable otolaryngology residents to address the more common aesthetic concerns of prospective rhinoplasty patients. Techniques to be learned by the resident for addressing the common causes of patients’ aesthetic nasal dissatisfaction include: shortening a long nose, removing a dorsal hump, narrowing a wide nose, straightening a crooked nose, and repairing a droopy, bulbous nasal tip.

Determine the patient’s candidacy for surgery at the rhinoplasty consultation.

A prospective rhinoplasty patient should be carefully evaluated for candidacy. The results of rhinoplasty surgery will be the centerpiece of their face. The aesthetic endpoint of successful rhinoplasty is to allow a patient’s nose to blend in, and become less distracting – not to transform the centerpiece into a masterpiece. Most patients who are pleased with their rhinoplasty surgery may receive complements from friends and acquaintances about their improved general appearance, but many times the change in nasal appearance is not appreciated by others.

The rhinoplasty consultation is the first, and best time to determine whether the patient has realistic expectations, and whether they may be achieved through rhinoplasty. During the consultation the surgeon determines, to the best ability, that if all goes as planned, the patient will be pleased with the outcome.

Surgeons may observe, while taking a history, that rhinoplasty may be suitable from an aesthetic standpoint, but careful listening, questioning, examining, and computer imaging may be necessary to ensure the patient has realistic expectations.

  • A practical approach to the rhinoplasty consultation

After greeting the patient, hand washing, and asking the source of referral, the intake form is reviewed, including current medications, and past medical history. If the patient is prescribed a psychiatric medication, the patient is asked the reason for prescription.  If the patient uses cocaine regularly, even infrequently, rhinoplasty should be avoided. If there has been no cocaine use for twelve months or longer, the patient may be considered for surgery, but is advised that future cocaine use be eliminated to avoid possible midline nasal destructive disorder.

The patient is then asked what is bothering them about the appearance of their nose. Descriptions are recorded verbatim in the medical record. The surgeon inquires and documents how long the patient has been dissatisfied with their nasal appearance.

To subjectively quantify nasal dissatisfaction, the surgeon may ask the prospective rhinoplasty patient how much they dislike their nose, from zero to ten. Ten may be defined as the “worst nose possible”, and zero may be defined as the “perfect nose”. Patients that quantify dissatisfaction at seven or higher are typically eagerly desiring change. Rhinoplasty surgery may not be appropriate if a patient has only mild to moderate dissatisfaction, or if the patient “likes” their current nasal appearance on occasion.

Patients with a high degree of dissatisfaction for a long duration, with repairable pathology, are some of the best candidates for rhinoplasty surgery, since they may be more inclined to accept improvement after surgery, and experience satisfaction with their results.

The history concludes with queries about nasal function, to include: nasal obstruction, rhinitis, anosmia, sinusitis, epistaxis, and previous nasal surgery. If the patient had prior dental extraction, the surgeon asks about prolonged bleeding. If the patient had other major surgical procedures, the surgeon inquires about general anesthetic allergies, or hemorrhage. The patient is asked if there is a family history of a bleeding disorder, malignant hyperthermia or succinylcolase deficiency.

A head and neck examination is performed, and the patient’s nose is to be examined last. While sitting or standing at the patient’s side, the patient’s face is gently positioned using both hands, so the patient is looking straight ahead, with the facial plane perpendicular to the floor. The surgeon’s index fingers palpate the sidewalls of the nose starting from the glabella, down to the tip while noting the thickness and mobility of the nasal skin, and the quality of the underlying cartilaginous and bony nasal framework. Patients with thin nasal skin, and firm nasal cartilage are more prone to encounter visible irregularities after rhinoplasty, and these considerations are communicated to the patient when diagnosed.

The surgeon may assess the patency of each nasal airway by gently occluding each naris with the pad of the thumb, without distorting the nasal appearance, and requesting the patient to inhale normally through the nose. Direct or indirect head lighting is used to illuminate the nasal airway and visualize internal nasal anatomy. The surgeon may lift the tip with one thumb, and view the caudal septum’s position, and the size and color of the inferior turbinates. The undersurface of the patient’s lower lateral cartilages may be visualized while palpating with the thumb and index finger. The thumb lifts the alar margin, just lateral to the soft tissue triangle, and the index finger pushes the dome of the tip down to see the internal configuration of the tip, and assess the quality and size of the alar cartilages.

The surgeon then moves toward the back of the patient’s examination chair, so with a turned head, the patient’s profile is visualized. The size and shape of the nose, along with it’s proportion with the lower face and chin is noted. The nose is then palpated with the thumb and middle finger on the sidewalls, and the index finger on the dorsum. Gentle squeezes start at the nasal bones and sequentially move down the bony-cartilaginous junction to the tip. The nasal tip is then palpated from side to side and from top to bottom with two fingers. The strength of the lower lateral cartilages and the thickness and adherence of tip skin are assessed. The length, position and mobility of the caudal septum is palpated with the thumb and index finger, and the spatial relationship between the medial crura, the caudal septum and the alar rim is noted.  If there is a dorsal hump and a droopy tip, the surgeon may use an index finger to camouflage the hump, and a thumb to lift the base of the nose to simulate a desired result – a mirror may be given to the patient to observe. (Photo1)

Anterior rhinoscopy enables further visualization of the cephalic and caudal margins of the lateral crura, and also enables identification of intranasal anatomy and recognition of coexistent pathology. Patients with obstructed nasal airways, or who are noted to have pathology on anterior rhinoscopy should have flexible fiber-optic nasal endoscopy and nasopharyngoscopy performed to complete the nasal examination.

If the surgeon feels comfortable offering cosmetic and functional rhinoplasty, computer imaging may be offered to assist the patient in visualizing what to expect after surgery. Computer imaging should be underdone. It is better to demonstrate a modest improvement, and observe to see if the patient appears satisfied with the morphed facial photos. If the patient points out small imperfections in the rhinoplasty simulation, this could indicate unrealistic expectations. The goals of rhinoplasty surgery are improvement, not perfection. If the patient appears to have unrealistic expectations, it may be best not to offer surgery.

The patient may be shown examples how others looked and felt as they progressed through their healing processes after rhinoplasty. Ample time should be reserved to answer all of the patient’s questions, and the patient is reassured the lines of communication will remain open.

If the surgeon feels confident that the patient may benefit from cosmetic and functional rhinoplasty surgery, the conclusion of the consultation may be conducted by an office assistant. The assistant may give a questionnaire to the patient to ensure a bleeding diathesis, medical problem, or psychiatric disorder has not been overlooked, and to assist with surgical scheduling and financing.

Close family support is essential, and rhinoplasty should be avoided if a patient’s close family member is strongly opposed to surgery. Patients are informed that approximately 20% may require non-surgical revision rhinoplasty with Liquid Injectable Silicone (LIS), and 10% may require revision rhinoplasty. Surgeons ought not to regret surgeries not performed, so if confidence is lacking that the patient will be pleased, or if the surgeon is uncomfortable in any way, surgery should be avoided, and the patient may be referred to a senior colleague for another opinion.

The preoperative visit should reassure both the surgeon and patient that rhinoplasty is indicated.

  • A practical approach to the preoperative visit.

The patient’s comprehensive preoperative visit occurs within two weeks of scheduled surgery, and is best performed in the presence of a loved one or caretaker who will drive and accompany the patient for the first twenty four hours after rhinoplasty surgery. The preoperative visit begins with a reiteration of the patient’s medical history, medications and review of systems. The physical examination includes auscultation of the lungs, heart, and abdomen. Radial pulses are palpated, the heart rate is measured, and the ankles are palpated.

Attention is then brought to the nose which is thoroughly re-examined and palpated, and the cosmetic and functional goals of surgery are re-discussed with the patient holding a hand mirror.

The patient may have a list of questions, and the patient is reassured that all questions will be answered before the preoperative visit ends. Printouts and consent forms are read aloud to the patient, as this practice typically addresses most of the patient’s concerns.

Prescriptions are given that typically include three doses of an anti-staphloccal antibiotic, ten tablets of a mild narcotic, twenty tablets of a low-dose, anxiolytic benzodiadepine, and three anti-emetic strips such as ondansetron. A printout with the names, dosages and purposes of these medications is provided for the patient and is read aloud. The medication printout also lists other products that should be obtained from the pharmacy, such as throat lozenges, lip balm, hydrogen peroxide and cotton applicators.

The next printout contains preoperative instructions on the front, and postoperative instructions on the back. The preoperative instructions delineate the importance of NPO, face washing without makeup or lotions the morning of surgery, wearing a zipper or button down top to the surgicenter, avoiding  NSAIDS and blood thinners, and calling if any questions or personal illness occurs before surgery. An upper respiratory infection that occurs between the preoperative visit and surgery may necessitate in-person evaluation.

The patient is reassured that postoperative pain is minimal since nasal packing is not routinely placed. Some patients are completely nasally obstructed the first postoperative week from inspissated blood and mucous and edema. The anxiolytic may be used liberally the first postoperative week for insomnia or anxiety. Cold compresses such as frozen peas in a sandwich bag, are applied at home to the patient’s eyes and forehead, twenty minutes on, and twenty minutes off for the first forty eight hours postoperative. Two days after rhinoplasty, the patient may use hydrogen peroxide on a cotton applicator to loosen blood and mucous that will accumulate in the nasal vestibules. The moistened applicator is placed into the nostril, to the end of the cotton tip, and is twirled like a baton between the thumb and index finger.  The patient is expected to remain on house-rest for the first postoperative week until the dressing is removed. Normal social activities may be resumed seven to ten days postoperative with artful concealer provided by an office assistant, and unrestricted physical activity is allowed three weeks postoperative.

The consent for surgery is also read aloud, and informed consent is obtained. The patient initials next to the delineated complications, and signs the document at its conclusion.

Reproducible, digital, full face photo-documentation is obtained at the preoperative visit, caring to keep the patient’s facial plane perpendicular to the floor, and to ensure the lighting and exposure is consistent. The eight necessary photos include the frontal view in repose and smiling, bilateral oblique views keeping the tip of the nose in line with the contralateral pupil, bilateral profile photos in repose and one smiling, and a base view of the nose while the patient looks at the ceiling. The quality of preoperative photos is assessed and are repeated repeated until all are acceptable and consistent.

The preoperative visit is concluded while viewing the frontal and profile computer imaging of the desired result. Any further questions are addressed, and the first postoperative visit is scheduled six to eight days after surgery to remove the dressing. The patient is given a direct emergency contact to the surgeon, such as a cell phone number, and the patient is encouraged to call, anytime, with questions or concerns.

Reproducible surgical techniques for addressing the most common causes of nasal dissatisfaction

The following sequence is one time tested method of performing rhinoplasty surgery that was taught to the senior author by Dr. Alvin I. Glasgold, who is a disciple of Dr. Jack Anderson.

  • Prep

The patient is visited and examined in the preoperative holding area. Last minute concerns are addressed, the goals of surgery are re-discussed, and the patient is reassured. The markings include the location of a trans-columella incision, which is mid-columella, just above the flair of the medial crura. If nostril narrowing is planned, the scars are placed on the nasal sills in an inconspicuous location, symetrically. Placement of nostril narrowing incisions is determined with the patient smiling, as this helps to delineate the isthmus between the posterior alar margin and the nasal sill. Redundant nostril skin may be excised as a small wedge in this area bilaterally, inconspicuously at the nasal base. (photo to be obtained) The path of lateral osteotomies is marked at the nasofacial junction from the frontal process of the maxilla superiorly to the glabella. The path of the lateral osteotomy should end anterior to the lacrimal fossa which may be palpated with an index finger. The profile is then viewed, and while placing the tip in the desired location, the dorsal hump is marked for resection.

General anesthetic with a cuffed orotracheal tube is preferred to protect the patient’s airway from aspiration. The tube is taped to the mid-line lower lip, rather than an oral commisure, to prevent distortion of the nasal base. The patient’s eyelids are taped closed, and the head of the table is rotated ninety degrees from the anesthesiologist to allow for instruments to be placed on a stand above the patient’s head (photo with labels). Surgical instruments above the head enables the surgeon to look up, rather than behind, to access instruments that may be unfamiliar to a new assistant. The instruments necessary for performing rhinoplasty should be those from a standard nasal surgical tray. Frequently used nasal instruments used for rhinoplasty include: a Converse tip scissor, two and four millimeter double pronged hooks, three sizes of Converse retractors, an Anderson-McCullough elevator, Brown-Adson forceps, a blunt, curved iris scissor, a right angle scissor, right and left Joseph saws, right and left four millimeter curved, guarded osteotomes, a four millimeter straight osteotome, nasal rasps, and a toothed forceps for  the columella skin closure.

Four stringed pledgets are saturated with four milllileters of four percent cocaine, and two of these are placed along the length of each inferior turbinate. The nose is infiltrated with approximately fifteen millileters of two percent lidocaine with 1:100,000 epinepherine along the entire subcutaneous soft tissue envelope of the nose and into each side of the nasal septum. After the septal infiltaration, the soiled intranasal pledgets are replaced with the other two fresh pledgets, and the nose and face is prepped with chlorhexidine.  Four towels are places around the face, and a sterile split-sheet drape is used. The split ends are taped to each other at the top of the patient’s head. The exposed field is from the hairline down to the chin, with the endotracheal tube in plain view. Care is taken not to tape the drape directly to the orotracheal tube.

  • Exposure

The non-dominant hand positions and stabilizes the nasal tip with the thumb and middle finger on each of the ala, and the index finger on the infra tip lobule. The columella is rotated away from the surgeon. A 6700 Beaver blade makes the first incision from the lobule-columella junction down to the skin marking. The columella is then rotated toward the surgeon and the contralateral columella is incised. These incisions are placed at the lower margin of the medial crura bilaterally. The columella is then incised with an inverted V in the center to break up the straight line that was marked in the holding area. Each of the four limbs of the transcolumella incision are equal in length (photo).

The non-dominant first three digits continue to stabilize the tip, and the index finger is re-positioned posteriorly, on top of the columella to protect the skin. The Converse scissor is used in a spreading and cutting technique to lift the columellar skin completely off the medial crura. The two millimeter hook is grasped proximally with the non-dominant thumb and index finger to lift the columella flap anteriorly, and the fourth digit is used to evert the nostril margin on each side to perform marginal incisions bilaterally. The elevation of skin and SMAS from the cartilaginous and bony framework is performed with sharp dissection, initially with the two millimeter hook retracting the columellar flap anteriorly, while using the Converse scissor with its tips down. The pad of the fourth digit of the non-dominant hand is used to push the lower lateral cartilages posteriorly, while the Converse scissor is used to establish the avascular plane  between the tip and dorsal cartilage, and the nasal SMAS. The third and fourth digits of the non-dominant hand also determine the depth of dissection and help avoid inadvertent skin perforations. Both alar cartilages are widely exposed, usually to the sesamoid cartilages, and the tips of the scissor point posteriorly, in the midline, to expose the lower dorsum.

Converse retractors  are next used with the non-dominant hand lifting the soft tissue envelope anteriorly and superiorly to complete the wide undermining and degloving to the mid dorsum, under direct vision. Next, a curved, blunt-tip iris scissor is placed under the flap, and the non-dominant first three digits are placed on the external nasal skin with the flap down. The exposure is completed with the iris scissor, using a snipping and and spreading technique. The surgeon’s elevation is completed when the closed iris scissor may be moved from one nasal sidewall to the other without resistance. The soft tissue envelope is then retracted superiorly using a stringed pledget along the dorsum, pulling the flap superiorly. The pledget string is clamped to the towel at the patient’s forehead providing wide exposure of the alar cartilages and lower cartilaginous dorsum.

  • Septal harvest for a columellar shoring strut, and possible tip graft, spreader graft(s) or batten graft(s).

The non-dominant hand uses a Brown-Adson forcep to retract the closer medial crus away from the midline, and the assistant uses a four millimeter hook to retract the contralateral medial crus away from the septum. The dissection to expose the caudal septum is in the midline, and is performed with the Converse scissor. The anterior septal angle is revealed and the ligaments from the medial crural foot plates to the posterior caudal septum may be left intact, or divided if septal shortening or if tip deprojection is desired. When the caudal septum is identified, the assistant may retract it away from the surgeon with a smooth forcep, and the subperichondrial septal plane may be developed sharply, typically using the pointed tips of the Converse scissor. The bluish hue of the septal cartilage is the proper plane for septal flap elevation. The contralateral septal flap is developed by retracting the caudal septum toward the surgeon with the Brown-Adson forcep, while using the Converse scissor to define the contralateral subperichondrial plane. When the septal flap is developed for one or more centimeters sharply, a medium or large nasal speculum is placed between the mucoperichondrium and the septum to aid in visualization and dissection. The speculum is held with the non-dominant hand, palm up, resting on the patient’s forehead. Gentle squeezing of the speculum opens the plane, and subperichondrial and subperiosteal septal elevation is completed with an Anderson-McCullough elevator, which has a smaller tip than a Freer elevatior, and is less likely to cause mucoperichondrial perforations. A transcartilaginous incision is made with the a blade at least one centimeter superior to the caudal septal margin, and the  nasal speculum is replaced to straddle the incised, posterior quadrilateral cartilage. The septal cartilage for harvest is best taken from the floor of the septum, at the maxillary crest, since this is the strongest and thickest part of the septal cartilage. A knife begins the incision at the floor of the septum, and the inferior septum is freed from the maxillary crest to the vomer with a right angle scissor. The closed tips of the right angle scissor are used to separate the septal bony-cartilaginous junction, and this scissor is then used to remove a septal cartilage graft that measures approximately three centimeters long, and one to two centimeters wide, depending on the needs of the surgeon. Septoplasty is then completed, and a 4-0 Chromic quilting suture is run from posterior to anterior to reapproximate the septal flaps, and close small perforations that may be encountered. A septal quilting suture that reapproximates the septal flaps in the midline, precludes the use of nasal packing and prevents the formation of a septal hematoma.

  • The nasal tip is transformed into a tripod by dividing the lower lateral cartilages and suturing the medial crura to each other in the midline.

A forcep is placed intranasally at the soft tissue triangle and is lifted anteriorly to delineate the angle where the medial crus meets the lateral crus, and a marking pen is used to delineate this position bilaterally (photo). The Brown-Adson forcep is used to retract the vestibular lining into the nose, and the Converse scissor is used to separate the vestibular lining from undersurface of the tip cartilages. In the majority of cases, the lower lateral cartilages are divided at their angles, and the medial crura are sutured to each other, approximately four millimeters posterior to the division point, with one 5-0 PDS suture. The nasal tip is now a tripod where the medial crural complex is the central limb, and both lateral crura are the other two limbs. This maneuver typically results in a change in the spatial relationship between the medial and lateral crura such that the anterior portion of the lateral crura may overlap.

The lateral crura are then retracted antero-inferiorly and the Converse scissor is used to dissect the intranasal mucosal lining from the undersurface of the cephalic margin of the lateral crura, at the scroll regions bilaterally. The Converse scissors are used to separate the lateral crura from the upper lateral cartilages from anterior to posterior. This separation allows for superior rotation of the lateral crura and tip, by freeing these two limbs of the tripod from their anatomical attachment to the upper lateral cartilages.

Depending on the bulbosity of the nasal tip, and size of the lateral crura, several millimeters of the cephalic margin of the lateral crura are resected symmetrically. The majority of lower lateral cartilage, greater than seven millimeters, is left intact to avoid overresection, postoperative nasal obstruction, and pinching of the nasal tip. The anterior portion of the lateral crura are not routinely sutured to the medial crural limb.

The retracting pledget is now removed, the flap is lowered, and a cold compress is used to squeeze edema and anesthetic from the flap. The nose and face is cleaned, and the position and configuration of the nasal tip is assessed from above and from profile. Deprojection may be achieved by lowering the central limb. Rotation may be achieved by excising the anterior projection of the lateral crura, the other two limbs of the tripod. The flap is lowered, and the tip reassed after each incremental excision until a desired tip configuration is attained.

  • A columellar shoring strut (C-strut) supports tip position, and may aid in tip projection and rotation.

When the desired  position and configuration of the nasal tip is achieved, a C-strut is carved from the septal harvest. Typical dimensions are approximately twenty-five millimeters long  by four millimeters wide. The lower columella, below the incision, is grasped with a Brown-Adson forcep, and a straight iris is used to create a pocket between the medial crura posteriorly to the premaxilla. The C-strut is placed in this pocket and sutured to the medial crural central limb. It extends from the premaxilla to the previously placed 5-0 PDS suture that secures the medial crura to each other.The C-strut is sutured to the medial crural complex in one or two locations with 5-0 PDS.

A long C-strut may aid in projection and rotation by lengthening the central limb of the tripod. A shorter C-strut, simply by its addition, will add cartilaginous support to the central tripod limb, and prevent postoperative tip ptosis. Before proceeding with dorsal reduction, the paths of lateral osteotomies are reinfiltrated with local anesthetic.

  • Dorsal reduction

Small bony humps may be lowered with rasps. Large humps are conservatively lowered with right and left Joseph saws. The hump is engaged superiorly with each saw, and is placed along the sidewall at the level of preoperative marking. When the bony hump is released, a large Converse retractor is placed under the flap, and the cartilaginous portion of the hump is lowered and removed en bloc with the attached bone using a 15 blade. The flap is replaced, and the nasal profile is reassessed. Further bony lowering is performed with nasal rasps, and cartilaginous dorsal lowering is performed with a blade or right angle scissor. The dorsal reduction is performed incrementally to avoid overresection. When the height of the nasal dorsum is lowered, the width of the patient’s nose increases on anterior view, and osteotomies are necessary to close the “open-roof deformity”.

  • Osteotomies

A needle point electrocautery device is used to make a three millimeter intranasal incision, just anterior to the inferior turbinates down to the bone of the frontal process of the maxilla. Curved, guarded, four millimeter osteotomes are placed into the incisions onto the piriform aperature. The dominant hand holds the osteotome, and the other hand palpates the instrument as it courses along the nasofacial junction up to the glabella. The assistant uses a mallet and will strike the osteotome twice upon request. The bone and skin gets progressively thinner as the osteotomy proceeds superiorly to the glabella. Care is taken to end the osteotomy anterior to the lacrimal fossa, and care is also taken not to perforate the thin nasal skin near the medial canthus.

After completing the osteotomy, the osteotome is lifted anteriorly, and rotated medially to infracture the upper and middle thirds of the nasal dorsum. If there is incomplete infracture laterally, the lateral osteotomy is repeated. If there is inadequate infracture medially, a straight osteotome is placed on the medial nasal bone between the superior upper lateral cartilage and septum with a large Converse retractor protecting the soft tissue and allowing direct visualization. The medial osteotomy is performed gently and moves laterally as the glabella is approached .

After hump removal, most patients require only bilateral lateral osteotomies to infracture the dorsum. Adequate bilateral infracture must be achieved before proceeding by repeating osteotomies as necessary.

  • Final adjustments to the nasal appearance and airway are performed before closure.

After bilateral osteotomies are completed, it is common to observe the dorsum raise several millimeters on profile, and further lowering may be necessary. The cartilaginous dorsum must be several millimeters lower than the tip to avoid a “poly-beak deformity”. The upper lateral cartilages should be at the level of the dorsal septum.

A 5-0 PDS septocolumellar suture may be considered to improve or secure tip rotation. Since this suture will reposition the free central limb of the tripod, the anterior projection of the lateral crura may require further shortening to achieve proper rotation.

If redundancy and bulging of the membranous septum is noted, interrupted 4-0 Chromic through-and through sutures may be utilized for medialization of the mucosa and elimination of dead space. Interrupted 4-0 Chromic sutures may also be placed from the membranous septum to the caudal septal strut to enhance or maintain tip rotation.

Spreader grafts may be fashioned and interposed between the dorsal septum and upper lateral cartilages to repair obstructed internal nasal valves. This may be observed and palpated with the flap down, and visualized directly with a Converse retractor. The length and thickness of a spreader graft is determined by direct visualization, and the graft is carved and sutured to the dorsal septum with a 5-0 PDS horizontal mattress suture. The upper lateral cartilages may then be sutured to the spreader graft and septum, if they need to be elevated to the height of the dorsal septum.

A pre-columella-lobule extended shield graft may be fashioned and used in patients with thick skin to achieve tip definition and projection. These grafts may be sutured to the medial crural complex with a 5-0 PDS horizontal mattress suture. These are typically seven millimeters wide at the tip and taper and extend posteriorly into a pocket inferior to the medial crura. A pre-columella plumping graft may be carved and inserted into the same pocket, with suture fixation to the medial crural limb, to repair a retracted columella.

Alar batten grafts may be necessary during revision rhinoplasty to replace previously overresected lateral crura, and open collapsed external nasal valves.

Inferior turbinate reduction may be performed with a Dennis bipolar probe at twenty watts. Three passes are made along each inferior turbinate after infiltration with local anesthetic.

  • Closure

The closure begins when the surgeon is confident that the nasal airway is patent, and that aesthetic goals have been achieved. The transcolumellar incision is closed with three 6-0 Prolene sutures at the corners and in the midline, and two paramedian 6-0 fast absorbing cat gut sutures are placed. A four millimeter hook is used at the alar margin to expose the marginal inciaions which are closed with 5-0 Chromic.

  • Taping

Quarter inch beige paper tape is important for stabilizing the reconstructed nose. The first piece is placed at the supratip. It is applied using the thumb and index finger from the dorsum down to the maxilla ensuring the skin flap is adherent to the framework. Smaller pieces are cut and placed along the dorsum up to the medial canthus.

A six centimeter piece of paper tape is cut, and each end is placed along the side of the tip. The U-shaped extension of the tape is pinched together until the lobule is reached, securing the position of the nasal tip. This is reinforced with another piece of tape – the middle of the cut piece is placed on the lobule, and the ends of the tape are pushed from the lobule up to the maxilla. A light aluminum splint is placed on the upper two-thirds of the nose and taped to the patient’s maxilla from medial to lateral with two fingers.

Postoperative care continues for a year or longer after rhinoplasty

There are five or more postoperative visits the first year of surgery – one week, one month, three months, six months, and then one year postoperatively. Seventy to eighty percent of nasal swelling dissipates in most patients one month postoperative, and the remaining twenty to thirty percent of swelling tends to linger in the lower third of the nose for a year or longer. Photodocumentation is obtained at each visit, and color prints are given to the patient at the end of each visit.

One week after surgery, the patient’s tape and splint are removed. The patient holds a tissue on the upper lip, and an adhesive remover is applied with a medicine dropper while the tape is gently removed with a forcep. The tape is particularly adherent to the columellar sutures, and the tape is removed in a posterior direction at the nasal base, toward the upper lip, to avoid wound dehiscence. The five columellar sutures are removed, and the airway is inspected and cleaned of dried blood and mucous. Intranasal Chromic sutures are left intact. The patient and the surgeon should notice a swollen, but improved nasal appearance. Concealer is applied by an assistant, who also teaches this to the patient, so normal social activities may be resumed promptly. The patient is given a concealer kit to take home.

One month postoperative, the patient’s periorbital bruising will be gone,the patient’s nasal tip will be firm and swollen,.and the upper and mid nasal dorsum should have little remaining swelling. Any persistent intranasal Chromic sutures may be removed during anterior rhinoscopy, and the airway is assessed. Patients who experience nasal obstruction may benefit from bilateral intraturbinate injections with one millileter of triamcinolone acetonide (TA), 40mg/cc, when necessary. Small cotton balls saturated with one percent lidocaine with 1:100,000 epinepherine are placed on the anterior inferior turbinates bilaterally for around two minutes. This renders the turbinate injections painless, and the topical epinepherine causes the inferior turbinates to shrink and become less vascular. If the patient breathes better when the topical anesthetic is removed, that is a good indicaton that the patient will have improved nasal breathing for three to four weeks post-injection. Nasal breathing will also continue to spontaneously improve as intranasal edema decreases over the next several months.

If there is excessive swelling in the supratip area one month post-operative, the surgeon may consider a diluteTA injection, 2.5mg/cc, to reduce swelling in this area. Supratip edema may be retreated at monthly intervals or longer, as necessary. The concentration of TA may be increased as necessary for the treatment of supratip edema, not to exceed 10mg/cc.

If a small indentation becomes visible on the front or profile view of the unswollen dorsum, microdroplet Liquid Injectable Silicone (LIS) may be considered to fill the defect as early as one month postoperative. If the surgeon palpates a swollen dorsum, LIS treatments should be postponed until the dorsal swelling has resolved. Silikon-1000, Alcon Laboratories, Ft. Worth, TX , 1000 centistoke LIS, may be administered with a one millileter, Luer-Lok syringe and a half-inch, 27 guage needle, with or without topical anesthetic. The patient must sign informed consent for the off-label application of LIS, a permanent filler. The depth of injection is between the skin and nasal framework. Less than a tenth of a millileter may be administered for the treatment a small dorsal or nasal sidewall indentation. The serial puncture microdroplet technique of LIS administration involves depositing 0.025 millileters, or less, per puncture to achieve a desired result. LIS should be considered irremovable, so conservative treatments are mandatory to avoid overcorrection. LIS treatments can be repeated at monthly intervals, or longer, as necessary. Microdroplet LIS treatments are safe, effective, and well received by most patients, for the non-surgical treatment of minor postoperative indentations and irregularities that may follow rhinoplasty surgery. Rhinoplasty related irregularities may be seen in approximately twenty percent of patients with thin, light-colored skin. Thicker and darker nasal skin types are less likely to reveal irregularities as swelling dissipates over the one-year healing period.

The three, six, and twelve month postoperative visits are scheduled to ensure the patient’s satisfaction, analyze the progression of healing, and to assess the need for further interventions, both surgical and non-surgical. As the surgeon begins the learning curve of performing rhinopasty surgery, it is important to maintain a working relationship with teachers, so postoperative issues may be successfully dealt with. Revision rhinoplasty surgery is exponentially more challenging than primary rhinoplasty since tissue planes become less distinct, and there is less septal grafting material to work with. Revision rhinoplasty may be offered twelve months postoperative, depending on the condition of the patient.

A surgeon’s Internet presence and reputation will be sought by most prospective rhinoplasty patients.

The importance of a surgeon’s internet presence is necessary to emphasize. Ninety percent or more prospective rhinoplasty patients will begin researching rhinoplasty on the internet. Patients site positive reviews, favorable before and after photos, and credentials as the top three factors they consider before scheduling their rhinoplasty consultations. A surgeon’s website should be an informative source of knowledge for prospective rhinoplasty patients, and should contain the surgeon’s credentials, patient reviews, and as many before and after photos as possible. Less than ten percent of patients will allow surgeons to post facial photos without modesty, and this number may increase to around thirty percent if digital photos are provided with the patient’s eyes and lips covered.

Before posting any patient’s photos on the internet, specific consent must be obtained for such use to avoid privacy and civil rights violations. The consent for posting patients’ photographs on the internet should specify the desired locations of the uploads such as the surgeon’s personal website, social media sites, and plastic surgery forums.

Even if satisfied patients are skittish about publicizing their photography, the majority will be happy to anonymously opine about their positive experience on one of many physician-internet-rating sites. The surgeon should work to deputize their happy patients, and encourage their composition of online reviews, since this rarely occurs spontaneously.

Unhappy patients are much more inclined to spontaneously compose epic narratives about their experiences, and copy and paste them to multiple physician rating sites. Other than a generic reply to a negative review, the surgeon’s response to the negative review is limited by HIPPA, and local privacy laws. Negative reviews tend to be read by more people since they are deemed by the public to be more interesting. Internet posts should be considered permanent and irremovable, and may be read by the majority of patients seeking rhinoplasty.

  • Conclusion

Rhinoplasty surgery is a difficult but rewarding otolaryngologic procedure for the surgeon and patient. When rhinoplasty surgery is part of the services offered by the otolaryngologist, there is a proper approach for achieving competency and successful outcomes. This begins during residency with dedication to learning from a skilled rhinoplasty attending, and continues into private practice. Rhinoplasty surgery should be avoided if the surgeon is not confident in his or her ability to achieve a desired result, or if the prospective patient is only willing to accept perfection rather than improvement. Keeping a favorable internet presence, sounded by the voices of the surgeon’s patients,  is important for the growth and success of the rhinoplasty surgeon. Frequent participation in online forums designed to help patients seeking rhinoplasty may serve to augment the data base of knowledge available for public review.

  • Your comprehensive Rhinoplasty consultation is the first step to help us determine whether surgery will be right for you.

At your rhinoplasty consultation, we will help you determine whether undergoing rhinoplasty surgery in our practice would be a suitable. We will listen to your concerns, and help you decide what might be best for you moving forward. It may be helpful to come with a list of your questions or concerns, and what you are looking to achieve after rhinoplasty. Your consultation will be professional, honest, and thoughtful – so we could see what might be best for you. We need to determine compatibility and suitability for a long-lasting and positive doctor-patient relationship, to optimize your experience and ultimate satisfaction.

A gentle examination of your nose will be performed to determine the quality of your skin, and underlying cartilage and bone. We will also check you for functional, breathing problems, like a deviated septum or enlarged turbinates, that may be corrected at the time of your rhinoplasty surgery. Near the end of your consultation, computer imaging may be helpful for you to see what to expect after surgery. We will show you examples how other patients look and feel as they have progressed through the healing process. We will answer all of your questions, and our lines of communication will remain open. If we feel you may benefit from rhinoplasty, your consultation will conclude with a questionnaire, and you will leave with a written quote, and copies of your morphed photos.

  • Further questions will be answered at your Rhinoplasty pre-op visit.

If you decide to give us the privilege of operating on you, your next visit will be a comprehensive pre-op visit so you will feel comfortable with what to expect after your rhinoplasty. You will receive your prescriptions, and a list of written instructions for both before and after surgery. We will take new photos, and review the computer imaging, and solidify our surgical plan.

  • Your rhinoplasty surgery will require general anesthetic, and a week of house-rest.

Your next visit will be at one of our accredited surgicenters. We typically operate Monday and Friday mornings, and we will see each other the morning of your surgery to alleviate any concerns, and to place ink markings on your nose. Rhinoplasty surgery takes around two hours, and your recovery should be with minimal pain. We do not routinely use nasal packing after rhinoplasty surgery. When you’re completely awake after your surgery, you will have some food, go to the bathroom, and be discharged, with a responsible adult, if all is well. Your dressing will be removed six to eight days post-op, and we will show you how to cleanse your skin and apply artful concealer, so normal social activities may be resumed at that time. You should restrain from strenuous activities for three weeks after rhinoplasty, at which time you may resume unrestricted physical activity. There are scheduled visits one month, three months, six months, and then one year after your surgery. You will be encouraged to see us anytime in between if you have any concerns.

  • Rhinoplasty Surgery may be helpful for achieving a smaller, straighter, and less distracting nasal appearance.

Many of our happiest patients that underwent rhinoplasty in our practice have been women with large, distracting, masculine nasal appearances. It is a blessing to witness the elation of an attractive woman who sees her nose without a bump for the first time when the dressing is removed, around one week after rhinoplasty surgery. With artful concealer, most of our patients resume normal social activities one week post-op. When a woman with a large masculine nose requests rhinoplasty, we try to establish a “cute feminine nose” as an outcome. The goal of rhinoplasty is to allow your nose to blend in, and not call attention to itself – it is common to see a favorable improvement as soon as your dressing is removed.
Raising the height of a nasal bridge during rhinoplasty surgery may be considered in ethnic patients with broad, flat noses – this is one of the few examples where making your nose larger may lead to a more desirable nasal appearance.

  • Rhinoplasty Surgery may be helpful for lessening strong feelings of dissatisfaction with your nasal appearance.

Rhinoplasty surgery is the surgery of millimeters, so the more you dislike your nasal appearance, the more likely you are to be happy with your rhinoplasty surgery. During your rhinoplasty consultation, you may be asked – “How much do you dislike your nose from 0-10, with 10 being the worst nose possible?”
An answer like: ” I have hated my nose since middle school”, is a good indication of postoperative satisfaction after rhinoplasty surgery in our practice.
In general, we may not recommend rhinoplasty surgery if you have a dissatisfaction score less than 6/10, or if you “like” your nose on occasion.

  • Microdroplet Silikon-1000 injections may be helpful for improving your results after rhinoplasty surgery, if they become necessary.

Silikon-1000 is an off-label, permanent filler that has a long track record of safety for non-surgical-rhinoplasty treatments. My retired rhinoplasty teacher, Dr Alvin Glasgold, taught the art of microdroplet silicone injections for the permanent correction of minor irregularities, asymmetries, or indentations that may occur following rhinoplasty surgery. We use microdroplet silicone injections, when necessary, in around 20% of our rhinoplasty patients to permanently improve our patients’ outcomes and satisfaction – and to minimize the necessity of revision rhinoplasty. Over the span of sixteen years, our personal revision rhinoplasty rate is under 2%.

  • It may be best to keep your rhinoplasty surgeon close to home.

There are five planned post-op visits the first year after your rhinoplasty surgery, and we encourage our patients to follow up anytime if there are any concerns. We have found that small issues may be magnified by long distance. We accept out-of-town patients, but an in-person consultation is required before scheduling rhinoplasty surgery.

Thank you.

Dr Joseph

http://www.ericmjoseph.com/teen-ethnic-revision-rhinoplasty-nj

In our practice, we will not commit to surgery on out-of-town patients without first meeting for a consultation. Email photos are not a substitute for an examination. After your consultation, if you and your doctor wish to move forward, you can schedule your pre-op visit and surgical date, and you should plan to stay for longer than seven days near your surgeon until your dressing is removed.

We have seen post-operative bleeding anytime within three weeks following rhinoplasty, so the longer you can stay, the better. After being discharged home, you should expect to see your surgeon around 3-6 months post-op, and then 9-12 months post-op.

Small issues during your healing may be magnified by long distances, so if possible, it is always preferable keeping your rhinoplasty surgeon close to home.

Hope this is helpful. Thank you.

Dr Joseph

Expert Rhinoplasty – teen, ethnic, revision

Local physician Dr. Eric Joseph is one of 100 doctors in the nation to receive the prestigious RealSelf 100 Award, out of nearly 8,000 board certified specialists with a presence on RealSelf—the leading online community helping people make confident choices in elective cosmetic procedures.
The medical professionals that made the annual RealSelf 100 list are recognized both for having an outstanding record of positive consumer feedback and for providing unique, valuable insights that can’t typically be found on the social web. The doctors who made the list are dedicated to empowering millions of consumers to gain access to information they need to make smart, confident health and beauty choices. Dr. Joseph also made the RealSelf 100 list in 2014.
“I’m thrilled to be included in the RealSelf 100 list for the second year in a row,” says Dr. Joseph, “I truly enjoy taking the time to answer the questions posed by patients on RealSelf and it’s wonderful to be recognized for it.”
Dr. Joseph is an active contributor to RealSelf, and to date has posted over a thousand answers to questions on RealSelf on topics including Rhinoplasty, Revision Rhinoplasty, and injectable fillers. Each month people from all over world ask important aesthetic-related questions, such as general expectations following rhinoplasty surgery and other cosmetic treatment. Dr. Joseph also maintains a patient star rating of five out of five stars from over 300 RealSelf reviews.
Dr. Joseph is an expert in primary and revision rhinoplasty surgery in the New York New Jersey area. He performs rhinoplasty surgery several times per week, and commonly treats conditions like: large, long noses, wide noses, dorsal humps, bulbous nasal tips, droopy nasal tips, hanging columellas, crooked noses, obstructed nasal breathing, ethnic rhinoplasty, and nasal feminization. For more information on Dr. Joseph, please visit http://www.ericmjoseph.com/.