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Blog
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Blog
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March 5, 2010
Question: Do you always put a cast on the nose following rhinoplasty or revision rhinoplasty?
Answer: The answer is – no. I will only place a cast on the nose if I have performed osteotomies (breaking the nose) during the rhinoplasty procedure. The cast, like for a broken arm, is intended to keep the bones in position during the early healing process. Unlike with your arm, however, we take the cast off within the first week. Dr. Hilinski.
Question: Why do some plastic surgeons only show the lateral or profile view of the nose following rhinoplasty or revision rhinoplasty?
Answer: This is a great question. In my opinion, plastic surgeons should provide at least two views of the nose in their before and after photos. Nasal reshaping is such a 3-dimensional process that I don’t a single lateral view can represent an accurate outcome of the surgery. Plastic surgeons should always try to provide before and after rhinoplasty photos of at least two views – preferably a frontal and side view. Sometimes the oblique or 45 degree angle view also helps in demonstrating an accurate change. Many plastic surgeons will post only the lateral view of the nose showing how, for instance, a hump has been removed or how the tip was elevated. That is great to see this view but the real question is how does that nose look from the front? Getting the frontal view symmetric and refined is the real challenge in rhinoplasty and revision rhinoplasty. Without the frontal postoperative photo, I personally don’t think that one can accurately judge how good of a rhinoplasty was performed. My humble opinion. Dr. Hilinski
March 4, 2010
I just completed an interview today with an independent journalist here in San Diego who was researching the topic of injectable filler use for the nose. This idea has actually been around for many years but has been gaining increasing media attention. It has been called among other things the non-surgical nose job as well as injection rhinoplasty and lunchtime rhinoplasty. These names and labels all refer to the technique of injecting a dermal filler (like Restylane, Perlane and Juvederm) into the nose to reshape and contour. It is not a bad option in those patients who want to bridge the gap and buy time before they ultimately undergo an actual rhinoplasty or revision rhinoplasty. We have had many rhinoplasty patients over the years here in San Diego opt for this procedure and then end up having their rhinoplasty performed after the filler has gone way (6-9 months typically for the temporary fillers mentioned).
Question: If I just want to narrow my nose by reducing the width of the base, do I have to undergo an anesthetic?
Answer: The answer to this is ‘no’ if that is all you want done in terms of a limited rhinoplasty or revision rhinoplasty. We have several patients every year that only want to narrow the base of the nose where the nostrils attach to the cheek and lip. There are a variety of methods used for base narrowing of the nose and essentially all of these can be done in the office under local anesthesia and sometimes an oral sedative medication. In most cases, this simple limited type of nasal reshaping can make a significant improvement in the appearance of the nose.
March 3, 2010
Question: What is Asian rhinoplasty and how is it different from standard rhinoplasty?
Answer: Asian rhinoplasty is quite different than the average rhinoplasty procedure. The reasons for this are multiple but primarily involve the desired endpoint in terms of esthetic outcome and the unique underlying anatomy. With regard to the desired esthetic outcome, any experienced rhinoplasty surgeon is going to agree that you cannot reshape an Asian (or any ethnic nose) the same as you would in a Caucasian rhinoplasty. Although the bridge is typically augmented and the tip is made more defined in Asian and ethnic rhinoplasty, the end result has to remain in balance with the rest of the facial features. Since there are such distinct differences in Asian and ethnic faces, your rhinoplasty surgeon must respect these unique characteristics and avoid performing ‘westernization rhinoplasty’ in this population. Only rarely do I have Asian rhinoplasty patients who truly desire to move away from their ethnic look. With regard to the anatomy of an Asian nose, there are very clear anatomic variances that warrant a different technical approach to the nose. For instance, the combination of thicker skin and weaker underlying cartilage in the Asian rhinoplasty patient means that your rhinoplasty surgeon has to alter their surgical technique to compensate for these variables. For these reasons and more, you need to make sure that your chosen rhinoplasty surgeon is experienced and versed in performing Asian rhinoplasty on a regular basis. Sincerely, Dr. Hilinski.
March 2, 2010
One of my San Diego revision rhinoplasty patients was just in and asked what many patients ask regarding nasal exercises. Is it normal to have pain with the exercises? The answer is absolutely. In fact, if you are not pushing hard enough on your nose to elicit some degree of pain, you are likely not pushing hard enough! In order to effectively move the nasal bone after we perform an osteotomy (fracture or break the bone) you have to push to the point where pain is felt. Many rhinoplasty patients worry about over correcting the bone, but this is essentially unheard of when performing nasal exercises. Happy healing. Dr. Hilinski.
February 27, 2010
Question: What are steroid injections and why are they used for rhinoplasty and revision rhinoplasty patients?
Answer: Steroid injections refer to an injectable corticosteroid (called steroid for short) solution that is used to decrease swelling and dissolve unwanted scar tissue. I use steroids quite commonly to help during the healing process following rhinoplasty and revision rhinoplasty. If taping the nose does not address the issue sufficiently and/or quickly enough, I might recommend a steroid injection to reduce an unwanted contour or prominence. Contrary to popular belief, steroid injections can be used even very late in the rhinoplasty healing process (like 6-12 months out).
The short answer to this question is – yes, if you have symptoms of nasal blockage that are not improved with medications. If you are found to have evidence of a deviated septum, or crooked septum, on examination by a facial plastic surgery or otolaryngology specialist, they will likely recommend surgical repair. In order for your insurance company to cover these services, your surgeon will submit paperwork documenting their opinion and recommending septoplasty surgery. If preauthorized (meaning the insurance company offers preliminary approval), then most patients proceed with the septoplasty and have the expenses covered by their insurance company. Of course, as the patient, you should be well aware of any and all restrictions and responsibilities related to your healthcare policy. Hope this helps. Dr. Hilinski.
This is a frequent question that I get asked from potential rhinoplasty and revision rhinoplasty patients. Normally most rhinoplasty patients will look ’supermarket’ presentable in about 10-14 days. I will remove the sutures, tape and cast (if placed) 5-6 days following your surgery. The nose looks swollen that day but, in general, rhinoplasty patients can appreciate the changes that were made even at that point in time. A significant improvement will be seen between that day and the 10-14 day mark to the point that most patients feel comfortable in the public eye. To visually see what I am talking about, the following link is provided so you can see one of our San Diego rhinoplasty patients at 5-6 days out from his rhinoplasty procedure. http://www.drhilinski.com/videos.htm
Question: I had an ear graft done as part of a complex revision rhinoplasty. Is it normal for my ear to hurt more than my nose?
Answer: Thank you for your inquiry. The answer is yes. It is quite normal to have more attention drawn to the ear as a result of discomfort and pain. The ear is quite sensitive being innervated by many sensory nerves. Therefore, it is expected to hurt more than the nose does following rhinoplasty. In most cases of rhinoplasty and revision rhinoplasty when there is no ear grafting, pain is actually very mild and usually requires only a few days of low dose Vicodin or equivalent. Best regards, Dr. Hilinski.
November 16, 2009
All patients undergoing rhinoplasty or revision rhinoplasty by my office are counseled on how to minimize chances of bruising following surgery. The onset and severity of bruising after cosmetic rhinoplasty is dependent on multiple factors, which can usually be accounted for by careful planning. All patients are instructed to review our list of restricted of medications that is handed out to you and is always on our website for reference. I prefer my patients avoid these potential blood thinners at least 10-14 days prior to their rhinoplasty procedure. I also highly recommend that my patients begin taking Arnica Montana starting two days before and continuing for one week after surgery (see photo below of the exact kit we carry in our office). Arnica is an herbal supplement that can significantly reduce chances of bruising from many plastic surgery procedures. Although scientific evidence of this effect is scant, I can tell you anecdotally that Arnica unequivocally aids in healing from nearly all plastic surgery procedures, including rhinoplasty and revision rhinoplasty. Patients who undergo osteotomies (breaking the bone) as part of their rhinoplasty procedure tend to have more bruising than those undergoing only cartilage and soft tissue reshaping of the nose. When performing osteotomies, rest assured I take extreme caution in my technique to help minimize unwanted bruising. This includes use of a specially formulated solution that I inject in your nose to chemically constrict the blood vessels. Elevating your head following surgery is another helpful step that works by counteracting gravity to decrease blood flow and, therefore, pooling of blood around the nasal bones. I am not a big fan of ice compresses applied directly over the nose as this can sometimes cause unwanted shifting of the cast and underlying bones. Instead, I prefer if patients apply a small packet of frozen peas or similar lightweight cold compress over each eye in a symmetric fashion. In doing so you can minimize chances of shifting the newly positioned bones and maximize control of bruising. Finally, limiting physical activity during the first 1-2 weeks following rhinoplasty further minimizes chances of bruising.
In many cases where patients are undergoing reshaping of the dorsum (bridge) I will recommend that we place spreader grafts at the time of the surgery. Spreader grafts are long, rectangular-shaped pieces of cartilage that are placed in parallel with the bridge in between the septum and the upper lateral cartilage. They are what we term ‘hidden’ grafts in that they are placed within a precise pocket without contacting the skin directly. This is in comparison to other grafts we use in rhinoplasty and revision rhinoplasty, such as tip and dorsal onlay grafts, that directly contact the skin and alter shape of the nose. Spreader grafts, in contrast, push or spread the upper lateral cartilage outward, thereby widening the middle one-third of the bridge indirectly. For this reason, the most common indication for spreader graft placement in cosmetic rhinoplasty is a pinched middle vault (another term for the middle one-third of the bridge). This can be a congenital finding in some patients who have never had rhinoplasty but also frequently occurs as a result of having had a prior nose job where this area of the nose was overlooked. In the latter instance, many of these revision rhinoplasty candidates present with what is called an inverted V deformity where the upper lateral cartilage has collapse inward creating unwanted shadowing in this particular shape. Other candidates for spreader graft placement are those with functional problems and difficulty breathing through the nose. These patients have narrowing of their breathing passage as a result of the upper lateral cartilage collapsing inward. When this occurs, a critical area inside termed the internal nasal valve becomes excessively narrowed causing a subjective feeling of difficulty breathing through the nose. In this case, spreader grafts are used to reopen the valve area and restore more optimal nasal breathing. It is for this reason that many patients who undergo spreader graft placement for cosmetic rhinoplasty also enjoy a moderate to significant improvement in their breathing as a passive side effect. To learn more about spreader grafts, you can read my online book chapter “Rhinoplasty, Spreader Grafts” on Emedicine.com (http://emedicine.medscape.com/article/1292527-overview).
November 11, 2009
Many patients who are scheduled to undergo revision rhinoplasty require ear cartilage grafting (also known as auricular cartilage grafting) as part of their surgery. This is commonly done when we need to add structural support and/or additional contour to the nose following prior rhinoplasty where too much cartilage or bone was removed. Patients often wonder what the ear is going to look like after the cartilage has been removed from their ear. As I tell any of my patients having this type of procedure, the ear should look essentially the same as it did before I took the cartilage. I use a hidden incision made entirely behind the ear and leave behind a sufficient amount of ear cartilage to maintain a normal shape. The ear tends to hurt a little more than the nose does, but this is managed with low dose pain medication during the first week. I have attached a photo below of one of my San Diego revision rhinoplasty patients who had ear grafting to the nose just one week prior. You will notice that her ear looks almost entirely normal without any obvious evidence that we were there.
 Appearance of Ear One Week After Surgery
November 5, 2009
Many times I will ask that my patients begin taping their nose following rhinoplasty. This is recommended to encourage your nose skin to adhere down to the underlying cartilage and bone that was just reshaped. In rhinoplasty patients with thin skin, this is usually not necessary. In rhinoplasty patients with thick skin, however, taping for several weeks to months following surgery can be of significant benefit. I will direct you if and when to start doing this as needed. I recommend that my patients use 1/2″ x 3″ steri-strips manufactured by 3M since these seem to provide the best quality tape for our purpose. In the past I have referred most patients to the 3M website since most pharmacies do not carry this specific brand. For my San Diego rhinoplasty patients, we have now discovered a local pharmacy close by in La Jolla that carries these same steri-strips. It is Burns Drugs at 7824 Girard Avenue and their website is burnsdrugs.com. Thanks to one of my revision rhinoplasty patients in La Jolla, Julie, for the updated information!
September 14, 2009
One of the most common questions I get asked during rhinoplasty consultation relates to how the nasal bridge (or dorsum) can be augmented or elevated. Different surgeons prefer different methods based on what works best in their hands. My preference is to use the patient’s own cartilage for dorsal augmentation if it is available in sufficient quantity. If only a slight amount of elevation is desired and/or there is only a short segment of the bridge to augment, cartilage taken from inside the nose (from the septum) or from the ear is generally sufficient. If there is septal cartilage present, this should be used before consideration of ear cartilage. If there is a more significant amount of augmentation desired, I may recommend you opt for costal, or rib, cartilage grafting. Rib grafting allows me to build up the bridge essentially using a single, long piece of cartilage. This method is preferred over use of several different pieces of cartilage, which increases the risk of unwanted absorption and, thus, contour irregularities. Rib cartilage can be harvested from one of your own ribs or as an alternative is provided by a tissue bank (termed cadaveric rib cartilage). When shaped with what we term is concentric carving technique, rib grafting can be done with less risk of warping and resorption.
It is worth noting in many cases of ethnic rhinoplasty (including Asian and African-American noses), the amount of septal cartilage available for harvesting is simply insufficient for bridge augmentation. In many of these ethnic noses, the amount of augmentation desired is considerable. Because of these factors, ethnic rhinoplasty often requires rib grafting to achieve the desired amount of bridge augmentation. In the rare case where a patient simply does not wish to undergo rib grafting or use cartilage from a tissue bank, we will discuss possible use of an implant, such as Goretex. In those ethnic patients with very thick skin overlying the nose, this type of material can be used with successful long-term results for bridge enhancement. However, patients must understand there is a higher risk of infection with use of Goretex and rejection of the material can occur in the future.
Dr. Hilinski's office in San Diego, CA is conveniently located near the following:
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