He had never had surgery. He exercised four times a week. He was not on any medication. The only thing wrong with him was a nose that had been crooked since a baseball hit it when he was a kid.
I am publishing this consult nearly as it happened, identifiers removed, because the questions men ask about their nose almost never get answered out loud.
Him: I broke it when I was young. It was a baseball. But ever since that, I’ve had complications and I know I have trauma inside. You can tell it’s kind of deviated. So I wanted to get that corrected. But if I’m going to do that, I might as well get the exterior as well.
Me: “Do you have problems breathing?”
Him: Yes. I get congestion right away. But I’ve lived like this for a long time, so it’s kind of normal for me. I do notice that I get congested a lot if I start doing exercise.
Me: “And what would you want to change about the way it looks?”
Him: Pretty much, I want to straighten it out. And I noticed that the tip is a little bit down. And I know the bridge here is kind of low. I don’t like that look, it’s too low for me.
He had already been to someone else
Him: I had an appointment with somebody else. The way they wanted to make my nose was too small for my face.
He had gone home, downloaded an app, and made his own version.
Him: I actually liked it more.
He was right. I said it out loud: “It doesn’t balance.”
What I found on exam
Me: “Your nasal base is a little bit wide. So we do bring these bones in, and that helps me straighten everything out. So they probably healed a little bit off. I’m going to look inside just to check your septum too.”
Me: “Your nose looks really irritated. I feel like you have a lot of allergies. And then your septum is going this way. So there’s a lot less space on this right side, and the left side is very open.”
Me: “So we’ll straighten that out. The breathing should improve, but it’s not going to change the congestion when it gets congested or there are allergies. Really, we can’t do much about that, but we can make it structurally more open.”
The tip, and why it barely moves
Him: Doctor, I don’t want my nostrils to be too…
Me: “No, we’re just going up a little bit, so really we shouldn’t change the nostrils at all.”
Me: “It’s just the tip a little bit, because on men we still like a right angle here. We don’t want to make it bigger than that, that’s more feminine.”
Him: So by lifting it, it won’t make it more round or anything?
Me: “No, it’s just going to rotate it up a tiny bit. We’re talking about like two millimeters.”
Him: And the tip of the nose, is it going to be kind of rounded?
Me: “Do you want to change that?”
Him: No.
So we left it.
Where the cartilage comes from
Me: “For this, I have to put in cartilage to fill that in, so it’s permanent and you don’t have to be adding anything else later. So first I’ll use the cartilage that’s in your septum. If it’s not enough, then we do have donor cartilage that we can use. It’s irradiated, doesn’t have any cells, but it saves me and you from having to get any from your ear or your rib, which can be more painful. So this makes it a lot easier, because the rib hurts a lot. And the ear can be uncomfortable too, and sometimes it can make it look funny too.”
The turbinates question
Him: Inside we have the ones that filter the air, the turbinates. Are those going to be reduced?
Me: “So they don’t look big, but on this right side, usually when your septum is deviated, the open side gets bigger, but in your case it’s not that big. So if anything, when I’m in there, if I see that they’re a little bit big, what I do is I fracture them and that makes them shrink a little bit. But I don’t think you need to get mucosa removed or anything like that.”
The scar
Him: The incision right here, am I going to have a visible scar?
Me: “You’re going to have a scar, but it’s going to be very hard to see. Usually it heals in a way that nobody sees it, and you’ll have to look at it in a mirror like this to see it.”
Recovery, in his words and mine
Me: “So it’s an open rhinoplasty. We’ll get everything centered, and the surgery takes about two, two and a half hours. It’s general anesthesia, you go home the same day. I do have to put splints on the outside and on the inside, so it might be a little stuffy for about seven days, then we’ll remove everything. At that point, your breathing should be better.”
Me: “You’ll see the changes in the nose, but it’s still going to be a little swollen. So it’s probably going to take a couple of weeks to start looking better and better. And then about six weeks, we’re pretty close to what it’s going to look like, but the nose itself takes about a whole year for it to keep getting better and better.”
Me: “But the good thing is that there’s no pain after surgery, so it’s a relatively easy recovery. We do have to wait about six weeks before going back to exercise. And going back to normal activity, you’ll feel fine after about three days. It’s just a matter of whether you want people seeing you with the splint or not.”
Me: “If you get any bruising, sometimes you get bruising, I would say only twenty percent of our patients get any bruising underneath the eyes, it can take two weeks to go away, and you can always put a little makeup on if you want to hide it.”
The last thing I told him
Me: “In the beginning, it may look a little extra. Because some of that gets reabsorbed, so we have to plan on it, on how it’s going to come down a little bit.”
He asked me to follow his own simulation during the surgery. I told him I would save it and reference it in the OR. That is not a concession. A patient who can show me what he wants has already done half of my planning for me.
My exam note from that afternoon: sunken and relaxed dorsum, deviation to the left with a subtle deviation to the right, previous trauma, slight downward tip rotation. Plan: rotate the tip up about two millimeters, shave the hump, add a graft for the radix, straighten the nose.
The takeaway
An old broken nose is a structural problem before it is a cosmetic one. The septum and the outside are the same operation. The tip on a man moves two millimeters, not ten. And the version of your nose that looks right is almost never the smallest one on offer.
I am a double board-certified plastic surgeon, certified by both the American Board of Plastic Surgery and the American Board of Surgery, a Mayo Clinic fellowship alum, and I teach plastic surgery as a Clinical Associate Professor at Texas Tech University Health Sciences Center.
Ready to Talk?
If you have been breathing through one side of your nose since middle school, you do not have to keep doing it. Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.
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