Mike's Revision Rhinoplasty 

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I had never been terribly insecure about my nose before,  but it was chronic sinus infections that led me to the office of a highly recommended Ear Nose and Throat/Facial Plastic Surgeon in my hometown of Tampa, FL.  After a very brief examination, the doctor found the culprit:  A deviated septum that was almost completely blocking one side of my nose.  He offered me a very quick and easy fix for my problem, which was a septoplasty and reduction of my turbinates.  Because he had experience in cosmetic surgery, and had done an excellent job on the facelifts of two of my family members, I asked him if he could sand down a very small hump and lift up a small piece of collumella that had fallen a bit.  My thoughts were that if I was having nose surgery anyway and was going to be in the hands of one of Tampa's finest, then I should take advantage of the situation and come out looking better, as well as breathing better.  At that time, I  was a TV producer (I've since changed careers), and thought that changing my nose might enhance my television career;  I'd always shied away from the camera, partly because my nose looked a little bit too big and slightly crooked on camera.  The doctor agreed that I'd benefit from what he called a very subtle change in the appearance of my nose, and assured me that he'd do a very conservative job on me.  I remember him saying, "You won't come out of this looking like Michael Jackson or a sixteen year old girl."

I never asked to look at any before and after pictures, nor were any taken of me.  My family members successful surgeries and the nice nose of his receptionist sold me on the surgery, and I signed up to have it done within a few weeks.  Later (of course), I learned that if I doctor doesn't have before and after pictures to show, and doesn't take any, that's a good sign to go somewhere else.  I'm convinced now that a consultation should always include going over a photograph of yourself with your surgeon, pointing out what you want to change, which I did not do.

The day of surgery arrived, and I showed up at the hospital outpatient surgery facility ready to have the surgery, eager to clear up my breathing problem and come out of it looking better to boot.  The doctor came into my room and gave me a short pep talk, and we headed into surgery.  I later learned from the operative report that the surgery itself only took 45 minutes to complete, which sounds like an awfully short time to accomplish all that we set out to.

I awoke from the surgery pretty easily, but nothing could have prepared me for not being able to breathe at all from my nose--both sides were completely plugged up with gel packing, which nobody warned me about before the surgery.  Over the course of the week following my surgery, the packing oozed out of my nose into the drip pad in place that had to be changed every few hours.  Every time that I swallowed, the packing would "squish about" inside my nose, but kept my nose permanently plugged up until the doctor removed it one week postoperatively.

Removing the packing was the most painful part of the surgery, and I've never heard of any other patients having a similar type of packing.  The doctor inserted a tiny cannula (for lack of a better word) into my nose, and sucked out all of the packing.  It took about 2 to 3 minutes per side, and it felt torturous.  It was the only time that I've cried from pain since childhood.  Next, the cast was taken off, and the doctor took one look and said," you look great!  And your profile is excellent now."  I was offered a mirror, and my first look didn't impress me much--my nose looked like a swollen version of its former self, and the profile looked really funny.  The tip projected out too much, but the doctor assured me that it was just swelling. 

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The swelling eventually disappeared, but the projecting tip never did.  I was left with a ski-sloped looking nose that was still crooked and was now too skinny.  Those close to me kept their comments about how my nose looked to themselves, but I knew that the surgery was a complete disaster.  Even worse, about a year later, the insides of my nose collapsed inwardly on both sides, making breathing even more difficult than before, and my nose looked pinched in from the front.  My surgeon was somewhat concerned, and offered to fix my problems free of charge, but at this point, my gut feelings told me to go elsewhere.

Looking for Dr. Fix-it

I started researching for a good plastic surgeon to fix my problems.  Because I lived near a medical school library, I learned as much as I could about nasal anatomy and began to pour through back issues of a journal called Plastic and Reconstructive Surgery.  From the many articles that I read, several names seemed to show up often:  Dr. Mark Costantian of Nashua, NH; Drs. Jack Gunter and Rod Rohrich of Dallas, TX., and Dr. Jack Sheen of Santa Monica, CA.  Dr. Gunter published one article that described cartilage collapse and how it can be corrected, and included several patient photos whose noses resembled mine.  The pictures of these patients following their surgery gave me a lot of hope that my problems could be solved by this doctor.  

Included in many of these journals were advertisements for physician meetings geared towards discussing rhinoplasty and its related problems.  The above doctors were often involved, and I also took note of other doctors who were scheduled to speak.  Once home, I called each of their offices to inquire about Dr. Gunter's ability and skill.  Each office that I spoke with described him as being among the best plastic surgeons in the world for fixing a messed up nose.

With this in mind, I had some photos taken of my nose and sent them to Dr. Gunter's office along with a letter describing what I didn't like about my nose and what I wanted to be fixed.  Dr. Gunter responded with a nice letter that agreed with many of my concerns and outlined how he could fix the problems.  Wanting to get this secondary surgery over with and not having much money to spend on numerous consultations with other doctors, I booked an in-person consultation with Dr. Gunter and surgery scheduled for the following day (knowing that I could always cancel my surgery if I felt really uncomfortable with him during the consult, although that would mean losing a deposit).

When I met Dr. Gunter, he reminded me of a younger version of my grandfather, who's also a doctor.  He seemed to have an air of confidence and a reassuring manner that somehow calmed me down and made me glad that I'd chosen to have surgery with him.  He described the technique he uses to do revision rhinoplasty called the open technique.  This technique uses a small external incision placed on the columella, the portion of the nose between the nostrils.  This technique is designed to give the surgeon a better view of the inside of the nose and the problems that lie within, and was a technique that had been perfected by Dr. Gunter himself, according to the research that I had done.

Once he opened up my nose, Dr. Gunter would then place cartilage grafts harvested from my ears into the areas of my nose that collapsed.  His first preference for a grafting material, he told me, was septal cartilage.  Because my primary surgeon had removed all of my useable septal cartilage, this was not an option.  Rib cartilage is the third choice, to be used when all other means have been used previously.

He also told me that he'd most likely have to perform an "alar wedge resection" on my nostrils, because they'd probably flare out too much after he widened my nose with the grafts.  These incisions are placed on the sides of the nostrils where they meet the face, and generally are inconspicuous.

He also took the photographs taken by his nurse and placed a clear plastic cover over them and drew what he planned to do during the surgery.  From the profile, he planned to straighten out the bridge and reduce the projection of the tip and lengthen the columella slightly.  I was amazed at how nice my proposed profile looked, and wanted to take a copy home that night to stare at before my surgery.  The drawings from the frontal view are very difficult for any doctor to do quickly and accurately, so these drawings were not as precise as the profile, but from the front, he planned to re-break my nose and set the bones slightly farther apart to widen my nose, as well as widen the tip using the ear cartilage.  This would also "lift up" the collapsed inner walls of my nose, allowing me to breathe better.  He'd also do a repeat septoplasty, as my nasal septum was still deviated following my primary surgery.  In all, the consultation took about 20 minutes and ended with a handshake when I ran out of questions to ask.

The Big Day

The following day, I checked into the hospital surgery center, and quickly changed into my gown and was given a sedative to relax me.  Dr. Gunter came into the room just prior to the sedative, and made sure that I didn't have any last minute concerns.  I had just a few, and they were quickly answered.  The sedative took affect, and I was wheeled into the O.R., where I was given a general anesthetic.  The surgery itself took about 6 & 1/2 hours, mainly because I had a profuse amount of scar tissue that had to be removed under a microscopic magnifier.  I woke up really easily, and was totally surprised at how well I could breathe from my nose.  Packing was not necessary, and the splints in place were designed to allow for pretty good breathing.

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Once in my hotel room, before slipping into a deep sleep, I looked in the mirror.  I was very bruised around my eyes, and my face was already swollen.  My stitches were tiny--just very small black dots along my columella and nostrils. My ears were also really swollen, and the incisions along the backside of each ear looked pretty big to me.  Because my ears were swollen so much, they stuck out extra far on my head, making the incisions more conspicuous.  They were quite numb, and also made it difficult to sleep--I couldn't move my head to either side, and had to sleep flat on the back of my head.  I really didn't experience any pain, only minor discomfort.  I took only one of  pain pills prescribed to me, and that was right after I returned from surgery, out of fear that I'd feel some pain after the anesthetic wore off.  Tylenol sufficed thereafter.  

The following day, I woke up with a very bloody pillow.  We quickly called Dr. Gunter's office, and were asked to come in immediately.  It turns out that my left ear developed a hematoma, or blood clot.  Dr. Gunter very quickly and painlessly removed the clot, and sewed my ear back up.  I must add that this very rare complication was unforeseen, and had nothing to do with the doctor's skill.

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Aside from that, my recovery was very uneventful and as pleasant as possible. When my nasal cast and stitches were removed, I gasped as I stared in the mirror for the first time.  I was unprepared to see how extremely swollen my nose was.  It looked really bad, but I was assured that the swelling would subside.

The swelling remained pretty bad for about three weeks.   I spent a great deal of time obsessing about how bad my nose looked, second guessing my decision to have it re-done in the first place and worrying about how it would turn out in the end.  My doctor's office told me to expect to be very swollen, but I really hadn't prepared for it.  One thing that helped was that Dr. Gunter's nurse told me that it only made sense that my nose was so swollen--afterall, a nose is really swollen after it is made smaller, so mine should be even more swollen after having material added to it.

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Once the initial swelling subsided, I was amazed at the changes.  Dr. Gunter was able to make all of the changes he mentioned during the consult, and my profile looked precisely like the one he drew for me during the consultation.  My friends and family gave me many compliments on my new nose. Many of them confided that they thought that my old nose didn't look good at all.  I now looked like my old self again, and was elated with my results.  My ears healed really nicely, and since they laid flat against my head, the incisions are impossible to see.  I've pulled my ears back to look at them, and they are now very thin and white incision lines.

Before & Afters

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Lessons Learned

Several things I learned from this experience:

• Always research before having any surgical procedure done.  Check up on your doctor and make sure that he or she is Board Certified.

• There seems to be a turf war between the Ear Nose and Throat (Otolaryngologists)  and Plastic Surgeons.  In general, each group claims to be more adept at performing nasal surgery, but I think that this argument is best solved on an individual basis--Find a doctor who you are comfortable with and who has a good track record.  One who performs several rhinoplasties a week is more likely to be a safer bet than one who performs one a month.  Dr. Gunter is Board Certified by both the American Board of Otolaryngology (Ear Nose and Throat) and the American Board of Plastic and Reconstructive Surgery, so this was one area I had no concerns about.  

• Always ask a doctor who you are considering to show you before and after pictures of past patients.  While these pictures are no guarantee of how your nose will look, they are a good indication of the doctor's aesthetic sensibilities.  If you don't like the pictures that are shown to you, chances are you won't like the result you'll get from that doctor.

• Check out before and after pictures of the doctor's other procedures, as well.  Do they look good to you?  Do you feel that the doctor has a good sense of aesthetics?  For instance, if a doctor has pretty good pictures of nasal patients, but the facelift patients look garish and overly pulled or the scars look sloppy, this might be a good sign to find another surgeon.

• Pay attention not only to the vibe that you get from the doctor, but also the doctor's office, as well.  Is it a nice, clean, well-kept office?  Is the staff friendly?  Are they prompt to answer your concerns?  Do they return your phone calls?  If you answer "no" to any of these questions, look elsewhere.

• If you cannot establish a good rapport with the surgeon during the consultation, by all means look elsewhere for another surgeon.  If you don't get along with the surgeon before the surgery, it will only get worse after the surgery.

• Know that rhinoplasty is not an exact art.  By this I mean that most people will not get a "perfect" result after a primary or secondary.  Much of your outcome is dependent upon not only the surgeon's skill and artistic sense, but also your nasal tissues, which sometimes don't respond well to surgery.  Expect some minor imperfections to show up after any nasal surgery.  Expect improvement and not perfection.

• Be prepared for swelling.  Wait at least one month following a primary and two months following a secondary rhinoplasty to judge the appearance of your nose.  Often, swelling will obscure the final results for quite a long time.  Everyone is different, and some people look great one week following nasal surgery, but these people are the exception and not the rule. Also, some doctors say that the open-incision method like the one used on me creates prolonged swelling in the tip.  This is up for a lot of debate, but in my experience, I'd definitely say that it's true.  While this may be the case, it certainly isn't a reason not to use a doctor who you'd otherwise feel comfortable with.  Each doctor has his or her preferred method, but their overall results are much more important than a tiny inconspicuous scar.

• Communicate any concerns pre- and post-rhinoplasty with your surgeon and the office staff.  This will not only give you piece of mind, but will also alert them if there are any problems that justify their attention (such as my post-op hematoma).  If you find that an office staff or doctor is difficult to communicate with prior to surgery, choose another surgeon (these are not the type of people who are likely to be there for you during any difficult times that may arise).

Copilotmike@aol.com

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