Rhinoplasty Myths We Wish You’d Stop Believing

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:10):
Hey, Dr. Koehler.

Dr. Koehler (00:12):
Hey, Kirstin.

Kirstin (00:13):
Today we're going to talk about rhinoplasty.

Dr. Koehler (00:15):
All right,

Kirstin (00:17):
Good. That's a good one.

Dr. Koehler (00:18):
Yeah. Love noses.

Kirstin (00:19):
Alright. Okay. Well rhinoplasty is one of the most talked about cosmetic surgeries. What is one thing wrong though that people get about rhinoplasties before they come see you?

Dr. Koehler (00:31):
Well, I don't know if it's people that get wrong, but I sometimes tell people, it's like, look, when you come in to talk about your nose, it's not like I'm going to show you a catalog and you get to pick number 32, and that's the nose you get. We can change the structure of the nose, but we still have to preserve the function of the nose, which is a very critical thing. And so sometimes, depending on the structure of your nose, there's some limitations to what we can achieve. And so it's not like, okay, I want my nose to look like this. It's nice that people bring pictures and help us to make sure we are on the same page about realistic expectations. But yeah, you can't just pick your nose. Well, you can pick your nose, but I don't recommend it.

Kirstin (01:14):
Okay. So I imagine most people don't just wake up one morning and decide that they want to rhinoplasty. In your experience, how long do patients usually think about it and what makes them finally decide to bite the bullet and come see you?

Dr. Koehler (01:28):
When it comes to decisions like this and changing your appearance, that oftentimes it's a process. It may be years that people think about it, they look at pictures, and then ultimately they get the guts to come and talk about it. So I dunno, it's different for every person, but I can't think of a standard timeframe that people tend to wait.

Kirstin (01:51):
Now you're thinking about picking your nose.

Dr. Koehler (01:53):
No, I'm scratching.

Kirstin (01:56):
Okay. Well, when somebody sits down with you for a rhinoplasty consult, is there a common feeling that you've noticed that maybe everyone shares?

Dr. Koehler (02:05):
Well, I will say this. A lot of times people say, oh, I broke my nose three times, or I've broken my nose. And I don't know if it's a way for people to kind of justify wanting to get their nose done. They're like, well, I broke it and so now I need to fix it. And I'd like to just change a few other things while I'm at it. I don't know, but maybe people have broken their nose. But I kind of hear that a lot of times, especially when people have a little dorsal hump, a bump on their nose, they want to associate that with, when I fell and hit my nose, they may or may not have broken it and they think, oh yeah, that's what caused the bump on my nose is when I hit my nose on the trampoline or something like that. Common things that we see is a dorsal hump or typically they want to make changes to the tip of their nose. Either it's too big or broad or wide, or they just want a more refined. Those are the two main things. It's the dorsum of the nose and the tip, and then sometimes width issues with the nose.

Kirstin (03:07):
Well, there's a lot of people that think about rhinoplasty as just making your nose smaller or prettier or more feminine, but what's the bigger picture of what rhinoplasty can do for patients?

Dr. Koehler (03:19):
First of all, back to misconceptions, the one thing that is very difficult to do if you've got a really big nose, like I said, you can't just take a big nose and make it a little nose. You can't. You can change proportions and you can make it look better and it can look smaller, but to a certain extent because you've got cartilage and bone and all these things provide the structure that allow you to be able to breathe. And if we take all of that down, then you might not be able to breathe. And the other thing is, one of the things, as part of our assessment, we're looking at the skin quality and some people have very, very thick skin and it makes it really hard to get good shape to the nose when you've got this really heavy, thick skin because that's covering all the stuff that you're doing.

(04:10):
So if you're reshaping cartilage, reshaping bone, but then you've got this thick layer of skin on top, all those changes we make are harder to perceive. Whereas some people have really thin skin on their nose and they have the opposite problem. We make even just the most subtle change to the bone and cartilage and it can be very visible. So that means that any little discrepancy is maybe even magnified when you have thin skin. So average skin is what we're looking for, but you can't shrink wrap a nose. You can't take a big nose and shrink it down, but you can make it look more proportioned. And I think that's the goal of rhinoplasty surgery is just to have proper proportions.

Kirstin (04:52):
You've talked about things that you can't do. Are there specific things that can't be corrected with rhinoplasty?

Dr. Koehler (04:58):
Some people have really weak cartilage, and so there are some things that are more difficult. So in those cases, we can change the shape of the nose, but we might also have to take cartilage grafts either from your septum or your ear, because if we have to shave those cartilages to get the proper shape, we may not have enough thickness or strength, and so we're going to need something else, another graft of cartilage to provide strength so that you still can again, properly breathe through your nose.

Kirstin (05:30):
Well, people say oftentimes that they want their nose to look natural, since that means something different to everyone, what do you do to make sure that you and the patient are visualizing the same? You have the same vision for their nose.

Dr. Koehler (05:44):
I like to sit down and look at actual patients that I've done and show before and afters and kind of get a feel for us. This is the kind of thing that they're looking for. Some people don't want natural. Some people want more of a scooped out type of a nose, and that's not natural looking. And I prefer when people want to have a natural look. I'd like your nose to look like if somebody had never met you before that you wouldn't go, oh, that person had a rhinoplasty. Now your friends and family and other people they're going to know, but somebody you'd never met before shouldn't know you've had your nose done.

Kirstin (06:18):
How do you manage expectations when somebody brings in a celebrity photo or a photo that's completely unrealistic for the nose that they already have?

Dr. Koehler (06:27):
I don't mind a celebrity photo as provided it's like if your nose is in the ballpark, I can do the things that I think I can do to get close to that. That's okay. That doesn't bother me. But sometimes people bring in pictures where they've photoshopped them and they've taken their nose and they're like, okay, and this is what I want it to look like. And I'm like, yeah, that's just, I can't do that.

Kirstin (06:51):
Has anybody ever brought you a Michael Jackson nose?

Dr. Koehler (06:55):
Which one?

Kirstin (06:57):
The third or fourth one?

Dr. Koehler (07:00):
No, no, but I've had people actually draw angles and stuff like that. And these are really red flags actually for a surgeon when people are like, I want my nose to be changed by two degrees here. I mean, it is an artistic operation and it is a very precise operation, but I couldn't look somebody in the eyes and say, I'm going to change two degrees. That's not within the threshold of what I can give you. So when people are like that, that's usually a red sign of people that have body dysmorphic disorder. These are people as surgeons we don't want to operate on because it is the Michael Jackson's of the world, the one that will never be happy with the nose they get because they're always seeking this perfection or this exact thing that they're looking for, which we may never get to.

(07:54):
I think that's all a part of establishing expectations. And again, looking at pictures and what they like and what they don't like. I think that's important. I used to use imaging years ago and I still occasionally will, but the imaging's not that accurate either. So I don't like to put a whole lot of weight in it. If I say, oh. But I also know the difference between when I adjust an image versus when a patient has done it themselves is I know what movements are realistic, and so that's a little different. So I can go, okay, yes, I can do this on a computer. I can make your nose look like however you want it to look like because it's just changing the shape. But I also have to think about the structure as I keep talking about. That's very important.

Kirstin (08:36):
Can someone that has an injury or breathing problem, can they also make cosmetic changes during a rhinoplasty or is that something that you provide?

Dr. Koehler (08:46):
Oh yeah. I mean, these two things are hand in hand. Now, people who don't have breathing problems to start with, we talk about how certain maneuvers and things we can do can impact negatively breathing, and there's things that we proactively do at surgery to minimize that prevent from happening. But people who come into the operation with breathing problems, like we're looking at look and see what those issues are so that we can address those at the same time. Because if your nose looks nice but you can't breathe through it, nobody's happy if you already have breathing problems. Yes, that's the perfect time to make changes to the shape because we've got to go in there and readjust all that structure. So if you want to make changes, that's a good time to do it.

Kirstin (09:32):
Yep. Is there a certain age that you should or shouldn't have a rhinoplasty? Can you do it at any age?

Dr. Koehler (09:38):
No, you got to be fully grown. I would say for most people around 16 or older, that's fine. I wouldn't want to be doing a rhinoplasty on younger than that anyhow, because you got to have the maturity and the understand. There's a lot that goes on there. So typically I want an adult patient,.

Kirstin (09:59):
Can you be 60 and get a rhinoplasty?

Dr. Koehler (10:02):
Yeah. I think for a lot of women, they're pretty much at 16, their majority of their growth is done. Men a little bit longer,

Kirstin (10:09):
Sixty like older.

Dr. Koehler (10:11):
Oh, Six zero?

Kirstin (10:12):
Yeah.

Dr. Koehler (10:13):
Oh yeah,

Kirstin (10:14):
Six, seven. Yeah, nevermind.

Dr. Koehler (10:17):
What am I supposed to do this thing now? Is that what you're supposed to do?

Kirstin (10:20):
Yes.

Dr. Koehler (10:21):
I don't even know what that means, but sure. We could do a six or a seven. Yes, a 60-year-old. Yeah. I mean, as you get older, your health is the limiting factor for elective surgery. In my mind, these are elective cases, so if you've got heart conditions and this and that, sometimes it's like leave it alone. It's not worth going through a big procedure if you're not healthy. But if you are, great. Yeah, 60 fine, no problem.

Kirstin (10:49):
Okay. Alright. Is it true that your nose continues to grow as you get older?

Dr. Koehler (10:54):
Nah.

Kirstin (10:55):
No.

Dr. Koehler (10:56):
It changes a lot, but it's not growing per se. But the cartilages get weaker, the support of the nose, so then the tip can start to drop and it can kind of look normal. And then there's certain skin conditions and things like rosacea where you can get overgrowth of the skin. And so there's other things where the skin can look thicker and bigger, and you get something called rhinophyma where the nose just really overgrows, the soft tissue does, but the underlying structures aren't growing. And so yeah, the nose definitely changes with age and it can look bigger for different reasons, but it's not continuing to grow.

Kirstin (11:40):
Gotcha. Okay. Myth busted.

Dr. Koehler (11:43):
There you go.

Kirstin (11:44):
Are there different techniques for rhinoplasty?

Dr. Koehler (11:47):
Yeah, there's a lot of different techniques.

Kirstin (11:49):
How do you decide what's right for your patient?

Dr. Koehler (11:52):
A lot of factors go into that. Initially I would say there were two main techniques. There's the closed rhinoplasty and the open rhinoplasty. A closed rhinoplasty is done where all the incisions are on the inside of the nose and there's no incisions on the outside of the nose. And that operation is great for if people don't need a lot of cartilage grafting, but they mainly just need a hump on their nose taken down, and maybe the tip narrowed a little bit. That's how I was initially trained in doing rhinoplasty, was closed rhinoplasty. And it's great because there's no external scar, but the scar really is typically not a problem. Open rhinoplasty has an advantage from the standpoint of, well, you make a little incision underneath the nose and then the rest of the incisions are inside the nose, but this is lifting up the hood of the car.

(12:41):
You get to lift the skin up, and so you can actually see all the structure, and especially when you have to do cartilage grafting or there's some asymmetries, it's definitely a nicer way to make sure that you've got the best symmetry possible. And it's also when you're teaching other people the operation, it's a lot easier to teach 'em because they can also see what's going on. It's not like working on the inside of someone's nose. So those are the two main techniques. But really in recent years, there's a lot more discussion of something called preservation rhinoplasty, and that's a little bit different, and it can be done both open or closed, like the incision techniques, but it's a different way of addressing humps on the nose and without getting super technical. In some cases, that can be really a much better technique to get rid of a hump. Recovery can be less. The issues with breathing, it can be better. So each case is individual. And as a surgeon, it's nice to have lots of different tools in your toolbox, but when I assess the patient, I'll give them my view of how we would go about doing it.

Kirstin (13:53):
What does recovery look like for a rhinoplasty? When can you go out in public and face the world?

Dr. Koehler (14:00):
It depends on bruising. Some people don't bruise hardly at all nowadays, and there's things we do to help minimize bruising, but typically the splint and the sutures come off at a week, but you may have some swelling. You might not feel so comfortable going out in public at a week, but for sure in a couple of weeks you should be fine. To be out in public, your nose is not going to look like it's going to, it takes time. Usually maybe four or six weeks for large majority of the swelling to go away. And if there is bruising that sometimes can take two or three weeks. But if you read online and say, oh, Google, how long is a no, say swollen after rhinoplasty, it's typically a year. I mean, surgeons say it's a year and it's not major swelling. It's very minor swelling, but it can take a while. And so it's the kind of swelling that only the person who had the procedure done is really probably going to notice. Vast majority of your swelling is gone in six weeks.

Kirstin (15:00):
Don't look in the mirror at one month and say, oh my gosh, I still hate my nose. It's not done yet.

Dr. Koehler (15:05):
Yeah, it's still changing and it's going to look better. I mean, you got to give it six months to a year for things to really look how they're going to look.

Kirstin (15:13):
Okay, so it's rare, but what would your options be if you have rhinoplasty and a year goes by and you still don't like your nose?

Dr. Koehler (15:22):
It depends on the situation. Re-operations are something that, especially with rhinoplasty surgery, I think you got to take very seriously if there's something very significant and something that both the doctor and the patient are like, yeah, no, I think we need to adjust this and make it better, then that's okay. I think you do need to wait appropriate period of time, like a year before you go back in there and each time you go back in there, circulation is affected. And that's the path that Michael Jackson went down. And it doesn't matter how skilled the surgeon is, there's scarring, there's blood supply issues, and it can just not turn out well. So a lot of doctors will do revision rhinoplasties of their own. Some doctors will not. They just don't do revision rhinoplasty. And I know some very good rhinoplasty surgeons, excellent surgeons that they've just decided like, look, I'll do my own revisions, but I'm not doing revision rhinoplasty. Partly because I mean, it is a path that it's a slippery path, and you may not know exactly what was done when the other person was in there. There's some people that really promote themselves as the revision rhinoplasty guys. That's all that they do. Their specialty is doing fixing or making those changes in difficult kind of noses. If you've had a second rhinoplasty and you're still not happy and you're thinking about a third, I would say think long and hard. I mean, each time it's exponential. So beware.

Kirstin (16:52):
Sort of along those same lines, we're going to talk about something that could be deemed a little controversial, I guess. Is there a non-surgical way to change the shape of your nose?

Dr. Koehler (17:02):
Well, I mean, you hear people injecting filler to try to affect the appearance of the nose. My advice is get a nose surgery. The injectables, yes, you can see some subtle changes, and I've seen some of that. They look decent, but you got to be very, very careful if that gets injected into a vessel. You can get skin necrosis like the skin dies, and it can be very traumatic. Also, when you start injecting these things in the nose, maybe at some point you do want to actually have your nose done and now

Kirstin (17:35):
Now you got filler in there.

Dr. Koehler (17:36):
Yeah, and that'll have to be dissolved, and you may have potentially made it a more difficult operation for the person that's going to do it. So to me, although people do fill her in the nose, not a huge fan, don't recommend it.

Kirstin (17:50):
Okay. One more thing I wanted to talk about since we've kind of gone over all the scenarios. What does a consultation look like with you for rhinoplasty?

Dr. Koehler (18:00):
We'll sit down and discuss, make sure your health is appropriate and what your concerns are, what you want to try to achieve. If you have pictures, we'll look at those. Then we will examine the nose and see what sort of structure we're dealing with. What's the skin like? Is it thick? Is it thin? How are the cartilages in the bone? And then after I make an assessment, we'll talk about realistic options of what we can achieve and then go through some pictures and talk about recovery.

Kirstin (18:28):
Wow, simple.

Dr. Koehler (18:29):
Simple.

Kirstin (18:29):
Easy. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (18:42):
Thanks, Kirstin.

Kirstin (18:43):
Go back to making Alabama beautiful.

Dr. Koehler (18:45):
Yes, I will.

Announcer (18:48):
Got a question for Dr. Koehler. Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.