Rhinoplasty: Everything You Need to Know About Changing Your Nose [Part 1 of #RiedlerKnowsNoses]

Recorded announcement (00:07):
You're listening to The La Jolla Cosmetic Podcast.

Monique Ramsey (00:15):
Welcome, everyone, to The La Jolla Cosmetic Podcast. I'm your hostess Monique Ramsey, and today we're going to talk about rhinoplasties, or nose jobs. Which, I've never really loved that term, but that's what it is. We're going to do a little job to make your nose look better.

Monique Ramsey (00:31):
Our guest today is Dr. Kiersten Riedler, she's a board certified facial plastic surgeon. We have a whole episode where we've met her, so you could listen to that. I'll have that in the show notes. But welcome, Dr. Riedler.

Dr. Kiersten Riedler (00:44):
Thanks, I'm happy to be here.

Monique Ramsey (00:47):
Let's talk about rhinoplasty. This is one of your areas of expertise, something you love doing. Tell us about why you love it, and what things can be corrected with rhinoplasty.

Dr. Kiersten Riedler (01:01):
I love rhinoplasty because it's a very complicated procedure that really is never the same, because two noses are never the same, and so it always requires some creativity. It's basically never boring.

Monique Ramsey (01:19):
What are the things that really cannot be corrected with a rhinoplasty?

Dr. Kiersten Riedler (01:25):
Everyone's face is asymmetric to some degree, and surgery can't correct that. However, usually the asymmetry is minor, and so it's not something that's obvious. Basically what we're trying to do with rhinoplasty is create overall facial balance and correct proportions, without any obvious asymmetry that anybody's going to notice.

Monique Ramsey (01:52):
Yeah, I remember seeing, when I used to do imaging with Dr. Olesen, he did a lot of noses, and you could split the screen, you could do two lefts of your face and two rights. Because people, I think, don't realize-

Dr. Kiersten Riedler (02:07):
They look like two different people.

Monique Ramsey (02:08):
It's so true, where you split that screen and you do two lefts, it looks like a completely different person, or two rights. I think it's a great way to illustrate to a patient really how symmetric our faces really are. Because I don't think any of us realize. So when you see it that way it's like, but that's what makes you you, and makes you look like you.

Dr. Kiersten Riedler (02:30):
Yeah.

Monique Ramsey (02:30):
Say somebody would have their nose broken, which makes it asymmetrical. Is that something that you are able to fix though?

Dr. Kiersten Riedler (02:42):
Yeah, definitely. Asymmetries that are obvious and not related to underlying facial asymmetry are definitely correctable. The main thing I'm talking about is when the midline of your face is not perfectly straight, so when the middle of your eyes and the middle of your central teeth don't line up perfectly straight, that's something we're not going to correct. So what we do is make your nose as straight as possible with regard to those two midlines. But we don't want to make your nose straight with respect to just your eyes or just your teeth, because then it'll look like a Picasso painting. It might match your teeth, but it doesn't match your eyes, and so it doesn't look quite right.

Monique Ramsey (03:33):
Interesting, I've never thought about that, but I love that. That's a really good visual for all of us. Is it true that your nose grows as you get older?

Dr. Kiersten Riedler (03:42):
Not exactly. The nasal tip, especially, becomes more droopy as we age, and studies have shown actually that that's due to atrophy of the skin and the muscles, and changes in the cartilage. But it's not actually growing, although it is changing in shape and becoming, apparently, longer and droopy. But it's not growing in size.

Monique Ramsey (04:06):
Isn't that great that everything droops, including your nose?

Dr. Kiersten Riedler (04:09):
Yeah, happens with your ears too. Ears get bigger as we age, and it's the same kind of thing. It's because they get droopy essentially.

Monique Ramsey (04:20):
Lovely.

Dr. Kiersten Riedler (04:22):
There's always something we can fix.

Monique Ramsey (04:25):
Could people, if they're thinking about having a rhinoplasty, can you have it at any age?

Dr. Kiersten Riedler (04:32):
In most cases, it's advisable to wait until your facial-skeletal growth is complete, so that's in general around age 15 in females and 17 in males. But it's also important to assess the degree of psychological maturity, because it's not just the physical growth that we want to consider. We want to make sure we're doing surgery on people who are mature enough to cope with the change in their appearance.

Monique Ramsey (05:06):
Are there different types of rhinoplasty techniques? How many different kinds are there?

Dr. Kiersten Riedler (05:13):
There are really hundreds of techniques that we use during rhinoplasty, but the main distinction is between the two most common approaches that we use: either the external or open approach, or the endonasal or closed approach. In the open approach, a small external excision is made on the skin in between the nostrils, and that's continued inside the nostrils. Whereas closed rhinoplasty technique is done with more extensive internal incisions, but no skin incision on the outside.

Monique Ramsey (05:53):
What would determine which approach you use?

Dr. Kiersten Riedler (05:59):
A lot of it is just surgeon preference and experience. I generally prefer the open or external approach, because it gives me really full access to all of the nasal anatomy and the septum, and just lets me manipulate everything and see everything clearly. The cases where I used closed technique is typically when it's, either a revision or just some minor changes need to be done.

Monique Ramsey (06:33):
So there's going to be a little incision there, so what does that end up looking like for the patient? Or, what's the healing of that scar?

Dr. Kiersten Riedler (06:41):
There are stitches there for a week after surgery, but even at a week, when we take the stitches out, it's not a very visible scar, and it heals so that it's pretty much imperceptible. Within a few weeks it's pretty much invisible. It's very small to begin with, and it's sort of hidden because it's on the underside of your nose, and that skin just tends to heal very well, luckily.

Monique Ramsey (07:07):
Can you even think about a cosmetic change when you need a rhinoplasty from an injury? So say you got hit in the face with a baseball, and then what are the steps that somebody might go through? And if they say, "Well, you know, I actually never really liked my nose before the baseball," what does that look like?

Dr. Kiersten Riedler (07:30):
I always recommend addressing any fracture deformities and cosmetic concerns at the same time rather than undergoing multiple procedures, because it's definitely easier to do it all at once, and definitely we can make cosmetic changes and correct an injury all at once.

Monique Ramsey (07:51):
Is that something that they have to wait, let's say, today I get hit with a baseball, can I have you fix me on Friday? Or do we have to wait a little while?

Dr. Kiersten Riedler (08:00):
Actually, when somebody breaks their nose and you have a fracture that is displaced, meaning the bone is out of alignment, the best case scenario is that that gets fixed in about a week. That doesn't involve an open surgery, that basically just involves resetting the bones in the correct place. Unfortunately, that often doesn't happen in time, and so the fracture heals, and in that case we usually recommend waiting for at least six months for surgery, so that you're fully healed from the fracture and all of the swelling has gone down, and we really see what the final outcome of the injury is before going in there an decision-making changes.

Monique Ramsey (08:48):
Speaking of swelling, that's a really good point. How long does it take to recover from a rhinoplasty, and when can you start to maybe go out and be amongst the public, and feel comfortable?

Dr. Kiersten Riedler (09:01):
Patients go home the same day of surgery, and generally they will want to stay home for the first few days after surgery. They have a small cast on the nose for a week, and they're free to go on long walks three to four days after surgery, and then start light aerobics after two weeks. Return to their usual activity after three weeks. But for the first two weeks, I would say, your face and your nose are going to be noticeably swollen, and there can be some bruising under your eyes, which usually results within 10 days. So I would say although you can go out really any time after surgery, you may not want to make a lot of public appearances for the first week to two weeks.

Monique Ramsey (09:51):
Does it affect your breathing? That swelling, I would think, makes it almost like you have a stuffy nose?

Dr. Kiersten Riedler (09:57):
That's a lot of feedback I get, is that there's not actually a whole lot of pain after surgery, it's more the stuffiness that people complain about. That's just because there's swelling on the outside and on the inside, and so it does take a few weeks to really clear up.

Monique Ramsey (10:16):
In terms of the final result, I've heard that there's a lot of swelling with noses, and that final result might take some time to see. What do you advise patients about?

Dr. Kiersten Riedler (10:30):
Other people might not notice, two weeks later, that you have a lot of swelling or just had surgery. You do still have quite a bit of swelling actually, and it generally takes about a year for the final results of rhinoplasty to emerge. Studies have actually measured the amount of swelling and shown that about 65% of the swelling goes away within the first six weeks, but then gradually, over the next year, the swelling, little by little, subsides.

Dr. Kiersten Riedler (11:08):
It's partially because the nose is not particularly vascular, so it takes longer for the swelling to go away. But it's also that it takes time for the skin to conform to the new structure underneath. So if you have a large nose or a hump, and we're reducing that, you still have the same amount of skin on the outside, so it takes time for that to kind of shrink wrap down to the new structure. That's a very gradual process.

Monique Ramsey (11:40):
Interesting, I've never really thought about that, but you're right. If you're fixing things inside, it's not like you can do ...

Dr. Kiersten Riedler (11:45):
Yeah, we're not taking things off on the outside, we leave that alone.

Monique Ramsey (11:51):
That's interesting, so 65% of the swelling is gone in about four to six weeks.

Dr. Kiersten Riedler (11:57):
Mm-hmm (affirmative).

Monique Ramsey (11:57):
So I know that it might be a rare thing, but what would your options be if you have a rhinoplasty and a year goes by, and you really have your final result, and you still don't like your nose?

Dr. Kiersten Riedler (12:10):
Of course nobody likes that outcome, the surgeon or the patient, but sometimes patients might have a concern or asymmetry that still bothers them. Typically if there is one, it's minor compared to their original concerns, and so in that case the options would be either a minor revision procedure to make a small change. In that case, for example, endonasal or a closed approach might be a good option if there are small changes that need to be made. Another option is actually non-surgical rhinoplasty, or liquid rhinoplasty. Especially if it's a small asymmetry externally, then just adding a little bit of filler can be an option as well.

Dr. Kiersten Riedler (12:58):
Revision rhinoplasty is pretty much always a little bit more challenging than a primary rhinoplasty, or somebody who's never had surgery before, but it's something that, I like the challenge of it I guess, and I do a lot of revision surgeries. Often one of the differences compared to primary rhinoplasty is that it might require the use of cartilage grafts, because after an initial surgery there might not be enough cartilage or underlying structure left to make the changes that we need to make.

Dr. Kiersten Riedler (13:38):
The other difference is that it can actually take quite a bit longer for the swelling to go down after revision surgery, because there already is scar tissue. We say that revision rhinoplasty can take up to two years for all of the swelling to go away completely, and for you to have your final result. But in general it's, really the vast majority is still gone within the first few months.

Monique Ramsey (14:03):
You mentioned cartilage grafts, and I actually want to talk to you more about that in a separate episode. Don't you think that we should? That's kind of a whole big topic that we could go into.

Dr. Kiersten Riedler (14:17):
Yeah, definitely. I think revision rhinoplasty and cartilage grafting, yeah, that would be a great topic for a future episode.

Monique Ramsey (14:23):
Okay, well we're going to do that. Let's get ready.

Monique Ramsey (14:27):
Is rhinoplasty different for different ethnic groups? So if you have Asian or African American patients, is there anything that you're having to consider as a surgeon, or them as a patient, in terms of what that approach might be, or what their risks might be, or what their outcome might be?

Dr. Kiersten Riedler (14:47):
Yes. The difference really lies in the anatomy. The shape and the structure of the nasal bones and the cartilages and the skin tend to differ in patients of different racial and ethnic backgrounds. One thing that Asian and African American patients request more commonly is dorsal augmentation, or augmentation rhinoplasty, which means building up the bridge of the nose. And another really important consideration for me, the surgeon, is that non-Caucasian patients often have thicker nasal skin, whereas somebody with really thin skin, you have to be careful that you're not going to see too much underneath, and that all the cartilage surfaces are very smooth. And somebody with thick skin, it's almost the opposite, where you want to have a bit more well defined structure of cartilage underneath, that you will be able to see through the thicker skin.

Monique Ramsey (15:51):
You talked about the dorsal height, I guess, how tall your nose is, maybe.

Dr. Kiersten Riedler (15:57):
Yeah.

Monique Ramsey (15:57):
But then what about the width of their nostrils? If the nostrils are extra wide, is there a way to sort of narrow that?

Dr. Kiersten Riedler (16:07):
Yes. There's something called alar base reduction, which involves making incisions, either along the outer edges of the nostrils or even inside the nostrils, and that can be done to reduce the overall width of the nose. There are different orientations of the nostrils, and there's a classification system, and based on that, there are different ways to narrow the base of the nose. But, yeah, that's something that is more commonly requested, I would say, in African American and Asian patients as well.

Monique Ramsey (16:47):
So really, you could either do it from the outside or from the inside, you're saying, depending on the ...

Dr. Kiersten Riedler (16:51):
Mm-hmm (affirmative). And sometimes actually a combination of the two.

Monique Ramsey (16:54):
Oh, okay. One thing that I've read is that we hear about body dysmorphia, and people who look in the mirror and they see something different about their body. It could be also having to do with their face, or maybe over-fixating on something on their face that bothers them. Is that a thing with rhinoplasty?

Dr. Kiersten Riedler (17:18):
Body dysmorphic disorder, or BDD for short, it's an obsessive preoccupation with either a very slight defect, or a nonexistent defect, in your appearance. It differs from kind of a normal concern with your appearance because it causes a lot of emotional stress, functional impairment. Patients may skip work or social events because of it, and really spend many hours a day thinking about it and trying to correct it. The prevalence in the general population is a little over 2%, but we have found that about 10% of patients who are seeking facial plastic surgery actually have body dysmorphic disorder, so it is a little bit more ... I mean it's not the majority of patients, definitely, seeking rhinoplasty, but it is more common in the patients seeking facial plastic surgery, including rhinoplasty, and so it's something to be aware of, for sure.

Monique Ramsey (18:32):
How are you able to help them to get a realistic expectation about what their outcome could be? Or, do you have certain tools that you use to help them be able to see that potential outcome, or help them through whatever barrier they're having?

Dr. Kiersten Riedler (18:54):
It's really important for me as a surgeon to recognize patients who might have body dysmorphic disorder, because in patients who have a severely distorted body image, their issue isn't really aesthetic, it's actually more psychological. So cosmetic surgery isn't a good option, because it's not going to make them happy. It's actually not going to relieve their distress at all. The vast majority of patients with body dysmorphic disorder, I think about 96%, 97%, are dissatisfied after receiving cosmetic treatments.

Monique Ramsey (19:33):
Oh.

Dr. Kiersten Riedler (19:34):
So it's always important for me to assess the patient's concerns, assist their goals, and then go over with them, in detail, what I think that we can accomplish. But in patients who seem to have unrealistic perceptions about their appearance, which is a little bit different, I kind of ask a few questions to delve into their history more, and their goals for surgery. And if it does seem that they might be suffering from body dysmorphic disorder, explain to them that really, my goal is to relieve their distress about what they're coming in to see me about. And when it's more related to an unrealistic perception, the most effective solution is actually discussing that with a psychiatrist or a psychologist who specializes in BDD for further assessment and treatment. It's a tricky subject, but I try to explain that I have their best interest in mind, and so in those cases that's really what's going to help them the most.

Monique Ramsey (20:51):
For the general population, I'm thinking, "I want my nose changed. Here's the things that I want to have fixed or modified." Then I have a consultation with you. What are the ways that you could help show me what my projected result might be?

Dr. Kiersten Riedler (21:12):
I always start by going over what the patient's concerns are, what bothers them, what they want to change, and then examining what I'm working with, what their anatomy is like. Then we take photos, and based on my conversation with them, during my visit I will morph the photos so that they can see the before, and then the simulated after photo. Then we review those to see if we're on the same page. That, I think, is a really good communication tool, because that really shows the patient what I think we're capable of accomplishing with surgery, and makes sure that I really understand what they're telling me. Because patients don't know all the anatomical terms for the nose and everything, and so it's sometimes hard to describe in words, but a picture is worth a million ... Wait, is it a thousand words?

Monique Ramsey (22:12):
Yeah, a picture is worth a thousand words.

Dr. Kiersten Riedler (22:15):
A picture is worth a thousand words, yeah.

Monique Ramsey (22:16):
You could have picture inflation, and it could be a picture is worth a trillion words, why not.

Monique Ramsey (22:24):
That's really nice, so that it helps become a way for the two of you to communicate. I think the other thing is, we are sitting here talking, looking at each other; you look at yourself in the mirror, and you see the front of your nose. But really, you don't see yourself in profile very often, unless somebody happens to take a picture of you. I think that imaging where you're actually then taking a profile photo of the patient, where they're with you and they can see ...

Dr. Kiersten Riedler (22:52):
And that's why I do the morphs from the front, and actually from both sides. Because like we said, there's always some asymmetry. So I morph the front view, and then also both of the sides, so we can evaluate all of those views.

Monique Ramsey (23:09):
How many times might a patient, once they see themselves from the side, maybe the balance is wrong with the chin? Or how many times is the chin part of that discussion?

Dr. Kiersten Riedler (23:23):
That's a good question, because in patients who have kind of an underdeveloped or small chin, that really changes the overall balance of the face, and will make the nose look relatively bigger than it is, just because of the proportions. So discussing a chin implant, or chin augmentation, with them is an important part of the consult, because that's really going to dramatically improve their rhinoplasty result, because it will give their whole facial profile a more balanced, harmonious appearance.

Monique Ramsey (23:59):
Is that something that, should that be recommended, and they're onboard, and you want to do that, you could do it in the same surgery?

Dr. Kiersten Riedler (24:08):
Oh definitely, yeah. Usually I would do it at the same time.

Monique Ramsey (24:13):
I think we really did a great job at covering rhinoplasty in general, and we're going to do some episodes, one we have already talked about. We want to do an episode about revision rhinoplasties, and using grafts, or maybe a nasal implant. We want to talk also with you about the non-surgical rhinoplasty, those liquid rhinoplasties. We also are going to do an episode, so everybody stay tuned, on septoplasty, or rhino-septo, which means, you're maybe dealing with, not just the external cosmetic prettiness of the nose, or handsomeness of the nose, but how it's functioning and how you can breathe. Which is sort of important.

Dr. Kiersten Riedler (24:54):
Uh-huh. Yeah, exactly. Those are the two critical functions of the nose, are to breathe, and also to fit your face and be balanced with the rest of your face. So that's kind of what a septorhinoplasty is addressing, is the function and the appearance. And sometimes the septum has a significant role in the external appearance of the nose two actually, so we'll have lots of things to talk about.

Monique Ramsey (25:26):
Yeah, I'm excited about that. So for our listeners, our audience, we'll have everything in the show notes that we've talked about today, and you'll be able to go onto our website, read about Dr. Riedler, you could listen to her other podcasts, and it's on her bio page, we have the meet Dr. Riedler episode, which is super interesting. I encourage you all to go take a listen. Then, really I think the next thing that a lot of people want to know is, how do I learn more about pricing? We have everything on our website, so we have everything in terms of ranges for prices in terms of financing options, or how you can save money, how you can spread your payment out. Fix what you want now and pay as you go. Which is, we've got to be realistic.

Dr. Kiersten Riedler (26:17):
Yeah.

Monique Ramsey (26:17):
I think a lot of people don't realize that we do have financing. And just like you finance your car, you could finance your notes.

Monique Ramsey (26:25):
So when they have a consultation with you, is it a virtual consultation, or is it in person?

Dr. Kiersten Riedler (26:31):
It's in person, because it's important for me to see the nose in its three dimensions, and also take the photos, and also to look on the inside of the nose too. Because it's the appearance we're looking at, but it's also important to know what the inside of the nose looks like, and what the septum looks like, and make sure that the breathing isn't an issue, and it's not going to become an issue. So I like to do that consult in person. I think I can get the most information, and get the patient the most information as well.

Monique Ramsey (27:06):
Great. Then if you're listening today, we want to ask you for a special favor. If you love the La Jolla Cosmetic Podcast, and you've learned something today, it's helped you make a decision, please tell your friends. We'd love that. And also write a review of the show on Apple Podcasts, or Goodpods, or wherever you're listening, because we love reviews, as you know. Our practice, we're all about reviews, and we have them on our website. On every page practically, you can read reviews. Which, we're proud of our 34 years of history so far, and the thousands of reviews that we have, and five-star reviews. So we want to hear from you also about the podcast, and if there's something you want us to discuss that piques your interest, and you'd like to have Dr. Riedler address it on a future episode, we'd love to have that.

Monique Ramsey (27:56):
Well thanks, everyone, for listening, and we'll catch you next time.

Dr. Kiersten Riedler (28:00):
Thank you.

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