A reconstructive cosmetic procedure for the nose. The purpose of the surgery is to improve the aesthetic, balance and functionality of the nose.
Before and After Gallery
Plastic Surgery Talk
Dr. Mulholland has spent a number of years treating complex facial fractures, including nasal fractures and advanced facial trauma.
His ability to manage the bone and soft tissue deficits of nasofacial fractures provided him with an excellent and unsurpassed foundation for subsequently performing cosmetic rhinoplasty surgeries.
Dr. Mulholland Discusses Rhinoplasty
Before & After
One of Toronto’s Best Nose Jobs
What is a Rhinoplasty?
A Rhinoplasty is a cosmetic plastic procedure performed on the nose to change its structure, shape and form, as well, improve simultaneously the airway flow and function, in order to improve nasofacial balance, function and overall aesthetic appearance.
Who is a candidate for a Rhinoplasty?
An excellent candidate for nose job is a Rhinoplasty patient who is medically well and has realistic expectations and who understands the risks and benefits of cosmetic Rhinoplasty surgery and would still like to proceed – this can include individuals with excessively large noses, dominant bridge bumps, bridge scoops, long noses or short noses, crooked noses, overly-resected bridges or “bridge scoops”, as well as wide nostrils and bulbous tips. All these nasal facial variants must have some desire to improve their naso-facial contour, balance or proportion. A thorough physical examination must be performed, both externally and internally. The inside exam, or endonasal exam is performed to diagnose any clinical or subclinical obstruction, deviation of the septum, with or without increased size of the turbinate bones. If there is evidence of an airway obstruction, a Septoplasty, or partial or near-total removal of the obstruction septum, or turbinate’s, may be required at the time of cosmetic Rhinoplasty surgery. Dr. Mulholland will take the time to review your cosmetic Rhinoplasty procedure in front of computer simulator, so you can assess the range of nose improvement that can be achieved before you decide to proceed with Rhinoplasty surgery.
How is a Rhinoplasty performed?
There are two broad categories of Rhinoplasty procedures performed by Dr. Mulholland. Rhinoplasty patients will benefit from Dr. Mulholland’s extensive, over 20 years of experience in performing Rhinoplasty surgery.
The first broad category of Rhinoplasty is an external Rhinoplasty, where a small incision is made in the base of the nose and the nasal skin is lifted up over the cartilages and bony structure to optimally visualize and reveal the nasal anatomy so it can be structurally changed and stabilized for an excellent long-term result.
The second broad category of type of Rhinoplasty procedure is a closed Rhinoplasty, Internal Rhinoplasty or endonasal Rhinoplasty. In a closed Rhinoplasty, there is no small incision at the base of the nose, in what’s called the columella, but rather the incisions are placed entirely inside the nose and inside the nostrils. An internal, or endonasal Rhinoplasty, as it is called, saves the cosmetic Rhinoplasty patient the small incision in the skin of the partition of the nose (columella), and is excellent for dorsal bridge reductions and some modest tip and airway breathing concerns, but is usually a suboptimal approach for more complex cosmetic Rhinoplasty procedures involving extensive or combined changes to the tip of the nose, balancing bridge and tip work or supporting the external valves of the nose and stabilizing all these structures so there is a predictable long-term result following your Rhinoplasty. For the majority of Rhinoplasty the external Rhinoplasty approach, combined with the internal incisions will give you the best possible cosmetic and functional outcome.
Dr. Mulholland, who has dual certification in both Plastic Surgery and Ear, Nose Throat (ENT) Advance Head and Neck Oncology, is an expert in both techniques in Rhinoplasty, both open (external) and closed (internal) and will deploy the best approach to achieve the optimal outcome for your Rhinoplasty surgery.
Figure 1. There are several incision options in performing a Rhinoplasty procedure. The majority of incisions for Toronto Rhinoplasty patients are inside the nostrils and inside the nose, where they not visible and these are used in the Endonasal or Internal Rhinoplasty. The External Rhinoplasty, which is a common Rhinoplasty approach for complex aesthetic nose changes of the nasal tip, uses a small incision in the middle of the external partition of the nose called the columella. This small scar is only several mm’s in length and usually heals beautifully and imperceptible and allows Dr. Mulholland to accurately visualize the nose cartilages and bones and to correct more accurately and for greater durability.
What are the different types of cosmetic noses that present for Rhinoplasty surgery and can be helped?
There are several common aesthetic variations of nose and face imbalance that can be improved with a cosmetic Rhinoplasty procedure. Broadly classified these Nasal – Facial imbalances can be divided into aesthetic concerns with the bridge, aesthetic concerns with the tip and base, issues with breathing, noses that are too long or too short and crooked noses. The most common reduction Rhinoplasty is a reduction of a bridge bump, while building up a bridge that is weak, that needs to be built up, is also a common presentation for cosmetic Rhinoplasty of the bridge.
A tip of the nose may be too wide or bulbous, or, over-projected or under-projected (also called a tension tip, if combined with a strong bridge). The nose may be too long or too short and can be straight or crooked. We will review the operative treatments for each of these Toronto cosmetic Rhinoplasty variants below
Figure 2. Common Cosmetic Nasal-Facial concerns that present for Cosmetic Rhinoplasty. Nasal Facial issues can affect the Bridge, Tip, length, projection, width and height of the nose and breathing passages. Some of the common Rhinoplasty concerns are shown in this figure.
What if I have a nose bridge bump? How is that reduced or improved?
It is very common for Rhinoplasty patients to present with a bump on the bridge, also called a dorsal hump. A bridge bump or bridge hump is usually as a result of a hereditary overgrowth of the bones and cartilages on the bridge of the nose. Occasionally, a bridge bump can result from over growth of tissue following an injury or fracture to the nose. Generally, Rhinoplasty patients with bridge bump concerns dislike their three-quarter and profile views, as the bridge of the and nose itself appears very dominant or excessive in size compared to other, more delicate features of the face. Individuals with bridge bumps may also have an excessively long nose and/or a plunging tip all in combination. For female Rhinoplasty patients, a bridge bump is often viewed as being “too masculine” and lacks the femininity and soft female features and contours that most women desire.
Figure 3. Bridge Bumps (humps) result from over growth of cartilage and nasal bones. The large bridge bump is reduced by filing down the nasal bones and over growth of the prominent septal cartilage and then breaking the nose (osteotomies) to reduce the width. Rhinoplasty patients who present for Bridge bump reduction also commonly have noses that are too long, that need shortening and over or under projected tip that need to be balanced.
For bridge bump patients, the bridge of the nose is surgically accessed through either an internal Rhinoplasty (Endonasal) or external Rhinoplasty incision approach. If the nose tip needs to be adjusted and balanced once the bridge is reduced, Dr. Mulholland’s preferred approach would be an external Rhinoplasty incision, as the scar heals extremely well and affords the greatest degree of exposure, analysis, bridge bump and tip correction and contouring leading ultimately to the best long-term stability.
Once the excessively high bridge is identified visually, the nasal bones can be reduced with a nasal rasp (sanding down the bump) and the excessive cartilage resected with specialized scissors. Small amounts of the bridge are removed each time and the contour assessed, until Dr. Mulholland is happy with the shape and improvement in your profile, with a beautiful and aesthetically appealing reduction of the bridge in relation to the nose and the rest of the face.
What if my upper nose is too wide? How can that be fixed?
For Rhinoplasty patients with excessively wide nasal bones, the approach is generally to perform a nose-breaking procedure, also called nose osteotomies. In performing a nose osteotomy, very tiny chisels are used with a small nasal hammer, to actually break the nasal bones and move them towards the midline, decreasing the excessive width of the upper portion of the nose, also called the bony nose or rhinion. Once the nasal bones are reduced and brought close together, this narrows the wide-looking upper nose and any irregularities in the bridge of the nose can be filed down with a nasal file.
Figure 4. Wide nasal bones lead to an excessive width of the upper portion of the nose. When the nasal bones are too wide and aesthetically displeasing, then a controlled, surgical in-fracturing or “breaking” of the nasal bones and bringing them closer together will improve the aesthetic appearance of a wide, dominant upper nasal side wall.
What if the middle width of my nose looks too narrow and it collapses when I breathe in?
Sometimes the middle portion of the nose can be too thin and unsupported, resulting in an overly narrowed appearance and collapse of the middle portion of the nose on inspiration. This kind of nasal sidewall, or nasal valve collapse can result in a functional breathing obstruction, as well as a front view of the nose that looks too thin in the middle third of the nose. In order to improve the aesthetic appearance of being overly narrow in the middle third of the nose, bits of cartilage harvested from the nasal septum or ear cartilages are sutured in place to “splint” the internal nasal valve and help prevent collapse. These bits of cartilage that are sutured in place are called “spreader rafts” and can widen the narrow middle third improving the aesthetic appearance and, in splinting the nasal valve collapse can often help improve breathing obstruction. Spreader grafts can also be useful in stabilizing the middle third of the nose when correcting crooked noses.
Figure 5. Spreader grafts are sutured in place on either side of the midline cartilage, called the septum. These spreader grafts can be bits of excess cartilage taken from the septum or from ear cartilage. The spreader grafts widen the aesthetically narrow middle third, help to splint the internal nasal valve collapse, thus improving breathing and can help keep a crooked nose straight.
How is the appearance of a Bulbous Tip improved during Rhinoplasty?
A bulbous tip, or button nose, is usually due to excessive overgrowth of the lower lateral cartilages, also known as the lateral crus of the lateral cartilages, located at the bottom end of the nose. This over development of the cartilages of the lower third of the nose is usually a hereditary phenomenon, although it could occur following trauma.
Using an external Rhinoplasty, Dr. Mulholland will expose the excessively large lateral crus of the lower lateral cartilages that contribute to the appearance of a bulbous tip. The upper portion of this cartilage is removed, narrowing the tip of the nose. Dr. Mulholland then uses fine nasal sutures to suture the tip together, to refine it and give it more definition and support.
Figure 6.Rhinoplasty patients that present with a bulbous tip, most often have an overgrowth and overdevelopment of the lower lateral cartilages of the lower third of the nose. To narrow the tip and improve the appearance of the bulbous tip, the lower lateral cartilages usually need to be resected, reduced and contoured. By removing a portion of the lower lateral cartilages and suturing the remaining cartilage together the appearance of a wide, bulbous tip can be greatly narrowed and improved. A bulbous tip correction can leave tip looking thinner, more defined and more feminine.
How do you correct a tip that is over projected and sticks out too far?
If the actual tip of the nose is overly projected, or too high, the lateral crus of the lower lateral cartilages may actually have to be completely divided and a horizontal section of the dome removed and re-sutured for stability and support. By resecting a portion of the dome, the nasal tipis dropped and de-projected to better match the now straight bony bridge bump. To drop an overprotected tip even further, portions of the medial crura can be resected, which can dramatically reduce the tip projection.
Figure 7. An over-projected tip, or one that sticks out too far from the face, will require the tip to be dropped, or de-projected back towards the face to improve nasal facial aesthetics. Rhinoplasty patients with an over-projected tip often require the complete division and resection of the dome of the lower lateral cartilages dropping a tip that is too strong and projected more in balance with the face. Alternatively, or additionally to drop an over projected tip the medial crural cartilages may need a vertical resection to directly drop the tip projection.
How is a crooked nose fixed?
It is not uncommon for Rhinoplasty patients to present with a nose that is crooked, and this usually is a result of deviation of the internal partition of the nose, also called the septum. The crooked septum can be developmental and hereditary or traumatic, from an injury. Nasal bones that are displaced during a fracture, can also lead to the appearance of a crooked nose. When the septum is irregular or deviated, it can pull the structure and appearance of the nose off to one side or the other. Often the crooked nose can be improved with a partial removal of the septum, called a Septoplasty, and restructuring the bridge to ensure that it is straighter with various supportive graft materials, often taken from the portion of the septum removed from the nose during the Septoplasty, and then to stabilize the septum in the midline and avoid subsequent return of the appearance of a crooked nose. These structural, sutured-in-place grafts are called “spreader grafts”
Figure 8. Correction of a crooked nose. Rhinoplasty patients who present with a crooked nose, often need to have structures released and moved to the midline. The midline support structures are then stabilized with cartilage grafts taken from the septum, called spreader grafts.
What if my nose is too long? How can my long nose be fixed during Rhinoplasty?
Usually an excessively long nose bothers patients both from the front view, ¾ view and the side view, (selfie views), as the nose dominates the face, looking too long and dominant. Often the excessively long nose also plunging, or droops on smiling. This kind of tip, is also called a “tension tip” or “plunging tip”. In diagnosing a long nose, one needs to determine if a bridge is deficient or if the bridge is too strong, as the bridge should be improved and operated on at the same time as shortening the nose. The approach to the surgical correction of a long nose is usually an external Rhinoplasty, lifting the skin bridge to expose the structures that lead to the excessive length. The lower portion of the septum, called the caudal septum, is removed to decrease the length and shorten the appearance of the nose. Often this shortening of the actual septum is combined with removing part of the septum to improve the airway, a procedure called a Septoplasty.
The nose tip may or may not have been reduced, depending on its projection, but the shortened tip needs to be supported in the midline with a cartilage graft and secure fixation sutures. This cartilage graft that stabilizes a shortened nose, is called a columellar strut graft and can be viewed as a “tent pole” supporting a “plunging tip” from dipping down. Once the tip has been surgical modified, in any way, the tip will often need long term support of the tip with a cartilage graft or strut hidden within the columella.
Figure 9.Rhinoplasty patients who have had their lower nasal cartilage operated upon, once the nasal tip has been modified and its ideal height finalized, a support graft (or tent pole) is needed, also called a columellar strut graft. To accomplish this, a cartilage graft placed in the columella, between the two medial crura to support the nasal tip and to retain nose projection over the long term.
Bony fractures of the upper part of the nose are performed to make the nose narrower and shortening the nose, with or without a bridge bump reduction. Rhinoplasty patients with excessively large, dominant noses present with this triad of: (i) a bridge bump; (ii) an excessively long nose, an overly projected nose and (iii) usually some degree of minor or moderate nose and septum deviation and all elements need to be improved at the time of the Rhinoplasty procedure.
How can you fix a bridge that is too weak and under projected?
A weak bridge, or a nose bridge that is not strong enough, can result from a hereditary lack of bony and cartilage tissue growth, or from trauma, including an over resected bridge during Rhinoplasty. The primary goal of a deficient bridge restoration is to “build it up” and increase bridge height. To increase the strength and height of a nasal bridge, Rhinoplasty surgeons have the following options: (i)use an artificial bridge which can be constructed with a simple injection of long lasting gel, such as Juvederm Voluma, a procedure called an Injection Rhinoplasty, or the 5 minute nose job. This injection Rhinoplasty can last up to two years. (ii) An artificial silastic bridge can be inserted that will be permanent or (iii) tissue from your own body, such as rib cartilage, bone or ear cartilage can be inserted to strengthen the bridge height.
Figure 10. A Weak Bridge, or under-projected bridge can be corrected by the insertion of a graft. This graft can be cartilage or bone, harvested from the rib, skull or pelvis. The Bridge augmentation can also be an artificial insert, such as silastic or medpore. The deficient dorsal bridge can also be augmented by injecting the patient’s own fat or HA gels such as Juvederm Voluma. The augmented bridge will create more vertical bridge height and narrow the appearance of a wide nose.
How to correct nostrils that are too wide and flared?
Rhinoplasty patients who present with nostrils that are wide can have the nostrils reduced by removing a portion of each of the wide nostrils, hiding the incision under the base of the nostril. A small wedge of nostril soft tissue is removed, narrowing the nostrils. This procedure is called and Alar Base Resection.
Figure 11. Rhinoplasty patients with wide nostrils can have a small wedge of nasal alar tissue removed from the nasal base making the width of the nasal bones narrower. This procedure is called and Alar Base Resection. The nostrils and alae will then appear more narrow and refined at rest and on smiling.
What are the contraindications to Rhinoplasty surgery?
The contraindication(s) to Rhinoplasty surgery are usually those individuals with unrealistic expectations. In addition, individuals who are not medically well and those who may be pregnant at the time of surgery, or who have had multiple previous Rhinoplasty and nose surgeries may have soft tissue that does not lend itself to repeated surgery and may not be Rhinoplasty candidates.
What kind of anesthesia is used during my Rhinoplasty procedure?
Many Rhinoplasty patients are concerned they will be aware during the surgery and want to be reassured they will have a “full anesthetic”. Because of the nature of the surgery and the need for weakening the bones of the nose, there may be some nasal fluids that flow back into the throat and this must be prevented from entering into the lung. Therefore, general anesthesia with throat protection is often used during Rhinoplasty procedures, unless the work is only of the soft tissue of the tip, which can be performed under local anesthesia. An anesthesiologist, a fully-trained and certified with an excellent reputation and work history, will meet you on the day of surgery and provide the level of anesthesia that is appropriate to your case and you will not be aware of anything during your Rhinoplasty surgery.
There is also local anesthesia injected into the nose once the general anesthesia has fully taken effect, so there will be additional protection against feeling any pain once the Rhinoplasty operation is done. The local anesthesia also contains some adrenaline and will constrict the blood vessels of the nose, which helps to minimize bruising and swelling and also minimizes inter-operative and post-operative pain on the part of the patient.
What is sequence of maneuvers commonly performed during the Rhinoplasty procedure?
In general, the sequence of surgical events during the Rhinoplasty procedure will depend upon the surgeon performing the operation, and the goals of the Rhinoplasty patient, but will include the following: the first step is to gain exposure, either through an internal endonasal Rhinoplasty approach, or an external Rhinoplasty approach. Once Dr. Mulholland has adequately identified the anatomical structures, then the a dorsal or bridge reduction, or bridge augmentation, is performed depending on the bridge status, followed by fractures of the nasal bones to narrow the bone and make the nose appear more elegant. The lower part of the nose may then require tip reduction or tip support augmentation or de-bulking the tip. Finally, after the bridge and tip have been shaped and brought into balance, the nostrils may need to be reduced and narrowed and often, the partition of the nose, or septum needs to be adjusted or partially removed to optimize the probability that there will be no airway obstruction following the Rhinoplasty surgery. All these procedures and maneuvers are decided upon in the pre-operative phase, during the computer simulated surgery consultation and can be adapted at the time of the procedure.
Is the recovery from a Rhinoplasty procedure painful?
There is surprisingly very little pain associated with post-operative Rhinoplasty procedures. There is usually some sterile packing inside the nose to minimize risk of bleeding. This packingis uncomfortable, though not usually described as painful. The packing is usually removed on, or about the 3rd post operative day. There is a cast placed on the nose to support the broken nose bones and delicate structures until they are reasonable stable, usually at about 7 days, where upon the cast and any tiny external sutures are removed. However, it is 6 weeks before contact sports can be resumed. Most Rhinoplasty patients describe the post-Rhinoplasty phase as uncomfortable, but not often associated with significant pain. Toradol and a minor Tylenol 3 equivalent should be all that is required for the first few days after your Rhinoplasty procedure.
How long does the Rhinoplasty procedure take to perform?
A Rhinoplasty procedure, whether it’s augmenting the bridge, reducing the tip, reducing the bridge, or combinations of these aesthetic concerns, or improving function, generally takes Dr. Mulholland approximately 90 minutes to perform. Patients need some post-operative care for the first few hours, until they can be picked up and given a ride home under the buddy system.
Where will the Rhinoplasty surgery take place?
Dr. Mulholland has owned and operated a fully certified overnight stay surgery center since 1997. The SpaMedica Cosmetic Plastic Surgery Center is certified by the government and Ontario College of Physicians and Surgeons of Ontario as a level one, General Anesthesia, overnight care surgery center. Most Rhinoplasty patients do not need to stay overnight but can often go home two hours after their surgery.
How long is the recovery following my Rhinoplasty procedure?
Most patients require a full week off from social activities and work. This is because at the time of the osteotomies, or breaking the upper nasal bones, there can be extensive bruising, swelling and “raccoon eyes” often occurs. This extensive bruising or “raccoon eyes” may also result in the blood deep in the tissues, leading to a delayed bruise that can be bluish, yellowish or green in color and may last a week or more. Immediately following the procedure, the packing inside the nose feels quite distended and the external cast prevents or minimizes any movement of the bones. The packing comes out on, or around, the 3rd post operative day and the cast comes off at one week. In general, individuals who take a week to ten days off are generally happy going back to work at that time and they look their best socially in approximately six weeks.
How long is the recovery following my Rhinoplasty and how will I look?
A Rhinoplasty procedure has a significant amount of early bruising and swelling, but only moderate pain and discomfort, although the nasal tip can remain swollen for five months or more. At the completion of the procedure and once the all the incisions are closed, some special skin tapes and a cast are placed on your nose and this is supported by tapes. Most Rhinoplasty patients begin to look acceptable at 3 weeks and quite good by 6 weeks. The final results, especially for the nasal tip, are not completed until one year.
What is the range in price of a cosmetic Rhinoplasty procedure?
The price of the Rhinoplasty procedure depends upon the severity of the aesthetic involvement, but, in general, most Canadian prices for well-trained plastic surgeons and ENT surgeons performing reduction Rhinoplasty start from $5,000 and, for secondary, or “corrective Rhinoplasty” (nose job that has been done before) start from $15,000, depending on the physician you’re seeing, their level of experience, speed and accuracy.
What kind of results can I expect following my external reduction Rhinoplasty?
Most Rhinoplasty patients will be quite self-conscious about the appearance of their nose for the first couple of weeks. What most nose job patients find out is that most individuals they know, or mere acquaintances rarely look at the faces of others very closely and therefore, it is entirely likely that very few people will know that you underwent a cosmetic Rhinoplasty procedure. If the Rhinoplasty is done very naturally, with a balance of aesthetic outcomes in play, few if any comments specifically about your nose will occur. Often simply changing the color of your hair dramatically just before your Rhinoplasty surgery will distract people you meet from any minor swelling in the nose and they will “comment on your hair”. Following your successful Rhinoplasty procedure, casual observers may think you have lost weight, changed your hair style, or make up.
Figure 11. A Toronto Rhinoplasty patient of Dr. Mulholland’s who underwent a reduction Rhinoplasty procedure with reduction of a strong bridge, shortening of the nose, Septoplasty and de-projecting the over projected nasal tip. This Rhinoplasty patient was operated on a Cityline TV segment and her results and journey can be found and viewed on our SpaMedica website.
Is there any way of estimating the type of cosmetic Rhinoplasty that will work best for me and how it might look after? Does Dr. Mulholland do computer simulated Rhinoplasty surgery before the actual operation?
Yes, in order to better understand what kind of nose improvement the patient hopes to achieve, a special, high-tech, three-dimensional camera-computer system called the VECTRA 3D will be used by Dr. Mulholland walk you through your computer simulated Rhinoplasty surgery at the time of your consultation, before you actually decide to proceed. Dr. Mulholland promotes a “try before you buy” approach to Rhinoplasty surgery, with computer imaging deployed in getting a patients to understand the range of improvement that can be achieved. With over 20 years of experience in cosmetic Rhinoplasty and dual certification in Plastic Surgery and ENT- Head and Neck Oncology, Dr. Mulholland is very good at showing you the range of nose improvements that can be achieved with cosmetic Rhinoplasty so there is no fear of a “surprise” result you were not expecting.
Dr. Mulholland is a very experienced cosmetic Rhinoplasty surgeon and he will use the VECTRA 3D computer simulated surgery and he will be able to very accurately simulate and predict the shape of your nose with different maneuvers and help you understand better the effect of a reduction Rhinoplasty on your overall facial appearance, both the front view, a close-up front view, the side view, the profile view and the back view.
Figure 12. Dr. Mulholland will perform an actual computer simulated Rhinoplasty procedure during your consultation to review with you the options and show you the range of improvements that are possible with a Rhinoplasty procedure. This “try before you buy” approach to Rhinoplasty virtually eliminates patients with surprise outcomes and dissatisfaction with their primary nose job.
How often does Dr. Mulholland need to do a revision Rhinoplasty on his own patients to correct concerns from the original nose job?
Dr. Mulholland has been performing a high volume of cosmetic Rhinoplasty surgeries for well over 20 years and he is very good at using computer simulated surgery and imaging to show patients very accurately the kind of results, they can expect from their Rhinoplasty. When Dr. Mulholland shows you the computer simulated outcome ranges, your actual results will very close to that. With this “try before you buy” approach, Dr. Mulholland’s Rhinoplasty patients are most often very happy with the expected and anticipated results of their Rhinoplasty surgery. The revision rate for Dr. Mulholland Rhinoplasty is approximates 1-2% and is most commonly the correction and filing down of a small dorsal bony fragment following an osteotomy.
Can I do a Rhinoplasty if I already had a nose job?
Repeat cosmetic nose job surgery is called secondary Rhinoplasty. Patients who have had a previous Rhinoplasty or Rhinoplasties can be candidates for revision nose surgery, but the ability to achieve a consistently good Rhinoplasty outcome, once surgery has already occurred diminishes. Scar tissue, distortion of normal anatomy and prior removal of critical structures can compromise the outcome of secondary Rhinoplasty. The outcomes and expectations for the magnitude of improvement following corrective, secondary Rhinoplasty needs to be conservative and realistic. In Dr. Mulholland’s Rhinoplasty practice, the correction of small residual dorsal bumps, slight nostril asymmetries are the most common reason for an enhancement Rhinoplasty and these patients, although uncommon, typically do very well.
How many Rhinoplasties can you have done?
Dr. Mulholland has performed over 1000-2000 cosmetic nose procedures over the past 20 years and is one of Canada’s most respected cosmetic Rhinoplasty plastic surgeons. Dr. Mulholland has performed live cosmetic Rhinoplasty procedures on TV shows, like Cityline and Breakfast Television and the video and excellent cosmetic results of these procedures are available for view on this website. Dr. Mulholland teaches the art and science of injection Rhinoplasty every month to hundreds of US based physicians
What if my nose is Caribbean, Asian or ethnic, am I a candidate for a Rhinoplasty?
Non Caucasian patients can also be good candidates for cosmetic Rhinoplasty surgery. Often Hispanic and Asian Rhinoplasty patients seek dorsal bridge augmentation and nostril width reduction, while Canadian Caribbean cosmetic Rhinoplasty is often focused on bulbous nasal tip correction and nostril reductions.
Will any external Rhinoplasty scars be visible?
In Dr. Mulholland’s hands, the columellar scar of an external Rhinoplasty heals very, very well and is barely visible within 7-10 days. Similarly, the scars from a reduction of the Alar Base and nostrils, if required is virtually undetectable when they heal. It is very uncommon to ever require a post Rhinoplasty scar revision, but laser treatment, if indicated are offered at no additional cost.
What complications can happen following Rhinoplasty surgery?
There are multiple complications that can theoretically occur following a Rhinoplasty procedure. Fortunately, in Dr. Mulholland’s experienced hands complications are rare and are often able to be fixed. Small irregularities of the bridge may occur from shifting bones following surgery and this can generally be adjusted with simple molding. The external scar on the columella generally heals imperceptibly, but can occasionally be visible. There is a risk of compromised breathing after making the nose smaller and more attractive, so a complimentary septoplasty, or reduction of the partition is often performed to increase the airflow to compensate for the reduction in the actual size of the nose.
There are many other potential complications, most of which are very rare, following any cosmetic plastic surgery, including Rhinoplasty. Dr. Mulholland and his operative team will review thoroughly the risks and benefits and recovery of your Rhinoplasty surgery at the time of your consultation
Will a Rhinoplasty affect my sense of smell?
The sense of smell is comprised of hundreds of specific olfactory nerves and each accounts for a specific smell. Most commonly, a Rhinoplasty will not affect the sense of smell. Very rarely, in the process of breaking the nose, the fracture lines can disrupt a sensory nerve that accounts for 1-2 specific smells. In these very rare circumstances, there may be a long term, or permanent loss of 1-2 specific smells, but the overall sense of smell itself is retained. There is no treatment for the long term loss of 1-2 specific smells.
Will a Rhinoplasty affect my tear ducts?
The tear ducts drain the normal tear film from the inner aspect of each eye into the nose. Generally, a Rhinoplasty does not affect the tear ducts or tear film. However, on very rare occasions, the fracture lines formed during breaking the nose can traumatize the tear ducts on the inner aspect of the corner of the eye and the ducts become blocked. This blockage may result in temporary or permanent blockage of drainage of tears into the nose. The successful treatment of a blocked tear duct is insertion of a stent, opening up the duct and facilitating drainage, a procedure which is covered by OHIP.
Will a Rhinoplasty affect my sinuses?
The maxillary, ethmoid and frontal sinuses all drain into the nose. On very rare occasions, a fracture line from a nose job may pass through one of the draining passages from a sinus, resulting in retained secretions and the risk of recurrent sinusitis. The treatment often involves a functional endoscopic sinus procedure to open up the sinus passage again. This corrective procedure is covered by your OHIP plan.
Will a Rhinoplasty make my migraines worse?
Over the past 22 years, Dr. Mulholland has seen several patients develop intermittent frontal migraines, that tend to resolve and disappear over time, or, may be long term and require standard migraine treatment when they occur. Conversely, Dr. Mulholland has also had migraine sufferers whose migraine frequency and severity disappeared or improved after their Rhinoplasty procedure.
Will a Rhinoplasty improve my snoring?
Snoring usually results from anatomic structures at the back of the throat, called the soft palate. Generally, snoring will neither get worse, nor better following Rhinoplasty surgery.
Will a Rhinoplasty alter my breathing?
Most Rhinoplasties are reductive in nature, that is, making large noses smaller. In the process of making the nose smaller, the airway passages may also be made smaller and breathing may become partially, or completely blocked on one, or both sides of the nose. Dr. Mulholland, with his training in both plastic surgery and Otolaryngology-Head and Neck surgery, performs a preventative Septoplasty and, if required turbinectomies, to ensure the enlargement of the airway passages, which should counteract making the nose smaller and help prevent any airflow obstruction or breathing problems after the nose job.
Will a Rhinoplasty cause nasal drip?
Nasal drip or, leaking nasal mucous out the front or at the back of the nose can happen for many reasons. In general, a Rhinoplasty will not improve nor make worse, nasal drip. Rarely, despite a successful Rhinoplasty, anterior (front) or posterior (back of the nose) rhinorrhea can occur and the treatment may require a Functional Endoscopic Sinus procedure, but the nasal drip may be permanent.
Will a Rhinoplasty affect my smile?
A reduction Rhinoplasty involves lifting and breaking bones around the nose and at the base of the nose at the front (base of the columella). The elevation of soft tissues and the Rhinoplasty fractures themselves, may traumatize the muscles that assist in smile and there can, rarely, be an alteration in the Rhinoplasty patient’s normal smile, limiting normal excursion and compromising a full dentate smile. A normal smile tends to return normally, after 12-18 months without any treatment.
In general, what is my post-operative care course like following my Rhinoplasty surgery?
Most patients will go home following their Rhinoplasty with internal packing in the nose to minimize the risk of bleeding in the first few days and a cast on the external portion of their nose. Patients return to the clinic on day three to have the small sutures under their nose, which are used for the external Rhinoplasty approach, removed. On this day, the nasal packing is also removed.
The first three days are usually impossible to breathe through the nose with the nasal packing inside the nose and you will be a “mouth breather”, but, once the packing is removed, free air exchange can occur easily through the nose again
The cast is usually removed on day seven and all sutures are out by day seven. Most patients can look quite presentable on day seven, with some minor to moderate or significant bruising under the eyes.
The nasal bridge aesthetic improvements following the surgery start to look very good by week three and the nasal tip looks presentable by week twelve. Overall, the aesthetic improvements for the Rhinoplasty occur gradually and over time. The final nasal tip result is not achieved till one year, but approximately 70% to 80% of the improvement is visible at 6 months.
Is there any maintenance required following my Rhinoplasty procedure?
There is no maintenance required following a Rhinoplasty procedure. Simple care and attention not to traumatize the nose is all that is required. Mother Nature and time, with reduction in swelling, will lead to the final results without any further therapeutic intervention.
What is a Septoplasty or a breathing operation?
A Septoplasty is a procedure performed on the internal cartilaginous partition inside the nose and is the wall that separates one nasal passage way from the other. A reduction any deviation of this partition, called a Septoplasty may be performed during your Rhinoplasty, particularly when that internal partition may be deviated or may compromise airflow on one side of the airway passage or the other. Often, when performing reduction Rhinoplasty and making a large nose smaller, a Septoplasty, or airway partition procedure, is performed to compensate for the smaller nose with an increased air flow. The goal of the Septoplasty is to remove any deviated parts of the septum and air passage, such that normal breathing can occur. Other internal nasal structures, such as the inferior turbinates’ may need to be reduced to ensure the best possible airway flow after your Rhinoplasty. A Septoplasty may also be performed, even if there is no obstruction of the airway, because cartilage pieces from the septum may be used as supporting structural grafts during your Rhinoplasty surgery.
Figure 13. A Septoplasty is commonly performed when there is an obvious nasal septum deviation (partition reduction). The Septoplasty, which involves removing deviated portions of septal cartilage to give rise to the obstruction and will increase the airflow though the nasal passages more efficiently.
What is a turbinectomy and is it performed during my Rhinoplasty?
The inferior turbinate, is one of three out pouchings from the lateral sidewall of the nose. The turbinate is normally involved in regulatory functions of the airway, but, on occasion one or both of the inferior turbinates’ may be very enlarged, encroaching upon the air passage way and may need to be reduced during your Rhinoplasty. You nose can function perfectly well, with partial reductions of the septum and, turbinates’.
Can other cosmetic surgery procedure be performed at the same time as a Rhinoplasty?
Yes, it is not uncommon for Rhinoplasty patients to undergo other cosmetic surgery procedures at the same time. Synchronous cosmetic surgery procedures that might be performed at the same time as your Rhinoplasty include a Blepharoplasty, browlift, face and necklift or, even body plastic surgery, such as a breast augmentation or liposuction.
Why choose Dr. Mulholland for your Rhinoplasty procedure?
Dr. Mulholland has an extensive 20+ year experience in cosmetic Rhinoplasty procedures and is certified by the Royal College of Physicians and Surgeons in both plastic surgery and has an advanced fellowship in ear/nose/throat head/neck oncology. This training has given Dr. Mulholland a unique opportunity to understand both the functional concerns of cosmetic nose surgery, specifically airflow and airway preservation, as well as the aesthetic concerns of Rhinoplasty surgery, with beautiful and proportionate nasofacial balance.
Prior to opening SpaMedica and pursuing a career of exclusively cosmetic plastic surgery, Dr. Mulholland spent a number of years performing advanced head/neck oncology, removing extensive tumors and cancers of the face, nose and neck and performing complex reconstructions of these defects, as well as repairing craniofacial trauma including nose fractures and injuries. His intimate knowledge of the anatomy of all aspects of the nose and face and ability to work with all tissues has made Dr. Mulholland one of Canada’s most-respected Rhinoplasty and cosmetic facial plastic surgeons.
In addition to Ear Nose and throat head/neck oncology, Dr. Mulholland has spent a number of years treating complex facial fractures, including nasal fractures and advanced facial trauma. His ability to manage the bony and soft tissue deficits of nasofacial fractures provided him with an excellent and unsurpassed foundation for subsequently performing cosmetic Rhinoplasty surgeries.
Dr. Mulholland, as part of your Rhinoplasty consultation, will perform a computer simulated Rhinoplasty procedure to show you the range of improvements that will likely occur and the kind of naso-facial balance you are likely to achieve with your Rhinoplasty procedure.
A Brief History of Rhinoplasty
1550 BC – A second Egyptian medical papyrus, known as the Ebers Papyrus, is found detailing crude methods to repair and reshape the nose.
800 BC – An Indian physician known as Sushruta develops surgical techniques to repair and even replace noses. He published a detailed manual and is the first to describe using a skin flap, cut from the forehead, to lay over the nose and repair it for aesthetic purposes.
27 BC – 476 AD (Roman Empire) – Cornelius Celsus is the next surgeon to publish medical notes on his techniques for reconstructing noses and ears.
300 AD (Byzantine Era) – Oribasius, the royal physician, published notes on using skin flaps in facial repair.
16th century – A professor of surgery at the University of Bologna, named Tagliacozzi, published notes on the surgical repair of facial wounds in soldiers. He is the first to record using a pedicle flap in reconstruction.
19th century – In 1887, Dr. John Orlando Roe is the first modern surgeon to perform saddle nose deformity Rhinoplasty and record it in medical journals.
20th century – Notable pioneers in Rhinoplasty surgery are Freer and Killian.
Dr. Mulholland is on the cutting edge of current techniques. Come in for a consultation to discover how his skill and artistry can help you achieve your goals.
Rhinoplasty surgery is quick and simple.
While each patient and procedure is different, none of them are quick and simple. It is an intricate and complex surgery that requires a very skilled surgeon. It can take up to four hours.
Any surgeon can perform Rhinoplasty.
A board certified plastic surgeon is the only doctor that has the required training and experience to do the intricate work needed and accomplish the outcome the patient wants while retaining a natural appearance.
The results won’t last for long.
A surgical Rhinoplasty is very long lasting. The nonsurgical 5-Minute Nose Job lasts about two years though.
“I will have breathing problems after the procedure”
Most Rhinoplasty surgeries will not affect the patient’s breathing long term.
Rhinoplasty is painful.
The actual procedure will not be felt due to anesthesia. Afterward, there will be swelling and discomfort, however, there is no extreme or long-term pain.
After Care Tips
Most patients will go home following their procedure with internal packing in the nose to minimize the risk of bruising in the first few days and a cast on the external portion of their nose.
The patient will return to Dr. Mulholland after three days to have the sutures and nasal packing removed.
After the surgery, you will be impaired from the anesthesia and will not be able to drive for at least 24 hours. Stock up on plenty of water and drinks, as you will be breathing through your mouth at first, which can cause your mouth to dry out. Soft foods like mashed potatoes or pudding are good choices to prevent unnecessary pain from crunching and chewing.
The first three days are impossible to breathe through the nose with the nasal packing and you will be a “mouth breather”, but, once the packing is removed, free air exchange can occur easily through the nose again
Expect the initial healing time to be about 6-8 weeks before you can perform any activities.
Be patient with the results as it can take up to a year for the final results to be apparent. The swelling will need some time to go down.
The cast is usually removed on day seven and all sutures are out by day seven. Most patients can look quite presentable on day seven, with some minor to moderate or significant bruising under the eyes.
The nasal bridge aesthetic improvements following the surgery start to look very good by week two or three and the nasal tip looks presentable by week six. Overall, the aesthetic improvements for the rhinoplasty occur gradually and over time. The final nasal tip result is not achieved till one year after the procedure, but approximately 70% to 80% of the improvement is visible at seven months.
For best care and ensuring proper healing time, please follow these instructions:
- Do not play with your nose; your nose is very sensitive following the surgery.
- Don’t do physical activities that require exertion, especially contact sport for a few weeks.
- Do not wear glasses for 6-8 weeks as they can ruin the bridge of your nose. Wear contacts instead.
- Avoid blowing your nose as much as possible.
- Avoid the Sun as much as possible and wear sunscreen. The Sun can cause discoloration especially after a surgery.
- Do not drink alcohol following the surgery as it can interfere with medication and the healing process.
- No smoking for at least a month. Smoking has direct impact on the lungs and breathing. You do not want to put stress on the nose even through coughing.
- Stay hydrated and stick to a proper healthy diet.