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Disclaimer: Any answers provided are for general informational purposes only and is not a substitute for professional medical advice. If you think you may have a medical emergency, call your doctor immediately. Always seek the advice of your doctor before starting or changing treatment.

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Disclaimer: Any answers provided are for general informational purposes only and is not a substitute for professional medical advice. If you think you may have a medical emergency, call your doctor immediately. Always seek the advice of your doctor before starting or changing treatment.

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Rhinoplasty

Rhinoplasty

A DxD Session with Dr Terence Goh


Ended on Thu Feb 28 2019
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Top Answers


Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

Thanks for your question. I echo some of the sentiments of the doctors who replied. Whilst  threads and fillers can be efficacious to effect a change in the nasal dorsum and improve tip projection, it may at best camouflage it, but it would not reduce bulbosity of the tip.

One of the reasons why patients undergo an open rhinoplasty is to create a more refined tip. This is done with careful debulking of the nasal tip, while preserving blood supply to the nose and using well placed sutures to manipulate the nasal cartilages to create a refined and projected nasal tip. If the tip bulbosity continues to bother you, I would suggest an in person consultation with a plastic surgeon that specialises in rhinoplasty. We have 3D software these days that are able to perform  a before and after simulation for you to see the possible changes that can be done. 

Hope this answers your questions! Have a great week ahead!

4 Sep 2018
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

Congratulations on your rhinoplasty and I am glad that you are happy with the results. Before you proceed with the HA nose fillers, you should check back in with your rhinoplasty surgeon to see if he has any other solutions for you. 

Fortunately, one of the advantages of a total autologous rhinoplasty, of which I am a strong advocate of, is that in comparison with an implant rhinoplasty, the nasal dorsum is made of your own tissue. Hence, there is a lower risk of the HA filler injection causing an infection if done properly, and no risk of rejection of the nasal implant or capsular contracture.

Whilst it is safe for you to have fillers to the nose after autologous rhinoplasty, you should highlight this to the doctor that is performing the filler injections. As Dr. Justin Boey has pointed out,  the vascular anatomy of your nose may have changed after the rhinoplasty surgery and there is an increased risk of vascular complications with filler injections after surgery.

Personally, I have given HA filler injections without any complications to patients who have had previous rhinoplasty. Some of my patients have opted for a revision of the nasal dorsum using only autologous tissue so that they do not have to undergo repeated HA injections. Should this option be available to you, it could also be another possibility to consider. 

I hope this answers your queries. Have a great week ahead!

Dr. Terence Goh

4 Sep 2018
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

Thank you for your question on deviated nose with difficulty breathing after a basketball injury.

The nose is one of the most commonly fractured bone in the face. This is often as a result of road traffic accidents, accidental falls or from altercations. In your case its is probably from an elbow or being hit by a ball during basketball. The severity of the injuries to the nose can also vary from simple contusions to complex fractures.

Not all broken noses will require surgery. If the fracture is straight and minor and there is no deviation of the nose, surgery is not required and the bones will heal in-situ. Painkillers and antibiotics may be all that is required. However, if it is a true nasal fracture, it does take 2 weeks for the bone to become stable and about 6 weeks to heal completely. During this period of time, it will be advisable to avoid wearing glasses and engaging in contact sports.  

Sometimes the swelling from the injury can mask the underlying deviation of the nose or underlying septal injury. Besides the nasal bones, the septum (comprising of bone and cartilage) inside the nose also needs to be considered. In instances where the septum is deviated or there is difficulty breathing, septorhinoplasty may be required. In your case, as the injury was 1 year ago, the swelling would have subsided and you would have noticed this deviation and nasal blockage some time back.

For my patients who present early with a nasal fracture that is displaced, I usually recommend a closed reduction (resetting of the nasal bones and septum, without any other intervention) within the first 14 days from injury. This is especially so if the deviation is troubling to the patient or if breathing is obstructed. Occasionally a septorhinoplasty may be indicated. If there is persistent deviation of the nose, a formal rhinoplasty is usually performed 9-12months after the injury. So you would fall in the latter category. 

Depending on the severity and whether the septum (cartilage within the nose) is deviated, you may benefit from surgery to realign the nasal bones and cartilage structure to correct the broken nose and also removal of the broken septum to improve breathing. 

At this juncture, we should perform a CT Scan and review your old X-ray to have an idea of what needs to be corrected. Depending on your insurance policy, this should be covered, but you would have to check with your provider about the claim periods. 

In addition, we are able to perform 3D realtime simulation of before-after impressions for rhinoplasty. I would recommend seeking an in-person consultation with a board-certified plastic surgeon who has a 3D-simulation software so that you can have a better idea of what your results would look like.

I hope I have answered your queries. Have a great week ahead!

Dr. Terence Goh

Plastic Surgeon, Singapore


The information provided is purely for educational purposes and does not constitute medical advice or create any physician/patient relationship. Results may vary between individuals.

16 Sep 2018
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

Thank you for your question. I'm not exactly sure what you are referring to when you mention a huge dent in the nose. As you rightly pointed out, one of the common causes for depressions in the nose is from traumatic injury to the nasal bone.

If you are sure that there is no previous trauma to the nose, the other possibility is acne scars. Depending on the severity this can be treated with CO2 lasers, fillers or fat grafts. I had a patient once who had  a depression in the tip of the nose, known as a bifid nasal tip (see below) and this could be caused by the separation of the nasal cartilages at the tip. This can be easily corrected by a tip rhinoplasty where sutures are used to align the cartilages and cartilage grafts are added to create additional tip support.

Bifid nasal tip. (Image courtesy of Rhinoplasty Archive)

Bifid Nasal Tip. (Image from www.rhinoplastyarchive.com)

I hope this answers your questions. I would recommend an in-person consultation with an experienced plastic surgeon who is able to manage both the functional aspects and cosmetic aspects of rhinoplasty. 

Have a great weekend ahead!

Dr. Terence Goh

Plastic Surgeon, Singapore


The information provided is purely for educational purposes and does not constitute medical advice or create any physician/patient relationship. Results may vary between individuals.

23 Sep 2018
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

This is a common question that I get asked all the time. It is good that you are asking these questions ahead of your surgery to prep properly. Plastic surgery is a journey and part of it requires you to be patient to give the body time to heal. 

Every surgery goes through the same stages of healing - hemostasis, followed by inflammation then proliferation and finally maturation.  I routinely provide this advice to my patients:

WHAT TO EXPECT AFTER YOUR RHINOPLASTY SURGERY:

Swelling varies from patient-to-patient and it also depends on what was done - simple dorsal augmentation with an implant versus tip-pasty. Generally speaking, your nose will be swollen after the surgery and it is usually worst in the first 3 days before it starts to settle. I routinely review my patients on the 5th post-surgery day to remove the stitches.

When the nasal splint is removed at this point, the nose may still appear more swollen and up-turned. This is to be expected. Most of the swelling should resolve over the next two weeks. At the end of the two weeks, most patients will be comfortable with returning to their work or school or social functions. The swelling will continue to improve over the next few months with the best results at 12 months. Do expect minor fluctuations in the swelling of the nose over the course of the next few months. 

Bruising will vary like swelling from person to person. Most bruising, if it occurs should resolve over the first 10 days. It will turn from pink/red to a purple/bluish colour before it becomes green and finally orange and then it fades away.

Nasal Drip. Some patients have allergic rhinitis or persistent nasal drip after rhinoplasty. We will prescribe a course of antihistamines to help you to reduce the nasal drip. 

Numbness. Your nose will be numb following surgery. This is normal and the numbness willl subside over the next few weeks to months. Occasionally you will feel pins and needles and this is a sign of the body healing. The nose will be hyper-sensitive during this time and accidental brushes against the nose may cause pain that is more severe than normal. 

Bleeding. Depending on the surgery performed, you may have some residual bleeding from inside the nose. This may trickle to the back of the throat or through the nose. If bleeding occur, lie down with your head elevated. You may pinch the sides of the nose gently and swallow the blood. Cold compression over the forehead in-between the eyes will help. Most of the bleeding should stop within 10 to 15 minutes. If bleeding continues, please contact our nurses or clinic.

RHINOPLASTY POST-OPERATIVE CARE INSTRUCTIONS 

1. Apply cool compress across the nose for the first 48 hours after surgery. This involves multiple washcloths and a basin of ice water. These washcloths should be changed out of the basins every twenty to thirty minutes to keep them cool. The washcloths should be applied diagonally over each eye and crisscrossed over the forehead. The nurse will demonstrate how to do this before you leave recovery.

2. The suture lines should be cleaned 3-4 times a day just before you apply the antibiotic cream. There will be absorbable stitches inside the nostril. You may apply antibiotic cream to the suture line inside as well. 

3. Patients may shower the second day following surgery, but it is important to keep the tape and splint on your nose dry at all times. 

4. You should try and avoid wearing eyeglasses for 2 weeks after your surgery. If necessary, eyeglasses may be worn with the nasal splint in place. If you are wearing glasses after the removal of splint ensure that the nose pads are not compressing the nose.

They should be either suspended from the forehead or supported on the cheek for a period of six weeks or until the swelling subsides. This is extremely important as the pressure on the nose may change its final shape. 

5. Avoid taking traditional medicine such as garlic, ginkgo and ginseng as these may increase the risk of bleeding. Avoid a high salt diet as this may cause increased swelling. Most other foods are fine as long as you do not have any food allergies.

I hope this answers your question. Have a great week ahead and all the best!

Dr. Terence Goh

Plastic Surgeon, Singapore 

24 Oct 2018
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

Thanks for your question. This is a commonly asked question and I would like to break it down into : Pre-Surgery Consult, Surgery and Post-Surgery Recovery.

Pre-Surgery Consultation

1. It is important to know why you are going for a rhinoplasty and what changes you want to achieve from the surgery. The motivation for a rhinoplasty should be self-driven and not for other reasons. 

2. Make the most of your consultation. Being able to identify what changes you would like to achieve will enable the surgeon to discuss with you the various possibilities of what can be achieve.

    a. Some of the common requests for Asian patients are: making the dorsum higher, making the nose longer, refining the nasal tip to make it sharper and narrowing the nasal base. Spend time to think about what changes you want and discuss with your surgeon if this is achievable and how it can be done. 

    b. The next common question is whether you should have an implant-based rhinoplasty or a total autologous rhinoplasty which may require additional donor sites such as using your ear or rib cartilage. Again, discuss with your surgeon the pros and cons of both.

    c. The consultation is a time for you to get to know your surgeon, to find out more about his experience, training and past patient.s It’s important not to leave the consultation with questions unanswered. Please take the time to find out the answers to all your concerns.

3. The internet provides a lot of information and it is always good to do some research on the procedure as well as the doctors that can do this surgery.

4. 3D Simulation and Consultation. An in-person consultation with your surgeon is most critical for you to get comfortable with your surgeon and also to discuss your surgical goals and to see if they can be met, considering your time requirements, downtime and donor sites. A 3D Simulation is very helpful for both the patient to appreciate the changes that will happen and also for the doctor to be able to understand if we have the same aesthetic goals.

5. Choose your surgeon carefully. When performed by untrained hands or a person with limited experience, a lot may go wrong with the procedure. Pick a surgeon that understands your objectives and have a look at some pre-post photographs. Speak with a few and pick the one that you are most comfortable with.

Rhinoplasty

Surgery

1. Plan for the surgery taking into consideration the recovery that you would need and always give enough time so that you can excuse yourself from important social or work events. In general, expect the nose to be swollen for up to a few weeks with the best results only after months. This is of course also dependent on how much is being done.

2. Double check your health. Ensure that you are optimised for surgery by making sure that you are not taking medications or supplements that can lead to excessive bleeding or bruising. If you are a smoker, consider quitting or stopping at least 2-4 weeks before surgery.

3. Get enough rest before the night of surgery.

Post-Surgery Recovery

     Here are some of my standard tips for recovery after a rhinoplasty procedure.

1. Apply cold-compress to the forehead, eyes and cheeks for the first 48 hours and get ample rest at home.

2. Keep the head elevated to reduce the swelling over the face and nose. You may want to sleep on more than one pillow. Taking frequent light walks will help the circulation and swelling to reduce.

3. Avoid strenuous activity for 2 weeks and any contact sports for up to 6 weeks. 

4. I routinely prescribe a nasal splint to help reduce swelling and also protect the nose during the healing period. This should be worn for a period of 2 weeks.

5. Avoid wearing glasses and sunglasses that may push on your nasal bones. This is especially so if an osteotomy of the nasal bones has been done. 

6. Try not to blow your nose for 2 weeks. Anti-histamines are often given to patients who are prone to have sniffles or allergic rhinitis. 

7. Avoid diets that are high in salt as this may increase the swelling. 

8. Stop smoking. This should be done 2-4 weeks before surgery and for 4 weeks after until everything has healed.

9. Gets lots of rest, sleep well, and drink lots of water.

Rhinoplasty is a very gratifying surgery that can give permanent long-term results. Following these will help you to expedite the healing process and obtain the most optimum results.

I hope this answers your question. Have a great weekend!  

30 Jan 2019
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

Understanding the difference between a rhinoplasty and a septoplasty is key to help you to choose the best treatment to fix a crooked nose. Both surgical procedures are meant to target issues with the nose but they have different objectives.

RHINOPLASTY. WHAT IS IT?

A rhinoplasty or nose job is a general all-encompassing term for a surgical procedure that enables patients to correct the shape, size, symmetry of their nose. The term is more commonly associated with cosmetic concerns - a rhinoplasty is able to correct a nasal hump, or a bulbous tip or large and wide nostrils. However, reconstructive rhinoplasties are also performed for noses that have been deformed by trauma, for reconstruction of defects after cancer surgery and for reconstruction of cleft noses in patients with cleft lip and palate deformities. 

SEPTOPLASTY. WHAT IS IT?

A septoplasty is a specific procedure that targets functional concerns with the nose, specifically relating to a crooked or deviated septum. The septum is the middle support of the nose that comprises of bone and cartilage and partitions the nostrils. Deviation of the septum from birth or as a result of nasal injury can lead to the appearance of a crooked nose, and difficulty breathing through one or both nostrils. As such, these patients would be an ideal candidate for a septoplasty procedure. A septoplasty can be performed alone or as part of a rhinoplasty procedure. It can also be performed as an open or closed procedure depending on the severity of the septal deviation. When performed as a closed procedure, a small incision is made in the inner lining of the nose to access the cartilage and bony septum, without a visible external incision.

What is a septoplasty?

(Photo credit: https://mychart.geisinger.org/staywel/html/Inpatient/3,89977.html)

 

RHINOPLASTY AND SEPTOPLASTY. WHICH IS THE SURGERY FOR ME?

If you have a visibly crooked nose and a deviated septum that affects your breathing, a septoplasty can be performed with the main objective to fix a deviated septum, whilst leaving the external shape of the nose untouched. However, a rhinoplasty can also be done during the same surgery if you have intentions to correct other parts of the nose eg. dorsal hump, bulbous nasal tip or droopy tip.

I hope this answers your question. Have a great weekend!

Rgds,

Dr. Terence Goh

Plastic Surgeon

8 Dec 2018
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

I completely understand the consideration of costs and as consumers in this era of connectivity, it is so much easier to search online, compare prices and look for something that is more "cost-effective". Certainly the old adage “you get what you pay for” still holds true and for a surgery as delicate as rhinoplasty, it’s often important to make sure you get it right the first time. Much more will be spent on revisions if the initial surgery is not done well. Let me help to break down what contributes to the costs of a rhinoplasty so that you can decide and prioritise your choices. 

What contributes to the total fees of a rhinoplasty:

1. Surgeon’s fees. This would usually form about 50-60% of the total fees. Pick your surgeon very wisely as a good and experienced surgeon will be able to advise you on what can be done and also what cannot be done, the potential complications and downtime and reduce the risk of requiring any revision surgery. 

2. Implant rhinoplasty without nasal tip surgery would probably be the simplest rhinoplasty surgery and more complex additions such as tip-pasty, alar base, osteotomy for nasal bone modifications will require significantly more expertise and time and hence increase the surgeon’s fee component. Hence the wide range of the total fees.

3. Revision surgeries typically require the surgeon to undo the scars from the prior surgery before proceeding with rhinoplasty and hence is more complex and requires more time.

4. Facility fees . Facility fees are always on the rise and this usually accounts for a sizeable amount of the bill. Depending on where you choose the perform the surgery, the costs will vary. This is usually charged in time blocks. Some surgeons will quote a fix fee. However, that limits his time to get the job done. Occasionally, more time may be required to refine the results and hence I often quote a range to cater for this.

5. Cost of consumables. This would include consumables such as sutures, nasal splints and silicone implants which are required for the surgery. These will usually make up a small part of the bill.

6. Ward fees. Most of the rhinoplasty surgeries I perform are done as an outpatient procedure and patients do not have to stay overnight. However, certain patients may either require or request for overnight monitoring and this will add to the costs. 

7. Anaesthesia fees. 

8. Medication. Minimal medications are required after a rhinoplasty. This usually includes pain killers, antibiotics, nasal decongestants and topical antibiotics.

9. Follow-ups. 

The range for a rhinoplasty can range from $4000-$20000 and this would depend on the complexity of the case and the time required to achieve all the objectives that you have. Before surgery have a look at this session question I answered on how to get the best results for rhinoplasty (https://www.doctorxdentist.com/questions/how-to-get-the-best-results-from-a-rhinoplasty). Speak to a few surgeons and find one that you are comfortable with before you decide on your surgery. Speak to your surgeon today and request for a breakdown of the fees so that you can understand what you are paying for.

I hope this answers your question. Have a great weekend!

Rgds,

Dr. Terence Goh

Plastic Surgeon

 

6 Feb 2019
Dr Terence Goh
Dr Terence Goh
"Plastic Surgeon at AZATACA Plastic Surgery"
(13 Reviews)

Do you have a saddle nose ? 

Some people are born with a slight upturn on the tip of their nose that is natural and attractive. However when this appearance becomes more pronounced, it may be described as “pug nose” or “ boxer’s nose”.

The first question to ask is : "Do you have a saddle nose ?". The nose bridge is supported by paired nasal bones and an underlying vertical cartilage known as the nasal septum. If you press on the middle part of you nose and it is very soft and collapsible, then you might have a saddle nose deformity. 

What is a saddle nose ?

A saddle nose is a deformity that results when the nose bridge has a weakness that causes it to cave in. It is the result of loss of support from the septum, specifically the cartilage that makes up the septum of the nose (see below).

This usually happens in the middle of the nose bridge which causes it to look very much like a horse saddle when looking at the side-view, which led to it being described as a saddle nose deformity. The severity can range from slight, which is barely noticeable, all the way to extreme which can be disfiguring. The good news is that there are treatment options that can restore the normal profile of a saddle nose.



Nasal Septum made of bone and cartilage. (credit: Wikipedia)

There are several reasons how a saddle nose can occur. 

1. Trauma. One of the common causes of a saddle nose is nose injury where a nose fracture leads to a break in the septal cartilage and a collapse in the middle part of the nose. 

2. Previous Rhinoplasty. This is getting more common. Rhinoplasty surgery or septoplasty procedures that are too aggressive and when excess septal cartilage is removed may lead to saddle nose deformity.

3. Medical conditions. Uncommon conditions such as automate diseases or infections of the nose can lead to destruction of the nasal cartilage and a saddle nose deformity.

4. Use of drugs. Although uncommon in our patient population, the use of both recreational drugs e.g. cocaine and nasal sprays through the nose can lead to damage of the cartilage and a collapse of the middle part of the nose.

How to fix a saddle nose?

The treatment for a saddle nose deformity would be to treat or manage the underlying cause. In cases where the saddle nose deformity is significant or when there is a difficulty in breathing, the definitive treatment would be a reconstructive rhinoplasty procedure. This should be performed by a surgeon that is experienced with treating such complex complications. The nose cartilage has to be rebuilt with autologous cartilage (your own cartilage) which may be taken from the remnant nasal septum. However, most often this is insufficient and the cartilage has to be harvested either from the rib cartilage or the ear cartilage. Using healthy cartilage, spreader grafts are use to reconstruct and reinforce the nasal septum so as to restore the stability to the middle part of the nose.

I hope this answers your question. Have a great weekend!

Rgds,

Dr. Terence Goh

Plastic Surgeon

6 Feb 2019