Dear Alice,

I am considering rhinoplasty. I am 23 years old. Why do I want to do so? The primary reason is my deviated septum, which although barely visible, if at all, from the outside, definitely makes it very difficult to breathe. But the reason that I don't want to settle for a simple septoplasty is that my nose is ever so slightly too big for my face. I would really like to underline ever so slightly. I am lucky to have a balanced face and nice proportions, but I am extremely self-conscious because my nose is just slightly too big. I understand that it's silly and that I should be grateful for my other features, with which I am very content. But ever since a silly ex-boyfriend foolishly joked that my nose is too big, I have become obsessed. I've thought through the reasons and I know that I am doing this for myself, not for anyone else. But I am still very concerned. I read that there can be complications. I even read that you may not wake up after the surgery due to complications with the anesthesia. A slightly big nose (and honestly I wouldn't even call it that) is definitely not worth losing your life! Can you please shed some light on the surgery, on the recovery, and on the risks? Will my voice change? Will I be able to sing? How long do most people walk around with dark circles under their eyes? What if I am unhappy with the results? The most important thing for me, of course, is being able to breathe through my nose and not having any complications.

What's in a nose

Dear What’s in a nose,

Nose surgery, or a “nose job”, is one of the most commonly performed procedures worldwide. Some people need nose surgery to improve their breathing or for reconstruction after an injury or skin cancer, while others want to smooth a bump or change the shape of their nose for cosmetic purposes. And some, like you, consider it for reasons related to both form and function.

The septum is the wall in the nose that separates the two nasal cavities. A deviated septum is when the septum is displaced or otherwise inappropriately constructed, leading to symptoms like you mention such as difficulty breathing, as well as snoring, pain, nose bleeds, and difficulty smelling. Septoplasty is surgery that realigns the septum without any cosmetic alterations to the nose. Rhinoplasty is surgery that involves reconstructing or correcting nasal and septum pathways, as well as aesthetically altering the patient’s appearance by reshaping the nose. There is also something known as a nonsurgical nose job, which refers to an approach of using injectable fillers to alter the nose’s appearance. While this can be an option for subtle exterior irregularities, nonsurgical procedures do not address internal structural issues like a deviated septum.  

Rhinoplasty can either be performed “open” or “closed” (endonasally). In open rhinoplasty the surgeon cuts the fleshy bit that separates the patient’s nostrils. In closed rhinoplasty there is no exterior cutting, with all surgical work done inside a patient’s nose. Closed rhinoplasty is considered a more difficult procedure, but has a shorter recovery and faster operating time. Open rhinoplasty requires less experience, but has a longer recovery, slower operating time, and risks external scarring.

Every surgery has its risks. Before nose surgery, patients are screened to alleviate the risk for complications. A surgeon will look for risk factors such as a history of respiratory issues, drug use, smoking, medications that thin blood, and predispositions to nasal infection. The most common complication during nose surgery is bleeding, which, except in rare cases, is easily addressed. Infection is also considered rare, but patients are given antibiotics intravenously to help with this risk prior to surgery. Other potential negative effects include blocked nasal airflow (commonly goes away after two to three weeks) or deformities that subsist for more than a year.

Both septoplasty and rhinoplasty can be performed under local or general anesthesia, depending on the exact procedure and the patient’s preference. General anesthesia can be administered either through an orally inserted tube (this method also helps reduce how much blood the patient swallows) or intravenously. Though anesthesia can be dangerous, cases of mortality from its use are rare and predominantly (>50%) involve young children (0-3 years). Cardiac arrest and respiratory system failure are possible complications from anesthesia. Out of roughly 1,000,000 patients given anesthesia over four years, less than 300 cases of cardiac arrest were reported with less than 75 of those resulting in a fatality. Things that increase the risk of anesthesia complications are youth (particularly 0-3 years), eating before surgery (at least eight hours of fasting is required), or being in a rushed/emergency situation.

In deciding between the different procedures, it might be of interest to know what patient’s say about their quality of life after having one done. A survey found that 85% of septoplasty patients with impaired nasal functions (mainly breathing related) report being satisfied with their procedure and found an average increase in a nose health/functionality performance scale from 23/100 to 67/100 following the procedure. Only 40% of rhinoplasty patients reported improved nasal airflow, though this is because many rhinoplasty operations are performed solely for cosmetic purposes. In terms of post-operation nasal appearance and function, 90% of rhinoplasty patients reported feeling satisfied.

If you decide to opt for rhinoplasty, look for a surgeon with experience in plastic surgery of the nose who has a good reputation of patient satisfaction and has before and after photos of their work available. The American Board of Plastic Surgery (ABPS) is the most common body that certifies rhinoplasty surgeons. Rhinoplasty can be a costly procedure, so you may want to call individual surgeons in your area to see what they charge. Insurance may cover surgery for a deviated septum though it usually does not cover purely cosmetic rhinoplasty, so be sure to check your policy before making an appointment.

It is unlikely that either procedure will affect your voice or singing abilities, but be sure to talk with any potential surgeon to determine your own risk depending on what will be done during your surgery. Bandages usually come off from surgery in less than a week. Depending on the extent of the procedure, the healing process can take many months to see final results once swelling and numbness subside.

While you consider a septoplasty or a rhinoplasty, it may be helpful to ask yourself when you began to consider your nose to be an issue. It sounds like your ex-boyfriend’s joking about your nose got a little under your skin. Is this the first time that you remember thinking about your nose this way or have you always felt this way? Has anyone else ever said anything about your nose to make you self-conscious? Because there is a chance that you might be unhappy with the results of a rhinoplasty, it may help to think about if you’re ready for a permanent change to your appearance. Check out some of the Related Q&As below on corrective surgery, surgery for cosmetic reasons, and body image that might address more factors to consider when deciding whether or not to get a procedure done.

After some reflection you might decide to embrace your unique look and opt only to address the breathing concerns associated with your septum. At the end of the day, and as you noted, this decision is really for you and you alone. Whatever option you end up choosing, hopefully you’ll be breathing easier soon!


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