The Procedure

Rhinoplasty is done with general anesthesia. It is always done on an outpatient basis. The operation lasts about 4 hours.
A small bandage is placed between the bottom of the nose and the upper lip. This is changed as often as needed during the day. A small amount of oozing is ordinary and expected. It should not concern you. The bandage may be changed one or a dozen times. The loosely closed incision allows blood to escape rather than flow back up into the nasal tissue. Most of this oozing stops by the evening of surgery or by the following morning. After the oozing has stopped, you no longer need to wear it.
A small cast is placed atop the upper two-thirds of the nose at the completion of the rhinoplasty.
This splint acts both as a protector for the freshly operated nose and helps to maintain the position of the newly sculpted nasal bones. The splint is removed in 5 – 7 days. Do not allow it to get wet or it may separate prematurely.

The First Week After Surgery

1. During the day and evening of surgery, cold moist compresses are used continuously over the eyes to minimize swelling and control bruising. A small ziplock bag filled with 1/3 cup of frozen peas should be applied over the nasal cast; over a single layer of moistened gauze is an effective compress. It is not necessary to maintain the compresses during the night, but they will be helpful if used during the second day. You should use the compresses for the first 48 hours after surgery only.
2. Puffiness or swelling of the eyelids is always most pronounced on the second morning following any facial plastic surgery (i.e., surgery on Monday, most swelling on Wednesday). It usually regresses quickly in the next few days. This normal and expected observation is no cause for concern.
3. Bruising and discoloration around the eyes is extremely variable. However, the majority of patients do experience minimal “black and blue.” Careful adherence to the recommended preoperative medication instructions is imperative. A few patients, despite taking all precautions, will develop marked bruising in the eyelids. Even this bruising is usually resolved by the end of the first week.
4. Invariably, there is some nasal stuffiness during the week after surgery. The external edema (swelling) is reflected internally, but the mild blockage will improve steadily. The application, 3 times a day for 2 weeks, of a small amount of bactroban ointment just inside the nostrils, acts to lubricate the surgically sutured area and prevent crusting. However, it is imperative to avoid extensive manipulation in this area. DO NOT BLOW THE NOSE. DO NOT INSERT ANYTHING INTO THE NOSE. Use several drops of AFRIN nasal spray at night if the nose feels congested. You may ONLY use this for 3 days beginning the day after surgery.
   Oceanspray nasal saline should be used AT LEAST 5 – 7 times a day in each nostril beginning the day after surgery.
5. For the first few post-operative days, you may expect a small amount of pink-colored nasal discharge. Usually, reapplication of a small gauze bandage beneath the nostrils is all that is required. Any continuous persistent show of bright red blood should be reported to me.
   Bleeding on the third, fourth, or fifth day occurs in less than one-percent of cases. First aid for such a rare occurrence is as follows:
   Lie down and elevate head. Place cold compress on the nose. Saturate a piece of cotton with nose drops (AFRIN) and place it in the bleeding nostril.
6. Discomfort following rhinoplasty is usually limited to the second or third hours just after the procedure. This may best be described as a headache. Severe pain is rarely a consequence of facial plastic surgery. The prescription for pain tablets that you have received is more precautionary than necessary, but please have it filled and available at your home bedside.
7. During the first two weeks, it is best to sleep with the head elevated by at least two pillows, both to decrease the amount of swelling and to aid in the resolution of any swelling that does occur.
8. During the first week, you may notice that the nasal tip is slightly elevated. This is a constant, temporary factor following all rhinoplasties. The position of the nasal tip at this time has little relationship to the final result. The tip will slowly drop to its new lower position over the next 8 to 12 weeks.
9. Exercise must be limited during the first week. While relaxed ambulation about the home and local shopping, dining or visiting is encouraged, any lifting, pulling or straining must be avoided, as it may cause bleeding and swelling.
10. Do not take Aspirin the first week after surgery.
11. Continue Vitamin C 2000mg for two weeks after surgery. The dose may be halved. This may promote healing.
12. The nasal splint will be removed on the fifth to seventh post-operative day. Start using Flonase, 2 puffs in each nostril once a day for 2 months.

The First Week After Surgery

1. During the day and evening of surgery, cold moist compresses are used continuously over the eyes to minimize swelling and control bruising. A small ziplock bag filled with 1/3 cup of frozen peas should be applied over the nasal cast; over a single layer of moistened gauze is an effective compress. It is not necessary to maintain the compresses during the night, but they will be helpful if used during the second day. You should use the compresses for the first 48 hours after surgery only.
2. Puffiness or swelling of the eyelids is always most pronounced on the second morning following any facial plastic surgery (i.e., surgery on Monday, most swelling on Wednesday). It usually regresses quickly in the next few days. This normal and expected observation is no cause for concern.
3. Bruising and discoloration around the eyes is extremely variable. However, the majority of patients do experience minimal “black and blue.” Careful adherence to the recommended preoperative medication instructions is imperative. A few patients, despite taking all precautions, will develop marked bruising in the eyelids. Even this bruising is usually resolved by the end of the first week.
4. Invariably, there is some nasal stuffiness during the week after surgery. The external edema (swelling) is reflected internally, but the mild blockage will improve steadily. The application, 3 times a day for 2 weeks, of a small amount of bactroban ointment just inside the nostrils, acts to lubricate the surgically sutured area and prevent crusting. However, it is imperative to avoid extensive manipulation in this area. DO NOT BLOW THE NOSE. DO NOT INSERT ANYTHING INTO THE NOSE. Use several drops of AFRIN nasal spray at night if the nose feels congested. You may ONLY use this for 3 days beginning the day after surgery.
   Oceanspray nasal saline should be used AT LEAST 5 – 7 times a day in each nostril beginning the day after surgery.
5. For the first few post-operative days, you may expect a small amount of pink-colored nasal discharge. Usually, reapplication of a small gauze bandage beneath the nostrils is all that is required. Any continuous persistent show of bright red blood should be reported to me.
   Bleeding on the third, fourth, or fifth day occurs in less than one-percent of cases. First aid for such a rare occurrence is as follows:
   Lie down and elevate head. Place cold compress on the nose. Saturate a piece of cotton with nose drops (AFRIN) and place it in the bleeding nostril.
6. Discomfort following rhinoplasty is usually limited to the second or third hours just after the procedure. This may best be described as a headache. Severe pain is rarely a consequence of facial plastic surgery. The prescription for pain tablets that you have received is more precautionary than necessary, but please have it filled and available at your home bedside.
7. During the first two weeks, it is best to sleep with the head elevated by at least two pillows, both to decrease the amount of swelling and to aid in the resolution of any swelling that does occur.
8. During the first week, you may notice that the nasal tip is slightly elevated. This is a constant, temporary factor following all rhinoplasties. The position of the nasal tip at this time has little relationship to the final result. The tip will slowly drop to its new lower position over the next 8 to 12 weeks.
9. Exercise must be limited during the first week. While relaxed ambulation about the home and local shopping, dining or visiting is encouraged, any lifting, pulling or straining must be avoided, as it may cause bleeding and swelling.
10. Do not take Aspirin the first week after surgery.
11. Continue Vitamin C 2000mg for two weeks after surgery. The dose may be halved. This may promote healing.
12. The nasal splint will be removed on the fifth to seventh post-operative day. Start using Flonase, 2 puffs in each nostril once a day for 2 months.

After the First Week

1. At the time of nasal splint removal, you will have your chance to see the new nose. It will appear quite swollen but, in most cases, even in this swollen condition, the improvement can be appreciated. It is not a time for critical evaluation since, over the next months, daily changes progress toward the final result. At twelve months, the final permanent result is achieved in most patients. In a few cases, it may take over one year. The nose will swell after the splint is removed. The swelling will start to come down after the third week. Many factors determine how quickly, or slowly, the nose assumes the final appearance. The most influential determinant is skin type. Skin that is thicker and oilier is certain to retain edema and swelling longer than skin that is drier and thinner. Individuals vary in healing potential.
2. During the second week the nose must not be bumped, (elbows, doors, etc.). Though the bones are firmly healing in place, even a slight blow could cause movement. Avoid any situation where a potential for nasal trauma exists.
3. You should not wear glasses for about one month. If glasses must be worn, taping the central bridge of the glasses to the forehead will allow as little pressure as possible on the nasal bones. If desired, a nasal splint will be provided that will disburse the weight of the eyeglasses, allowing you to wear them on the bridge of the nose. Please let us know the day the cast comes off so we can prepare your splint from the one used after surgery.
4. It is wise not to sunbathe for about two months. A sunburn will cause the nose to swell and delay the final result. Walking about between sun and shade or sitting with a hat, is permitted.
   It is always best to apply a waterproof factor 30 sunblock to the nose if strong sun exposure is anticipated. The nasal skin is somewhat insensitive following rhinoplasty. This can be appreciated by touching the skin, which will seem slightly numb. The advice concerning sun exposure also applies to the winter cold. It is possible to experience frost-bite if exposed for long periods to sub-freezing weather during activities such as skiing. Both sun and the winter cold are natural enemies to the skin and prolong the usual post-op course.
5. A natural reaction of all types of nasal skin to this surgery is a pronounced increase in nasal oiliness. Even skin that is usually dry will need to be wiped with an astringent on a cotton pad once or twice a day for two weeks or more. Stridex pads can be used for this purpose. This nasal oiliness can persist for months.
6. Another universal observation is the presence of flaking or peeling of the skin, much like that caused by sunburn. This also resolves in about two weeks.
7. Most discoloration is resolved in 7-10 days. However, though unusual, this may persist longer as pigmentation beneath the eyes. Occasionally, olive-skinned patients may retain this pigment for several months.
8. During the 4th week, you may begin exercise. Start slowly and progress. After the sixth week, you may begin contact sports.
   Please do not participate in school physical education for one month following removal of the splint. We will provide a note if necessary.
9. At the time the nasal splint is removed, any undissolved sutures will also be removed from the internal nasal area. You will be given a follow-up appointment for eight weeks. After that visit, your follow-up return examinations are based on an individual, case-by-case evaluation.
10. Small irregularities may be felt below the smooth skin, especially over the nasal bones. These irregularities are common. Most noses, even without surgery, have palpable bone irregularity beneath smooth skin.

PRE-SURGERY TO DO-LIST

PRECAUTIONARY MEASURES TO ADHERE

Please Obtain Before Surgery:

General information and preparation for surgery with Dr. Chouake

MUST READ PRIOR TO SURGERY

It is very important for your safety that we know ALL MEDICATIONS, VITAMINS OR HERBAL MEDICATIONS that you are taking. To prevent any bleeding during or after your surgery, we want to make sure that you are not taking any of the following:

Please read package inserts of any substances which you are taking and make sure that it does not have a warning about causing bleeding or worsening any bleeding disorder. These medications should be discontinued at least 2 weeks before surgery and not be re-started until you have checked with your surgeon. If these medications have been prescribed to you by another physician, you must consult with him prior to discontinuing them. If you have any questions, please ask.

1. Specializing Exclusively in Facial Plastic Surgery National & International clientele 15 years of experience with over 3,000 Natural-Looking Outcomes Achieved. There are certain medications that affect blood clotting. To avoid bleeding during the operation, and to ensure the least possible “black and blue” discoloration following the operation, do not take any Aspirin for 2 weeks before your scheduled procedure.
   Many over-the-counter drugs contain Aspirin. Please check any medications you might take to be certain that it is not part of the formula.
   The newer anti-arthritis drugs all contain substances which can be many times more potent than Aspirin in their blood clotting interference (i.e., Indocin, Motrin, Clinoril, Advil, Motrin, Nuprin, Mediprin, etc.) These medications must also be discontinued 2 weeks before surgery.
   Please advise our office of all medications, prescribed or over-the-counter, that you are currently taking.
2. Please discontinue Vitamin E, just as you are to avoid Aspirin. Vitamin E is present in many multi-vitamins.
   There is some indication that it too may upset the first stages of the clotting process. You may begin Vitamin E again two weeks after surgery.
3. Vitamin C may aid in preventing bruising and in speeding healing. If you are not one of the rare people who are sensitive to this vitamin, please take 2000 mg. per day (you may divide this into two doses – AM & PM) beginning two weeks before surgery. If you are a smoker, you must take at least 4000 mg. of Vitamin C a day. Smoking deactivates Vitamin C, accounting for poor healing. Continue to take for 2 weeks after surgery.
4. Apply Bactroban ointment with a Q-tip inside each nostril three times a day 2 weeks prior to surgery, which is very important to avoid infection. Continue this for 2 weeks after surgery.
5. Antibiotics are given to help prevent infections. Antibiotics and anti-viral medications are used in conjunction with facial laser and dermabrasion treatments.
6. If you routinely take any medications, if you are allergic to any medications, or if you forget to discuss any medical condition during the consultation, please call me.
7. You must allow yourself a period of time to recover following your operation. The earliest you should expect to be presentable is as follows: Rhinoplasty – usually one week. There are variations to these estimates but most patients are presentable after these time periods. Please remember that it will take more time, in some cases, 12 to 14 months, before you will see the final results of surgery.
8. Alcohol is a potent New York vessel dilator and, in the post-operative condition, can promote swelling of the surgical area and even bleeding. It is best to avoid alcohol intake for at least one week after surgery and three weeks after surgery.
9. You must remain in the New York metropolitan area for at least one week after surgery. We will help make New Yorkarrangements for out-of-state and foreign patients if you have no local residence.
10. Getting a suntan before surgery is not a problem. However, it would not be advisable to undergo surgery if you have a severe sunburn.
11. Exercise which increases the heart rate can begin at 4 weeks after surgery. Exercise during the first week postop can cause bleeding. During the second week after surgery, it will increase edema or swelling. At 30 days, full exercise can begin.
12. A frequent question is “…when can sexual activity resume…” As a moderately exertional activity (caloric expenditure), sexual activity can safely be resumed at 4 weeks following facial plastic surgery.
13. Observe, in yourself and in those around you, that the two sides of the human body are not the same. Aesthetic surgery can never make them exactly the same.
14. If you smoke, you must stop one week before surgery and for two weeks after surgery. The harmful effects of smoking are most damaging following facelift surgery. Nicotine’s “tourniquet-like” effect on small blood vessels can cause skin death.
15. A slight fever of 100+ is not unusual following facial surgery. This is especially true following nasal surgery. It does not mean you have an infection. This elevation in temperature is a natural response to surgery. If the temperature is above 101, please call us.
16. Whether you are contemplating or have decided to undergo facial plastic surgery, be prepared to hear all manner of stories and judgments from relatives and friends. If you ask an opinion about your surgery, mostpeople will not be supportive. Many will have some tale of difficulty to tell you; it is an unfortunate fact of human nature. Occasionally, relatives and friends who are told you have made a definite decision about facial surgery are more supportive. After surgery, almost everyone will forget their negative statements. They will admire the results and see, for the first time, what you were talking about.
17. Our purpose and goal in facial aesthetic surgery is improvement and not perfection.

POST-OPERATIVE RHINOPLASTY CARE

1. DO NOT wear glasses for one month after surgery. Our office will provide you with a splint if necessary. In an emergency, tape can be wrapped around the bridge of the glasses. Leave a sticky tab of tape facing up towards your forehead. Keep the glasses off the bridge of your nose by taping the glasses up onto your forehead.
2. AVOID salty and spicy foods (anything that causes your face to flush or retain fluid). Prolonged swelling can contribute to scar tissue formation and a less refined result.
3. ALCOHOL consumption can be resumed, with caution three weeks after the surgery. Alcohol will cause swelling that will last for twenty-four hours. Again, prolonged swelling will contribute to scar tissue formation and a less refined result.
4. Finish using the bactroban ointment in your nostrils with a Q-tip, go up the nostril as far as the cotton on the Q- tip.
   This helps maintain moisture during the healing process. Continue this for 2 weeks after surgery.
5. You may BLOW YOUR NOSE gently (after the first week), simultaneously, through both nostrils at this time. It is best to try this first during, or after, a shower. Excessive nose blowing will contribute to nasal stuffiness and can cause bleeding. Start using Flonase once the nasal splint is removed to help with congestion. 2 puffs in each nostril once a day for the next 2 months.
6. Continue to SLEEP WITH TWO PILLOWS under your head for another 2 weeks.
7. Be very careful about SUN EXPOSURE. A hat or visor should be worn in strong sunlight. Waterproof sunblock SPF 30 should be applied thirty minutes prior to sun exposure for two months after surgery.
8. SMOKING cigarettes or exposure to cigarette smoke will impair the healing process and contribute to scar tissue formation. It should be avoided.
9. BRUISES may be covered with make-up and may take a few weeks to resolve. You may apply makeup 7 days after surgery.
10. VITAMIN C 2000mg taken daily should be continued for two weeks after surgery to promote healing. It also has a slight anti-inflammatory effect.
11. EXERCISE may be resumed at 4 weeks from your surgical date. Upon resumption if you feel pressure in your nose while exercising stop and wait until the fourth week.
12. You may notice increased FACIAL AND NASAL SKIN OILINESS. Use an astringent like Stridex pads to control this. You may resume acne preparations that you were using before surgery.
13. In the unlikely event of a NOSEBLEED, cotton or facial tissue can be saturated with nose drops (Afrin) and placed into the nostril that is oozing. Leave in the nostril for several minutes and call our office.
14. A BASEBALL CAP with a firm brim can be worn to prevent trauma. This is useful when handling small children or when you know you will be with a group in a crowded room.
15. It is ok to fly 7 days after surgery. You should use Afrin nasal spray 30 minutes before take-off and 30 minutes before landing.

FINALLY

Please try to be patient during the healing process! The results will be worth the wait.

Please call us with any questions or concerns, the team at Madnani Facial Plastics is always here for you