Dr. Andres Bustillo has been practicing facial plastic surgery for over ten years. He is one of the few double board certified facial plastic surgeons, meaning he does not perform any breast or body surgery. Approximately 50% of his practice is devoted to rhinoplasty and revision rhinoplasty. He performs over 300 nasal surgeries a year, making him one of the most experienced nasal surgeons in South Florida. In addition to creating a beautiful nose, he will deliver one that will function and breathe amazingly well.
Dr. Bustillo is known for providing the most natural and conservative rhinoplasty results. He delivers a “look” that fits and blends harmoniously with the patient’s facial features. Dr. Bustillo has an enormous experience in rhinoplasty with different types of noses, such as Caucasian, Asian, Hispanic, African American, and Middle Eastern.
Andres Bustillo teaches students, residents, and other physicians the art and craft of rhinoplasty. He has been invited to Asia, South America, and the Caribbean where he has taught other plastic surgeons his rhinoplasty techniques. He has written and published several chapters on the rhinoplasty surgery. The following information was developed by Dr. Bustillo to educate and inform the public about the rhinoplasty procedure.
The Miami rhinoplasty operation can result in an amazing improvement in the overall appearance of a person. However, there are limitations to what can be achieved with the surgery. There are technical limitations that may be due to the overall size, shape, and skin of the nose. In addition, it must be remembered that the nose’s primary function is breathing. For example, a very dramatic thinning of the nose will sacrifice breathing.
My personal philosophy regarding rhinoplasty was fashioned through a fusion of the craft I learned from my mentors and my personal experience after performing hundreds of nasal surgeries. As with all thought processes, it is an evolving one. I learn every day after evaluating every one of my surgical results. I continuously strive to deliver a natural result that will last throughout the patient’s life.
For the last fifteen years there has been a great debate on whether the rhinoplasty operation should be performed in an open or a closed fashion (Figure 3). However, these are only approaches. They are called approaches because they are simply the method the surgeon uses to assess the areas of the nose that need to be altered. They are not techniques. Techniques are the methods that the surgeon uses to change or alter the specific anatomic areas of the nose. The “open” or external approach involves an incision in the columella, or the column between the nostrils (Figure 4, 5, 6, 7). The “closed” or endonasal approach involves a series of incisions inside the nose. One approach is not better than the other. They are different and each one is used for different types of noses. Having the operation performed in one way does not guarantee a better result. Instead, I believe that there are noses that may be better served with the closed approach and some that are better treated with the open approach. I perform both the open and closed approaches, depending on the nose.
For example, a nose with a perfect nasal tip and a small hump, may be best treated with a closed approach to reduce the nasal hump (Figure 8, 9). The advantage in this case is that the tip is not distorted, the surgery involves less trauma, and the recovery is faster.
A nose with a weak and wide nasal tip and a hump may be better served with an open approach. The tip can be strengthened and narrowed with dome sutures and the hump reduced. The advantage is that all of the elements of concern can be addressed and an excellent result is achieved.
Because all noses are different and the rhinoplasty operation should be individualized for every patient, I believe the rhinoplasty surgeon should be versatile and capable of performing both the “open” and “closed” approaches.
Over the past decade, great advances have been made in the art and science of rhinoplasty. In the past, rhinoplasty was performed in a reductive manner. In fact, there are still many surgeons that perform rhinoplasty in this fashion. In reductive rhinoplasty, the surgeon removes much of the bone and cartilage to achieve a smaller nose. The nasal tip is reduced in size by cutting off and removing portions of the nasal tip cartilages.
In essence, the structural framework of the nose is weakened and destroyed. While most of these noses have a satisfactory appearance in the immediate post-operative period, their shape can continuously change for several years (Figure 10). This occurs as the healing and scarring forces take over a nose that has lost all of its structural support. More often than not, the end result is a nose with a surgical appearance. In addition, removal of nasal tip cartilages can result in severe breathing difficulty that can be very difficult to correct.
Experience has taught modern rhinoplasty surgeons that simply cutting away the nasal tip cartilages can lead to functional and aesthetic complications. Today’s advanced rhinoplasty techniques shy away from removing the important structural elements from the nose. Instead of removing cartilage, I reshape it using specialized techniques. With the use of special sutures, the nasal tip cartilages are reshaped, to give a more defined nasal tip. Because the sutures allow the surgeon to control the exact shape, this technique allows more predicable results. By placing the sutures on different locations on the nasal tip cartilages, the surgeon can change the shape of the cartilage without removing or cutting them.
I have been using state of the art techniques to improve the structural framework of the nose since I began practice. One of the techniques that I sometimes employ in rhinoplasty is the use of grafts. Grafts are structural elements made of live tissue, typically cartilage. While not all rhinoplasties require grafting, some cases require it to achieve a good result. Grafts should be shaped with smooth and rounded edges to avoid visibility.
The cartilage can be acquired, or harvested, from the septum, which is inside the nose. If the patient has had a previous septoplasty, I may take the cartilage grafts from the ear. This is done through a small incision that is hidden behind the ear. The ear does not change in shape or appearance after the cartilage is taken.
The skin and soft tissue overlying the bone and cartilage is an important anatomical component of the nose. Understanding its importance in rhinoplasty is paramount. Patients with thin skin can achieve relatively good tip definition (Figure 11a, Figure 11b). In fact, great care must be taken with these patients so that all of the cartilage and bony edges are rounded, so there are no sharp edges. I avoid the use of certain types of grafts in these patients, so as to avoid any showing through the skin. The contouring of the bony and cartilaginous framework must be impeccable. Any small irregularity will be noticeable once the post-operative swelling has subsided.
On the other hand, patients with thick skin are limited in the definition that can be achieved (Figure 12a, 12b). I employ various techniques in order to attempt to achieve the maximum tip definition possible. For example, I may use tip grafts to help “push” the thick skin and obtain definition. In addition, I will thin the skin from the inside to help improve the definition. The use of structural rhinoplasty is very important in patients with thick skin. The nasal tip must be strengthened in order to combat the extra weight of the thick skin. If the nasal tip is not strengthened, the extra weight of the skin will tend to drop the nasal tip, thus loosing definition and projection. Patients with thick skin may also encounter prolonged swelling and scar tissue formation. I will sometimes use steroid injections to help bring the nasal swelling down.
The decision about having the rhinoplasty operation is a very important and personal one. You should consult with your surgeon and your family. For most patients that undergo the procedure, the results are life changing. Patients describe an increase in confidence and boost in self-esteem. They can become more comfortable in social settings and feel better about how they photograph. In fact, many patients wonder why they waited so long to have the procedure done.
The ideal candidate for rhinoplasty is a healthy person who is not content with their nose and would like to have it improved. There is no ideal age for rhinoplasty, as I perform rhinoplasty in patients ranging from age fifteen and on. Female patients can undergo the rhinoplasty operation at age fifteen and male patients from sixteen on.
The patient must have the proper expectation before undergoing surgery. Although with modern rhinoplasty techniques, results are better than they ever were, there are still limitations. It is important that the patient have a good understanding of what can be achieved. Clear communication between the patient and the surgeon is very important. I use computer imaging to help me communicate with my patients.
Surgeons are human and therefore are not perfect. While most rhinoplasty patients enjoy the benefits of an improved nasal contour and profile, it is important to remember that surgery, like all other human actions, is not perfect. A skilled rhinoplasty surgeon can achieve near perfection. This achievement results from the coming together of artistic skill, impeccable surgical technique, and proper healing forces within the nose.
The consultation process begins with a discussion about the specific issues and concerns regarding the appearance of the nose. Any functional problems are discussed at this time. For example, the patient should communicate whether there is nasal obstruction. This is often corrected during the rhinoplasty procedure.
A thorough physical examination is then performed. The nasal cavities are examined. The septum is examined for any deviations and any inflammation or swelling of the turbinates is noted. The patient is asked to inhale through the nose to observe the internal and external nasal valves. Any collapse found here will be addressed in the surgery to help improve the breathing.
The external nose is then carefully examined and palpated. The dorsum, or bridge of the nose, is examined for any humps that may have to be reduced. The nasal bones are then palpated for irregularities, asymmetries, or curvatures. The nasal tip is then examined and palpated. The tip is examined for fullness and width (Figure 13a, 13b).
The tip projection, which is the length of the tip from the base of the nose to the end of the tip, is examined. Tips that are too projected (Figure 14), or long, need to be reduced and those that are to short, may need to be lengthened. Tip rotation, which is the angle of the tip in relation to an imaginary vertical line drawn at the base of the nose is analyzed.
Tips that are under-rotated, or “droopy” (Figure 15) need to be rotated up, while tips that are over-rotated and appear “piggy” need to be de-rotated or brought down. Certain nasal tips that move when the patient talks or smiles may require strengthening.
Pre-operative pictures are then taken and computer imaging is done. Computer imaging involves the digital manipulation of the patient’s picture to evaluate various nasal and tip contours (Figure 16a, 16b, 16c). This is a fantastic communication tool that allows the wishes of the patient to be aligned with the surgeon. In fact, I want the patient to participate in the process, so that I can have their input when making the computer-generated image (Figure 16d, 16e). I will always give the patient a computer-generated image that I believe is achievable. Using computer imaging will allow me to have a clear understanding of the patient’s aesthetic goal and allow the patient to have a clear understanding of what I think is surgically possible.
“Computer Image” demonstrating the proposed changes for this female patient. The hump was lowered, the tip was rotated and defined.
Patients undergoing cosmetic nasal surgery, commonly referred to as a “nosejob”, are required to obtain pre-operative labs prior to surgery. If the candidate is over the age of forty-five or has certain medical conditions, Dr. Bustillo will request a medical clearance to be done before the rhinoplasty. Patients should stop all aspirin, anti-inflammatory products (naproxen, ibuprofen), and vitamins such as A, ginkgo biloba, and St. John’s wart ten days before undergoing the rhinoplasty surgery. These products limit blood clotting and can cause excessive bruising around the nose and eyes. Alcohol should also be avoided for five days before surgery to decrease swelling. Patients are required to start taking 2000 mg of vitamin C a day, starting one week before the surgery and then for two weeks after the rhinoplasty. This helps to reduce the swelling around the nose and speed the healing process.
Dr. Bustillo performs the rhinoplasty surgery on an outpatient basis in an AAAASF-certified surgical facility. The recovery after the cosmetic nasal surgery is best carried out at home or in a hotel room in a peaceful environment. The anesthesia is provided by board certified anesthesiologists (MD), which are part of the Baptist Hospital Anesthesiology Department. Dr. Bustillo does not use nurse anesthetists to provide anesthesia.
The rhinoplasty surgery is performed with general anesthesia. Dr. Bustillo and the anesthesiologist believe that this is the safest method to provide anesthesia for patients undergoing nasal surgery. General anesthesia allows the anesthesiologist to protect the airway. In this way, any blood or secretions that may travel to the back of the throat do not enter the lungs and cause irritation. IV sedation anesthesia, on the other hand, does not protect the airway during nasal surgery. Any secretions that travel towards the back of the throat may enter the lungs and cause irritation and coughing. The surgery usually takes about 2 hours to perform.
Like every surgical procedure, there are some possible complications that can follow the rhinoplasty operation. Bleeding after the surgery is rare, but if it occurs, it can be controlled with measures such as cauterization or packing. The risk of post-operative bleeding is about 1%. There is also the risk of infection, which extremely rare, and occurs less than 1% of the time.
The patient should spend night of the nasal surgery relaxed. Activity should be kept to a minimum. A liquid diet is best for the first eighteen hours after anesthesia. The head should be kept elevated using two pillows to help reduce swelling of the nose and eyes. Patients should place small zip lock bags with frozen peas on the eyes 10 minutes, for every hour spent awake for the first 48 hours. This is done to help reduce swelling around the nose and eyes, which typically resolves in five days.
The post-operative period after rhinoplasty is not painful. Tylenol is usually enough to control any minor discomfort. You will be provided you with additional pain medication, in the event that you need it. Occasionally, a small cotton is placed in the nose, which is removed on the first day after the surgery. There is a small cast that is applied to the bridge of the nose. This is removed in the fifth post-operative day.
There is a variable amount of swelling that occurs on the nose after the rhinoplasty operation. About seventy percent of the swelling resolves in the first three weeks. It is recommended that physical activity, such as running or lifting be resumed only after the fourth week. The remainder of the swelling can take up from four to twelve months to completely resolve. Most patients can return to wok or school on the fifth post-operative day.
While the final results of the surgery may not be completely evident until several months after the surgery, most patients look better than before surgery right when the cast comes off. In about ten months or so, Dr. Bustillo will take before and after pictures of your nose and print them for you, so that you can them, along with the surgical record and drawings if you wish. Patients that undergo rhinoplasty are, by enlarge, extremely happy.
What is rhinoplasty?
Rhinoplasty, or cosmetic nasal surgery, is a plastic surgery procedure that improves the shape and size of the nose. The procedure can remove a hump, change the shape of the nasal tip, and straighten the nose. Occasionally, the size and shape of the nostrils can be changed. The goal of rhinoplasty is often to achieve better harmony between the nose and the other facial features and, often times, even the slightest alteration can greatly improve a patient’s appearance. If the patient has breathing difficulty, Dr. Bustillo may perform septal and turbinate surgery at the same time.
Who are good candidates for rhinoplasty?
Healthy teenagers and adults who wish to have an improvement in their nasal appearance are good candidates for the rhinoplasty procedure.
Can rhinoplasty be performed at any age?
Dr. Bustillo performs the rhinoplasty procedure beginning at age fourteen in female teenagers and fifteen in male teenagers.
What happens during a consultation for rhinoplasty?
Dr. Bustillo will personally meet with you during the consultation. He will examine and evaluate you. He will then show you before and after pictures and then explain the surgical procedure from beginning to end. This explanation will include what surgical technique he will use, where the surgery will be performed, what type of anesthesia, and a step-by-step explanation of what the recovery will be like. You will then meet with the patient care coordinator, who will explain the scheduling details and the cost.