A patient arrived at Southwest Plastic Surgery on a Friday afternoon with one item on his list. He had broken his nose as a child, and it had been crooked ever since. He had never had surgery, exercised four days a week, and took no medication.
What follows is that consultation with Dr. Frank Agullo, nearly as it happened, with identifying details removed.
The Problem He Came In With
Patient: I broke it when I was young. It was a baseball. But ever since that, I’ve had complications and I know I have trauma inside. You can tell it’s kind of deviated. So I wanted to get that corrected. But if I’m going to do that, I might as well get the exterior as well.
Dr. Agullo: “Do you have problems breathing?”
Patient: Yes. I get congestion right away. But I’ve lived like this for a long time, so it’s kind of normal for me. I do notice that I get congested a lot if I start doing exercise.
Congestion that shows up during exercise is a common way an old nasal fracture announces itself years later.
A Second Opinion He Did Not Agree With
The patient had consulted elsewhere first, and had been shown a plan that made his nose considerably smaller.
Patient: The way they wanted to make my nose was too small for my face.
He had gone home, downloaded a simulation app, and built a more conservative version himself.
Patient: I actually liked it more.
Dr. Agullo: “It doesn’t balance.”
Dr. Agullo agreed with the patient’s own, smaller plan, saved his image, and told him it would be referenced during surgery.
The Examination
Dr. Agullo: “Your nasal base is a little bit wide. So we do bring these bones in, and that helps me straighten everything out. So they probably healed a little bit off.”
Dr. Agullo: “Your nose looks really irritated. I feel like you have a lot of allergies. And then your septum is going this way. So there’s a lot less space on this right side, and the left side is very open.”
Dr. Agullo: “So we’ll straighten that out. The breathing should improve, but it’s not going to change the congestion when it gets congested or there are allergies. Really, we can’t do much about that, but we can make it structurally more open.”
Surgery corrects structure. It does not treat allergies, and Dr. Agullo says so before a patient schedules.
Two Millimeters at the Tip
Patient: I don’t want my nostrils to be too…
Dr. Agullo: “No, we’re just going up a little bit, so really we shouldn’t change the nostrils at all.”
Dr. Agullo: “It’s just the tip a little bit, because on men we still like a right angle here. We don’t want to make it bigger than that, that’s more feminine.”
Patient: So by lifting it, it won’t make it more round or anything?
Dr. Agullo: “No, it’s just going to rotate it up a tiny bit. We’re talking about like two millimeters.”
Where the Cartilage Comes From
Dr. Agullo: “For this, I have to put in cartilage to fill that in, so it’s permanent and you don’t have to be adding anything else later. So first I’ll use the cartilage that’s in your septum. If it’s not enough, then we do have donor cartilage that we can use. It’s irradiated, doesn’t have any cells, but it saves me and you from having to get any from your ear or your rib, which can be more painful. So this makes it a lot easier, because the rib hurts a lot. And the ear can be uncomfortable too, and sometimes it can make it look funny too.”
The Turbinates and the Incision
Patient: Are the turbinates going to be reduced?
Dr. Agullo: “So they don’t look big, but on this right side, usually when your septum is deviated, the open side gets bigger, but in your case it’s not that big. So if anything, when I’m in there, if I see that they’re a little bit big, what I do is I fracture them and that makes them shrink a little bit. But I don’t think you need to get mucosa removed or anything like that.”
Patient: Am I going to have a visible scar?
Dr. Agullo: “You’re going to have a scar, but it’s going to be very hard to see. Usually it heals in a way that nobody sees it, and you’ll have to look at it in a mirror like this to see it.”
Surgery and Recovery
Dr. Agullo: “So it’s an open rhinoplasty. We’ll get everything centered, and the surgery takes about two, two and a half hours. It’s general anesthesia, you go home the same day. I do have to put splints on the outside and on the inside, so it might be a little stuffy for about seven days, then we’ll remove everything. At that point, your breathing should be better.”
Dr. Agullo: “You’ll see the changes in the nose, but it’s still going to be a little swollen. So it’s probably going to take a couple of weeks to start looking better and better. And then about six weeks, we’re pretty close to what it’s going to look like, but the nose itself takes about a whole year for it to keep getting better and better.”
Dr. Agullo: “But the good thing is that there’s no pain after surgery, so it’s a relatively easy recovery. We do have to wait about six weeks before going back to exercise. And going back to normal activity, you’ll feel fine after about three days. It’s just a matter of whether you want people seeing you with the splint or not.”
Dr. Agullo: “If you get any bruising, sometimes you get bruising, I would say only twenty percent of our patients get any bruising underneath the eyes, it can take two weeks to go away, and you can always put a little makeup on if you want to hide it.”
Dr. Agullo: “In the beginning, it may look a little extra. Because some of that gets reabsorbed, so we have to plan on it, on how it’s going to come down a little bit.”
The Plan on the Chart
Sunken and relaxed dorsum. Deviation to the left with a subtle deviation to the right. Previous trauma. Slight downward tip rotation. The plan: rotate the tip up about two millimeters, shave the hump, add a graft for the radix, and straighten the nose.
Dr. Frank Agullo is a double board-certified plastic surgeon, certified by both the American Board of Plastic Surgery and the American Board of Surgery, a Mayo Clinic plastic surgery fellowship alum, and a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Patients considering nasal surgery at Southwest Plastic Surgery can also ask about skin treatments at MedSpa West while they are planning their timeline.
Ready to Talk?
If you have been breathing through one side of your nose for years, you do not have to keep doing it. Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at drworldwide.com.
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