Doctor (Nose) Best – Not All Nose-Jobs Are Created Equal
“This doctor ripped me off! I could have gotten one for $200!”
Many patients are always puzzled in the difference of
pricing between surgeons who perform rhinoplasty.
Some doctors may perform a rhinoplasty (nose job) for as
little as USD $200.00 and yet some surgeons who may charge as high as USD $10,000
to $20,000.
Why is there such a huge discrepancy in pricing?
After all, a nose job is nose job is a nose job! How
different can it be?
Not All Nose-Jobs or Surgeons are Created Equal?!
Just like a car – 4 doors, 1 steering ,1 gear box and 4
wheels.
A Yugo or a Perodua is not a BMW, Jaguar or a Bentley. And we
all know that! Yes, the Yugo gets you from A to B and so does the BMW – here is
where all similarities end.
So, yes not all surgeons are of the same ability or pedigree
(not that a better pedigree equates to a better result) as there are various
factors at play including the surgeon’s experience with rhinoplasties and the
technical and intellectual ability of planning the rhinoplasty AND the material
used to perform the rhinoplasty.
Asian Rhinoplasty – Enter the Silicone Nose Implant
In Asia, the most popular form of rhinoplasty is with the
use of the closed method rhinoplasty.
The doctor makes a small incision (cut) at the nose margin,
dissects and inserts an L -shaped silicone implant and voila – a nose job done
in 30 minutes or so!
Patients are more often extremely happy with the results and
the surgeon is commended for being fast with an economical price to boot.
Downtime is minimal, there is no harvest of rib, nasal septum
or intricate procedures that result in prolonged swelling and a higher price to
boot.
Indeed, for many doctors this is what they only know how to
do or for some, only choose to do.
Many patients may be limited by budget and also some
unprepared to use autologous material such as rib (costal cartilage) or nasal
septum and additional ear cartilage grafts; and swayed by online marketing ads
often come to my practice requesting a pure silicone L shaped rhinoplasty. Although
not my first choice, a safe reasonable result is often achievable with silicone
nose implants. I do perform silicone rhinoplasties for certain patients with limited budget who understand its limitations.
Today other options include filler injections and PDO
threads (again, not my preference although I have performed these procedures
extensively at one point). I will touch more on that in future.
Wait! Isn’t A Silicone Nose Job Cheap & Good Enough?
For many decades, silicone nose job was the preferred choice
of material for nose jobs. It was cheap (and still is!), the surgical procedure was quick and
patients were thrilled (especially immediately post-surgery).
The patient also avoids additional general anesthetic and
recovery room charges.
Ideally, the augmentation rhinoplasty should be achieved
with autologous materials (from own body such as buttock dermal fat, rib and
septal cartilage). These procedures are uncomfortable and unpleasant for the
patient if not performed under general anesthesia.
However, there were specific complications associated with
the use of silicone implants in rhinoplasties. The complications typically don’t
occur until 12 months and sometimes a few years after nose implant surgery.
Silicone nose implant extrusions are one of the known
complications as the nose tip skin is thin.
Examples of impending extrusion and extrusions due to excessive
pressure of silicone implant on nose tip skin (a shorter implant should have
been used)
And yes, if you are asking, the results of a shorter implant
would be less aesthetic. Here, there is compromise between safety and enhanced appearance.
As silicone nose implants are foreign bodies and the implant
has no external shell (unlike breast implants), they carry a higher risk of
infection compared with cartilage grafts and dermo-fat grafts.
When infection (pus/abcess) and impending extrusion occur –
the only solution is removal of the implant and replacement with a more
biocompatible implant material such as Megaderm or autologous (own) rib graft or dermo-fat graft (more on that later).
Silicone being a foreign body elicits capsular contracture with calcification and can occur causing a distorted upturned nose even years or a
decade after implantation.
Examples of silicone nose contractures
Up close of view of Calcium deposits on the silicone nose implant causing contractures.
This is not a knock against surgeons who continue to use
Silicone nasal implants (even I do too!) but it is important to understand why
cheap surgery is not always cheap in the long term.
Our nose has two joints, one connecting the cartilage with
the bone and the other one connecting the alar cartilage with the upper
cartilage.
These joints allow free movement of the nose from left to right,
upwards and downwards.
If we place a hard silastic silicone implant above these
structures, the joints will be fixed and any medium velocity force to the nasal
area can lead to resulting trauma, much like placing a nail over the nose. Thankfully,
we have much better silicone implants today such as the hybrid soft-hard silicone
implants that I now use in my practice.
Ok Doc- You Sound Like Your Surgery Costs a Bomb! What
are the Alternatives?
Rhinoplasty Is way more than putting in an implant!
Surgical work on the tip to manipulate the size and shape is
as important as increasing bridge height.
But anyway, let’s talk briefly on alternative implants (they
cost more but are safer and more biocompatible)
Acellular dermal matrix (example Megaderm) is derived in the
lab from human skin components that have been washed off immunological and
bacterial debris leaving only the viable matrix. They have no risk of extrusion
and have a lower risk of infection compared to Gore-Tex and silicone nose
implants. Megacartilage are obtained from cadaveric ribs and are
immunologically cleaned and hence inert and safe.
Megaderm & Megacartilage nasal implants
Dermofat (skin and fat graft) can be used to augment the
nasal bridge safely.
Dermofat graft harvested from the buttock in an inconspicuous
manner hidden incision. This is less invasive than a rib graft harvest.
All the aforementioned above are more costly than a simple
silicone rhinoplasty and hence will cost more. It is not easy on the wallet
short term but are safer and more stable for the nose structure.
Rhinoplasty is more than just placing in an implant!!!
Sometimes internal cartilages are crooked and impair breathing
or cause the nose to be deviated.
They have to be removed, straightened and placed back into
the space inside the nose.
And no, the implant alone will not solve this problem!
Sometimes in a fat nose tip, the size has to be reduced by
removing some cartilage as follows.
The green area of the upper lateral nose cartilage is
removed.
Once removed the upper lateral cartilages are smaller and a
finer nose tip is possible.
But that’s not all!
Tip sutures further refine the nose.
Notice how the suture makes the tip finer and less wide.
Dome spanning sutures further increase the height of the
nose.
Example of a tip work with cephalic trim and domal sutures,
patient also had Septal Extension grafts and various techniques of tip grafting
An example of a shield tip graft (obtained from rib or ear
cartilage) to increase projection in the nose.
Sometimes the nose buckles when a shield tip graft is placed
hence a collumelar strut is needed to add strength so the nose maintains its
shape over decades.
Various types of Septal Extension Grafts/Collumelar Struts are used to change
tip inclincation, shape and direction.
Again, these are minute intricate surgery requiring the septal
surgery and modification. We have not yet touched on osteotomies (breaking the nasal bone to reduce a wide nose) and other intricate procedures such as spreader grafts, correcting alar flaring and alar overhang and various other types of grafts, This is not achievable with a simple 30 -minute “cheap
and good” silicone rhinoplasty.
Example of an osteotomy design (in blue) to break the nasal bones to allow repositioning to be less wide.
Osteotomies may require spreader grafts to prevent breathing difficulties in future.
Parting Thoughts
Rhinoplasty is an intricate surgery requiring specialized
skills and training for satisfactory long-term results. Silicone rhinoplasty
although less favourable is still the main choice in the Asian market due to
competitive pricing, low downtime and high number of surgeons able to perform pure
silicone rhinoplasty.
However, there are better implants in the current market
such as Megaderm, Mega Cartilage and Silicone-PTFE Hybrid implants. The best
option is autologous material from dermo-fat, ear cartilage or rib grafts.
Patients may not agree to have dermo-fat or rib cartilage harvested. Many
patients also have limited understanding on various grafting techniques to improve
the appearance, inclination and angle of nose. Nose tip refinement techniques
do cost more time and require good skill and experience of the rhinoplasty
surgeon. Not all surgeons are created equal AND not all nose-jobs are created
equal.
Sometimes we get exactly what we pay for! Remember you do
your rhinoplasty once but should last you a lifetime. A good surgeon will find
a middle path between technique/approach, budget and expectations while not
breaking the bank! Don't let your nose job become a botch job.
#nosejob #rhinoplasty #siliconenosejob #asianrhinoplasty
#budgetnosejob #cosmeticrhinoplasty #functionalrhinoplasty #botchednose
#cheapandgood #plasticsurgery #skincheckmalaysia88 #gemclinic #drleesengkhoo
Follow us at http://www.facebook.com/skincheckmalaysia and on
Instagram #skincheckmalaysia88 #drleesengkhoo
To make an appointment to see the rhinoplasty works (before
and after) of Dr Khoo, please Whatsapp +6014 2006558 or call 03-5621 1909.
Alternatively, you may email contact@skincheckmalaysia.com
Sincerely Yours,
Dr Lee Seng Khoo
