You Want a Rhinoplasty. Do You Know How to Select Your Surgeon?

If you don’t, you’re looking for trouble! And I’ll bet you don’t.

Steven Denenberg
Nov 15 · 15 min read

A nose job, or rhinoplasty, is the operation that changes the appearance of the nose.

Before and after photographs of a rhinoplasty patient.
Before and after photographs of a rhinoplasty patient.
Photographs Copyright 2019 Steven M. Denenberg

If there’s something that bothers you about your nose’s appearance — there’s a bump on the bridge, the tip is too wide, the nose sticks out too far forward from your face— then it’s probably reasonable to at least consider having a rhinoplasty.

But how do you select a surgeon to operate on your nose? It’s not obvious. It’s not something they teach us in third grade. And most of what you read about how to select a surgeon is useless at best and utterly false at worst. So listen up, and I’ll make sure you know what you need to know.

First, I’ll introduce and explain the problem. Then, I’ll show you what to do about it. (Footnote [1] contains my qualifications to write this essay. All footnotes are optional reading.)

Evaluating your surgeon is crucially important

What are you trying to accomplish with an informed and careful evaluation of your surgeon? You are trying to avoid being operated on by a surgeon who doesn’t have the ability to do an excellent rhinoplasty, a surgeon who does only mediocre work (or much worse) throughout his entire career.

“Really,” you ask. “Is that a risk? Are there surgeons like that out there” Yup. But more than just yup. The great majority of plastic surgeons cannot perform a good rhinoplasty. Hmm. Why is that?

A rhinoplasty is not a commodity. What does that mean? If you want to buy a Honda Civic, you can go to any Honda dealership and buy a Civic, and it will be the exact same car. Not that way with a rhinoplasty. Every surgeon will give you a different nose, and you have to find the surgeon who will give you the nose that you want, or at least as close as our science will allow.

What causes such a difference between surgeons? People are different. They have different levels of natural skill, different quality of training, different abilities to learn from their experiences, to fine-tune their practices. Come on, you know that some hairdressers and some car mechanics are just inexcusably bad at what they do, day in and day out. Plastic surgeons are like that, too. They’re just people, and not all people live up to your high standards.

Further, rhinoplasty is one of the most complicated of the plastic surgery operations. That one operation should require specialized training, in addition to the plastic surgery residency. A surgeon really needs to observe, or assist on, or perform with supervision, hundreds of rhinoplasties in order to get a feel for what’s going on — knowing a plethora of useful techniques, how to decide which techniques are required, having the judgment to select the techniques well, with an aesthetic eye, and having the dexterity and control to execute those techniques superbly. But many plastic surgeons go into practice having had experience with just a handful of rhinoplasties. And many plastic surgery residents in training have teachers and professors who are quite poor at the operation, so they don’t get a chance to see the operation performed with expertise.

But beyond that, you don’t want a surgeon who’s only competent. You want someone who’s truly excellent. Let’s say that you dream of playing classical piano on stage, touring with symphony orchestras. You can’t just decide you want to do it, and it happens. You must study for years and years. You must care deeply about it. But unfortunately for you, wanting it and working for it are not nearly sufficient. You’re not good enough to go on that symphony tour just because you took fifteen years of piano lessons and worked hard at it and were the best pianist in your high school. You must have exceptional innate talent in the piano, too.

Now we jump to the training of a plastic surgeon. At some point, usually at the end of medical school, you decide you want to be a plastic surgeon, and you apply to plastic surgery residencies. You are accepted or rejected on the basis of your grades and recommendations, similar to applying to college after high school.

You just decided you wanted to be a plastic surgeon, were accepted to the training program, and bingo, there you are on stage. Your visual ability to see a body part and imagine how it can look better was not evaluated. Your dexterity was not evaluated. Your empathy — how much you truly care about the well-being of your elective surgery patients — was not evaluated. Neither was your ability to develop and employ the refined judgment to help you guide your patients toward great decisions about their care. And neither, frankly, was your ethics. You just took a few introductory piano lessons and decided you’re going on tour with the symphony orchestras. This process, as you might guess, leads to problems.

The risks can be high. If you’re interested enough to read this article, then perhaps you’ve read messages on online forums from people who had bad rhinoplasties and are looking for revisions — second operations. It can be incredibly disruptive to one’s life, to one’s self image, to have a nose in the middle of your face that you dislike. Doing good research into your doctor before signing up for surgery is simply crucial.

Please, I don’t want to sound pessimistic. I just want you to take this task seriously.

What to expect, to anticipate — perhaps to demand — at your consultation with the plastic surgeon

So what do you do at your consultation with the plastic surgeon? You have an appointment. You believe this surgeon might be the one for you, and you are now going to evaluate him. (In a future article, I’ll discuss the question of how to find a couple of possibly-skilled surgeons with which you may want to consult.)

Your task is to figure out whether this surgeon tours legitimately with the symphony orchestras, or whether he just barely gets by, or whether he really should have a different occupation altogether. (Footnote [2] contains an apology for my use of pronouns.)

First, let’s talk about photographs. If the surgeon doesn’t show you his before and after photographs, scratch him off of your list. Period. No exceptions. Deal-breaker.

You pick a surgeon primarily from his before and after photos. You need to see that he was able to accomplish for someone else, what you want for yourself! That’s your only indication of his skill. Your. Only. Indication.

A thought experiment: you intend to hire a portrait painter to paint your spouse’s portrait. Would you really hire an artist if the artist wouldn’t show you any of the other portraits she’s painted?! No, it would never occur to you to hire her. Well, now you’re going to hire a surgeon to permanently change your nose — a hugely important structure right in the middle of your face — and you aren’t going to insist on seeing examples of his work, proof that he knows what he’s doing? Think about it.

A graphic artist patient of mine understood this issue and put it well. She said, “I can’t get work without presenting my portfolio. Why should the surgeon be any different?”

Further, you must see photos of other patients who had some features similar to your nose. For example, if your nose has a wide and drooping tip, don’t be satisfied if you see only profile photos of patients who had a bump on the bridge shaved off. Narrowing and elevating a tip can be incredibly more complex than carving down a bump (which itself isn’t an easy task!).

What if the surgeon is new-ish, though, and he simply doesn’t have photographs to show you? Totally reasonable question, which I’ll discuss in Footnote [3].

You don’t have to be a tough guy to take charge of your consultation. Just be yourself. Ask for what you want.

Here’s how it’s supposed to go. You have the correct mental posture for the conversation: you are the boss. You are hiring him. He is at a job interview, not you. You are not intimidated. There’s no reason to be afraid or nervous — you’re not obligated to have anything done. You are just gathering information. Have fun. Talk plain. Be yourself.

The doctor patiently listens to what you don’t like about your nose, what you want to change. He examines your nose, looks inside. He puts you in front of a mirror, makes sure he understands your concerns precisely. He discusses what can be corrected, what can be only partially improved, what can’t really be changed. He makes some suggestions you might not have thought about.

He morphs photos of your face, to show what he’s picturing doing to your nose. You give him feedback (you raised the tip too much, you didn’t lower the bridge enough for me, etc.). You and he use the morphs to come up with a surgical plan that you like and that he thinks is possible and realistic in his hands.

He shows you some before and after photographs of his (or you have already seen his work on his web site), demonstrating that he has the ability to accomplish the changes you are seeking.

You leave the office feeling that all of your questions have been answered. Yay. That’s an acceptable consultation.

But your consultation might not go like that.

If the surgeon won’t patiently listen to what you want for your nose, you can’t hire him. How will he know how to make you happy if he won’t hear what your preferences are? Some surgeons literally won’t listen to the patient’s preferences at all: “I’ll give you the nose you’re supposed to have.” Nope. He doesn’t get to decide what to do to your nose, not without your understanding and approval.

There are so many features and measurements to the size and shape and prominence and symmetry and balance of the nose, and how it fits with the rest of the face. The surgeon must prove to you that he thoroughly understands what you want, by repeating it back to you in detail. Don’t ever accept a “yes yes of course I can do all that” consultation.

If the surgeon conducts the consultation from behind his desk and doesn’t examine your nose, deal-breaker. He needs to know the anatomy he’s dealing with, so he knows — and can tell you — what can be done and what can’t. He can’t know your nose’s tiny details from across the room, and most of those details can’t be known without feeling the nose.

If it’s the nurse and not the surgeon who conducts the consultation, with the plan that you’ll meet the surgeon on the morning of surgery, run away fastest. Sound crazy to you? Good.

Use your intuition. If the doctor treats you as a commodity, or doesn’t explain things for you, or won’t address your concerns and make the effort pin down a detailed goal to your satisfaction, or if you just don’t feel you are connecting with him, you must reconsider using him. Even if surgery goes perfectly, you’ll need good, open communication with the surgeon to have an acceptable experience.

By the way, all of these recommendations apply if the surgeon is out of town and you are conducting your consultation through email and over the internet, telephone, Skype, Facetime. Consultations from afar like that are quite common nowadays, especially since most cities don’t have excellent rhinoplasty surgeons.

I think we need expand our discussion about morphing your nose.

Not every surgeon will morph your nose to make a surgical goal. I guess it’s not a out-and-out deal-breaker, but oh boy, if I were the patient, I’d be much more comfortable with the surgical plan if I’d had the opportunity to discuss that plan with the surgeon over some morphs.

You need to know exactly what the surgeon is planning to accomplish. You told the surgeon how you want to change your nose; when he makes the morph, you get to see how well he understood you. Here are a few possibilities:

1. You love the morph. You and the surgeon probably share the same idea of an attractive nose, and the surgeon understands what changes your nose requires.

2. You don’t like the morph — it looks strange to you. Maybe it’s because you didn’t communicate your desires clearly enough, and now you have a chance to fix that. Thank your stars the surgeon took the time to morph your nose. Without this chance to correct your mis-communication, the surgeon was destined to give you the icky nose you see in that morph you don’t like.

3. Again, the morph looks strange to you. Maybe how you thought you wanted to change your nose really doesn’t work on your face. So much better to figure that out at the consultation than a month after surgery!

4. You don’t like the morph. Maybe it’s because the surgeon doesn’t know what an attractive nose looks like, and it’s a clue to flee the office. You’ll figure that out as the consultation progresses.

5. You don’t like the morph, but it’s pretty close. Maybe he’s the world’s best surgeon and the world’s best morpher, but you just need to clarify for him how far to elevate your tip or how far to lower your bridge into a teeny-tiny scoop. The morph gives you the chance to have that extra, excellent communication, and come up with the best possible surgical goal.

Similarly, the morphs are crucial for the surgeon, too. As the surgeon, I need to know as precisely as I can what changes my patient is seeking. That way, I have the best chance of making her happy with her result. If she wants something that’s possible but off the beaten path, fine, and we’ll get it figured out. If she’s seeking something unrealistic for her nose, it gives me the chance to teach her what is possible and what is not.

As the patient, you’ll also discover whether the changes the surgeon proposes are large enough to be meaningful to you. For example, if you’re looking for a huge change, but your nose can only realistically be tweaked, maybe you’ll reasonably decide against surgery. If the surgeon recommends some changes that you hadn’t thought of, you need to see the morphs, so you can see whether you like those changes.

How would you and the surgeon ever get all that figured out without the morphs? Whew!

(Footnote [4] describes my experience morphing before we had computers. Footnote [5] discusses showing a different surgeon’s morphs to your surgeon.)

Now, how about some useless ways of checking out your surgeon.

Make sure he’s board certified. Surprised? Much of my practice is revision rhinoplasty, and nearly 100% of the horrendous results I’ve seen from bad rhinoplasties have come from board certified surgeons. The “boards” don’t give or withhold certification based on the quality of the surgeon’s results. Board certification is no guarantee whatsoever of skill in this operation. The “boards” will always tell you (have you read this in a hundred places?) that checking for board certification is your assurance of a surgeon’s skill. Nope.

This issue, relying on board certification, is the biggest mistake my revision rhinoplasty patients made. For their first-time rhinoplasty, they assumed that any board certified surgeon would do a superb job on their nose, and they did not investigate the surgeon’s skills further.

Academic appointments and medical licensure and hospital affiliations. It doesn’t help you that the surgeon went to a prestigious medical school or is the chairman of the plastic surgery division at the biggest hospital in town. He didn’t get to be chairman by doing beautiful noses. And the hospital will not throw him off staff if he routinely turns out mediocre or awful results. It doesn’t help you if the surgeon is a professor at the local medical school. You only care about how well he makes beautiful noses.

Spending time on these issues will just distract you from what’s important.

More: location. A doctor isn’t great because he practices in a particular neighborhood. Or city. Or country. Every surgeon must be evaluated individually.

Don’t ever use a surgeon only because your primary care doctor referred you to him, or because you know him, or your kids know him, or he lives on your street, or he did a beautiful job on your breast enlargement, or because he took out your tonsils, or your wisdom teeth, or he’s doing your septoplasty anyway, or because you saw his advertisement, or his awards, or you heard about his reputation. Don’t use him because he’s the only one in your town who does rhinoplasties. I’ve seen all of these happen, and I just shake my head. But you’ve read far enough in this essay that you’re shaking your head now, too!

If your gut tells you “no,” don’t use the surgeon. It’s much, much better not to have surgery than to have bad surgery.

Conclusion

There are many skilled rhinoplasty surgeons, but the great majority of plastic surgeons who perform rhinoplasty shouldn’t be doing the operation. It’s an incredibly difficult procedure, technically demanding, requiring experience, skill, judgment, an artistic eye, an exceptional level of communication and thoughtfulness and ethics, and a rare level of empathy and caring for the patient. The good news is, it’s absolutely possible for you to navigate these waters to a nice result: now you know how to evaluate your surgeon.

A couple of topics for my next essay:

1. How do I gather a few names of surgeons to interview/evaluate? You told me what to do after I’ve selected a few surgeons, but you didn’t tell me how to find and select them in the first place!

2. Are there special instructions if the surgeon I’m evaluating lives far from me geographically — in another city or state or country?

3. I’ve had a rhinoplasty and I think I need a revision. How do I evaluate whether I should let my first surgeon perform the revision operation?

Steven Denenberg, M.D.
October 2019

Footnotes

[1] Dr. Denenberg has been practicing ethical facial plastic surgery for thirty-five years. He is certified by the American Board of Facial Plastic and Reconstructive Surgery and by the American Board of Otolaryngology (though, you’ll learn in this essay that checking board certification is not the way to evaluate your surgeon). Dr. Denenberg has been selected as one of America’s Top Doctors by Castle Connolly. Unlike the many spin-off awards, which are typically local popularity contests, Castle Connolly allows only physicians to nominate, and vote for, Top Doctors. An “America’s Top Doctor” is selected by a national review of recognized experts in the doctor’s field. Dr. Denenberg is one of the rare surgeons to receive that award every year since the program began in 2001.

[2] I shall use masculine pronouns for plastic surgeons in this essay. You don’t want me using “he or she”, or “he/she”, do you? (And I know the ultra-pedantic of you don’t want me using “they” to refer to a singular antecedent!)

[3] Your surgeon doesn’t have a good collection of photographs to show you because he is too new in practice. It happens to every surgeon. It happened to me, of course. He may have a couple photos to show you from his training, cases where he was the primary surgeon. The brief answer is, yes, some people need to be among the surgeon’s first patients, but let other people be those patients. The new-ish surgeon will get his experience — not everyone on the planet will read this essay — and if he’s good, he’ll acquire the photos he needs. But if you’re reading this essay because you want to be thoughtful and complete about your research, the new surgeon isn’t for you. Good surgeons get better with experience; give the new surgeon time to get his.

[4] I made morphs for my patients long before we had computers to accomplish the task. I would take photographs of the patient when she came for her consultation. Later, when the 35mm slides were developed (are you old enough to remember 35mm slides? Slide projectors?), I would bring the patient back, project the slides onto a close wall so the image was real-life size, put a piece of paper over the image, trace the nose and profile with a pencil on the paper, and then I’d sit with the patient and adjust the contours of the nose, on the drawing, to demonstrate and refine the surgical plan. Well worth the time it took!

[5] Frequently, I am emailed photos by a prospective patient. I make morphs to show what can be done, the patient is appreciative, and often I never hear from the patient again. That’s fine. Although of course the patient can do what she wishes with my morphs, if I get the chance, I recommend mildly that she not show my morphs to her surgeon! If her surgeon makes his own morphs, she gets to see whether he understands the important issues of her nose, and how her nose should be changed. On the other hand, if she just shows my morphs to her surgeon, and he says “Of course I can make your nose look like that,” then she doesn’t really know if he fully understands, or even recognizes, the important changes shown in the morphs. Beyond that, you already know that rhinoplasty is not a commodity; just because a surgeon is handed a nice morph does not mean that he can create those changes during surgery. This same mild caveat applies when you have the ability to make your own morphs to show to your surgeon.

Steven Denenberg

Written by

Steve Denenberg is interested in computers and math. His degree is in Engineering and Applied Physics, Harvard University. He is also a facial plastic surgeon.

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