Why Plastic Surgeons Say ‘On-the-Table’ Rhinoplasties Are Not to Be Trusted

Why Plastic Surgeons Say ‘On-the-Table’ Rhinoplasties Are Not to Be Trusted featured image
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No stranger to social media, Nashville plastic surgeon Daniel Hatef, MD relies on the visual tool of Instagram to showcase his practice, communicate with prospective clients, and share some of those oft-secretive, celebrity-treatment shots that even the most dedicated of patients aren’t always so quick to post.

One thing he’s not a fan of: Something he refers to as the “on-the-table” rhinoplasty before-and-afters—an increasingly popular post he thinks “looks amazing on the operating room table but, within a year, looks operated on.”

“The main reason is that the nose changes over time with healing,” shares Dr. Hatef, when pressed on why he’s not a proponent of showcasing the storied nose job surgery in this fashion. “Classic reductive techniques done in closed rhinoplasty lead to dramatic aesthetic changes on the operating room table, and they are notorious for changing for the worse over time.”

While he says his opinion is not to disparage the closed approach—”but the classic pinched tips and supratip deformities that we often see with this technique don’t show up until six-to-12 months postoperatively, if not longer”—he strongly stands by the fact that, in rhinoplasty, “you cannot base the favorability of a result based on the immediate postoperative appearance.”

The reason: “These pictures are typically taken from the profile view,” Dr. Hatef explains. “While this is fine for social media, when patients are looking for a rhinoplasty surgeon, they should ask to see frontal views as well. Although a change in the profile is almost always desired, this is the easier view to change.”

Plus, he explains, plastic surgeons will take the “before” picture on the operating room table after they’ve injected local anesthesia and epinephrine, which isn’t necessarily indicative when playing a part in the final result.

“We do these injections for pain control and to minimize bleeding, but they can be used to make the nose look bigger—and the after result much more dramatic in comparison,” he says. “I encourage surgeons to post their operative before-and-afters, and I do the same. It’s a great way to see how a result changes over time, but they should be taken accurately and before any injection is done.”

“And patients should know these things so that they can be more discerning in their choices.”

Eugene, OR plastic surgeon Mark Jewell, MD backs the above and gives the life extension of our iPhones an equally as bad review.

“It’s impossible to show accurate outcomes in the operating room from a rhinoplasty, even if there’s a discernable change,” he says. “And a phone picture of a nose taken before-and-after is, in my opinion, poor quality, non-standardized imaging. Rhinoplasty results need at least six months to mature and for swelling to completely resolve.”

One case where it may be suitable, says La Jolla, CA plastic surgeon Robert Singer, MD: If it helps ease some post-surgery fears. “It may be worthwhile to show the patient what was achieved at surgery during the time they are anxious and have their splint on. It is not, however, an adequate representation of the final result as swelling diminishes.”

Encino, CA plastic surgeon George Sanders, MD is also not a fan of any kind of aesthetic result being photographed on the operating table. “It is not the final result that is seen after months have passed since surgery,” he says. “Scar tissue, skin shrinkage, settling of the tissues and resolution of swelling all affect the final result that the patient will have. Granted, it takes time to acquire those long-term before-and-after photos, but these are a much better indicator of the final surgical result than what is seen in the operating room.”

“Patients should insist on long-term before-and-after photos if they are going to rely on these as an indicator of the surgeon’s skill.”

While she is quick to point out she doesn’t do much rhinoplasty work, Pasadena, CA plastic surgeon Lily Lee, MD also stresses the fact that she is not a fan of the “showing your immediate post-op work” trend.

“It is not a great for any part of the body, as so much changes throughout the healing process.”

Nevertheless, New York facial plastic surgeon Konstantin Vasyukevich, MD says evaluating before-and-after pictures is still the best way to assess the rhinoplasty results. 

“However, the importance of the timing for the ‘after’ photos can not be overstated,” he stresses. “Few people realize that our nose is not just a static feature of our face, but rather a very complex mechanical structure. Multiple forces act on the cartilages of the nose simultaneously pulling it in all different directions. When these forces are in equilibrium, the nose will maintain its shape. When the forces acting on the cartilages are out of balance the nose will start changing its shape: becoming longer or shorter or more upturned or deviating to the side.”

“The art of rhinoplasty is being able to surgically balance all the forces acting on the nose, so the long term result does not differ from the result seen at the end of surgery. Therefore, taking a photo of the nose on the operating table can be quite misleading. If rhinoplasty surgery was expertly performed the nose will look the same in the years to come, alternatively, the nose could potentially look completely different just a few short month down the road.”

Westborough, MA facial plastic surgeon Min S. Ahn, MD even goes as far to peg the “generally accepted time” when you can compare an after to a before is at the one-year mark. “It truly takes that long for all of the swelling to resolve. So it is a little misleading to show an on the table after and suggest that it is final result.”

“On the other hand, a picture on the table at the end of surgery is helpful for the prospective patient to see the extent of surgical changes that can be made,” he says. “Also, it’s kind of cool and dramatic.”

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