Q: Dr. Eppley, I am interested in a revision rhinoplasty. My ENT performed a septoplasty in March of this year. He added cartilage from my septum to make my nose shorter and wider for breathing purposes. While my breathing has never been better, my appearance has changed, and I’m not a big fan of how my nose looks now. I would love to see if this is something that could be corrected.
A: By your description, you likely had spreader grafts placed in the middle vault and perhaps even alar batten grafts. These do successfully open up the internal valves and improve nasal breathing but can make the nose in some patients potentially wider.
The question is now how make your nose look better without recreating your breathing issues. This is most likely an augmentation approach for your revision rhinoplasty but I would need to see some pictures of your nose now to see what potentially could be done if anything. Given your improvement in breathing I would not recommend removing your spreading or batten grafts. Rather I would look at building up the bridge and tip of the nose somewhat to overcome the shorter and wider nose.
Dr. Barry Eppley
Q: Dr. Eppley, I have a question about nasal airway obstruction surgery. I am a 25 year old female who ever since I can remember,I had difficulties breathing. My right nostril’s been doing almost all the job of breathing, while my left nostril had difficulties breathing and sometimes wouldn’t breathe at all, like it’s clogged. I thought it is a normal thing to do for a nose until recently someone told me that both nostrils are supposed to breathe at the equal intensity. I asked my mother if I ever broke my nose when I was a child, she said “no”. I recently found out from my father that I actually did fall on my face/nose more than once when I was six or seven years old (I vaguely recall the incident). He also told me that they never took me to see a doctor, although I had been bleeding from the nose, I had blue circles under the eyes and a swollen nose. As a result I am soon planing on getting my nose x-rayed to find out if it is broken or not. But even if it’s not broken, is there a way to enlarge nasal canals to make breathing easier (or maybe change the shape of the nose to help easier breathing)? I’ll greatly appreciate your response. Thank you for your time.
A: While nasal breathing may not always be completely equal between both sides of the nose, it is not normal to have a feeling of being completely blocked on one side. With your history and those symptoms, this strongly suggests that you do have an internal nasal obstruction either from a septal deviation, inferior turbinate hypertrophy, middle vault collapse or some combination from all of the above. While you can get an x-ray (CT scan) to see the complete anatomy of the internal nose, a good physical examination will can also make the diagnosis. Undoubtably some form of a septoplasty and inferior turbinate reduction may be beneficial at the least.
Dr. Barry Eppley
Q: Dr. Eppley, I have some questions regarding cranioplasty, rhinoplasty, and septoplasty. I have a form of craniosyntosis and my skull has indentations that could be improved by a cranioplasty, I also have a severe deviated septum and crooked nose that needs correcting by having a combination of rhino/septoplasty. Insurance will cover the procedures for my nose to get corrected. I believe I have seen somewhere on your website where someone asked a question similar to this, and you said something along the lines of it is ideal to get the cranioplasty and rhino/septoplasty all done at once. That probably is not a possibility in my case, because getting my insurance to cover the cranioplasty is going to be difficult, so I am going to have to put that off for now until I have the money to get it done.
My questions are:
1.Would it be OK to get rhinoplasty/septoplasty done before getting a cranioplasty?
2.Or is it better to get the cranioplasty done first?
3.Or does it not matter at all in which order I get these procedures done?
A: In answer to your questions:
1) Insurance may cover the septoplasty portion of your nasal deformity but not the rhinoplasty portion.
2) Insurance will not cover any type of cranioplasty for skull recontouring. Indentations of the skull are not a medical condition but a cosmetic one.
3) The order of septorhinoplasty and cranioplasty is a matter of personal preference. There is no medical reason as to how they staged or in what order.
Dr. Barry Eppley
Q: Dr. Eppley, I have a deviated septum after getting a broken nose. I’ve dealt with this for about 12 years now and am working to becoming a chef and would like the full use of my nose as this would be a great plus for my job in getting my sense of smell back. The only allergy I have that I know of is I am allergic to Lortabs, If you would like to know more about me just ask I would like to know how much this would cost?
A: Septoplasty, the most recognized surgical name/procedure to improve an obstructed nasal airway, is just one aspect of nasal airway improvement. Straightening a deviated septum is often combined with inferior turbinate reductions as well as spreader grafts to the middle vault to open up the internal nasal valve. Whether one or all of these intranasal procedures are needed would depend on an internal nasal examination. What needs to be done will affect the time to do it and the subsequent cost. As a general cost guideline, a ‘septoplasty’ could cost anywhere from $2,500 to $ 4,000. In regards to your sense of smell, there is no guarantee that just because your nasal airway exchange improves that your smell will as well.
Dr. Barry Eppley
Q: I was wondering what kind of doctors perform septoplasty? Are plastic surgeons the only types of doctors that can perform septoplasty? I was reading that some health insurance can cover a septoplasty but you have to prove to them that your deviated septum is causing you breathing problems. Is it safe to get a septoplasty/rhinoplasty together? Can you get a septoplasty first.. and a rhinoplasty later or will that be considered a revision? Thank you very much for your time Dr Eppley.
A: Septoplasty can be performed alone (if the only objective is to correct breathing problems) or it can be done in conjunction with rhinoplasty. (known as a septorhinoplasty if both breathing and the shape of the nose are concerns) Most major rhinoplasties always include a septoplasty as the septum provides a source for cartilage grafting which is necessary for many nasal reshaping surgeries. Septoplasty and rhinoplasty are never separated into two stages if one’s intent is to address both function and aesthetics of the nose. Septoplasty may be covered by insurance if there is evidence of significant septal deviation and/or inferior turbinate hypertrophy.
Dr. Barry Eppley
Q: I am considering having my septoplasty and rhinoplasty done at the same time. It does seem like it would be cheaper and more practical to have both done at the same time and only pay one anesthesia bill, surgery room cost, etc. If the septoplasty is medically necessary and you have to have it anyway, it should be substantially cheaper to go ahead and have the nose reshaped at that time as well. I recommend finding a Dr. that will work with you on this. There is a big variation on prices out there. I heard from a friend that needed upper eyelid surgery (blepharoplasty) for excess eyelid skin. The plastic surgeon she first went to see just assummed insurance would not pay it and did not even let me get tested to see. Then she went to an Opthalmologist, and in less than one week, had insurance approve the procedure. I am a healthy person in my thirties, who never gets sick, and don’t feel like when I do need a procedure, insurance should try to get out of paying. (Which they did not, but the first MD assumed they would not)
A: While on the surface this basic insurance coverage question seems reasonable, it reflects a deeper misunderstanding and a general societal feeling about health insurance companies. (not that I have any great compassion for them either) The issue is one of justifiable coverage and insurance fraud. Trying to get a cosmetic procedure covered under insurance, is quite frankly, fraudulent. That is not what health insurance is designed to cover and their policy guidelines make this quite clear. While some physicians will code certain diagnoses and procedures so that they appear medically necessary, so the patient doesn’t have to pay and they can bill for the procedure, this is ethically wrong and illegal. While it may be common practice, that does not make it right or justifiable. There are many plastic surgeons who will not exhibit such unethical behavior and this may make the patient feel that they are being unreasonable. In reality, they are being quite honest and forthright. And what reasonable patient would ask a plastic surgeon to risk his license or practice for something that their insurance company is not obligated to pay?
This is not to be confused with the benefits of performing a cosmetic procedure with a medically necessary one, such as a rhinoplasty and a septoplasty. Many believe that the benefit is that the insurance company will pay for the operating room and anesthesia costs of the rhinoplasty as just part of the septoplasty. Again that is fraudulent behavior that the hospital or surgery center will no longer allow. The patient is obligated to pay for all additional costs related to the rhinoplasty once the septoplasty is completed, including operating room and anesthesia costs. The combined benefit is that the additional time to complete the cosmetic portion is less than if the cosmetic procedure was performed alone, thus reducing one’s out-of-pocket expenses. In addition, many plastic surgeons may discount their professional fee for the cosmetic procedure as a courtesy for doing both at once. That is the ethical and legal approach to getting a financial benefit for the patient from combining such procedures.
Dr. Barry Eppley
What Would Be The Cost Of Rhinoplasty When Done With An Insurance-Covered Septoplasty and Turbinate Reduction?
Q: I am in need of a septoplasty and turbinate reduction for nasal obstruction and snoring. I am considering rhinoplasty at the same time as I have a larger nose which I want to make smaller. Do you perform turbinate reduction with radiofrequency ablation? Do you have an idea how much my insurance may cover due to breathing problems and what part I would have to pay for the rhinoplasty?
A: Contemporary turbinate reduction can be done by a variety of methods, all intended to shrink the size of the turbinates rather than by just cutting them out. Several methods exist including radiofrequency ablation. That is not a technique that I use. I use diathermy or cautery ablation and have done so for years. Whether one method over the other provides a better result is unknown as both approaches cause shrinking of the inferior turbinate by devascularization and some degree of mucosal necrosis.
Insurance almost always covers any form of internal functional nasal airway surgery and their willingness to do so has actually improved over the years unlike many elective medical procedures. Such allowed coverage is determined beforehand through the typical insurance pre-determination process.
Doing rhinoplasty at the same time as nasal airway surgery is obviously common and efficient from a nasal perspective. While insurance does not cover rhinoplasty, there is no question that it does help to lessen the cost of rhinoplasty as opposed to it being done as a stand alone procedure due to time efficiencies and many surgeon’s willingness to accept some reduced cosmetic fee for doing it.
The answer of the cost of rhinoplasty with internal nasal surgery would be based on what type of rhinoplasty is needed (partial vs. full) and what facility the procedure may be performed in. (different facilities have varying fees for operating room use and anesthesia charges) As a result of these variabilities, definitive cost estimates would require knowing what type of rhinoplasty you need and where it would be performed.
Dr. Barry Eppley
Q: I have two differently sized nostrils. My left nostril is smaller than my right. It looks like just removing some skin will fix the problem. How easy is this to do? I have attached a picture of my nose from below for you so you can see the problem.
A: There are numerous causes of one nostril being different than the other one. Since the nostril is geometrically a triangle, changes in the any of three legs (columella, alar rim, nostril sill) can cause a change in nostril size and shape. The most common cause of nostril asymmetry is an alteration of the vertical leg. That is the piece of skin between the nostrils known as the columella. It is supported from behind by the end of the septal cartilage, known as the caudal septum. This is frequently deviated or deflected to the side into the nostril space. When this occurs, the oval-shape of the nostril will become deformed making it look smaller. This is exactly what your picture shows…a classic deviated caudal end of the septum.
Whether more of the septum is off of the midline as it goes deep into your nose is unknown. You would probably know that because such a deviation is likely to cause breathing problems of which you would be aware. Regardless, correction of this problem is through a septoplasty procedure. The septum is moved back to the midline behind the columella. This anatomic correction returns the nostril size and shape back to better symmetry with the opposite nostril.
Septoplasty is commonly performed as part of many cosmetic rhinoplasty surgeries.
Dr. Barry Eppley