Key Questions To Ask Before You Pick Your Nasal Surgeon

What I learned after eight nasal surgeons checked my nose. Two of them graded my nose a difficulty level of 8 out of 10. While another three surgeons were too scared to even consider treating it. I soon began to realize fixing my nasal septum wasn’t going to be as easy as I thought.

If you are considering any nasal surgery, then here’s a short list of questions to have ready when you meet with your nasal surgeon. I compiled this short list over the course of 18-months and many consultations with top surgeons to fix my deviated septum.

You can add more questions as well. But here’s what I asked for my case: 

  1. Degree of difficulty level? (0-10)
  2. What % of your practice is septoplasty/rhinoplasty for functional breathing?
  3. Will this be done with the use of an endoscope?
  4. Will this functional rhinoplasty be an open approach? Or closed?
  5. Skill with 90 degree caudal deviation? (see questions 3 and 4)
  6. Hemitransfixion incision? Not Killian incision?
  7. Avoid removing inferior turbinates?
  8. Will you need to use rib bone?
  9. All options within/without your skillset?

Degree of difficulty level? (0-10)

How easy (or difficult) will your surgery be in this surgeon’s hands? Ask them on a scale of 0 (low difficulty) to 10 (high difficulty) how difficult your nose procedure looks for them? If they say the difficulty level is 7 or 8 or higher, then perhaps you might wish to interview another surgeon. 

Of the eight surgeons that inspected my nose, or viewed my CT scan, two of them said my nose was a difficulty level of 8 out of 10. In fact, another three surgeons didn’t even rate the difficulty; they simply referred me to another surgeon because they immediately said my nasal procedure was beyond their comfort level. By this time, I started to realize that fixing my nose wasn’t going to be as straightforward as I thought. 

Imagine, out of eight (8) top surgeons, five of them would not be a good fit given the degree of surgical difficulty. The remaining three (i) a rhinologist graded it a 4 out of 10 difficulty (ii) an ENT graded it a 3.5 out of 10 difficulty level and (iii) a facial plastic surgeon 2 out of 10 difficulty level.

Therefore, I felt only those 3 out of the 8 surgeons were qualified.

Notice the level of valve collapse that occurs when I breathe in.

What % of your practice is septoplasty rhinoplasty for functional breathing?

If you’re looking to breathe better, then make sure to choose a surgeon that focuses on the nose. Some rhinologists only work on noses (no throat nor ears). Other ENTs are fine with polyp removal and other procedures where there is less work needed, but are not comfortable with more comprehensive nasal surgery. 

If you plan to choose a facial plastic surgeon, be certain they perform a high number of functional nasal surgeries. Oftentimes, facial plastic surgeons focus much of their time on face lifts and liposuction. And not so much on the inside anatomy of the nose. 

Be sure to ask each surgeon you interview how much of their practice is devoted to nasal surgery for functional breathing. You will find the surgeons who are most trained to handle nasal surgery focus all of their time performing septo-rhinoplasty for functional breathing or fixing other surgeon’s botched work (revision rhinoplasty).

Will this be done with the use of an endoscope?

Do they intend to use an endoscope for any part (or all) of your surgery? An endoscope in nasal surgery is a little tiny tube with a camera and light on the end. It is intended to help the surgeon navigate and see the inside parts of your nose better. Not all surgeons use them. ENTs are known for using endoscopes. But not all do. The same is true with facial plastic surgeons.

Will this functional rhinoplasty be an open approach? Or closed?

With a closed functional septoplasty the incision is inside the nose. But the open technique involves an external incision. 

If all you are looking to do is a septoplasty by itself, then a closed technique might suffice. If the procedure is less complex, a less invasive closed technique might be enough.

In some cases, depending on the severity of structural problems, an open technique is the best choice. In my case, to fix the septum, nasal valves, inferior turbinates and straighten the nose, an open technique made sense. In my case, I had no desire to change the length nor external shape of my nose. I was less concerned about cosmetics. I wanted to be able to breathe again, and make the nasal deviation as straight as possible.

Skill with 90 degree caudal deviation? (see questions 3 and 4)

A caudal deviation is a bend in the septum cartilage at the tip of the nose. From what I quickly learned along my journey, this really scares some surgeons off. The tip cartilage has little fibers that link to the tip of the nose. In my case, I had a 90 degree caudal deviation (not good). 

One of the surgeons I interviewed in Milwaukee immediately pinched his two fingers together inside the tip of my nose. Within 20-seconds he told me he couldn’t manage my case; and he suggested to refer me to his colleague that can expertly handle the tip portion of noses.

Hemitransfixion incision? Not Killian incision?

I learned the Hemi-transfixion incision is the preferred approach. If a Killian incision is used, which is higher up in the nose, then it makes it difficult to reach or see the septum in the front part of the nose. The top three surgeons that I interviewed avoid Killian incisions.

Avoid removing inferior turbinates?

This is a most important question. Some nasal surgeons still amputate/remove all (or part of) the inferior turbinate bone. This is not recommended, except in very rare cases. Removing the inferior turbinate bone can lead to empty nose syndrome. So avoid removal of turbinates.

Inferior turbinate resection can be accomplished without removing any of the inferior turbinate bone. Techniques like coblation or debridement can be done to remove the inflamed tissue between the inferior turbinate bone and the skin of the inferior turbinate. 

Double check to verify. If your surgeon suggests an inferior turbinate resection, verify that the procedure only entails resection (or debridement) of the inflamed tissue surrounding the inferior turbinate (and not the turbinate bone).

Will you need to use rib bone?

Depending on how complicated, or in cases of revision rhinoplasty, it might be preferred to use rib bone to fix your nose. If you’re told that you will need a rib graft to fix your nose, just know there is some controversy among nasal surgeons on which approach is best for ribs and noses.

All options within/without your skillset?

Lastly, ask the surgeon of any other options you might have. Whether it’s within or beyond their skill set. A surgeon might recommend something or someone that turns out to be a hidden gem.