Chapter 3

Your Consultation

What to Expect

An office consultation is an exchange of information. You and the surgeon are interviewing each other! Your job is to assess whether he is the right surgeon for you. His job is to decide whether he thinks you are a good candidate for surgery.

What should I bring to my first visit?
Come with some thoughts about what you would like changed about your nose. Come with a written list of questions. Be prepared to tell us your medical history, any past surgeries (including all prior nasal surgeries), current medications, drug allergies, and so forth.

The Surgeon's Evaluation of You

Questions the surgeon has for you:

Medical history - most of this will have been filled out by you in the form, and will be reviewed by the doctor with you. I want to be sure you are healthy, that you are medically fit for surgery.

What you don't like and why? This is the "thesis statement" - the reasons you want surgery. Of all the things you tell the doctor, this is the most important information.

An example in primary rhinoplasty: "Doctor, my nose is too big for my face. Also, my tip is bulbous, and I don't like my hump. There are some other things, but these are my major concerns."

An example in revision rhinoplasty: " Doctor, too much was taken in my last rhinoplasty - from my bridge, and from my tip. My nose is twisted, my tip is pointy looking and unnatural. Also, my profile is uneven. Also, I can't breathe through my nose."

This should be your lead-off statement to the doctor! Everything else you discuss with him, he will have your goals foremost in his mind. This approach will surely allow you to get the most out of your consultation.

Some patients like the doctor to look at their nose and tell them what is wrong with it. It is fine to proceed this way, but just make sure that at some point, you tell the doctor what you don't like, what you want addressed!

Do you have Reasonable expectations This is discussed above, and is an important part of the evaluation.

What are your specific questions or concerns regarding the surgery process? Everyone has certain things that are particularly on their mind. Write these down, and discuss them with your doctor. Common questions/concerns are logistical, relating to the type of anesthesia, what recovery will be like, etc...

The Physical Examination

Question:Can you describe how a surgeon analyzes a patient's nose, and how it deviates from the ideal?
Answer: A surgeon will first consider the 'first impression' of the nose, such as whether it's too big, twisted, has a large hump or has been over-operated on. Often times, this first impression is what bothers the patient as well. The surgeon will also find out from the patient exactly what it is that he or she dislikes about their nose.

Next, the surgeon will examine the nose from the front. He will make a note of whether the nose is straight or twisted, whether the nasal tip is asymmetric, bulbous or otherwise abnormal, and whether the nose is too wide, too narrow or normal. The surgeon will also examine the skin to determine its quality, whether it is thick, thin or medium.

The nose is also examined from the side. This will allow the surgeon to determine whether the nose is too short or too long and if the profile of the nose has a hump or is a 'ski slope'. At this time, the tip of the nose is also examined so the surgeon can determine if it is overprojected or underprojected or just right. The surgeon will also see if there is too much nostril show present.

The nose is examined from all angles in order to provide important information about the nasal anatomy that is crucial to the planning of a successful surgery. In addition, the surgeon will feel the nose.

Question:Can you provide an example of a specific patient and your analysis of their nose and what you did for them?
Answer: Shown below is a patient who came to me in hopes of improving the appearance of his nose because he felt it was too big for his face and because he had trouble breathing. My first impression of the nose was that it was, indeed, too big for his face. When I examined his nose from the side, I discovered that he had a large nasal hump and that his nose was overprojected (it stuck out too far from his face). On a positive note, the length of this patient's nose is just right, neither too long nor too short, and, from this angle, the nostrils have a normal shape.

Computer Imaging
After the examination, we undertake computer imaging. Computer imaging is a very helpful way to communicate surgical goals. The patient understands that computer imaging is a video game - it is not a guarantee, but it is a way to find our shared goal. It is important for the surgeon to know what the patient wants to accomplish, and the patient must know what the surgeon envisions as a goal for the surgical result. Computer imaging is extremely useful to communicate this information, and we therefore perform computer imaging on virtually all patients prior to surgery.

With computer imaging, Dr. Becker works with the patient to generate an imaging result that is the goal for surgery, and he wants to be sure that the patient agrees to the goal. The patient understands that this is not a guarantee, but that this is our shared goal.

Discussion of Plan

The surgeon at this point will summarize his conclusions, and review the technical details of any proposed surgery. Dr. Becker will ask you at this point if you have any questions.

Your Interview of the Surgeon

Questions you have for the surgeon

The frequently asked logistical questions (with our answers) are listed here:

Question: Where does Dr. Becker perform surgery?
Answer: Dr. Becker performs surgery at Kennedy Surgical Center, a state-of-the-art, certified and accredited outpatient unit. Kennedy Surgical Center is a member of the Kennedy Health System.

Question: Do I have to stay overnight in the hospital?
Answer: No, this is outpatient surgery. Dr. Becker's patients typically go home after surgery; or, when they are from out-of-town, they stay at one of a number of fine hotels in the area.

Question: What kind of anesthesia is used?
Answer: Dr. Becker performs rhinoplasty with the patient under general or sedation anesthesia. These days, he is finding that more patients seem to prefer general anesthesia, but either way is fine with Dr. Becker. Under sedation, your nose and surrounding areas will be numb and you will drift in and out of sleep. With general anesthesia, you will be asleep for the entire procedure.

Question: How long does a rhinoplasty take?
Answer: Depending on the complexity, 1-2 hours. More complex cases may take longer. Dr. Becker will be able to tell you how long yours will take after he has examined you.

Question : What happens if I (the patient) get sick - catch a cold - a few days before surgery?Let us know the moment you think you are catching something. If we catch it in time, we may be able to proceed. Otherwise, we would reschedule your surgery.

Question: Is there a lot of pain or nausea?
Answer: Not typically. Time after time, Dr. Becker's patients are surprised at how little pain and how little nausea there is. After-surgery, pain is usually well-controlled with a mild narcotic.

Question: Is there any nasal packing?Answer: No. Dr. Becker does not find nasal packing to be necessary. There is no nasal packing.

Question: What is recovery like?Answer: We suggest that patients take a week off from work. Patients tell us that recovery is uneventful. Typically, there is little pain and little nausea. A little bleeding is common, and your nose will be stuffy. Dr. Becker will ask you not to blow your nose for about 1 week. Your main job after surgery is just to rest.

You will notice some swelling and bruising around your eyes that typically begins to disappear within a few days. Resting with your head elevated helps speed this process. By the time your nasal bandage is removed in 5 or 6 days, much of the bruising has resolved, and it should completely disappear by 2 weeks.
As noted, Dr. Becker will typically remove your nasal bandage in 5 or 6 days. There are no stitches to remove, because Dr. Becker uses dissolvable stitches.

Most surgeons provide their patients with detailed after-surgery instructions. A copy of the instructions that Dr. Becker provides to his patients after surgery is found in the Appendix.
After removal of the small nasal bandage (or "splint"), most patients are presentable in public. Most of Dr. Becker's patients are able to return to work the next day after nasal splint removal.

Question: How Long Does Rhinoplasty Last?

Question: What is the recovery period?
Answer: The "recovery period" is approximately one week.  It takes just a few days to recover from anesthesia.  There is typically some swelling and some slight bruising that is dramatically reduced  by 1 week.  Patients wear a small nasal bandage for 6 days.

After I remove the small nasal bandage (or "splint"), most patients are presentable in public.  Most of my patients return to work the very next day after nasal splint removal.  As noted in the "patient instructions" below, there are restrictions on activity for a few more weeks after that. And of course, there is continued healing and reduction of swelling that continues to take place, quickly at first and then gradually for at least a year.

Question: I have heard that it can take a year to see my final result. Is this true?
Answer: While the major changes will be apparent immediately, the more subtle changes do take time to become apparent. This is the case because healing is a relatively slow, gradual process. We typically advise patients that it takes one year for 80% of the healing to take place.

In addition to these and whatever other questions you might have, a few questions to consider adding to your list include:
What percentage of your patients are satisfied with your work?
I understand that even the best surgeons have complications. What is your revision rate?

What specific types of complications have you had in rhinoplasty?

Please give me examples of types of revisions you have needed to do on your patients.

May I see examples of your work - both primary and revision?

May I speak with a patient who has undergone rhinoplasty by you in the last few years?

 Understanding the Common risks

You should understand the difference between temporary side effects and complications. A temporary side effect is something like bruising, swelling, nausea after anesthesia. These require no extra treatment.

An immediate complication is something like bleeding, infection.
Complications relating to surgery include the risk of a cosmetic abnormality or a breathing abnormality. There is a lot of information on Dr. Becker's websites relating to risks of surgery.

Costs/Financing: Typically, the office manager will discuss the costs of rhinoplasty with you. Financing options are generally available.

After your consultation

You should summarize your thoughts to yourself after your consultation. What was your overall impression? Do you have a good rapport? Do you agree with his philosophy of rhinoplasty, and with the specific surgical plan? Was the surgical plan explained in plain English? Did you understand it.

Talk to other patients

Some patients wish to hear from some of his previous rhinoplasty patients to talk about their experience - we are happy to accommodate this request. This can be helpful to hear what the experience was like, from the point-of-view of someone who actually went through it. We try to identify a patient who had the same problem - for example, a twisted nose, or a bump, or a bulbous tip, or a revision.

Out-of-Town Surgery

Surgeons who have developed a reputation in rhinoplasty often have a national and even international patient group. A significant number of rhinoplasty patients really do their research! This is one of the reasons patients come from all corners of the United States, including New York, Florida, California, Chicago, Virginia, Maine and many others and also from overseas, from as far away as Australia, London, Ireland, Mexico, Canada, Greece, Hong Kong and Singapore to see Dr. Becker. We recognize the additional logistical inconvenience this may present, and we are well equipped to facilitate every step of your treatment. We believe we succeed in our goal, which is to make your experience almost as easy as if our office were just around the corner. Below, we describe the logistics for "out-of-town" patients.

Make Contact

The first step is to call or e-mail our office to make contact. Because of the distance involved, if you wish you may mail, Fedex or email us. Tell us your story, including what you do not like about your nose, what you would like Dr. Becker to fix about your nose. Include any specific questions or concerns you may have. If you need help or have any questions at this stage, or at any other time, call our office.

Include PHOTOS

Include photos in your message. Try to come as close as possible to the photos in this book. They should be close-up to your face. At a minimum, include front view and right and left side views. Also helpful are the bottom (nostril) view and a right and left side smiling view. The better the photos, the better Dr. Becker can assess your nose.

Dr. Becker's Assessment

Dr. Becker will assess whether you appear to be a good candidate for corrective surgery in his hands. If so, the office will contact you to discuss pre-operative care, costs, recovery, local accommodations and any questions related to your procedure(s).

Of course, if you want to discuss logistics prior to sending us your photos and other information, you may call and speak with the helpful office staff. If appropriate, Dr. Becker will speak with you by telephone as well.

Schedule Your Procedure

Once you have decided to proceed, no down payment is required. However, payment is due two weeks prior to your surgery date.

The decision to proceed is tentative. You have not yet been seen or examined as a patient by Dr. Becker, so really, surgery is contingent on a successful meeting prior to surgery. This office visit can be the day before surgery, or it can be the week before or months before - whatever works best for you.

Dr. Becker does not feel that an absolute decision for surgery can be made without an office visit. You need to meet Dr. Becker to make a final decision - and he needs to see you, examine you, look at and feel your nose to give you the 100 percent "green light." He will have a detailed conversation with you about your goals of surgery. This discussion will include computer imaging, which he finds is an extremely useful tool for establishing the shared surgical goal.

Therefore, while your spot can be reserved prior to your office visit and your payment will be taken 2 weeks prior to surgery, if you do not have surgery for ANY REASON, your payment will be fully refunded. Dr. Becker has found that this approach has been successful in his practice. His patients have told him repeatedly that the confidence they had in him from reading about him on the Internet and seeing examples of his work was only reinforced by their visit to his office and by meeting with him.

Read, Initial, Sign

Shortly after your surgery is scheduled, you will receive a packet in the mail containing pre-operative instructions and procedure consents. These documents must be read carefully and all instructions followed closely. These will be reviewed with you and signed on your office visit prior to surgery. (Appendix)

Logistics: Lodging, Transportation, After-Surgery Care

Where to Fly Into, Where to Stay
Dr. Becker's offices are conveniently located from Philadelphia International Airport. There are a number of fine hotels to stay in. If you do not have ground transportation, we will help you make arrangements.

Getting Around
We will help you with every logistical step - getting to the office and the hotel, getting to the surgery center the morning of surgery, getting to the hotel afterwards, and so forth.

The Surgery Center
Dr. Becker operates at a state-of-the-art, accredited, State Licensed, Hospital Based Surgery Center. The surgery center is within steps of his office. The anesthesia team, nursing staff, and other team members are top-notch, caring professionals. We believe that you will appreciate the nurturing atmosphere you encounter at every step.

The Surgery
You will be instructed on what time to arrive at the surgery center. You will be taken back to the preoperative area where you will be assessed by the nursing staff and by the anesthesia team. Dr. Becker will see you before you receive any medications, to greet you, to review with you the surgical plan, and to answer any last minute questions you may have.
You will be taken to the operating room by a member of the anesthesia team. You may notice your preoperative photos and the "Surgical Goal" pictures, which will be in the operating room taped to the wall. Since a picture is worth a thousand words, Dr. Becker keeps these pictures within easy view so that he can refer to them during the surgery. In this way, he keeps your shared surgical goal foremost in his mind as he strives to achieve this result for you.

After Surgery
After surgery, you will be taken to the recovery room where you will be attended to by the nursing and anesthesia staff. Fortunately, recovery from this surgery is typically fairly brief and uneventful.

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