Many questions come to CS from interested readers, and I enjoy answering them. Occasionally we get a question that warrants a full column, and I think this is one.
“Dear Dr. Jahn: My 17-year-old daughter is a classical singer. She has sometimes mentioned getting her nose surgically altered. Would such an operation affect her ability to sing?”
For singers, cosmetic surgery of the nose has some obvious benefits, but also some less obvious potential downsides. It is important to weigh the pros and cons, which I would like to discuss.
Rhinoplasty is an operation that changes the shape of the nose. Most frequently, patients are concerned that their nose is too big, either with a hump on the top or a large tip. At times, the nose is not straight, either angled or curved to one side. Some feel that their nostrils are too large. Not uncommonly, there are also internal deformities, with a deviation of the septum and obstruction of the nasal passages. In these cases, corrective surgery should address both the cosmetic and structural issues.
So the first question is whether there are functional problems or you are just concerned with appearance. Functional issues suggestive of septal deviation or enlarged turbinates include chronic obstruction, snoring, prolonged colds, and recurrent or prolonged sinusitis. Additionally, for singers, the voice may be hyponasal and in the back, and the singer may have difficulty bringing the voice forward or putting it into the mask. If there are functional issues (remembering that none of these is life threatening), surgery may be beneficial—and if you are considering cosmetic changes to the outside of the nose, it may be a good time to do both. Keep in mind that your medical insurance will usually cover the functional part (septoplasty) only, while you will have to pay for the cosmetic part yourself.
If the concerns are cosmetic only, I would suggest that you analyze what it is that you don’t like about your nose. Obviously if the nose is curved or deflected with an asymmetric appearance, your interest in correction is understandable. But if your focus is on smaller details, you need to weigh the pros and cons.
Nasal resonance is a significant component of singing. The nasal cavities resonate with sound, amplifying the voice. Sound travels to the nose not via the pharynx (since the palate is elevated and the nose is closed posteriorly during singing), but through vibration of the walls of the nose, especially the floor, which is the hard palate. Perception of the sound in the mask is also important in placing the voice during singing, and in cases of unilateral nasal obstruction, singers may feel the voice asymmetrically in this area.
Nasal breathing is also important. The nose cleans, warms, and humidifies the inhaled air. Additionally, nasally inhaled air activates the nasopulmonary reflex, which makes the lungs more compliant and easier to expand. These issues come into play when you consider an operation to open your obstructed nose (septoplasty or reduction of turbinates) but should also be kept in mind when the nose is reduced cosmetically and the nasal valves (the slightly narrower area just inside the nostrils) may become constricted, either from removal of tissue or from scarring during healing.
Of course, the cosmetic result is also important. It is, after all, why you’re considering the operation. Singers usually have their noses for good reasons, some of which are listed above. A large nose, or a nose with a large or droopy tip may limit the kinds of roles you might be hired for and can make the face look older. When asked whether her rhinoplasty affected her singing, one Met mezzo joked, “It means I can finally open my mouth completely when I sing, without my upper lip getting caught under my nose!”
What about age and timing? I would not recommend considering surgery until the nose is fully developed, unless there is a significant structural and functional deformity. Many teenagers who have a nose job early wish later in life that they had waited since, with further growth, the shape of the nose may continue to change. Nasal surgery in teenagers should always be conservative. This leaves open the possibility for a touch-up later, whereas if the operation is more aggressive, it can be difficult to correct. As the patient grows older, the nose typically droops, and with loss of fatty tissue in the face, it may begin to look bigger. This is another time when rhinoplasty could be considered, and this time the procedure can be a bit more aggressive and definitive.
Timing needs to take into account postoperative bruising and swelling. Even after the black and blue is gone, the nose and adjacent face may appear a bit swollen. Much of this can be covered with makeup, but consider timing in terms of your vocal commitments.
So, here are my suggestions. First, you should think about a rhinoplasty only for good reasons and have realistic expectations. As ENT residents, we are taught early on to avoid patients who come in with a photograph and a request “I want to look like that.” You can look only like yourself. A rhinoplasty will change only your appearance—it most likely won’t change your life. You may not make more money, and it will not make your spouse love you more. So, use reason.
Regarding your postoperative appearance, most cosmetic surgeons can now use computer software to simulate how you will look, based on your requests. This is just a model, however, not a guarantee. Expect small, specific changes, not a new nose. The ideal postoperative cosmetic nose doesn’t look different, just better.
Functionally, you are looking to combine good airway and good resonance on the inside with a more pleasing aesthetic appearance on the outside. As an architect patient of mine joked, “An ideal rhinoplasty is like a church with a Gothic exterior and a Romanesque interior.” Avoid a nose that is too small. It will decrease both airway and resonance and may not be in harmony with the rest of your face.
As for scarring, the incisions for most rhinoplasties are internal, and the less common external incisions are small and hidden. But remember that any surgery involves scarring, and the healing (and healed) nose is typically stiffer than before surgery. A common internal incision is just inside the nostrils, and if this scars excessively, the nasal vestibule may narrow, decreasing air flow. Other healed cuts you may have are a reasonable indicator of what to expect in terms of scarring. To minimize scarring and stiffness, the less dissection, the better.
Following nasal surgery (septoplasty or rhinoplasty) it is common to have some temporary loss of sensation to the two upper-front incisors and to the hard palate (premaxilla) immediately behind them. This usually resolves, but may have some temporary impact on articulation of dental consonants (/d/, /n/, and /l/) following surgery.
Both general plastic surgeons and ENT/Facial Plastic surgeons perform rhinoplasty. In some parts of the U.S., oral surgeons are also getting into the business. As with any procedure, and especially elective procedures, check qualifications and experience, ask around, and speak with other singers before making your decision. It helps to see the surgeon’s pre- and postoperative pictures—but even more helpful (if possible) is to speak with other patients about their experience and their degree of satisfaction.
A well executed rhinoplasty can improve your appearance, and possibly your career, but have reasonable expectations and be aware of all aspects of the procedure.
