If you’re unhappy with how your nose looks in the weeks after surgery, most patients don’t have a bad result – they have a nose that’s still working through the healing process. That’s not me brushing off a genuine concern. It’s the single most useful thing to understand at this stage.

I’ve just returned from a run of conferences over the summer, at home and in Lisbon, and it’s left me thinking about a word I hear a lot from prospective patients but that I’m genuinely careful with: ‘botched’.

Botched rhinoplasty is a term that’s often used when a patient isn’t completely happy with the result after nasal reshaping surgery, and I think that does a disservice to a much more useful distinction. In my own practice, a botched rhinoplasty is specific: a result that needs significant reconstruction for functional reasons, aesthetic reasons, or both, where the outcome is genuinely worse than where the patient started. Most of the revisions I perform aren’t that.

They’re minor refinements to an otherwise sound structure – a small asymmetry, a little more definition at the tip – and that’s a normal part of rhinoplasty, not evidence that anything has gone wrong.

Why I’m careful with the word botched

Part of it is fairness to other surgeons. I work with people who’ve travelled to see me from all over the country, and occasionally from further afield, and it would be easy to be sensationalist about ‘nose jobs gone wrong’ and ‘cosmetic surgery tourism’. However, you can find highly skilled and specialised rhinoplasty surgeons abroad.

Calling every disappointing result ‘botched’ also carries a weight of blame that isn’t always deserved, and it isn’t something I think serves patients well either. It can make people feel embarrassed or judged for coming forward, when what they need is a calm, accurate assessment.

The trouble with judging a result too early

A nose is not a static thing. At the end of an operation, I can – within reason – make a nose look very favourable on table: good lighting, a little oil, the right angle. But that isn’t a live result, and it isn’t what the nose will look like once it heals. Skin has a memory, cartilage settles, and swelling resolves unevenly over roughly the first year, with the tip typically taking the longest. I deliberately don’t use on-table or very early post-operative photos in my own before-and-afters, because they’re not a fair representation of the long-term result, and I don’t think it’s right to set that expectation.

So, when someone tells me their result looks ‘botched’ at six weeks or three months, it is often because the nose is still settling, not because it has failed.

What leads to a genuinely poor outcome

When I do see a result that needs significant reconstruction, a handful of factors are usually behind it. Techniques that reduce or reshape the nose without reinforcing its structure – shaving down a hump without rebuilding support, for instance – can look convincing immediately and then change as they settle.

Heavy grafting, using large amounts of a patient’s own septal or ear cartilage, can leave very little to work with if a later correction turns out to be needed.

And at a recent conference I heard a presentation on what was, essentially, an off-the-shelf approach to rhinoplasty – a menu of set noses to choose from. It genuinely surprised me. A nose must fit an individual face, and it’s permanent, so treating it as a cookie-cutter choice does a disservice to the patient in front of you.

Consultation and consent matter just as much as technique. I’ve done a fair amount of work on clinical negligence and national consent guidance, and one thing comes through clearly: proper consent is a process, not a form you sign on the day. For an operation like this, I think patients need more than a single meeting – ideally at least two consultations, with time in between to think it over. When that process is compressed, or when there’s a communication gap between surgeon and patient about what’s achievable, the risk of a mismatch between expectation and outcome goes up considerably, regardless of how technically skilled the surgeon is.

A word on travelling for surgery

Medical tourism is a big part of this conversation, particularly for rhinoplasty, and I want to be fair. Good surgeons and good results exist well beyond the UK. But a few things are worth weighing up honestly.

Package-style pricing doesn’t always leave room for the multiple consultations I’d want a patient to have. Marketing images – before-and-afters in particular – are, in some markets, more likely to be altered than they would be here, which makes it harder to judge a surgeon’s real results. And continuity of care is genuinely harder to arrange from a distance: if a problem develops once you’re home, who do you call, and how quickly can they see you? None of that means the price difference isn’t real, or that people are wrong to weigh it up. It just means it’s worth asking those questions before you travel, not after.

If you think you may have had a botched rhinoplasty

A few honest bits of advice. Unless there’s something that needs urgent attention, like a sign of infection or real difficulty breathing, try to give it a year before judging the aesthetic result – it will very likely look different, and probably better, than it does now.

When you are ready to be assessed, see a surgeon who routinely performs revision rhinoplasty surgery, not only primary rhinoplasty; the two aren’t the same skill set, and not every surgeon who does one does the other. Ask to see their own revision results, from more than one angle. And expect, and ask for, more than one consultation before anyone agrees to a plan – if a surgeon is willing to book you in for a correction on the strength of a single conversation, that’s worth being cautious about.

For my own patients, I review as often as needed for up to a year after surgery, and where I’m revising my own primary operation, I don’t charge a further surgical fee – only the hospital costs involved. I think the surgeon who performs your rhinoplasty should be genuinely invested in how it turns out, well past the day of surgery itself.

If you’re unhappy with the results of your rhinoplasty surgery and wish to discuss your options, book a revision rhinoplasty consultation with Mr Annakan Navaratnam.

Mr Annakan Navaratnam is a Consultant ENT and Facial Plastic Surgeon based in London, specialising in septorhinoplasty and nasal surgery. He practises privately at Welbeck Hospital and The Clementine Churchill Hospital, with NHS consultant posts at the Royal National ENT Hospital and UCLH, and an honorary consultancy at Great Ormond Street Hospital. He is a national advisor for ENT with NHS England’s GIRFT programme and has authored over 70 peer-reviewed papers and six national clinical guidelines.

Read more about Mr Navaratnam.

If you’ve spent any time researching rhinoplasty, you may have come across the term ‘twilight anaesthesia’ as the superior alternative to rhinoplasty under general anaesthetic and going fully under. It can sound appealing: less intervention, a quicker wake-up, a lighter experience all round. But for the vast majority of rhinoplasty and septorhinoplasty procedures, it isn’t the preferred option, and it isn’t what Mr Annakan Navaratnam uses for most of his patients.

We spoke to Dr Toby Ashken, consultant anaesthetist at University College London Hospitals (UCLH) and Honorary Clinical Teaching Fellow at UCL, who has worked alongside Mr Navaratnam for many years, about why general anaesthesia is the preferred approach for most nasal surgeries, and what patients can expect on the day.

Twilight anaesthesia isn’t as clear-cut as it sounds

The first thing to understand, Dr Ashken explains, is that twilight anaesthesia is essentially a form of deep sedation, and the line between deep sedation and general anaesthesia is far blurrier than the marketing suggests. “It’s not really a black and white line,” he says. “In practical terms, the key difference is that under general anaesthetic, an airway is secured. Under twilight anaesthesia, it isn’t.”

That distinction matters more than patients might assume. “With twilight anaesthesia, you can’t really guarantee the patient won’t recall anything,” Dr Ashken says. There is also less control over the patient’s blood pressure, which has a direct bearing on the surgical field and can influence the outcome of the procedure itself.

“It’s not to say that there’s no role for deep sedation, but in my opinion, it’s not the optimum approach for rhinoplasty procedures.”

Why the nose makes this especially important

Rhinoplasty and septorhinoplasty present a particular challenge: the nose is both a very small operating area and highly vascular. “Even quite small amounts of bleeding obscure the surgical field and make it harder for Annakan to do the operation technically,” Dr Ashken says. Under general anaesthesia, the anaesthetist has far more control over blood pressure, keeping the field as clear as possible for the surgeon throughout.

These procedures are also more invasive than patients might picture from the outside. Septorhinoplasty typically involves inserting an endoscope into the nose and reshaping the bone and cartilage, which can be traumatic if recalled later.

For context, UCLH, where Mr Navaratnam holds his NHS practice, runs one of the largest rhinoplasty practices in the country, and procedures are done under general anaesthesia as standard. Dr Ashken is clear that this isn’t because twilight anaesthesia is inherently unsafe.

“I don’t think there’s a big distinction between the safety profiles of general anaesthesia and twilight anaesthesia,” he says. “Rather, it’s that twilight anaesthesia sits in more of a grey zone, whereas general anaesthesia is a far more controlled, predictable experience for both the surgical team and the patient.”

There are plenty of operations where Dr Ashken uses deep sedation routinely – often alongside a nerve block, so the patient is comfortable and calm in theatre while the “hard work” of numbing is done by a local anaesthetic. It’s an approach he uses often for hand or elbow surgery, for example. “But that’s quite difficult to do in the nose.”

Longer, more complex procedures need more control

Mr Navaratnam’s operations aren’t always short. “His operations can take several hours,” Dr Ashken explains. “Also, surgery can reveal more complexity than anticipated once underway. For procedures of this length and unpredictability, general anaesthesia gives both the surgeon and the anaesthetist far more control over the patient’s condition throughout the procedure.”

What patients can expect from rhinoplasty under general anaesthetic

For anyone who hasn’t had a general anaesthetic before, Dr Ashken talked us through the process from booking to recovery.

Pre-assessment

Once surgery is booked, patients are contacted by the hospital or clinic’s pre-assessment service. This is usually a form, sometimes followed up by phone or in person, and a nurse will go through details including allergies and any previous experience of anaesthesia.

For Mr Navaratnam’s patients, this is also where any breathing issues linked to septal problems are identified, alongside a general screening for heart, lung, and other health conditions. If anything is flagged, it’s communicated to Dr Ashken, and further tests – such as blood tests – may be arranged to ensure the patient is optimised for anaesthesia.

Before surgery

The hospital provides instructions on arrival time and, critically, fasting. “Having a full stomach under anaesthesia is basically quite dangerous,” Dr Ashken says, and operations will be postponed if fasting instructions aren’t followed, purely for safety reasons.

On the day

Patients are seen by both Mr Navaratnam and Dr Ashken on the morning of surgery. Mr Navaratnam goes through surgical consent, while Dr Ashken talks patients through what to expect and rechecks allergies and medications. Once in theatre, standard monitoring is attached: a blood pressure cuff, ECG dots across the chest to track heart rhythm, and a sensor on a finger for oxygen levels. An intravenous line is placed so that anaesthetic drugs can be administered.

Going to sleep

For approximately 95% of Dr Ashken’s patients, everything is delivered through that IV line – an approach called total intravenous anaesthesia, or TIVA. A mask is still used, but it delivers only oxygen. “I favour TIVA because patients tend to wake up better afterwards, with fewer side effects.” The first medicine typically makes people feel lightheaded, sometimes slightly euphoric; the second brings sleep within about 30 seconds.

Once asleep, Dr Ashken adds a further piece of monitoring – a sensor across the forehead that reads electrical activity in the brain’s frontal region. “This technology has become more widely used over roughly the last decade. It allows us to judge the depth of anaesthesia precisely: not so light that a patient risks becoming aware during surgery, but not so deep that recovery – particularly for older patients – takes longer than necessary.”

During surgery

Dr Ashken remains in the room throughout, continuously monitoring the patient. Rhinoplasty and septorhinoplasty fall into what anaesthetists call shared airway surgery: because the surgical site is the airway itself, the patient’s head is positioned further away from the anaesthetist than in most other operations, and the surgeon’s work can directly affect the airway that’s been secured.

Dr Ashken points to his long working relationship with Mr Navaratnam – built up over many years, since before either of them became consultants – as an important part of managing this safely.

Waking up

As the operation finishes, the anaesthetic is lightened, and patients typically wake within minutes. Most don’t remember the first ten to fifteen minutes afterwards at all, even if they were talking during that time. In recovery, a dedicated nurse looks after each patient one-to-one, offering food and drink (most patients are hungry after fasting) and making sure they’re comfortable and free of nausea before they’re moved to the ward. Mr Navaratnam and Dr Ashken typically check in again later the same day.

Recovery after rhinoplasty under general anaesthetic

Coming round after septorhinoplasty isn’t inherently harder than after other operations, Dr Ashken says, though patients often want to touch their nose because of the cast, and aren’t fully lucid for the first ten minutes or so. Septorhinoplasty is not an especially painful operation, and most patients recover quickly, wake, and return to the ward.

“As a rule, longer anaesthetic times or being unwell before surgery can extend recovery – neither of which tends to apply to Annakan’s patient group, who are often younger, generally well, and back to themselves quickly.”

The success of a rhinoplasty is not solely dependent on surgical skill; it is a collaborative effort where expert anaesthetic planning plays an indispensable role. Mr Annakan Navaratnam has worked exclusively with a small team of consultant anaesthetists for many years. This partnership ensures every aspect of your well-being is managed to the highest standard, directly contributing to a safer procedure, a smoother recovery and, ultimately, a better result.

To find out more about rhinoplasty under general anaesthetic, and what to expect during your operation with Mr Annakan Navaratnam, call +44 (0)203 627 2918 to arrange a consultation.

Rhinoplasty has traditionally been viewed as a procedure for younger people. Teens and young adults often seek rhinoplasty to improve the appearance of their noses, boosting confidence and self-esteem, particularly in recent years with the advent of social media and selfies.

However, an increasing number of patients are now seeking a midlife rhinoplasty.

In fact, the most recent data from the American Society of Plastic Surgeons shows that patients aged 40 to 54 now account for the same share of the rhinoplasty market as patients in their 20s.

It’s true that selfie culture has made us all more aware of our angles, but there are many reasons why patients might delay a nose job until later in life.

“I’ve seen many older patients who have decided now is the right time, and they have a clearer idea of what they want. It’s no longer a matter of peer pressure,” Mr Annakan Navaratnam explains.

Why now?

Partly this is due to the reduced stigma surrounding plastic surgery. Gen X-ers may have been unhappy with the appearance of their noses since their teenage years, but at the time, cosmetic surgery was not as commonplace as it is now. There is now greater awareness of what can be done to address something that may have long been a concern.

They may now be in a place, career-wise and financially, where they can devote the necessary time and resources to both the surgery and its recovery. Often, they are more emotionally ready for the post-surgery period, carefully following the aftercare instructions and any post-op restrictions.

Although older patients typically experience slower healing, with swelling and bruising persisting for several weeks longer than in younger patients, they are more likely to have realistic expectations and dedicate themselves to their recovery, which can actually improve outcomes.

“Some of my younger patients have been very anxious during the recovery stage, often expecting swelling to be very short-lived when it can be present for months. I think there has been a proliferation of videos on social media recently where the cast comes off, and the nose is perfect. Patients don’t realise that this has been filmed many months after surgery.”

The ageing nose

Even for patients who were previously quite happy with the appearance of their nose, it can become their new insecurity as they age.

A common misconception is that the nose continues to grow as we get older. The bone and cartilage do not grow or change, but the ligaments that connect the nasal tissues become less elastic over time, and the nose can start to look longer or wider, and the tip can start to droop. As the skin thins, any bumps and asymmetries might become more noticeable.

In men, the nasal skin can often get thicker and more sebaceous, making the nose appear more bulbous. Other ageing changes to the face, such as a receding chin or sagging cheeks, can make the nose appear more prominent.

Although rhinoplasty is not usually considered an anti-ageing procedure in the same way as a facelift, a recent UCLA study using age-estimating AI tech to compare before-and-afters and found that women looked three years younger after a nose job alone.

“There are also functional changes that occur as the nose ages,” leading London ENT surgeon Annakan explains. “The drooping of the tissues as the ligaments loosen can cause nasal blockages. Inflammatory changes can mean they develop sinusitis or rhinitis that compounds the issue. Septal surgery alone might not resolve the problem, and a septorhinoplasty or rhinoplasty is required.

“Opportunity presents itself through other means, either trauma or functional issues, and they can then address an aesthetic concern that may have been bothering them for a long time.”

This lovely patient underwent a septorhinoplasty after nasal trauma. The improved form and function of her nose after surgery allowed her to breathe freely through her nose, and her sleep quality improved immensely. She was also really happy with the aesthetic improvement to her nose.

“Result is fantastic – my breathing and sleeping are so much better, and my nose is perfectly straight now, or as my daughter put it – I am less beaky now!”

Second time round

Another factor in the increase in midlife rhinoplasties is revision surgery.

There are no official figures, but it’s estimated that approximately 15% of patients who undergo primary rhinoplasty eventually seek revision. This might be because they now want a more age-appropriate appearance, or the original changes to the nose removed too much of the supportive structures, causing deformities and breathing issues.

“Previously, the trend in female rhinoplasty was to create a ‘button’ or ‘ski-slope’ nose with a scooped-out bridge and upturned tip. Women who underwent a rhinoplasty in their late teens and early 20s may now regret these changes as they’ve got older. Or they have run into problems with function.”

The aesthetics of the over-40s nose job

Mr Annakan Navaratnam finds that older patients typically want subtle, conservative refinements that keep the nose in proportion with the rest of the face and align with their cultural identity.

The charming lady sustained a nasal injury, resulting in flattening of the lower two-thirds of her nose and a deviation of the nasal septum. Careful repositioning of the nasal septum and tip sculpting and suture techniques resulted in a refined and natural appearance of the nose.

“Firstly, there is a psychological aspect. They have lived with their nose for most of their adult life and even slight adjustments can have an impact. Older patients typically do not want a drastic change, whereas some of my younger patients have wanted to completely remodel their noses.

“Mature patients have also had time to make a considered decision. If it’s only one aspect they are bothered by, they just want that addressed. This natural approach lines up with my own surgical philosophy.”

To discuss whether rhinoplasty can fulfil your expectations, call +44 (0)203 627 2918 to arrange a consultation with Mr Annakan Navaratnam.