Rhinoplasty
Sometimes the most minor adjustments and modifications in nasal proportions can result in the most significant changes in your facial expression.
Rhinoplasty (nose surgery) can address various problems in the nose, depending on what is needed and desired.
In some patients, this may be to improve the shape of the nose, its proportions, and overall facial harmony.
For others, it may be to correct impaired breathing caused by structural defects in the nose and nasal septum.
It is not uncommon for a patient seeking rhinoplasty to have both cosmetic and functional concerns.
A well-trained rhinoplasty surgeon should be familiar with what it takes to address both concerns.
The nose is the most prominent feature of the face. When it is beautiful, it accentuates the eyes, mouth, and cheeks.
When the nose is disproportionate, the whole face looks less appealing.
This is why a nose job can have such a big effect on a person’s appearance and self-image.
Rhinoplasty and Nose Surgery
Rhinoplasty means changing the shape, form, or function of the nose.
It is also known as a nose job and is performed purely for cosmetic reasons.
It is a surgical procedure performed to bring the nose into a more harmonious balance with the rest of the face.
A septoplasty is performed to improve functional breathing from the inside of the nose and improve the dynamics of airflow through the nose.
A turbinate reduction on the inferior turbinates is also performed to improve breathing from inside the nose.
A turbinectomy also improves airflow through the nose.
Rhinoplasty can be performed along with internal functional breathing procedures.
In addition, a broken nose can be repaired at the same time as rhinoplasty or septoplasty if needed.
Nasal surgery is one of the most complex of all cosmetic procedures because the nose is a 3-dimensional structure that includes bone, cartilage, and skin.
These components must look symmetrical in a 3-dimensional manner as well as allow for proper breathing.
Changes to any of these components can affect other elements within the nasal structure, altering both functionality and appearance.
After rhinoplasty surgery, the patient’s nose should look very natural and be in balance with the rest of the face.
Open VS Closed Rhinoplasty
Your rhinoplasty surgeon will decide which technique is better for you.
Both techniques provide excellent exposure for the surgeon to perform the rhinoplasty.
With the closed technique, 2-4 incisions are made inside the nostrils, the skin is then lifted off the cartilage and bone, the surgery is performed, and the skin is put back.
In the open technique, the incisions are made on the inside as well as an incision across the columella (outside), and the skin is peeled upwards at the tip to expose it.
The skin is then lifted off the cartilage and bone, the procedure is performed, and the skin is reapplied.
The incision over the columella is then suture-closed. The advantage of the closed technique is that there is no external incision, and healing is faster.
The advantage of open rhinoplasty is that you get more exposure, which is sometimes needed for revision rhinoplasty.
The disadvantage of the open technique is that the incision is visible for several months. There is more scar tissue and prolonged swelling and edema at the tip.
This is a compromise when performing difficult revision rhinoplasty, such as when cartilage grafts are used.
(Name of doctor) has performed thousands of rhinoplasty surgeries and can use both open and closed techniques.
He prefers to perform most routine primary rhinoplasties through the closed technique, while most revision rhinoplasties can be performed using either the closed or open technique.
Limitations of Rhinoplasty
When performing a rhinoplasty, realistic expectations from the patient’s perspective are very important.
The goal of rhinoplasty is to shape and sculpt a new nose that blends harmoniously with the face and is unique to each patient.
Every rhinoplasty is different. There is no such thing as the perfect nose.
General Conditions
The earliest age at which rhinoplasty should be performed is usually at age 15 for girls and about 17 for boys.
The growth plates of the nasal bone have not finished growing by this time, and cosmetic surgery should be deferred until the face is fully developed.
The nasal septum continues to influence the growth of the middle part of the face and the upper jaw.
Any alteration of the septum, either surgically or by injury before it reaches maturation, may affect further facial development.
The Surgeon and Anesthesiologist
Choosing the right surgeon to perform your rhinoplasty is of utmost importance.
Appointment and Consultation
The preoperative appointment will take place with one of our surgeons after you have scheduled surgery.
- Rhinoplasty technique will be explained.
- Realistic expectations discussed.
- Opportunity for the patient to express any changes.
- The patient’s medical history.
- The patient’s physical examination.
- Operative instructions.
- Expectation.
- Medical history relevant from an anesthesia standpoint.
- Previous or current injuries to the nose.
- Current respiratory problems.
- Allergies Medications, herbal supplements, and use of nasal sprays.
- Follow-up examinations, costs, and appointments.
The consultation with one of our surgeons is a comprehensive review of your nose, goals, and desires.
It is an opportunity to sit down and discuss your nasal issues.
Your surgeon will examine the nose during the consultation, both internally and externally.
Computer imaging will also be performed at the time of the rhinoplasty consultation.
Your surgeon will take photos of the profile, and through computerized morphing software, patients can see what their new nose will look like after rhinoplasty surgery.
What to avoid before rhinoplasty surgery
- Smoking: It is best to stop smoking two weeks before surgery and two weeks after surgery, as tobacco smoke irritates the nasal passages and can slow the healing process.
- Avoid exposing the nose to sunburns for the first month after rhinoplasty, both in natural sunlight and in a tanning bed.
- Patients should wash their hair and face the night before surgery and avoid applying makeup on the morning of rhinoplasty.
- It is very important not to eat or drink anything after midnight the night before rhinoplasty. The reason for this is to avoid nausea and vomiting during and after the surgery.
The day of the operation – surgery, and anesthesia
Your surgeon feels it is important to meet with you to go over the rhinoplasty/ Nasal Surgery in detail again so that both the surgeon and the patient understand the plan.
At this time, any last-minute minor changes to the rhinoplasty surgical plan can also be discussed.
If routine medications need to be taken (i.e., blood pressure pills, etc.), they can be taken with a small sip of water.
The anesthesiologist will ask about any specific medical conditions, food allergies, latex allergies, or allergic reactions to the anesthesia.
Patients will then be taken to the operating room. An intravenous line is placed, usually in the right hand, and a sedative is given to relax the patient.
Then the anesthetic propofol is administered to put the patient to sleep.
Once the patient is asleep, a small breathing tube called an LMA (laryngeal mask) is placed over the vocal cords and left in place for the duration of the surgery.
The patient breathes on his or her own under general anesthesia and has no memory of the procedure.
Anesthesia is much safer today than it was many years ago due to improvements in technology, anesthetics, and monitoring devices used during the procedure.
In addition, a local anesthetic is placed in the nose to prevent bleeding. To ensure patient safety, the anesthesiologist monitors the patient’s vital signs throughout the anesthesia.
While your surgeon focuses on the fine-tuning of the new nose, the anesthesiologist takes care of the patient’s anesthesia and the equipment used to monitor the heart, breathing, oxygen, and circulation.
The monitors that are used are the ECG, which monitors the heart, the blood pressure cuff, which monitors blood pressure during the procedure.
The pulse oximeter, which measures the concentration of oxygen in the blood, and a ventilation monitor, which usually monitors the patient’s own breathing and breaths.
Carbon dioxide and temperature monitors are also used during the procedure to closely monitor the patient’s safety.
The Day of the Surgery
The surgery takes 1 – 2 hours, depending on the complexity of the work to be performed.
During the procedure, the pre-existing characteristics of the nose determine the length of the procedure.
Rhinoplasty usually involves sculpting or reshaping the nasal bones, the upper lateral cartilages (middle 1/3 of the nose), and the lower lateral cartilages (the tip).
Sometimes septoplasty is performed to improve functionality and airflow dynamics through the nose, along with turbinate surgery if needed to improve airflow.
Reshaping the nasal septum and other tissues inside the nose fixes functional breathing problems.
Sculpting and reshaping of the bridge of the nose usually involve the reduction and ablation of bone and cartilage of the bridge of the nose.
Occasionally, augmentation or rebuilding of the bridge of the nose is required if too much has been removed in the past or if there is a traumatic injury.
The bridge of the nose is made up of both bone and cartilage, with bone making up the upper portion and cartilage making up the lower 2/3 of the nose.
During the rhinoplasty itself, the excess bulge of bone and cartilage is removed with an osteotome or rasp (a file-like instrument).
After the dorsal hump is removed, the lateral sidewalls must be narrowed. Otherwise, an open roof deformity will develop and must be closed.
The open roof deformity is closed with osteotomies in a very controlled manner, making very small and fine incisions in the nasal bones and reshaping the nasal sidewalls to create a more natural shape.
To increase the height of the bridge of the nose during rhinoplasty, your surgeon may need to add some cartilage from the nose.
In rare cases, he will also use an alloplastic or synthetic material.
This is usually done when there is no cartilage left on the inside of the nose or when the patient needs a very large augmentation, such as in Asian rhinoplasty.
Our surgeon prefers to use the patient’s own natural tissue and will usually use cartilage from the septum.
In the rare case that there is no cartilage left in the nasal septum, he may also need to use a piece of cartilage from the ear.
To correct a crooked nose, the bones must be realigned by making fine small incisions in the nasal bones with an osteotome and realigning and straightening the nasal bones.
The cartilage usually follows the nasal bones, and then a cast is applied.
When patients wake up in the recovery period, the nose is relatively numb, but most patients experience some sort of mild burning and stuffiness.
Some patients have a headache, but it subsides with some mild pain medication in the first few hours after surgery.
The nose tip surgery
Rhinoplasty on the tip of the nose is performed to shape a new tip that matches the rest of the nose.
The nasal tip is made of cartilage and lies over the top of the cartilaginous nasal septum.
When the tip of the nose is reshaped, it is usually reduced in size so that it is less bulbous and fits better and more harmoniously with the rest of the face.
Occasionally, its shape is sculpted and refined, its size is increased, or its length is increased, but most commonly, the size, thickness, and bulbousness of the tip are reduced.
Your surgeon may remove some of the tip’s cartilaginous bulge to bring it more in line with the rest of the nose.
A wide, thick, bulging tip is made narrower by placing stitches in the tip cartilage to hold it together.
Occasionally, cartilage grafts such as a spread graft, a tip graft, or a shield graft are placed at the tip to improve the appearance and projection of the tip.
Most patients who need rhinoplasty require a full rhinoplasty, but in rare cases, a tipoplasty is performed where only the tip area of the nose is operated on.
The rest of the nose must be in excellent balance if only the tip is surgically addressed.
Rhinoplasty Cartilage-Transplantation
In many cases, the nose or tip needs to be built up for esthetic or structural reasons.
If the preoperative condition of the nose shows a lack of cartilage in either the tip, the lateral walls, or the bridge of the nose, sometimes cartilage grafting is necessary.
The graft is placed inside the nose for structural and cosmetic reasons. When cartilage in the nose or tip needs to be augmented or built up, your surgeon uses cartilage that usually comes from the patient’s septum.
When cartilage is harvested from the nasal septum, your surgeon removes some of the non-structural cartilage from the septum that does not interfere with the support mechanisms of the nasal tip or bridge.
When cartilage is removed from the ear, your surgeon makes a small incision that is hidden behind the ear.
If the amount needed to augment the nose is greater than the amount that can be achieved by using the patient’s own cartilage, then an alloplastic synthetic implant is used.
These implants are commonly used in Asian augmentation rhinoplasty.
Surgical Narrowing of Wide Nostrils
Wide nostrils can make the nose look heavy at the bottom. During the rhinoplasty procedure, your surgeon may narrow the shape and width of the nostrils at the sill to further balance the tip of the nose.
If the nostrils are too wide or too large, your surgeon will remove a wedge of tissue where the nostrils meet the cheeks.
This is called a Weir excision of tissue. This excision is hidden in the natural nasal fold at the junction of the nostrils and is easily concealed.
The sutures for this are usually dissolvable. Once your surgeon has completed the rhinoplasty, in which he reshaped the cartilage and bone of the nose, the Weir excisions are performed.
All incisions are placed on the inner portion of the nose and are dissolvable. Dissolvable sutures dissolve on their own and do not need to be removed.
Creating the Cast of the Nose
After the anesthesia medications are turned off, your surgeon will apply a cast to the new nose, if necessary, to hold the position of the nasal bones.
This also helps to reduce swelling in the nose. A small plastic aquaplast splint is made and placed over the bridge of the nose to stabilize the newly formed nasal bones and tissue.
Patients do not receive packing on the inner portion of the nose, but they do wear a small gauze mustache bandage to catch the drainage from the nostrils.
Weak Chin Profile and Chin Augmentation
Chin augmentation is sometimes necessary when there is a weak chin profile. In many cases, patients who have a prominent nose also have a receding or weak chin.
Chin augmentation is performed at the same time as rhinoplasty to achieve better facial harmony when a receding chin gives the impression that the nose protrudes too far.
Chin augmentation is performed at the same time with a Silastic synthetic chin implant that is sized to the patient’s needs.
The implants come in small, medium, large and extra-large sizes, as well as square and round chin profiles.
This gives the face a more balanced profile.
The procedure is also performed under general anesthesia and takes about 30 minutes.
An incision is made below the chin, which is closed with very small stitches.
The chin implant is made of a very natural feeling Silastic plastic and is not felt by the patient or anyone else after healing.
Effects of Anesthesia
Some patients who are prone to motion sickness are also prone to nausea and vomiting after rhinoplasty. This can also be the result of anesthesia, ingested blood, or narcotics.
These are the three reasons that most commonly lead to nausea and vomiting in the postoperative period.
Your surgeon, therefore, recommends taking anti-nausea pills and makes sure that patients do not swallow blood down their throat after surgery.
Post-op Pain Relief
Many years ago, it was popular to place a pack in the nose. This was very painful and unnecessary and is no longer done.
Side effects of Rhinoplasty
- Pain associated with rhinoplasty is usually very minor and is more likely to be accompanied by a burning sensation or headache.
- Bruising: Bruising usually occurs in the cheek area and lasts about 7 to 14 days after the procedure.
- Swelling: Patients can expect swelling of the nose to last about a year after the procedure. The surrounding tissue swells for a maximum of 48 hours after the procedure and then subsides quickly.
- Most of the swelling is gone in about the first month after surgery, but there is still 20-30% swelling that takes a full year to subside.
- For revision nose surgery and complicated tip surgery, healing must be further prolonged as lymphatic vessels and fluid accumulation prolongs the healing period.
- Most patients are congested for about a week after their rhinoplasty, and the congestion seems worse if sinus surgery or septoplasty and/or turbinate surgery has been performed.
Complications of Rhinoplasty
- Bleeding: Excessive post rhinoplasty bleeding can occur, and the chance of this happening is about 1 in 1000, at which time packing will need to be placed in the nose to stop the bleeding. This is the only time a pack may be placed in the nose.
- Irregularities under the skin are probably the most common occurrence after surgery. The bridge of the nose may develop a small callus or calcification that requires scraping or filing of the bridge of the nose to get rid of the offending bump. These are usually minor and are performed free of charge. This occurs in about 10% of patients.
- Asymmetry: this is a result of postoperative scarring in the nose under the skin, which can cause the nasal bones and cartilage to shift, move or migrate in three dimensions.
- Infection is extremely rare after rhinoplasty.
Appointments and Aftercare
One week after rhinoplasty, patients return to Lelux Hospital.
At this appointment, the cast is removed, the inner portion of the nose is suctioned, and your surgeon examines to make sure all tissues on the outer and inner portion of the nose have healed well.
The splint is removed from the bridge of the nose, and this allows the patient to see their nose for the first time.
Normally, the bridge of the nose is compressed by the cast, which widens slightly as the swelling goes down.
The tip is quite swollen and tends to go down over time, so the nose becomes more balanced as the healing process progresses.
Once the cast and splint are removed, patients have the opportunity to observe the shape of their new nose, but this is only the beginning of the new healing process.
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