Nose Surgery
(Rhinoplasty)

About rhinoplasty

Rhinoplasty is a well-established procedure that has been helping men and women feel more attractive and self confident for years.

One of the most popular forms of aesthetic surgery, it may be done in two different ways:

• In closed rhinoplasty, all incisions required to reshape the tip and bridge of the nose are placed inside the nostrils. As a result there are generally no external scars, unless the size of the nostrils is also reduced (alar base reduction.) In this situation, there may be small scars in the furrow between the nostril and the lip. If the tip of the nose requires considerable reshaping, a small scar under the midline of the nose may also be necessary.
• In open rhinoplasty in addition to the incisions inside the nostrils, there is a small incision placed on the columella (the small bridge of skin between the nostrils.) Some surgeons prefer this approach because it gives them greater control if intricate reshaping is required for the cartilages in the tip of the nose. The advent of computer simulation in the preparation for surgery, leads to greater accuracy of the planning process and therefore higher expectations from the patient. Our practice believes open tip rhinoplasty offers a more accurate way of achieving these specific targets.

Nose surgery consultation: some important decisions

During your consultation, your surgeon will ask about your general medical history and any previous surgeries or injuries to your nose. He'll also want to know how well you are currently breathing through your nose.

He will be especially interested in why you are unhappy with the appearance of your nose and what results you are hoping your procedure will achieve. Most people would like their noses to be smaller. In some cases, though, an increase in size may be appropriate.

• It is very important that you be entirely forthright with your surgeon about what kind of nose you would like to have. People sometimes fail to describe their true expectations, asking for an average nose when, in reality, they have a very specific size and shape in mind. Only by telling your surgeon exactly what you want can you and he determine whether it is possible and desirable.
• At the same time, you need to be aware that everyone is different and what may work well for one person may not work well for another. For example, skin thickness varies enormously and a small, delicate nose and rarely be made from a large, thickened one.
• Feel free to bring photographs of noses you admire.
• Your surgeon may also use computer simulations to help you see what changes are feasible and what they would look like. These simulations can often help patients describe the results they want and the changes they would like to avoid. You need to be aware, though, that a computer simulation is not a guarantee of the result, as each person's tissues have their own healing pattern that may influence the outcome to some extent.
• This discussion of the kind and degree of change you want will determine which type of procedure your surgeon recommends.

Types of rhinoplasty procedures

Reduction Rhinoplasty:

Reduction rhinoplasty, which aims to reduce the way a larger nose can dominate the profile, is the kind of rhinoplasty most commonly requested by both men and women.

• A mistake people often make is assuming that simply reducing the size of the nose will produce a positive outcome.
• It is important to appreciate that when the chin projection is insufficient, the profile seems to be dominated even by a small or average nose, but the solution in that case may be to augment the chin and possibly do a small reduction or no reduction to the nose.
• In a significant reduction procedure, all elements of the nose are influenced, and the skin will take more time to redrape and settle down fully.

Augmentation rhinoplasty (ethnic rhinoplasty):

Augmentation rhinoplasty, a group of procedures that involve increasing the projection of the bridge and the tip of the nose, is more commonly requested by patients from ethnic groups that tend to have a softer cartilage support to the nose and a less defined configuration of the bridge. It is also sometimes necessary in patients that have undergone significant injuries, or multiple procedures.

• Materials used to support the tip and augment the bridge can be artificial, or taken from the patient's own tissues (bone or cartilage).
• In our practice, we have found a rib cartilage to be versatile material that shows excellent tolerance and long-term benefits.
• Use of implants for augmentation purposes is widely popular, as it is a simpler procedure to do, but unfortunately carries also higher risks of infection and revision.

What to expect from nose surgery

Rhinoplasty is typically carried out under general anaesthesia.

The first step is the removal of any hump to provide a new profile.

• If nothing else were done at this point the bridge line of the nose would be too wide, so it is usually necessary to fracture the nasal bones in a carefully controlled way to allow them to meet at the midline and form a narrow bridge line.
• Cartilages under the skin that shape the tip of the nose are adjusted in size and shape to refine your nose to match your new profile.
• When surgery is complete, small dissolvable stitches are placed inside the nostrils and tapes and plaster cast are applied.
• A small plaster cast is required for seven days to support and protect the bones while they set in their new position.

In some cases it is necessary to implant tissue into the nose to obtain the desired result. This procedure, termed a graft, may use tissue obtained from the nose itself or from the cartilage of the ear. Less often, the graft is taken from the ribs or uses man-made material. In these graft situations, the risk of infection is slightly higher so antibiotics are prescribed.

Frequently, internal silicone rubber nasal splints are used to ensure the lining of the nose sets correctly. This means you will most likely have to breathe through your mouth until they are removed during a simple procedure seven days after your surgery. This technique is more common when significant nasal deviation is corrected during surgery.

Even if packs or splints are not used, your nose may feel blocked up and you'll be unable to breath through it fully due to normal post-operative swelling. If the breathing passages have been operated on, it may take some time for the nose to clear. after your surgery.

Because your nasal bones will have been re-set, you may have "black eyes" after surgery and your face may be swollen. Most of this swelling will should settle in two weeks and you may use makeup to cover any bruising as soon as the plaster has been removed (usually in about a week).

Pain after Rhinoplasty, however, is not usually a problem and can be easily relieved by injections for the first few hours and a mild analgesic such as Paracetamol in the following days.

After your surgery you will be advised to take a number of precautions:

• It is important to avoid aspirin for some time because it can promote bleeding.
• You should also avoid stooping or vigorous activity for two or three days to reduce the risk of a nosebleed.
• It is imperative that you not blow your nose for 10 days after surgery. You may loosen and remove any crusts or clots on the insides of your nostrils using a little Vaseline or water on a cotton bud rolled around inside the nostril margin.
• There is some evidence that to take Arnica for a week before your surgery can help reduce the bruising. Continuing to take it during the two weeks following surgery will help decrease swelling and bruising.

Recovering after nose surgery

It is essential to remember that the shape of your nose when the cast is removed is not the final one. Indeed, the healing process takes at least six months.

During the following six months, you'll notice some changes:

• If you have chosen an alar-base reduction, your sutures will usually be removed at one week. The scars may be a little red at first but will be hidden in the natural shadows of the nose.
• It is normal for the tip of the nose to feel a little numb after surgery, however the sensation will recover as the nerve supply to the skin regenerates.
• In the months after your surgery, scar tissue forms beneath the skin of the nose. During this process, called scar maturation, your internal scars will gradually change their shape. This may have a profound effect on the final shape of your nose.
• Scar maturation takes an average of six months but can take longer. Generally speaking, the thicker the nasal skin the longer the period of scar maturation. This process can sometimes be accelerated with small injections of anti-inflammatory steroid in the tip of the nose.
• You can gauge the progress of the healing process by gently squeezing the tip of a normal nose, then squeezing yours to compare the firmness.
• Very occasionally, a blind boil type of infection may occur in the nose tip. This can readily be treated with antibiotics.
• Significant bleeding (secondary haemorrhage) is very rare and usually caused by infection.

A patient approach

It is important to take a patient approach. Remember, the final result of your surgery will not be properly visible for at least six weeks, and will take in excess of six months to settle completely.

In a small but significant number of cases (about 10%) both the patient and surgeon feel the shape of the nose after six months is not quite that which was intended. This problem is most common in cases where the patient has had a severe injury or a very large reduction in the size of the nose.

A second procedure may be called for. If the first procedure has touched on the majority of the targets set, these secondary procedures are usually simply minor adjustments, however, it is important to remember that they cannot be carried out immediately. The nose has to be allowed to settle before further surgery is safe or desirable.