Rhinoplasty (nose job) is an operation that changes the shape and size of the nose. Rhinoplasty could be considered in the following situations:
- There is general dissatisfaction with the shape or size of the nose. The nose seems to be too large or too small, or out of proportion with the face
- The dorsum of the nose is either too wide, too high (nasal hump) or too low (saddle nose deformity)
- The tip of the nose is too droopy, too upturned, too protruding (long), or too wide
- There is discomfort regarding the shape or size of the nostrils. Nostrils could be too big, too visible, or flared
- The nose is deviated or deformed due to previous trauma or due to congenital problems
There are two basic techniques for performing nose correction: closed (endonasal) and open (external) rhinoplasty.
In the closed approach rhinoplasty, all incisions are placed inside the nasal passages.
As a result, there are no external scars, unless the size of the nostrils is also reduced (alar wedge and/or nostril sill excision). Although working through nostrils limits visualization, an experienced surgeon can still perform all required reshaping of the tip and dorsum. The advantage of the closed technique is that it enables the surgeon to see changes in the shape of the nose during surgery in a gradual fashion, it is less aggressive, and therefore allows much faster recovery. This approach is a preferred surgical technique in my practice.
In the open approach 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). If the columellar incision and its suturing are done properly, the scar is almost invisible. The open technique has the advantage of providing better visualization of the nasal structures allowing better accuracy during surgery in some cases. Unfortunately, it is far more aggressive surgery and may lead to unpleasant surprises in the long term: collapsed noses, fallen tips and irregularities. In our practice, the open approach is used in following situations: revision rhinoplasty and/or reconstructive rhinoplasty; heavily deviated or deformed nose; reduction of large nose with significant upturn of the tip, or rhinoplasty in patients with very thick and oily skin. In these situations, better visibility and control weigh up the disadvantages of the open approach.
Preoperative consultation and planning
Approximate duration of the consultation is about 60 minutes. Patients can always take additional consultations, if they feel that some important aspects need to be discussed more thoroughly. A VIRTUAL CONSULTATION is becoming increasingly popular. In that case, consultation is done online (Skype or Zoom) or by using e-mail. You can read how to take photographs for a virtual consultation here.
Conventional consultation consists of an interview with the patient and taking photographs of the nose and the face in different angles. The latter are then analysed and discussed with the patient. In order to understand patient’s expectations better and improve communication between consultant and patient, the desired result is simulated by appropriate software. The patient has to understand that simulation of the photographs does not guarantee exact results. Simulation is a useful tool for a surgeon to understand patients’ desires better, and to demonstrate possibilities and limitations of the rhinoplasty.
More detailed information about preoperative preparation can be found here.
Rhinoplasty procedure steps
Rhinoplasty consists of three main steps:
- Correction of the nasal dorsum
- Correction of the nasal tip
- Correction of the shape and size of nostrils and alars
All those steps can also be done as a separate independent operation. Many patients, for instance, only require hump removal to achieve the desired aesthetic result. Some patients, especially males, are looking only for correction of the deviation or deformity, which usually involves only the dorsum area. On the other hand, some other patients only want to change the shape and size of the tip without touching the dorsum. Infrequently, some patients only wish to improve the shape and size of the nostrils and alars. In some cases, rhinoplasty is performed in combination with septoplasty and the procedure is then called septorhinoplasty.
If all three steps are required, the sequence of the steps is as follows:
- Correction of the nasal dorsum may involve reducing or increasing the height of the dorsum, narrowing or widening of the dorsum, or correction of the deviation. In aesthetic rhinoplasty, the most common procedure is lowering the height of the dorsum (removal of the hump) in combination with its narrowing. It can be done by using various techniques. In cases where the dorsum of the nose does not have a sharp-angled hump, but is too high in its entire length instead, the most preferred technique is full mobilization of the entire bony pyramid using a micro-saw. After osteotomies and mobilization, a few millimetres wide strip of cartilage is removed from the upper part of the septum, followed by a push-down manoeuvre of the dorsum. The advantage of this technique is the preservation of original dorsal anatomy and aesthetics and belongs among one of the PRESERVATION RHINOPLASTY techniques.
In some cases, mobilization of the entire bony pyramid and push-down manoeuvre can be done without dissection of the dorsal skin. In this case, postoperative cast becomes unnecessary. A before-and-after picture demonstrates the hump removal result using the modern push-down technique. In patients who have a sharp-angled hump or severe deviation/deformity of the nose, correction of the dorsum has to be done in a classical way. That includes dissection and elevation of the dorsal skin, followed by direct manipulation of the bony and cartilaginous structures. Very rarely, increasing the height of the dorsum (augmentation) is required. In less severe cases, it can be done using septal or ear cartilage, and in more severe cases rib cartilage grafts have to be harvested.
- Correction of the nasal tip. In aesthetic rhinoplasty, the most common procedure is shortening of the tip (decreasing its projection) and, at least to some extent, upturn the tip (upward rotation). The tip surgery always has to follow dorsal correction, not in an opposite sequence, as the shape and size of the tip should be tailored according to the new dorsum. Application of preservation rhinoplasty techniques for the tip surgery needs to follow two main principles. Firstly, the dissection of the tip cartilages should be done using the subperichondrial plane. By doing so, tip cartilages are fully denuded and without any soft tissue remnants on them.
Subperichondrial dissection is more difficult than conventional suprapericondral dissection and is therefore time consuming. However, it carries two very important advantages: a) there is less postoperative swelling and bruising, b) revision surgeries, if needed, become much easier to perform. The second principle of preservation rhinoplasty is minimal removal of cartilaginous tissue. Instead, desired change in the shape and size of the tip should be achieved by changing shape and orientation of the tip cartilages. The goal is to replace resection with preservation, excision with manipulation and reduce the risks and the need for revisions. The picture here shows immediate postoperative result compared with a preoperative situation after removal of the hump and tip surgery.
- Correction of the shape and size of nostrils and alars. Two main procedures are alar wedge excision to reduce alar flaring, and nostril sill excision to reduce the size of the nostrils. These procedures can be combined. They are always performed at the final stage of the surgery. Patients should keep in mind that all those procedures leave behind scars, which are fortunately barely visible if done properly.
Early postoperative period
Frequently, internal silicone 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 5-7 days after your surgery. Tapes and a cast will be put over the nose to assist with healing and it can be in place for 7 to 10 days. All stiches used are self-resorbable and do not require removal. If the patient wishes, they can be removed at the time of cast removal. In the early period after surgery, during the first 3-4 weeks, patients can experience nasal blockage. It usually resolves spontaneously. Hematomas and bruising around the eyes are most intense on the 3-4 postoperative day and will resolve within 2-3 weeks. Surprisingly to most patients, postoperative pain is slight to moderate. The pain can easily be controlled with paracetamol or ibuprofen. In most cases, the course of per oral antibiotics is described to avoid infectious complications. Antibiotic containing cream must regularly be applied to internal and external wounds during the first 1-2 postoperative weeks. More detailed postoperative care is described here.
The shape of the nose after cast removal is not the final one. Recovery and healing processes are highly individual depending on the extent of surgery, the type of skin and general tissue responsiveness to surgical trauma. Early estimation about the expected result can be given after 1 month. Most of the healing process is done after 6 months and the final result is achieved after 1 year. In patients with very thick skin, full recovery takes up to 2 years. Until the very end of the healing process, patients may experience numbness of the nose tip. This is a normal response to surgical trauma and the sensation will slowly recover as the nerve supply to the skin regenerates. It is also normal to experience stiffness to the tip of the nose, particularly in the early period after surgery. Such stiffness resolves together with the remnants of the swelling. You can see before-and-after pictures of some our patients here. More recent results can be found in Instagram.
In a small but significant number of cases (about 10-15%), both the patient and surgeon feel that the shape or size of the nose is not quite that was intended. In these cases, revision rhinoplasty could be considered. Revision operations occur even with the most experienced surgeons because reasons for unsuccessful surgery are variable:
- Surgical faults (limited experience, inappropriate surgical techniques, time strain)
- Patient-related problems (drop of the tip due to weak cartilages, excessive development of scar tissue or other abnormal response of tissues to surgical trauma, excessive bleeding during surgery)
- Discrepancy between surgeon’s experience and skill on the one hand, and patient’s expectations on the other hand
Fortunately, revision surgery involves minor correction or retouching in most cases, especially in cases where preservation rhinoplasty principles were followed. If over resection was avoided and modification or reorientation of the bones and cartilages was preferred, the need for extensive reconstructive procedures is highly unlikely. It should be emphasized that revision surgery can be undertaken after complete healing, which means no earlier than 6-12 months after the last surgery. The risk for revision rhinoplasty is higher in the following situations:
- The nose has previously been operated multiple times. In those cases, probability for the third, fourth or even more corrective procedures is very likely
- The extent of primary surgery was very long. In these cases, the risk for revision surgery is higher because extensive surgery does not allow to control every detail in the shape of the nose. It is very rare that patients may request revision surgery because they could not cope with the new nose and the face.
- The nose was severely deformed or asymmetric
- There was extensive intraoperative bleeding. This, on the one hand, limits visualization during surgery and, on the other hand, leads to excessive postoperative swelling and scar tissue formation during healing. Scar tissue has a tendency to shrink over time and can cause several deformities
- Intraoperative exposure of unexpected anatomical malformations or deformations
Please note: We usually give some guarantee for the result. That means that if the revision surgery is needed (chance is about 10-15%) you do not need to pay the surgeon’s fee. You only have to pay for house expenses, your stay and for the anaesthesia.
The report card of rhinoplasty
- Preoperative preparation: Do not eat or drink 6 hours before the operation. Blood tests must be done a week before surgery
- The type of anaesthesia: General anaesthesia
- Duration of the surgery: 2 to 4 hours
- Duration of hospital stay: Can be discharged during the same day
- Pain after surgery: Light to moderate. Common painkillers are enough to control the pain
- Haematomas around the eyes: 7-14 days. Some patients do not develop hematomas
- Splints and cast: If they have been applied, they are removed after 7 days
- Stiches: Usually resorbable stiches are used which do not require removal
- Physical activity: Slight physical activity 2 weeks after surgery, full training after 4 weeks
- Last shape: Early estimation after 1 month, approximate result after 6 months and final result after 1 year