Rhinoplasty is a well-established procedure that has been helping patients feel more attractive and self confident for years. Most people considering rhinoplasty want to bring the size and shape of their nose into better balance with their face. A smaller percentage of patients consider nose reshaping due to nasal deformity either from previous nose injuries or innate anomaly. Many patients have been teased about their noses since they were children, and they are eager to correct characteristics that have caused them years of embarrassment. They want a nose that compliments their other features rather than dominating their appearance.
Candidates for rhinoplasty
Most frequently, patients who desire rhinoplasty are concerned that their nose appears too large or out of proportion to the face, are bothered by the hump on the bridge of their nose, or feel that their nasal tip is too wide or droopy. Another common reason for rhinoplasty is to correct a crooked nose deformity. The latter is usually accompanied also by breathing difficulties.
A good candidate for nose reshaping surgery may:
- Have a nose that is too large in comparison with other facial features
- Have a hump on the bridge of the nose
- Have a wide nose
- Have a nasal tip that is droopy, enlarged or bulbous
- Have nostrils that are excessively flared or pinched
- Have a nose that is crooked or off-center
- Have been injured so that the nose is asymmetrical or deformed
Preoperative consultation and planning
Besides the interview, the most important part of the consultation is taking photographs and evaluating them with the patient. Various aspects of the nose are digitally changed in order to have an idea how each aspect of the procedure will change the final appearance of the nose. It is also a useful tool to improve communication between the patient and the surgeon and to understand the patient’s needs.
The cartilaginous and bony skeleton of the nose is accessed by two surgical approaches:
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. Contrary to common misconception, closed rhinoplasty enables to reshape entire nose. If extensive modification of the nasal tip is performed, some surgeons call this as hybrid or open-closed rhinoplasty.
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). This allows surgeon to see and work on the nasal framework in its natural position under direct view. 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. If the columellar incision and its suturing are done properly, the scar is almost invisible. However, our practice belives that better visibility during open approach rhinoplasty does not weigh up its disadvantages like greater surgical trauma, more pronounced post-operative swelling, and less predictable results.
Below are examples of closed rhinoplasty. The first picture has been taken immediately before and the second picture immediately after operation.
What to expect from nose surgery
Rhinoplasty is typically carried out under general anaesthesia. The first step is the removal of any hump, if present, 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. Next, 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.
In some cases it is necessary to implant tissue into the nose to obtain the desired result. This procedure, termed a grafting, may use tissue obtained from the nose itself (typically nasal septum) or from the cartilage of the ear or from the ribs. Some surgeons use also man-made material for grafting, such as silicone, which we don’t used in our practice.
Early postoperative period
When surgery is complete, small dissolvable stitches are placed inside the nostrils. There is no need to remove them. 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.
Even if packs or silicone 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 settle in two weeks and you may use makeup to cover any bruising as soon as the cast has been removed.
Most patients are surprised to experience relatively little pain and it can be easily relieved by mild analgesics such as Paracetamol or Ibuprofen.
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 6-12 months.
During the following 6-12 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. It is also normal to experience stiffness to the tip of the nose, particularly in early period after surgery. Such stiffness resolves together with the remnants of the swelling.
- 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.
- Very occasionally, an infection may occur in the nose tip. This can readily be treated with antibiotics.
Remember, the final result of your surgery will not be properly visible for at least six weeks, and will take in excess of 6-12 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.