Rhinoplasty (Nasal Surgery)
Rhinoplasty can be one of the most rewarding aesthetic procedures. Rhinoplasty is surgery of the nose which is done to recontour the external features of the nose in order to improve the external appearance of the nose. Rhinoplasty is done to improve certain nasal characteristics which detract from the nose and facial appearance.
The goal is to reshape, redirect or resize the nose in order to obtain a more harmonious aesthetic balance of the nose with other facial features.
The nose is a prominent and central facial feature. The symmetry and form of the nose is the first thing that catches ones eye when they look at a face. Imperfections in form, symmetry, and facial balance between aesthetic units can detract from ones overall beauty.
The nose is a complex facial feature and is unique in each individual. In rhinoplasty as in other aesthetic procedures the individuality of your nose and its relationship to other facial features must be recognized and respected. When forming a plan for nasal surgery, our team tries to preserve the positive characteristics which make your nose individual and unique and modify only those characteristics which detract. It does not make sense to envision the perfect nose placed on your face–This is illogical because it ignores the need to have balance between your nose and other facial characteristics and does not respect the individuality of your facial features.
In addition to aesthetics, the nose performs critical functions in breathing. The nose allows the passage of air into the airway while humidifying the air, filtering the dust, and warming the air to the ideal temperature for your lungs. In rhinoplasty surgery we must respect the physiologic functions of the nose. Making a nose smaller and narrower can negatively affect the passage of air through the nose by creating increased resistance. By making certain modifications to the rhinoplastic procedure we can maintain the functions of the nose.
Septoplasty and Turbinoplasty
In addition to Rhinoplasty, two related procedures can be performed in order to improve the function of the nose: septoplasty and turbinoplasty.
Septoplasty is surgery that is done on the nasal septum the middle wall between the right and left passages. In many patients this wall is bent, twisted, bulging or displaced off of the center line. In these cases correcting the anatomical discrepancy can increase the ease with which air passes through the nasal passages. In severe cases it can help to improve sinus function if the septum impinges on the drainage points from the sinuses.
Turbinoplasty is a surgery of the turbinate bones. Turbinate bones are curly bones within the nasal passages, which help warm and moisten the air as it passes through the nose by increasing the surface area of the mucosa. In some cases especially with septal deviation, the turbinate’s can become enlarged malformed and impinge on the nasal walls, in these cases a conservative surgery on the turbinate’s can improve the nasal airway. Many times when rhinoplasty is considered, septoplasty and turbinoplasty are also considered.
Deciding on Surgery
In all cases the principles of conservatism overrides in nasal surgery. When approaching any cosmetic surgery, the patient must understand that in a small percentage of cases, minor adjustments or additional revisions may be necessary following the initial surgery. This occurs in less than 10% of the cases but the patient must be prepared for this eventuality or possibility. Because conservatism is an overriding principle, it is always better to under correct than to overcorrect a deformity. Patients must also realize that their final result will not be evident for several months after the surgery due to swelling and continued healing of the wounds. In rhinoplastic surgery any revisions are delayed for 6 – 12 months.
No rhinoplasty result is ever totally perfect. It is important the patient focuses on the degree of improvement of their nose instead of any small lack of perfection. Although perfection is my goal when performing surgery, no rhinoplasty result is ever totally perfect. If small imperfections will prevent you from focusing on the degree of improvement in your nose, you should probably not have a rhinoplasty. It should also be noted that every small imperfection following surgery should not be reoperated. Reoperation procedures are less predictable and involve more risk. By entering into the procedure with the idea of improvement and not perfection you will be able to enjoy your result and your experience will be a rewarding one.
The initial consultation visit will consist of a medical history and physical exam. The medical history will focus in on that which is pertaining to your nose such as trauma, allergic conditions and previous surgical procedures that may have been performed on the nose but will also cover all general medical aspects. Of special interest are any specific problems which you are experiencing with your nose or aesthetic qualities which you consider undesirable and would like corrected. Next the examination will consist of an external examination of not only the nose but of the entire face. This will be followed by internal nasal examination. We will discuss in detail your desires and the degree to which you feel these desires can be met by a surgical procedure. Preoperative photographs will be taken. These are critical to the planning procedure and follow-up of your rhinoplasty and are maintained as a portion of your record. Prior to the procedure I will analyze the photographs and use them to help plan the operation.
You will be given specific presurgical instructions when you are scheduled for your surgery it is important that you follow these written instructions completely. In addition to the normal presurgical instructions of fasting before surgery, there are certain specific instructions for rhinoplasty that you should be made aware of.
No aspirin or medications containing aspirin should be taken for at least two weeks prior to surgery since they will interfere with normal blood clotting. Tylenol is acetaminophen and may be used instead. Some common medicines that contain aspirin and which should be avoided include:
Alka-Seltzer, Anacin, Ascription, BC Powder, Bufferin, Corescedin, Darvon compound, Fiorinal, Tristan, Excedrin, Mytodal, Sinaide, Sinoff, Norgesic Percodan, anything that has “ASA” abbreviated on the bottle, etc.
If in doubt check the label carefully, ibuprofen and ibuprofen containing medicines such as Advil, Motrin, etc should also be avoided.
Another area of concern is nicotine use. Smoking or chewing tobacco is a source of nicotine. Nicotine causes constriction of blood vessels and can impair circulation to tissues. The body’s ability to bring oxygenated blood to healing tissues is directly related to healing. Tobacco use impairs healing greatly. Tobacco use should be discontinued at least 6 weeks prior to the procedure and for a minimum of 6 months following the procedure. Please see the section under Surgical Instructions> Rhinoplasty
The Rhinoplasty Surgery
Rhinoplasty, septoplasty and turbinoplasty procedures may be performed either using IV sedation or general anesthesia. Often these procedures can be performed right in our own in-office surgical suite. The procedure is performed through small incisions made inside the nose or inconspicuously on the outside of the nose.
Internal splints or packs may be necessary and are usually left in for only a few days. But in some cases no packs or internal splints are used. Due to swelling and drainage of material and fluid following surgery, some degree of blockage of the nasal airways is normal. But you will be able to breathe partially through the nose. A thin external splint will be applied to the outside of your nose if repositioning or reshaping of the nasal bones is part of the surgical procedure. The nose will also be taped and the tape usually remains in place for five to seven days post-surgically.
You will be given prescriptions for pain medications and other medications to enhance your healing and the directions should be followed carefully. Discomfort from the nasal procedures is usually worst in the first 24 hours, but minimal after that. It is common for patients to use only over-the-counter pain medicines like Tylenol to control pain. Use the pain medications as prescribed. One aspect of the care of the nose after surgery is careful cleaning with a saline nasal spray. This is essentially like natural tears but for your nose. By using this as directed you will be able to keep your nasal passages open and clean. If blood clots form at the openings of the nose, then it will be necessary to use a solution of 50% water and 50% hydrogen peroxide via a cotton tipped applicator (Q-tip) to gently dap away the clotted blood. Diligent use of the saline nasal spray and careful attention to the nose will maintain it in an open and clear condition. Drainage from the nose is normal for at least 3 days following the surgery and may continue longer. It may be heavy enough that you will need to use a small piece of gauze taped beneath the nose like a mustache. This we refer to as a mustache dressing. It is important that you do not blow your nose after surgery. You may gently sniff in especially when doing the saline nasal sprays. Do not sniff in strongly.
The tape that is placed over the nose assists in having the skin appear to the new nasal framework. It also helps to minimize postoperative swelling. The tape should be kept as dry as possible but can be wetted. As the patient may take a shower and let water run over it. Do not soak the tape completely and do not allow soapy water on the tape. Soapy water will remove the adhesive and the tape will peel off. Depending on the amount of perspiration and oiliness to your skin the tape may begin to loosen at only 3 days. In this case loose ends of the tape may be trimmed.
After surgery you will be able to see some of the changes immediately however you will notice that the tip of your nose will retain the swelling more than the rest. After the first two weeks you will notice most of the changes that have occurred. However subtle changes will continue to occur for months especially in the nasal tip.
Once again it is important to focus on the overall improvements and not worry about slight differences in certain areas. If the nasal bones have been modified as part of the surgery you should not wear glasses for at least 6 weeks. Be careful to avoid any inadvertent blows or pressure on the nasal bridge or any portion of the nose. This can cause displacement of the nasal bones. If by accident something should occur, please contact my office immediately. A small surgical procedure may be able to be done to reposition the bones so that they can heal in the proper position.
Bruising is normal following rhinoplasty. Especially if the nasal bones have been modified. This usually resolves in 10-14 days. With the use of specialized make-ups patient’s can completely hide any bruising within 3-5 days. Strenuous exercise should be minimized for at least 2 weeks following surgery. Activities such as stooping, bending over, and lifting objects should be avoided especially in the initial 72 hours. The nose will have a decreased sensation to touch for several weeks following surgery. The sensation will gradually return. Changes in sensation can return for up to 2 years after surgery. Again the nasal tip will be the last area to regain sensation.
Risks and Possible Complications of Rhinoplasty
Excessive bleeding following nasal operations can occur but serious bleeding occurs in less than 5% of cases. Should this occur additional packing of the nose or examination and control of the bleeding point by caudery may be necessary. The initial treatment is to use Phenylephrine nasal spray (Afrin). This shrinks the blood vessels temporarily and may be enough to stop any bleeding. Do not use afrin or any other nasal spray on a regular basis unless it is prescribed. The chronic use of nasal sprays other than saline nasal spray will make the Phenylephrine nasal spray less effective, or completely ineffective. Slight irregularities or under correction of small areas of the nose may result following rhinoplasty and may require further correction. Infection is possible but is rare. Inadvertent blows or manipulation of the nose may produce movement of the nasal structures which might result in a loss of the desired configuration or symmetry of the nose and may require reoperation. If recognized early these abnormalities may be corrected with simple operative procedures. Cartilage relapse is a problem where the cartilage regains its original shape. The cartilage of the nasal septum and the nasal structure of the tip is spring-like and even when it is moved and reshaped surgically the cartilage can partially return to its original shape. In-so-far-as the septum is concerned a portion of the cartilaginous septum must be left in place in order to support the nasal tip. There is a delicate balance between maintaining the support mechanism and correcting its abnormal position and or shape. For these reasons incomplete correction or recurrence of deformities can occasionally occur. Failure to heal properly can occur some patients tend to heal with excessive scar formation the shrinking nature of scars is very powerful and can deform the internal or external shape of the nose. Perforations or holes in the nasal septum may also occur due to poor healing. These may require secondary procedures to correct change in smell can occur following rhinoplasty especially if extensive septoplasty is performed but in any case is rare.
To preview Pre-Operative Instructions, Consent and Post-Operative Instructions along with the scheduled visits, see Surgical Instructions> Rhinoplasty.
To view our photo gallery see Before and After Gallery.