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Rhinoplasty

Procedure:

The incisions are made and the skin and fat are lifted off the cartilage and bone which are the structural elements of the nose. Reshaping is done by some removal of the cartilage or bone. At times sutures can be used to help remodel the cartilage and at other times cartilage or bone grafts can be used to augment change or hide the shape of the native structures.

Usually the tip cartilage is addressed first then the dorsal hump is removed or reduced. That can be done by rasping the tissue or by direct removal with an osteotome or chisel. Removal of the dorsal bump usually leaves what’s called an open sky deformity which mean there is an open space on the top of the nose. That typically requires fracturing the side bones of the nose to bring them together on top. That can be done either internally or externally depending on the surgeon’s preference. At that point the incisions are closed, the nose is packed and an external splint is applied. Variations from these techniques are done depending on each individual patient and the surgeon.

Primary and secondary

Primary rhinoplasty refers to first-time rhinoplasty whether it is performed for aesthetic, functional, or reconstructive purposes. Revision rhinoplasty, also known as secondary rhinoplasty, is a nose operation performed to correct or revise the outcome of a previous rhinoplasty.

Revision to a rhinoplasty may occur in 5% to 20% of cases. Revision may be required for functional reasons, because the patient is not satisfied with the outcome or breathing problems continued or occurred. The causes of dissatisfaction with the results are varied. It may be a technical problem, issues with scaring or unwanted changes in function that occurred after the surgery.

Satisfactions with the results of a rhinoplasty depend on many things including the patient’s own anatomy and what is technically possible. It may also be the technique of the surgeon or unexpected post surgical problems. In desiring revision it is very important for the patient to understand the causes of the problem and what is surgically possible.

Secondary opinions from other surgeons may be helpful.

There are two main reasons for performing secondary rhinoplasty. Patients often seek secondary rhinoplasty to correct a cosmetic deformity of the nose.

A patient may be unsatisfied with all or part of a previous "nose reshaping.”. A nasal fracture may not have been reduced enough, or too much. A prominent or bulbous nasal tip may have not been addressed appropriately, or over-aggressively. The nose may looked pinched, it may look like a parrot’s beak, or like a boxer’s nose. There are many ways in which previous nose surgery may have left a nose aesthetically unappealing to a patient. The second reason is functional. The original nasal surgery may have been carried out to help with difficulties in breathing, and the outcome may have been unsatisfactory. Alternatively, the original surgery may have been performed for cosmetic reasons, but may have disrupted a normal physiologic mechanism involving the inspiration or expiration of air, making it difficult to breathe. Secondary rhinoplasty is a procedure often said to be extremely complicated. Because the nasal framework has often been destroyed or deformed from previous surgery, revision rhinoplasty experts frequently must reconstruct the support structures of the nose using cartilage grafts from either the ear (auricular cartilage graft) or from rib cartilage (costal cartilage graft). Most revision rhinoplasty specialists perform secondary rhinoplasty via the open approach. This allows the surgeon to directly visualize the deformity. Advances in rhinoplasty techniques, such as stabilization of rib cartilage grafts and utilization of the open approach, now allow satisfactory results in secondary rhinoplasty that were not possible in the past.

Functional and reconstructive

Reconstructive rhinoplasty refers to restoring the normal shape and function of the nose following damage from a traumatic accident, autoimmune disorder, intra-nasal drug abuse, previous injudicious cosmetic surgery, cancer involvement, or congenital abnormality. Rhinoplasty can restore skin coverage, recreate normal contours, and re-establish nasal airflow. To improve nasal breathing function, a septoplasty may also be performed. If there is turbinate hypertrophy, an inferior turbinectomy can be performed. Rhinoplasty may be sought in the aftermath of traumatic deformity. Traumatic accidents are the most common cause of nasal deformity. Typically the nasal bones are broken and displaced. Occasionally, the nasal cartilages are disrupted or displaced, and in the worst cases the nasal dorsum is collapsed. Rhinoplasty allows shaving of the displaced bony humps, and re-alignment of the nasal bones after they are cut. When cartilage is disrupted, stitching of the cartilage for re-suspension, or use of cartilage grafts to camouflage depressions allows re-establishment of normal nasal contour. When the dorsum is collapsed, grafts of rib cartilage, ear cartilage, or cranial bone can be used to restore continuity to the dorsum. Although synthetic implants are also available for augmenting the nasal dorsum, cartilage or bone graft from the patient’s own body poses fewer risks of infection or rejection.

The lower lateral cartilage (greater alar cartilage) exposed through the left nostril for modification during a rhinoplasty. Rhinoplasty is sometimes sought for a collapsed nose due to septum perforation. Autoimmune problems such as Wegener’s Granulomatosis, Sarcoidosis, Churg-Strauss Syndrome, and Relapsing Polychondritis can lead to creation of a hole in the nasal septum, and loss of support in the dorsum leading to a saddle nose deformity. Intra nasal use of drugs such as cocaine, or extreme abuse of nasal decongestant sprays can similarly cause septum perforation and nasal dorsum collapse. Dorsum reconstruction is accomplished through the use of rib cartilage or bone grafts.

Rhinoplasty to correct nasal obstruction following injudicious cosmetic surgery is common. Reconstructive rhinoplasty after injudicious cosmetic surgery allows the restoration of normal breathing. When nasal cartilages are over-aggressively trimmed during rhinoplasty, the nose can appear pinched and nasal potency compromised. Patients complain of nasal blockage that is worsened by attempts at deep inspiration. Internal cartilage grafts to support the nasal tip (batton grafts) or widen the middle vault of the nose (spreader grafts) can be quite effective in restoring normal breathing. These grafting techniques will increase the size of the nasal tip and widen the dorsum.[6] Rhinoplasty for skin cancer excision also exists. Excision of skin cancers from the nose can lead to loss of internal support as well as external skin coverage. Skin cancer excision in the nose is commonly accomplished via the Mohs’ technique. Once the cancer is removed, reconstructive rhinoplasty aims to provide skin coverage utilizing techniques such as skin graft, local skin flaps, or pedicle flaps. If cancer resection leads to loss of tissue in the area of the nasal tip, cartilage grafts are utilized to maintain support and prevent long-term distortion, by the force of scar contracture.

Rhinophyma is the late stage manifestation of a skin condition known as Rosacea, where the skin is infected with acne roseacea. The skin in the area of the nasal tip becomes red, thickened, and enlarged as exemplified by W C Fields. Although known acne treatments such as antibiotics and Acutane can halt the progression of this disease, thickening of the skin and obscuring of the nasal tip landmarks can only be remedied by surgical correction. Currently, laser excision of thickened abnormal skin represents the best option in rhinoplasty for Rhinophyma. The CO2 laser and the Erbium YAG laser are the most effective types of laser for this disorder.

Vascular malformations and cleft lip anomalies are relatively common causes of congenital nasal deformities. In vascular malformations, the disease process can cause distortions of the skin and underlying structure of the nose. In cleft palate abnormalities, the size, position, and orientation of the nasal tip cartilages may be distorted. Rhinoplasty for reconstruction of vascular malformations can involve laser treatment of the skin and possible surgical excision. When the underlying cartilage structure is disturbed, cartilage grafts and stitching of the native nasal cartilages can help improve nasal appearance. In cleft lip patients, reconstructive rhinoplasty allows re-orientation of the nasal tip cartilages. Additional refinements with cartilage grafts to the tip are also frequently employed.

Ethnic

Although techniques and methods employed during rhinoplasty surgeries are the same regardless of ethnicity[citation needed], there are some trends that apply to patients of certain ethnic backgrounds, due to their similar anatomic features. East Asian patients often want their noses to appear narrower and their bridges higher. If very little elevation of the bridge is desired, the nasal bones can be cut and moved towards the midline. This technique will narrow the bridge and also cause a slight elevation in the dorsum. East Asian patients who seek greater augmentation of the bridge of their nose require implants. A variety of alloplastic implants including Gore-Tex, Med-Por, or silicone can be used. Tissues from the patient's own body (autologous) can be used for augmentation, in order to reduce the risk of complications such as infection or extrusion. Septum cartilage, rib cartilage (costal cartilage), ear cartilage (auricular cartilage), and fascia are being often used. In non surgical rhinoplasty, filler materials such as hyaluronic acid or calcium based microspheres can be injected under the skin, in the bridge of the nose. These injections however, are non permanent lasting between six months to a year.

Patients of African descent commonly seek narrowing of wide nostrils in a procedure known as alar base reduction. This procedure may include removing sections of the base of the nostrils or sections of the nose where it meets the face. Risk of keloid scar formation is very low, if the patient has not had keloids in the past. The tip of the nose can be restructured by removing tiny sections of cartilage to give the nose more definition, or adding cartilage grafts to provide additional structure to the nasal tip.

Non-surgical

Non-surgical rhinoplasty refers to reshaping the nose with injectable substances rather than surgical means of altering the shape and structure of the nose. It is also called a "non-surgical nose job", and can be performed in the outpatient setting without anesthesia. Another non-surgical option used by some people are flexible "nose inserts" that are placed in the nostril area between the nose tip and back of the nose. The nose inserts reshape one's nose only while worn.

Recovery

The patient returns home after the surgery. Most surgeons recommend antibiotics, pain medications, and steroid medication after surgery. Most people choose to remain home for a week, although it is safe to be outdoors. If there are external sutures, they are usually removed 4 to 5 days after surgery. The external cast is removed at one week. If there are internal stents, they are usually removed at four days to two weeks. The periorbital bruising usually lasts two weeks. Due to wound healing, there is moderate shifting and settling of the nose over the first year.

Health risks

Although rhinoplasty is usually considered to be safe and successful, several complications can arise. Post operative bleeding is uncommon and often resolves without needing treatment. Infection is rare and can occasionally progress to an abscess that requires surgical drainage under general anesthetic. Adhesions, which are scars that form to bridge across the nasal cavity from the septum to the turbinates, are also rare but cause nasal obstruction to breathing and usually need to be cut away. A hole can be inadvertently made at the time of surgery in the septum, called a septal perforation. This can cause chronic nose bleeding, crusting, difficult breathing and whistling with breathing.

If too much of the underlying structure of the nose (cartilage and/or bone) is removed, this can cause the overlying nasal skin to have little shape resulting in a "polly beak" deformity. Likewise if the septum is not supported, the bridge of the nose can sink resulting in a "saddle nose" deformity. The tip of the nose can be over-rotated causing the nostrils to be too visible and creating a pig-like look. If the cartilages of the tip of the nose are over-resected, this can cause a pinched look to the tip. If an incision is made across the collumella (open approach rhinoplasty) there can be variable degree of numbness to the nose that may take months to resolve.

Natural Looking Designed To You.

Although each person's results will differ, before and after photos are good examples of potential changes. They should be used not only as a comparison of techniques and surgeons, but are good starting points for evaluation, comparison and discussion with your surgeon. Please note that these are post surgical photos that are not suitable for all audiences. Viewers should be 18 or older to view the gallery images.

See More Before and After Photos >

Side Effects

There is expected temporary discomfort, swelling, and bruising. A temporary feeling of tightness may also be possible.

Smoking

Smoking may be one of the most important factors that increase the risk to facial surgical complications. If you are a smoker, you will need stop smoking for least two weeks before the surgery and two weeks after. You must not smoke for this time period to ensure proper healing, because cutting down is not adequate. Nicotine gum and nicotine skin patches can lead to the same healing problems caused by smoking.

Other Medications:

Some medications that increase bleeding times may add to the risk of bleeding during any surgery but especially during facial surgery. It is important to discuss all medications that you are taking both prescription and over the counter.

Risks

These include infection, pooling of blood beneath the skin (hematoma), and loss of sensation.

Recovery

Bruising is usually minimal but may last 2-3 weeks.

Duration of Results

Results may be enjoyed for 7 to 10 years.