Rhinoplasty Surgery by Jan Stanek at Surgical Aesthetics

Rhinoplasty means alteration to the shape of the nose.  However, apart from shape alteration it can also imply change to the size.  In one form or another, it has been practised for thousands of years, but it was only a hundred years ago that surgeons started to operate through the inside of the nose, thus producing a “scar-less” operation.

Until quite recently, rhinoplasty was always carried out through incisions made inside nostrils.  More recently, surgeons have started to use an “open rhinoplasty” which, by making a small incision in addition to classic incisions, allows the surgeon to see the operative field, thus making the operation more accurate and predictable, especially in difficult noses.

The most common complaint about a nose is that “it is too big with a bump”.  If a nose is judged to be too big, it means that its size outbalances that of the face itself. The nose thus stands out becoming a feature rather than complementing the face.  Even a “beautiful nose” which is too big for the face will become an unattractive feature.  A hump, or bump on the bridge of the nose has a similar effect.  Moreover, it makes the face look masculine, which is the reason why most women want to have a retroussé nose or inward curved profile.  The size is as important as width, and when reducing one the other may have to be reduced at the same time to keep the nose in proportion.  Proportions of dimensions will have an important effect on the final outcome of rhinoplasty, and these have to be determined by the surgeon during surgery, this is where the surgeon’s eye is as important as his manual dexterity.

The nose’s tip is the final challenge to the surgeon’s skill and is arguably the most difficult in some cases.  The difficult noses are those with thin or very thick skin.  In noses with thin skin the surgeon has to avoid producing an over sculpted shape, which to the naked eye appears to be operated on.  Thick skin may disguise the reshaping of the cartilage or gristle, because it does not drape the new shape very well and has a tendency during the healing phase to form thick scar tissue.  Healing has the final say in how the shape is going to turn out, and this is outside the surgeon’s control.

Closed or classic rhinoplasty

Most surgeons carry out this technique for the majority of noses, and the results are good.  Access to the structures to be altered is gained through incisions in both nostrils, and the skin is lifted off the cartilage and bone.  If the bone is to be re-shaped or altered in size it is done by chiselling or filing, and the sides of the nasal bones are perforated and broken to alter their pitch and reshape the bridge to its natural round contour.  If the septum or nose partition is crooked, it may have to be re-shaped to give the nose a straight appearance.  It may have to be done, especially if the septum obstructs breathing on one side.  The tip cartilages, which determine the tip shape, are also altered through these incisions, either by size reduction, and, or by changing their shape. 

At the end of the operation the incisions are usually closed with absorbable stitches.  The skin is firmly taped up so that it re-drapes the new shape, and a splint is applied which prevents the nose swelling up too much during the first week after surgery.  A small pack is usually inserted into each nostril to stop blood dripping; it is removed the following day.

Open Rhinoplasty

The addition of a small cut across the lower part of the nose, the columella, joins up the internal incisions, and allows the skin to be lifted.  This allows the surgeon to see directly the structures he wants to alter.  This is particularly important for the tip cartilages and their symmetry.  The surgeon can also use grafts, such as cartilages from the ear.  Precise grafting can sort out even the most difficult of noses.  This applies particularly to noses that have been operated on several times.

Rhinoplasty: Possible Complications

  1. Bleeding:  surprisingly, a nose bleed after rhinoplasty is very rare, unless you already have a tendency to nose bleeds.  In most cases this problem is sorted out by re-packing the nose.

  2. Infection:  a very uncommon complication and cured by antibiotics.  It may be of a more serious nature when grafts, particularly man-made, are used, because it can lead to their rejection and subsequent removal.

  3. Scars:  although scars are hidden, scar tissue can influence the final shape of the nose, and this is particularly so in the area of the tip in people with thick or thin skins.  Some of this behaviour can be controlled by steroid injection after surger

  4. Difficulty in breathing:  Initially there is almost invariably some restriction to breathing due to internal swelling.  In some cases breathing may be reduced when the nose is narrowed or the scar tissue narrows the air inlet inside the nostrils.  It can be corrected by further surgery.

  5. Asymmetry: Although the surgeon will endeavour to make the nose as symmetrical as possible, there may remain differences between the two sides. 
     
  6. Persistent swelling: In those patients who have thicker skins, particularly males, it may take a long time for the tip swelling to subside. Some may need injections of steroids to try and speed up this process

Rhinoplasty: Post-op healing

After the swelling has finally settled, which may take six to twelve months, the patient may not be entirely happy with the outcome.  This is usually due to the difficulty the surgeon has in determining what the patient’s expectations are.  Until the operation is carried out it is impossible to show the new shape of the nose.  Computer imaging does help to a certain extent by showing the effect certain changes have on the face.  However, these are simulations and do not represent what actually happens.  They are not guarantees of what the patient is going to end up with.  Most dissatisfaction relates to the degree of change, e.g. the nose may not appear small enough or the profile may not appear curved enough.  These “problems” can easily be corrected by further relatively minor surgery.  The likelihood of having revision surgery after rhinoplasty in this Practice is 5%.

Finally, it is essential for the patient to consult a surgeon to decide whether surgery is a solution to his or her particular problem.  Only after such a consultation is he or she in a position to decide whether to go ahead with surgery.

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