Rhinoplasty is surgery to change the shape of the nose. This can range from reconstruction of missing parts of the nose with correction of severe deformity, to altering the form of an essentially normal nose to a change of shape that leads to improved confidence or a better acceptance of a patient’s appearance. The former falls within the realms of reconstructive surgery and the later could be termed cosmetic rhinoplasty. Often functional aspects of the nose such as mechanical airway blockages, caused by a bent septum, can be carried out at the same time. Correction of bends in the septum is known as septoplasty. Septo-rhinoplasty is therefore the alteration to the shape of the nose and septum carried out at the same time. This short article will concentrate on rhinoplasty techniques and not major reconstruction, although, the spectrum of techniques needed, are often the same.
Cosmetic rhinoplasty can be carried out either by a closed technique, where there are no external scars; or an open method. This will involve full exposure of the underlying structures of the nose (which comprises cartilage of the tip and septum and bones of the nasal bridge). This should result in a small discrete scar on the columella, which is the skin between the two nostrils. The choice between open and closed techniques depends on the complexity of the problem.
Cosmetic rhinoplasty can involve minor correction of defects such as small humps on the bridge of the nose. Sometimes more complex procedures, such as the use of cartilage grafts, maybe necessary to improve the shape or function of the nose. Usually these grafts can be obtained from the septum itself (or more rarely, if there is not enough, cartilage is harvested from the ear or even the ribs). The grafts are carefully attached to critical areas of the nasal tip or septum to provide support or to improve the form or projection of the nose. The grafts can also be used to improve the airway by strengthening or widening specific internal areas of the nose. It is also not unusual for the nasal bones to be carefully broken during surgery. This is known as “infracture” and is needed when a large hump is taken away from the dorsum (front) of the nose.
The judgment regarding when to operate or not is one of the most difficult aspects of plastic surgery. Selection is the key. The greatest difficulties arise when there is a mismatch between what is technically or clinically possible and the expectations of the patient. The perception we all have of our appearance can be very different from how the outside world observes us. It is therefore imperative to determine the true nature of a patient’s wishes and match this with the surgeon capability of achieving this. Generally if the patient communicates concerns about a specific, visible problems, such as a hump on the dorsum of the nose or worried about the size (more often large rather than small), then results are better than non-specific anxieties. On the other hand concepts of nasal size can be distorted by other clinical aspects the patient may not be aware of such as the proportions or relative sizes of three main levels of the face. These are the forehead, midface and chin. The patient should be made aware that sometimes rhinoplasty alone may not achieve the best outcome or may not be the correct procedure to improve the appearance.
It is not uncommon for patients to bring along photographs of faces and noses they would like to have. Whilst this is always useful, it is important to understand there will never be any guarantees of a specific outcome. This is because there are many factors that affect the eventual result. Of course technique is paramount and surgical experience is undoubtedly very important. However there are also known unknowns, which are the way in which an individual’s scars or the behaviour of the bones, cartilage and soft tissues heal and behave after surgery.
Most rhinoplasty can be carried out under local anaesthetic and sedation in my practice. Often an external nasal splint needs to be worn for a week after surgery, especially if an infracture has been carried out. Sometimes a dissolvable pack is needed to stop internal bleeding from the nostrils. There will be swelling and sometimes bruising around the eyes. However the level of discomfort and pain after rhinoplasty is often surprisingly small. Time back to work depends on its nature but ten days to two week is not unusual.
It will be some time before one can judge the final outcome of rhinoplasty. Certainly three months will be the minimum, as swelling and natural distortion can occur during this time and beyond. Because of all these factors, there will be a surgical revision rate of between 10 to 15%. “Re-do surgery” is usually for unexpected residual lumps or twists post-operatively and in general should not be carried out until after a year has elapsed. This allows for disappearance of swelling and scars to have matured.
In summary, I do not believe there is any such thing as an easy rhinoplasty. Selection is the key as well as the appropriate technique. Due to the many factors affecting outcome there will be an inherent revision rate. It is so important that the surgeon truly understands the patient’s needs and that the patient is fully aware of all the surgeon aims and possible outcomes.
Donna Cooper did a lot of research about rhinoplasty before deciding to work with Mr Nishikawa, click the link to read her rhinoplasty under local anaesthetic with sedation story. T.M. also was happy with the result of her rhinoplasty with Mr Nishikawa and has provided a lovely story about her experience, read her story by clicking here.
The bottom portion of my nose is quite wide, can it be changed?
This procedure is known as a tip rhinoplasty. It involves adusting the size and shape of the cartilaginous skeleton that has a major and important influence on the size and shape of the nasal tip. The procedure can either be carried out as a “closed operation” which involves scarring inside the nostril but often an open approach is used which results in a small scar on the collumellar (the bridge of delicate skin between the nostril).
Can I see before and after pictures of patients considering the same procedure?
Most certainly! During consultation I am happy to share before and after photos with you of people who have had the same procedure(s) you are considering. By doing this during the consultation, and in person, I have the opportunity to relate the example specifically to your situation, highlighting outcomes and helping with expectations.
What if I’ve already had a consultation elsewhere, are you happy to provide a second opinion?
A decision to move forward with surgery following a consultation forms the basis of a contract between surgeon and patient; if you are not comfortable with your medical professional in this process then you certainly must seek out a second opinion.
I am happy to provide a consultation for someone who has already had a consultation with another cosmetic surgeon. The process is the same as any initial consultation and I will likely ask many of the same questions but this is necessary for me to make a decision about suitability, outcomes and potential risks.
Can you tell if rhinoplasty will help me based upon photographs?
The question whether a rhinoplasty would help really depends on the patient’s insight into what they feels is wrong.
However, to judge the possible outcome of a rhinoplasty it is necessary to have a good idea of the true proportions of the face. This includes the vertical and horizontal relationships between the lower middle and upper thirds of the face with the apparent length of the nose from the tip to its root at the base of the forehead. The relationship of the position of the eyes as well as the width of the eyelids and the position of the eyes in relationship to the width of the nose are also important features to analyse.
It is very difficult to accurately ascertain this information from photographs and to give truly objective advice, hence the reason an in-person consultation is always recommended.
Wide angle photographs can distort the position of the eyes and make the size of the chin appear small.
With all rhinoplasty procedures one has to be very careful in reducing the size of the nose in terms of the width of the area between the eyes and also the length because by doing this there is a chance of accentuating other features of the face unintentionally. The eyes may look further apart and because the chin is small the nose may still appear large post operatively. Perhaps the shape of the tip can be altered but only after assessment clinically by an experienced clinician who can look at your features accurately as well as the state of your health, skin and psychology that can greatly affect outcome of any surgery.
With all rhinoplasty and septorhinoplasty procedures, the surgeon can concentrate on aspects of the nose which are troubling you as well as excluding any functional problems such as airway disturbance.
Does jaw alignment have an affect on rhinoplasty?
I think that the position of the jaw can sometimes have a significant effect on the out come of rhinoplasty. It is always important to assess the proportions of the whole face before planning any surgery that may alter the dimensions of a nose. I believe that it is wise to make sure nasal asymmetry or apparent size is not due to disproportion elsewhere in the face. For example, the nose may appear large or protruding because of a small recessed chin or an upper jaw, which is disproportionately backward in relationship to the lower jaw. The prominence of the cheeks, or the lack of, can also influence the planning of rhinoplasty especially when determining any change in projection.
The surgeon should also check that a bend in the nose is true and not apparent. Abnormal neck positions, known as torticollis, can give the optical illusion that the nose is bent. Sometimes the nasal deviation is part of rare craniofacial conditions such as plagiocephaly, when the twist to the nose is part of a larger facial deformity. Lastly, the position of the eye sockets (orbits) can greatly influence the apparent shape and size of the nose. If the orbits are slightly positioned wider apart then noses can appear smaller therefore decreasing the width of the nose can accentuate the characteristic of the widely placed eyes.
In conclusion, part of the planning for a rhinoplasty must include an experienced assessment of the whole craniofacial skeleton in order to advise the patient about predicted outcomes.