Rhinoplasty

Rhinoplasty, also known as nose reshaping, is among the most popular facial plastic surgery procedures. The majority of individuals who undergo nose reshaping are dissatisfied with the appearance of their noses and wish to improve the proportions of their facial features. A smaller percentage of rhinoplasty candidates are patients who deal with discomfort or breathing difficulties due to structural abnormalities or previous nose injuries.

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 she or he feels is too large or too small 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

Important! Patients who are very non-specific about the changes they want on their nose or have very unrealistic expectations are not good candidates for rhinoplasty.

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.

Surgical techniques

The aesthetically pleasing nose is a composite of lines, shadows, and highlights with specific proportions and breakpoints. During rhinoplasty surgery the size, shape and orientation of the cartilage and bone are modified to achieve a desired look of the nose. The cartilaginous and bony skeleton of the nose is accessed by three surgical approaches:

In a standard closed rhinoplasty approach, all of the surgical incisions are made inside the nostrils and visible scars are prevented. Such standard closed approach enables to modify only the nasal bridge, for example to remove dorsal hump or to correct bony deviations or asymmetries. It could not be used for tip surgery, which is the major disadvantage of the method.

In an open rhinoplasty, a small incision is made in the columella (trans-columellar incision), which is the little strip of skin that separates the two nostrils, in addition to incisions similar to closed rhinoplasty. If the trans-columellar incision and its suturing are done properly, the scar is almost invisible. This approach allows the nasal skin to be lifted off of the tip of the nose and expose the entire cartilaginous and bony skeleton. This allows surgeon to see and work on the nasal framework in its natural position under direct view. Therefore, it is easier for the surgeon to see what needs to be done and to accomplish those tasks. The disadvantages of the open approach are greater surgical trauma, due to more extensive dissection, and more pronounced post-operative swelling and a longer recovery period.

So-called hybrid or open-closed rhinoplasty is becoming more popular among rhinoplasty surgeons. This approach means that an external incision will not be made and, therefore, a scar on the outside of the nose cannot form. It uses the best advantages of either open or closed rhinoplasty, allowing reshaping of entire nose, including the nasal tip. It is an excellent alternative to a more aggressive external approach as it allows minimally invasive techniques when possible and a more extensive surgery when necessary. A shorter recovery period due to less surgical trauma and absence of external scar are great advantages of the method and highly appreciated by the patients. It also provides greater feedback for surgeon during surgery, thus possibly preventing over- or undercorrection, and allows to perform and see gradual changes in the shape of the nose. The only disadvantage is that the method is technically more difficult. It requires good knowledge about the anatomy of the nose and is therefore feasible for more experienced and skilled rhinoplasty surgeons.

The example of the patient operated using the combined approach. The surgery was undertaken to lower nasal dorsum, to lift up droopy tip and to improve overall aesthetical appearance of the tip. The right picture has been taken immediately after operation. Note that there are no visible scars and how small is swelling after careful handling of the tissues enabled by this approach.

Recovery period

After a rhinoplasty procedure a cast will be put over the nose to assist with healing and it can be in place for 7 to 10 days. The cast holds the bones firmly in place during the initial stage of healing. Discomfort caused by swollen nasal tissues and internal and external incisions is common in the first week, as is bruising around the eyes. Most patients are surprised to experience relatively little pain.

Once the cast is removed, an initial results could be evaluated. Bruising typically resolves in 10 to 14 days, but swelling will reduce over the weeks and months to come. About one-third of swelling resolves more over the following year. It is also normal to experience stiffness to the tip of the nose, particularly after open approach, which may take a year or longer to resolve together with the remnants of the swelling.