Rhinoplasty

What are Rhinoplasty and its Intended Use?

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Rhinoplasty, also referred to as ‘nose reshaping’,  is intent to make the appearance of the nose harmonious with aesthetic sizes and other parts of the face; and consequently, positively change the self-confidence, body perception, and psychology of the person.

For this purpose, not impairing the nasal functions and even solving respiratory problems (if any) when changing the shape of the nose it is important.

Can Nasal Septum Deviation and Nasal Breathing Problems be solved with Rhinoplasty?

Skewness known as septum deviation located in the central part of the nose, which impedes breathing through the nose or makes it difficult, and also excessive growths in the form of structures called concha at the side walls of the nostrils, are corrected during rhinoplasty, as well.

What is the Age to get Rhinoplasty?

Rhinoplasty is generally recommended at 17 years of age in females, and at 18 years of age and above in males. It is important for the individual to reach a psychologically adequate maturity, besides waiting for the nasal tissues to reach adult sizes. It would be good if the person, in whose face a permanent change will be made, has reached a certain psychological maturity and balance so that he/she becomes psychologically ready for the change, has realistic expectations from the surgery, and can easily adapt to his/her new appearance after the surgery.

On the other hand, in some special cases, prominent nose deformities and breathing problems that seriously affect the psychology and social behaviors of the individual can be treated at early ages. Dr. Chauhan et al. have performed rhinoplasty on 30 patients between 13 and 19 years of age, who had aesthetic and functional nasal problems, and have reported that the recovery of the nasal shape and respiration have positively affected the psychologies and quality of lives of the patients. (Chauhan N, Warner J, Adamson PA. Adolescent Rhinoplasty: Challenges and Psychosocial and Clinical Outcomes. Aesthetic Plast. Surg. 2010 March 24.)

Characteristics of Suitable Candidates for Rhinoplasty

  • Spiritually mature and well balanced.
  • Has a prominent nasal deformity.
  • Has also respiratory problems besides deformity.
  • Has realistic expectations: not seeking perfection, contented with just a better appearance.
  • Has a positive personality, optimistic, gets on well with people around him/her.

Characteristics of Unsuitable Candidates for Rhinoplasty

  • Has no or a mild nasal deformity.
  • Extremely exaggerates his/her nasal deformity.
  • Unable to exactly specify his/her nasal deformity.
  • Indecisive about having an operation.
  • Has a narcissistic personality, and wants the perfect.
  • Has problems in his/her social and emotional relationships.
  • Expects momentous changes in the form of his/her life after surgery.
  • Blames his/her appearance for his/her problems.
  • Blames his/her previous doctors.
  • Exhibits suspicious behaviors.

Under What Conditions Does Rhinoplasty Need to Be Performed?

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Rhinoplasty

Rhinoplasty should be done in fully-equipped and sterile operating room, and under general anesthesia.  Small-scale partial interventions in the nose can be performed under local anesthesia.

Why is Rhinoplasty Difficult; Why Does It Require Education and Experience?

The nose is located in the middle of the face, and plays a critical role in its appearance. The error margin of rhinoplasty is very low compared to other plastic surgery procedures. Millimeters determine the good and bad results. Even if everything goes well, it takes time to adopt the new appearance, for both the patient and people around him/her.

For ensuring the success of the rhinoplasty, the right analysis and plan should be made before the surgery, the planned changes should be carried out using the right techniques during the operation, and additional problems should not be experienced in the postoperative wound healing period. The doctor should be adequately trained and experienced, and able to predict the potential problems and consequences, for completing all these phases without problem. On the other hand, the structure of the nasal skin that the doctor cannot check, the wound healing characteristics of the patient, and his/her obedience to postoperative advices are of great importance.

It is observed that, apart from the obvious surgical errors, most of the patients unsatisfied with rhinoplasty have no serious problems with the appearance of their noses, but they have different expectations from the postoperative process and result, and are not in a mood that enables them to accept the result. Training and experience are essential for both the performance of the surgery and it refusal based on the diagnosis of this kinds of diseases before surgery.

Preoperative Planning and Preparation Stage

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Before Rhinoplasty

A proper communication should be established between the doctor and the patient who have a nasal deformity complaint; and the patient’s complaint and expectations from the surgery should be well consistent with the plastic surgeon’s opinions and the change that he/she plans to make in the nose. Most of the patients who become unhappy after surgery are those who have different expectations, and who are mentally not ready for such a change. Preferably, photos of the person taken from different camera positions should be discussed, the problematic areas should be identified, and the procedure to be performed should be determined.

The structures of the nasal skin and the mucosal tissue that lines the nasal cavities are evaluated. From the frontal view, deviations of the nose, asymmetries, width of the nose tip, width of the nasal base, and structures of the nose wings and nostrils are evaluated. In your profile analysis, forehead-nose angle (nasofrontal angle), nose-upper lip angle (nasolabial angle), height of nasal ridge, height of nasal tip, side views of the nose wings and the nasal tip are evaluated, and the problematic points are identified. With the changes made on the photographs in computer environment, an opinion about the postoperative nasal appearance can be formed but the result cannot be guaranteed to be exactly the same. The plastic surgeon also examines other parts of the face besides the nose, and evaluates their proportions to each other. Especially the chin, forehead and cheekbone areas are the structures affecting the appearance of the nose. Sometimes, it is possible to have a better-balanced and more beautiful nasal and facial appearance when cosmetic surgery procedures are performed on these.

Whether there are concomitant problems such as nasal septum deviation (concha) hypertrophy that impedes breathing through the nose is investigated during intranasal examination. For this purpose, computerized tomography is performed, if necessary, for examining the nose and the anatomical structures around it in more detail.

If the plastic surgeon finds the person a suitable candidate for rhinoplasty, in consequence of the medical examination, laboratory tests and consultations, and if the candidate is satisfied with the doctor’s explanations, a surgery is planned.

All the questions in the mind of the surgical candidate should be asked and satisfactorily answered in the preoperative period. Particularly, a written consent form regarding the postoperative period, the risks and possible complications of the surgery should be requested from the doctor. Before the planned day of surgery, the consent form should be carefully read and understood without acting hastily or carelessly  The points to take into consideration before the surgery, as well as the drugs and herbal preparations to be avoided, should be discussed in particular.

Surgical Phase

After general anesthesia, inside and around the nose is cleaned with an antiseptic solution. To reduce bleeding, injections are made inside and outside the nose. A rhinoplasty takes averagely 1.5-2 hours, depending on the technique used and the complexity of the surgery. Whether the surgeon has made the planned changes and completed the surgery with a feeling that he/she has done his/her best is more important than the duration of the surgery. Sometimes, it is important to try some procedures repeatedly during the operation, in order to get the best result. At the end of the surgery, a plastic or plaster mold is placed on the nose, with intent to control edema and bleeding, and protect the newly given shape of the nose. And inside the nose, a normal pack or silicon packs that allow air passage are placed, depending on the characteristics of the surgery and the surgeon’s preference. Sometimes, no pack is placed into the nose.

Surgical Techniques

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Rhinoplasty Surgical Techniques

In recent years, important changes have been observed in the philosophy and techniques of rhinoplasty. The mentality of making the nose as small as possible by just removing the nasal cartilage and bone tissue has been left. The mentality of forming a well-balanced, proportionate and natural-looking nose, instead of a small nose, has been dominant. Sometimes, it is possible to achieve a more aesthetic and natural-looking result by making some points of the nose (e.g. the nasal root, nasal tip) more prominent, and reducing some points of it (e.g.  nose ridge), instead of making the nose completely smaller. While doing all these, an additional procedure is performed, which does not risk nasal breathing and even makes it easier.

In rhinoplasty, mainly two techniques called the open and closed techniques are used. In the closed technique, the nasal skin is liberated from the underlying cartilage and the bone structures, and then these structures are intervened just through incisions made inside the nose. In the open technique, an incision is made in the section called columella between the two nostrils, in addition to the incisions inside the nose, and then the nasal skin is lifted and the nasal cartilage and the bone structure are completely brought into the open.

The most important advantages of the open technique:

  • The bone and the cartilage structures are directly observed and a more precise anatomical diagnosis is made.
  • The both hands are used more easily.
  • A better bleeding control is ensured.
  • More controlled and easier changes are made in the bone-cartilage structure.
  • Better and more controlled shapes can be formed with sutures in the cartilage structures.
  • There is the chance of applying more alternative techniques for a specific deformity.
  • There is a less need for cartilage grafts.
  • If cartilage grafts are intended to be used, open technique allows for proper positioning of the grafts, and enables them to be fixed with sutures.

And, the disadvantages of the open technique:

  • Surgery time is longer.
  • Edema on the nasal tip lasts longer.
  • A scar may remain at the incision site on the columella.
  • There may be a circulatory disorder in the columella skin.

In recent years, the open technique has been more preferred, for achieving more consistent and predictable results. The technique is determined based on the characteristics of the procedure to be performed, and the doctor’s preference. However, the surgeon’s command of the technique that he/she uses, no matter whether it is open or closed, as well as his/her experience in that technique are important to the same extent.

Is Rhinoplasty Different in Men and Women?

The nasal aesthetic dimensions differ in men and women. Ensuring not to make a feminine nose is the most important point to consider in a rhinoplasty operation done on a man. When viewed from the side, the nasal ridge in men must be aligned with the nasal tip, whereas the nasal ridge in women can be 1-2 mm behind the nasal tip. The nose-lip angle in men is 90 degrees, whereas it is 100-105 degrees in women. Lifting a man’s nose up to an angle greater than 90 degrees leads to a feminine appearance.

Postoperative Packs and Molds

In the surgery, the bone and cartilage structure of the nose is changed to give a new shape to the nose. Tapes and molds (made of plaster or plastic) are placed on the outside the nose, for giving the new shape and ensuring the tissues to recover in such a way as to maintain that shape. At the same time, these tapes and mold prevent excessive swelling and bleeding of the nose. Sometimes no pack is placed into the nose, depending on the type of surgery performed, the doctor’s preference, and the bleeding condition of the patient. Especially if the middle section of the nose called the septum has been intervened as well, a pack is placed into the nose, with intent to keep the septum in the midline, prevent hyperaemia formation (accumulation of blood), and control the bleeding from other parts of the nose. The quality of the pack and its removal time is determined by the doctor. In the past, large packs were placed into the nose, and they were kept there for a period of at least 3 days. Today, packs are removed 24 hours after operation, for enabling the nasal functions to return to normal as soon as possible. Silicone packs that allow for nasal respiration are also commonly preferred for this purpose.

Tapes and molds applied to the nose are generally removed 10-14 days after operation. This period of time may be shorter or longer, depending on the procedure and the patient’s characteristics.

Postoperative Period

  • After recovery from anesthesia, the patient must be calm and breathe through the mouth. Lip moisturizer should be used against dryness in the lip.
  • The head should be kept in the midline as much as possible, and it should not be turned left and right.
  • The patient should lie with his/her head is slightly elevated, and cold compresses should be done to reduce edema and bleeding.
  • Leakage of a small amount of blood from the nose and mouth is normal. The leakage will decrease gradually and its color will turn from red to light pink throughout the first 24 hours. The leakage may last for a few days more.
  • 4-6 hours after the surgery, the patient begins to intake fluid foods orally, and he/she is allowed to get up.
  • For not causing an increase in the bleeding, the patient should rest in a serene environment, by lying with his/her head is slightly elevated, and should not talk too much. The patient should avoid straining in the toilet.
  • There will be a certain amount of swelling and bruising around the eyes. This swelling will be at the maximum level in the first 3 days, and will then begin to rapidly go down.
  • After the removal of the packs, there will be catarrh-like nasal congestion, and it will then go away gradually within a week. The sense of smell will return gradually, as well. Inside the nose will reach its final form approximately 6 weeks after the operation.
  • Generally the first 24 hours are spent in the hospital.
  • After the operation, the nasal packs (if any) are removed before discharge from the hospital.
  • Saline water, antibiotic pomades as well as antibiotic pills are prescribed for intranasal care at home.
  • The patient is advised to avoid working actively, carrying heavy things, and driving car in the first week. Resting at home and short walking exercises are recommended.
  • A week after the operation, some sutures are removed from the nose. The tapes and the splint placed on the nose ridge are replaced.
    The patient can begin to live his/her school, work and social lives in the second week after the surgery.
  • By the end of the period of 10-14 days, all the tapes and splint will have been removed.
  • When the tapes are removed, the nose, especially the nasal tip, is still swollen and a little bit numb. The massage technique to be taught by the doctor will help reduce edema.
  • Eyeglasses should not be worn, and sports and intense exercises that could cause the nose to be knocked should be avoided for a period of 6 weeks. There is no problem with using lenses.
  • In order to avoid color changes and blemish formation on the nasal skin, the nose should be protected from direct sunlight for the first one month, and sunscreens should be used during the summer months.
  • THE NOSE COULD GETS ITS FINAL SHAPE AFTER 6-12 MONTHS; so, patience is required.

New Apperance

The most important difference of rhinoplasty from the other plastic surgery procedures is the fact that its result does not appear immediately. After surgery, a relatively annoying process is experienced due to swellings in the face, in addition to inadequate nasal respiration. When the tapes and splint is removed from the nose, the nose is far from its final appearance. At first glance, it can be seen that the obvious problems in the nose have been solved, but the nose is still swollen in general. It should be remembered that the appearance encountered when looking in the mirror for the first time is not the final appearance of the nose. During this period, it would not be favorable to frequently examine the nose, take photos, and try to gain insight about the result by carrying out milimetric measurements. Intranasal tissues return to normal within about 6 weeks; however, emergence of the details and appearance of the final shape of the nose takes 6-12 months. Especially within the first 3 months, the swelling in the nasal skin gradually goes down, the stiffness on the nasal tip begins to get soften, and the nasal tip itself begins to get thinner. The nose-forehead angle and the nose-lip angle return to normal.

In the first months after surgery, different reactions and criticisms could be made especially by the people from immediate surroundings, who are accustomed to the former appearance; so, the patient should be psychologically ready for all these, and should wait for the final result with patience.

What is Nasal Droop?

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Nasal Droop

Some comments like “The nose looked very nice after the surgery, but then it drooped.” are heard. Probably, more than adequate amount of nasal cartilages have been removed, and the nasal tip has not been adequately supported during the surgery; however, the problem could not be noticed in the early period due to the swelling in the nasal skin. In the course of time, as the nasal edema goes down and the real appearance of the nose comes in view, the deficiency in the nasal ridge and nasal tip begin to be noticeable.

What Are the Most Common Complications Encountered after Rhinoplasty?

In the early postoperative period, bleeding, infection, circulatory disorder and partial necrosis in the nasal skin, and allergic reactions to the suture materials, the tapes and pomades could be observed. Long-lasting swelling and stiffness in nasal skin and long-lasting numbness or pain in the nose are some of the problems, which are rarely encountered in the late periods. Under the nasal skin, there could be irregularities which are felt when touched, and the nostrils may not be exactly symmetrical.  The appearance of the nose might be different from the appearance expected by the patient.

What is Revision (Secondary) Rhinoplasty?

When Should It Be Performed?  It is the second rhinoplasty operation performed to make more perfect the appearance or function of the nose that had previously been operated on.

Cases requiring revision surgery can mainly be classified into two groups.  The first group is related to deformities caused by obvious mistakes made by inexperienced surgeons, and especially by those who are not plastic surgeons. Some of these include the excessively drooped nose ridge, reduction of nasal support and nasal collapse due to excessive removal of septal cartilage, inadequate height of nasal tip, separate and deviated nasal bones, excessive or inadequate nose-forehead and the nose-lip angles, nose shorter than normal and too lifted nose. In case of such deformities, the nose is re-opened under general anesthesia, the deficiency of cartilage tissues are filled (by taking cartilages from the intranasal parts, pinnae or ribs) and the nose is re-shaped.

On the other hand, even in averagely 5-10% of the operations performed by the most experienced surgeons, a second surgical intervention (even if a minor operation) could be required. For example, small irregularities in the nasal ridge, and asymmetries on the nasal tip or nasal wings.  Especially during the wound healing period, the two sides of the nose could heal differently from each other; and consequently, swelling, contractions or irregularities may develop. Sometimes, there is stiffness and swelling more than normal on the nasal tip, and local cortisone injections can be made for these.

Revision rhinoplasty should be performed at least 6 months, and even 1 year after the previous rhinoplasty.
To watch Prof. Dr. Cengiz Açıkel’s video about rhinoplasty operations, please click here.

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Prof. Dr. Cengiz Açıkel, Aesthetic Plastic Surgery Specialist, Nose Reshaping, Rhinoplasty, Nose JobAesthetic nasal surgery

Frequently Asked Questions About Rhinoplasty:
How Many Hours does Rhinoplasty Take?
Anesthesia in Rhinoplasty
What is the Suitable Age for Rhinoplasty?
Closed Technique in Rhinoplasty
Open Technique in Rhinoplasty
Can Nasal Septum Deviation and Breathing Problems be solved with Rhinoplasty?
What can be Change with Rhinoplasty?
Why is Rhinoplasty Difficult?
Before Rhinoplasty
For Whom Rhinoplasty Can be performed?
Surgical Techniques for Rhinoplasty
Advantages and Disadvantages of Open Technique Rhinoplasty
Rhinoplasty Phase
Rhinoplasty in Men and Women
Packs and Molds after Rhinoplasty
New Appearance after Rhinoplasty
Nasal Droop
Complications of Rhinoplasty