Nose surgery (Rhinoplasty) is a procedure to reshape the nose in order to create a more pleasing look and, in some instances, to correct severe breathing problems.  Rhinoplasty usually involves reducing the size of the nose, and/or improving its shape, by removing and sculpting the nasal tissues in order to enhance the facial appearance.  The results are unique to each individual, and depend upon such factors as skin condition and thickness, nasal and facial structure, genetic contributions, and age.  Traditionally, a “nose job” was performed only to correct major problems.  However, recent surgical innovations allow us to address details of shape.  In general, the goal is a better facial balance and overall appearance.

General Procedure

The rhinoplasty procedure lasts from one to three hours.  The surgeon may elect to utilize either local or general anesthesia, depending upon the complexity of the operation.

To begin the surgery, tiny incisions are made which allow the surgeon to access the underlying nasal structure.  Once the skin is opened, the cartilage and bone are reshaped to form the basis for the new look.  Two basic methods are utilized for performing nose surgery.  These methods are referred to as the ‘open’ and the ‘closed’ techniques.  The open technique allows for maximum visibility and control over the procedure.  The incision used in the open technique is placed in-between the nostrils on the columella (between the nostrils).  In the closed technique, the incisions are internal; however, there is less surgical control over the outcome.  The physician can discuss which technique is best during the initial consultation.

Recovery Process

Some swelling occurs; however, most of the swelling will disappear within a few weeks.  A small amount of swelling often lasts longer.  A splint, bandages, and/or gauze are applied immediately following surgery.  Patients must refrain from smoking for several weeks before and after the surgery.  In addition, any corrective glasses that are worn must be taped up and off the nose.  The nose will need to be well-protected from the sun for the first year after the procedure while the body is adjusting to the new look.  Pain and swelling varfy, depending upon the extent of the surgery.  While complications are unusual, patients can minimize the risk of potential problems by carefully following the post-surgical directions.  The most common complication is an imperfect result, and this is the reason for very careful planning and meticulous attention to detail.

The following article was published as an informational article for other doctors.

RHINOPLASTY, AN OVERVIEW

The expression, “as plain as the nose on your face” indicates the prominence of the nose as a facial feature. Nasal contour can influence our evaluation of the maxilla, mandible, and lips. Rhinoplasty can, under certain circumstances, influence upper lip length and incisor show. The nose even participates in how some people smile. And narrowed nasal air passages can cause mouth breathing and even sleep apnea in some individuals.

Although there are many methods of nasal assessment, a brief review of some key anatomic relationships is will clarify the approach to preoperative analysis. The soft tissue nasion point is ideally near the vertical level of the upper eyelid crease, 8 to 14 mm anterior to the pupil, and 4 to 6 mm posterior to the glabella in the profile view. The nasal bridge, or dorsum, makes an angle of 34⁰ (female) to 36⁰ (male) with the facial plane. The nasal tip is the most anterior point. The distance from soft tissue nasion to tip is equal to the distance from stomion to menton, or two-thirds of midfacial height (alar base to glabella). The anterior end of the nose, or lobule, is rather round, but it is more complex in shape than simply globular. It ideally has subtle curvatures which create four light reflections, or tip defining points. It is also usually desirable to have a slight indentation between the lobule and the dorsum: this is called the supratip break. Between the nostrils is the columella, which ideally makes an angle of 95⁰ (male) to 105⁰ (female) with the upper lip. Lateral to each nostril is the nasal ala. On each side, an alar cartilage curves from within the columella, to the nasal tip (giving shape to the tip), and the alar cartilage continues laterally inside part of the nasal ala. Nasal projection in profile is measured from the junction of the nasal ala with the cheek, to the nasal tip. Projection should be just over two thirds of the nasal length (nasion to tip). I routinely record many additional nasal measurements. A number of other factors, such as skin thickness and nasal bone length must also be noted prior to rhinoplasty. Analysis of life- sized photos, and often a moulage (facial impression and model), are helpful.

To make matters more complex, visual illusions have a significant role in rhinoplasty. For example, narrowing the part of the nasal bridge between the eyes makes the eyes look farther apart. Reduction of the prominence of the dorsum makes the nose appear wider, the eyes farther apart, and it makes the tip appear to be rotated upward. A low soft tissue nasion makes a dorsal nasal hump appear larger. These visual illusions highlight the importance of objective measurements.

In addition, surgical maneuvers can have interacting effects. The following are only a few of such interactions. The nasal tip can be made more prominent by using sutures to bring the domes of the alar cartilages closer together, and this also narrows the tip (which is usually desired). The tip can be supported and stabilized with a strip of cartilage harvested from the nasal septum and placed within the columella (from anterior nasal spine to near the nasal tip): this makes the tip more prominent, the nostrils longer, and the tip rotated upwards.

Now, if we have all of the knowledge alluded to above, can we artistically shape the nose to the ideal contours? Not quite. There are some additional “hurdles”. For example, a large nose (“hump”) can be made smaller by reducing the underlying structures and expecting that the overlying skin will shrink. But there is a limit to how much shrinkage will occur. Thick skin will not shrink very well, and it can only be thinned to a certain degree before the skin becomes devascularized (and dies). When we make a large nose smaller it is often necessary to modify the inferior turbinates and septum in order to allow an adequate airway. Interestingly, the turbinates can enlarge again over time, to impinge upon the airway months or years later. If the base of the nose (nostrils, columella, lobule, alae) is large, it is difficult to reduce this area in size dramatically. Thus, in this instance, the size of the upper part of the nose should be made in proportion to the size of the base. Very thin skin will show any slight underlying bony or cartilaginous irregularity. And cartilage can distort to varying degrees- even five or ten years later. The bridge of the nose is often narrowed via osteotomies along the nasal-maxillary junction, but there is no good way to rigidly fix the bones in position. Thus, these bones can shift somewhat postoperatively.

Techniques are available to influence nostril size and shape, but ideal and stable adjustment of the width of the nasal base cannot be achieved in all cases. The nasal alae can be modified adequately to address most issues, such as too much or too little nostril show on lateral view. The columella can be straightened, and its angulation, shape and width can be adjusted. It is in altering the columella and the prominence of the nasal tip that we can best effect changes in the upper lip. A classic example of this is the patient with a “pinched tip” deformity. In this situation, the nasal tip is prominent, the columella-labial angle is obtuse and rounded, and the upper lip is often short. Reduction of tip prominence and improvement of the columella can significantly lengthen the upper lip. This is one situation in which the rhinoplasty should be performed prior to creation of the dental smile line (as an exception to the general rule of order).

The rhinoplasty procedure has classically been performed entirely via incisions inside the nostrils. In recent years, the “open approach” has been popularized. This technique involves an incision across the skin of the columella, and it provides excellent vision, control and stabilization- especially of tip contour. The nasal dorsum can also be more readily visualized, allowing small grafts to be placed and stabilized with sutures.

It should be clear that each rhinoplasty is performed quite differently. Rhinoplasty is a collection of operations much more complex than all of orthognathic surgery. The challenge of rhinoplasty is not just to provide some improvement in form, but rather to give the most ideal result possible.

This overview should be a basis for understanding your plastic surgeon and future articles on this topic.