Rhinoplasty (Surgery of the Nose)
Every year, half a million people who are interested in improving the appearance of their noses seek consultation with facial plastic surgeons. Some are unhappy with the noses they were born with, and some with the way aging has changed their nose. For others, an injury may have distorted the nose, or the goal may be improved breathing. But one thing is clear: nothing has a greater impact on how a person looks than the size and shape of the nose. Because the nose is the most defining characteristic of the face, a slight alteration can greatly improve one's appearance.

If you have wondered how nose surgery, or rhinoplasty, could improve your looks, self-confidence or health, you need to know how rhinoplasty is performed and what you can expect. No article can answer all your concerns, but this one can provide answers to many of the questions you may have.

Successful facial plastic surgery is a result of good rapport between patient and surgeon. Trust, based on realistic expectations and exacting medical expertise, develops in the consulting stages before surgery. Your surgeon can answer specific questions about your specific needs.

What is Rhinoplasty?
A nose job (technically known as Rhinoplasty), or surgery to reshape the nose, is one of the most common of all plastic surgery procedures. Rhinoplasty can reduce or increase the size of your nose, change the shape of the tip or the bridge, narrow the span of the nostrils, or change the angle between your nose and your upper lip. It may also correct a birth defect or injury, or help relieve some breathing problems.

Is Rhinoplasty for You?
As with all facial plastic surgery, good health and realistic expectations are prerequisites. Understanding nose surgery is also critical. Since there is no ideal in rhinoplasty, the goal is to improve the nose aesthetically, making it harmonize better with other facial features.

Skin type, ethnic background and age are important factors to be considered in discussions with your surgeon prior to surgery. Before the nose is altered, a young patient must reach full growth, usually around age 15 or 16. Exceptions are cases in which breathing is severely impaired.

Before deciding on rhinoplasty, ask your facial plastic surgeon if any additional surgery might be recommended to enhance the appearance of your face. Many patients have chin augmentation in conjunction with rhinoplasty to create a better balance of features.

Making the Decision for Rhinoplasty
Whether the surgery is desired for functional or cosmetic reasons, your choice of a qualified facial plastic surgeon is of paramount importance. Many facial plastic surgeons are trained in both ear, nose, throat and facial cosmetic surgery, which provides you, the patient, with the highest level of training and expertise. Your surgeon will examine the structure of your nose, both externally and internally, to evaluate what you can expect from rhinoplasty. Your surgeon also will discuss factors that may influence the outcome of the surgery, such as skin type, ethnic background, age, degree of deformity, and degree of function of nasal structures.

You can expect a thorough explanation of the surgeon's expectations and the risks involved in surgery. Following a joint decision by you and your surgeon to proceed with rhinoplasty, the surgeon will take photographs of you and discuss the options available. Your surgeon will explain how the nasal structures, including bone and cartilage, can be sculpted to reshape the nose and indicate how reshaping the chin, for example, could enhance the desired results.

After conducting a thorough medical history, your surgeon will offer information regarding anesthesia, the surgical facility to be used, and the costs for the procedure.

Understanding the Surgery
The definition of rhinoplasty is, literally, shaping the nose. First, incisions are made and the skin of the nose is lifted from its underlying bone and cartilage support system. The majority of incisions are made inside the nose, where they are invisible. In some cases, an incision is made in the area of skin separating the nostrils. Next, certain amounts of underlying bone and cartilage are removed or rearranged to provide a newly shaped structure. For example, when the tip of the nose is too large, the surgeon can sculpt the cartilage in this area to reduce it in size. The angle of the nose in relation to the upper lip can be altered for a more youthful look or to correct a distortion.

The skin is then redraped over the new frame and the incisions are closed. A splint is applied to the outside of the nose to help retain the new shape while the nose heals. Soft, absorbent material may be used inside the nose to maintain stability along the dividing wall of the air passages called the septum. Risk factors in rhinoplasty are generally minor, and your facial plastic surgeon will discuss these prior to surgery.

The best candidates for a Rhinoplasty Surgery

• Rhinoplasty surgery can enhance your appearance and your self-confidence, but it won't necessarily change your looks to match your ideal, or cause other people to treat you differently. Before you decide to have plastic surgery, think carefully about your expectations and discuss them with your surgeon.
• The best candidates for rhinoplasty surgery are people who are looking for improvement, not perfection, in the way they look. If you're physically healthy, psychologically stable, and realistic in your expectations, you may be a good candidate.
• Rhinoplasty surgery can be performed to meet aesthetic goals or for reconstructive purposes to correct birth defects or breathing problems.
• Age may also be a consideration. Many surgeons prefer not to operate on teenagers until after they've completed their growth spurt around 14 or 15 for girls, a bit later for boys. It's important to consider a teenager's social and emotional adjustment, too, and to make sure it's what they, and not their parents, really want.

All Rhinoplasty Surgery carries some uncertainty and risk

• When rhinoplasty surgery is performed by a qualified plastic surgeon, complications are infrequent and usually minor. Nevertheless, there is always a possibility of complications, including infection, nosebleed, or a reaction to the anesthesia. You can reduce your risks by closely following your surgeon's instructions both before and after plastic surgery.
• After rhinoplasty plastic surgery, small burst blood vessels may appear as tiny red spots on the skin's surface; these are usually minor but may be permanent. As for scarring, when rhinoplasty surgery is performed from inside the nose, there is no visible scarring at all; when an "open" technique is used, or when the procedure calls for the narrowing of flared nostrils, the small scars on the base of the nose are usually not visible.
• Incisions are made inside the nostrils or at the base of the nose, providing access to the cartilage and bone, which can then be sculpted into shape.
  In about one case out of ten, a second procedure may be required for example, to correct a minor deformity. Such cases are unpredictable and happen even to patients of the most skilled surgeons. The corrective surgery is usually minor.

Planning your Rhinoplasty Surgery
Good communication between you and your physician is essential. In your initial consultation, the surgeon will ask what you'd like your nose to look like, evaluate the structure of your nose and face, and discuss the possibilities with you.

• He or she will also explain the factors that can influence the procedure and the results. These factors include the structure of your nasal bones and cartilage, the shape of your face, the thickness of your skin, your age, and your expectations.
• Your surgeon will also explain the techniques and anesthesia he or she will use, the type of facility where the rhinoplasty surgery will be performed, the risks and costs involved, and any options you may have like trimming the septum improves the angle between the nose and upper lip.
• Most insurance policies don't cover purely cosmetic surgery; however, if the procedure is performed for reconstructive purposes, to correct a breathing problem or a marked deformity following injury, the procedure may be covered. Check with your insurer, and obtain pre-authorization for your plastic surgery.
  Be sure to tell your surgeon if you've had any previous nose surgery or an injury to your nose, even if it was many years ago. You should also inform your surgeon if you have any allergies or breathing difficulties; if you're taking any medications, vitamins, or recreational drugs; and if you smoke.
• Don't hesitate to ask your doctor any questions you may have, especially those regarding your expectations and concerns about the results.

Preparing for your Rhinoplasty Surgery
The surgeon removes a hump using a chisel or a rasp, then brings the nasal bones together to form a narrower bridge. Cartilage is trimmed to reshape the tip of the nose. You will be given specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, taking or avoiding certain vitamins and medications, and washing your face.

Carefully following these instructions will help your surgery go more smoothly.
While you're making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days if needed.

Where your Rhinoplasty Surgery will be performed
Your Rhinoplasty surgery will be performed at an outpatient surgery center, or a hospital. It's usually done on an outpatient basis, for cost containment and convenience. Complex procedures may require a short inpatient stay.

Types of anesthesia
Rhinoplasty surgery can be performed under local or general anesthesia, depending on the extent of the procedure and on what you and your surgeon prefer. With local anesthesia, you'll usually be lightly sedated, and your nose and the surrounding area will be numbed; you'll be awake during the surgery, but relaxed and insensitive to pain. With general anesthesia, you'll sleep through the operation.

The Rhinoplasty Surgery

• If the nostrils are too wide, the surgeon can remove small wedges of skin from their base, bringing them closer together.
  Rhinoplasty usually takes an hour or two, though complicated procedures may take longer.
• During surgery the skin of the nose is separated from its supporting framework of bone and cartilage, which is then sculpted to the desired shape. The nature of the sculpting will depend on your problem and your surgeon's preferred technique. Finally, the skin is redraped over the new framework.
• Many plastic surgeons perform rhinoplasty from within the nose, making their incision inside the nostrils. Others prefer an "open" procedure, especially in more complicated cases; they make a small incision across the columella, the vertical strip of tissue separating the nostrils.
• When the surgery is complete, a splint will be applied to help your nose maintain its new shape. Nasal packs or soft plastic splints also may be placed in your nostrils to stabilize the septum, the dividing wall between the air passages.

After your Rhinoplasty Surgery

• To improve the nasal airway, the shape or position of the septum may be altered. Or, the deviated portion of the septum may be partially removed.
• After rhinoplasty plastic surgery particularly during the first twenty four hours your face will feel puffy, your nose may ache, and you may have a dull headache. You can control any discomfort with the pain medication prescribed by your surgeon. Plan on staying in bed with your head elevated (except for going to the bathroom) for the first day.
• You'll notice that the swelling and bruising around your eyes will increase at first, reaching a peak after two or three days. Applying cold compresses will reduce this swelling and make you feel a bit better. In any case, you'll feel a lot better than you look.
• Most of the swelling and bruising should disappear within two weeks or so. (Some subtle swelling unnoticeable to anyone but you and your surgeon will remain for several months.) A little bleeding is common during the first few days following surgery, and you may continue to feel some stuffiness for several weeks. Your surgeon will probably ask you not to blow your nose for a week or so, while the tissues heal.
• If you have nasal packing, it will be removed after a few days and you'll feel much more comfortable. By the end of one or, occasionally, two weeks, all dressings, splints, and stitches should be removed.

Getting back to normal

• A splint made of tape and an overlay of plastic, metal, or plaster is applied to help the bone and cartilage of the nose maintain their new shape.
  Most rhinoplasty patients are up and about within two days, and able to return to school or sedentary work a week or so following surgery. It will be several weeks, however, before you're entirely up to speed.
• You will be given specific guidelines for gradually resuming your normal activities. They're likely to include these suggestions: Avoid strenuous activity (jogging, swimming, bending, sexual relations any activity that increases your blood pressure) for two to three weeks. Avoid hitting or rubbing your nose, or getting it sunburned, for eight weeks. Be gentle when washing your face and hair or using cosmetics.
• You can wear contact lenses as soon as you feel like it, but glasses are another story. Once the splint is off, they'll have to be taped to your forehead or propped on your cheeks for another six to seven weeks, until your nose is completely healed.
• You will schedule frequent follow-up visits in the months after surgery to check on the progress of your healing. If you have any unusual symptoms between visits, or any questions about what you can and can't do, don't hesitate to call your doctor.

Your new look

• After surgery, the patient has a straighter bridge, a well defined nasal tip, and an improved angle between the nose and upper lip.
• In the days following surgery, when your face is bruised and swollen, it's easy to forget that you will be looking better. In fact, many patients feel depressed for a while after plastic surgery it's quite normal and understandable. Rest assured that this stage will pass.
• Day by day, your nose will begin to look better and your spirits will improve. Within a week or two, you'll no longer look as if you've just had surgery. Still, healing is a slow and gradual process. Some subtle swelling may be present for months, especially in the tip. The final results of plastic surgery may not be apparent for a year or more.

Additional information:

Understanding the Surgery
The definition of rhinoplasty is, literally, shaping the nose. First, incisions are made and the skin of the nose is lifted from its underlying bone and cartilage support system. The majority of incisions are made inside the nose, where they are invisible. In some cases, an incision is made in the area of skin separating the nostrils. Next, certain amounts of underlying bone and cartilage are removed or rearranged to provide a newly shaped structure. For example, when the tip of the nose is too large, the surgeon can sculpt the cartilage in this area to reduce it in size. The angle of the nose in relation to the upper lip can be altered for a more youthful look or to correct a distortion.

The skin is then redraped over the new frame and the incisions are closed. A splint is applied to the outside of the nose to help retain the new shape while the nose heals. Soft, absorbent material may be used inside the nose to maintain stability along the dividing wall of the air passages called the septum. Risk factors in rhinoplasty are generally minor, and your facial plastic surgeon will discuss these prior to surgery.

What To Expect After the Surgery
Immediately after surgery, a small splint will be placed on your nose to protect it and to keep the structure stable for at least five to eight days. If packing is placed inside the nose during surgery, it is removed the morning following the surgery. Your face will feel puffy, especially the first day after surgery. Pain medication may be required. Your surgeon will advise you to avoid blowing your nose for seven days after surgery. In the immediate days following surgery, you may experience bruising and minor swelling in the eye area. Cold compresses often reduce the bruising and discomfort. Absorbable sutures are usually used that do not have to be removed. Nasal dressing and splints are usually removed six or seven days after surgery.

It is crucial that you follow your surgeon's directions, especially instructions to keep your head elevated for a certain period after surgery. Some activities will be prohibited in the weeks after the procedure. Sun exposure, exertion and risk of injury must be avoided. If you wear glasses, special arrangements must be made to ensure that the glasses do not rest on the bridge of the nose. Tape and other devices are sometimes used to permit wearing glasses without stressing the area where surgery was performed.

Follow-up care is vital for this procedure to monitor healing. Obviously, anything unusual should be reported to your surgeon immediately. It is essential that you keep your follow-up appointments with your surgeon.

Insurance does not generally cover surgery that is purely for cosmetic reasons. Surgery to correct or improve nasal function or surgery for major deformity or injury may be reimbursable in whole or in part. It is the patient's responsibility to check with the insurance carrier for information on the degree of coverage.

(©Copyright 2000 American Academy of Facial and Reconstructive Plastic Surgery)