A Rhinoplasty, commonly referred to as a “nose job,” is a surgical procedure that reshapes the nose. Most patients seek the procedure because they want a smaller nose, a better shape or improvements on a past nose surgery. It is one of the most intriguing and challenging plastic surgery procedures that I perform. The reason is, in part, because the nose is the center of the face and changes in the structure of the nose can have a profound effect on the general appearance of the face. Therefore, it is my responsibility to spend time with you to communicate my personal experience with this procedure and to find out desirable changes,
Media-driven fears of plastic surgery are an epidemic. Many patients fear of an overdone or “botched” nose job. Michael Jackson is the poster child for a nose job gone wrong. The reality is quite different, however, in experienced hands. The procedure should be reliable and consistent with satisfying results.
The typical patient request is for modest changes to the nose. They want improvements to their nose but they want their general appearance to others to be the same. Often, patients desire a lowering of a nasal hump, a narrowing of a nose that is too wide, and refinements to an unshapely or unflattering nasal tip.
A Rhinoplasty is an outpatient procedure performed in my office operating facility. In most cases, a standard Rhinoplasty procedure takes about 2-3 hours to complete. Swelling is moderate for the first week and bruising can last up to two weeks. Sutures are removed after five days if used and the splint on the top of the nose is generally worn for the first week. It takes a week or two to feel comfortable in the public eye. At times, I tell my patients tape their nose for several weeks after surgery or massage their nasal bones to keep them narrow. I may suggest a periodic steroid injection into the nasal tip to control the swelling and shape.
Unless I am working on the nasal tip alone (which is uncommon), I prefer general anesthesia for Rhinoplasties. This protects the airway from bleeding that occurs during surgery. IV sedation and local anesthesia do not guarantee that patients will not inhale blood during surgery, which can be very dangerous.
If work needs to be done on the inside of the nose (the turbinates or the septum), internal nasal splints and packing may be used for up to five days. Your nose will generally be “stuffy” after surgery from the swelling and your head may feel a bit “heavy.” A nasal decongestant may be prescribed to reduce the swelling and improve breathing for the first two weeks. Using saline spray internally will keep the nose clean. Contacts can be worn at any time, but glasses should be avoided for a month after surgery.
Patients come to the office the first week after surgery, once in the first month, at six months, and finally a year and a half after surgery. Although most of the initial surgical swelling subsides after two weeks, it takes up to two years for the nose to take its final shape. There is no doubt that the nose keeps getting better with time.
If the final result is a “normal” appearing nose, most patients can’t remember the nose they had before surgery! This is a good thing. This is the desired outcome—it’s a better, more refined nose, but it’s still yours. My patients are always amazed to see that an improvement to the nose generally goes unnoticed by others.
Complications immediately after surgery are generally uncommon. Bleeding is the most common problem seen after work on the turbinates or septum. If this did happen, it would be in the first two weeks and is often treated by putting the head back and compressing the end of the nose until bleeding stops. In rare cases, patients may need to come to my office to have packing placed in the nose to dry it up. Make sure you tell the surgeon if you are taking blood thinners, aspirin or any other over-the-counter or homeopathic medications as these can increase the risk of bleeding.
Athletic activities can be resumed after about 10 days after surgery. It is advisable to avoid any activity that may result in trauma to the nose for six weeks afterwards. The nose will be healed after several weeks internally, but a direct blow to the nose may alter the surgical result. The nose and central face may swell during and after physical activity for up to two months afterwards.
Long-term complications after a Rhinoplasty are uncommon, thankfully. The most common issue would be the desire for improvements on the results you have obtained. Patients may want the tip even smaller, or they may want a small hump or irregularity improved. When a nose is “overdone” or not expertly done from the start, long-term healing may reveal a result that isn’t ideal. Understanding the cause of these undesirable outcomes and taking measures during a Rhinoplasty to minimize the possibility is the key to success and is always on the mind of an experienced surgeon.
For instance, a bridge that is lowered too much and is “scooped,” or a tip that has lost all support and looks “pinched” or asymmetrical may come about in the long term. Grafts used may “show” after all the swelling is gone. The shape of the mid-part of the nose may look like an “inverted V” from collapse of the mid-nose. A “pig nose” may result from overly-aggressive reduction of the cartilage of the tip of the nose. The best way to avoid these types of undesirable outcomes is to trust only an experienced and reputable surgeon.
There are some technical features that are common to most Rhinoplasties. Tip work usually consists of trimming and suturing the tip cartilages. Grafts may be used to shape and support the tip complex. A nasal hump is often reduced by taking down a small amount of bone and cartilage along the bridge of the nose. A nasal fracture is performed by breaking the nasal bones and moving them into a better (generally narrower) position. Cartilage grafts may be used in the nose to prevent unfavorable changes after the two years of swelling is over. The nasal septum may be straightened by removing part of it or reshaping it. Turbinates, or the “air conditioning” units of the nose, may be reduced to ensure unobstructed breathing.
Cartilage grafts used in Rhinoplasty are usually obtained from the nasal septum. Secondary sources include the cartilage of the ears or even ribs on rare occasions. A graft of fascia may be harvested from the area above the ear if needed. It should be noted that the use of grafting material other than your own cartilage is at higher risk of post-operative complications. I’m referring to “off-the-shelf” synthetic material that typically does not perform consistently in Rhinoplasty.
Digital imaging has been used and abused in Rhinoplasty. It can be used to market the procedure – to get the patient excited to schedule surgery. The problem is that it may not be possible to achieve the computer result with your anatomy! Computer imaging can, however, clearly demonstrate some of the “big picture” changes, and it’s nice to see these changes on your face. A before and after side-by-side picture shows well how a new nose will fit with your facial features, but it cannot be guaranteed that post-surgery nose would look exactly like the computer imaging.
I personally enjoy performing the Rhinoplasty. I find the results are very gratifying to my patients. To make sure that you have been exposed to surgeons who practice Rhinoplasty regularly, I would suggest you visit with several surgeons before settling on the one you feel most comfortable with.