Nose Job (Rhinoplasty Surgery) Information

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basic procedures/techniques

Anesthesia: General or Sedation
Location: Hospital, surgical center or office
Surgery time: 1-4 hours

Rhinoplasty is one of the most common procedures plastic surgeons perform and also one of the most difficult as the surgeon performs it mainly by feel. Rhinoplasty may be performed in order to increase the patient's ability to breath, improve the nose by reducing or reshaping it and/or, straightening an injured nose.

Techniques:
There are two main options for the incisions that your plastic surgeon can use: closed rhinoplasty and open rhinoplasty.

Closed rhinoplasty involves incision confined to the inside of your nose. Swelling improves soon and recover is fast. However, your surgeon may have a limited ability to achieve some changes in your nose because of her or his inability to see parts of the inside of the nose.

Open rhinoplasty involves a small incision across the columella, between the nostrils, in addition to incisions on the inside of your nose. Open surgery is usually preferred in more complicated cases.

Some surgeons prefer the open rhinoplasty because it allows them greater visibility of the nose. Swelling and bruising lasts longer with open rhinoplasty. Either way, if you sleep with your head elevated for the week following your nose surgery, the swelling will be minimized and will subside much faster. When deciding on open vs. closed rhinoplasty, you should follow the advice of your plastic surgeon.

The Operation:
Nasal surgery can change your nose by recontouring the underlying cartilage and bone. Your surgeon can make your nose larger, shorter, smaller, straighter, or thinner. Most of the incisions for reshaping the nose are made internally and scars will not be visible.

How thick or thin your skin is plays a big role in the results of the operation. Thick skin will not "drape out" as well over the new underlying structure as thin skin. But, thick skin will hide small irregularities of the cartilage and bone better than thin skin.

The operation normally lasts about 1-2 hours. The surgery will either be performed under local anesthesia with heavy sedation, or under general anesthesia.

Common changes made:

Tip of the nose: corrected by adding or excising cartilage at the tip and stitches the cartilage together. A low tip of the nose can be raised by adding cartilage to support the tip, removing excess cartilage in the septum, or repositioning the cartilage.
Dorsal bone: the hump of the bridge can be corrected by removing (with a chisel or rasp) excess cartilage and bone, then brings the nasal bones together.
Wide bony portion of nose: corrected by breaking the bones of the nose and repositioning them inward.
Wide base of the nose: corrected by removing tissue at the base of the nose and the nostrils moved closer together.
Nostrils too wide: corrected by removing small wedges of skin from
their base and bringing them closer together.
Angle between nose and lip: corrected by trimming the septum.

recovery

Pain Level: Moderate-severe discomfort. 2-10 days of pain medication
Swelling and bruising: 1-6 weeks for closed, 1-6 months for open
Numbness: lasts several weeks (tip of nose)
Bandages: Changed in 5-10 days
Work: Return after 1-3 weeks
Exercise (including swimming): Wait 6 weeks
Sunblock: very important for first few months (long term use recommended)
Final result: Seen 3 months-2 years

During Recovery your nose may be:

asymmetrical
crooked
swollen
bruised
numb
painful

For faster recovery:

Apply cold, dry compresses often (follow your doctor's protocol, some recommend warm compresses after 24 hours)
Avoid nasal medications for 3 months
Use humidifier and saline spray for 2 weeks
Keep head elevated to reduce swelling
Avoid blowing or picking your nose for the first 4 weeks to reduce bleeding and abnormal healing

Immediately after surgery a splint is usually applied to the nose to maintain the shape. Nasal packs or soft plastic splints also may be placed in the nostrils to stabilize the septum. If it is necessary to pack the nose, it is usually for 2-6 days. Most doctors recommend ice packs over your eyes for the first 2 days to minimize swelling. Pain medication and sleeping pills can help with pain management. The splint will be removed by your surgeon at your first post operative visit (usually a week after the surgery).

After surgery, your nose and eyes will be swollen and bruised, they may ache, and your face will feel puffy. The extent of this will depend on the extent of the operation and if the nasal bones were broken. The swelling and discoloration increase in the first few days and then will subside after the first week or so. Your upper lip and tip of your nose may feel numb for a few months. You'll also feel like you have a cold for the first few weeks because of the congestion of the nasal passageways. A little bleeding is common during the first few days following surgery. Any sudden increase in bleeding or pain should be reported to your physician.

If you swallowed a lot of blood during the procedure, you may be more likely to feel nauseated and possibly vomit post-operatively. Your stool may also be darker due to blood content.

Take the time to ensure that your nose properly heals. The nose is delicate and you'll greatly reduce your chance of complications and secondary surgery by following your doctor's advice carefully.

A good diet helps the healing process. Start your recovery with a mild liquid diet (water, juice, soup or broth). It's important that your stomach is settled before you resume normal eating and drinking. Vomiting can interfere with your recovery and healing time.

Keep your head elevated while you sleep. You should also keep your head up during the day and avoid bending over. This will minimize swelling. You may have a slightly longer recovery period, if your surgery required breaking the nasal bones. You are usually able to return back to work in 10 days-3 weeks with make-up.

Although the final result ill be apparent in about 2 weeks, small changes may continue to occur over the next 6-12 months. The final outcome depends upon your age, skin type, and healing ability.

Activity:
The best rule is to avoid any activity which causes you discomfort. Any strenuous activity or exercise that has the possibility of resulting in a nose injury should be avoided for at least 6 weeks. You'll also want to avoid bending over. Check with your doctor regarding bathing and showering; generally it is allowed as long as the nose splint remains dry.

Revisions: There is a 20% chance you will want or need revision surgery. This is because plastic surgery of the nose is difficult and your nose can also change in ways that cannot be predicted following surgery. You must accept this risk before having cosmetic nose surgery.

If you require revision surgery, wait at least one year from the date of your last nasal operation. If revision surgery is performed sooner, it will be less likely to accomplish your desired result.

Revision rhinoplasty is more complicated than original rhinoplasty. If you need a second surgery, choose a doctor who specializes in revisions.

Long Term Expectations: There should be no major changes in your nose after rhinoplasty. The surgery is normally permanent. Your nose will change slightly with the normal aging process.

risks/complications

List of possible complications:
Abnormal shape of nose (pinched tip, polly beak, pug nose, scooped out nose; corrected by secondary surgery, often with an implant)
Airway obstruction
Anesthesia reaction
Asymmetry
Bleeding (may require nasal packing to control it)
Burst blood vessels
Depression
Discoloration
Extrusion (implants)
Infection (risk is less than 1%)
Signs of infection: pain, swelling, warmth, redness
Internal scar/adhesions
Keloid (heavy scar)
Loss of smell
Loss of structural support
Nerve Damage
Numbness
Pain
Perforation of septum
Permanent numbness (risk is less than 1%)
Reactions to medications
Septal hematoma
Sinusitis (treated with antibiotics and medications that shrink the nasal lining)
Skin irregularities
Skin necrosis or skin death (1500% more likely with smokers)
Slow healing
Swelling
Toxic Shock Syndrome
Wound Infection
Visible scar

When rhinoplasty is performed by a qualified plastic surgeon, complications are rare and are usually minor. However, all surgery has the risk of complications and undesirable outcomes. You can reduce your risks by closely following your surgeon's instructions both before and after surgery.

Burst Blood Vessels
After surgery, small burst blood vessels may appear as tiny red spots on the surface of the skin. These are usually small, but may be permanent. This rarely happens, but it is a possibility you should be aware of.

Bleeding
Bleeding may occur for up to four weeks after operation. The patient must resist any urge to blow or pick the nose to minimize bleeding.

Abnormal Shape
An abnormal shape of the nose may be due to an error during surgery or the patient not keeping their head elevated enough or sleeping on one side without a proper side. The nose can pull to one side if the cast does not support it properly. There are other factors that go beyond human control, as well.

Wound Infection
The rate of wound infection following rhinoplasty is less than 2%. Abscesses, cellulitis or granuloma may be treated with antibiotics and drainage. Use of an implant increases the chance of infection.

Risk of smoking
Smoking significantly reduces your body's circulation and vascularity. This means difficulty in bringing much needed oxygen to your tissues and greatly increases your risk for slow healing and other complications. It is important to stop smoking for at least 4 weeks before and after surgery.

Toxic Shock Syndrome
This is very rare, occurring in only 0.016% of rhinoplasty surgeries. However, if it does occur, the mortality rate is about 11%. Symptoms include fever, vomiting, diarrhea, and a sunburnlike rash.

According to an article authored by S. Valentine Fernandes on emedicine.com "the complication rate for nasal surgery varies from 4-18.8%. In individual hands, this rate generally falls as surgical experience accumulates. Skin and associated soft tissue complications occur in up to 10% of cases. According to estimates, severe systemic or life-threatening complications occur in 1.7-5% of rhinoplasty cases. Intracranial complications are rare."

The entire article is extremely informative and we highly recommend reading it. You can access it at: www.emedicine.com).

Clinical Experience
Dr. Ronald P. Gruber, a clinical assistant professor at Stanford University, Oakland, CA, recorded data on 32 patients who underwent an extended closed rhinoplasty technique: "16 patients had thick skin; nine requested no columellar scar; four had poor circulation resulting from multiple prior surgeries or trauma, and three were smokers who were unable to stop smoking. None of the 32 patients exhibited scar contracture along the medial crura or even a depression of the tip as a result of contracture of the extended scar. Five patients required secondary corrections of the nose: two needed grafting of a weak external valve involving the lower lateral crus, two required grafting of the tip to achieve greater tip projection, and one elderly patient whose tip complex did not remain at the desired level with respect to the septum underwent correction by rerotation of the tip. "

Source: RP Gruber. Suture Technique in Rhinoplasty by Use of the Endonasal (Closed) Approach. Aesth Surg J March/April 1998;18:99-103

scars

Surgical scars are permanent. If you have a closed procedure, your scars will be completely hidden inside then nose. If you have an open procedure, you will have a small scar on the base of your nose, between the nostrils. This is usually not noticeable upon normal observation.

Information provided is for general education about cosmetic surgery. This information is subject to change. Board Certified Database.com does not guarantee that it is accurate or complete, and is not responsible for any actions resulting from the use of this information. General information provided in this fashion should not be construed as specific medical advice or recommendation, and is not a substitute for a consultation and physical examination by a physician. Only discussion of your individual needs with a qualified physician will determine the best method of treatment for you.
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