Rhinoplasty: An Informed Choice

Created on 25th September 2008

Leading plastic surgeon Mr Geoffrey R. Wilson takes us through the nose reshaping procedure step by step

The nose is the central feature of the face. Many people are self-conscious of a shape that they may regard as too big or deformed, or occasionally too small. The psychological effect can be quite severe. They tend to avoid the camera, and may turn their head when passing others so that that their side profile is not on view. Young men often seem to suffer the psychological effects more.

The problem may be an inherited family nose, or from injury. I feel that an injury can occur in childhood and remain undetected until the teenage years. Previous injury may damage the septum, which is the midline cartilage of the nose, and cause breathing problems as well as a deviation of the nose from the midline. The nose grows a lot from about twelve to sixteen years of age so any surgery should be delayed until the late teenage years. The only exception would be a very deviated nose in a child, when I believe the nose should be straightened without removing any tissue and then revised as necessary at a later date.

Balance is very important for the appearance of both the whole face and each individual feature. If the chin or cheeks are particularly small then they may need to be augmented as the nose may still look big after successful surgery. If the chin is very small, I will only carry out a reduction rhinoplasty in combination with surgery to the chin. Figures 1 and 2 show the effect on the balance of the face following chin augmentation.

The operation
The operation is carried out under a general anaesthetic. Traditionally a rhinoplasty was carried out with all the incisions within the nose and none on the external skin of the nose. The most important advance in rhinoplasty over the last 20 years has been the open rhinoplasty. A small incision is made at the base of the columella (where the midline of the nose joins the upper lip) as well as the cuts just inside the nose. This allows the surgery to the bones and cartilage to take place under direct vision.

Surgery can decrease (or increase) the size of the nose, alter the shape of the bridge line or nasal tip and alter the size and shape of the nostrils and the angle between the upper lip and nose (figures 4 and 5). The septal cartilage may be reduced as part of the rhinoplasty, and also straightened (septoplasty) if there is deviation of the nose or breathing problems. The skin of the nose is elastic so shrinks onto the new underlying frame. A bulky tip can be reduced by excising some cartilage, and removing any tissue between the cartilage and the skin. However, if the skin is thick and sebaceous, this cannot be changed.

At the end of the procedure the incisions inside the nose are stitched with dissolving sutures and the small wound in the skin stitched with sutures that need to be removed at six to seven days. The skin of the nasal bridge is then supported with paper tapes and then a metal splint. If there has been a lot of work carried out on the septal cartilage, then the nasal cavities will be packed with small sponges. These are removed at 48 hours. For a more straightforward rhinoplasty nasal packs are not needed.

After the operation
Following surgery you will be nursed in a sitting up position, and may have ice packs applied intermittently. This is to reduce bruising and swelling. Bruising can be severe particularly if the nasal bones have been broken to narrow the nose. The discoloration will normally be settled by two weeks. Swelling takes longer to resolve. The nose will be very swollen for two weeks and a bit swollen for about six weeks. However the tissues are not fully settled for twelve to eighteen months.

Pain is not normally a feature of rhinoplasty operations and only mild painkillers are normally needed. You might have some discomfort and feel congested. This settles as the swelling of the internal membranes reduces.

Patients leave hospital after one or two nights and return at one week to remove the small sutures and splint. Gentle massage of the nose will start at two weeks. You will notice that the tip of the nose is numb and feels ‘wooden' and this improves over a number of months.

You can expect to have some minor bleeding from the nostrils and you should dab this gently with gauze swabs. You should not blow your nose for the first six weeks and if you need to sneeze, do it with your mouth open and into a tissue. Most patients will take two weeks off work.

What are the risks and limitations?
It is important that you are clear in your mind what it is that you dislike about your nose, and that you can explain this to your surgeon. If the skin of the tip is thick and oily, the amount of refinement is often minimal. If you have a very large nose, there is a limit to how small it can be made.

The number of operative complications is few. Serious bleeding is uncommon as is infection. As a general anaesthetic is used, there is a small risk of a chest infection or deep vein thrombosis - both these risks are increased in smokers, which is why I won't carry out this procedure in patients who are actively smoking. Smoking also delays healing.

Any cosmetic operation may need revision, and this is usually a much more minor operation. Of all the aesthetic procedures, rhinoplasty has the highest rate for second operations, at about 10%, but this is not carried out for twelve to eighteen months, once the swelling has fully settled. It is important to be sure that a second procedure is going to improve the initial result, and not make things worse.

The commonest revisions are tidying up of the small scar on the nose, rasping of the nasal bridge or minor adjustment of the cartilages in the tip of the nose.

If a septoplasty has been needed to straighten the nose or improve breathing, then it important that the nose is packed after surgery to allow the membranes to heal against the cartilage. A collection of blood or an infection can cause a hole in the septum. If this is small and near the front of the nasal cavity there may be a whistling noise when breathing out through the nose. A large hole can cause an annoying discharge from the nose. Correction of this can prove very difficult.

Rhinoplasty is a common and usually very successful cosmetic procedure. CSMUK