In Harmony

By: Mr Antonio Orlando
Created on 09th November 2009

Rhinoplasty is one of the most commonly requested surgical procedures and Mr Antonio Orlando of Bristol Plastic Surgery explains how a surgeon can achieve facial harmony with this operation

Rhinoplasty is a surgical procedure used to shape the nose in order to improve the appearance or to repair damage from cancer or trauma. In both cases the goal is to achieve the most pleasant aesthetic look in harmony with the rest of the face.

The nose, because of its central position, plays an important part in the aesthetic appearance of the face. The rhinoplasty is certainly the most commonly requested facial aesthetic procedure. Abnormality of the nose can affect people from a very young age and cannot be hidden or improved with any non-surgical procedure or make-up. Most other operations on the face aim to rejuvenate, whilst the goal of rhinoplasty is to re-establish harmony in the face, giving the right shape, symmetry and dimension to the nose.

The nose is a complex anatomical structure determined by the shape and dimension of the bones and cartilages on which the skin is laid. In order to modify them, cartilages and bones need to be exposed. This can be achieved through either an 'open' approach with an external incision across the base of the nose, or with a 'closed' approach when the operation is carried out through the nostrils.

It is not uncommon that an aesthetic deformity can be associated with obstruction and difficulty in breathing. This problem can be corrected with an operation called septo-plasty which can be done at the same time of the rhinoplasty, obtaining an improvement of both aesthetic appearance and function of the nose.

What can be done?
The nose can be straightened if necessary, a bump can be reduced, the profile can be changed, the size and dimension of the nasal tip can be modified and also the angle between the tip of the nose and the upper lip can be altered. All these modifications can be achieved by accurate resection of cartilage and bone and by the use of carefully placed stitches and cartilage grafts.  

The operation
The operation is usually carried out under general anaesthesia as a day case or with an overnight stay. At the end of the operation there is frequently some bruising around the eyes and there is a splint to support and protect the nose. Swelling and bruising can take up to three weeks to completely disappear. The splint needs to be worn for at least a week after surgery, sometimes longer. This is not usually a painful procedure and apart from the swelling and bruising and some minor dripping of blood from the nose, there is hardly any pain.

A week after surgery the splint and tapes are usually removed. At this time the nose usually looks swollen and bruised and the reaction from the patient can be very variable. Some are already very pleased from the beginning, some take a few days to adjust to the new shape, bearing in mind that the final result will not be visible until a few months after surgery.

Sometimes there are minor asymmetries or irregularities in the shape soon after surgery, but most of the time they tend to settle spontaneously after a few months. In about 5-10 per cent of cases some minor revision surgery may be indicated, but not before 12 months after the first operation to allow the nose to fully settle before any further correction

Limitations of surgery
The main goal of the operation is to address the specific concerns for the patient. I do not offer the same operation to every patient, but tend to personalize the surgery to the specific requirement of each individual. One person may be particularly concerned about a bump, another about the shape of the tip or the dimension. Even if all features of the nose can be changed with rhinoplasty, it is not always necessary to do so.

Once the patient expresses his or her specific concern, I will discuss the possible correction that can be achieved, but also the limitations of the operation and possible complications. There are features of the nose which cannot be changed such as the thickness of the skin and sometimes the dimension of the nostrils. In patients of middle age who have a very large nose, there is a limit to the amount of reduction that can be achieved in the cartilage and bone because the skin has lost some of the elasticity which is needed to re-drape the new frame.

There is also the so-called 'secondary' rhinoplasty which is an operation carried out to correct unsatisfactory results from previous surgery. This surgery is more difficult because there is always scar tissue which makes the operation slower and more difficult. When excessive cartilage or bone has been removed in the previous operation, it is sometimes necessary to reconstruct the lost tissue with a graft harvested from the nasal septum, the ear or from the rib.
CS&AM