Right on the Nose

By: Ruth Kerrison
Created on 25th March 2010

Rhinoplasty is one of the most common cosmetic surgery procedures but can have a profound impact on a patient's life. Leading plastic surgeon Mr Richard Matthews gives us the lowdown

The principal components of body image are the face and the hands. Of these, the face is the most important and the nose is the central feature. It is therefore no surprise that the desire to alter nasal shape is fairly common.

Sometimes the nose is misshapen as a result of trauma and may be accompanied by breathing difficulties through one or both nostrils, all of which requires attention. Alternatively, an exaggerated form of the ‘family nose' may be attracting uncomfortable comment and affecting self-confidence and composure. Or it may be a more subtle feature relating to size and/or shape that requires attention, perhaps with regard to the bridge of the nose, causing concern about nasal profile, or with respect to the tip.

Shaping up

If you feel your own nose, you will find the upper half is solid bone and immobile, whereas the tip is mobile from one side to the other and compressible. This is because the tip is made of several pieces of semi-solid material called cartilage, like your ear. The structure of the nose is a bit like an old-fashioned tent, except that the main tent pole is continuous all the way up the inside, resulting in a left and right airway to breathe through, each opening at the nostrils. This central partition is called the septum.

The individual shape of all these nasal components determines the exact shape of the nose and by performing a rhinoplasty (from the Greek ‘nasal-refashioning'), the cosmetic surgeon seeks to adjust to suit. If the septum also requires attention (e.g. if breathing is also affected after nasal trauma), the operation is called a septo-rhinoplasty.

Sleeping beauty
Such surgery is almost invariably carried out under general anaesthesia and is often performed entirely from inside the nose with no external cuts or scars: this is termed a closed rhinoplasty.

An open (tip) rhinoplasty, on the other hand, involves a cut on the piece of skin about half way between the nose tip and the upper lip, linking in with cuts inside the nose. This allows the skin to be lifted up and back off the nose tip and for very precise adjustment of the nose tip structures to be achieved under direct vision. When the skin is put back into place at the end of the operation, the resultant scar on the underside of the nose tip usually heals well and inconspicuously.

Sometimes cosmetic surgeons will take a ‘hidden' piece of cartilage from the septum or from the ear and use it as a graft to enhance shape and volume, particularly in the nose tip. ‘Robbing Peter to pay Paul' like this is a commonly used approach throughout the specialty of plastic surgery, including reconstructive aspects.

No pain... gain
Rhinoplasty may be carried out as a day case if adjustments are fairly minor but most often involves a night in hospital. Quite frequently an internal splint is inserted into each nostril at surgery to provide support and to minimise bleeding. If this is dissolvable, the nose will remain blocked for several days. If removable, then it is simply slid out the morning after surgery and nasal breathing is re-established.

Quite surprisingly, rhinoplasty rarely causes great pain and mild discomfort is often the most that is experienced. Bruising and swelling are generally expected after a nose job, bruising being more severe if the upper nasal bones have needed attention, when an external nasal splint is usually worn for about a week for protection of the setting bones.

Whilst most bruising has gone by three weeks and swelling will have improved, some remaining swelling may take several months to completely disappear, particularly after an open rhinoplasty.

Artistic endeavours
Rhinoplasty surgery presents one of the most demanding challenges to the cosmetic surgeon, as small details can make a big difference and, as well as finding a surgeon who is empathetic to your wishes and in whom you feel able to place trust and confidence, it is obviously important that he or she has the artistic vision of the sculptor as well as the precise technical expertise required.

Whilst the best cosmetic surgeons are careful to avoid rhinoplasty in people with an abnormal view of body image (dysmorphophobia) - for whom surgery will never provide satisfaction - achieving a good result for a patient is accompanied not only by the satisfaction of a job well done but, most importantly, by the knowledge that that person will now be able to move forward in life with enhanced selfconfidence and purpose.