What is rhinoplasty?
Rhinoplasty is the rearrangement of the bony and cartilaginous framework of the nose. Because the nose sits at the centre of the face, its effect on appearance is considerable; rhinoplasty, however, is not an operation about appearance alone.
The nose has two tasks: to establish the balance of the face, and to warm and filter air on its way to the lungs. These two functions depend on the same structures. A sound rhinoplasty plan therefore addresses shape and breathing together.
Why is breathing part of the plan?
The partition inside the nose (the septum), the alar cartilages and the entrance region of the nostrils (the nasal valve) determine the resistance to airflow. A procedure that focuses only on outward appearance may weaken these structures and impair breathing.
For that reason the examination assesses not only the profile of the nose but breathing as well: the state of the septum, the size of the turbinates, the width of the valve region and any history of allergy.
In patients with a deviated septum the two procedures are combined in the same operation; this is called septorhinoplasty.
Planning
Planning begins with understanding what the patient wants. Two people ask for different things from the same nose; the aim is a result that suits the individual’s face.
The assessment considers: the proportions of the upper, middle and lower thirds of the face, the profile of the nasal dorsum, the structure and support of the tip, the nasolabial angle, skin thickness and symmetry.
Skin thickness has a direct effect on the result: on thick skin fine detail shows less, while on thin skin small irregularities become more apparent. This is discussed so that expectations are set correctly from the outset.
Techniques
| Approach | How it is carried out |
|---|---|
| Closed (endonasal) | All incisions are made inside the nose; no mark is left on the outside |
| Open (external) | A small incision is added across the columella, the region that separates the tip of the nose; it gives a direct view of the structure, and the mark fades with time |
| Preservation techniques | Repositioning bone and cartilage tissue while preserving as much of it as possible |
| Cartilage grafts | Where support is weak, the structure is reinforced using the patient’s own septal, ear or rib cartilage |
The choice of method rests on the structure of the nose, the extent of the change to be made and whether the patient has been operated on before. There is no general rule that one method is superior to another.
Surgery and recovery
Rhinoplasty is performed under general anaesthesia. The duration varies with the extent of the planned procedure.
- After the operation a splint is placed on the dorsum of the nose; it is usually removed within a week.
- Where silicone tubes are used to support breathing, they are taken out within a few days. Conventional packing is no longer necessary in most cases.
- Oedema and bruising are most pronounced in the first 48-72 hours; the greater part of the bruising passes within 10-14 days.
- Return to social life is usually within 1-2 weeks. A longer period is needed before contact sports and wearing spectacles.
- Oedema at the tip of the nose is the slowest part to resolve; the settling of the final shape can take more than a year. On thick skin this period is longer.
Risks and realistic expectations
The subjects that need to be discussed are: bleeding, infection, asymmetry during the course of healing, irregularity of the nasal dorsum, an unexpected change in breathing, altered sensation and problems with scarring.
Because rhinoplasty depends on the way tissue heals, it is not an operation whose result is entirely predictable. The same technique may give a different result in different people. Honest planning therefore includes the limit of the change that can be achieved.
Revision rhinoplasty
In a nose that has been operated on before, the tissue planes will have altered and the supporting structures may have been weakened. Revision surgery is for this reason harder than the first operation; it often requires a cartilage graft, and recovery takes longer.
Before a decision about revision, the tissue has to be allowed to mature after the first operation; this period is usually at least one year.
Assessment
The right decision in rhinoplasty emerges when the structure of the nose, the state of breathing and the patient’s expectations are read together. Examination determines both what can be changed and what ought not to be changed.
You are welcome to book an appointment for an assessment; if you have had nasal surgery before, it helps to bring the notes from your previous operation.