- General information about rhinoplasty (nose reshaping)
- Reasons patients seek rhinoplasty
- Nasal anatomy and image
- Pre-operative planning for rhinoplasty (nose reshaping)
- Closed and open rhinoplasty techniques
- Surgical maneuvers used in rhinoplasty
- Ancillary rhinoplasty maneuvers
- Specialized instruments used for rhinoplasty
- Anesthesia for rhinoplasty
- Recovery and follow up
Rhinoplasty is a procedure that reshapes the nose. Many patients in North Carolina seek rhinoplasty every year and report that they have more self confidence and feel more at ease in social situations. The nose contributes to the general facial appearance and is a respiratory organ. When changing the shape of the nose with rhinoplasty, the functional aspects should also be considered. In changing the shape of the nose with rhinoplasty, the goal is to retain or create normal anatomy in relation to the face. The anatomical characteristics of the nose that are desirable or “normal” are well known to Plastic surgeons and the general goal of the rhinoplasty surgery is to create that normal anatomy.
The first step in getting a rhinoplasty is to attend a consultation. During the rhinoplasty consultation the goals and concerns of the patient are discussed. While most patients have not studied the specific details of normal nasal anatomy, they do have a sense of what is esthetically appealing. Most patients also have a sense of the desired nasal shape that fits their face. When planning a rhinoplasty, more is considered than just the shape of the nose itself. A primary consideration is facial shape, and the relationship of the face to the nose. Another consideration for rhinoplasty is the gender of the patient. A feminine face fits with a feminine nose, and a masculine face fits with masculine nose, and gender considerations are important when planning a rhinoplasty. In most rhinoplasty procedures, a new nose is not created. Most rhinoplasty procedures simply change the shape that is naturally present by changing the internal structures of the nose. In addition to changing the shape of the nose during rhinoplasty, in some patients breathing problems are corrected at the same time. While the rhinoplasty procedure is not the cure for all challenges in life, it can improve self confidence dramatically.
The shape of the nose is determined by the internal structures (skeleton) of the nose. The variation in nasal shapes (anatomy) in patients seeking rhinoplasty is very wide. There is wide variation in the bone and cartilage, and also variations in skin thickness. In addition, there is wide variation in facial shape. The skeleton of the nose consists of two main types of tissue, cartilage and bone. The upper one third to one half is bone, and the lower one half to two thirds is bone. The intersection of the cartilage and bone can be determined by flexing the bottom of the nose. The cartilage intersects with the bone at the point of immobility during this maneuver. In order to change the shape of the nose with rhinoplasty the internal structures of the nose are altered surgically. The nose shape works something like a tent, where the frame of the tent holds up the tent cover. In the nose, the frame of the nose is the skeleton, and the cover is the skin. The skeleton of the nose holds up the skin so the shape is completely determined by the internal structures. A rhinoplasty changes the internal structures of the nose, which is the the cartilage and bone, and the skin then re-drapes over the internal structures in a new shape. In most patients, there is no direct change to the skin during rhinoplasty. In other words, in most patients there is no need to surgically remove skin because it adapts, either by shrinking or stretching, to reflect the shape of the underlying structures.
The nose is evaluated from two general perspectives. The first is the size of the nose. The size of the nose is an important consideration when planning a rhinoplasty. There are three dimensions of the nose that are considered. The first is the nasal width. That is the width of the nose at the bottom of the nostrils as viewed from the front. The mouth width is generally one and one half times the nasal width. The second dimension is the nasal projection. This is the length of the nose from the face to the tip of the nose as viewed in profile. The nasal length varies greatly from patient to patient. The third dimension of the nose is the nasal length, which is the length from the deepest area between the eyes (glabella) to the tip of the nose. The length of the nose is generally equal to the height of the ear. These three dimensions will vary from patient to patient, and whether they are in proportion or not depends on many factors including the shape and dimension of the face. The second general perspective when considering the rhinoplasty procedure is the nasal shape. Nasal shape also has wide normal variation. The ideal shape of the nose is a straight to slightly under contoured nasal dorsum, a nasal tip with well defined anatomic points, and a gentle curve from the top of the nose to the bottom of the nose when viewed from the front. During the rhinoplasty consultation, the size and shape of the nose are discussed in relation to the general shape of the face. If a patient has a round shaped face, then a more rounded nasal shape matches, and if the patient has a narrow face, then the nose should be more narrow in order to match. In addition to size and shape, angles of the nose are considered. These angles and the normal variations of these angles have been well described in the rhinoplasty literature.
There are several common complaints that patients voice at a rhinoplasty consultation. Concerns about an over projecting dorsum (top) is one of the most common complaints. In simple terms, this is when there is a “bump” on top of the nose, also referred to as a “heavy dorsum”. The bump is caused by an over projection of the cartilage and bone which holds the skin up. In some patients seeking rhinoplasty the nasal dorsum is also too wide. Patients commonly voice concerns about the nasal tip when seeking rhinoplasty. In some patients the nasal tip is over-projecting, which means the nose appears long when viewed in profile. In some patients the nasal tip is too broad, and appears “boxy” or “square”. In some patients the nasal tip droops, and in profile appears to have a “hook” shape. The nasal tip shapes are a reflection of the shape of the cartilages of the bottom half of the nose. The nasal tip and the dorsum can also have a combination of these less desirable shapes in some patients. To change the shape of the nose, the cartilage and bone are surgically altered in shape or size. In some patients, the changes made in a rhinoplasty may just be in shape of the cartilage and bone. In other patients getting a rhinoplasty, the change may be an increase or decrease in size in cartilage and bone. In other patients the changes during a rhinoplasty may be a combination of size and shape of the cartilage and bone. In some patients, a graft may be utilized during the rhinoplasty procedure to improve the appearance of the nose.
The rhinoplasty procedure has been refined significantly in the past thirty years. Thirty years ago, the typical rhinoplasty consisted of some very basic surgical maneuvers to change the shape of the nose. Today, thirty years later, the anatomy (structures) of the nose has been further studied and defined, and many more surgical maneuvers have been described to refine the final result of the rhinoplasty procedure. One significant change in the rhinoplasty procedure is the increased use of the “open rhinoplasty”. In this procedure, the nasal structures are observed by access through the bottom of the nose, which allows maneuvers to be performed that were difficult or impossible with more traditional techniques (“closed rhinoplasty“). This technique not only allows direct visualization of the lower parts of the nasal structures, it also allows visualization of the upper parts of the nose, including the nasal bone. Because the structures are changed under direct vision, some surgeons feel that the surgery is more accurate and therefore more predictable. The choice between “closed” and “open” techniques depends on the preference of the surgeon as well as the complexity of the surgery.
The specific plan for each rhinoplasty is completed before the day of surgery. A rhinoplasty “work sheet” is completed which details the plan for the surgery. The work sheet shows how the internal structures of the nose will be altered, as well as the expected outcome from those changes. If any grafts are planned that is also noted in the plan. Common rhinoplasty plans include lowering the nasal dorsum (top), narrowing the nasal dorsum (top), narrowing the nasal tip (correction of broad nasal tip), shortening the nasal tip (for over projecting tip), raising the drooping nasal tip, or a combination of those plans. Another concern that some patients have is asymmetry, or lack of both sides being in proportion. This can occur naturally (from birth) or can be a result of trauma. Usually asymmetry of the nose can be improved during rhinoplasty, and the correction sometimes requires grafts.
The anesthesia for rhinoplasty varies on the preference of the surgeon and the complexity of the procedure. Rhinoplasty can be performed on most patients with local anesthesia and intravenous sedation. The length of time of the rhinoplasty procedure varies widely depending upon the complexity of the surgery. For example, if the nasal tip is the only part of the nose that will be changed, then the operation will last about an hour or less on average. If the entire nose is changed and there are breathing problems that also need to be addressed, then the operation would take longer to complete. The rhinoplasty surgery is an outpatient procedure for most patients which means that the patient is able to go home after the surgery.
After the rhinoplasty procedure there is always some swelling, and sometimes some bruising. The use of oral pain medicine after rhinoplasty is adequate for pain relief. The swelling and bruising after rhinoplasty usually resolves very quickly, which allows the patient to resume normal day to day activities in a few days. After the initial swelling resolves, the internal nasal structures will “remodel” over a period of months so that the final result is not seen immediately. Even though the final remodeling takes months to complete, most patients can see a difference in nasal shape immediately after surgery. After rhinoplasty surgery, patients are followed for many months so that the surgeon can follow the changes as long term healing occurs. In a small number of patients a small rhinoplasty revision may be performed many months after surgery to refine the final result.
- Procedure: Reshape nose by reducing or increasing size, removing hump, changing shape of tip or bridge, narrowing span of nostrils, or changing angle between nose and upper lip. Surgery of the nose may also correct impaired breathing caused by structural abnormalities in the nose. (May be covered by insurance.)
- Length: 1 to 2 hours or more.
- Anesthesia: Local with sedation, or general.
- In/Outpatient: Usually outpatient.
- Side Effects: Temporary swelling, bruising around eyes, nose and headaches. Some bleeding and stiffness.
- Recovery: Back to work: 1 to 2 weeks. More strenuous activities: 2 to 3 weeks. Avoid hitting nose or sunburn: 8 weeks. Final appearance: 1 year or more.
- Duration of Results: Permanent