Rhinoplasty (Nose Job)
RHINOPLASTY (NOSE JOB)
INTRODUCTION OF RHINOPLASTY (NOSE JOB)
Noses come in all shapes and sizes, and any good rhinoplasty (or nose job) surgeon knows that every surgery is therefore also unique. Using exactly the same set of techniques on every nose leads to problems and, more often than not, that “done” look. Therefore, your facial plastic surgeon must possess a large array of different techniques and skills in order to address the various cosmetic concerns related to the nose.
Sometimes, when looking at the nose, we forget that its primary purpose is for breathing. Changing the outer appearance of the nose can also alter its function–and not always for the better. For this reason, rhinoplasty (or the nose job) must achieve a pleasing shape without compromising one’s ability to breathe. In fact, there are many people who have rhinoplasty not only to improve the appearance of their noses, but to breathe better, too!
For this reason, any surgeon specializing in rhinoplasty must also have an intimate understanding of nasal function. Facial plastic surgeons must first train in head and neck surgery before going on to complete fellowships in facial plastic and reconstructive surgery. As a result, they not only understand the aesthetic relationships of the nose, but also how and when to fix the nose. A smaller nose may look better, but breathing could be worse. Addressing form without impairing function is of tantamount importance in nose surgery.
And finally, in order to start learning how to communicate your cosmetic concerns, I have labeled a photo of the nose here with some fairly common terms. Being able to use these terms to describe the anatomy of your nose will help you and your facial plastic surgeon communicate about the aesthetic goals you have for your nose and face. This is the first step towards understanding the complex topic of rhinoplasty.
INDICATION OF RHINOPLASTY (NOSE JOB)
The nose is most prominent part of one’s face. A rhinoplasty can repair deformities of the skin, lining, bone or any part of the nose. The procedure can be carried out to shorten excessively long noses, straighten noses with a drooping tip, smoothen bumps on the nose, lengthen too short a nose, level out depressed noses, trim down the lumpy ones. It can correct deformities due to injuries or previous surgeries. It is also performed when one develops breathing difficulty following a previous nose job. Sometimes a septoplasty or correction of a deviated septum may have to be done along with a rhinoplasty for optimum results.
The nose is always associated with one’s character.A man with a large nose is thought to be sinister, small nose weak, red nosed an alcoholic and a crooked nose a criminal or psychopathic behaviour’.1
One must convey information regarding the desired size, angulation and shape of the nose to the aesthetic surgeon and he will decide on the extent of surgery required. His judgement will also be based on his assessment of the patient’s skin character, the patient’s overall facial features, his profile and so on. The doctor may take photographs of the straight as well as the profile view of the patient to take measurements and also for future reference.
A rhinoplasty symbolizes the art and practice of plastic surgery-attention to the psychosocial status of the patient, modification of form and improvement of naso-respiratory function.2
Basic blood tests for hemoglobin, sugar and an ECG for an older patient may be the investigations required before the operation. The patient would be instructed by the doctor to stop medicines such as aspirin or other blood thinners before the operation.
The operation is sometimes done under local anesthesia, although many surgeons prefer to have the patient sleeping with a general anesthetic. A six- hour starvation is required before the operation. The patient is anesthetized before the surgery commences.
TYPES OF RHINOPLASTY (NOSE JOB)
- Reduction Rhinoplasty
A significant proportion of patients seeking rhinoplasty surgery are concerned that the sheer size of their nose is disproportionate with their facial features.
Areas of particular concern are the presence of a bump on the bridge of the nose, excessive width of the bridge tip of the nose, and possibly excessive width of the nostrils.
- Augmentation Rhinoplasty
Augmentation rhinoplasty refers to the type of surgery where the dimensions of the nose are increased.
This may well be the case in congenital underdevelopment of the nose, after injuries were the support cartilage has been damaged, after surgery which has led to loss of support, or when too much tissue has been removed.
- Ethnic Rhinoplasty
In essence, all rhinoplasties are ethnic rhinoplasties, because they take in consideration ethnic characteristics of the nasal shape, skin and facial proportions.
The term has been associated however more with rhinoplasty for population groups with softer nasal contours, like the Afro-Caribbean, the Far Eastern or Pacific Rim populations.
- Post-traumatic Rhinoplasty
Injuries to the nose, frequently lead to damage to the bone and cartilage support, and change the appearance of the nose, resulting in deviations, asymmetries and sometimes airway problems.
Deviations of the bones and cartilages of the nose, can be reset with relatively good success rate within the first week to 10 days after the injury.
ANESTHESIA RHINOPLASTY (NOSE JOB)
The type of anesthesia used for nose job surgery depends on the amount of work that will need to be done and the patients and the doctors preference.
For example, if you only want or need your tip worked on, you can have this done under a local anesthesia (numbing the tissues), or you can choose to have IV sedation or a General Anesthesia if you are frightened of experiencing the process.
If however you need extnesive internal work performed, you will likely need a General Anesthesia so that you do not experience the pain, and so that your airway can be protected during surgery. (Amy T. Bandy, DO, FACS, Newport Beach Plastic Surgeon)
Most nose job surgery is performed under deep sedation or general anesthesia. The reason for this is two-fold: There is always some bleeding that can get into your airway during the surgery, so general anesthesia, where a breathing tube is used, protects your airway.
No one really wants to be awake for this procedure, no because there is pain, but because its just uncomfortable for most to be aware of the procedure.
That being said, some minor procedures can be performed under minor sedation with local anesthesia. It all depends on what needs to be done. (OlehSlupchynskyj, MD, FACS, New York Facial Plastic Surgeon)
PREOPERATIVE PROCEDURE OF RHINOPLASTY (NOSE JOB)
You must first meet with your surgeon to discuss whether you’re a good candidate for rhinoplasty. You’ll talk about why you want the surgery and what you hope to accomplish by having it.
Your surgeon will examine your medical history and ask you about any current medications and medical conditions. If you have hemophilia, a disorder that causes excessive bleeding, your surgeon will likely recommend against any elective surgery.
Your surgeon will perform a physical exam, looking closely at the skin on the inside and outside of your nose to determine what kind of changes can be made. Your surgeon might order blood tests or other lab tests.
Your surgeon will also consider whether any additional surgery should be done at the same time. For example, some people also get a chin augmentation, a procedure to better define your chin, at the same time as rhinoplasty.
This consultation also includes photographing your nose from various angles. These shots will be used for assessing the long-term results of surgery and may be referred to during the surgery.
Make sure you understand the costs of your surgery. If your rhinoplasty is for cosmetic reasons, it’s much less likely to be covered by insurance.
You should avoid painkillers containing ibuprofen or aspirin for two weeks before and two weeks after your surgery. These medications slow down the blood-clotting process and can make you bleed more. Let your surgeon know what medications and supplements you’re taking, so they can advise you about whether or not to continue them.
Smokers have more difficulty healing from rhinoplasty, as cigarettes slow the recovery process. Nicotine constricts your blood vessels, resulting in less oxygen and blood getting to healing tissues. Quitting smoking before and after surgery can help the healing process.
PROCEDURE OF RHINOPLASTY (NOSE JOB)
Rhinoplasty can be done in a hospital, a doctor’s office, or an outpatient surgical facility. Your doctor will use local or general anesthesia. If it’s a simple procedure, you’ll receive local anesthesia to your nose, which will also numb your face. You may also get medication through an IV line that makes you groggy, but you’ll still be awake.
With general anesthesia, you’ll inhale a drug or get one through an IV that will make you unconscious. Children are usually given general anesthesia.
Once you’re numb or unconscious, your surgeon will make cuts between or inside your nostrils. They’ll separate your skin from your cartilage or bone and then start the reshaping. If your new nose needs a small amount of additional cartilage, your doctor may remove some from your ear or deep inside your nose. If more is needed, you might get an implant or a bone graft. A bone graft is additional bone that’s added to the bone in your nose.
POSTOPERATIVE PROCEDURE OF RHINOPLASTY (NOSE JOB)
During the first week following your surgery, you can expect to have some bruising and swelling. Do not lie flat to rest or sleep for one week, instead prop yourself up with 2-3 pillows, as this will help reduce the swelling.
Try to avoid sleeping on your side as this can lead to deviation of the nose if sufficient pressure is applied. Using Arnica tablets before and after surgery can reduce the bruising.
It is advisable not to blow your nose for the first 3 weeks after the surgery to avoid nose bleeds and air trapping under the skin. If required, the nose can be cleaned gently with wet cotton buds. The other options include using saline irrigation solutions (Sinurinse available from Boots the chemist). You may have a blocked nose for a few weeks following surgery due to the swelling, and until the swelling settles, it is possible to use decongestants (in tablets form preferably).
Avoid strenuous exercise or anything that is likely to increase your blood pressure, particularly within the first 10 days as it is more likely to trigger nose bleeds. Exercise can be resumed in 3-4 weeks following surgery. Try to avoid leaning or stooping forward, as well as straining following surgery, again to reduce the risk of nose bleed.
If you feel a sneeze or cough coming on, open your mouth and allow the pressure to escape through your mouth, avoiding pressure inside the nose.
The splint will be removed in 7 days, along with any sutures at the tip of the nose. Internal splints are often used. These will be removed at the same time. There are dissolvable sutures inside the nose and they will fall out by themselves.
You may be discharged with some antibiotics and it is important that the whole course is completed. Please avoid taking Aspirin/anti-inflammatory medication as these can cause bleeding. You may commence your usual medication as soon as you can eat or drink unless otherwise advised.
It is best to avoid wearing glasses or shades that take support over the bridge of the nose for the first 6 weeks following your operation. Glasses or shades that take support on the side can be used starting at about 2 weeks after surgery as they are not likely to influence the shape of the nose.
It is best to avoid flying for the first month after your operation. If you need to fly for work purposes before this period of time, try to avoid flying at least for 2 weeks and in the course of the first 1 or 2 flights, you can take an Aspirin with food to thin the blood and reduce the risk of clots in the leg veins.
It is important to walk around very early after your operation so that the circulation in the legs is restored. Although the risk of clots in the leg veins with this type of surgery is relatively low, it is important to address it as the problems related to it can be severe.
If you want to wash your hair in the early days after surgery, you will need to try and protect the splint from the water. You can wash your face gently around the dressings but for the hair, you will need to lean back and avoid the face being soaked by the running water.
Most people find that the tip of the nose is quite numb in the early stages after surgery. This is a perfectly normal occurrence and should not alarm you. The feeling in the tip of the nose will return gradually, but in the course of a few months’ time.
If you tend to ride a motorbike, it is important to be careful when applying helmet to avoid injury to the nose. This is particularly relevant in the first month after your surgery, after which the strength of tissue recovery is much better and the likelihood of injury decreases significantly.
COMPLICATIONS OF RHINOPLASTY (NOSE JOB)
Rhinoplasty is considered to be an operation with high risks, primarily because of the limited predictability of the aesthetic result. What are the reasons? A perfect result immediately after surgery may be totally different one year later. Reports on long term results of rhinoplasty are rare. Limited predictability is mainly due to the dynamics of the healing process. Many different types of tissues are involved: bone, cartilage, mucosa, skin, fat, fascia, muscles, nerves, vessels, perichondrium and periosteum. The individual reactions of these tissues are not always under the control of the surgeon. This is especially true for cartilage, the main supporting structure of the nose.
An unfavourable result of rhinoplasty is clearly visible (“everybody is an expert”). The patient very often blames the surgeon for this result while the surgeon tends to call it a complication. In principle, both are possible and cannot be definitely distinguished in many situations. Complications are effects of the individual reaction and the healing process. They are not under the control of the surgeon. In this case the physician has to identify the complication early enough and react adequately. Some “complications” however are in fact a mistake in preoperative analysis or surgical planning, in applying an inadequate technique or in postoperative care . An earnest analysis is essential for prevention. The main issues of this article are postoperative deformities, their frequency and possible factors. It does not deal with the numerous techniques for revision surgery but with the types of deformities and their prevention. Risks and complications of rhinoplasty are emphasised and the nasal septum only adressed if it is an essential part of the deformity.