Rhinoplasty is a surgical procedure aimed at changing the shape of the nose, and is commonly known as “nose reshaping surgery” or a “nose job”. Since the nose occupies the central portion of the face it plays a major role in the overall appearance of the face, and rhinoplasty surgery is one of the most commonly requested cosmetic procedures to improve appearance.
Goals of Rhinoplasty
The overall goal of rhinoplasty surgery is to improve the shape of the nose while at the same time preserving or improving the ability to breathe through the nose. The results from the surgery should appear natural and inconspicuous. Rhinoplasty should create a more refined or attractive version of a person’s natural nose that balances with other facial features, rather than give an unnatural “operated” look. Changing the shape of the nose involves meticulously sculpting the underlying structure of the nose (cartilage and bone) and allowing the skin to drape evenly over these structures. Once healing is complete, the improvements made in your nose will appear natural to others.
Before & after rhinoplasty.
Considerations for Rhinoplasty
When considering rhinoplasty surgery there are several factors that you and your surgeon will evaluate together. These factors will help guide the surgical plan and could impact surgical outcomes.
Age: Typically rhinoplasty surgery is not recommended at a young age until growth is nearly complete. This age varies for each person but tends to occur around 15 to 16 years for girls and 17 to 18 years for boys. Undergoing surgery earlier than this could impact the final growth of the nose or the natural growth following rhinoplasty may change the overall shape of the nose in an unwanted manner. Surgery may be recommended for some younger patients with severe nasal obstruction.
Skin thickness: Rhinoplasty changes the underlying structure of the nose, and these changes are seen through the skin covering the nose to give the overall nasal shape. Some people have very thin nasal skin meaning changes to the underlying cartilage and bone are more easily seen, while in others the nasal skin is thick and it is harder to see small changes to the underlying structures. Your surgeon will discuss the impact of skin thickness on your rhinoplasty outcome.
Gender and ethnic differences: Nasal shape can vary widely across different races and genders. There is not a “one size fits all” approach to rhinoplasty. You and your surgeon will discuss a tailored approach to rhinoplasty that fits with your ethnic and gender identity.
History of previous surgery: Previous rhinoplasty or deviated septum surgery can impact the approach taken for revision surgery. It is important to tell your surgeon about all previous nasal surgeries.
Facial harmony: The nose is only one of many important facial features that make up a person’s overall appearance. Desired changes to the shape of the nose should be considered in conjunction with other facial features to preserve or improve overall facial harmony. For some people there may be a combination of facial features that are out of balance such as a prominent nose and small chin. Addressing both factors simultaneously will help restore facial harmony better than a rhinoplasty alone. Your surgeon may suggest a computer generated photo simulation to demonstrate how the surgical changes with affect your overall facial harmony.
Medical history: Your surgeon will discuss your medical history including current medications and any impact that might have on your surgery or recovery.
The nasal tip is made up of two arched pieces of cartilage that support the nostrils. These cartilages are joined in the center and their shape creates the areas of highlights and shadows that are visible across the skin on the tip of the nose. This is a very important aesthetic feature of the nose and altering the shape of the nasal tip is a common reason for rhinoplasty.
Viewing the nose from the front, some people feel their nasal tip is too broad or “bulbous” and would like to refine the tip. Others have a nasal tip that is too pinched or narrow, while others have a tip that is asymmetric. Various surgical options exist to change the shape of the nasal tip with a goal of producing a symmetric and smooth appear tip that has a natural appearance.
Viewing the nose from the side as a profile, the nasal tip can be adjusted in several ways. The distance the tip of the nose sticks out from the face is called tip projection. Nasal tips that protrude too far can be shortened, while those that are too short can be lengthened. Additionally, the tip is examined in terms of the angle the tip of the nose makes with the upper lip which is called nasal rotation. Some noses are too droopy at the tip and need to be lifted while others are turned upward too far and need to be adjusted closer to the lip.
The overall goal of a tip rhinoplasty is to change the position and shape of the tip of the nose to create a balanced and attractive result in all three dimensions.
Before & After: Tip rhinoplasty.
Before & After: Tip rhinoplasty.
The nasal dorsum refers to the bridge of the nose and is made up of bone toward the top between the eyes and cartilage toward the tip of the nose. A common rhinoplasty request is to smooth out a bump on the bridge of the nose known as a “dorsal hump.” With this procedure a person can change from a profile that is curved outward along the dorsum to a straight profile that blends in with the tip of the nose. Dorsum rhinoplasty involves carefully sculpting the cartilage and bone that make up the bridge of the nose to create a smooth nasal profile.
The width of the nasal bridge can also be adjusted if it seems too wide or too narrow. If the nasal bridge is too narrow after straightening a dorsal hump this may lead to an overly pinched appearance or even difficulty breathing through the nose. In this situation cartilage grafts taken from the nasal septum are often used to preserve the desired width of the nasal bridge and maintain breathing through the nose. Alternatively, the bridge may appear too wide after removing the hump and give the bridge a flattened or “cut off” appearance that is unnatural. In this case controlled cuts are made in the nasal bones to allow the bones to move toward the middle of the nose and restore the smooth, curved appearance of the bridge of the nose.
Before & After: Dorsum rhinoplasty.
Rhinoplasty is never a simple surgery, but when the nose has been operated on previously, sometimes more than once, there are additional challenges to the surgery. Previous surgeries will create some scar tissue in the nose and may have removed or changed some of the nasal cartilage. Many times revision rhinoplasty requires the placement of cartilage grafts to either improve nasal breathing or change the nasal shape in a way that preserves function. The nasal septum is a good source of cartilage to use for grafting, but after previous surgery there may not be enough cartilage remaining in the septum to use. Additional sources of cartilage for revision rhinoplasty include a portion of the cartilage from the ear or the rib cage. Your surgeon will discuss if these options will be needed as well as the pros and cons of each.
The nose is just one feature that makes up a person’s facial appearance. The most attractive faces demonstrate good harmony among all the facial features. A common example of this is the relationship between the size of the nose and the chin. An undersized chin gives the appearance of a nose that is too large and the opposite is also true. Some people who desire a smaller nasal profile with a rhinoplasty may also benefit from slightly enlarging the chin to achieve better facial balance. There are several options available for chin augmentation and your surgeon will discuss whether you are a candidate for these.
Combined Functional & Cosmetic Rhinoplasty
Difficulty breathing through the nose can be caused by a variety of issues. Some of these issues may relate to the underlying structure of the nose as well as sinus or allergy problems. Your surgeon will carefully evaluate for each of these factors and discuss which may be contributing to your obstruction. There are a variety of surgical procedures that can be used to improve nasal breathing. Many of these procedures use the same approach used in rhinoplasty and it is common to combine surgery to improve breathing as well as the shape of the nose. When structural issues are present that require surgery to improve breathing, these procedures are typically covered by most insurance companies. Surgery to change the shape of the nose that does not affect breathing is not covered by insurance and carries a separate cost, but can easily be combined with surgery to improve breathing during the same operation. In this way the time under anesthesia and recovery time is combined.
What to Expect
At Your Appointment
At your first appointment you will meet with the surgeon who will carefully review your personal and medical history along with your desired changes to your nasal shape. Your surgeon will perform a careful examination of your nose both inside and out. Be prepared to discuss any difficulty you have breathing through your nose as well as previous nasal surgeries. Part of the examination may include nasal endoscopy to carefully inspect the structures inside the nose. This involves placing a small endoscope into the nostrils to see more detail than is visible looking directly through the nostrils, a topical numbing spray will be used prior to the exam.
Each person has a different idea of his or her ideal nasal shape. There is no “one size fits all” nose. Be prepared to discuss specific aspects of your nose that you dislike or want changed. Bringing pictures of noses that you consider ideal can be helpful to demonstrate your desired changes, but remember that the nose must remain in harmony with your other facial features. Photographs of your nose will be taken from various angles during your visit and used to help guide your decision for surgery and surgical planning. Your surgeon will review each of your desired changes and discuss what surgical options exist. Some people are interested in seeing a computer simulation of what these changes might look like, and this can be done based on your individual photographs. In this case a second visit is recommended to specifically review the computer simulation.
Your surgeon will explain the details of the surgery, operative risks, expected recovery time, post-operative medications and restrictions along with your follow up visit schedule. You should expect the opportunity to ask all questions you may have about the surgery and understand what to expect throughout the process.
At Your Surgery
Rhinoplasty surgery is done in the operating room under general anesthesia to optimize your comfort and surgical outcome. Expect to arrive to the hospital or surgery center one to two hours before your scheduled surgery time and remember not to eat or drink anything after midnight before surgery to minimize risks related to anesthesia. You will meet the Anesthesiologist and operating room team at this time. Your surgeon will also see you before the surgery starts to review the plan and make sure all of your questions are answered.
The surgery itself will last several hours, but to you will feel like only a few minutes have passed when you wake up in the recovery room. The skin of the nose will be covered with surgical tape and often a plastic cast. Dissolvable sutures will be present inside the nose and if needed there may be some sutures on the strip of skin between your nostrils. Sometimes flexible splints are secured inside your nose. You may have some occasional oozing of blood from the nostrils as well as some swelling and discomfort of the nose. There may also be some bruising under the eyes.
In the recovery room you will be closely monitored to ensure your pain is well controlled and all vitals are stable. At this point you will be cleared for discharge home. You will need a friend or relative to drive you home after surgery and stay with you for the first one to two days after surgery.
During Your Recovery
After surgery you will be discharged home with prescriptions for pain medication and possibly antibiotics or anti-nausea medication. You will also have written wound care instructions which include spraying the inside of your nose with a saline spray several times per day and applying antibiotic ointment to the incision lines. It is common to have some intermittent drops of blood from the nostrils for the first several days that can be dabbed away with a tissue. Expect your nose to feel congested after surgery especially if splints are placed inside the nose.
You will have pain following surgery, but with the medication the pain should be tolerable. This rapidly improves through the first week. You may also have some swelling or bruising under the eyes. Elevating your head during sleep and applying light weight ice packs to the cheeks can help speed up the resolution of the swelling and bruising. You should be up and around the house after surgery but avoid any strenuous activity, bending at the waist, or heavy lifting to minimize swelling, bleeding, and discomfort. Walking and light activity is encouraged and may help speed up your recovery.
Your first post-operative visit will be scheduled for five to seven days after surgery. At that time you will meet with the surgeon to review your recovery. The external nasal splint will be removed at that time along with any sutures on the skin or splints inside your nose. Your nose will be carefully examined to assure that you are healing well. At this visit your surgeon will discuss the next steps in your recovery including any limitations on activity or work and additional follow up visits. Most people return to work one week after surgery. While recovery proceeds quickly in the following weeks, keep in mind that it will take a full year for all the swelling to resolve and your final results to be achieved.