Rhinoplasty (Nose Job)

Rhinoplasty (Nose Job)

Rhinoplasty (Overview)

Rhinoplasty is one of the most common types of plastic surgery, and is also well known as a ‘nose job’. Rhinoplasty is a surgical procedure that reshapes the nose by modifying the bone or cartilage for both aesthetic and functional purposes.

The procedure can enlarge the nose or make it smaller, as well as change the angle in relation to the upper lip, correct indentations, bumps or other defects, as well as alter the tip of the nose.

The most common reasons for a rhinoplasty procedure are to change the appearance of the nose (aesthetic) or improve a person’s quality of breathing.

The upper portion of the nose structure is bone and the lower, cartilage. A rhinoplasty procedure modifies the cartilage and bone structure, as well as the skin surrounding it. A plastic surgeon may require additional material to augment (enhance or reinforce) the nose. Materials commonly used include alloplasts (synthetic implants), alloenous materials (these are obtained from cadavers) or autologous implants (materials harvested from a patient’s own tissue, usually the rib or fascia).

Functional reasons for this type of procedure include providing structural support for areas of the nose that are deficient of material (upper or lower lateral cartilages), and allowing a person to breathe a little more effectively.

Aesthetic reasons include increasing the projection of the nose (the nasal dorsum) in profile view (correct the proportion of the nose in relation to the rest of the face) and modifying the nasal tip. Grafts may be placed to camouflage any irregularities of the upper or lower lateral cartilage or the bony dorsum.

Surgeons qualified to perform rhinoplasty procedures are typically trained in plastic surgery, otolaryngology (specialising in the ears, nose and throat), or both.

A plastic surgeon will take into careful consideration your facial features, the skin on your nose and what specifically you would like to change. He or she will then discuss whether this procedure is appropriate for you and whether it can achieve your desired result.

If it is agreed that you are a candidate for surgery, a customised plan will be developed for you. Depending on your medical health insurance plan, some or the entire procedure may be covered. Procedures, purely for cosmetic reasons may not be covered at all and you will need to cover the costs independently.

Anatomy of the nose.

Why is rhinoplasty done?

Changing the shape of the nose purposefully to repair, correct, or alter its appearance is done for both aesthetic and functional (health) reasons. Some may require a rhinoplasty procedure to repair abnormalities due to an injury, correct breathing problems or birth defects. Others primarily wish to make aesthetic adjustments to their nose.

Changes a plastic surgeon can make include:

  • Adjusting the size and angle of the nose
  • Straightening the bridge of the nose
  • Reshaping the tip of the nose
  • Narrowing the nostrils

An aesthetic adjustment should only be done when the nasal bone is fully grown. For females, growth tends to stop at around the age of 15 or 16, while boys may still be growing into their late teens (17 – 18 years of age). If the purpose of a rhinoplasty procedure is to correct a breathing impairment or chronic congestion, surgery can take place at a younger age.

Drawing of where incision options for rhinoplasty surgery are made.

What happens during your first consultation?

Before a rhinoplasty procedure can be scheduled, a consultation with a plastic surgeon will be required. During the consultation, he or she will discuss with you all the factors necessary to determine whether you are a candidate for surgery (whether the procedure is likely to work for you and achieve the desired results).

The discussion will likely cover the below factors:

  • Your medical history: First and foremost, your motivation for wanting the surgery and the desired result will be discussed. From there, your surgeon will ask questions relating to your medical history. This can include whether or not you have a history of nasal obstruction, previous surgeries and a list of any medications and supplements you may be taking. If it is known that you have a bleeding disorder, such as haemophilia, your surgeon will likely rule out the possibility of having the surgery.
  • A physical exam: If there are not reasons why you aren’t a candidate for surgery at this stage, a complete physical examination will be conducted, and may also include blood tests and other necessary lab tests. Your surgeon will also inspect the skin, as well as the inside and outside of your nose. This is to assess whether the desired changes are achievable and how your physical features may affect the possible results. Your surgeon will assess the thickness of the skin and the cartilage at the end of your nose. A thorough exam is necessary to ensure that the impact of the procedure doesn’t in any way result in impairing your ability to breathe properly post-op.
  • Photographs: If the surgeon is satisfied with their assessment and there are still no reasons to rule out the procedure, photographs of your nose will be taken from different angles. Computer software may then be used to manipulate the images to show you the kinds of results that may be possible. These images are often used for before-and-after assessments, as a reference during the surgery and for long-term reviews.
  • Your expectations: You and your surgeon will then further discuss your motivations and expectations in more detail. It’s important that you are completely honest about your expectations of the surgery. Your surgeon will have a much clearer indication as to what the procedure can and can’t do for you at this stage of the consultation. He or she will detail how the surgery is likely to meet your expectations, or alternatives where it may not be possible and why. Sometimes a surgeon may offer an alternative for consideration. A small chin can sometimes create the illusion of a larger nose. If you are not a candidate for rhinoplasty, this procedure may be an option for you to give your facial profile an improved proportion. In some cases, a chin and rhinoplasty procedure may be recommended and done at the same time.

From this point, if your surgeon agrees that you are a candidate for surgery, you may then schedule your procedure. In preparation for the procedure you will need to take into consideration that you will need to arrange safe transport from the hospital or outpatient surgical facility following the procedure as you will not be fit to drive yourself (as the anaesthetic wears off).

You may also like to arrange for someone to stay with you the first few days after surgery in case you need assistance with personal care tasks, as you can experience lapses of memory, slowed reaction time and impaired judgement as the anaesthetic wears off in the body.

Your surgeon will also request that you avoid medications containing aspirin or ibuprofen for at least 2 weeks prior to and after surgery as these can slow down the blood-clotting process and increase your risk of internal bleeding. Any medications or supplements you continue to take must be approved or prescribed by your surgeon.

Smokers may be asked to stop smoking before the procedure and during recovery. Smoking typically slows down the healing process (constricting the blood vessels, resulting in less oxygen and blood being able to get to the body’s tissues) and can make you more susceptible to infection-related complications.

How is the procedure done?

Surgeon shaping and preparing cartilage implant for rhinoplasty procedure.

A rhinoplasty procedure will be done in a hospital or other outpatient surgical facility. In some cases, an overnight stay may be required. Local or general anaesthetic will be used and will depend on the simplicity or complexity of the procedure.

For simpler procedures, a local anaesthetic may be used to numb the nose area and surrounding areas of the face (injected into the nasal tissues). Medication may also be administered through an IV line (intravenously) through a vein in the arm. This may not put you to sleep, but will likely make you feel a little groggy.

A general anaesthetic is usually preferred for complex procedures or if the patient is a child, and will either be inhaled or administered through and IV line.

Once numb or unconscious, your plastic surgeon will make incisions (cuts) between or inside your nostrils (less visible), or through an external incision at the base of the nose, and begin separating the skin from the cartilage or bone that normally supports the structure. Reshaping can begin from there.

There is no set series of steps to this procedure. Each surgery is customised to a patient’s specific anatomy and desired results. Bone and cartilage may be removed, or tissue may be added. How the reshaping takes place depends on the desired effect by both the patient and the surgeon, as well as available materials and how much needs to be added or removed.

Additional cartilage (in a small amount) may be needed for additional structure support during the procedure and may be harvested from deeper inside the nose or from the ear. If this is necessary, your surgeon may insert an implant (or synthetic filler) or a bone graft (additional bone added to your own bone in the nose, sourced from your rib or bone from others parts of the body).

Once the re-shaping is complete and the skin and tissue has been re-draped over the new nose structure, your surgeon will place a splint (metal or plastic) on the outside of the nose to support the new shape. This will be left in place during the recovery period.

Nasal packs or splints may also be placed inside the nostrils to stabilise the septum. If all goes well, the procedure generally takes between 1 and 2 hours. More complex procedures can take a little longer. Once inside the recovery room, a medical care team will monitor your return to consciousness. This can take up to a few hours following surgery. If there are any health concerns, you may be required to stay on for a day or two, otherwise you will be able to return home the same day.

Rhinoplasty (nose job) surgery.

What to consider before deciding to have rhinoplasty done

Before going ahead with the procedure, it is strongly advisable to consider the following:

  • Self-image: The nose is a prominent feature on your face and has a big impact on your appearance. If your nose is the source of a low self-image, rhinoplasty can help to improve your levels of self-esteem or self-confidence. As the procedure is a cosmetic alteration it is very important to ensure that you have clear and realistic expectations of the surgery and what it can and can’t achieve. Most who are happy with their results were clear about their expectations, happy within themselves and with their surgeon beforehand.
  • Anaesthetic: A general anaesthetic will sedate you to the point of unconsciousness (being deeply asleep). You will not feel anything during the surgery procedure, hear anything happening around you or be able to recall anything about the operation (during and shortly after) process. If you elect to have a local anaesthetic, you will not be completely sedated and will be able to hear your surgical team and the sounds associated with working on the bones and cartilage of your nose. If this makes you uncomfortable, this means of sedation may not be a good option for you. Local anaesthetic will only be an option for simpler procedures. If you are comfortable with this, it is best to prepare yourself ahead of time for what you may be exposed to.
  • Medical health insurance: Unless your procedure is being done for medical reasons (to correct a functional problem or impairment, or defect caused by injury or disease such a deviated septum or similar), a medical health insurance company will likely regard the surgery as purely cosmetic and may not cover the cost at all. Some insurance companies will cover a portion of the cost. Costs will include the surgeon’s fee, operating facility fees, the anaesthesiologist, medicines, splints and other services or materials. If your healthcare system requires you to be financially responsible for all medical consultations and procedures, it is strongly advisable to check your policy and enquire what your health insurance will or won’t cover before going ahead with the procedure.

Risk factors and complications

Infection, excessive bleeding or an adverse reaction to anaesthetic (or irritation from the surgical tape or bandaging) are some of the more common rhinoplasty complications which can occur during (or soon after) the surgery. This procedure may also increase your risk of:

  • Nosebleeds (these can be recurring)
  • A numb nose (in and around the nose. This can be permanent)
  • Injury or holes to your septum, known as septal perforation (the wall that separates the nostrils)
  • An asymmetrical nose (uneven-looking)
  • Scarring
  • Difficulties with breathing and nasal blockage (caused by swelling inside the nose)
  • Skin necrosis (breakdown of skin tissue)
  • Persistent pain, discolouration or swelling

There is some degree of risk that you may not be satisfied with the results of your surgery. A second surgery may only be considered once the nose has fully healed, in this case.

Recovery and maintenance

What to expect during recovery

Swelling and bruising around the eyes and nose after a rhinoplasty procedure is to be expected, but is temporary and will fade through the healing process. You may also experience numbness or discolouration around the eyes for a about 10 to 14 days. Slight swelling can persist for longer but can be treated with cold compresses or ice packs.

To help reduce any bleeding and swelling during recovery, you will need to rest with your head elevated above your chest. You may be given a drip pad (a piece of gauze taped beneath your nose) to absorb any blood and mucus. A drip pad should never be secured directly on the nose. Your surgeon will advise how often this should be changed.

You will be required to leave splints and dressings in place for up to a week following surgery. This will be removed by your surgeon during a follow-up appointment. Your nose will be a little swollen or packed with cotton, causing a congested feeling.

Your surgeon may have sealed incisions with absorbable (dissolvable) stitches. These will not require any removal procedures. Stitches that aren’t will usually be removed by your surgeon about a week after your surgery. Internal dressings will also need to remain in place for between 1 and 7 days after your surgery.

During the initial recovery, you may experience memory lapses, a slow reaction time and impaired judgement following anaesthetic or as side effects from prescribed pain and antibiotic medications.

You may also experience headaches, or have a ‘puffy feeling’ in your face in the days after your surgery. Pain medication can be prescribed for this.

Your surgeon will also request that you avoid doing any of the following during the initial weeks after surgery:

  • Strenuous physical activity (including gym, aerobics, swimming or running)
  • Blowing your nose
  • Resting eyeglasses or sunglasses on your nose (for at least 4 weeks)
  • Facial expressions that require a lot of movement such as  smiling or laughing (try to be mindful of your expressions as you heal)
  • Vigorous tooth brushing
  • Excessive chewing
  • Taking baths instead of showers while you still have bandages and dressings on your nose
  • Spending time out in the sun (care will need to be taken with levels of sun exposure as this can permanently discolour the skin around the nose)
  • Wearing clothing that fastens in the front (or back) and avoid those that need to be pulled over your head
  • Contact sports may be strongly advised against for several months, and even up to a year

It is also helpful to ...

  • Ensure that your diet is rich in fibre to avoid any occurrences of constipation (which can cause strain and put pressure on the sensitive nose while healing)
  • Limit your sodium intake during surgery as this can help alleviate further swelling

Follow-up care is very important after a rhinoplasty procedure, so be sure to keep all of your appointments with your surgeon and follow his or her care instructions properly.

Skin care before and after rhinoplasty

Skin care following a rhinoplasty procedure is very important. Your surgeon will discuss skincare with you before and after your rhinoplasty procedure. A significant part of a successful recovery involves proper skin care and products to help you achieve better results, especially during the first few days and weeks after the surgery (when the skin is at its most sensitive). Healthy skin will heal better and quicker.

Rhinoplasty is an invasive procedure and can make post-op skin care a little more complicated. Cleaning or cleansing your skin may involve:

A hypoallergenic moisturiser and or / night cream with no fragrance may be applied to the rest of the face daily. You will be encouraged to use a sunscreen with a minimum SPF of 30 when you are outside, especially around the nose. Excess sun can cause permanent discolouration in the skin of the nose.

Your surgeon may request that you avoid soap-based cleansers, moisturisers with no fragrance and other non-hypoallergenic products and sunscreens with an SPF higher than 40 as these may clog your pores.

Your surgeon may have a preferred range of skincare products which he or she may suggest or recommend, as well as a specific cleansing regimen to follow. A skincare regimen may even be recommended about a month before your procedure, and ending 10 days prior. You may be requested to recommence up to 3 weeks after surgery, allowing the skin to breathe during healing.

A recommended skincare regimen will depend on factors such as your skin type and colour, season of the year, as well as how your skin generally responds to certain products.

Make sure to keep hydrated as this helps to keep your skin rejuvenated and flush out any toxins. Your wounds will heal on their own. It is best to refrain from picking at scabs that may form or peeling skin, as this can cause infection or scarring.

You may wish to disguise swelling and bruising effects with a little make-up. Mineral-based products (foundations and powders) are generally gentler on the skin. A green colour-based foundation can help to alleviate redness (inflammation) and gives many patients a more natural looking skin tone. A powder which is one shade darker may also help to reduce the appearance of redness while healing. Any make-up products used must be thoroughly cleansed at night.

Results

Rhinoplasty (nose job) before and after patient.

The healing process can take a while and it should be expected. It is advisable that you discuss the process of recovery with your surgeon during the early stages so that you are clear about what to expect, what is normal and when something may be of concern.

For the most part, rhinoplasty is a relatively safe and uncomplicated procedure. You may be fully recovered within a few weeks or you may experience some effects months down the line. It can be an entire year before you can fully appreciate the end result of your surgery (sometimes swelling can take many months to completely heal).

End results may be minor (sometimes even a few millimetres worth of a difference) or significant, depending on the complexity of correction and alteration you wanted. Realistic expectations to begin with generally result in a happier outcome. Results are permanent and are only generally altered through subsequent injury or further surgery.

If you are dissatisfied with the results you can wait up to a year before you may be able to have a second surgery for further refinements (the nose can naturally undergo changes and will continue to do so during your lifetime). However, the more nasal surgeries you have, the more complex these procedures and corrections become.

FAQs

What is the difference between closed and open rhinoplasty?

A rhinoplasty procedure is unique in the sense that it almost entirely depends on the individual characteristics of a person’s physical features, as well as their personal desires.

An ‘open rhinoplasty’ procedures involves and incision along the columella (the soft tissue between the nostrils). This allows a surgeon direct ‘open’ access to cartilage and easier manipulation of the nasal shape. It can also give a surgeon more control and better precision.

A ‘closed rhinoplasty’ surgery involves incision that are made inside the nostril. This surgery method can considerably reduce the operative time, results in less swelling and reduced post-op healing time. Scarring along the columella is also avoided, and any scars that occur as a result of the incisions are not visible.

Is there such a thing as non-surgical rhinoplasty?

The shape of the nose can be slightly altered without the need to go under the knife. Some surgeons may be able to perform a relatively quick and non-invasive alternative with less risk than a traditional rhinoplasty procedure.

This can be achieved through a series of dermal filler injections that are virtually painless, have no recovery time and do not require anaesthetic. This may be an option for very slight aesthetic adjustments that will fulfil a person’s desires, as well as match facial features, creating a more symmetrical facial profile.

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