Anesthesia

Surgery is performed with the patient asleep using IV sedation and a Laryngeal Mask Airway^TM (LMA). An anesthesiologist or certified nurse anesthetist monitors the patient. The procedure is performed without a need for anesthetic gas, intubation, ventilation or paralysis. Patients are able to breathe on their own, although they remain asleep. This is the newer type of anesthetic that enhances patient safety, reduces recovery time, and almost eliminates postoperative nausea, which is good news for patients who have experienced this previously with more traditional anesthetics. The usual operating time is one to two hours.

Rhinoplasty: Treatment Areas

The Dorsum

The dorsum of the nose makes up the (mainly bony) portion of the nose from the nasal bridge (where eyeglasses rest) to the soft, cartilaginous tip of the nose. Patients may be concerned about a "dorsal hump", asymmetry, or excessive width of this structure.

The dorsum is approached using an incision on the inside of the nose where it is hidden. A rasp (sharp surgical file) is used to file down excess bone in this area. The profile of the nose is checked from the side. Rasping continues until the profile has been reduced to a pleasing slope. At this point, the dorsum needs to be narrowed to avoid the appearance of a flat-top. The nasal bones are folded in to produce the desired narrowing.

The next step is to release the nasal bones. A mallet and curved chisel are used to release the nasal bone where is attached to the cheek bone, allowing it to be folded in. This is done on both sides, using small incisions that are also hidden inside the nose.

These procedures make up the bony work, which is needed in patients with a deformity of the bony part of the nose. Most of the postoperative facial swelling and bruising under the eyes are caused by this surgery on the nasal bones. Surgery to the tip of the nose alone causes swelling, but no bruising.

Is it necessary to break the nasal bones?

Yes, most often it is. Patients have often seen rhinoplasties on TV and find the part where the surgeon breaks the nasal bones particularly unappealing. They may have heard that a rhinoplasty is painful and ask me if there might be a way to avoid this part.

In most cases, it is simply not possible to reduce the size of the nose or reduce a hump without including this part of the procedure. It is possible to file down a hump and the profile would look much better, but the nose would look too wide. That is why the bones are folded in – to avoid a flat top.

Of course, patients are asleep during surgery, so they are unaware and are not in pain. Fortunately, the recovery is not as painful as people think. You look worse than you feel because of the bruising and swelling. But it is not as painful you might imagine.

The Tip

The tip is the soft part of the nose. Some patients just have a wide "bulbous" tip, their dorsum is fine, and they undergo a "tip rhinoplasty". Patients having bony work on the dorsum typically also have work on the tip to refine the cartilages and reduce it so it is in harmony with the reduced dorsum.

The tip is made of a delicate framework of cartilages. Working through incisions just inside the nostrils, the surgeon exposes the "alar" cartilages. They are trimmed, refining the external appearance of the tip. Sometimes, the cartilages are shortened to make the nose less prominent. They are often brought together in the middle with sutures to make the tip of the nose appear less boxy or "bulbous." The incisions inside the nose are all closed with absorbable sutures, which dissolve in a few weeks.

Treating "Flared" Nostrils

Some patients request narrowing of the nostrils to treat a condition called "alar flaring" that may be accentuated by smiling. To accomplish this, incisions are placed in the crease around the base of each nostril. The small sutures are removed about one week after surgery.

The Septum

A deviated septum is not a trivial problem. Nasal airway obstruction can interfere with exercise tolerance, sleeping, and consequently can negatively affect quality of life.

The septum may be treated at the same time as the rhinoplasty to alleviate this obstruction and improve breathing. The surgeon works between the mucosal flaps covering the septum to take out the obstruction portion of the septum. This procedure is called a "septoplasty". A septoplasty is conceptually easy, but technically demanding. It needs to be done properly to ensure the obstruction is relieved while avoiding a "septal perforation" (hole in the septum), which is sometimes a complication of a septoplasty.

Septoplasty + Rhinoplasty = Septorhinoplasty

It makes sense to combine the rhinoplasty and septoplasty in one operation, a "septorhinoplasty". The septoplasty may be covered by insurance; the purely cosmetic rhinoplasty part is not. Not all plastic surgeons perform septoplasties. They may concentrate on the appearance part (rhinoplasty) and have an ENT surgeon do the functional part (septoplasty). But it saves an operation to have the same surgeon do both, if he or she is suitably trained.

People who have never experienced normal breathing through the nose are as gratified with their improved breathing as they are with their enhanced appearance.

Turbinates

The turbinates are the structures which hang down from the internal sidewalls of the nose. Patients with allergies often have enlarged terminates that may be trimmed or cauterized to help open the airways.

The Skin

People wonder how nose surgery can be done without trimming any skin. You would think there would be an excess of skin after the nose structure is reduced by taking down the extra bone and trimming the cartilage. Of course, any external incisions to remove extra skin would leave visible scars. Fortunately, the skin is able to contract after it is redraped on the reduced nasal framework. Because of its inherent elasticity, it can take up the slack. This property of living tissue is a small miracle in itself, avoiding unsightly scars on the nose. After surgery, the nose appears almost magically transformed.

Thick Skin and Rhinoplasty

Some patients have thick skin with deep pores; this type of skin is called "sebaceous." A rhinoplasty will not change the quality or thickness of the skin. Thick skin can be a limiting factor in patients who desire a refined tip. They need to understand that there is a limit imposed by the skin that cannot be overcome by overresection of the framework, which would risk collapse. Overthinning the skin from the underside may interfere with blood supply and cause skin loss with scarring. When I discuss this limitation with patients, Michael Jackson's name invariably comes up as an example of overtreatment with disastrous results (Everyone agrees he should have stopped circa 1983 when he appeared on the Thriller album). It is extremely difficult or impossible for any surgeon to treat such a problem, and the label "nasal cripple" has been used in the past to describe such a result.

Grafts

It is not unusual for surgeons to take grafts of cartilage from the septum or ears to use in the nose, particularly in Asians, to help build up the dorsum or increase the projection of the tip. Sometimes, cartilage is harvested from a rib, although this is unusual in my practice. I can usually obtain enough cartilage from the septum and ear(s). The back of the ear is an excellent donor site because the incision is hidden in the crease behind the ear and no one can tell that cartilage has been taken from this part of the ear.

Silicone Implants in Rhinoplasty

Asian plastic surgeons often use silicone implants in their Asian patients to augment a flat dorsum. The downside is that silicone implants are encapsulated by the body and remain foreign objects, subject to movement, infection, and possibly extrusion (sticking through the skin) in rare instances. The plus side is that implants do not get absorbed over time and the operation is faster and easier because it is unnecessary to operate to obtain graft material – it's off the shelf, so to speak.

Most North American surgeons prefer to use patient's own tissue whenever possible. Living tissue heals to the surrounding tissue, is natural in consistency and unlikely to become infected or extrude. But it is more demanding of surgical expertise and absorption is possible.

Touch-up rhinoplasty

All plastic surgeons have patients that have a persistent or minor deformity that return for a touchup or revision – about 15%, even for very experienced surgeons. A touchup rhinoplasty may be recommended to treat a persistent contour irregularity of the dorsum, or to further refine the tip. Most surgeons discount the fee for touchup surgery on their patients, to cover the cost of the anesthesia and surgery center.

It is important to recognize that perfection is unattainable. One well-known surgeon with a reputation for his nose surgery, commented that he had never had a "perfect 10" outcome – he could always find something that could be a little better. So patients need to have appropriate expectations. It may be wiser to accept an improved, although certainly not perfect, result than to pursue perfection, which may ultimately lead to a less satisfactory outcome.