Rhinoplasty
Indications
Rhinoplasty is a term which covers several procedures to
reshape the nose. Surgery can be used to alter the height,
length and width of the nose; to straighten a bent nose;
to change the shape of the bridge-line, tip or nostrils
and/or alter the angle between the upper lip and nose. Sometimes
breathing difficulties can be corrected at the same time
- a “septoplasty”.
Rhinoplasty may be performed for cosmetic and/or functional
reasons which may arise from “normal” variations
and deformities after trauma; both may be associated with
breathing difficulties, which may require a septoplasty.
Common problems leading to a request for rhinoplasty include
prominent dorsal hump, wide bridge and/or wide tip, the
long nose, the large nose.
Anaesthetic
Most British surgeons prefer to carry out rhinoplasty under
general anaesthesia.
Technique
Most rhinoplasty operations can be done using cuts made
inside the nostrils so that there are no visible scars.
Some surgeons use a technique known as “open rhinoplasty”;
with this technique an additonal small cut is made across
the nasal columella (the bridge of skin and cartilage in
the midline between the two nostrils). Via these incisions
the surgeon reshapes the bony part of the nose and the nasal
tip. Any bridge line hump is cut away. To straighten and
narrow the nose the nasal bones are cut from where they
join the cheek bones - the bones are then moved closer together.
The length of the nose and the shape of the tip can be adjusted
at this stage by reducing the amount of cartilage which
shapes the end of the nose. Narrowing the nose may make
the nostrils seem too wide; if this is the case then they
can be narrowed by cutting out a small triangle of nostril
skin. It is occasionally necessary to add tissue to alter
the shape of the nose; mostly this is as a graft of cartilage
taken from the nose itself or from an ear via a cosmetic
incision. If there are breathing difficulties then a septoplasty
can also be performed using the same incisions.
At the end of the operation the incisions are stitched,
sticky tapes are placed over the nose and a splint is applied
to keep the nasal bones in the corrected position. Packs
are often placed inside the nostrils for 24 - 48 hours.
Folded gauze (drip-pad) is placed beneath the nostrils to
soak up any minor bleeding which may occur. The splint and
drip-pad are held in place using sticky tape applied to
the face and forehead.
Length of Operation:
1 - 2 hours.
Time in Hospital: Usually
an overnight stay
Post operative Discomfort/Limitations
Pain is usually mild and can be controlled by simple pain-killers.
There is some discomfort because packs prevent breathing
through the nose. There will be bruising and swelling especially
around the eyes. Bruising may take 2-3 weeks to settle,
most swelling has gone by this time; but a small amount
of residual swelling exists for several months. The splint
is left in place for 7-14 days. The nose should not be blown,
nor crusts removed from inside the nose for about two weeks.
The nose will be numb and feel “stiff” for several
months following rhinoplasty.
It is essential that the surgeon understands what the patient
thinks is wrong with their nose; unless a patient can decide
what they dislike about their nose and can explain this
to the surgeon, the surgeon will not be able to explain
what is surgically possible and what is not. It is important
to understand that the procedure has some limitations -
for instance if the nose is very large there may be a limit
to the amount of reduction that is possible; if the skin
is very thick and oily it may not be able to reduce the
bulk of the nose as much as wished for; if the skin is very
thin irregularities after the operation may be very visible
and if the nose is bent after an injury then it may not
be possible to make it perfectly straight.
Time off Work
It is possible to return to work after a few days; however,
in view of the bruising, swelling and splint most will stay
off work for about 2 weeks until bruising has settled.
Risks and Complications
General anaesthesia is safe; but in a tiny proportion caries
a very small risk of serious
complication.
The most common problem after rhinoplasty is an unsatisfactory
cosmetic result - about 10% of patients are not happy with
the result (see below); excessive fullness just above the
nose tip (“polly-beak” deformity) is the commonest
problem.
Heavy bleeding may occasionally occur after rhinoplasty;
this may be shortly after surgery or after about 10 days.
Infection is very unusual and responds to antibiotics if
recognised early enough. Difficulty with nasal breathing
is common in the first few weeks following rhinoplasty -
this usually settles with time; occasionally this is a permanent
problem.
Outcome
About 10% of patients are not happy with some aspect of
the result following rhinoplasty. This is may not be apparent
for a few weeks when the swelling has settled. In most of
these cases it is possible for the surgeon to carry out
a second operation to try and correct the residual problems.
This second operation should wait until all swelling has
settled and the suppleness has returned to the tissues of
the nose - this is usually after one year.
