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Facial Nose Surgery


Overview

 
Example of large nose overwhelming facial harmony. (Click picture to enlarge).

The nose is the first thing that people notice when they look at you. This is especially true when the nose is large or disproportionate to the rest of the face. This is because it is the most central structure and effectively dictates the look of the face. A large nose will dominate the face and attract unfavorable attention. An attractive nose is aesthetically pleasing and allows the observer to pay more attention to other structures such as the eyes and lips. There is no set way that a nose should look, but one thing is for sure; it should be unobtrusive and in harmony with the rest of the face.


The medical term for surgically altering the nose for cosmetic reasons is rhinoplasty. Rhino means “nose” and plasty means ”to shape. ”


Patients seek rhinoplasty for various reasons. Sometimes, it is traumatic nasal injury that has altered the nose. More often, it is because someone is simply unhappy with its appearance. Common reasons why someone is unhappy with his/her nasal appearance include: a hump, a deviated nose, a wide nose, a crooked nose, a long or short nose, a pug nose, a ski nose, a beaked nose, flaring nostrils, a bulbous tip, and many others. All of these can be corrected or at least markedly improved with rhinoplasty.


Commonly, there are 2 ways to perform rhinoplasty. The first way is called aclosed rhinoplasty and the second way is an open rhinoplasty. There is also a third way which is a combination of the two otherwise known as a delivery technique. Many plastic surgeons favor one particular way. There is no right or wrong way. The only important thing is that whoever does the rhinoplasty must be comfortable with that particular technique and the bottom line is, obviously, the final result.


Some doctors utilize the closed technique when the majority of the nasal work is performed on the top and the bridge of the nose or if only small modifications are being made to the nasal tip. This technique is performed through incisions inside the nose which are not visible from the outside. The complete lack of any visible scar is an advantage but the downside of this technique is lack of exposure of the nasal tip.


He uses the open technique when there is a significant amount of work that needsto be done on the nasal tip. This technique requires that a very small incision is made along the thinnest part of the skin between the two nostrils. This normallyheals without a visible scar. This provides excellent exposure of the nasal tip and allows for a more accurate rhinoplasty.

 


Finally, many doctors perform the delivery techniquewhen there is a moderate amount of work necessary to be done on the tip. This technique does not require any visible scars yet it still allows significant exposure of the nasal tip.


Another reason for nasal surgery includes airway problems. Airway problems may lead to difficulty in breathing at certain times or, perhaps, all the time. This may be due to a deviated nose or an enlarged turbinate among other reasons. Determining the exact cause requires consultation with a plastic surgeon. Airway problems can usually be resolved by correcting the underlying problem.


Rhinoplasty is the quintessential plastic surgery operation. It incorporates all the skills as well as the artistic prowess that a plastic surgeon develops over the course of his/her training. The techniques used are quite predictable, however, the way each individual patient heals is different and this must be anticipated as much as possible.


Changes in the appearance of the nose have a profound effect on the facial aesthetics. Removing a large dorsal hump or making the nose somewhat thinner and smaller can dramatically improve one's appearance.


Benefits

The most significant benefit of rhinoplasty is dramatic enhancement of self confidence. Other benefits range from cosmetic reasons to breathing improvement. Here is a brief list of the benefits of rhinoplasty:


  • Corrects a large dorsal hump.
  • Makes the nose smaller.
  • Makes the nose appear more in harmony with the rest of the face.
  • Corrects a deviated or crooked nose.
  • Makes the nose thinner.
  • Narrows nostrils that flare.
  • Sharpens and defines the nasal tip.
  • Improves the contour of nose and corrects bumps or irregularities.
  • Corrects nose length whether it is too long or too short.
  • Corrects a droopy nasal tip.
  • Improves breathing.
  • Prevents the nose from collapsing in during deep inspiration.

During consultation, your plastic surgeon will examine and discuss with you exactly what it isyou wish to correct.


Are you a good candidate?

Example of thick skin on tip of nose. Result is good but would be better if skin were thinner.

Almost anyone, who is self-conscious about the way their nose looks, can have something done to either correct the problem or dramatically improve it.


There are people, however, that respond less favorably to rhinoplasty than others. Nasal tips with thick, oily skin are more difficult than those with thin skin. This is because thick skin is less likely to show changes in the underlying nose as readily as thin skin. Thick skin is much less capable of adapting to a new shape. Dr, Cruise will evaluate your skin and tell you exactly what you can expect from arhinoplasty. Summarized below is a brief list of issues that can be corrected by rhinoplasty.


  • Large dorsal hump.
  • Wide nose out of proportion to the face.
  • Deviated or crooked nose.
  • Wide, flaring nostrils.
  • Bulbous or fat tip.
  • Boxy tip.
  • Irregular contour of nose.
  • Nose that is over or under projected.
  • Nose that is too long or too short.
  • Difficulty breathing caused by airway obstruction within the nose.

 

Possible complications

The most common complication of rhinoplasty is that the desired appearance was not fully obtained. This often can be corrected by minor touch ups usually within the office under local anesthesia to obtain the desired results. Other possible complications are: infection, wound healing problems, unfavorable scarring, fluid or blood collection, numbness, asymmetry, and contour irregularities.


Do's and Don'ts prior to surgery

  • Medications. Certain medications thin your blood and should not be taken within 3 weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should not be used within 3 weeks of surgery.

  • Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your plastic surgeon for something to help you sleep.

  • Smoking. Do not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. It also affects your airway, therefore, makes anesthesia much more difficult.

  • Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with your doctor and the anesthesiologist.

  • Washing. It is a good idea to wash the surgical area thoroughly the night before and the morning of surgery. Blow your nose and clean it the morning of surgery using a Q-tip. It is most helpful to trim your nasal hairs 3 days before the procedure. Do not apply any make up

  • Arrival. It is best to arrive on time to make sure things go smoothly. Please be sure to have someone else drive you.

  • State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned.


Anesthesia

The anesthesiologist will discuss with you what type of anesthesia is best for you prior to the procedure. He/she will take into consideration your medical history, the procedure, and your personal wishes.


General anesthesia is typically used. Minor rhinoplasties may be performed under local anesthesia, with or without sedation.

After the procedure

The procedure itself will take approximately 2 hours.


  • Immediately. Right after the operation you will be watched for 1 or 2 hours and encouraged to walk around. Of course, there will be swelling and bruising but there is surprisingly little pain. You will have a splint on your nose and a dressing under your nostrils. When you lay down you must keep your head elevated usually on 3 pillows to prevent swelling.

  • That evening. It is recommended that you take it easy. You can walk around, eat, but not too much more. You must sit and lay with your head up on at least 3 pillows. You should take as much pain medication as necessary and try to go to sleep early. You will be given medication to help keep the swelling down as well as to prevent infection.

  • First 48 hours. You can take a body shower the next day. Be sure to use cool water. Let the water rinse over your nose and splint. Leave the splint in place. There will be some oozing from your nostrils. This is to be expected. When you get out of the shower dab dry. Reapply a dressing under your nose as necessary. The tip of your nose will be markedly swollen as it swells more than any other part. Be sure to take your antibiotic and anti-swelling medication.

  • First week. Your first postoperative visit with will be most likely at one week. Sutures may be removed. Leave the splint on. You will be swollen with some bruising under your eyes. The majority of the bruising and swelling will go away in about 2 weeks. Finish the antibiotic prescribed.

  • Beyond. Swelling will not completely resolve for about 6 months especially in the tip. It takes at least 3 months for the swelling to go down and then another 3 months for the skin on the tip to contract leaving you with the desired result. The final result will not be evident until 6 months when all the swelling has resolved and skin contraction is complete but you will certainly notice a significant improvement right away.


Recovery time

The swelling and bruising will resolve in about two weeks. Some people with sedentary jobs go back to work after 3-5 days. If your job, however, requires strenuous activity then it may take as long as 2-3 weeks to return to work. Most people return to work in about 1 week.


Consultation

We have outlined below what you can expect from your rhinoplasty consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to your plastic surgeon what you want to accomplish.


Health History

All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used but also applies to local anesthesia. Rhinoplasties may be done under general or local anesthesia depending what needs to be done and on the preference of both the plastic surgeon and the patient. Prior to meeting with your plastic surgeon you will be given a health history questionnaire to fill out in the waiting area. There are 5 areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.


  • General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are: high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.


What will the plastic surgeon do if I have medical problems?


In short, he will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.


If you have a health problem or are over 50 years of age you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.


If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating you are able to tolerate surgery.


If you are not able to tolerate general anesthesia it may be possible for your procedure to be done under local anesthesia, with or without sedation. This must be discussed with your plastic surgeon.


  • Past Surgical History

On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With rhinoplasty it is especially important to mention all previous nasal or sinus surgeries. Previous trauma to the nose is important. If you have traumatic changes to your nose it is helpful to bring in pictures of what you looked like before your injury.


  • Medications

Be sure to list all medications you take including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least 10 days before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.


  • Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.


  • Smoking, Drinking, and Drug Use
These 3 will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 2-3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory. Specific Nose Issues.

During your consultation you must be very accurate with nasal problems. Of particular concern is a history of breathing problems, sinus problems, nasal drug use, nasal trauma, and any previous nasal surgery. If you had previous nasal surgery, call the surgeons office and have them fax over the operative note. Bring this operative note to your consultation. This is very helpful so that your plastic surgeon can see what has been done. Revision rhinoplasties are challenging because of the scar tissue left by the first operation.


What Do You Want To Change?

It is important that you have a clear idea of what you want changed when you go for consultation. The least favorite thing a plastic surgeon wants to hear is: What do you think I need done?


Look in a mirror and identify what bothers you. Be specific. It is helpful to break up the nose into four parts. 1) Dorsum2) Tip3) Alae4) Airway obstruction. Evaluate each one of these areas individually as this is what the plastic surgeon does in his exam.


 


  • Common complaints
    • Dorsum: Too wide, too narrow, too big, too small, deviated.

    • Tip: Too big, too pointy, too long, too pushed up, droopy, deviated.

    • Alae: Too wide, too bulbous, nostrils too big.

    • Airway: This must be examined individually.


Physical Exam

The key to the nasal physical exam is to determine exactly what is causing the problem. Rhinoplasty is a high finesse procedure and requires that the plastic surgeon knows exactly what you want. If there is a particular nasal characteristic that you like, it is helpful to bring in a picture of someone with this particular feature. Obviously, this look will not be duplicated but it helps convey your wishes.
Below is a typical sequence that an experienced plastic surgeon uses to evaluate each nose. The nose must be evaluated in relation to other facial characteristics.

 
Dorsal line between eye brow and tip should be curvilinear and smooth
  • Dorsum

When looking at the nasal dorsum, there should be a continuous curvilinear line that begins within the eye brow, joins harmoniously with the radix of the nose, and continues to the tip. When the dorsum is too big or too wide this continuity is broken and the nose appears out of place or too big.

 

 
Skin removed revealing the two bones and four cartilages of the nose. Compare to picture above.

 

 

Removal of a large, dorsal hump or narrowing a wide dorsum will correct this problem and give a smaller, more pleasant appearance. Often this will require an osteotomy which means breaking of the bones in order to reposition them correctly.


 
Red line depicts typical osteotomy location.

 

 

Nasal osteotomies usually cause bruising around the eyes that lasts about 17 days.


The image on the left outlines the typical location of the osteotomy. After the nasal bones are broken they are then repositioned medially to narrow the nasal vault.


This repositioning is one of the methods many doctors use to improve the balance between the eye brow and the nasal tip as described above.


 
Woman with deviated nose. Notice that nasal bones, dorsum, and tip are all deviated to her right. Correction by Dr, Cruise required osteotomy, cartilage grafting, and suture technique.
  • Deviation

Nasal deviation can occur anywhere in the nose from the bridge to the tip. It is a very difficult problem to completely correct but can usually be improved tremendously. The treatment depends on the cause. The cause may be within the nasal bones, the upper nasal cartilages, the lower nasal cartilages, the septum, or all of the above. Usually, the nasal bones will need to be broken and repositioned.


 

The cartilages will also need to be repositioned. If one's nose has a concavity on one side it may be necessary to fill this gap with a cartilage graft. This cartilage is usually obtained from the nasal septum inside the nose.


Postoperatively, after an osteotomy or deviation correction, one will need to wear a nasal splint for 1 to 2 weeks. Complete bone healing takes about 6 weeks. Swelling of the nasal dorsum lasts up to 6 months but the majority is gone by 6 weeks. This is quicker than the tip, which takes a year for the final result to be evident. Once again, the majority of the swelling is gone by 6 weeks.


  • Tip

The tip should be a smooth continuity of the dorsum. Too large of a tip will cause people to focus on it. An attractive tip does not draw attention. A large or deviated tip causes the observer to immediately focus on this area. Nasal harmony with the rest of the face is disrupted.


The most common cause of a large, bulbous tip is a large, rounded lower lateral cartilage. This can be reduced and a sharper tip created if the overlying skin is not excessively thick.


 
Notice that the cause of the bulbous tip is the rounded shape of the lower lateral cartilage.
 
Woman with long nose as well as a droopy tip. Correction by Dr. Cruise included shortening of the septum and projecting tip.

 

Long noses are often caused by long septums. Shortening the nasal septum willcorrect this.


Droopy nasal tips are usually caused by poor tip support. Correction can be obtained by adding support and bringing the tip upward.


 

 
Woman with long nose as well as a droopy tip. Correction by Dr. Cruise included shortening of the septum and projecting tip.

 

 

Short noses have a pushed up appearance and/or can have an irregular contour. Correction can be achieved by lengthening the nose using cartilage grafts.


 

 

 

Deviated tips, as mentioned above can have many causes and are more difficult to completely correct. While it may be said for all rhinoplasties, it is even more true with deviated rhinoplasties-The first operation is critical. Secondary rhinoplasties are much more difficult because there is always scar tissue to deal with from the first operation. For this reason, it is essential to go to a plastic surgeon with considerable experience in rhinoplasty. See above picture of woman with deviated dorsum as well as deviated tip.


 

  • Alae
Ideally, the alae should not flare wider than the inner corner of the eye.
 
Seen from below, the alae and tip should form an elegant equilateral triangle.

 

An attractive alae, like the tip, should go unnoticed. When they become too wide or too large they draw negative attention. The most common complaints with the alae are that they are too wide, too bulbous, or the nostrils are too big.

 

 

Alae reduction is accomplished by removing a precise amount of the alae at its base.

 
Wedge excision of alae base results in incision line that hides in natural crease.

 

 

 
Normal Airflow
  • Airway

Airway obstruction is a significant problem and the causes are numerous. Airway obstruction that can be relieved during rhinoplasty fall into two categories.

 

 

 
Enlargement of the inferior turbinate is the most common cause of airway obstruction.

 

The most common is enlarged turbinates. Turbinates are three mounds of mucosa on the inside on each nares. They are called the superior turbinate, middle turbinate, and the inferior turbinate. They humidify the air as it travels to your lungs and help trap foreign particles. Enlarged turbinates may impede airflow. Correction involves reducing the size of the turbinates by either cauterizing them or excising them.

 

The other common cause is nasal deviation. A deviated septum will cause turbulent airflow with each breath and make breathing much more difficult. This will often be markedly improved or resolved when the deviated septum is repositioned or removed.


  • Chin

Evaluation of the nose would be incomplete without mentioning the importance of the chin. Einstein was right even when it comes to facial proportions. Everything is relative. A small chin makes the nose appear larger.


A strong chin gives a more authoritative look to men and a more attractive triangular shape to women. Ideally, the chin should project forward to the level of the lower lip in woman and slightly farther in men.


Typical Incisions

 
Closed Rhinoplasty Incision
 
Open Rhinoplasty Incision

 

 
Nostril Reduction Incision