Nasal Surgery (Rhinoplasty)
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The goal of nasal surgery is to achieve an improved but natural appearance and to correct internal structural deformities responsible for any breathing problems that may coexist. This goal is not always achieved simply by the removal of portions of bone and cartilage as was the routine years ago. While still important, it is sometimes necessary today to also add cartilage in the form of a graft in order to achieve the best result. The grafts may be added to the tip to improve the profile for example, or they may be added internally to open up a narrow airway that may be causing a breathing problem. In other instances underlying nasal tip cartilage is reshaped by permanent sutures to improve the overall appearance of the tip. This can avoid a pinched tip that commonly resulted from older methods that only removed cartilage instead. The modern approach to nasal surgery therefore is to use a combination of techniques that include tissue removal, cartilage reshaping with sutures, and adding cartilage grafts to produce the best aesthetic and functional result. Common sources of cartilage graft material include the nasal septum internally and the back of the ear.
Traditional rhinoplasty techniques use incisions hidden inside the nostrils for access to the underlying cartilage and bone. This approach is still ideal for those that require only simple internal changes such as removal of a bump and minor modification of the tip. It is also applicable to those who only require work on the internal part of the nose in order to correct a breathing disorder. The advantage of this method is that there is less swelling postoperatively. The disadvantage is that the visibility of structures inside of the nose is more restricted for the surgeon.
The “open” method is a more recently developed technique that provides the surgeon with a wider range of options for making internal changes to the nose. This is accomplished by adding a small incision across the skin that separates the nostrils. This allows the skin of the tip to be lifted to expose the entire internal framework of the nose to direct vision. The surgeon can better assess the alterations needed to produce the desired effect and implement the necessary changes with a greater degree of precision. This technique is particularly helpful for carrying out more delicate tip shaping maneuvers, adding cartilage grafts, and for reconstructing a tip deformed by previous surgery. Tip swelling may take longer to resolve compared to the traditional technique but the benefits of improved surgical exposure are worth it. The scar is typically insignificant.
Secondary nasal surgery refers to correcting deformities resulting from previous nasal surgery. Most of these corrective procedures are done by open technique and frequently require cartilage grafts to rebuild areas where too much cartilage has been removed previously. These grafts may be used to build-up a concave (scooped) profile or to add volume and improve the shape of a pinched tip. Sometimes the grafts are added internally to open up a narrow airway, straighten a nose that deviates to the side, or make an overly narrow nose wider. It is possible today to make major improvements in the appearance and function of a deformed nose using these techniques.
The ability to breathe well depends in part on the internal anatomy of the nasal septum and the adjacent outer nasal walls. Surgery to improve a breathing disorder is not appropriate unless there is a significant deformity of one or more of these structures. While a deviated septum may contribute to breathing problems, there are also nonsurgical factors such as allergies and chronically swollen lining tissue that may be the real cause of poor breathing. Improvement of breathing after surgery in these cases may be limited despite complete correction of a coexisting structural deformity.
The skill of the surgeon is an obvious key determinant of the final result of nasal surgery. There are other factors such as the thickness of the nasal skin that influence the final outcome and cannot be completely controlled. Thick skin, for example, can mask fine sculpting of the underlying nasal tip cartilages and thereby limit the amount of tip definition possible. Tip cartilage that is either strongly bent or weak and flimsy can also impose limitations on what can be achieved surgically. Fortunately, in most cases there are no major limiting factors.
The most common adjunctive procedure performed in conjunction with a rhinoplasty is placement of a chin implant. This is recommended if the chin is recessive or weak in relation to the cheekbones. It restores balance to the bony structure of the face in these cases and makes a prominent nose a less dominating feature in facial appearance. A chin implant may improve the profile dramatically but usually makes a more subtle change on the front view. It is placed through an inconspicuous incision underneath the chin and is permanent. There is little if any awareness of it once healing is complete. It adds about 20 minutes to the procedure. Sometimes liposuction of the neck is also helpful and this can be done at the same time.
One of the best ways to visualize the plan for surgery is to look at sketches of the proposed changes. Sketches can be made based on the preoperative photographs primarily to demonstrate what the new profile will look like. Reviewing the sketches is often very reassuring and particularly helpful when a chin implant or liposuction of the neck is also being considered. These sketches represent the ideal result. It is important to remember that there are other factors that affect the final surgical result such as the thickness of the nasal skin and the quality and shape of the underlying bones and cartilage. Therefore the drawings do not represent a guarantee but do indicate what the key goals are. Sketches will be done upon request and reviewed at a separate meeting.
Surgery is performed in the office as an outpatient. General anesthesia with a breathing tube is usually necessary to adequately protect the airway from secretions that can run down from inside the nose during surgery. Lighter forms of anesthesia are sometimes associated with memories of the procedure and also are not as safe in protecting the airway. Anesthesia concerns can be reviewed with the anesthesiologist prior to surgery. Most procedures last less than two hours. Surgery to correct multiple deformities resulting from a previous rhinoplasty can take as long as three hours. All surgery is performed entirely by Dr. Hidalgo.
At the end of surgery the nose is taped and a plastic splint applied. These are removed five to six days later. The nose is not deeply packed but a small piece of gauze is placed in each nostril and usually removed the next day. Stitches inside of the nostrils are of the dissolving type and do not need to be removed. If there are skin stitches between the nostrils, they are removed after five to six days.
The pain associated with nasal surgery is generally mild and usually lasts for less than 24 hours. Oral pain medication is sufficient but often is not needed.
Swelling of the nose and bruising around the eyes is typical after nasal surgery and begins to subside after 48 hours. It is usually possible to return to school or work seven to ten days after surgery. Most types of exercise may be resumed after three weeks. Ball sports are not recommended for at least six weeks.
Complications are rare in nasal surgery. The most common problem is bleeding. While this may be troublesome, it almost always stops spontaneously. Rarely the nose must be packed for a few days. Infection is also possible but is extremely rare.
While every effort is made to make the nose as aesthetically pleasing and symmetric as possible, minor irregularities or asymmetry may occasionally become apparent months later. If a touch-up procedure is indicated it is usually not performed until one year after the original surgery in order to allow complete healing and softening of the tissues to occur. Most revisions are short procedures that do not cause prolonged swelling or discoloration.
It may be helpful to go back and highlight specific paragraphs in this letter that you wish to discuss further during your consultation. We encourage scheduling a second appointment if there are important issues that require further clarification. Our nurses are also available to answer questions of a more routine nature that may arise after your consultation.
Copyright © 2007 David A Hidalgo, M.D.
