Rhinoplasty (nasal surgery)
What is the goal of rhinoplasty?
The goal of nasal surgery, or rhinoplasty, is to achieve an improved but natural appearance and to correct internal structural deformities contributing to any coexisting breathing problems.
Who is a candidate for rhinoplasty?
Adolescents and young adults compose the largest group seeking rhinoplasty. Minimum age is guided by the concern that nasal growth is complete prior to surgery. Surgery is usually permitted in normally developed females by age fifteen and males by sixteen. Most patients are primarily motivated by the prospect of better appearance but some are interested in improving breathing at the same time. A much smaller group of patients seek improved breathing without wanting to change their appearance.
There is a second group of patients, usually older, who seek corrective rhinoplasty. These patients have had an unsuccessful procedure previously and typically have very specific aesthetic and functional issues to address. Most are good candidates for correcting the problem areas.
How is rhinoplasty accomplished?
Rhinoplasty is accomplished by combining various surgical maneuvers to address common aesthetic concerns such as a hump seen on profile, a bulbous tip, a drooping tip, or asymmetries. Changes are made to the structural framework inside the nose in order to achieve the desired outside appearance. Internal changes can be made to improve breathing problems at the same time.
There are three structural parts to the nose that determine outside shape and influence breathing capability. The upper portion consists of bone, the middle portion cartilage (called upper lateral cartilage), and the tip also cartilage (called alar cartilage) (Figure 1, left). The nasal septum is a cartilage strut that divides the nasal airway into two sides and provides support for the middle and lower thirds of the nose (Figure 1, right).
Bone is removed from the upper third of the nose to remove a hump. Later in the procedure the bones are moved inward to reduce the width and thereby restore a normal cross-sectional configuration to the upper nose (Figure 2). The middle third cartilages are also reduced because they contribute to the lower part of the hump, as does the septum. They are also shortened in order to allow the tip to rise. The lower third cartilages are typically reduced in dimension to make the tip less bulbous and also to allow the tip to rise. The cartilages are also bent inward with stitches to narrow the tip (Figure 3). The lower part of the nasal septum is also shortened to help elevate a drooping tip. These are some of the common surgical maneuvers performed during rhinoplasty. There are many others used to address specific issues.
Where are the incisions made for rhinoplasty?
There are two ways to access the internal structures of the nose for making aesthetic and functional improvements. Surgery performed entirely through the nostrils is called the endonasal method and is the traditional approach. The open method includes an incision across the skin between the nostrils (Figure 4, left).
The endonasal method remains ideal for those requiring only simple changes such as hump removal and minor tip modification. It also works well for those only requiring internal work to correct a breathing disorder. The advantages of this method are that there is less swelling after surgery and it is more efficient to do. The disadvantage is that the visibility of structures inside of the nose is more restricted for the surgeon.
The external incision used with the open method allows lifting of the tip skin to expose the entire internal framework of the nose to direct vision. This greatly aids examination of the underlying structures that determine nasal shape. Changes can be made more precisely and more technical options can be used with this method. This technique is particularly helpful for executing delicate tip shaping maneuvers, adding cartilage grafts, and for reconstructing a tip deformed by previous surgery. Tip swelling takes longer to resolve compared to the endonasal method and the procedure takes longer too. However, the benefits afforded by the improved visibility are worth it and the scar is typically insignificant (Figure 4, right).
What about breathing problems?
The ability to breathe well depends in part on the anatomy of the nasal septum, the adjacent side walls, and the internal opening inside the nostrils called the internal nasal valve. 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.
How are breathing problems treated?
The most common form of treatment for breathing problems is to remove the deviated or twisted part of the nasal septum that narrows the airway on one or both sides, leaving a sufficient portion intact to support the shape of the nose (Figure 5). Less commonly, enlarged side wall structures called turbinates must be pushed outward to enlarge the airway.
Breathing problems can also result if the middle third cartilages do not provide enough support to the internal nasal valve. It is sometimes necessary to add cartilage to buttress and enlarge this opening (Figure 6). Tip cartilages that are oriented along the wrong axis or do not adequately support the nostril side walls also cause breathing problems. There are methods available to reorient the tip cartilages and strengthen them with cartilage grafts.
What adjunctive procedures exist to enhance the aesthetic results of rhinoplasty?
The most common procedure combined with rhinoplasty is placement of a chin implant. Chin implants are made out of solid plastic and do not need to be changed in the future. The smallest ones are most commonly used and are slightly larger than an almond in size. Chin implants improve facial balance when the chin is recessive, or weak, in relation to the cheekbones (Figure 7). It helps make a prominent nose a less dominant feature. While a chin implant may dramatically improve the profile it has only subtle influence on the front view. Chin implants are placed through a short incision underneath the chin. There is little awareness of it once healing is complete.
Liposuction of the neck, when indicated, is another useful adjunctive procedure that can be done at the same time. It can significantly improve neck contour in those who are good candidates for it. It is performed through a very small incision under the chin (or through the chin implant incision if done in conjunction) and adds very little time to the procedure.
How will I know what my nose is going to look like after surgery?
Computer imaging is a popular way of previewing surgical results. A more artistic method is to sketch the anticipated results. Side (Figure 8) and front view sketches (Figure 9) are based on preoperative photographs. They include the effects of chin implants and neck liposuction when these adjuncts are recommended. Sketches do not take into account variations in individual healing or limitations imposed by thick skin and other unfavorable anatomical characteristics. Therefore the drawings do not guarantee the result but do clearly illustrate the surgical goal.
How long do the benefits of surgery last?
The beneficial effects of nasal surgery are permanent. Rhinoplasty does not need to be repeated unless for some reason the desired result was not achieved the first time. Most patients have only one operation and remain pleased.
Where is the surgery performed and how long does it take?
Rhinoplasty is performed in the office as an outpatient procedure. Operating time is about two hours using the endonasal, or closed method. The open method takes longer, up to three hours. Internal work such as treating a deviated nasal septum can add another twenty to thirty minutes to either approach. Placement of a chin implant adds about fifteen minutes.
Surgery to correct multiple deformities from a previous rhinoplasty can take four hours or more depending on the complexity of the problem. All surgery is performed entirely by Dr. Hidalgo.
What type of anesthesia is used?
Surgery is performed with general anesthesia only. This provides for both a pleasant experience and optimal airway protection from nasal secretions produced during surgery. Lighter forms of anesthesia may be associated with procedure memories and offer less effective airway protection. A board certified anesthesiologist is present for the entire procedure and uses state-of-the-art monitoring equipment.
What are the risks associated with rhinoplasty surgery?
The most common problem following rhinoplasty is bleeding. While troublesome it almost always stops spontaneously. Persistent heavy bleeding can be treated by infusing a medication to stop it. Packing the nose to treat bleeding is seldom necessary today.
Infection following rhinoplasty is extremely rare. Sometimes narrowing the nose to improve aesthetics can compromise breathing ability. Small bumps and irregularities occasionally appear after swelling resolves completely. They may or may not require additional treatment.
Removing deviated septal cartilage can sometimes leave a hole inside the nose between the two air passages. It can cause whistling and contribute to nasal dryness. This occurs rarely but is very difficult to treat. Fortunately, most patients do not have any complications from nasal surgery.
Why is smoking so harmful for surgery?
Smoking severely reduces blood supply to the skin and also delays healing. It is therefore essential to stop smoking completely for at least three weeks before surgery and six weeks after surgery. Simply cutting back is not enough. Nicotine containing patches and gum are equally harmful.
What is the recovery like?
At the conclusion of surgery the nose is taped and a plastic splint applied. Both are removed five to six days later. The nose is not packed deeply. Instead a rolled dressing is placed just inside each nostril and is removed the next day. Stitches inside of the nostrils are of the dissolving type. Visible skin stitches placed between the nostrils with the open method are removed together with the splint.
Cool compresses are placed over the eyes for the first twenty-four hours. It is not necessary to stay in bed. The pain is generally mild and usually lasts for less than twenty-four hours. Oral pain medication is sufficient but not often needed. Swelling of the nose and eyes with variable amounts of bruising is typical. This begins to subside after forty-eight hours. It is usually possible to return to school or work seven to ten days after surgery.
Flying and driving are not recommended for two weeks. Walking outdoors can begin after a few days, weather permitting. Mild cardiovascular exercise without impact such as a stationary bike can begin at two weeks. It is best to wait as long as six weeks before resuming more intense exercise and activities such as jogging, weightlifting, ball sports, skiing, and horseback riding.
What are some of the limitations associated with nasal surgery?
There are some pre-existing conditions that can limit the quality of the final result. Thick nasal tip skin, for example, can mask fine sculpting of the underlying nasal tip cartilages and thereby limit the amount of tip definition possible. Noses that are severely deviated to one side or have either a “C” or “S” shaped twist on frontal view are difficult to straighten completely. Fortunately, major improvement can usually be achieved despite these pre-existing conditions.
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. Touch-up procedures are usually not performed until one year after the original surgery to allow for complete healing and softening of the tissues to occur. Most revisions are short procedures that do not cause prolonged swelling or recovery. The vast majority of patients have only one procedure and are pleased with the results.
What is a secondary rhinoplasty?
Secondary rhinoplasty is a procedure to correct deformities resulting from previous nasal surgery. It is much more involved than a simple touch-up procedure. Most secondary rhinoplasties are done by open technique and frequently require cartilage grafts to rebuild areas where too much cartilage has been removed previously.
The cartilage needed is harvested from the nasal septum or from behind the ear. Cadaver cartilage is another good source. Cartilage grafts may be used, for example, to build-up a concave profile or to improve a pinched tip by adding more substance to it. Cartilage grafts can be added to straighten a nose deviating to one side, or open up a narrow airway and simultaneously make an overly narrow nose wider (Figure 6).
It is routinely possible to make major improvements in the appearance and function of a deformed nose using these techniques. Secondary rhinoplasty to correct problems is complicated though, and usually takes much longer to perform than the original procedure.
What are the costs involved in having surgery?
There are separate fees for surgery, anesthesia, and operating room use. A chin implant, if recommended, is additional. Costs also include preoperative lab tests and medical grade photographs.
What are the steps involved in proceeding with surgery?
At the initial consultation you will be examined and your goals assessed. A surgical plan will be proposed provided that you are a good candidate for the procedure. Once the plan is agreed upon a surgical date can be scheduled. Photographs are obtained both for reference in the operating room and for making sketches that will help visualize the desired result beforehand. A few blood tests are required prior to surgery.