Candidates for Rhinoplasty
Patients who seek rhinoplasty for aesthetic reasons are most commonly bothered by a bump on their nose, a tip that is too large or wide, a drooping tip, a nose that is too long or generally too large, nostrils that are too large, or simply a nose with an unattractive appearance. Another very common request is to correct a visible nasal deviation. The latter is often accompanied by difficulty breathing through the nose.
A suitable candidate for rhinoplasty is a patient who:
- has a bump on the bridge of the nose
- has a nasal tip that is too large, wide, and/or drooping
- has a nose that is too wide in the bony part
- a nose that is too large
- have nostrils that are too large or deformed
- the nose is visibly crooked, asymmetrical, or deformed
Pre-operative consultation
The pre-operative consultation includes, in addition to the patient’s examination, photographing the face and nose, and a thorough analysis of the photos together with the patient. Photo editing is used to better understand the patient’s wishes and reach a mutual understanding. Every surgeon has their own vision, and therefore it is very important to review the selected surgeon’s photo collection of patients before and after surgery. Among other things, this gives the patient a more realistic idea of what can be achieved with rhinoplasty.
Surgical Methods
Two main methods are used to correct the shape and size of the nose:
In closed rhinoplasty, the incisions necessary to access the bony and cartilaginous structures of the nose are made inside the nasal cavity. Therefore, there are no externally visible scars, except in cases where excess skin is removed from the edges of the nostrils where they meet the cheek. In the latter case, the scar remains within the natural skin fold at the border between the nostril and the cheek and is barely noticeable. Closed rhinoplasty is technically more complex to perform, but this effort is offset by better and more stable results. Closed rhinoplasty has undergone significant development in recent years. While in earlier periods closed rhinoplasty was predominantly used to operate on the bridge of the nose and less frequently to correct the tip, the modern closed method has no such limitations. The desired changes can be achieved very successfully on both the bridge and the tip of the nose. In recent years, the closed method has given rise to the movement of preservation rhinoplasty. This is the most modern rhinoplasty technique, the essence of which is to preserve the nose’s normal anatomy as much as possible, and the desired changes are achieved by correcting the size, shape, and position of the structures. The use of excessive cartilage grafts is avoided.
In open rhinoplasty, in addition to the internal incisions in the nose, an additional incision is made in the skin between the nostrils. The resulting scar is generally small and barely noticeable. The open method is preferred by some surgeons because it provides very broad access to all nasal structures and offers excellent opportunities, particularly for altering the shape, size, and position of the nasal tip cartilages. Unfortunately, the improved visibility does not outweigh the disadvantages associated with open rhinoplasty, which include greater surgical trauma, a longer recovery time, a less predictable final result, and often unstable outcomes. For this reason, open rhinoplasty is rarely used in our practice.
Surgery
Rhinoplasty is generally performed under general anesthesia. The procedure typically begins with the removal of a hump from the nasal bridge, after which the shape, size, and position of the tip are adjusted to match the new height of the nasal bridge. In some cases, it is necessary to use filler material or grafts during the surgery. The most commonly used material is cartilage from the nasal septum, less frequently from the ear or rib. We do not use synthetic implants in our practice.
Immediate Postoperative Period
All incisions are closed with self-dissolving sutures that do not need to be removed. At the end of the surgery, silicone plates are typically placed in both nasal cavities to support the nasal septum; these are removed 5–10 days later. Externally, several layers of skin-colored dressings and a plaster cast are applied to the nose for up to 10 days. Postoperatively, swelling of the nasal mucosa develops, which causes nasal breathing obstruction. Recovery of nasal breathing may take several weeks.
Due to the incision of the nasal bones, bruising around the eyes occurs in the early postoperative period. This worsens along with facial swelling during the first 3–4 days. The bruising and facial swelling subside within the first 2 weeks. Many patients are often surprised that postoperative pain is relatively mild. Paracetamol and Ibuprofen are suitable for pain relief.
Recovery
It is important to emphasize that the shape and size of the nose immediately after the cast is removed are not final. Further healing and the resolution of swelling take 6–12 months, depending on the patient, skin type, and the method used. During the recovery period, you may notice the following changes:
- if excess skin was removed during surgery from the edges of the nostrils where they meet the cheeks, these stitches will be removed along with the cast after 7–10 days. During the first few weeks, these scars will be visible as reddish lines, but over time they will become barely noticeable
- Numbness at the tip of the nose in the early post-operative period is normal. This disturbance in skin sensitivity is temporary and will resolve as nerve and blood supply recover. In addition to numbness, the tip of the nose will initially feel hard and stiff to the touch. This is due to postoperative swelling, and the nose will become softer and more freely movable as the swelling subsides.
- Postoperative subcutaneous scarring lasts for several months. As the scar tissue matures and contracts, it gradually reshapes the nose and gives it its final form. In rare cases, scar tissue contraction can cause the nose to change shape in an undesirable direction.
- The maturation of scar tissue and the resolution of swelling take 6–12 months. As a general rule, the thicker the skin on the nose, the slower the healing process, and vice versa. In rare cases, anti-inflammatory hormones are used to accelerate the resolution of swelling.
- Very rarely, skin inflammation may occur at the tip of the nose in the immediate postoperative period. Antibiotics are used to prevent and treat this.
Keep in mind that initial results after rhinoplasty are visible 1–3 months later. The final result can be assessed 6–12 months later.
Revision Surgery
In a small but significant number of cases (approx. 10%), both the patient and the surgeon agree that the changes in the nose’s shape, size, or position are not as expected. The likelihood of a revision surgery is higher in patients whose:
- have had multiple previous surgeries on their nose
- have undergone extensive rhinoplasty resulting in a significant change in the shape of the nose
- had a severely deformed nose due to trauma or significant asymmetry
- experienced intense intraoperative bleeding, which on the one hand impairs visibility but on the other hand causes excessive postoperative swelling
- anatomical abnormalities or tissue deformities were discovered during the operation that could not have been foreseen
- an incorrect surgical technique was chosen
In all these cases, deformities caused by sinking or scarring may develop during healing. Some problems that arise during healing are difficult to predict in advance. For example, there are no very good indicators that can predict severe bleeding or identify patients who are highly prone to developing bone cysts. In the latter case, areas where the bone has been cut or shaved develop excess bone tissue growths that can be felt upon palpation and are visible externally. The need for revision surgery may therefore be due to patient-related factors, such as unrealistically high expectations, excessive scar tissue growth, or other tissue reactions, or surgeon-related factors, such as overly optimistic promises to the patient, limited experience in handling problems that arise during surgery, or the choice of an inappropriate surgical technique.
Fortunately, in most cases, revision rhinoplasty involves correcting minor irregularities. Major revision surgery is rarely necessary. It is important to emphasize that revision surgeries cannot be performed immediately. To achieve the best results and ensure safety, revision surgery should be considered 6–12 months after the previous surgery.
