Rhinoplasty (nose reshaping)
What is Rhinoplasty?
Rhinoplasty is an operation whereby the shape of the nose is changed by modifying the underlying bone and/or cartilage (gristle) of the nose.
Who will the operation help?
There are many features of a nose which can be changed, including:
- Removing a bony “hump” from the top of the nose
- Narrowing the nose
- Shortening the nose
- Lengthening the nose
- Making the tip less bulbous
- Lifting a drooping tip
- Lowering an upturned nose
- Straightening a twisted or bent nose
- Making the nostrils smaller
In addition to altering the external appearance of the nose, the cartilage inside the nose can be straightened to improve the nasal airways. This procedure is called a septorhinoplasty.
What are the limitations of rhinoplasty?
It is important that any patient contemplating a rhinoplasty understands that there are limitations to how effective this operation can be, and that patients have realistic expectations before proceeding with surgery.
Because we are all individuals, every nose is slightly different. Differences in skin thickness, skin tension, relative stiffness of cartilage, underlying scar tissue from previous injury to the nose etc mean that every nose will respond in its own unique way to surgery. As a consequence of this there are limitations to what can be achieved with a rhinoplasty, and no surgeon can guarantee the outcome of surgery. The surgical aims will be discussed at the consultation and at operation those aims will be achieved as closely as possible within the limitations of that individual patient's tissue characteristics.
What else should I consider?
Facial harmony is important, and ideally the size of the nose should be in proportion with the rest of the face. Occasionally patients come along requesting a rhinoplasty because their nose looks too big. On examination, their nose is the correct size but their chin is too small. A small chin can make the nose look too big. In this case a chin implant can correct the small chin and restore facial harmony without needing a rhinoplasty.
Is rhinoplasty available on the NHS?
In general, rhinoplasty is a cosmetic operation and as such is not available on the NHS. However, an NHS rhinoplasty is available for significant deformity after injury and congenital abnormally shaped noses. If patients are experiencing significant difficulty breathing through their nose, a septorhinoplasty may be considered.
Which approach is best?
- Closed rhinoplasty: Rhinoplasty can be done with small incisions hidden up each nostril. The advantage of this is that there are no visible scars afterwards. The disadvantage is that there is far less control over the final shape of the tip of the nose.
- Open rhinoplasty: Alternatively, rhinoplasty can be done with an additional scar across the bridge of skin between the nostrils. This allows accurate modification of the nasal tip. The final scar usually settles beautifully.
For these reasons if any tip work is required, an open rhinoplasty is my preferred approach.
How is the operation done?
Each rhinoplasty operation is tailored to the individual patient to achieve their aims. The operation is done under general anaesthetic (with you asleep). Instruments are passed up into the nose through the incision in each nostril. The bony hump is removed with a fine chisel or rasp , and the cartilage hump is removed with a scalpel or scissors:
This leaves the top edge of the nose too flat and too wide, so the bony sides of the nose are then gently fractured and moved inwards:
The cartilage of the tip of the nose is then reshaped by trimming and stitching it:
Finally the incisions are closed with dissolvable stitches inside the nostrils and removable stitches outside. A plastic splint is placed on the nose to hold the bones in place for one week, and each nostril is gently packed.
How long does the operation take?
Rhinoplasty usually takes about 60-90 minutes
How many days in hospital?
Rhinoplasty patients usually stay in hospital overnight and go home on the day after surgery.
Postoperative period in hospital
When you wake up you will have a splint on your nose and packs up each nostril. You will only be able to breathe through your mouth, and as you will also have had a tube in your throat during the anaesthetic, you are likely to have a sore throat for a couple of days afterwards. You will receive regular painkillers which should keep you comfortable. Black eyes are common and you can limit eyelid swelling by sleeping propped up with extra pillows.
Postoperative Follow Up
After discharge you will be provided with written information to explain the postoperative course. An appointment will be made to see my Cosmetic Nurse one week after your operation. She will remove your dressings and inspect your nose. There will be bruising and swelling, so do not expect to see a perfect nose at this stage! She will remove any stitches and will give you advice on wound care, bathing and exercise.
You will be given an appointment to see me six weeks after your operation. At this appointment I will be checking on the early outcome of surgery; if all is settling satisfactorily I shall arrange to see you for a final visit six months later.
What are the possible risks?
All surgery carries the potential for complications. The specific complications that may occur with rhinoplasty are:
- Infection; fortunately infection is rare, but can cause swelling, redness and tenderness up to 3 weeks after surgery. This usually responds well to a course of antibiotics but very infrequently the infection can spread inside the nose. If any cartilage grafts have been used to build up part of the nose, infection can dissolve these grafts.
- Bleeding: bleeding can occur at any time over the first ten days after surgery, and therefore it is wise to avoid anything which could raise the blood pressure in your head, for example bending over, lifting anything heavy or strenuous exercise. Minor nosebleeds are fairly common in the first few months after surgery.
- Ugly scarring: although most scars settle very nicely to leave a pale flat line, occasionally scars may become red, raised, wide, itchy or ugly. This is very uncommon in rhinoplasty, and is determined more by a person’s body tissue than by the surgery itself.
- Skin numbness: the skin of the top of the nose and especially over the nasal tip can be numb after a rhinoplasty. This usually improves with time, but can occasionally be permanent. As the nerves begin to regain function you may notice occasional sharp shooting pains which could be described as being like a small electric shock. This is a good sign indicating nerve recovery and can continue for up to 18 months after surgery.
- Asymmetry: despite leaving the nasal structures symmetrical at the end of surgery, the natural scarring processes that will follow surgery may act asymmetrically on the nasal framework and result in a degree of asymmetry. This is more likely to occur if the postoperative recovery period is complicated by an infection or bleeding.
- Bony irregularities: great care is taken to cut the nasal bones in exactly the right place, but occasionally (with weak or previously injured bones) the bone may fracture in the wrong place or irregularly and give rise to bony irregularities. Thick skin may disguise this well, but in thin skinned individuals these bony irregularities may even be visible. If this is the case the bony spicules can be rasped smooth under local anaesthetic.
- Rhinitis: rhinitis is an inflammation of the inner lining of the nose. This can make the nose run, itch, swell, and sneeze and give you a “bunged up” feeling for several months after surgery. It usually settles on its own, but may require steroid nasal sprays.
- Watery eyes: the tear ducts which drain tears from the corner of your eyes empty into your nose. Any swelling near the tear ducts may block these ducts. As a result of this tears may spill over the lower eyelids until the swelling has fully resolved.
- Airway problems: removing bony humps and narrowing noses often narrows the airway and it is not uncommon for their to be some noticeable reduction in the nasal airway after rhinoplasty. This often improves with time, as it can take up to a year for the swelling to fully settle.
- Altered sense of smell/taste: as a result of localised swelling in the lining of the nose the nose may be much less sensitive to smells, and as a result there can be a loss of taste for many months after surgery.
- Pigmentation; the skin of the nose may become slightly darker for up to a year or so after a rhinoplasty. To avoid or minimise this you should avoid sunbathing or sun exposure in the early months after surgery.