Surgery on the nose may be functional or cosmetic. Commonly we are asked by patients to correct a nasal problem. Some patients have difficulty breathing – a functional problem. Others do not like the way their nose looks – a cosmetic problem. We will be discussing, in general terms, the correction of problems in both of these areas.

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Frequently Asked Questions About Rhinoplasty

There is no one nose that looks good, although there are anatomic relationships in the “attractive” face that important factors in planning the operation. No experienced surgeon adopts the same operative strategy for each patient. Gender, race, bone structure, age, etc. must all be factored into what constitutes an appearance suitable for a given individual.

There are two basic surgical approaches to rhinoplasty – open versus closed. The open technique involves peeling most of the skin off the top of the nose. This allows excellent exposure of all the bone and cartilage for surgical correction. It requires, however, a small incision across the columella -the small skin strut between the right and left nostrils. The open rhinoplasty is the best approach for complicated nose operations, for revisions of previous surgery, and for congenital nasal deformities.

The closed technique approaches the nose through separate incisions inside of each nostril. The approach avoids the incision across the columella. Manipulation of the anatomy is partially a “blind” maneuver, however, as exposure is compromised. This technique works well for simpler and more straightforward nose operations.

After many years of doing rhinoplasties, I’ve chosen to use the open approach on most cases. In my opinion, the technique gives the most predictable and reproducible results. I have found that asymmetries are encountered, and dealt with, that would not be recognized in a closed rhinoplasty.

Most of the problems with healing from rhinoplasty have to do with appearance. In spite of the rather luxurious supply of sensory nerves, most patients experience little pain after rhinoplasty. Pain medication, although routinely prescribed, may not even be necessary. Patients do complain of obstruction to nasal airflow both before and after the packing is removed (within 24 hours), but this is a modest problem in most circumstances.
After the operation, a nasal splint is often applied to stabilize the nose, particularly if the bones have been cut for repositioning. This is a thin sheet of plastic that conforms to the new contour. The splint is removed in 3 to 5 days. Tape may be used to help redrape the skin after the splint has been removed for several more days.
Patients may have bruising and obvious swelling for 1-3 weeks. After this, although swelling exists, it usually subsides enough so that the nose does not look as though it has been injured. Residual swelling may take as long as 6 months to totally subside. However, this is relatively subtle and usually of no great aesthetic concern. Bruising is more likely when the bones of the nose are repositioned to narrow its width.
Any aesthetic operation can produce a result that might benefit from a revision. Occasionally, a rhinoplasty will require a revision. Usually they are minor procedures. However, most contour issues that patients think will require reoperation disappear as time passes. Almost never is a revision undertaken before a year of recovery. Dr Zubowicz does not charge an additional professional fee for any revision.
There usually is packing in the nose for a few hours. In an exclusively cosmetic rhinoplasty, the packing is in the front of the airway and the patient can remove it before bed on the day of the operation. If airway improvement surgery has been performed, the packing remains in overnight and is removed by the surgeon the next morning.
Changing the appearance of the nose should not effect the airway. Conversely, improving the airway surgically does not change the way a nose looks. However,many cosmetic nose procedures are performed in conjunction with operations that improve airway. Obstruction to breathing may be caused by septal deviation, enlarged turbinates (stalactites of erectile tissue in the airway to humidify, filter, and moisten inhaled air), or problems with the nasal “valve.” Even though these procedures do not effect the appearance of the nose, they may have resulted from the same injury that caused an aesthetic problem. In the absence of coincidental trauma, because the problems are approached through similar incisions, they often are dealt with at the same time.

Yes, it is possible. One particularly difficult problem compromising the airway is collapse of the nasal valve. Simplistically, nature saw fit to supply the nose with a support mechanism which keeps the nasal wall from collapsing when a deep breath is taken through the nose. If the soft tissue side wall of the nose were totally passive, it would collapse into the airway as negative pressure is generated during deep inhalation. The nasal valve supports the wall so that the air passage does not slam shut.

In some patients, occasionally as a result of trauma but, most commonly, the result of previous nose surgery, this valve is ruined. The nasal vault collapses during deep inspiration as it now acts as a passive membrane. To fix this problem, another operation may be necessary where the surgeon employs a “spreader graft”, carefully placed to prevent this collapse. This involves the use of a small piece of ear or septal cartilage. Occasionally, an artificial prosthesis may be used.

Analysis of breathing problems may be complex. Patients may confuse airway obstruction with “sinus” problems, expecting undeliverable results from the operation. Polyps, septal perforations, and other intranasal pathology must be ruled out before airway corrective surgery is performed.

Recovery usually does not involve much pain but may present the patient with some annoyances. Almost always there is some obstruction to normal breathing because of swelling. This will improve over time. Various intranasal medications may be prescribed to hasten recovery or improve symptoms while the nose is healing.

Cosmetic appearance of the nose is always a concern in aesthetic rhinoplasty. Most gross swelling (the swelling that looks like the patient has been punched in the nose) recedes in a week or so. In addition, during this first post-operative week, an external splint or tape commonly protects the nose. These protective dressings are, of course, obtrusive by their mere presence. Although they don’t interfere with most activities, they can be embarrassing.

More subtle swelling that does not bring attention but may obscure the definition of the operation takes much longer to resolve. Patients are told to plan on six months of healing before the end product of the operation is obtained. It may be longer or shorter by weeks or even months, but this period allows for the delicate refinements to emerge.

Sometimes recalcitrant swelling may be treated with injections of steroids, but only if there is something abnormal about the progress of resolution. In general, the body does a wonderful job of healing itself without intervention by the surgeon.

The patient and the surgeon must come to an agreement about the final anticipated aesthetic product of the operation. Obviously, this must fall under the umbrella of what is technically accomplishable. Although the ultimate result is meant to please the patient, the plastic surgeon should be aware of certain “norms” of facial appearance which limits, somewhat, the choices for the patient. These are explained as part of the pre-surgical consultation.

A most useful communication tool is the imaging computer. Here the surgeon and patient may create a post-operative nose on the patient’s face using digital photography and image manipulation. The surgeon can also demonstrate the importance of the relationships between the nose and other anatomic structures. From this, a specific operative plan will be drawn up.

The surgeon will also factor in such elements as brow position, upper and lower jaw relationships, projection of the chin and cheeks, etc., for the purposes of planning. The computer assists in visually demonstrating how these variables influence the operative design. Ancillary procedures (e.g. chin implant) may be decided upon.

do not feel that a smaller nose is necessarily a better-looking nose. Most aesthetic surgeons agree with this and with the idea that the nose, when considering surgical outcome, should be harmonious with the face. Good plastic surgery is anonymous. Bad plastic surgery advertises itself. The post-operative nose should not look as though it has been operated upon. It should not draw attention to itself because it does not fit into the facial picture.

The initial evaluation and surgical strategy must embrace the expectations of the patient, basic principles of facial beauty and harmony, and the capabilities of the operation. Computer imaging helps both the surgeon and the patient understand the effect certain changes will impart on the appearance of the face. Although the image is ideal and may not be totally achieved in practice, it establishes a “goal” agreed upon by both the surgeon and patient.

The operative plan and ultimate goal should factor in a number of facial, skeletal, and soft tissue variables. Chin projection, brow overhang, cheek strength and height, and width of the eyes are but a few of the considerations presented to the thoughtful surgeon and should be explained to the patient. Occasionally, modifications will be made on these features at the time of the operation.

Every nose operation is different. This is what makes nasal surgery so interesting and challenging. However, it precludes a cookbook description of what the surgeon will do each and every time in the operating room. Nevertheless, we can say a few things about strategy in general.

The nose is divided into 3 aesthetic units from top to bottom. The highest is made of bone. It is the vaulted rigid structure between the eyes that is immovable (after all, it’s bone). Adjustments to the height and width of the upper aesthetic unit are commonly made during a rhinoplasty. When the upper unit is narrowed, the bone must be cut. This is colloquially referred to as “breaking” the nose. It is, however, a controlled break, unlike a punch in the nose.

The middle aesthetic unit separates the upper aesthetic unit and the nasal tip. Its height and width are adjusted during surgery as well. This unit is made of cartilage and is bendable. Furthermore, cartilage can be shaped by carving, which the surgeon may do with a scalpel. This middle unit is also the site of the nasal valve, which must be recognized and preserved during the operation to prevent later breathing problems.

The lower aesthetic unit is the nasal tip. It is made up of a pair of cartilages that make several elaborate and intricate curves to define the nasal tip – its shape, projection, width, overhang, etc. The most critical adjustment of a rhinoplasty, in my opinion, is the nasal tip. The surgeon has has the opportunity to shape and position these critical and delicate structures in an innumerable ways. I find that video imaging is useful in analyzing and explaining to the patient anticipated changes.

As stated earlier, airway problems are commonly corrected at the same time a cosmetic nose operation is performed. In general, these operations have no visible effect on the nose. Conversely, cosmetic operations on the nose seldom effect the breathing functions of the nose.

Most patients in my practice are operated upon under a general anesthetic. On occasion, if the patient desires it, the operation can be accomplished with sedation and local anesthesia. General anesthesia is remarkably safe and allows the operation to be done more efficiently. For small revisions, it may be unnecessary.

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VINCENT N. ZUBOWICZ MD VNZ Plastic Surgery Emory University Hospital & Health Clinic 5 Star Rated Facelift and Breast Aug Makeover

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