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The nose is the dominant feature of the face and is the most common reason to seek plastic surgery consultation. In a rhinoplasty, the bone and cartilage framework are modified and the skin is redraped. Thin, smooth skin redrapes, but thick, oily skin will limit the final result. Of all the plastic surgery procedures, rhinoplasty results are the most variable as they depend on both physician judgment and technique, and it is important to select a surgeon with an interest and experience in rhinoplasty. Nasal surgery is usually not considered until the patient has reached young adulthood, since surgery can limit future growth.
About your evaluation
In the nasal evaluation, a dialogue between patient and surgeon regarding likes, dislikes and objectives as well as what is perceived in the nose and what change is desired is vital. What is most important is that the surgeon verbalizes what he sees, what he intends to change, and a general idea of what can be expected. A surgeon who cannot put such things into words that are clearly understood should not instill confidence.
Of course, the nose does not only serve as a focal point for cosmesis but also has the important physiologic function of breathing. Abnormal anatomy must be identified, as it may cause difficulty breathing by reducing the area of the passage either due to fixed anatomy or functional obstruction. The external nasal valve is formed by the alar rim, columella, and nasal floor. The internal nasal valve is formed inside the nose between the septum, nasal floor, and upper lateral cartilages of the nose. If either of these valves is narrowed, functional septorhinoplasty is indicated and correction of the internal nose for breathing and the external nose for aesthetic purposes can be done at the same time. Even if no breathing problems exist prior to cosmetic rhinoplasty, the surgeon may recommend repair of internal structures (deviated septum, turbinate hypertrophy, collapsed nasal valve) during the rhinoplasty in order to avoid the development of functional problems.
Insurance
Cosmetic surgery on the nose is not covered by insurance. Functional problems, however, are typically covered by insurance companies. Reconstructive nasal surgery because of previous injury, surgery, or disease process also may be covered by insurance. If a combined procedure for both function and cosmesis is anticipated, a portion of the procedure might be covered.
The procedure
Most rhinoplasties can be performed under local anesthesia with intravenous sedation or general anesthetia and typically takes between 1 and 3 hours.
A closed rhinoplasty can be performed with incisions only inside the nose if the nasal tip does not need significant modification. An open rhinoplasty allows wide exposure to the entire nose including the tip and all bone and cartilage structures, but it does involve a scar across the nasal columella and prolonged swelling.
Treating the tip may require sculpting the tip cartilages, repositioning the tip cartilages with suture, or grafting cartilage (usually from septum or ear).
Treating the nasal dorsum may include removal of projecting nasal bones and upper nasal cartilages with a combination of resection and filing, narrowing the nasal bones with controlled fracture, or grafting cartilage (septum or ear), fascia (temporal), or bone (skull or rib) to dorsum, radix, or tip.
A long nose can be shortened by sculpting the tip cartilages and shortening the nasal septum. Straightening a crooked nose will usually require a septoplasty to straighten the deviated septum and fracture of the nasal bones. Excessive nasal lobule or alar flare can be corrected with a wedge excision of the lobules at the junction with the lip or by a wedge excision in the floor of the nostril above the lip. Each techniqe will result in a scar, but in most instances, it is barely visible.
After your operation
After the operation, the nose may be packed for 24 to 48 hours to limit bleeding. Overnight observation may be required. For 1 – 2 weeks, an external dressing limits swelling and splints stabilize the nasal bones and septum when needed. Swelling and bruising of the nose and eyes is inevitable, but can be limited with ice and elevation. Drainage is common and may be bloody for several days. Pain and discomfort is fairly easily controlled with prescribed medication and subsides within a few days.
Most people return to work, school, or daily activities while the external splint is in place. Light exercise can be resumed within 2 to 3 weeks and strenuous exercise within 4 to 6 weeks. The final result may not be fully appreciated for up to one year following the operation. In most instances, it is wise to delay any revision for at least 12 months to allow all swelling to resolve and scar tissues to soften.
Secondary rhinoplasties are even more technically difficult than the initial nasal operation and it is imperative that patients seek out a surgeon who is experienced in secondary rhinoplasty. Common revision rhinoplasty deformities include “ski jump deformity” characterized by a deficient dorsum, “polly beak deformity” characterized by a lack of normal depression above the tip, an underprojecting tip, a pinched or narrow nose, and asymmetric nostrils.
All of the descriptions for the various procedures are condensed from the text of the upcoming textbook written by Dr. Christopher Park and Dr. Malcolm Marks and are copyrighted, "The Artistry of Plastic Surgery: Exploring the Experience” . |
