Nose job/correction (Rhinoplasty)

Introduction/History

Surgery for nose restoration dates back thousands of years but Dieffenbach was the first to describe improvement of the shape of the nose in 1845. Jacques Joseph, who in Berlin in 1898 formed the first endonasal correction, is considered the father of modern cosmetic nose surgery. Today, rhinoplasty to improve nasal configuration is one of the most common facial cosmetic procedures. At the same time, rhinoplasty is also among the most difficult procedures in Plastic Surgery. This is because in addition to the plastic improvements, the functional properties of the nose must be taken into account. As a result, the oftentimes complex, individual measures during rhinoplasty, and their effects on form and function must be carefully considered to achieve a harmonious outcome.

Anatomy

As a central part of the face, the nose defines the entire facial expression imparting "profile" and character to the face. Here it is critical that the operator have exact knowledge of the topographic anatomy of the nose. The cartilaginous and bony supports of the nose participate in determining both form and function. Thus, any alteration of the internal nasal scaffolding determines the external shape of the nose. Especially with a plastic esthetic alteration of the nose, it is very important to consider the skin and soft tissue portions of the nose as well, in order to attain a harmonious result.

Goal of the operation

The goal of rhinoplasty or rhinoseptoplasty is to succeed in creating a nasal contour which matches the existing facial proportions yet without restricting function, or, if there is a preoperative respiratory obstruction, to correct this during the same procedure (esthetic functional rhinoplasty).

Preoperative analysis

In every case, we first discuss the patient's goals and realistic surgical implementation during an extensive preoperative interview in our special Nose Clinic. Since the procedure entails an irreversible modification, the decision must be considered carefully and not be the result of a momentary impulse. At the same time, potential risks and complications must be weighed. Part of the case history will include the review of past trauma, nose injuries, or past surgery.

Blood thinning medications should be discontinued approximately two weeks prior to surgery, if possible (after consultation with the family doctor, cardiologist, or neurologist). Then we examine the exterior shape of the nose (by determining important angles, distances, and proportions compared to other parts of the face, and skin quality) as well as shape and function of the nasal interior (course and integrity of the septum, size of the nasal turbinates, inspection of the outer and inner nares, free or obstructed air flow). These parameters are analyzed with the aid of professional photographs and patient exam. Every patient also undergoes nasal endoscopy. If needed, an added functional examination with rhinomanometry is ordered.

Using the images obtained, the goal of the operation can be delineated in a drawing. We do not use virtual computer graphics for they often involve the danger of representing the three-dimensional system of nasal anatomy in but limited fashion. It is only after these examinations and our interview that we can develop a detailed operative concept so as to achieve the most harmonious nasal contour possible.

Operative procedure

Basically, a rhinoseptoplasty consists of a combined correction of the inner and outer nose, which can be fundamentally subdivided into the following stages:

  1. Access (open/closed)
  2. Correction of septum (correction of the nasal partition)
  3. Turbinate correction
  4. Distal nose (tip of nose) correction
  5. Correction of nasal bridge (dorsum of nose)
  6. Correction of the bony nasal pyramid
  7. Refinements (last small adjustments and correction of irregularities)
  8. Dressing (a special combination of band-aids and nose plaster/cast)

Postoperative course/follow-up care

Inpatient stay is about one to four days (depending on the extent of the operation). Tamponade sponges are removed after three days. The special dressing (consisting of bandage tape and cast plaster) is generally kept in place for two weeks. The first check is carried out after about a week at which time the open access bridge threads are removed. If the plaster loosens after decrease of swelling, it is replaced after the first week. The inset silicone splints (needed for additional stability, and prevention of synechiae [adhesions] and septal bleeding) are removed two weeks after the operation together with plaster removal.

After removal of the hard plaster bandage, there mostly remain only tape bandages for another week. Exercise should be avoided for six to eight weeks. If possible, the patient should also avoid wearing glasses for three weeks (if contact lenses are not tolerated, thermoplast splints can be fitted).

Complications/risks

If your operation has been performed by a qualified plastic surgeon, complications tend to be rare and generally a lasting good result is achieved. However, it is not possible to guarantee a surgical outcome.

  • Swelling (maximum is after two to three days, then continued decrease)
  • Hemorrhage (e.g. septal bleeding)
  • Wound infection
  • Poor wound healing
  • Transient numbness, hypersensitive nasal tip

Overall, rhinoplasty is a procedure with few complications, however the desired result is not always achieved.

Key points at a glance

  • Anesthesia: general
  • OP duration: one to three hours
  • Hospital stay: one to four days
  • Plaster bandage: two weeks
  • Suture removal: after one week
  • Tamponade removal: three days
  • Disability: approx. two weeks
  • Exercise restriction: six to eight weeks