Rhinoplasty

The term rhinoplasty means "nose molding" or "nose forming." It refers to a procedure in plastic surgery in which the structure of the nose is changed. The change can be made by adding or removing bone or cartilage, grafting tissue from another part of the body, or implanting synthetic material to alter the shape of the nose.

Rhinoplasty is the most frequently performed cosmetic surgical procedure in the United States as of the early 2000s. According to the American Society of Plastic Surgeons (ASPS), 356,554 rhinoplasties were performed in the United States in 2003, compared to 254,140 breast augmentations and 128,667 facelifts.

Rhinoplasty is most often performed for cosmetic reasons. A nose that is too large, crooked, misshapen, malformed at birth, or deformed by an injury or cancer surgery can be given a more pleasing appearance. If breathing is impaired due to the form of the nose or to an injury, it can often be improved with rhinoplasty.

The best candidates for rhinoplasty are those with relatively minor deformities. Nasal anatomy and proportions are quite varied and the final look of any rhinoplasty operation is the result of the patient's anatomy, as well as of the surgeon's skill.

The quality of the skin plays a major role in the outcome of rhinoplasty. Patients with extremely thick skin may not see a definite change in the underlying bone structure after surgery. On the other hand, thin skin provides almost no cushion to hide the most minor of bone irregularities or imperfections.

A cosmetic change in the shape of the nose will change a person's appearance, but it will not change self-image. A person who expects a different lifestyle after rhinoplasty is likely to be disappointed.

Rhinoplasty should not be performed until the pubertal growth spurt is complete, between ages 14-15 for girls and older for boys.

The cost of rhinoplasty depends on the difficulty of the work required and on the specialist chosen. Prices run from about $3,000 to over $6,000. If the problem was caused by an injury, insurance will usually cover the cost. A rhinoplasty done only to change a person's appearance is not usually covered by insurance.

The external nose is composed of a series of interrelated parts which include the skin, the bony pyramid, cartilage, and the tip of the nose, which is both cartilage and skin. The strip of skin separating the nostrils is called the columella.

Surgical approaches to nasal reconstruction are varied. Internal rhinoplasty involves making all incisions inside the nasal cavity. The external or "open" technique involves a skin incision across the base of the nasal columella. An external incision allows the surgeon to expose the bone and cartilage more fully and is most often used for complicated procedures. During surgery, the surgeon will separate the skin from the bone and cartilage support. The framework of the nose is then reshaped in the desired form. Shape can be altered by removing bone, cartilage, or skin. The remaining skin is then replaced over the new framework. If the procedure requires adding to the structure of the nose, the donated bone, cartilage, or skin can come from the patient or from a synthetic source.

When the operation is over, the surgeon will apply a splint to help the bones maintain their new shape. The nose may also be packed, or stuffed with a dressing, to help stabilize the septum.

When a local anesthetic is used, light sedation is usually given first, after which the operative area is numbed. It will remain insensitive to pain for the length of the surgery. A general anesthetic is used for lengthy or complex procedures or if the doctor and patient agree that it is the best option.

Simple rhinoplasty is usually performed in an outpatient surgery center or in the surgeon's office. Most procedures take only an hour or two, and patients may return home right away. Complex procedures may be done in the hospital and require a short stay.

During the initial consultation, the patient and surgeon will determine what changes can be made in the shape of the nose. Most doctors take photographs at the same time. The surgeon will also explain the techniques and anesthesia options available to the patient.

For legal reasons, many plastic surgeons now screen patients for psychological stability as well as general physical fitness for surgery. When a person consults a plastic surgeon about a rhinoplasty, the doctor will spend some time talking with the patient about his or her motives for facial surgery. The following are considered psychological warning signs:

The patient and surgeon should also discuss guidelines for eating, drinking, smoking, taking or avoiding certain medications, and washing of the face.

Patients usually feel fine immediately after surgery; however, most surgery centers do not allow patients to drive themselves home after an operation.

The first day after surgery there will be some swelling of the face. Patients should stay in bed with their heads elevated for at least a day. The nose may hurt and a headache is not uncommon. The surgeon will prescribe medication to relieve these conditions. Swelling and bruising around the eyes will increase for a few days, but will begin to diminish after about the third day. Slight bleeding and stuffiness are normal, and vary according to the extensiveness of the surgery performed. Most people are up in two days, and back to school or work in a week. No strenuous activities are allowed for two to three weeks.

Patients are given a list of postoperative instructions, which include requirements for hygiene, exercise, eating, and follow-up visits to the doctor. Patients should not blow their noses for the first week to avoid disruption of healing. It is extremely important to keep the surgical dressing dry. Dressings, splints, and stitches are removed in one to two weeks. Patients should avoid sunburn.

Patients should remember that it may take as long as a year for the nose to assume its final shape; the tip of the nose in particular may be mildly swollen for several months.

Any type of surgery carries a degree of risk. There is always the possibility of unexpected events, such as an infection or a reaction to the anesthesia. Some patients may have a so-called foreign body reaction to a nasal implant made from synthetic materials. In these cases the surgeon can replace the implant with a piece of cartilage from the patient's own body.

Some risks of rhinoplasty are social or psychological. The ASPS patient brochure about rhinoplasty mentions the possibility of criticism or rejection by friends or family if they feel threatened by the patient's new look. This type of reaction sometimes occurs with rhinoplasty if the friends or relatives consider the shape of the nose an important family or ethnic trait.

When the nose is reshaped or repaired from inside, the scars are not visible, but if the surgeon needs to make the incision on the outside of the nose, there will be some slight scarring. In addition, tiny blood vessels may burst, leaving small red spots on the skin. These spots are barely visible but may be permanent.

About 10% of patients require a second procedure; however, the corrections required are usually minor.

Chou, T. D., W. T. Lee, S. L. Chen, et al. "Split Calvarial Bone Graft for Chemical Burn-Associated Nasal Augmentation." Burns 30 (June 2004): 380-385.

Daniel, R. K., and J. W. Calvert. "Diced Cartilage Grafts in Rhinoplasty Surgery." Plastic and Reconstructive Surgery 113 (June 2004): 2156-2171.

Honigman, R. J., K. A. Phillips, and D. J. Castle. "A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery." Plastic and Reconstructive Surgery 113 (April 1, 2004): 1229-1237.

Raghavan, U., N. S. Jones, and T. Romo, 3rd. "Immediate Autogenous Cartilage Grafts in Rhinoplasty after Alloplastic Implant Rejection." Archives of Facial and Plastic Surgery 6 (May-June 2004): 192-196.

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). 310 South Henry Street, Alexandria, VA 22314. (703) 299-9291. http://www.facemd.org.

American Society of Plastic Surgeons (ASPS). 444 East Algonquin Road, Arlington Heights, IL 60005. (847) 228-9900. http://www.plasticsurgery.org.

American Society of Plastic Surgeons. Procedures: Rhinoplasty. http://www.plasticsurgery.org/public_education/procedures/Rhinoplasty.cfm.

Cartilage — Firm supporting tissue that does not contain blood vessels.

Columella — The strip of skin running from the tip of the nose to the upper lip, which separates the nostrils.

Septum — The dividing wall in the nose.