Case Studies

Rhinoplasty (Nasal Surgery)

Rhinoplasty, nasal surgery, a nose job – whatever you want to call it, this surgery is one of the most iconic procedures of aesthetic surgery.  Everyone recognizes surgery to change the shape of the nose as one of the classic cosmetic surgery procedures.  It is one of the oldest of the modern aesthetic procedures having been first done in the 1880’s, but rhinoplasty was actually performed in about 4000 BC in India.  There are references to the procedure as a treatment for those persons who had their nose cut off for a criminal offence.  The famous barber surgeon of Renaissance Italy, Gasparis Taliacotii, resurrected rhinoplasty and wrote about it in his book, De Curtorum Chirurgia Per Insitionem.  So changing the nose is nothing new.

We have all heard the statement, “If I could only change . ? .  I would be handsome”.  While that might not be true for every facial cosmetic surgery, changing the shape of the nose can actually do this.  Rhinoplasty by it self can truly bring out all the good features of the rest of a face and allow the aesthetics of that face to shine through. 

Technically, changing the appearance of the nose is one of the most challenging of all the cosmetic surgery procedures.  Most of the time the surgeon is working “blind” in that he cannot actually see where the instrument is but must “feel” the work as it is done and visualize what he is doing in his mind’s eye rather than in actuality.  An artist’s eye is absolutely necessary in this surgery.  You can make a change to the nose with a baseball bat but that is hardly what patients want.  The nose is one of the most important features of the face, second only to the eyes.  A nose disproportionate to the rest of the face or deformed due to trauma or disease will dominate the viewer’s attention and detract from the aesthetic lines of the face.  Shape, balance and harmony are the desired goals of rhinoplasty along with the maintenance of racial and cultural heritage

Before Surgery

The consultation for rhinoplasty will cover many subjects, particularly the desires of the patient and the limitations of the procedure.  It is always best to have some reference point from which both the patient and the plastic surgeon can begin the conversation so I ask my patients to bring in several photos of both the perceived problem (snapshots of their nose) and noses that they believe are good looking and applicable to their own face.  In that way, the patient can more easily convey his wishes and I can understand just what he wants.  From there it is easier to explain what can and cannot be done to achieve the patient’s goals.  Most patients have a fairly good idea of what they want and how much can be achieved.  Then the plastic surgeon’s job is fairly easy.  However, there is the patient who wants marked changes, not always within their ethnic background, that cannot be done or should not be done as it will destroy the balance of the face.  Telling someone that the changes in shape they want should not be done but would be better done in a different way is sometimes tricky.

Occasionally, there are other features that bring disharmony to an otherwise attractive face.  While I rarely recommend procedures to a patient unless asked to, in this case I will.  Small or recessed chins are particularly difficult for some patients to appreciate since it is only on profile that it becomes apparent.  The chin position is of significant concern when changing the nose as the balance of the face is determined in large measure by the forehead, nose and chin alignment.  In the male face the nose has a dominant position as does the chin.  Each of these features attributes to the masculine look of the face.  Without proper proportion in both, the strength of the face is lost.  In cases where chin revision would assist in creating facial harmony, I do suggest this procedure.

The initial consultation is where all decisions should be made.  The patient should have a clear understanding of the goals of surgery and how those goals will be achieved.  Once this is accomplished, attention should be turned to the preparation of the patient for the operation.  You will need lab tests, a preop history and physical, prescriptions for medications after surgery, etc, etc.  All of this will be explained at the consultation along with a review of complications and what they mean.  The complications of rhinoplasty of relatively few and occur infrequently.

The Surgery

Rhinoplasty is usually done as an outpatient procedure.  The length of time in the operating room varies between 1.5 and 2.5 hours depending on the technique and the amount of work to be done.  The average rhinoplasty is done using the “closed” technique where there are no incisions on the exterior of the nose, only in the interior so there are no visible scars.  Noses that are twisted, severely deformed or have had previous rhinoplastic surgery are usually done with the “open” technique.  In the latter, there is an incision across the lower part of the columella (that part of the nose between the nostrils) which allows full exposure of the nasal tip and its cartilages.  In almost all cases, changes are made to the bones of the nose and to the nasal tip cartilages.  Occasionally the nostril width will need to be narrowed and may require an external incision.  Should there be deformities of the septum and/or turbinates within the nose, this will be corrected at the same time.  If work is done on the interior of the nose, there is usually packing that will be in place for one to several days.  An external splint is used on most cases.

Post Surgery and Recovery

When the surgery is completed and bandages applied, the patient is transferred to the Recovery Room (or PACU).  Nasal surgery is usually done as an outpatient so once the patient has awakened from surgery and the vital signs are stable, the patient may go home.  So long as you live within an hour’s drive of the IAS Surgery Center you may then return to your own bed for 24 hours of bed rest.  Sleeping or snoozing for a day is the best way to get off to a good recovery and rapid healing.  Pain is usually minimal.  There will be some swelling and bruising about the eyes when the nasal bones are changed.  Iced compresses to the eyes/nose are required constantly for 48 hours, then warm compresses for 20 minutes 4 x per day until all the bruising and swelling is gone – usually 10-14 days.  There will be a splint on the exterior of the nose for about 5-6 days.  If work was done on the septum or turbinates there will be packing in the nose for 1-6 days.  When you return to the office for your 1st postop visit, the splint will be removed.

Most patients take off work for 2 weeks because they do not want to be seen with swelling and bruising.  However, you can go to work at 1 week postop if you wish depending on your job.  Don’t do anything to increase your blood pressure or you may start a nose bleed.  Follow your instructions for postop care and activity restrictions.  (You will have been given a 2 page instruction sheet when surgery was scheduled with before and after surgery instructions and you must follow those instructions exactly.)  Nobody wants a complication and these instructions have been specifically designed to prevent postop complications.

Your postop visits will usually be at 5-6 days postsurgery (to remove the splint and packing), each week for the next 2-3 weeks, at 6 weeks, at 3 months and 6 months and at 1 year.  The nasal bones will require 6 weeks to heal.  Don’t expect the nose to look perfect when the bandages come off.  This isn’t the movies.  There will be swelling and bruising when the splint is removed.  Most of the swelling will be gone in 2 weeks. However, there will be a very small amount of swelling that will gradually go away over a 1 year period.  All of these things will be covered during your consultation and in your instruction sheets.  Photographs will be taken frequently.

Risks & Complications

This is a surgical procedure and therefore complications may occur.  I can’t imagine how many times I have said this to patients during the consultation.  Frequently about this time, a glaze comes over the eyes and the patient “tunes out”.  Risks of surgery and possible complications are not the most pleasant thoughts when you are excited about getting your new look but my advice, pay attention.  The cause of a complication may not be something done at surgery, but rather something you inadvertently do in the postop period.  Simply blowing your nose to soon can cause bleeding or a hematoma that sets off a string of complications.  The list of usual complications and their causes are covered in detail at the consultation so listen attentively.

The Cost

When budgeting for nasal surgery, remember there is the fee for the surgeon, the cost of the surgery facility and the fee for the anesthesiologist.  There are miscellaneous other costs such as lab tests, medications, preop physical, etc.  Once you are seen in consult and all factors evaluated, a final cost will be quoted for you.  If you would like to get a general range of fees, please call the office at 404-252-3672 and ask for the patient coordinator as she will be able to ascertain your general needs and give you a baseline average cost.

 

 

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