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Nose Surgery, AKA Rhinoplasty
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| Example
of large nose overwhelming facial harmony. (Click picture
to enlarge). |
Overview
The nose is the most central
part of the face. Ideally, it should not attract attention. A large, deviated, or disproportionate nose will dominate
the face and attract unfavorable attention. An attractive
nose is aesthetically pleasing and allows the observer to
pay more attention to other structures such as the eyes and
lips. There is no set way that a nose should look, but
one thing is certain, it should be unobtrusive and in harmony
with the rest of the face.
The medical term for surgically altering
the nose for cosmetic reasons is rhinoplasty. Rhino means nose and plasty means to shape.
Patients seek rhinoplasty for various reasons. Sometimes,
it is traumatic nasal injury that has altered the nose. More
often, it is because someone is simply unhappy with its appearance. Common reasons include: a hump, a deviated nose, a wide nose,
a crooked nose, a long or short nose, a pug nose,
a ski nose, a beaked nose, flaring nostrils, a bulbous tip,
and many others. All of these can be corrected or at
least markedly improved with rhinoplasty.
 Commonly,
there are two ways to perform rhinoplasty. The first
way is called a closed rhinoplasty and the second
way is an open rhinoplasty. Dr. Cruise likes
to think of a third way which is a combination of the two
otherwise known as a delivery technique. Many
plastic surgeons favor one particular way. Dr. Cruise
utilizes all three techniques depending on the situation. He
has developed skills with all three techniques because he
feels that each technique has a particular advantage depending
on what he wants to obtain. There is no right or wrong
way. The only important thing is that whoever does the
rhinoplasty must be comfortable with that particular technique
and the bottom line is, obviously, the final result.
Dr. Cruise utilizes the closed technique when the majority of the nasal
work is performed on the top and the bridge of the nose, or
if only small modifications are being made to the nasal tip. This
technique is performed through incisions inside the nose which
are not visible from the outside. The complete lack of
any visible scar is an advantage but the downside of this
technique is lack of exposure of the nasal tip.
 He
uses the open technique when there is a significant
amount of work that needs to be done on the nasal tip. This
technique requires that a very small incision is made along
the thinnest part of the skin between the two nostrils. This
normally heals without a visible scar. This provides
excellent exposure of the nasal tip and allows for a more
accurate rhinoplasty.
Finally, Dr. Cruise performs
the delivery technique when there is a moderate
amount of work necessary to be done on the tip. This
technique does not require any visible scars yet it still
allows significant exposure of the nasal tip.
Another reason for nasal
surgery includes airway problems. Airway problems may
lead to difficulty in breathing at certain times or, perhaps,
all the time. This may be due to a deviated nose or an
enlarged turbinate among other reasons. Determining the
exact cause requires consultation with Dr. Cruise or a competent
plastic surgeon. Airway problems can usually be resolved
by correcting the underlying problem.
Rhinoplasty is the quintessential
plastic surgery operation. It incorporates all the skills
as well as the artistic prowess that a plastic surgeon develops
over the course of his/her training. The techniques used
are quite predictable, however, the way each individual patient
heals is different.
Changes in the appearance
of the nose have a profound effect on the facial aesthetics. Removing
a large dorsal hump or making the nose somewhat thinner and
smaller can dramatically improve one's appearance.
 Dr. Cruise's philosophy regarding nose surgery
 Rhinoplasty is one of my favorite cosmetic surgery procedures. It is a very satisfying procedure because the results are quite dramatic and the effect it has on my patients is profound. There is no other procedure in plastic surgery that requires such balance between artistic finesse and technical ability. During your consultation, we will take digital photographs of your face and nose from multiple directions. I will examine your nose so you can show me exactly what it is that bothers you. At this point, I will digitally alter the pictures of your nose to demonstrate what you will likely achieve by having rhinoplasty. This is a very powerful tool as it helps me determine exactly what you are looking to achieve. No result can be guaranteed but I can tell you with great certainty that it will be very close if not right on.
Benefits
The most significant benefit
of rhinoplasty is dramatic enhancement of self confidence. Other
benefits range from cosmetic reasons to breathing improvement. Here
is a brief list of the benefits of rhinoplasty:
- Corrects a large dorsal hump.
- Makes the nose smaller.
- Makes the nose appear more in harmony
with the rest of the face.
- Corrects a deviated or crooked nose.
- Makes the nose thinner.
- Narrows nostrils that flare.
- Sharpens and defines the nasal tip.
- Improves the contour of nose and
corrects bumps or irregularities.
- Corrects nose length whether it
is too long or too short.
- Corrects a droopy nasal tip.
- Improves breathing.
- Prevents the nose from collapsing
in during deep inspiration.
During consultation, Dr. Cruise will examine and discuss with you exactly what it is
you wish to correct.
Possible complications
The most common complication of rhinoplasty is that the desired appearance was not fully obtained. This often can be corrected by minor touch ups usually within the office under local anesthesia to obtain the desired results. Other possible complications are: infection, wound healing problems, unfavorable scarring, fluid or blood collection, numbness, asymmetry, and contour irregularities.
Are you a good
candidate?
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| Example of thick skin on tip of nose. Result is good but would be better if skin were thinner. |
Almost anyone, who is self-conscious
about the way their nose looks, can have something done to
either correct the problem or dramatically improve it.
There are people, however,
that respond less favorably to rhinoplasty than others. Nasal
tips with thick, oily skin are more difficult than those with
thin skin. This is because thick skin is less likely to show
changes in the underlying nose as readily as thin skin. Thick
skin is much less capable of adapting to a new shape. Dr,
Cruise will evaluate your skin and tell you what you can expect
from arhinoplasty. Summarized below is a brief list of issues
that can be corrected by rhinoplasty.
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Large dorsal hump.
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Wide nose out of proportion
to the face.
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Deviated or crooked
nose.
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Wide, flaring nostrils.
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Bulbous tip.
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Boxy tip.
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Irregular contour
of nose.
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Nose that is over
or under projected.
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Nose that is too long
or too short.
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Difficulty breathing
caused by airway obstruction within the nose.
Prior to surgery
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Medications. Certain
medications thin your blood and should not be taken within
3 weeks of surgery. The most notable is aspirin and
aspirin containing products. Vitamin E and many herbal
products also thin the blood and should not be used within
3 weeks of surgery. Dr. Cruise will go over this
more thoroughly prior to the procedure.
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Sleep. It is important to get a good night's rest prior to the
procedure. If you think this may be a problem, please,
do not hesitate to ask Dr. Cruise for something to help
you sleep.
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Smoking. Do
not smoke within 3 weeks before and after surgery. Smoking
has a profound effect on reducing wound healing capabilities. It
significantly increases the likelihood for infection,
wound healing problems, and scar formation. It also
affects your airway, therefore, makes anesthesia much
more difficult.
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Eating. Do
not eat within 8 hours of surgery and do not drink within
6 hours of surgery. It is OK to take medications
with a sip of water. Please discuss all medications
with Dr. Cruise and the anesthesiologist.
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Washing. It
is a good idea to wash the surgical area thoroughly the
night before and the morning of surgery. Blow your
nose and clean it the morning of surgery using a Q-tip. It
is most helpful to trim your nasal hairs 3 days before
the procedure. Do not apply any make up
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Arrival. It
is best to arrive on time to make sure things go smoothly. Please
be sure to have someone else drive you.
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State
of mind. Remember, this should be a happy
and exciting time. A certain amount of nervousness
is normal but you should not be overly concerned. Dr. Cruise and ICRS are both well trained and experienced. Excessive
worrying can actually be detrimental and you should discuss
this with Dr. Cruise prior to surgery so that something
can be prescribed to make sure you remain calm.
Consultation
We have outlined below what you can expect from your rhinoplasty consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to your plastic surgeon what you want to accomplish.
 Health History
All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used but also applies to local anesthesia. Rhinoplasties may be done under general or local anesthesia depending what needs to be done and on the preference of both the plastic surgeon and the patient. Prior to meeting with your plastic surgeon you will be given a health history questionnaire to fill out in the waiting area. There are 5 areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.
General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are: high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.
What will Dr. Cruise do if I have medical problems?
In short, he will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.
If you have a health problem you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the health problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.
If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating you are able to tolerate surgery.
If you are not able to tolerate general anesthesia it may be possible for your procedure to be done under local anesthesia, with or without sedation. This must be discussed with Dr. Cruise.
On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision. With rhinoplasty it is especially important to mention all previous nasal or sinus surgeries. Previous trauma to the nose is important. If you have traumatic changes to your nose it is helpful to bring in pictures of what you looked like before your injury.
Be sure to list all medications you take including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least two weekds before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.
Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.
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Smoking, Drinking, and Drug Use
These 3 will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.
Specific Nose Issues.
During your consultation you must be very accurate with nasal problems. Of particular concern is a history of breathing problems, sinus problems, nasal drug use, nasal trauma, and any previous nasal surgery. If you had previous nasal surgery, call the surgeons office and have them fax over the operative note. Bring this operative note to your consultation. This is very helpful so that your plastic surgeon can see what has been done. Revision rhinoplasties are challenging because of the scar tissue left by the first operation.
What Do You Want To Change?
It is important that you have a clear idea of what you want changed when you go for consultation. The least favorite thing a plastic surgeon wants to hear is: What do you think I need done?
Look in a mirror and identify what bothers you. Be specific. It is helpful to break up the nose into four parts. 1) Dorsum 2) Tip 3) Alae 4) Airway obstruction. Evaluate each one of these areas individually as this is what the plastic surgeon does in his exam.
Common complaints
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Dorsum: Too wide, too narrow, too big, too small, deviated.
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Tip: Too big, too pointy, too long, too pushed up, droopy, deviated.
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Alae: Too wide, too bulbous, nostrils too big.
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Airway: This must be examined individually.
Physical Exam
The key to the nasal physical exam is to determine exactly what is causing the problem. Rhinoplasty is a high finesse procedure and requires that the plastic surgeon knows exactly what you want. If there is a particular nasal characteristic that you like, it is helpful to bring in a picture of someone with this particular feature. Obviously, this look will not be duplicated but it helps convey your wishes.
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| Dorsal line between eye brow and tip should be curvilinear and smooth |
Dorsum
When looking at the nasal dorsum, there should be a continuous curvilinear line that begins within the eye brow, joins harmoniously with the radix of the nose, and continues to the tip. When the dorsum is too big or too wide this continuity is broken and the nose appears out of place or too big.
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| Skin removed revealing the two bones and four cartilages of the nose. Compare to picture above. |
Removal of a large, dorsal hump or narrowing a wide dorsum will correct this problem and give a smaller, more pleasant appearance. Often this will require an osteotomy which means breaking of the bones in order to reposition them correctly.
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| Red line depicts typical osteotomy location. |
Nasal osteotomies usually cause bruising around the eyes that lasts about 17 days.
The image on the left outlines the typical location of the osteotomy. After the nasal bones are "broken" they are then repositioned medially to narrow the nasal vault.
This repositioning is one of the methods Dr. Cruise uses to improve the balance between the eye brow and the nasal tip as described above.
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Woman with deviated nose. Notice that nasal bones, dorsum, and tip are all deviated to her right. Correction by Dr, Cruise required osteotomy, cartilage grafting, and suture technique. |
Deviation
Nasal deviation can occur anywhere in the nose from the bridge to the tip. It is a very difficult problem to completely correct but can usually be improved tremendously. The treatment depends on the cause. The cause may be within the nasal bones, the upper nasal cartilages, the lower nasal cartilages, the septum, or all of the above. Usually, the nasal bones will need to be broken and repositioned.
The cartilages will also need to be repositioned. If one's nose has a concavity on one side it may be necessary to fill this gap with a cartilage graft. This cartilage is usually obtained from the nasal septum inside the nose.
Postoperatively, after an osteotomy or deviation correction, one will need to wear a nasal splint for 1 to 2 weeks. Complete bone healing takes about 6 weeks. Swelling of the nasal dorsum lasts up to 6 months but the majority is gone by 6 weeks. This is quicker than the tip, which takes a year for the final result to be evident. Once again, the majority of the swelling is gone by 6 weeks.
Tip
The tip should be a smooth continuity of the dorsum. Too large of a tip will cause people to focus on it. An attractive tip does not draw attention. A large or deviated tip causes the observer to immediately focus on this area. Nasal harmony with the rest of the face is disrupted.
The most common cause of a large, bulbous tip is a large, rounded lower lateral cartilage. This can be reduced and a sharper tip created if the overlying skin is not excessively thick.
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| Notice that the cause of the bulbous tip is the rounded shape of the lower lateral cartilage. |
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Woman with long nose as well as a droopy tip. Correction by Dr. Cruise included shortening of the septum and projecting of the tip. |
Long noses are often caused by long septums. Shortening the nasal septum will correct this.
Droopy nasal tips are usually caused by poor tip support. Correction can be obtained by adding support and bringing the tip upward.
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Woman with short nose and contour irregularity. Correction consisted of cartilage graft and lengthening of the septum. |
Short noses have a pushed up appearance and/or can have an irregular contour. Correction can be achieved by lengthening the nose using cartilage grafts.
Deviated tips, as mentioned above can have many causes and are more difficult to completely correct. While it may be said for all rhinoplasties, it is even more true with deviated rhinoplasties- The first operation is critical. Secondary rhinoplasties are much more difficult because there is always scar tissue to deal with from the first operation. For this reason, it is essential to go to a plastic surgeon with considerable experience in rhinoplasty.
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Woman with deviated nose. Notice that nasal bones, dorsum, and tip are all deviated to her right. Correction by Dr, Cruise required osteotomy, cartilage grafting, and suture technique. |
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| Alae |
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Ideally, the alae should not flare wider than the inner corner of the eye |
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Seen from below, the alae and tip should form an elegant equilateral triangle |
An attractive alae, like the tip, should go unnoticed. When they become too wide or too large they draw negative attention. The most common complaints with the alae are that they are too wide, too bulbous, or the nostrils are too big.
Alae reduction is accomplished by removing a precise amount of the alae at its base.
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Wedge excision of alae base results in incision line that hides in natural crease |
Airway
Airway obstruction is a significant problem and the causes are numerous. Airway obstruction that can be relieved during rhinoplasty fall into two categories.
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| Enlargement of the inferior turbinate is the most common cause of airway obstruction. |
The most common is enlarged turbinates. Turbinates are three mounds of mucosa on the inside on each nares. They are called the superior turbinate, middle turbinate, and the inferior turbinate. They humidify the air as it travels to your lungs and help trap foreign particles. Enlarged turbinates may impede airflow. Correction involves reducing the size of the turbinates by either cauterizing them or excising them.
The other common cause is nasal deviation. A deviated septum will cause turbulent airflow with each breath and make breathing much more difficult. This will often be markedly improved or resolved when the deviated septum is repositioned or removed.
Evaluation of the nose would be incomplete without mentioning the importance of the chin. Einstein was right even when it comes to facial proportions. Everything is relative. A small chin makes the nose appear larger.
A strong chin gives a more authoritative look to men and a more attractive triangular shape to women. Ideally, the chin should project forward to the level of the lower lip in woman and slightly farther in men.
For more information on the chin evaluation see the section chin implant.
Typical Incisions
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Closed Rhinoplasty Incision |
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Open Rhinoplasty Incision |
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| Nostril Reduction Incision |
Anesthesia
Dr. Cruise only uses board certified
anesthesiologists to make sure you have the best anesthesia
possible. The anesthesiologist will discuss with you what
type of anesthesia is best for you. He/she will take into
consideration your medical history, the procedure, and your
personal wishes.
General anesthesia is typically
used. Minor rhinoplasties may be performed under local anesthesia,
with or without sedation.
After
the procedure
The procedure itself will
take approximately 1-3 hours.
Immediately. Right
after the operation you will be watched for 1 or 2 hours and
encouraged to walk around. Dr. Cruise is a strong advocate
of good pain relief so you will be given as much pain medication
as necessary, both immediately after the operation and for
the entire postoperative period. Of course, there will be
swelling and bruising but there is surprisingly little pain. You will have a splint on and/or in your nose.You will also
have a dressing under your nostrils. This dressing will need
to be changed periodically for the first 2-3 days as needed. When you lay down you must keep your head elevated usually
on 3 pillows to prevent swelling.
That
evening. It is recommended that you take it easy. You
can walk around, eat, but not too much more. You must
sit and lay with your head up on at least 3 pillows. You
should take as much pain medication as necessary and try to
go to sleep early. You will be given medication to help keep
the swelling down as well as to prevent infection.
First
48 hours. You can take a body shower the next day. Be sure to use cool water. Let the water rinse over your nose
and splint. Leave the splint in place. There will be some
oozing from your nostrils. This is to be expected. When you
get out of the shower dab dry. Reapply a dressing under your
nose as necessary. The tip of your nose will be markedly swollen
as it swells more than any other part. Be sure to take your
antibiotic and anti-swelling medication.
First
week. Your first postoperative visit with Dr. Cruise will be at 1 week. Sutures may be removed. Leave the
splint on. You will be swollen with some bruising under your
eyes. The majority of the bruising and swelling will go away
in about 2 weeks. Finish the antibiotic prescribed.
Beyond. Swelling
will not completely resolve for about 6 months especially
in the tip. It takes at least 3 months for the swelling to
go down and then another 3 months for the skin on the tip
to contract leaving you with the desired result.
Recovery
time
The swelling and bruising
will resolve in about two weeks. Some people with sedentary
jobs go back to work after 3-5 days. If your job, however,
requires strenuous activity then it may take as long as 3
weeks to return to work. Most people return to work in
about 1 week.
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