The objective of rhinoplasty is to improve nasal shape with or without improving the airway to allow easier nasal breathing. The goals will differ between men and women since men and women possess different aesthetic ideals. A woman’s nose is generally smaller in all dimensions (width, length, projection), more tilted, and more sloped. Conversely, a man’s nose tends to be a be a bit wider, longer, and less tilted. While these are generalizations, it should be recognized that men and women often prefer more gender-neutral noses . Not all women like a traditional 105 degree nasal tilt, and often men ask for more narrow noses. Thus the real goal is understanding one’s expectations and meeting them.
Rhinoplasty is a surgery of sub-millimeters. Complicating this is the unpredictable nature of healing of noses. Approximately 20% of rhinoplasties will benefit from a touch up or revision in the hands of an excellent rhinoplasty surgeon. While 20% may “benefit”, often the trade-off for a secondary procedure such as potential costs, post-surgical swelling, and again relying on perfect healing outweighs the potential improvement of a small imperfection.
Noses that have obvious imperfections should be corrected. The specific imperfection(s) will determine the type of revision (open approach, closed approach, injectable).
To minimize the need for revisions, certain precautions are taken intraoperatively. Certain stitches are placed to secure cartilage, support cartilage (as in the case of a columellar strut) is placed to help prevent the nasal tip from dropping, specific dimensions of cartilage are left behind to withstand the contractile forces of healing, bone is filed, and the list goes on and on. Despite all of these techniques, what one has little control over is internal scar formation and the forces of healing.
One’s first step in reducing the need for revision rhinoplasty is to have your rhinoplasty performed by a board certified plastic surgeon who understands both the aesthetic ideals and the operative maneuvers to internally stabilize the nose as it heals.
More than likely, imperfections may not be visible for several months after surgery. This is because swelling hides imperfections, and, the nose will take on the forces of healing which includes internal scar formation, possible callus formation, and skin contraction. In most cases, due to swelling, revisions will not be offered until at least 6 months up to a year. This is because it is very difficult to dissect through tissue as it is swollen and healing, and, any corrections in swollen tissue are camouflaged in the swelling leaving the surgeon to some “guess work” during surgery.
Usually, but not always. There are generally two types of revisions: Addition rhinoplasty where one has to rebuild and add tissue (usually cartilage), or subtractive (where one has to remove bone or cartilage). A combination of the two, of course, is a third type of revision but in most cases it is a “too much” or “too little” was taken (to meet the expectations of the patient). If addition is required, the surgery is easier if there is adequate cartilage to harvest and the skin is reasonably thick. Thin skin means more visibility of the underlying “reconstruction”. Such visibility often isn’t “visible” until swelling subsides months after surgery. And to complicate this, the cartilage (or bone) reconstruction can change in shape or size as the nose heals. Thus, very thin skin noses are forewarned that there is a risk of more visible imperfections than thick skin noses.
The nature and region of the revision is also something to consider. Often, nostril or tip imperfections are more challenging to correct than dorsums or middle third.
In only the most severe cases of saddle nose or collapse will rib cartilage be required to reconstruct the nose. This is a rare circumstance but one that is correctible.
For primary rhinoplasties (primary meaning “first”) it would be unusual to require ear cartilage harvest unless there has been a prior septoplasty or septum pathology (as is the case of “cocaine noses” where one may see erosion of tissue). The cartilage from the septum is more straight and stronger than ear cartilage. It is preferable for support. Ear cartilage is curved and is more preferable for tips and nostrils, but only if the septum is unavailable or its harvest would complicate other aspects of the surgery.
Cartilage in rhinoplasty is often removed from certain areas and placed in others. The cartilage removed that creates visible deformities (“bump” or “boxy tip”) can be reshaped to add more refinement to the nasal tip or create more pleasing “dorsal aesthetic lines”, the gentle C curve of the nose on front view from forehead to tip.
Often, a rather large piece of the septum is taken and used to support the nose on its base. This is called a columellar strut.
Other grafts one may read about alar batten grafts to support nostrils from collapsing, shield grafts to add shape to the lower part of the tip, and spreader grafts to improve airflow and enhance dorsal aesthetic lines.
Ear cartilage can be harvested to help reshape the nose.
No. The cartilage taken from the ear is conchal cartilage, the curved firm piece on the lower part of the ear just above and behind the lobule. Not all of it is taken, and taking a large amount will not change the shape of the ear or alter hearing. There will be a scar behind the ear but this is almost always not easily visible.
Open and closed rhinoplasty mainly refers to the placement of incisions. A closed approach will place all incision within the nostril. An open approach places some incisions inside the nostrils and one incision along the columella (skin between the nostrils).
Some surgeons feel comfortable with one approach. Others will perform the approach that, in their hands, will give the best result. That is, some surgeons will reserve the closed approaches if only the hump needs to be taken down.
When it comes to the closed approach, there are two surgical methods. One delivers cartilage so that the tip cartilages are visible (and outside the skin), and the other will not deliver tip cartilage leaving a lot of the work less visible for the surgeon.
The open approach affords the best visibility to the surgeon and access to perform specific and precise cartilage resection and stitch placement.
The closed approach will cause less post operative swelling and avoid any visible scars. The open approach will result in a few more months of swelling and leave a scar, albeit just about invisible in most patients.
Because the open approach affords more visibility and access, more difficult noses or noses that will require a lot of tip refinement are probably best suited for this approach. However, with tip delivery, in skilled hands closed approaches are probably equally reliable.
Only with an open approach will one potentially see a scar. In most individuals, even those of dark skin that tend to heal poorly, the scar on the columella is virtually imperceivable even within intimate distance (18” face to face).
If ear cartilage is harvested, one can expect a scar running along the crease behind the ear. This is a scar that blends well and just about goes unnoticed in most people.
Books are written on this very subject. To simplify, there are the:
Nasal bones, upper lateral cartilages, lower lateral cartilages, and septum.
Depending on the deformity, these areas are augmented, reduced, or reshaped. Perhaps the most common complaint is a big “hump”. In this instance, the hump is usually a combination of bone and upper lateral cartilage (ULC). A second common complaint is a “bulbous tip”. The bulbous tip is composed of lower lateral cartilage (LLC). For the patient with a hump and bulbous tip, the operation would go as such:
An open approach is performed. The skin and soft tissue is elevated off the underlying cartilage framework to expose the LLC, ULC and nasal bones. The hump on the bone is filed down. The ULC are trimmed. A deep part of the septal cartilage is taken to be used later. The LLC is trimmed and sutured to alter shape and make the tip pointier. The nasal bones are broken to narrow the upper portion of the nose. A piece of cartilage from the septum that was harvested is positioned internally to support tip. The tip may be rotated and secured with this support cartilage. A piece of the LLC that was trimmed is reshaped and placed on the tip to give it more definition. Incisions are closed.
There are three main reasons why a surgeon will break a nose during rhinoplasty: to correct asymmetry, to narrow a nose, to “close” an “open roof”. One and two are self explanatory. An “open roof deformity” occurs during rhinoplasty as the surgeon files down the nasal bone and removes cartilage along the dorsum. Essentially, the “roof” of these components were removed. To close this defect, the bones are broken and pushed together to narrow the nose and cover the “roof”.
For primary rhinoplasties, expect swelling for up to 6 months or a year or more. Most of this swelling will subside in a few months. However, the tip will remain swollen for much longer. Thus, while the nose won’t look like a big ball for this duration, it simply just won’t look as refined until this stubborn edema subsides. The closed approach may shave a few months off this process. Revision noses may stay swollen longer.
splint will be applied if the nose is broken and be worn for 7 days. If the nose is not broken, tape will be applied for 7 days.
Downtime means different things to different people. There will not be much “pain downtime”. Surprisingly, the nose doesn’t hurt that much after surgery. Most people will complain of the nasal packing which makes breathing through the nose difficult or impossible (if both nostrils are packed). All stitches, splint, packing, and tape is removed by day 7. In some cases, prolonged taping can help control shape and reduce swelling. Thus, patients may elect to tape an additional week or wear tape during the night. They must be taught precisely how to apply tape. Improper taping can cause serious complications such as skin necrosis.
One should not exercise for 3 weeks following nasal surgery. Anything strenuous that raises heart rate or blood pressure can cause a bleeding episode. Glasses should be avoided for 6 weeks to avoid causing depressions on the bridge. Glasses, however, may be taped to the forehead.
Depending on whether certain maneuvers are performed, one will awake with either no packing, one side with nasal packing, or both sides with nasal packing. If extensive septal work is performed, or in certain cases of nasal fracturing, packing may used. Packing is removed anywhere from post operative day 1 to day 5. When packing is in place, it is imperative that one take antibiotics. Failing to do so can lead to a rare, life threatening infection called “toxic shock”. Such rare cases are usually seen if packing is in place for longer than 7 days. Nonetheless, antibiotics should not be ignored.
The septum is the cartilage that runs perpendicular to your face separating both left and right airways. This piece of cartilage ideally is straight, but often not. Curves either on a “C” or “S” can encroach on an airway to reduce airflow upon inspiration or cause the nose to deviate from midline. Deviations occur from genetics or trauma. A septoplasty refers to surgery on the septum to straighten it. This often includes removing portions of cartilage and mobilizing it off the nasal spine to the midline.
It is possible, but unlikely, that rhinoplasty will worsen nasal breathing. When nasal bones are fractured and narrowed, this will unlikely affect airflow but no guarantees can be made. More common, breathing is improved with rhinoplasty since septal cartilage may be harvested or grafts can be placed to support collapse on inspiration. In addition, spreader grafts can be placed between the septum and upper lateral cartilage (ULC) to widen the airway. Turbinates, which sit inside the nose to humidify air, can be reduced quite easily during surgery if enlarged turbinates contribute to airway impedance.
Rhinoplasty should not change one’s voice. However, no guarantees can be made. If one has a very “nasal” voice that is related to airway obstruction of the septum and that airway is completely corrected, theoretically the voice can develop a less nasal quality after an aggressive septoplasty. But even that is unlikely. There is probably a greater risk of voice alteration from a vocal cord injury with intubation (when the breathing tube is placed down the throat) than from the surgery itself. Thankfully, such a complication is exceptionally rare. One should take comfort that many well known vocalists have had rhinoplasty during their career.
The most common errors in rhinoplasty are over resection of cartilage and aggressive bone reduction. The other cause of poor results is simply bad luck. Neither patients or surgeons have a lot of control over healing. This is the most frustrating aspect of rhinoplasty. To reduce the healing variable being the culprit in a poor outcome, surgeons must cut no corners and use proper support techniques and obey many of the rules we are taught with regard to shape preservation. While an on table result may be perfect, often is not the case one year later when swelling subsides and the forces of healing rule. To combat this enemy of beauty, an understanding of nasal anatomy and its dynamics is critical. This starts with solid training and improves with experience. Equally important is an eye for aesthetics.
A bulbous tip is one where the tip of the nose is large and roundish. This deformity, if we may be so cruel to call it that, is caused by the lower lateral cartilages (LLC). With a bulbous (and boxy) tip, the LLC are large. To correct a bulbous or boxy tip, the LLC is trimmed. This is referred to as a cephalic trim because the upper, or cephalic” part of the cartilage is remove leaving about 6 to 8 mm of LLC. The trim alone will only partially correct the bulbous tip. For a full correction, the two LLC are reshaped with stitches and sutured closer together. A cartilage graft may be placed on the tip to add more definition.
A dorsal hump refers to the bump on the nose that is most easily visible on profile. The hump is usually both bone, upper lateral cartilage (ULC), and septum. Thus, the correction of a dorsal hump includes filing of bone and cartilage resection. If such a resection results in an “open roof” (see Why do surgeons break the nose sometimes during rhinoplasty?), then nasal bone fracturing will be required to narrow the nose and close the open roof.
The cost of rhinoplasty will be determined by geography, experience or reputation of surgeon, difficulty of the rhinoplasty, if it’s primary or revision, and if an anesthesiologist will be performing the anesthesia (versus nurse anesthetist). Other factors that will alter the price is if other procedures such as chin augmentation or facial fat grafting are included. The cost for a rhinoplasty by Dr. Neavin starts at $8,500.
Chin projection must always be evaluated when one considers rhinoplasty if the ultimate goal is to improve profile. Weak, underprojected chins will make a nose larger. Chin augmentation can create more aesthetic harmony with the nose and improve the visual effect of the nose.
The nose is framed by the midface, chin, and lips. Evaluation of these three areas are important if the desire is to harmonize the face. You may have seen how even bland paintings pop with ornate frames in museums. Likewise, beautiful cheeks, nose and lips will make a beautiful nose pop. Fat grafting, lip augmentation and chin augmentation are often combined with rhinoplasty in both men and women to accentuate the beauty o the newly reshaped nose.
If one desires a permanent solution to improve nasal shape, there are but two options. One, surgery. Two, permanent stitches. The placement of a permanent stitch can narrow nostrils, but do little more. This stitch, often referred to an Erol stitch named after the surgeon who described it, can narrow the nostril base and prevent the nose form widening with smiling.
The injections of fillers is a second method to improve nasal aesthetics. The most common products for non-surgical rhinoplasty is of the hyaluronic acids such as Resty lane ® or Juvederm ®. These products often last for a year or more in the nose. Areas of augmentation include the dorsum to smooth out or camouflage a hump, the tip to add definition, or the columella to raise the tip. Great caution must be exercised with nasal fillers as there runs a real risk of devascularization of the skin and resulting skin necrosis. Thankfully, this very rare but serious consequence is reversible if it is identified quickly by the use of hyaluronidase. Thus, any nasal injection must be performed only in experienced hands with those who have a very solid understanding of vascularity to the nose, and those who have the experience and know-how to identify an ensuing problem and the ability to promptly treat it before disaster.
It should be noted that injections add volume. They do not narrow the nose. Addition of voume to the nose, however, can paradoxically make it look smaller if humps are camouflaged.
Insurance may cover the correction of an obstructed airway but not any cosmetic surgery. Corrective airway breathing includes septoplasty, inferior turbinate surgery, and possibly spreader grafting. Of these three, the only procedure that effects cosmesis is spreader grafting. Spreader grafts can enlarge the nasal airway and will widen the nose in the middle third. Sometimes, this widening improves nasal shape by improving what is called the dorsal aesthetic lines (the gentle curve on front view from forehead to lower third of the nose). Other times, the widening of the nose is undesirable.
If corrective breathing surgery is performed at the same time of a cosmetic surgery, the operative record will be noted of start and stop times for insurance companies to aid in their reimbursement of only the corrective breathing portions.
Lastly, “covered by insurance” does not mean “will be paid by insurance”. This is a complicated but important difference that will need to be discussed with the office of the surgeon or one’s insurance company since such things a deductables, co-pays, and “allowed amounts” will confuse even the most astute minds.