Who Is Suitable?
If you have an understandable, but not excessive concern about visible features of your
nose, you will probably benefit from rhinoplasty. It is important for Your surgeon to relate
your undesirable feature to some underlying anatomy that can be surgically altered to achieve the desired result. Because of the limitations of surgery, you must accept that we are aiming for an improvement rather than perfection in the way you look. You should be physically healthy, psychologically stable and realistic in your expectations.
Many surgeons prefer not to operate on teenagers until their growth spurt is complete -
around 14 or 15 for girls and a little later for boys. It is important to consider a teenager's
social and emotional adjustment, and to make sure it is what they themselves, and not their parents, really want.
Preoperative Evaluation
During your first visit, your expectations and concerns will be sought and documented. Your surgeon will analyse what you don't like about the shape of your nose and what alterations
appear to be desirable.
The inside of your nose will be examined and any obstructions to your airway noted. In some cases it may be necessary to get the opinion of an Ear, Nose and Throat Surgeon about any potential or existing problems inside your nose. If there are significant problems with nasal function, your surgeon may recommend a combined operation, with an E.N.T. surgeon attending to the internal problems whilst your surgeon reshapes the external features of your nose.
Your general health and medical history will be noted.
Photographs will be taken and at a second visit, Your surgeon will discuss these with you.
He will explain what is the best shaped nose for your face and sketch this. In our practice,
we use computer-assisted imaging to help predict a new shape for your nose. You must
accept that computer imaging provides a basis for discussion and is not a guarantee of the surgical result. However the goal for the final shape of your nose is the combined decision of yourself and your surgeon.
When you and your surgeon are happy with a shape that is surgically feasible, plans for surgery can be made.
Shape can be adjusted using computer imaging. This exercise is only a guide to your new
nasal shape and is not a guarantee of a result. It does, however, provide vital assistance in arriving at a goal of surgery .
Nasal shape can be adjusted by narrowing the nasal bones and adjusting the cartilages of the nasal tip.
The Operation
The operation is performed either entirely through small incisions placed just inside the
nostril (the so-called “closed” rhinoplasty) or by adding an incision across the vertical strip
of skin between the nostrils (columella) to get a better view of the underlying structures.
This is the “open technique”. Each approach has its benefits and indications. Your surgeon will explain these to you when advising which approach is more suitable for your particular problem. There are several steps to the operation.
This incision across the columella can aid in obtaining a better view of the nasal structures
to be changed - this is called an ‘open technique'.
The nasal bridgeline is lowered. This may involve bone or cartilage or both structures.
Upper lateral cartilages and septum are ‘shaved' to reduce the height of the bridge and
modify the profile.
Rounded appearance of tip can be reduced by resection of portion of the alar cartilage.
Length of nose can be reduced by resecting a portion of the end of the septum and correction of the upper lateral cartilage.
‘Correction' of tip of nose.
Septum.
Septum may have to be trimmed to tilt and aid in shortening of the nose. If the septum is twisted, this will need to be straightened by a procedure known as SMR.
Narrowed nose and approximate position of suture lines usually leads to imperceptible scar.
Removal of wedge by excision of skin to narrow nostrils.
Alar base resection
Narrowing the bridge of the nose by cutting
the nasal bone free from the cheek and gently
pushing the bones together (so called “Infracture”).
When the operation is complete, a small splint is applied to help maintain the new shape
and a small pad is taped under the nostrils to collect any secretions. This external splint is
kept in place for up to fourteen days. A tubular silicone splint is also inserted in each nostril
to maintain the internal shape and assist breathing. This internal splint is maintained for up
to seven days.
The splint is applied for approximately 7-14 days after the operation.
Paper tape.
Nasal splint.
New Nasal Shape
The shape of the modified underlying skeleton of the nose determines the shape of the skin which shrinks to adhere to the altered nasal structure.
The overall appearance can be assessed after correction of all the above bony and cartilage
parts of the nose.
Occasionally, grafts of cartilage from the septum, the ear or even the ribs
may be used to overcome irregularities or highlight the bridge line or nasal tip.
Post Operative Course
A fter the operation, you will wake up with a splint on the outside of your nose which you
must wear for 7-14 days. This splint is made of an adhesive-backed plastic which melts in
hot water. When applied to your nose and held in place whilst it cools, it adapts to the shape
of your nose and is held there by its adhesive backing. There will also be a splint inside your nose . This is a tubular splint of silastic, a smooth soft rubber. Because of its construction, it is comfortable to retain, and being tubular-allows you to breathe for the five to seven days it sits inside your
nose. If the tube becomes blocked with blood or mucus, you will not be able to breathe. Therefore, your surgeon will insert a small pack into the tube at the end of the operation.
When you are fully awake and able to sniff in to keep the tube clear, the nurse will remove
the pack and leave you with a clean open tube. You should cover each nostril in turn and
inhale once an hour to maintain an open tube. If the tube does block, it can be cleaned by gently passing a
pipe cleaner or similar implement along the tube as demonstrated by our staff. By keeping
the tubes clear, your early post-operative experience will be ever so much more pleasant.
Black Eyes About half the patients wake up with bruising around the eyes. This is an
expectant by-product of nicking a small blood vessel (of which there are many) at the time
of infracture. Black eyes do not indicate that you have a bleeding problem or that your
surgeon had to use excessive force to perform the operation. The surprising feature is that
only half the patients develop black eyes. But, as we cannot predict which half, we promise black eyes
to all our patients so that no-one will be disappointed after the operation.
Rhinoplasty is rarely a painful procedure, but you may have a dull headache and discomfort
in your nose. You will probably need only Panadol or Digesic for a day or two. Antibiotics
sometimes are given intravenously during the operation and may be continued orally for a
few days afterwards if your surgeon feels there is some potentially infective problem to be concerned about.
If the nasal bones have been moved, there will be bruising and swelling around the eyes and cheeks for a week or two. Cold compresses will help reduce this swelling. You will feel a lot
better than you will look. It is best to stay in bed for the first day with your head elevated.
There may be a little bleeding from the nostrils for the first few days following surgery. Do
not blow your nose for a week or so while the tissues are healing. Your internal nasal splint
will be removed after 5-7 days. The external splint and any stitches are usually removed at
7-14 days. Your surgeon's staff will instruct you in the proper use of camouflage make-up.
You will be up and about in a day or so. Most rhinoplasty patients return to school or work
in a week or two depending on their activities and job.
Please avoid strenuous activity (jogging, swimming, bending, sexual relations) or any
activity that increases your blood pressure, for three weeks. Avoid excess alcohol for three weeks. Keep out of the hot sun and try not to bump your nose for eight weeks. Please do
not sleep on your face during this time. Tape your glasses up off your nose and onto your forehead for one month.
Massage of the nose can hasten the resolution of the swelling.
You will be shown where to massage, if this is desirable, after the splint is removed.
You will be seen post operatively as often as necessary until all swelling subsides. Although most of the swelling is gone by two weeks and the general result is apparent at that time, it may take up to six months for complete resolution to occur. This is the normal healing
process and will not be noticeable to your friends and relations. You will not be fully able to assess the final result until then.
Do not be surprised if you feel a bit down after the operation and get some negative
reactions from family and friends. They may say they do not see much change in your
nose or they may be resentful that you have changed a family or ethnic trait. This is all quite natural and should not be a cause of concern to you. Try to keep in mind why you had the surgery in the first place. If your goals have been met, the surgery is a success.
Possible Complications
Complications are quite uncommon in rhinoplasty surgery, but unexpected events can
follow any operation. Your surgeon feels that you should be aware of things that may take place so that your decision to proceed with this operation is taken with all relevant
information available to you.
(i) Bleeding
There is always some bleeding immediately after surgery. This is expected and will stop in
some hours. It is the result of making incisions in the skin to perform the operation.
In some cases, unexpected bleeding may occur in the first 48 hours or from the 10th to
14th day. The early bleeding is called “reactionary”, and occurs when the drugs your
surgeon uses to constrict the blood vessels of the nose wear off. The late bleeding (so-called
“secondary”) is the result of a clot inside the nose becoming infected and causing an
underlying blood vessel to bleed once more. This bleeding can be controlled by packing
the nose. Sometimes, readmission to hospital may be necessary. Avoid Asprin and aspirin-containing products during this time. Also any activity which raises the blood pressure (see previous note) should be discouraged.
(ii) Infection
This occurs in less than one percent of cases and can be treated with antibiotics. You may
notice unusual redness and swelling. Again notify your surgeon if you feel any concerns in
this regard.
(iii) Eye Injury
This is avoided by careful protection of the eye during surgery. The nasal bone fractures are
sited well away from the eyes' drainage system and damage to the tear drainage apparatus
is rare.
(iv) Intracranial Complications
Infection in the cranial cavity (e.g. meningitis) is a recognised complication of nasal injuries.
It results from a communication between the nose and the coverings of the brain. As rhinoplasty is a form of controlled nasal injury, meningitis must be recognised as a potential problem. It is, however, very rare. Any severe headache, stiffness of the neck or intolerance
to bright light must be reported to your surgeon as a matter of urgency.
(v) Skin Problems
Usually these are minor and transient. Most common are pustules with or without allergic dermatitis to the tape that is applied to the nose beneath the splint. If the tape is too tight it
may cause skin excoriation. In cases of excessive pain, the tape and plaster are always
removed and the skin checked for pressure problems or infections.
Late Complications
1. Burst vessels in the skin. These occur in a few people and can be treated with a
suitable laser. Avoiding alcohol and spicy food will make them less obvious and you
will be instructed in the most effective use of camouflage make-up.
2. Scars on the columella or at the nostril bases are rarely visible, but can occur. They are
almost always imperceptible after one month.
3. Bony Irregularities . These are more often felt than seen and are an inevitable result of reshaping the bone of the nose. If visible, they can usually be ‘rasped' down in a minor procedure. Only visible irregularities warrant any treatment. Palapable irregularities are
usually disregarded as being of no consequence.
More obvious deformities may be corrected with cartilage or bone grafts. Although every
effort is made to achieve a favourable result in one operation, some rhinoplasties may be improved by a fine adjustment. However, time must be allowed to pass before this can be adequately assessed. We usually await until all swelling has settled and the nose has fully recovered from the first operation - usually after one year.
This will involve you in further hospital and anaesthetic costs if it is needed. It is not
reasonable to regard the need for adjustment surgery as an indication of a poorly
performed original operation.
4. Nasal Obstruction . There is usually a temporary reduction in the nasal airway due to
post-operative swelling of the nasal lining. This subsides in some weeks to months.
Allergic conditions, enlargement of a turbinate or a crooked septum may only begin to cause symptoms after a rhinoplasty and then require treatment. If there is an indication of such a problem before your operation, your surgeon will order special investigations and may refer
you to an E.N.T. surgeon for assessment. A joint procedure with both surgeons operating on you at the same time may then be recommended. However, these problems may not lead to symptoms before your rhinoplasty. If they become manifest after surgery, they may then be
dealt with in an appropriate manner.
5. A retracted or hanging columella may need adjustment. This is a simple procedure which
will usually be performed in the Day Surgery Centre at your surgeon's rooms.
6. Decreased sense of smell is a theoretical possibility. You need to be aware of this as a potential source of irritation.
7. Dark circles under the eyes can occasionally persist for many months. This is usually
more common in olive-skinned people and is the result of the retention of the pigments of
the blood in the skin around the eyes when the bruise resolves. Although this can be
irritating to you cosmetically, there are creams which your surgeon can prescribe which
can help bleach the skin. You may benefit from the use of camouflage makeup whilst this darkness improves as it always will over time.
CALL YOUR SURGEON IF YOU EXPERIENCE THE FOLLOWING:
Excessive pain or bleeding
Abnormal swelling
Fever during the first 24 hours after discharge
Concerns about your post-operative recovery
Severe headache or light intolerance
How Much Will The Procedure Cost?
T he costs of this surgery relate to:
a) surgeon and assistant surgeon
b) anaesthetist
c) hospital
d) ancillary charge (pharmacy, etc)
Your surgeon can tell you his fee and give you some indication of the costs of the other
people involved in your care.
You must appreciate that the ultimate cost to you will depend on where you choose to go
for your procedure and what rebates you will receive from your medical fund and Medicare. This in turn depends on who you may be insured with and what level of insurance you
have chosen. Please advise your surgeon if your insurance has a front end deductible cost
or "excess". With all the relevant information doctor's office should be able to give you a
very close approximation of what your final costs might be.
Private insurance including Medicare may pay the cost of that part of the operation
designed to improve the airway, but not the cosmetic part. If so, they would also contribute
to the anaesthetic and hospital costs.
It is always preferable to arrange all your finance prior to surgery to avoid unnecessary
stress afterwards which will detract from your enjoyment of having achieved your goal
of a more desirable nose.