I want a better shaped nose
Rhinoplasty (nose job) is a popular cosmetic surgery procedure for those who feel that their nose does not suit the rest of their face. A common complaint is of a hump, or that the nose is too long or too wide.

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Nose Surgery

This is a surgical procedure to reshape the nose and is also one of the most popular procedures with men and women. There are 2 different types of procedure.

Most people considering rhinoplasty want to bring the size and shape of their nose into better balance with their face. Many have been teased about their noses since they were children, and are eager to correct what they consider to be an embarrassment, and better compliments their appearance rather than dominating it.

• Closed rhinoplasty - With this procedure the incisions should be placed inside the nostrils, so that there are no external scars, unless the size of the nostrils is also reduced (alar base reduction.) In this situation, there may be small scars in the furrow between the nostril and the lip. If the tip of the nose requires considerable reshaping, a small scar under the midline of the nose may also be necessary.

• Open rhinoplasty - In addition to the incisions inside the nostrils, there is a small incision placed on the columella (the small bridge of skin between the nostrils.) Some surgeons may prefer this approach because it gives them greater control if intricate reshaping of the cartilage in the tip of the nose is required. Some surgeons may use computer simulation in the preparation for surgery. This generally leads to greater accuracy of the planning process.

Your consultation

During your consultation, your surgeon should take a general medical history and ask about any previous surgery or injury to your nose. He should also want to know how well you are able to breathe through your nose.

He should be interested in why you are unhappy with your nose and what results you are hoping to achieve.

• It is very important that you are honest with your surgeon about what kind of nose you would like. People sometimes fail to describe their true expectations, but in reality have a specific size and shape in mind. Only by telling your surgeon exactly what you want can you and he determine whether it is possible and desirable.

• At the same time, you need to be aware that everyone is different and what may work well for one person may not work well for another. As skin thickness varies enormously a small, delicate nose can rarely be made from a large, thickened one.

• Feel free to bring photographs of noses you admire.

• Your surgeon may also use computer simulations to help you see what changes are feasible and what they would look like. These simulations can often help patients describe the results they want and the changes they would like to avoid. You need to be aware that computer simulation is not a guarantee of the result, as each person has their own healing pattern.

Types of rhinoplasty

Reduction Rhinoplasty - This is usually the kind of rhinoplasty most commonly requested by both men and women. It is worth bearing in mind that simply reducing the size of the nose may not always produce a positive outcome.

• It is important to appreciate that if chin projection is insufficient, the profile may seem to be dominated by a small or average nose. In this instance the solution may be to augment the chin and not to reduce the nose at all, or to do a small reduction only.

• In a significant reduction procedure, all elements of the nose are influenced, and the skin will take more time to redrape and settle down fully.

Augmentation rhinoplasty (ethnic rhinoplasty) - This is a procedure that involves increasing the projection of the bridge and the tip of the nose and is more commonly requested by patients from ethnic groups that have a less defined bridge. It may also be necessary for patients that have undergone significant injuries, or multiple procedures.

• Materials used to support the tip and augment the bridge may be artificial, or can be taken from the patient, i.e. cartilage or bone.

• Sometimes implants are used, but these unfortunately carry higher risks from infection and the need for revisional surgery.

Secondary or revision rhinoplasty - Sometimes the outcome is unsatisfactory. This could be due to surgical errors, healing problems, or injuries after the first operation. In other instances this could be due to a lack of communication between yourself and your surgeon.

In all these cases repeat surgery requires an experienced and dedicated surgeon, as well as an understanding of the type of changes that the first operation would have created. Revision rhinoplasty often involves use of grafts, commonly cartilage from inside the nose but also from other areas (rib, ear), and will often require a longer period of time to settle down.

Achieving a good result from rhinoplasty is dependant on thinking through your needs and communication with your surgeon. It is better to have more than one consultation rather than embark on costly surgery without being certain of the outcome.

What to expect from your operation

Rhinoplasty is typically carried out under general anaesthesia.

• The first step is the removal of any hump to provide a new profile.

• It is usually necessary to fracture the nasal bones in a carefully controlled way to allow them to meet at the midline and form a narrow bridge line.

• The cartilage that shapes the tip of the nose is adjusted in size and shape.

• When surgery is complete, small dissolving stitches are placed inside the nostrils and tapes and a plaster cast are applied.

• A small plaster cast is required for seven days to support and protect the bones while they set in their new position.

In some cases it may be necessary to implant tissue into the nose (a graft) to get the desired result. Usually tissue is taken from the nose or from cartilage in the ear, or occasionally the ribs or synthetic materials. As the risk of infection is slightly higher with man made materials, antibiotics should be prescribed.

Frequently, internal silicone rubber splints are used to ensure the lining of the nose sets correctly. This means you will probably need to breathe through your mouth until their removal around 1 week after surgery. This technique is more common in the correction of significant nasal deviation.

In any event, your nose may feel blocked up and be swollen post-operatively, therefore you will probably be unable to breathe through it fully. If the breathing passages have been operated on, it may take some time for the nose to clear.

After surgery

Because your nasal bones will have been re-set, you will probably have “black eyes” after surgery and your face may be swollen. This should settle within 2 weeks. Makeup may be used to hide the bruising when your dressings have been removed.
Any pain you experience can be relieved by your surgeon with an injection. Once you go home, mild pain killers such as paracetamol are fine.

After surgery you should be advised to:-

• Avoid aspirin for the next few weeks whilst healing, as it can promote bleeding.

• Avoid stooping or vigorous activity for 2 or 3 days to reduce the risk of a nosebleed.

• Avoid blowing your nose for 10 days after surgery. Any mucus, clots, or other obstructions may be loosened and removed with a little water, or Vaseline on a cotton bud, but do ensure that this is done very gently.

• Arnica may be taken for 1 week prior to your surgery and for 2 weeks after surgery. This can help reduce the swelling and bruising.

Over the following months

• Once the cast is removed the healing process will take at least 6 months. During this time your nose should settle as scar tissue forms and internal scars gradually change their shape as they mature. Generally, the thicker the nasal skin the longer the period of scar maturation. This process can sometimes be accelerated with small injections of anti-inflammatory steroid in the tip of the nose. All of these factors may have an effect on the final shape.

• If you have chosen an alar-base reduction, your sutures will usually be removed at 1 week. The scars may be a little red, but should be hidden in the natural shadows of the nose.

• The tip of your nose may feel a little numb, but full sensation should return as the nerve supply regenerates.

• You can gauge the progress of the healing process by gently squeezing the tip of a normal nose, then squeezing yours to compare the firmness.

• Very occasionally, a blind boil type of infection may occur in the nose tip. This can be treated with antibiotics.

• Significant bleeding is rare and is usually caused by infection. If this occurs, contact your surgeon.

Do not rush things

It is important to be patient. The final result of your surgery will not be properly visible for at least 6 weeks, and will take more than 6 months to settle completely.

In around 10% of cases, after the 6 months have passed, it is concluded by both the patient and surgeon that the shape of the nose is not quite what was intended. This problem is most common in cases where the patient has had a severe injury or a very large reduction in the size of the nose and a second procedure may be necessary.

Possible complications

Abnormal shape to the nose, problems with airflow through the nose, need for corrective surgery, bleeding (may require a nasal pack to control), nasal septum haematoma/perforation, infection (<1% risk), nerve damage with possible numbness, asymmetry, change in skin colour, skin loss (necrosis), prominent scars, loss of smell, extrusion (of implants), reaction to medications, loss of structural support to the nose, toxic shock syndrome, and internal nasal adhesions/scars.

It is important to realise that very few people who have a rhinoplasty by a reputable consultant plastic surgeon have any complications, and those that do occur usually only suffer minor problems. But all surgery does have some risk and you should reduce your risk of complications by closely following your surgeon's instructions, both before and after your surgery.

Bleeding

There may be some minor bleeding for up to a month after surgery. One should resist the temptation to blow or pick at the nose.

Alteration in skin colour

Following rhinoplasty there may be some small blood vessels under the skin that burst and appear as tiny red spots on the skin's surface. The area affected is usually small and the problem usually resolves spontaneously, but rarely are the changes permanent.

Abnormal shape

There are many factors that may influence the final shape of the nose, it is possible for the surgeon to create a shape you are not happy with, there may be trauma to the nose such as knocking yourself whilst sleeping, the dressings applied may not provide adequate support, as well as a multitude of other factors that are outside of our control.

Wound infection

Infections are rare following rhinoplasty, although the use of any implants increases your risk. Infections may require further surgery but are usually treatable by antibiotics alone. 

Smoking risks

Smoking significantly reduces the ability of your body to deliver oxygen to your tissues and this means that there is a much higher risk of complications. Skin necrosis (skin death) is 1500% more likely in smokers and there are much higher rates of delayed healing and infection as well. You should try to stop smoking at least 4 weeks before and after your rhinoplasty.

Toxic shock syndrome

This is a very rare condition that occurs in only 0.016% of rhinoplasty cases. However if it does occur it is a serious condition that may be fatal. Symptoms include a high temperature, vomiting, diarrhoea, and a widespread sunburn-like rash.

Rhinoplasty scars

Surgical scars are permanent but if you are having a closed procedure all of the scarring will be hidden inside the nose. If however you have an open procedure, you will have small scars on the base of your nose (between the nostrils). These scars fade with time and are usually not noticeable to others. 

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