Overview of Open Rhinoplasty
Rhinoplasty, or a “nose job,” is considered one of the most intricate surgeries to learn and execute. It demands a solid grasp of the structure of the nose and precise surgical techniques. The main goal of this surgery is to enhance the look of the nose and/or its function. Although there are various ways to do this surgery, the “open” technique is often used because it gives the surgeon a better look inside the nose.
This procedure involves careful evaluation of the patient and a detailed plan that takes the natural anatomy of the patient’s nose into account. All these aspects together contribute to the successful outcome of the surgery.
Anatomy and Physiology of Open Rhinoplasty
The following are key terms used to describe different parts of the nose, which will help you understand what your doctor may mention during a discussion about a nose job, or rhinoplasty:
* Ala – The lower side surface of your nostril, formed by the lower side cartilages.
* Alar groove – The dip between the lower part of your nostril, internally (medially), and the ala, or the outer part.
* Anterior septal angle – The angle formed by the two parts of your nasal septum, which divides your nose into two nostrils.
* Columella – The skin between the tip of your nose and the base, in between your nostrils.
* Dome – The front projection of your nose where the internal and lateral (side) parts of your nostril meet.
* Dorsum – The external middle ridge of your nose, between the tip and where your nose connects to your forehead.
* External nasal valve – The opening of your nostril including the rim, columella, and nasal sill.
For a comprehensive understanding of the nose’s structure and how it works, you may need to do additional reading.
When your doctor examines your nose, they’ll look closely at its structure and how it works. This helps them provide a personalized treatment plan that addresses both the look and function of your nose. It’s important to remember that what’s considered the “ideal” nose can vary greatly depending on cultural differences and personal preferences.
The doctor will inspect your nose from the front, side, and bottom. They’ll divide your nose into three parts – the upper, middle, and lower third – and assess each part individually. They’ll look for any issues with symmetry, width (if the bones in your nose are wide), irregularities in the shape (such as a bump on the top), the shape and location of your nose tip, how much it sticks out, how much it rotates, its length, and more.
Your doctor will also check the thickness of your nasal skin – this can affect both the surgery and the recovery process. For instance, thicker skin may need more changes to the structure underneath to achieve a desired look, and it may also be associated with longer post-surgery swelling.
In addition to visual inspection, your doctor will also touch your nose to assess the support it has, the integrity of the septum, and the size and position of the nasal bones. They’ll also inspect inside your nostrils to assess the condition of different structures as problems here may affect the type of surgical techniques needed.
Why do People Need Open Rhinoplasty
Rhinoplasty, also known as a “nose job,” is a type of surgery that’s done to fix any problems with the way the nose works or looks. There are two main ways to do this surgery, through a closed approach (inside the nose) or an open approach (making an extra cut at the base of the nose). While both methods are used, many doctors prefer the open approach. This method allows doctors to see better and more accurately make changes during surgery. Additionally, it helps those learning to perform rhinoplasty, as they can observe the steps in more detail.
When a Person Should Avoid Open Rhinoplasty
There are certain downsides to the traditional, “open” nose job that you should be aware of:
First, there is a chance you may experience increased swelling. Additionally, this type of surgery may take longer than minimally invasive methods. It can also upset the stability of the internal structures of your nose, resulting in changes to its shape. Lastly, this type of surgery leaves a small scar on the outside of your nose. However, 98% of patients don’t mind their scar, and 90% of them think it’s invisible or hardly noticeable. Another good point to know is if you’re worried about having stitches removed, your surgeon can use stitches that dissolve on their own to make the experience less uncomfortable.
But remember, before deciding on getting a nose job, your surgeon needs to know certain things about your medical history. They need to be aware if you have allergies, a constantly runny nose, any previous injuries or surgeries on your nose, respiratory issues like asthma or cystic fibrosis, and any sinus problems. Also, if you’re using illegal drugs like cocaine through your nose, this can make the surgery more complicated and affect your recovery.
Some factors can increase the risk of bleeding after the surgery or developing a painful swelling in the septum (the wall between your nostrils). These include taking certain medications or supplements that thin your blood, like anticoagulants, antiplatelet drugs, and nonsteroidal anti-inflammatory drugs. Certain herbal supplements such as chondroitin, ephedra, echinacea, glucosamine, Ginkgo biloba, goldenseal, milk thistle, ginseng, kava, and garlic can also increase the risk. Having uncontrolled high blood pressure before and during surgery can also lead to these complications.
Lastly, if you have Body Dysmorphic Disorder (BDD)-a mental health disorder where you’re obsessively concerned about small or nonexistent flaws in your appearance-it’s critical to tell this to your surgeon. Patients with BDD tend to be less content after surgery and may have more disputes with their surgeons. BDD is surprisingly common in facial plastic surgery patients: up to 13% of all patients have BDD, and this goes up to 43% amongst those seeking cosmetic nose jobs.
Equipment used for Open Rhinoplasty
Here’s what’s typically done before, during, and after your surgery:
Before the surgery:
+ Local anesthesia is used to numb the area. This is usually a mix of 1% lidocaine with 1 per 100000 epinephrine, with 0.5% bupivacaine with 1 per 200000 epinephrine.
+ Nasal pledgelets, which are small pieces of absorbent material, will be soaked in a nose-clearing drug like oxymetazoline.
+ An antiseptic, such as povidone-iodine paint, is applied to kill bacteria on the skin.
+ A shoulder roll is used to put you in the “sniffing” position, your ideal position for the surgery.
During the surgery:
Your surgeon will use a range of specialized tools, including a headlight, scalpel, fine and heavy scissors, forceps, and various other instruments for specific tasks like crushing cartilage or retracting the nasal skin. Some of these tools, like the osteotomes and elevators, are used to cut and move bone and soft tissue. A speculum is used to widen your nostrils to give the surgeon a better view. Other implements like the Frazier suction are used to clear away fluids, while the caliper is used to measure precise distances. Finally, sutures, or stitches, are used for closing incisions and securing the new shape of your nose. Different surgeons might prefer different types of sutures.
After the surgery:
+ An antibiotic ointment is applied to prevent infection.
+ Adhesive tape, such as paper tape, is used to secure bandages or dressings.
+ A nasal cast, often made from a plastic that softens with heat, is placed to protect and shape your nose as it heals.
+ Septal splints, like custom silicone sheets, are used to support the inside of your nose.
+ A “mustache” dressing of rolled 4×4 gauze is applied under your nose to catch any fluid discharge.
+ Nasal packing, such as rolled non-adherent gauze, is used to control bleeding and support the septum, the inner wall of your nose, as it heals.
Who is needed to perform Open Rhinoplasty?
An anesthesiologist is a special kind of doctor who gives you medicine to help you sleep and not feel pain during the surgery. A surgical scrub technician prepares the operating room and handles surgical instruments to ensure they are sterile (free from germs) for the surgery.
An operating room nurse, also known as a circulator, helps to manage the operation setting. They make sure everybody follows the guidelines and safety rules in the operation room and take care of the needs of the patient and surgical team during the surgery.
A surgical assistant is also very important during an operation. Their job is to help the surgeon by keeping the surgery area clear (retracted), controlling any bleeding that happens during the operation, and cutting the stitches (sutures) that have been used to close the surgical cuts. This helps the surgeon to focus on the critical parts of the surgery.
Preparing for Open Rhinoplasty
Before a nose reshaping surgery, also known as rhinoplasty, certain steps are taken to make sure the patient is in a good enough health for the procedure. This is called ‘medical clearance’ and involves checking and improving one’s overall health condition.
Before the operation, photos are taken from different angles – front view, side view, base (bottom up), and dorsal (top down) view – to record the shape and position of the nose, any unevenness on the face, and how the nose changes when the person smiles. These images can be used in a special software to show the anticipated results of the surgery. This can help in better communicating with the patient about what to expect from surgery.
Where the incisions (cuts) will be made is carefully planned out and marked on the narrowest part of the piece of skin separating the nostrils, known as the ‘columella’. This method is known to reduce noticeable scarring. If changes to the bone structure of the nose are needed, the path for this, known as the ‘osteotomy pathway’, is also marked. Any other specific points on the nose that may need attention during the surgery could also be marked.
The operation is usually done under general anesthesia (where you’re fully asleep), or it can also be performed using specific intravenous drugs like propofol. If general anesthesia is used, muscle relaxants can also be given.
Before the operation starts, patients are given a one-time dose of a special antibiotic that protects against skin infections, a steroid injection to help in reducing swelling, and a dose of a medicine called tranexamic acid to help minimize bleeding during surgery.
Anesthetics are then injected into various parts of the nose to numb the area. Care is taken not to distort the normal appearance of the nose. Special pads soaked in a nasal decongestant are applied inside both nostrils.
Lastly, the small hairs inside the nose, known as vibrissae, are trimmed to improve the process of the surgery and to decrease the formation of crusty matter after the surgery.
How is Open Rhinoplasty performed
An open rhinoplasty, or nose job, is a complex operation and there can be many ways to get the same result. It involves balancing all the subtle changes that are made during the procedure, especially how they affect the shape of the tip of the nose. These days, we try to keep as much of your natural cartilage as possible and make small changes to the bone and cartilage framework.
The process basically involves these steps:
First, the surgeon makes an incision at the base of the nose (around the area with the smallest gap between the cartilage and the skin). They then carefully use special instruments to make more cuts and peel back the skin on the nose to expose the cartilages. Once these are visible, the surgeon separates the cartilages at the middle to prepare for the next steps.
Next, the surgeon may straighten the cartilage that divides your nostrils (septoplasty), if it is crooked. After this, they take care to leave at least a 1.5 cm piece of cartilage to maintain the structural support of the nose.
If there’s a bump in the middle of your nose, the surgeon then reduces this using specific tools. The hump at the level of the rhinion (a point on your nose where the bony part ends and the cartilaginous part begins) should be left slightly higher than the rest of the nasal skeleton. Also, importantly, reducing the bump helps create an optical illusion of rotation at the tip of the nose.
Next, the doctor may reinforce the middle part of your nose with donated cartilage grafts or from cartilage remaining from the hump reduction. The goal is to fix a collapsed internal nasal valve or recreate aesthetic lines.
The overall stability of the nose is then improved before changing the shape of the nose tip. If the nose tip doesn’t need rotation or projection, the surgeon can strengthen it using a columellar strut (a thick piece of cartilage placed in-between the cartilage in the nose). If changes are necessary, this part of your nose can be reshaped using an end-to-end or side-by-side caudal septal extension graft (adding more cartilage to alter its appearance).
Then, the nasal tip is reshaped with different surgical techniques – usually using sutures or softened cartilage grafts. There are maneuvers to adjust the tip, and selected methods depend on the specific condition.
If needed, any dorsal readjustment is done after setting the tip. This can involve adding more cartilage or soft tissue, or further reducing parts of the dorsal cartilage.
Small grafts may be added under the skin along the nostril edges to prevent their retraction. These can also widen the nose’s length and width, improving its function.
If the base of your nose becomes wide due to a reduction in tip projection, the surgeon would reduce the alar base. This involves removing skin between the nostril and the ala (the rounded outer part of the nostrils).
Finally, the surgeon might make precise cuts in the bone (osteotomies) to straighten any deviated nasal bones, narrow the width of the bony part of the nose and sidewalls, and close any ‘open book deformity’, which is caused by a previously excised hump.
These steps allow the surgeon to reshape the nose, correct any functional issues, and maintain the structural integrity for a natural-looking, balanced result.
Possible Complications of Open Rhinoplasty
After having a nose reshaping surgery (rhinoplasty), serious complications are rare, only affecting less than 0.7% of patients. The more common issues that could arise after the surgery include nosebleeds, bruising, swelling, and dissatisfaction due to new or ongoing appearance or function issues.
There are several specific cosmetic problems that can occur:
* Tombstone deformity: This happens if a graft (tissue transfer) used during surgery is too rigid, making it visible under the skin of the nose.
* Rocker deformity: This happens when the cuts made on the bones on the side of the nose go too high up, causing the upper part of the nose bone to be pushed out when the lower bones are pushed in.
* Inverted-V deformity: This can happen if there is a lack of a smooth transition between the cartilage and bone of the nose after a “bump” or hump has been removed, creating a visible triangle-like shadow. Using additional grafts during surgery can help avoid this problem.
* Polly beak deformity: This happens from either removing too much of the bony bridge of the nose, not removing enough of the cartilage, or the lower third of the nose becoming relatively overprojected, creating a fullness in the area above the tip of the nose.
* Ski slope deformity: This happens from a too aggressive removal of a hump on the nose, making the nose overly scooped. Using cold packs and careful evaluation during surgery may prevent this problem.
* Saddle nose deformity: This can happen due to lost support in the middle part of the nose, causing a depressed area, changed nose tip direction, and a shortened nose. This can be avoided by leaving enough support structure during surgery. Fixing this problem can vary from using grafts to rebuild the bridge of the nose to a full nose reconstruction with rib tissue.
* Nasal bossae: This happens when there are unevenness in the framework of the nose cartilage, giving rise to a knob-like outgrowth on the nose.
* Open roof deformity: This occurs from incomplete cuts on the side of the nose bone, leading to a noticeable separation of the nasal bones over the bridge of the nose.
The chances of needing another nose surgery after an initial rhinoplasty is low, at only 3%.
What Else Should I Know About Open Rhinoplasty?
Open rhinoplasty is a surgical procedure used to improve both the appearance and the working order of the nose. When undertaking an open rhinoplasty, it’s crucial to assess the patient thoroughly, formulate a treatment plan based on their unique physical characteristics, and execute the plan effectively. By doing so, the surgery can be safe, dependable, and produce pleasing results for the patient.
