Overview of Rhinoplasty
Rhinoplasty, or what you might know as a “nose job”, is quite popular in the United States. In fact, in 2022, nearly 45,000 of these surgeries were carried out, making it the third most common facial plastic surgery procedure. Rhinoplasty was first described in 1887 by John Roe, and since then, the approaches and techniques have improved considerably. Now, people opt for this surgery for various reasons such as wanting to change the appearance of their nose, improving airflow, adapting their physical appearance for gender affirmation, or rebuilding the nose after cancer or an injury.
In the past, rhinoplasty was mainly used for cosmetic purposes and relied mostly on making the nose smaller. But as we understood more about the nose and its structure, surgeons started to use more balanced techniques, including grafting and stitching.
There have been many pioneers in the field of rhinoplasty throughout history, each contributing their own techniques and perspectives. Among them are doctors like Jacques Joseph, Maurice Cottle, Samuel Fomon, and Jack Sheen. Interesting to note, the techniques these doctors developed are still in use today. For instance, Cottle highlighted the importance of the nasal septum, which is the wall of cartilage that separates the nostrils, in creating the shape of the nose. This led him to coin the phrase, “As the septum goes, so goes the nose.”
Past surgeons also put a high emphasis on teaching the theory and technique of facial surgery in classrooms and textbooks. Jack Sheen, in particular, opened up new possibilities in considering different methods for non-Caucasian or revision rhinoplasty, which is a secondary surgery to correct issues from the initial surgery.
As surgical techniques keep improving, we are also learning more about how changes to the nose can affect other factors. Understandably, our nose plays a big role not only in our appearance but also in our ability to breathe, smell, and even our psychological health. Any unwanted results from the surgery can have a negative impact on the patient’s experience, but well-executed surgery can provide many benefits. The nose’s central position on the face means its shape and symmetry significantly influence our perception of overall facial attractiveness. Given this, surgeons must be very careful when making substantial changes.
Evaluating the success of a rhinoplasty is not straightforward and involves both the patient’s and surgeon’s input. Usually, surgeons will compare before and after photos and evaluate the patient’s satisfaction. They will also take into account their complication and revision rates, which generally stand at 3% and up to 15%, respectively.
To gauge how a patient feels after the surgery, doctors often use certain validated questionnaires that aim to measure changes in postoperative quality of life. The data these tools provide offers essential insight into how patients perceive the success of the surgery. Consequently, carefully choosing the right patients for this procedure significantly paves the way for successful results.
If a second surgery or “revision surgery” is necessary, due to aesthetic or functional reasons, surgeons must consider several factors. This includes the challenge of operating on a previously operated and scarred area, potential limited cartilage for grafting, potential damage to the nose’s blood supply, and how it affects the septum and skin-tissues. Plus, the patient’s psychological well-being is another essential factor. All in all, rhinoplasty is widely recognized as one of the most complex types of facial plastic surgery due to these numerous considerations.
Anatomy and Physiology of Rhinoplasty
Rhinoplasty – the medical term for a nose job – needs the doctor to understand the complex structure of the nose. This is key to making good decisions in surgery because any change to one part of the nose can affect other parts and change how your nose (and even your face) looks. Some changes can lead to unexpected results, which surgeons sometimes refer to as the “Newton third law of rhinoplasty” (for every action, there is an equal and opposite reaction).
Your nose is made up of several parts on the outside. It has a skeleton made of bone and cartilage (a firm yet bendy material), which is covered by muscle, tissue, and skin. The top third of your nose is made up of nasal bones in the middle and parts of other bones called the maxillae on the sides. These bones join with another bone called the ethmoid bone, which forms part of what is known as the bony septum. The middle part of your nose is formed by structures called the upper lateral cartilages, which attach to the nasal bones.
There’s a point on your nose where the nasal bones end and the cartilaginous septum starts—this area forms an important part of how the bridge of your nose will look. Surgeons need to keep or even widen the angle between these parts during surgery to ensure good airflow after surgery. The lower part of your nose is supported by structures known as the lower lateral cartilages and other key support structures that form the framework of the nose.
Various muscles in your nose play a crucial role in keeping your nostrils open, which is important for breathing properly. Other parts of your nose include the septum (the wall in the middle of your nose) and the skin-soft tissue envelope, which varies in thickness based on factors like sex, age, ethnicity, and history of surgery or trauma.
The inside of your nose is made up of several elements covered in mucosa (a layer of cells that secrete mucus). The septum and the turbinates (structures along the wall of your nose) are key structures when it comes to how your nose looks and how you breathe. The septum, a rigid structure covered in mucosa, is central in your nasal cavity, dividing the left and right sides. It provides key support to your nose. Parts of the septum have certain roles in how different areas of your nose look and function. The turbinates are outgrowths along the wall of your nose covered in mucosa, containing a tissue that can expand or shrink.
Why do People Need Rhinoplasty
Rhinoplasty is a surgical procedure on the nose that can be done for either functional problems like breathing difficulties, cosmetic issues like changing the shape of the nose, or often, a combination of both. People who seek this treatment due to nose obstruction or for beauty reasons often don’t realize how fixing one issue can affect the other. That’s why it’s so important for the doctor and patient to have a good understanding and an agreement on the surgery outcome.
Finding the ideal patient for nose surgery can be tough because there’s no certain way to know who may not be happy with the results. Therefore, doctors need to do a complete evaluation, both physical and psychological, to predict whether the operation will be beneficial or not. Doctors try to understand the patient’s goals and see if they can be achieved, as the patient’s satisfaction after the operation is the main goal of the surgery. They do this by asking questions about the patient’s life and circumstances to gather more information about them.
When it comes to the nose itself, it’s crucial to talk about the specific features that the patient doesn’t like and explain what can be improved and how. Some surgeons use computer simulation software to give the patient an idea of what their nose might look like after surgery. However, this tool has its drawbacks because some patients may insist on the simulated outcome and be unhappy with anything less than that, which is why some surgeons choose not to use it.
Figuring out who would benefit from a second or third nose surgery, known as revision surgery, can be more complicated. These patients’ expectations are often shaped by their past experiences, which can either make them more informed or unreasonable, expecting the new surgeon to fix the problems from the previous surgery. Depending on the situation, the techniques used in revision surgery may be different from those used in the first surgery. It could be more aggressive, or it could be minimally invasive, targeting one or two small issues.
The type of approach the surgeon takes can vary. The open approach, where the entire nose is exposed, can be done for both the first and repeat surgeries but can be more challenging the second or third time due to scar tissue and previous changes to the cartilage. The open approach is often used when changes to the tip of the nose are needed because it provides better exposure. However, there’s also the endonasal approach, which modifies the upper part of the nose and also allows for some changes to the lower part of the nose. This approach often results in less swelling after surgery and avoids creating a scar on the nose.
When a Person Should Avoid Rhinoplasty
Several conditions can sometimes prevent doctors from performing a rhinoplasty, or in simpler terms, a nose job.
Mental health conditions such as body dysmorphic disorder or untreated depression can become an obstacle. Body dysmorphic disorder is when a person is extremely worried about a flaw in their appearance that is either very small or doesn’t exist. These patients find social interactions challenging and have low life satisfaction. They often have higher rates of depression and are more likely to commit suicide. If a person has this disorder, surgery might make their symptoms worse, and they may still be unsatisfied with their appearance afterwards. Similarly, people whose depression is not under control might struggle more after the operation. Therefore, it’s essential to stabilize their mood before considering surgery.
Obstructive sleep apnea which causes repeated breathing disruptions during sleep could pose additional risks during and after surgery. If a person has obstructive sleep apnea, they should be aware of these risks. They can take precautionary measures like using a continuous positive airway pressure device to lessen the chances of complications during surgery. After surgery, it’s better for people with this condition to be kept in the hospital overnight for monitoring in case they have low oxygen levels.
People who snort cocaine are more likely to encounter complications since cocaine can cause severe narrowing of the blood vessels and chronic inflammation. Depending on the severity, complications can range from mild redness to large holes in the nasal cavity. Avoiding elective nasal surgery is advisable for people who are currently using cocaine. People who had used cocaine in the past could still be considered for nasal surgery, but it’s important to be cautious as their wounds may heal at a slower pace.
Though tobacco smoking does not affect nose surgery outcomes significantly, quitting smoking before the procedure is highly recommended due to the overall negative effects smoking has on health.
People with conditions that influence blood clotting could also face complications and make surgery more challenging. Patients should inform their doctor about any history of excessive bruising or bleeding, their intake of certain drugs, supplements, vitamins that affect blood clotting, and if they’ve had any blood clot-related problems in the past. If possible, they should stop any substance usage that disrupts blood clotting before surgery.
The patient’s age is also a consideration. Nose surgery is typically performed when the nose’s structure is fully developed, which usually happens at about 15 for girls and 17 for boys.
If a person has previously had a rhinoplasty and is unhappy with the results, they should generally wait at least a year before getting another surgery. This waiting period ensures that the nose’s shape from the first surgery is finalized before any further changes are made.”
Equipment used for Rhinoplasty
Before performing an operation, surgeons require specific tools both on and around the surgical area. Some tools needed on the outskirts of the operating area could include reference photographs taken before surgery, tapes or adhesive films to protect the eyes, and cotton-like pads soaked in decongestants to pack the nose. They also use a local numbing solution to block pain and assorted tools like a nasal widening device and a specialized set of tweezers for precision.
Directly on the surgical area, surgeons use a specific toolset. This involves a skin marker, a variety of sutures (a form of stitches), and various hooks for manipulating skin. They would also use specialized scalpels for making cuts, many different types of scissors, and a variety of prying tools to lift and manipulate tissues. Other tools include devices to shape bones, a tool for crushing cartilage, a device to measure distances, various files to smooth bones, and different kinds of forceps.
Additional tools, such as needle holders, a pair of pliers for removing bone, a suction device, retractors to hold tissue away from the surgical area, and a device for controlling bleeding, are also used. Other necessities include specialized plasters, nose casts, saline solutions for cleaning purposes and creams to prevent infection. A device to reduce the size of the nasal cavities, if necessary, might be employed too.
Who is needed to perform Rhinoplasty?
Rhinoplasty, or a nose job, is usually done by a specialist doctor such as an ear, nose, and throat doctor, a facial plastic surgeon, or a general plastic surgeon. Some oral and facial surgeons who have the specific training can also perform this procedure. Although it’s not absolutely necessary, a surgical assistant can be handy to help with things like retracting, suctioning, and cutting stitches.
A surgical technician or scrub nurse is an essential part of the team. This person’s job is to help manage the surgical instruments and maintain a clean and sterile operating area.
If you’re going to be put to sleep for the procedure (also known as general anesthesia), then an anesthesia provider will also be part of the team. An additional nurse, known as a circulating nurse, will be there to assist and monitor the procedure, making sure everything runs smoothly.
Typically, these kinds of procedures are performed on an outpatient basis, which means you can go home the same day. However, because you might still be feeling the effects of the anesthesia, it’s essential for someone to drive you home after the procedure.
Preparing for Rhinoplasty
Before undergoing a rhinoplasty, which is a type of surgery to reshape the nose, there are several steps that must be taken. This includes discussing the patient’s past medical history, including any previous nose surgeries and mental health concerns such as depression or body image disorders. It’s important to be aware of these factors to develop a suitable treatment plan or potentially delay the surgery. Other conditions like sleep apnea, sinusitis, high blood pressure, and bleeding disorders should also be discussed as they may require additional treatment. The usage of recreational drugs can affect the choice of anesthesia and pain medication, and the use of cocaine may lead to a delay or cancellation of surgery due to its harmful effects on the nose’s blood vessels.
As part of the pre-operation process, pictures of the patient’s face should be taken from different angles. The photographs serve as a reference for the doctor to help in making decisions during the operation and may also be used for legal purposes. Consultation about the surgery largely depends on what the patient wants to achieve and requires a balance between aesthetic and practical expectations. There are potential risks associated with any facial surgery, such as dissatisfaction with the results, pain, bleeding, swelling, infection, scarring, changes in the sense of smell, a need for additional surgery, and possible mental health impacts. In certain cases like a revision surgery or reconstruction after an injury, a patient might also need additional tissue harvested from other parts of their body for the procedure.
The nose is made up of several parts whose appearance can change greatly depending on the individual’s ethnicity. For example, Caucasian individuals usually have slim and highly projected noses, African individuals typically have flat and wide noses, and Asian, Middle Eastern and Latin individuals fall somewhere in between. While examining the nose, it’s important to assess its symmetry, as issues like a deviation from the middle line or a C-shaped curvature can affect the outcome of the surgery. Previous surgical interventions can leave marks and changes in the shape of the nose that should also be considered.
It’s also essential to assess the middle portion of the nose, including the area inside the nostrils. Testing should be done to make sure the patient can breathe comfortably after the surgery. The best results from a rhinoplasty are achieved when the surgeon thoroughly understands the patient’s health history, their expectations, and the unique features of their nose.
How is Rhinoplasty performed
Every surgeon has their own style when it comes to performing a nose job, or rhinoplasty, and the following explains one common method. This approach is often referred to as the “in-to-out and top-to-bottom” workflow. The table contained within the original document provides a quick guide for surgical techniques to correct different kinds of nose shapes that may be encountered during the surgery.
If required, a modification to the nasal passages, or turbinoplasty, and reduction of the septal swell body (a bulging area within the nose) is performed before the main part of the rhinoplasty process. This is to firstly allow time for any bleeding caused by the turbinoplasty to subside during the rest of the operation, and secondly, to apply the force required for the process before any further delicate work is made on the rest of the nose. However, if the nasal septum (the thin wall between your nostrils) is so crooked that it prevents access to one or both of the turbinates, the turbinoplasty may be deferred until after the septoplasty to straighten the septum is complete.
The final structure and look of the septum and the dorsal hump (the hump on the bridge of the nose) is decided in the same stage of the surgery. To avoid a thin and weak structure, some surgeons prefer to make changes to the septum first, then address the dorsal hump. However, during a revision surgery (a repeat surgery), the order of the process may need to be changed, depending on the presence of scar tissue and where grafting materials (the materials used to replace or regenerate tissue) may have been previously placed.
Next, the surgical incisions are made, creating more detailed access for the surgeon. Depending on the goal of the rhinoplasty, the surgeon may choose one of several approaches. The open approach involves making a small cut at the base of the nose, which allows for direct access to the underlying structure of the nose. An alternative endonasal approach involves making a cut inside the nostrils, preserving the external appearance of the nose. In the case of the tip-delivery approach, additional incisions are made for better visualization of the lower lateral cartilages and to allow the domes (the high point of the curve of the nose) to be positioned into the nasal vestibules (the areas within the nose).
Septoplasty might also be performed as part of the operations which is a procedure used to fix a crooked septum, provide relief for nasal blockage, or to remove cartilage for use in the grafting process. Usually, this step is performed early in the nose job to accommodate the steps that follow.
Possible Complications of Rhinoplasty
Rhinoplasty, often referenced as a ‘nose job’, can be a tricky surgical procedure. This is because the nose is made up of not just bones but cartilage, skin and other soft tissues which interact in complex ways. Every individual has variations in their body structure and physiology. These factors often make the surgical outcomes differ for different patients, and may also change over time. Even if the results look great just after the surgery, they might change over months and even years.
When we discuss the complications that can occur after a rhinoplasty, they are categorized as functional, aesthetic, bleeding-related, infection-related, and traumatic. Any deviations from the expected recovery can be problematic. However, the concerns that really impact patients are the functional and aesthetic complications. This is because they cause psychological distress and lead to lawsuits more often. Additionally, patients who have existing mental health problems like depression, anxiety or body dysmorphic disorder have a higher chance of being unhappy with the surgical results and might also experience post-surgery depression. Therefore, such patients require thorough counseling before surgery, and lots of social support while they recover.
Functional complications can occur after rhinoplasty too. Sometimes, patients experience blockage in the nose even though the surgery was done to clear the airway. ‘Reduction rhinoplasty’, which shrinks the size of the nose, can particularly lead to this complication. Several technical factors during surgery can contribute to the nasal blockage. Moreover, repeated interventions to reduce ‘turbinates’ – structures inside your nose that warm and moisten the air you breathe – can improve airflow but may also lead to a sensation of blockage. This is termed ’empty nose syndrome’ and can be very stressful for the patient.
Another possible functional problem after rhinoplasty is the development of a hole in the nasal septum – the cartilage separating both nostrils. This is most commonly due to injury caused while conducting the surgery and can cause multiple symptoms, from a whistling sound to blockage? nosebleeds, or deformities. The severity of symptoms will depend on the size of the perforation and it may require more surgeries to fix it.
Surgery can sometimes impact senses, particularly the sense of smell. This change could be a decreased sense of smell, distorted smell or in some cases, improved sense of smell. Usually, these changes resolve on their own but it might require additional treatment in some persistent cases.
Additionally, aesthetic complications can follow rhinoplasty. This means that patients may not be satisfied because they do not perceive the appearance of the outcome as expected. Dissatisfaction might not necessarily indicate a complication. Genuine aesthetic complications are the result of technical problems during surgery causing deformities or failure to correct issues present before surgery.
The upper one-third of the nose can develop deformities known as ‘open roof’, ‘rocker’ and ‘step off’ following the surgery. These occur due to weak bones on the upper part of the nose. Prominent deformities in the middle part of the nose can include ‘saddle’ deformity which occurs due to removal of excessive cartilage during surgery. It’s important to ensure the necessary amount of cartilage is left intact to avoid this complication.
What Else Should I Know About Rhinoplasty?
Rhinoplasty, commonly known as a “nose job,” is a surgery that can change the shape or improve the function of your nose. When done correctly, it can have many benefits, both physically and psychologically. For example, it can boost one’s social confidence, especially among women, and improve their overall quality of life. Men often report high levels of satisfaction with the results too. It’s been noted in a 2020 study that sense of smell can subtly improve after the operation. In some cases, it can even reduce issues like snoring and obstructive sleep apnea, conditions that interfere with normal sleep.
People suffering from allergic rhinitis, or hay fever, may also experience improved nasal airflow after a nose job, similar to those who don’t have this allergy. In fact, rhinoplasty can be quite helpful if traditional medications don’t relieve the nasal blockage caused by hay fever.
Regarding nasal airflow, certain surgical techniques used during a rhinoplasty have been shown to offer significant improvements. One such technique known as septoplasty with turbinoplasty can reduce the effects of nasal obstruction by a substantial amount. If other procedures are then added, the reduction in nasal obstruction symptoms can be even greater.
However, a successful rhinoplasty and the accompanying benefits can’t be assumed. It needs a skilled surgeon who not only has excellent technical skills but also has the ability to make wise decisions – from the first assessment of the patient through to after-care. The surgeon needs to thoroughly understand a patient’s expectations and help them understand what results are realistic. Also, they should provide excellent patient care during the entire process. In performing the nose job, the surgeon should consider the patient’s overall facial features to achieve the best result.