RhinoplastyCosmetic Surgery of the Nose

By Barry J. Cohen, MD, P.C.
Diplomate, American Board of Plastic Surgery

Cosmetic alteration of the nose can have a profound impact on one’s appearance. The nose is the focal point of the face. A large bump, a broad tip or a wide nasal pyramid can lead to facial imbalances that can draw one’s attention away from more attractive features such as pretty eyes or full lips. One of the most common areas in which cosmetic surgery can play a substantial role in improving one’s appearance is in cosmetic rhinoplasty. Cosmetic rhinoplasty or “nose jobs” have evolved tremendously over the past several years. The days of the retrousse scooped noses have been replaced by more subtle balanced rhinoplasty. In many cases augmentation or adding either cartilage or synthetic materials to raise certain areas of the nose have replaced the traditional complete reduction rhinoplasties.

Ethnic variations in nose anatomy has been increasingly understood. Clearly there are major differences in technique that one uses in treating people of various ethnicities. Indeed, rhinoplasty (nose job) can be used to somewhat alter one’s ethnic characteristics or only improve upon those characteristics within the frame work of one’s ethnic background.

Most nose surgeries are performed through incisions inside the nose. The exceptions to this rule are small incisions, which are sometimes required at the columella or the island of skin separating the nostrils. Very wide based noses will sometimes require external incisions to narrow flaring nostrils. However, the preponderance of nose surgery reduction can be carried out through completely inconspicuous incisions inside the nose.

In general, the nose can be broken down into several major areas, which benefit from correction. The tip is defined as that area just above the nostrils. It is the area of the nose that projects the furthest from the face. In some people, this projection is inadequate and in some people, it is too great. Either of these anatomic variations can be corrected through surgery. A broad or boxy tip can be refined and an inadequate tip can be augmented.

The middle third of the nose is often characterized by a substantial bump. This bump is usually of cartilage origin. This is simply reduced by removing extra cartilage through incisions made inside the nose.

The upper portion of the nose is made up of the nasal bones. Nasal bones will often times contribute to a large nose. This can be reduced by rasping or other methods.

Finally, the width of the nose can be addressed by small incisions inside the nose, which can allow for the movement of the nasal bones closer together. In certain ethnic groups, augmentation of the nose is desirable. It is now possible to augment the nose either with one’s own tissues or with completely safe, inert, synthetic materials. This allows us to either raise the profile or improve the nasal tip. Altering the angle with which the nose meets the face can be modified through similar techniques.

A commonly asked question with regard to nose surgery is how will this impact upon my breathing? Well, in fact, functional and cosmetic nasal surgery are often combined techniques. Many people suffer from chronic obstructed nasal breathing. This is usually due to either a deviated septum or enlargement of bones on the sides of the nose referred to as turbinates. Both of these items are easily correctable during surgery. This can be done with or without alterations of the external nose. These aspects of rhinoplasty are often covered by most insurance carriers.

Recovery from nasal surgery is remarkably swift. The average patient, having a complete rhinoplasty, will have a splint on the outside of his nose for five to seven days. Most people are somewhat bruised from the surgery, but this bruising disappears within 10 to 14 days. Cover up make up can be used to diminish the apparent bruising after the first several days. Functional nasal surgery will often require that internal splints be placed inside the nostrils. These cannot be seen and are removed at approximately two to three weeks after the operation.

The amount of pain associated with nasal surgery is remarkably small. Most patients require very little pain medication after the operation. What is most important after nasal surgery is to not do any heavy lifting, bending or straining to avoid bleeding. Breathing is sometimes impaired in the immediate post operative period, especially when functional nasal surgery is done. This improves as the swelling goes down over the ensuing few weeks. An important point to understand about nasal surgery is that the final outcome of the operation is not seen for six months to one year. The reason for this is that swelling persists for a very long time in the area of the nose. The last area in which the effects of nasal surgery can be seen is at the tip. It is in this area that swelling persists the longest. Revision nasal surgery is required in 5 to 10% of all patients undergoing surgery of the nose. The reason for this is typically related to shifting and twisting of cartilages in the post operative period and scar tissue formation at the area of the operation. Unfortunately, the need for revision cannot be predicted based upon the pre-operative examination. The reasons why people require revision are manifold. Operative error is typically low on the list of reasons why subsequent surgery is necessary. Twisting of cartilage, which was left straight, is quite common. Shifting of the nasal bones, which were once straight, is also not uncommon. There is a significant interplay among numerous structures in the nose, which undergo alteration during the surgery. It is because of the continued shifts and stresses that one sees in the post operative period that the revision rate is apparently so high. The good news is that in most cases, revisions are quite minor.

The surgery is done as an outpatient. It can be done either under general anesthesia or with intravenous sedation. The results of rhinoplasty can be dramatic. The timing of rhinoplasty is dependent upon patient desire. Typically one does not undertake nose surgery prior to complete maturation of the facial skeleton. In girls, one usually would not proceed with rhinoplasty before the age of 12 to 13, and in males, one would typically not proceed with rhinoplasty until the age of 15 to 16. The upper age range is driven by patient desire. Indeed, the nose continues to grow as we get older and age related changes of the nose can also be seen, such as a drooping tip. A drooping nasal tip is frequently repaired along with other facial rejuvenation procedures. Nasal surgery is often times combined with correction of other areas of facial imbalance, such as a weak or overly projected chin. These ancillary procedures should be recommended by a plastic surgeon when evaluating the face as a whole.

Nasal surgery is a wonderful operation, which can change the self esteem and appearance of many individuals.