People usually care so much about how they look. They are always seeking a better appearance, face, and body. Cosmetic surgery has made it so easy for people to change any feature in their body they don’t like, especially in the face. 

People freak when they find any abnormality in their faces, any scar, discoloration, fine wrinkles, or blemishes. They immediately visit their dermatologist or plastic surgeon to get rid of the unpleasant appearance. 

People would also go to the dentist, endure braces and pleaching pains to have what’s called the “Hollywood smile”. Besides, surprisingly, you can now change certain parts in your body in terms of size, you can either reduce or enlarge some part of the body, for example, breast augmentation and breast reduction surgeries. 

Today, we are going to discuss one of the most required changes in appearance, specifically in the face. Today, we are discussing rhinoplasty, or also known as a nose job.  

Anatomy and Physiology

A thorough understanding of nasal anatomy is the foundation of a successful rhinoplasty. A little alteration in one nasal component can have a significant influence on the remainder of the nasal structures, resulting in a dramatic shift in face shape.

Let’s start with the external nose, the visible component that projects from the face allowing the entrance of air into the nasal cavity. It is thought that the external nose has a pyramid shape with nasal root located superiorly and is continuous with the forehead. While the nasal tip ends inferiorly. Just immediately inferior to the apex are the nares are opened. They are pyriform openings that lead inside the vestibule of the nose, in other words, to the inside of the nose. These nares are connected medially by the nasal septum and laterally bounded by lateral cartilaginous wings of the nose called ala nasi. 

The external nose consists of a bony and cartilaginous framework, covered by muscles, soft tissue, and skin.

The skeleton of the external nose is made up of both bone and cartilaginous components. 

• The bony component. It represents the superior part of the nose and is made of the nasal, frontal and maxillary bones. 
• The cartilaginous component. It is the inferior part and consists of two lateral cartilages, two alar cartilages, and septal cartilage.

The skin that covers the bony part is thin, while the skin that covers the cartilages is thicker with many sebaceous glands. Then the skin extends through the nares by a muscous into the vestibule of the nose where there are hairs that filter the air before entering the respiratory tract. 

As for the paranasal sinuses, they are four air-filled extensions of the nasal cavity. They are named according to the bone they are located at. They are the maxillary, sphenoid, ethmoid, and frontal sinuses. 

The external nose consists of a bony and cartilaginous framework, covered by muscles, soft tissue, and skin.

• Lightening the weight of the head. 
• Supporting the immune defense of the nose. 
• Increasing resonance of the voice. 
• Humidifying inspired air. 

The nose is both a smelling and respiratory organ. And its nasal cavity has four main functions: 

• Warming and humidifying inspired air. 
• Removing and trapping foreign bodies and pathogens. 
• The sensation of smell. 
• Draining and cleaning the paranasal sinuses and lacrimal ducts. 

Now as we explained everything about the structure of the nose, back to rhinoplasty.

Rhinoplasty

Indications 

Rhinoplasty can be done for functional, cosmetic, or both reasons. It is crucial to note that patients who are originally seeking functional improvement only frequently express concerns about the aesthetics of the nose during the interview, and postoperatively, they place greater emphasis on the aesthetic outcomes than on their capacity to breathe properly. This is one of the reasons why doing a comprehensive conversation with the rhinoplasty patient is crucial.

Despite the fact that much has been written on the difficulties of selecting the optimal candidate for surgery, there is no established method of properly diagnosing high-risk individuals who will most likely be dissatisfied regardless of the outcome. As a result, the surgeon must assess other non-visible features of the patients and rely on instinct to judge whether or not the operation would be useful.

Interrogation is essential at the initial consultation to determine whether the patient's expectations are realistic, as patient satisfaction postoperatively is a factor of the surgery's success. By asking open-ended questions regarding the patient's life and background (family composition, community relationships, etc.), the physician can listen and interpret nonverbal features that might be valuable in forming an overall picture of the individual.

SIMON (single, immature, male, over-expectant, narcissistic) is a widely used acronym to characterize patients who should be deemed unsuitable for surgery, whereas SYLVIA (secure, young, listens, verbal, intelligent, attractive) has been used to describe the ideal candidate.

Following a general examination, it is critical to address the specific aspects of their nose that they dislike (dorsal hump, nasal deviation, tip problems, etc.) and explain step by step what can and cannot be corrected. This may be accomplished through the use of computer simulation. This is a useful technique for identifying patients with unreasonable expectations by using real-life photographs of the individual and simulating an approximate surgical outcome.

Anterior rhinoscopy is used in the functional analysis to look for frequent reasons of blockage such as turbinate hypertrophy and septal deviations. A nasal endoscopy may be useful in individuals with airway blockage without a visible reason to detect alternative sources of obstruction, such as polyps.

Breathing difficulties in the past, a history of sinusitis, obstructive sleep apnea, previous hospitalizations, pharmaceutical or cocaine use, and a history of mental illness should all be documented.

As with any surgical treatment, informed consent must be discussed seriously with the patient so that he or she completely knows every stage of the process, including its risks and benefits, alternatives, and possible results.

This operation is often performed when nasal components have fully matured and nasal shape will not alter significantly in the future. This corresponds to roughly 15 years of age for girls and 17 years of age for males.

For example, there is a well-known nose defect called “Deviated nasal septum”. The cartilage of the nose that separates the nostrils typically sits in the center and divides the nasal cavity evenly. However, some people have uneven septum, which makes one nostril larger than the other does. It is a very common problem that according to The American Academy of Otolaryngology-Head and Neck Surgery, 80% of all septums are deviated to some degree. 

This condition can cause severe symptoms such as: 

• Nosebleeds, 
• Sinus infection. 
• Difficulty breathing. 
• Snoring or loud breathing during sleep. 
• Blocked nostril. 
• Nasal congestion or pressure. 

The challenge of producing "the same nose in every patient" is exacerbated by anatomical differences in inner structures and varying thicknesses of soft tissue envelopes. Furthermore, there is no such thing as a "perfect nose," because a nasal shape that suits one patient's face may not fit another's.

Rhinoplasty is more than just a cosmetic treatment. The procedure also seeks to preserve or improve nasal function if the patient has decreased airflow owing to an obstructive condition. This adds to the operation's difficulty since interior nasal structures must be changed to remedy functional problems.

All of these variables work together to explain why rhinoplasty is such a pleasant procedure with such positive outcomes.

Correct surgical patient selection, as well as thorough preoperative analysis and planning, are essential stages in improving rhinoplasty outcomes and avoiding subsequent operations.

Intracranial injury is an uncommon condition that can result in a cerebrospinal fluid leak, causing rhinorrhea and migraines. This issue necessitates hospitalization and a neurosurgery assessment.

• Rhinitis: 

This is frequently a transient problem, especially once a blocked airway has been cleared. It might cause nasal discharge, dryness, and breathing problems. Topical treatments are often used to treat it. A CSF fluid leak might be considered if rhinorrhea persists after a few weeks.

• Injury to the Lacrimal Ducts: 

This can result in epiphora, which can be accompanied by bleeding. It is sometimes induced by lateral osteotomies and requires duct intubation to be treated. It is crucial to understand that epiphora may occur in the first few weeks following the surgery as a result of edema compressing the lacrimal ducts, which usually resolves spontaneously.

The appropriate age for a Rhinoplasty

Usually, if you are considering the surgery for aesthetic reasons, your surgeon will tell you to wait until your nasal bones are fully grown before considering a nose job. For girls, this is at the age of 15. Boys can be growing until they are older. However, if you are considering the surgery for breathing difficulty, the surgery can be performed at a younger age. 

Rhinoplasty procedure

• If all is well and you have decided to do this procedure already, you need to know how to prepare yourself. 
• Typically, your doctor will tell you all the instructions before and after the procedure. Before the procedure, you will discuss with your doctor if the rhinoplasty will work well for you or not.  Your doctor will investigate and ask you many questions.
• He or she will start with your medical history. This is a very important discussion because your doctor can know your motivation for undergoing this surgery and your goals. Your surgeon will also ask you about any previous nose conditions in your medical history such as nasal obstructions, surgeries, or any medications. 
• He or she will also ask you if you have any bleeding disorder such as hemophilia because if you do, you might not be a good candidate for rhinoplasty. 
• After that, your surgeon will conduct a complete physical examination including examining your facial features and the inside and the outside of your nose. He or she will ask for some laboratory tests such as blood tests as well. 
• This physical examination is very critical and can significantly affect the results of your surgery if done right. It is important to examine  your skin thickness, and the strength of the cartilage because it helps your surgeon to determine what changes need to be done. It will also study the impact of the surgery on breathing.
• Here comes the most famous step, the one that appears to you whenever you are googling the word rhinoplasty, the photography. 
• The surgeon will send someone to take some photographs of your nose from different angles. It makes it easy for your doctor to show you what the results will look like. Using some computer software, the surgeons can manipulate these photos to show you how your nose might look after the surgery. These photos are also important for the before-and-after assessment and reference during the surgery. The specialist might also use these photographs to show his work and get some good reviews after taking your consent, of course. 
• In the end, the surgeon will ask you about your expectations. Based on it, he will tell you what he or she can or can’t do. It might seem a bit uncomfortable for you to talk about something that is making you self-conscious. But, for your own good, you have to be open and honest with your surgeon and tell him or her all your concerns and goals. 
• If a patient has a small chin and is planning for rhinoplasty. The surgeon might advise the patient to have a chin augmentation surgery because a small chin might give the illusion of a larger nose. 
• When everything is set, and you have decided the date of your surgery, your surgeon will advise you to arrange for someone to drive you home after your surgery. 
• If you want to know more information about the different techniques of rhinoplasty, the care after having rhinoplasty, and how the procedure is done in detail, stay with us, we have a surprise for you. 

Contraindications

Patients with an unstable mental state at the time of consultation or surgery, patients with BDD or unrealistic expectations, obstructive sleep apnea, active cocaine users, and patients with comorbidities that contraindicate surgical treatments are all common contraindications for rhinoplasty.

• Body Dysmorphic Disorder (BDD): 

Excessive concern with a perceived or barely perceptible flaw in appearance characterizes this mental illness. Patients have greater difficulty socializing, have a lower quality of life, are more prone to depression, and have a higher risk of suicide ideation as a result of these factors.

Because symptoms may develop postoperatively if not recognized, and the patient will be dissatisfied with the results, it is critical for surgeons to notice this sort of patient early. There is currently no validated questionnaire available to properly diagnose these individuals. Referral for mental assessment is required if clinical suspicion emerges.

• Obstructive Sleep Apnea: 

Repeated bouts of airway blockage during sleep define this illness with a high incidence. Perioperative problems are more likely in patients with this disease. The patient's symptoms might lead to a diagnosis, although it can also be asymptomatic. Although screening questionnaires can be employed, their accuracy is restricted.

Polysomnography is the gold standard for diagnosis. Patients with this condition should be informed of the dangers, and preoperative treatments such as the use of a continuous positive airway pressure device (CPAP) might be used to minimize complication rates.

• Cocaine Abuse:

Patients who misuse cocaine are a distinct category of people. Because of the many contaminating ingredients, inhaled cocaine causes severe vasoconstriction and persistent mucosal inflammation.

Mild inflammation to serious septal holes can be discovered during a rhinoscopy. These individuals are also more prone to experience postoperative problems such as septal collapse or delayed septal mucosa healing, and they should avoid nose surgery.

• Tobacco Smoking: 

Although it appears that cigarette smoking has no influence on the success of septoplasty, patients should be advised to quit smoking before the surgery because of the numerous negative consequences.

• Bleeding Disorders:

Blood clotting problems might arise following surgery. Patients should be asked if they have a history of significant bruising or bleeding, whether they take anticoagulant drugs, supplements, or vitamins, and if they have had past thrombotic events. Any drug, vitamin, or supplement that affects coagulation may need to be discontinued prior to surgery.

Generally, patients that had a previous rhinoplasty and are unhappy with the results should wait at least one year before any evaluation on the definite result or secondary procedure can be performed.

Rhinoplasty cost

According to 2020 data, the average cost of rhinoplasty is $5,483. This average cost is only a portion of the whole cost; it does not cover anesthesia, operating room facilities, or other associated costs.

Rhinoplasty questions to ask

To ensure that you get a comprehensive picture and understand everything regarding rhinoplasty, we invited Dr. Jeon who is a renowned cosmetics surgeon from Seoul, Korea and Dr. Kyung Tae Kang who is the head of cosmetics surgery at Lahyeon Plastic Surgery to address any questions you may have from an experienced point of view.

Lets start with Dr. Jeon:

1. What is the main rhinoplasty in Korea?

In Korea, since most of our patients tend to be Asian, the most common surgery for rhinoplasty is to correct small or short nose tips. So, we perform many augmentation rhinoplasty in order to expand or increase the nose. We also correct noses with bumps or humps around the nose bridge.

2. What is the difference between all of this?

For augmentation surgery, we use inserts of various kinds to achieve the desired height or length. For nose bumps, we can shave off the nose structure or insert implants to level the nose to be straight. We also correct crooked noses to be straight.

3. Are there any changes between previous and second rhinoplasty techniques?

Basically, since the shape of the ideal nose is generally understood to be set, if we were to compare the two surgery techniques, the main difference is the peeling process as the ones who need surgery redone may have lots of materials inside or even capsule formations that must be removed first. Also, the time needed, and the skills needed is higher.

4. How often do you receive cases of unsuccessful rhinoplasty which other doctors do?

Our hospital tends to have many consultations for redo surgery. Relative to other hospitals, we tend to have many who come for redo surgery. Out of ten patients, three to four are here to redo their rhinoplasty. Most are from other hospitals locally or from abroad who have had rhinoplasty but were not satisfied.

5. What are the risks of having rhinoplasty?

Rhinoplasty is not a surgery with big risks and tends to be trouble-free normally. However, when implants are used there can be infections or protrusions. In addition, there can be bleeding or pain, so we try our best to limit such risks in our surgeries.

6. What kind of person is not suitable for rhinoplasty?

We don’t particularly have any. However, there are cases where the patient has a low forehead but desires a tall nose, or a patient with thick skin and wide nose yet wants to raise it high – we can do so within a limit. We explain to the patient our opinion in such cases and discuss. When the expectations are too high, there are situations that limit such outcomes. But basically, there are no unsuitable patients.

7. Do people have to take extra care after having the surgery?

When surgery is done with implants there can be some inflammation, but we take care right before and after the surgery for inflammation and bruises. Relative to other surgeries, the nose is not a moving organ, and the host blood vessels should be guarded.

8. We have rhinoplasty and so what is septoplasty?

Septoplasty, medically speaking, if there is discomfort while breathing due to a misaligned bone or cartilage between the septum, is surgery to correct the issue. In cosmetics surgery, we do augmentation or lift procedures for aesthetic reasons. 

9. Why do clients come for revisional rhinoplasty?

Most come due to their dissatisfaction with the shape of their nose. Those who want to lift their nose or lower their nose. In some cases, they come to correct tilted noses. And in rare cases, some come to remove their infections from prior surgeries.

The next interview is with Dr. Kyung Tae Kang:

1. What is the rhinoplasty procedure?

Rhinoplasty covers a wide area of nose jobs including functional, aesthetic procedures. For example, raising the nose tip, diminishing the nose size, lengthening the nose, shortening the nose length, or straightening a crooked nose fall under the category of rhinoplasty. Rhinoplasty covers simple procedures to complex ones that require anesthesia. While the whole process is complex, these are what describes rhinoplasty in a nutshell.

2. What is the difference between all of this?

For augmentation surgery, we use inserts of various kinds to achieve the desired height or length. For nose bumps, we can shave off the nose structure or insert implants to level the nose to be straight. We also correct crooked noses to be straight.

3. What are the difference between nose wing reduction, septoplasty and rhinoplasty?

First, wing reduction is suitable for people with large nostrils, wide noses as well as flat noses. By reducing the nasal wing, the nose can appear sharper, raised and narrower with smaller nostrils. Septoplasty is a procedure to straighten the crooked bone and cartilage that divides the space between the two nostrils, resulting is improvement of function, as well. While these two mentioned procedures target the specific issues noted, rhinoplasty encompasses all nose procedures including the two mentioned. Rhinoplasty can remedy functional issues through surgery as well as purely aesthetic reasons. Within rhinoplasty, it includes wing reduction to reduce wide and large nostrils as well as septoplasty, which fixes crooked noses.

4. Is it possible to correct a bulbous nose tip with nose ring reduction or any other procedure that are needed?

Yes, this is a nose shape that is predominant with people from a certain region. When the nose is wide and the tip is bulky, we can simultaneously perform both correctional procedures together. Additional surgeries that may be done are shaping the nose or use the cartilage from the ears to sharpen the nose tip, and procedures to make the nose thin by removing some internal tissue.

5. If the patient has difficulties in breathing, is it, can it be improved by having rhinoplasty?

Depending on the causes for the difficulty in breathing, instead of the procedure being for cosmetics, it is for functionality. Also, it merits to know if the reasons are not based on issues with the nose but perhaps based on otorhinolaryngology related problems. Rhinoplasty will not solve everything. If the shape of the nose is the issue, then it can be solved with rhinoplasty. But is there are other underlying reasons, the patient may have to consider otorhinolaryngology departments.

6. Do you recommend nose filler for your patients?

Personally, I believe fillers have certain advantages. There are many advantages such as cost and recovery time. Instead of a surgery right away, a patient can see how it works out with fillers as it is easy to reverse the course if dissatisfied with the results. So, using fillers to achieve a desired shape has its advantages.

7. Are there any structural difference between Western and Asian noses?

Classifying strictly as Western and Asian is not possible. Instead, they are based on certain regions and certain DNA. Yes, it is true that Asians tend to have a little more cases of low noses, wide nose tip, large nostrils, short and pointing up noses relative to the West. But we can fix all these issues nowadays with cosmetics surgery.

8. How long does it take to return to daily life?

As short at three days and as long as seven days, which should be more than plenty. Usually, within five days, one can return to normal daily life. There are no major issues with going to work around then.

9. What are the possible side effects after having nose surgery?

Several side effects are possible. Asymmetry, infection, prosthetics popping out of place, scars, etc. The hospital must be well equipped to prevent such side effects. The experience of the surgeon also matters. Good maintenance after surgery is also important. If one has surgery in a hospital that has ample experience, we can say that rhinoplasty is within the low-risk surgeries available today. 

10. What’s unique about the nose surgery in your clinic?

Our hospital’s unique surgery methods treat short noses, wide noses, bulbous noses by using techniques that rely on minimal surgery with fast recovery. We have many patients who rely on our expertise. That is our strength. 

Conclusion

In Korea, since most patients tend to be Asian, the most common surgery for rhinoplasty is to correct small or short nose tips. So, doctors perform many augmentation rhinoplasty in order to expand or increase the nose. They also correct noses with bumps or humps around the nose bridge.

For augmentation surgery, we use inserts of various kinds to achieve the desired height or length. For nose bumps, we can shave off the nose structure or insert implants to level the nose to be straight. We also correct crooked noses to be straight.

Rhinoplasty is not a surgery with great risks and tends to be normally problem-free. However, when implants are used, there may be infections or lumps, problems or pain.

There are no unsuitable patients for rhinoplasty, however if the patient has requests that do not go with his anatomy or his facial shape, the surgeon gives his opinion and discusses with him.

Rhinoplasty, whether for cosmetic or practical reasons, may provide outstanding results in the hands of a skilled surgeon. Satisfaction with rhinoplasty results can improve the patient's quality of life. For this reason, a solid grasp of nasal function, shape, and anatomy, as well as the application of a surgical technique that respects key components, are essential characteristics of a rhinoplasty surgeon.

As previously stated, proper identification of surgical candidates is an essential step in achieving high patient satisfaction rates. It is also essential that the patient follows postoperative instructions properly and communicates with the surgical team as soon as possible if any warning signs or symptoms develop.