Overview

Rhinoplasty or a nose job is a procedure done to change the functioning or appearance of the nose. From changing the shape, size, and proportions of the nose to fixing medical problems such as breathing difficulties, congenital disabilities, or trauma defects, there are plenty of reasons why you should consider rhinoplasty.  

But whatever the reason, it is imperative to understand the procedure and it's worth before deciding to go under the knife. This article will educate you about the procedure and its benefits, recovery period, and other considerations so that you can make the right decision for your nose job.

 

Rhinoplasty meaning

Rhinoplasty is one of the most common cosmetic operations in the world. More than 200.000 procedures were performed in the United States alone in 2018, making it the third most common cosmetic surgery procedure in the country.

Since the initial cosmetic operation reported by John Roe in 1887, the process has evolved dramatically. This lengthy evolutionary process was not just technical, but also, and perhaps more importantly, philosophical. In order to achieve better and more consistent outcomes, the reduction-only idea in nose surgery was gradually replaced with a more proportionate technique that included meticulous reduction and grafting. Such breakthroughs were made possible mostly via a greater knowledge of anatomical structures and the efforts of outstanding surgeons such as Joseph and Sheen. They detailed many strategies that are still in use today.

Despite this paradigm change, rhinoplasty remains one of the most difficult surgical procedures in Plastic Surgery. Nasal dimensions and symmetry are intimately related to facial attractiveness since they are a fundamental hallmark of the face. Even for very experienced surgeons, the technical hurdles, the large range of diverse approaches presented, and the battle to produce consistent results can be tough.

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

Rhinoplasty is more than just a cosmetic operation. The procedure also tries 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 solve functional concerns.

All of these elements work together to explain why rhinoplasty is such a gratifying operation with such positive outcomes. Correct surgical patient selection, as well as thorough preoperative analysis and planning, are key elements in improving rhinoplasty outcomes and avoiding additional surgeries.

 

Anatomy and Physiology

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

The external nose is made up of a bony and cartilaginous skeleton that is surrounded by muscles, soft tissue, and skin.

• Nasal Bones and Cartilages: The bony pyramid, which comprises the upper third of the nose, is defined by the paired nasal bones and the frontal process of the maxilla. Nasal bones have a close association with the ethmoid bone's perpendicular plate. The top lateral cartilages, which link to the nasal bones cranially, compose the middle third. The "Keystone region" is formed by the nasal bones overlapping the top lateral cartilages for 4 - 5 mm. This anatomical marker is vital for the dorsal contour's aesthetics and should be addressed with attention during surgery. Upper lateral cartilages also join dorsally to the septum, producing an angle of around 10 - 15 degrees. This limited zone of air resistance is known as the internal nasal valve, and it is clinically significant. It is critical to maintain this tilt throughout surgical techniques in order to ensure patent airflow. With their medial, middle, and lateral crura, the lower lateral cartilages constitute the lower third. The form and size of the nasal tip region are determined by the anatomical configuration of these cartilages. They also serve as the foundation for the external nasal valves.
• Muscles: The nasalis, levator labii aleque nasi, and depressor septii are the primary mimetic muscles of the nose. The nasal superficial musculoaponeurotic system is a fibrous fascia that encloses and connects these muscles (SMAS). The role of nasal muscles is commonly overlooked, yet they are critical for maintaining a patent airway. Patients with facial paralysis demonstrate this, as evidenced by a collapse of the external nasal valve.
• Skin and Soft Tissue Envelope (SSTE): The tissue covering the Rhinion zone is the thinnest when separated into the upper, medial, and lower thirds of the nose, followed by the upper and then lower thirds, which are the thickest. SSTE can be thinner or thicker depending on a variety of factors such as gender, age, ethnicity, and others. This is very important in surgical planning. Slight alterations in nasal cartilage and bone structures will have a substantial influence on the form when dealing with individuals with extremely thin SSTE, and small imperfections of grafts used can be highly evident.

 

The internal nose is constituted of the septum and the turbinates, all of which are covered by mucosa.

• Septum: The nasal septum is a stiff, quadrangular-shaped mucosa-covered structure positioned in the middle of the nasal cavity. It divides the two nostrils and serves as the nose's primary support. The anterior septal angle, located between the dorsal and caudal septums, aids in determining nasal projection. It also aids in the definition of other aspects of the nasal anatomy, such as the dorsal and columellar regions. It plays a critical function in keeping a patent airway via the internal nasal valve. The septum is made up of cartilaginous and bony components, the latter of which include the maxillary crest, vomer, and the ethmoid bone's perpendicular plate.
• Turbinates: Turbinates are bony outgrowths that are mucosa-covered. These structures provide routes through which air travels, where it is warmed and humidified. They also aid in the removal of pollutants from the inspired air and aid in the regulation of airflow by contracting and expanding. They are classified as superior, medium, or inferior turbinates. The majority of the airflow is routed through the middle and inferior turbinates. Some factors, such as rhinitis or septal deviation, can promote turbinate hypertrophy, which can restrict the airway to varying degrees. If an obstruction is discovered, it must be removed via surgery to enhance nasal function.

 

Benefits of rhinoplasty:

Rhinoplasty gives long-lasting results, and you observe gradual changes in the appearance and functioning of the nose over the course of one year with permanent end results. Here are the benefits of rhinoplasty that can change the way you look or breathe:  

• Improved breathing.
• Corrected congenital disabilities such as clefts, masses, lumps, underdevelopment, etc.
• Restored facial symmetry.
• Improve self-confidence.

 

Deciding on Rhinoplasty

Rhinoplasty for medical reasons is indicated if all other conservative treatments fail to provide relief. A common medical reason that requires surgery is difficulty in breathing through the nose due to nasal obstruction. As far as cosmetic reasons are concerned, rhinoplasty can produce exceptional results and give the desired shape to your nose for an improved facial appearance.  

Another thing to consider while deciding whether to opt for surgery is the cost of rhinoplasty. The expenses vary from hospital to hospital and could depend upon the extent of surgery required and your facial appearance. Though you should keep all these factors in mind while deciding about your nose surgery, looking for the best rhinoplasty surgeon is equally essential to get the desired transformation. 

It is critical to examine the precise elements of their nose that they detest (dorsal hump, nasal deviation, tip difficulties, 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 method for identifying patients with unreasonable expectations by using real-life photos of the individual and simulating an approximate surgical outcome. It has gained popularity among surgeons in recent years, and according to a 2017 survey, 63 percent of them use it in rhinoplasty consultations. There are both 2-D and 3-D simulation tools available.

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

For more information see: Understanding revision rhinoplasty

 

Contraindications

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

• Body Dysmorphic Disorder (BDD): This mental condition is distinguished by an obsessive obsession with a fictitious or scarcely discernible flaw in one's appearance. Patients have difficulty socializing, have a lower quality of life, are more prone to depression, and have a higher suicide risk. It is critical for surgeons to identify this sort of patient as soon as possible since symptoms may intensify postoperatively if not detected, and the patient will be dissatisfied with the outcomes. There is currently no validated questionnaire available to appropriately diagnose these people. Referral for mental examination is required if clinical suspicion emerges.
• Obstructive Sleep Apnea: This common condition is characterized by recurring bouts of airway blockage while sleeping. Patients with this syndrome are more likely to experience perioperative problems. Diagnosis might be suspected based on the patient's symptoms, although it can also be asymptomatic. Screening questionnaires can be employed, although their accuracy is restricted. Polysomnography is the gold standard for diagnosis. Although it is not an absolute contraindication, patients with this illness should be informed of the risks, and preoperative treatments such as the use of a continuous positive airway pressure (CPAP) device should be undertaken to lower complication rates.
• Cocaine Abuse: Patients who misuse cocaine are a distinct category of patients. Because of the various contaminating components, inhaled cocaine causes severe vasoconstriction and persistent mucosal inflammation. The findings of a rhinoscopy might range from minor inflammation to serious septal perforations. These individuals are also more prone to experience postoperative problems such as septal collapse or reduced septal mucosa healing, and they should be cautioned against having nose surgery.
• Tobacco Smoking: Although it appears that tobacco smoking does not affect septoplasty outcomes, patients should be encouraged to quit prior to the procedure because of other harmful effects. 
• Bleeding Disorders: Coagulation problems might lead to postoperative difficulties. Patients should be questioned if they have a history of severe bruising or bleeding, if they have taken any medicines, supplements, or vitamins that modify the coagulation cascade, or if they have had any previous thrombotic episodes. Any medication, vitamins, or supplements that weaken coagulation may need to be discontinued prior to surgery.

 

How is Rhinoplasty done?

Nose plastic surgery is performed under general anaesthesia, or local anaesthesia with sedation. There are two techniques used when surgically altering or improving the nose's appearance; open and closed technique. Both the techniques are different, offer individual advantages and cannot be compared for better outcomes.  

While the open technique has an external incision on columella, there is no external incision on the outer side of the nose in the close technique as incisions are hidden inside the patient’s nose, and modifications are performed from inside the nostrils. There are some more advantages of C&N (Close Rhinoplasty & Natural Look) such as:

• No lifting of the skin.
• No scar.
• Shorter surgical time.
• More natural look.
• Faster recovery.
• Less trauma.
• Excellent experience in both primary and revision cases.

Though the close technique seems more advantageous for some nasal modifications, still, your surgeon is the best person to decide whether an open or closed technique can give the optimal treatment results. 

This way, nose lift or nose reshaping is performed. In addition to cosmetic surgery, we also restore the function of the nose at the same time by correcting the nasal septum deviation and reducing the size of turbinate’s to improve the nasal airway and breathing.

Before and after photos

 

Recovery after the procedure

You can go home the same day after the procedure, but at least one week off from work is required to allow healing. You should take proper rest and apply ice on the nose. No forceful blowing of the nose is permitted, and it should be cleaned thoroughly every day. Swelling may occur for the first 3–4 days and gradually subsides after that. Pain medications are given to decrease the discomfort but are generally required only for the first few days.  

Within a week, all the discomfort, pain and swelling resolves, and the cast and splints can be removed. You can join work and do all daily activities, including workouts. But any contact sport must be avoided for at least six weeks to prevent injury to the nose. Complete healing from the surgery may take 6 to 12 months.

 

Complications

As previously noted, rhinoplasty is one of the most difficult surgical operations, and one of the primary reasons for this is its lack of predictability. An immediate positive surgical outcome may not be such one year later. This is mostly due to the numerous factors involved in the healing process. Individual nasal tissue responses are not always predictable, and as a result, adverse outcomes might occur.

Although the likelihood of serious consequences is limited, functional and, in particular, cosmetic difficulties might generate social and psychological problems, as well as legal challenges for the surgeon. Hemorrhagic, infectious, traumatic, functional, and cosmetic surgical problems are all possible.

Hemorrhagic Complications:

• Epistaxis: Bleeding after rhinoplasty is a typical problem. They are typically minor and can be treated with head elevation, nasal decongestants, and compression. If the bleeding persists, an anterior tamponade should be done, and the patient should be reviewed. If the bleeding continues despite the anterior tampon, posterior hemorrhage should be considered, and a posterior tampon should be used. Although significant bleeds are uncommon, an endoscopic approach or angiographic embolization may be required in some cases.
• Septal Hematoma: It is an early complication that, if not addressed swiftly, can result in significant harm. Septal hematoma manifests itself as a postoperative painful lump in the septum. It is often painful, and the patient may also exhibit fever, anosmia, and airflow restriction. Septal hematomas should be drained as soon as possible if they are detected to avoid infection and loss of septal cartilage. Following drainage, anterior tamponade should be used, and the patient should be evaluated in 24 hours. If a septal abscess is suspected, antibiotic therapy should be initiated very once.
• Infectious Complications: Infections during rhinoplasty can vary from moderate cellulitis to serious systemic infectious diseases. As an early complication of rhinoplasty, cellulitis may occur. It normally responds well to cephalosporins, although regular monitoring is required to prevent progression. Septal abscesses are a consequence of an untreated hematoma, and the treatment of choice is surgical draining followed by antibiotics. They might occur in the septum, tip, or dorsum of the body. Severe infectious processes are quite uncommon. They occur in fewer than 1% of all cases. To avoid complications such as tissue necrosis or toxic shock syndrome, early readmission, intravenous antibiotic therapy, and fast tissue debridement are critical. There have been several studies on the use of antibiotics during and after surgery, but there is still no agreement. There is evidence that prophylactic antibiotics are effective in avoiding postoperative infections. In terms of the usage of antibiotics following surgical intervention, the WHO does not advocate using them for more than 24 hours after surgery due to the minimal infection risk.
• Traumatic Complications: These include septal abnormalities or collapse caused by L-strut damage, intracranial injuries, and lacrimal system injury. Deformities are often found as a late consequence of an undiagnosed septal injury, as the soft tissue envelope tightens over the nasal structure. Secondary operations are frequently required to remedy them. If a septal damage is discovered during surgery, it must be corrected before the wound can be closed.
• 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 vital to understand that epiphora may occur in the first few weeks following the treatment as a result of edema compressing the lacrimal ducts, which usually resolves spontaneously.
• Septal perforation: A continuity defect caused by rips in the manipulation of mucoperichondrial flaps or an undiscovered septal hematoma. The necessity of avoiding tears or fixing them when they occur is critical for their prevention. When a hole occurs after surgery, it can range from a minor perforation that causes whistling when breathing to a big perforation that causes epistaxis and rhinitis owing to turbulent airflow. Treatment may not be necessary if symptoms are minor owing to a tiny perforation. Larger holes may necessitate surgical treatment with flaps, which will have a high recurrence rate.
• Nasal adhesions: Synechiae can form between abraded mucosal surfaces. They can be avoided by using a Silastic splint during septoplasty. They should be surgically split if discovered postoperatively.
• Rhinitis: This is frequently a transient consequence, especially after 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 detected if rhinorrhea persists after a few weeks.

 

Conclusion 

Rhinoplasty, whether for cosmetic or practical reasons, may provide great results in the hands of a skilled surgeon. A strong grasp of nasal function, shape, and anatomy, as well as the application of a surgical technique that respects important components, are essential characteristics of a rhinoplasty surgeon.

As previously stated, thorough identification of surgical candidates is a key 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 emerge. Satisfaction with rhinoplasty outcomes has been shown by several writers over the years to increase the patient's quality of life, as evaluated by an improvement on the ROE scale and other scales following the treatment.