Rhinoplasty

Rhinoplasty is a facial cosmetic procedure.

Rhinoplasty is a facial cosmetic procedure, usually performed to enhance the appearance or reconstruct the nose. During rhinoplasty, the nasal cartilage and bones are modified, tissue is added or removed and, in some cases, implants are used to improve the visual appeal of the nose.

Rhinoplasty is also frequently performed, often delayed to repair nasal fractures inadequately or when proper reduction cannot be done at the time of injury. When rhinoplasty is used to repair nasal fractures, the goal is to restore the pre-injury appearance of the nose.

Septorhinoplasty is a related procedure performed for patients with nasal obstruction due to the nasal septum being displaced or problems with the nasal turbinates. Septorhinoplasty not only improves the appearance of the nose, but it removes internal obstructions and stabilizes structures that may be blocking nasal breathing.

There are many different types of rhinoplasties and many different possible components for each type.

Reduction rhinoplasty reduces the size of the nose and, often, in particular, the nasal hump. Bony and cartilage reduction is often necessary for a smooth result. If the removal is significant, infracturing or scoring and breaking the nasal bones is often necessary for a refined nasal appearance and a nasal dorsal width that compliments the new nasal height.

Augmentation rhinoplasty makes the nose higher and may use autologous tissue or implants or a combination of both to do so. Alteration of the nasal tip is an integral component of most rhinoplasties. Narrowing of the nostrils may be performed with either an augmentation or reduction rhinoplasty.

Open rhinoplasty is a means of exposing all the structures of the nose during the procedure and leaves a tiny scar on the skin between the nostrils but allows for extensive correction of nasal shape and size.

Closed rhinoplasty is performed through incisions inside the nostrils where they cannot be seen. In some circumstances, incisions may be necessary at the base of the nose (where the nostrils join the upper lip, the nasal rims (where the nostrils join the inner cheeks), or in the upper buccal sulcus (above the front teeth). Each of these exposures, procedure components, and incisions provide risks and benefits and allow for certain aspects of the desired outcome to be achieved.

Cosmetic concerns and expectations should be fully discussed before surgery. The surgeon's recommendations and any particular limitations set forth by the structure of your nose, face, and skin are important to understand and have explained.

Photographs (without make-up) are usually obtained before surgery to help with preoperative planning and after surgery to document postoperative results. Three-dimensional renditions of the likely result of surgery are often reviewed so that the surgeon and the patient have a clear understanding of what is going to be attempted with the upcoming procedure.

In most situations, the surgery is performed as an outpatient at either the hospital or the surgicenter. In both facilities, quality care can be provided without the expense and inconvenience of an overnight stay.

An anesthesiologist is present to monitor vital functions and provide either sedation or anesthesia throughout the procedure. Usually, the anesthesiologist will call the night before surgery to review the medical history.

Preoperative laboratory studies will need to be done several days in advance.

Here is a checklist to follow before rhinoplasty surgery:

• Transportation after the procedure will need to be arranged and someone should stay with the patient during the first night.
• Aspirin, or any product containing aspirin, should not be taken within 10 days of the date of surgery.
• Non-steroidal anti-inflammatory medications (such as Advil, Motrin, and Naprosyn) should not be taken within 7 days of the date of surgery.
• Many over-the-counter products contain aspirin or Advil-type drugs so it is important to check all medications carefully. If there is any question regarding medications, the surgeon's office should be contacted or the pharmacist consulted. Tylenol is an acceptable pain reliever before surgery should one be necessary. Prescriptions for pain medications are usually written before the date of surgery and should be filled in advance.
• No food or liquids should be consumed within 6-8 hours before the time of surgery. This includes even water, candy, or chewing gum. Anything in the stomach increases the chances of an anesthetic complication. Smokers should make every effort to stop smoking, or at least reduce the number of cigarettes smoked. This will help to reduce postoperative coughing and bleeding. Difficulty with tissue healing has also been noted in smokers during the postoperative period.
• Any illness before the day of surgery should be reported to the surgeon's office as soon as possible. If illness occurs on the day of surgery it is best to proceed to the surgical facility as planned and be evaluated by both the anesthesiologist and surgeon to decide if surgery is safe.

• It is important to check in with the surgical facility on time.
• Bring all papers and forms including any preoperative orders and history sheets.
• Wear comfortable loose-fitting clothes that do not have to be pulled over the head.
• Leave all jewelry and valuables at home.
• Remove all make-up with a cleansing cream or do not apply any that morning. This includes make-up other than that applied to the nose.
• Thoroughly wash the face with soap and water and do not apply makeup or creams.
• Do not take any medication unless instructed to do so.
• Usually, a nurse will start an intravenous infusion line (IV) in the pre-operative holding room and medication may be given for relaxation.

• In the operating room, the anesthesiologist will usually use a mixture of gas and intravenous medication. General anesthesia is usually preferred for all but the most minor of rhinoplasties in order for the anesthesiologist to have complete control of the airway of the patient during the procedure.
• Continuous monitoring during the procedure usually includes a pulse oximeter (oxygen saturation), expired CO2 levels, and EKG (cardiac rhythm and rate).
• The surgical team is prepared for any emergency.
• In addition to the surgeon and the anesthesiologist, there will be a nurse and a surgical technician in the room.
• Depending on what is required and what additional procedures are performed, the surgery may take one to several hours.
• The surgeon normally talks with any family or friends once the patient is safely in the recovery room.

Patients are monitored after surgery in the recovery room by a nurse. A patient can go home the same day as the surgery once fully recovered from the anesthetic. This usually takes several hours. Transportation home will need to be arranged. A responsible adult should be in the same residence overnight for help on short notice.

At home, the patient should have bed rest with the head elevated on 2-3 pillows. Edema and swelling are minimized by keeping the head elevated above the heart. An assistant should be available for out-of-bed excursions to the bathroom. Straining should be avoided. If constipated, take a stool softener or a gentle laxative.

• Swelling and bruising of the nose, upper lip, cheeks, or around the eyes for several days after surgery is a normal occurrence. This will gradually go away over the next 7 to 10 days. Ice, indirectly applied on the face, bridge of the nose, and eyes typically for 20 minutes per hour will help to minimize these problems although nasal splints and packing interfere with cold transfer. This will also help with postoperative edema and pain. Some patients have found frozen vegetables in packages (for example, bags of frozen peas) to be a convenient ice pack that conforms to the face and can be best used under a moist cloth so as not to overcool the skin.
• A nasal splint or cast will cover the outside of the nose, and will usually be removed five days to one week following surgery. As swelling subsides, the splint tends to fit less tightly. If the cast gets wet it may come off prematurely; this is usually not a problem and does not affect the outcome of the procedure. There is also nasal packing in place which is usually removed on the day following the procedure.
• Moderate bleeding from the nose is normal, and will gradually decrease. The gauze dressing ("mustache dressing") just below the nose will collect blood and should be changed only when saturated. It is not unusual to change these dressings every hour during the first 24 hours after surgery. This dressing will usually not be needed after a few days. Do not take aspirin, aspirin-containing medications, or non-steroidal anti-inflammatory medications (such as Advil) for 3 weeks following surgery.

Picture of Mustache Dressing

• It is best to eat a light, soft, and cool diet as tolerated after recovery from the anesthetic. Avoid hot liquids for several days. It is best to go slowly with food immediately after the procedure to prevent postoperative nausea and vomiting. Patients occasionally vomit one or two times immediately after surgery; if it persists, medication to settle the stomach may be prescribed. It is not unusual to vomit blood or old blood as some, sometimes, is swallowed or enters the stomach. In the immediate postoperative period, this is not of concern. It is important to remember that a good overall diet with ample rest promotes healing.
• Antibiotics are often prescribed around the time of the surgery. It is important to finish all the pills that have been ordered. Some form of a narcotic will also be prescribed (usually Vicodin) which is to be taken as needed. If narcotics are taken, it is important not to drive or engage in activities where impaired judgment could cause injury.
• In some situations, steroids may be prescribed to be taken either preoperatively and/or postoperatively. It is very important to take this medication as prescribed, and not discontinue it prematurely.
• An anti-emesis medication such as phenergan may be prescribed for nausea or vomiting postoperatively.
• Possible drug reactions to any of these medications, such as a rash, should be reported to the doctor as soon as noticed.
• No other medications, either prescribed or over-the-counter, should be taken without the knowledge of your doctor.

• Arrangements should be made for someone else to drive to and from the office for this first visit.
• Eat a light meal before this visit and avoid taking excessive pain medications.
• Immediately after the nasal packs are removed, a saline nasal spray such as "Ocean Spray" is used several times per day to prevent crusts from forming in the nose.
• Several subsequent office visits are necessary to assess healing, remove crusts, and ensure a speedy recovery.
• The nose is usually tender after surgery, so a spray of special numbing medication may be used before removing crusts.
• After the packing has been removed, breathing through the nose is acceptable, but do not blow or sneeze through it for 7-10 days.
  • Any sneezes should be channeled through the open mouth.
  • Expect some light blood-tinged drainage from the nose for several days.
  • If the bleeding becomes excessive, apply ice and rest quietly with your head elevated while holding the nose.
  • If bleeding continues, call the surgeon.
• Rest for the first week following surgery.
  • Avoid excessive talking, smiling, hard chewing, strenuous activities, lifting heavy objects, bumping the nose, and bending over.
  • Try not to rest glasses on the bridge of the nose until soreness and swelling subside.
  • Contact lenses can be worn once eye swelling and any irritation have resolved.
  • Alcohol and tobacco should be avoided because they may prolong swelling and healing.
  • Smoke, dust, and fumes may irritate the nose and cause an infection.
  • Facial tanning is discouraged for 6 months after surgery.
  • Number 15 or greater sunblock is recommended during any sun exposure. Make-up may be worn anytime after surgery.
• Lubricate the nostrils, as instructed, with a Q-tip and Vaseline to soften any hardened crusts. Peroxide helps to loosen crusts.
  • After several days a few of the absorbable sutures may become noticeable.
  • Be gentle while brushing the upper teeth.
  • They will often be tender for several weeks, and there may be some numbness of the teeth and palate for several months.
• Exercise and swimming may be resumed after 3 weeks if there are no bleeding problems.
  • Diving should be postponed for two months.
  • It is advisable not to schedule travel for three weeks following surgery to allow for proper postoperative recovery and healing.

When to Notify Your Doctor

1. A sudden increase in the amount of bleeding from the nose which is unrelieved by ice, and head elevation.
2. A fever greater than 101.5 degrees F.
3. Persistent sharp pains or a headache that is not relieved by the prescribed pain medication.
4. Increased swelling or redness of the nose or eyes.

This surgery, like any surgery, may involve risks of unsuccessful results, complications, or injury from both known and unforeseen causes. Because individuals differ in their response to surgery, their anesthetic reactions, and their healing outcomes, ultimately, there can be no guarantee made as to the results or potential complications.

The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. Although many of these complications are rare, all have occurred at one time or another in the hands of experienced surgeons practicing the standard of community care.

• Nasal obstruction due to failure to straighten the septum or later re-deviation of the septum, collapse of the nasal cartilage, or the re-growth or swelling of the turbinates.
• Failure to resolve coexisting sinus infections, recurrence of coexisting sinus problems and/or polyps, or the need for further or more aggressive surgery.
• In rare situations, bleeding can lead to a need for blood products or a blood transfusion. Autologous (self-donated) or designated donor blood may be arranged in advance in case an emergency transfusion is necessary.
• Chronic nasal drainage or excessive dryness or crusting of the nose or sinuses.
• Need for allergy evaluation, treatments, or environmental controls. Surgery is not a cure for or a substitute for good allergy control or treatment.
• A cosmetic result that does not meet expectations; with the possible need for revision surgery.
• Failure to resolve associated "sinus or nasal" headaches. The exact cause of headaches can be difficult to determine or be from many different causes. A consultation with another specialist such as a neurologist may be necessary.
• Damage to the eye and associated structures (rare).
• Permanent numbness of the upper teeth, palate, or face.
• Prolonged pain, impaired healing, and the need for hospitalization.
• Septal perforation (a permanent hole inside the nose between the two sides).
• Failure to restore or worsening of the sense of smell or taste, or failure to relieve nosebleeds.