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There are as many shapes and sizes
of noses in the world as there are faces. No two are alike,
although similarities of faces and their noses exist. The
ideal rhinoplasty maintains or improves the flow of air through
the nose and creates a nasal shape which harmoniously blends
with and complements the rest of the face.
At times this may mean also altering the shape of other parts
of the face, such as the chin, cheekbones, or jaws and teeth,
and the plastic surgeon may decide you are best to be treated
by a combined, team approach with other health professionals.
Surgery to alter the appearance of the nose has been at the
centre of plastic surgery since its earliest days. In a continuous
search for more long-lasting, dependable and predictable results,
plastic surgeons are constantly re-evaluating known techniques
and working with new ones.
It takes many months or longer for the consequences of surgery
to become clear, and what may look good two or three weeks
after surgery may not last over time. Although you may feel
one area or your whole nose is too large, the is a complex
three dimensional structure which needs to balance with the
rest of your face. No one operation is right for every patient.
The surgery must be carefully planned to respect the need
for balance and proportion in each patient. Operations which
routinely involve reduction of cartilage, shaving off and
narrowing the bones, and shortening the nose may produce an
over done look, with thicker skin and not very much definition.
Most of our patients want a nose which is proportionate but
with more graceful lines and good definition.
It is amazing how the results of a satisfactory rhinoplasty
can be transformative.
This effect has been known to plastic surgeons for generations
and is partly why rhinoplasty became one of the earliest operations
to be widely accepted. |
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Although most patients who request
rhinoplasty are concerned with the shape of their nose and
usually feel one area or the whole nose is too large, the
nose must be viewed as a complex structure made up of many
three dimensional structures which need to blend together
with the rest of the face in a harmonious whole. No one operation
is right for every patient. The surgery must be carefully
planned to respect the need for balance and proportion in
each patient. Because of this, the rhinoplasties which were
done in earlier years and which are still done by some surgeons
which routinely involve reduction of cartilage, shaving off
and narrowing the bones, and shortening the nose, will often
produce a nose that eventually looks like it has been partially
amputated and may even look mutilated.
Selective, subtle reduction and refinement of the bone and
cartilage combined with selective augmentation with cartilage
grafts usually is more successful in creating a nose which
is balanced and harmonious within itself and the rest of the
face.
This does not necessarily mean reducing the size of a nose
which looks too large. This appearance may be an optical illusion
created, for example, by a nasal bridge which is disproportionately
low and wide for the tip region. Instead of reducing the tip
which may result in an operated upon look, the surgeon may
feel augmenting the bridge area may restore balance and maintain
a natural appearance. I have often used Meryl Streep’s
nose as an example of one which has grace and proportion giving
an appearance of beauty without being small.
For a surgeon, deciding whether or not to operate, is probably
more difficult in rhinoplasty surgery than in almost any other
area of esthetic surgery, for several reasons. The psychological
effects of a nose which is seen to be unsightly by the patient
have likely been present for many years, often since early
adolescence. Among other factors, the patient may have been
teased by peers, or felt rejected emotionally, or felt to
be ethnically conspicuous. Expectations of the operation may
run unrealistically high, and because the effects of surgery
do not appear immediately, disappointment may set in and be
persistent.
The surgeon must try to select the patients who can understand
the aims of surgery in their individual case, along with the
limits to what can be performed. A host of factors determine
the outcome of surgery, only some of which are under the control
of the surgeon. These include the texture and thickness of
the skin, the strength and size of the underlying bone and
cartilage and the age of the patient, among others. But it
is not just the combination of factors involved, and the shape
of the patient’s nose prior to surgery which determine
the final outcome. The patient’s concern may be the
most important factor, and this is often not easy to determine
in pre-operative discussions. Concern with small details may
be either the warning of a patient who will never be satisfied,
or may indicate one who will appreciate a good result. Obsession
with detail, on the contrary, indicates the patient will likely
not be satisfied, given that small imperfections result from
nearly every operation. If definite, relatively predictable
surgical maneuvers will likely give the kind of shape the
patient desires, and if the patient expresses these desires
clearly and without obsessiveness, there is a high chance
of success.
The functional aspects of the nose must also be considered.
The flow of air through the nose may be unsatisfactory prior
to surgery due to development or to previous injuries such
as a broken nose. There may be reduced airflow due to allergies
and chronic inflammation, and these will not be helped by
surgery. In cocaine users, the wall running down the centre
of the inside of the nose (the septum) may develop a hole,
or perforation, and at an extreme, the nose may collapse due
to loss of support from the septum. There are other illnesses
which may cause problems with the function of the nose, and
these need to be discussed with your doctor, diagnosed, and
treated, if possible.
Surgery may, in part, aim to improve the flow of air but in
reducing the size of the nose the flow of air may be reduced
and some measures may have to be taken to improve this. The
nose may appear nearly straight, but a twist or bend in the
septum, the wall running down the centre of the nose, may
become more apparent as the bridge of the nose is reduced.
Making a crooked nose perfectly straight is exceedingly difficult
although much can be done to improve the alignment of the
nasal architecture. Patients who want their noses reduced
beyond what is likely compatible with function and those who
want a perfect nose when it is slightly or completely crooked
prior to surgery, should likely not undergo surgery.
The operation is usually general
anaesthesia ( with the patient asleep but it is nearly always
done on an outpatient basis. We usually use a small incision
between the nostrils connected to the inside incisions, giving
greater control over the way the tip can be shaped, because
the complex shape of the tip cartilages can be better assessed
and changed accurately this way. Structures higher up in the
nose can also be seen better than they can through the traditional
key-hole incisions inside the nose.
What
about splints and “packing”? Traditionally
there was a white plaster cast on the nose extending onto
the cheeks and forehead, and the inside of the nose was packed
with several feet of gauze. Removal of the packing was always
uncomfortable and sometimes an ordeal. External splints are
now smaller, thinner and lighter, and internal thin plastic
splints or stitches replaces packing in most cases, or at
least limits its use to a very short period.
The external splint is usually removed at five to seven days.
The external stitches are usually absorbable and don’t
need to be removed. At a week after surgery there is usually
still some crusting on the incision and in side the nose and
this feels uncomfortable but it gradually clears. This may
be aided by frequent application of antibiotic ointment to
reduce drying and crusting. Sneezing through the nose should
be avoided if possible.
Return
to work: You can expect to be back to work in seven
to ten days, by which time most bruising has resolved. Light
exercise can start at ten days and full sports at six. Swelling
usually takes at least six months to fully resolve, although
a lot of it is gone by six weeks. It takes a lot longer for
the remaining to swelling to settle so the final shape of
the nose isn’t seen for many months. You will usually
feel the tip being stiff and rather numb during this time.
As with any surgery, bleeding, infection and changes of sensation
are possible. Infection is highly unusual, and bleeding requiring
treatment occurs in only about one per cent of cases, although
it is normal to have slight post-operative bleeding for the
first day or so after surgery. It is highly unusual to have
any significant alteration in the sense of smell subsequent
to surgery. There is always some temporary numbness of the
tip of the nose and the nose will feel stiff for several months
after the surgery. Some cold sensitivity during the first
winter after surgery is common.
The flow of air through the nose may be altered by surgery.
Any surgery to the nose can alter the flow of air, although
we generally aim to improve the flow–– but any
attempt to narrow the nose, especially, can reduce the flow.
You may even feel reduced flow, strangely enough, with improved
flow of air, on occasion, if you have always felt the turbulence
of reduced airflow, you may now not feel anything when breathing
without obstruction, and may be under the illusion there is
no flow.
The most common problem from rhinoplasty surgery is dissatisfaction
with the esthetic result. This may be remedied with secondary
surgery, so that when the source of dissatisfaction is well-defined,
and there is a clear anatomic solution, ultimate satisfaction
is usually the result of secondary surgery. However, when
the cartilages and other structures have been reduced and
are deficient, reconstruction may be a difficult matter. All
plastic surgeons see patients from time to time who have had
previous rhinoplastic surgery and are dissatisfied.
The following patient underwent rhinoplasty many years
earlier under the care of another surgeon and was left
with a prominent “knuckle” of the left nostril
cartilage ( most obvious from below). This was repaired by
reconstructing the arch of the normal cartilage with cartilage
grafts, and the splayed out nostril base was also improved,
resulting in a normal looking and harmonious shaped nose. |
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Often the original surgeon is best
able to do the secondary procedure, partially because he or
she knows what was done previously, and knows what is available
for secondary surgery.
In general, because the final shape from a rhinoplasty is
not achieved until all swelling has resolved and scar healing
is complete, it is best not to contemplate revision until
at least six months have passed since the original procedure.
I have seen numerous patients who expressed some initial dissatisfaction
with the result at four to six weeks after surgery and were
reassured that there was still significant swelling; by six
months after surgery many of their concerns had resolved.
As with many other plastic surgical procedures, patience is
rewarded. |
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Deciding whether Cosmetic Nose Surgery is right for you starts with a personal consultation with Dr. Gelfant.
You are invited to contact us at our Vancouver offices to arrange a meeting.
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