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Rhinoplasty - Simon Withey, BAAPS and LPSA

Rhinoplasty

Rhinoplasty, derived from Rhinos: nose and Plastikos: to mould, this operation is the procedure referred to as a nose job. As the nose has both functional and aesthetic properties rhinoplasties may be undertaken to improve the appearance of the nose, its function or a combination of both. Cosmetic rhinoplasty is the fourth most common aesthetic surgery operation after breast augmentation, eyelid surgery and liposuction.

Twenty years ago aesthetic rhinoplasty was a fairly formulaic operation that largely relied on the removal of tissues to change the shape and proportion of the nose, and this would often result in standardised “operated on” look. Over the last ten years there has been an increasing emphasis on “augmentation rhinoplasty”, in this operation tissues are added to the nose as often as they are removed. This has expanded the number of ways in which the aesthetics of a nose can be altered; it has helped surgeons tailor the procedure for the patient. Far from the days of the formulaic rhinoplasty, each operation is now individualised following a detailed analysis of the patient’s nasal and facial features and a discussion focusing on their objectives.

In this short article I will limit myself to the fundamentals of aesthetic rhinoplasty. When discussing the operation with a patient it is helpful to have a clear idea of what they dislike about their nasal appearance. It is important to help them look at the nose both as a whole and as isolated units, and as a part of the rest of the face. Photographs will be taken and shown to the patient to develop a detailed understanding of their objectives. I often find it helpful to use a software programme to “morph” the photographs to give the patient an idea of the objectives of surgery. During the consultation the surgeon will discuss the limitations of surgery, the implications and any potential complications that you should consider. You will be advised about any medication you should stop before surgery, and any tablets you should take preoperatively. If you smoke your surgeon will warn you of the increased risk of continuing and will suggest stopping.

The operation is generally performed under a general anaesthetic and depending on the complexity of the surgery will last from between an hour and three hours. The operation may be performed as a day case procedure, but patients undergoing long and complex rhinoplasties will often stay in hospital overnight.
The operation may be performed using incisions that are all within the nose: the closed approach, or it may involve a small incision across the collumellar (the tissue between the nostrils), the open approach. Two tiny punctures may be made where the nasal skin meets the cheek to allow the nasal bones to be broken, and on occassions where the nostrils are flared an incision may be placed in the base of the nostril to allow reduction. In cases where augmentation of the cartilage structure is required, cartilage, and occasionally bone, will be “harvested” from elsewhere in the body and “grafted” to strengthen, support or aesthetically alter the nose. The graft tissue may be taken from elsewhere in the nose, from the ear or occasionally from a rib. This harvest will involve further incisions, but all tend to be well hidden.

Recovery

Clearly with a procedure that offers such a broad spectrum of approaches and technical challenges, the recovery period and the advice given to patients is as tailored as the technique. Broadly most patients will wake to find their nose covered with paper tapes, a plaster or a splint that will be present for a week, this helps reduce swelling and provides protection for the nose. Very occasionally it is necessary to pack the nose, and it is likely that in these circumstances the pack will be removed the day after the operation. Typically rhinoplasty patients do not complain of anything more than mild pain and this is usually easily controlled with simple pain relief that will be prescribed by your surgeon or anaesthetist. In my practice any patient who has undergone grafting will be given a dose of antibiotics and an antibiotic cream to use in the nose for five days.

Most patients will take a week to ten days off work following surgery; during this time they are encouraged to lead a fairly normal life. If the nasal bones have been broken, swelling and bruising should be expected around the eyes and cheeks for about ten days. To minimise the swelling and bruising, rhinoplasty patients are advised to prop themselves up when sleeping or resting, and avoid strenuous exercise and lifting for a month. The dressing will be removed after a week. Blowing the nose should be avoided for two weeks, and try and avoid situation that might make you sneeze. Lightweight glasses can usually be used after ten days but in cases where the nasal bones have been broken I advise against the use of heavy glasses and sunglasses for a month. Patient should be advised to protect the scars from the sun for eighteen months and to avoid contact sports and anything with a high-risk of nasal trauma for six months. The swelling in your nose following surgery may effect your ability to equalise ear pressures when flying and scuba diving, the risk of this depends on the type of surgery that was performed and I would suggest asking your surgeons advice if undertaking either in the first six weeks after surgery.

Patients undergoing aesthetic surgery must be aware of the risks of complications of surgery, these will relate to the exact nature of the surgery being performed and to the pre existing health of the patient. Risks that should be discussed include bleeding, infection, scar thickening, numbness, changes in the airway affecting breathing, palpable and aesthetic irregularities, perforation of the nasal septum, movement of grafts, change to the sense of smell and the risks of anaesthetics.

The costs of surgery vary and much will depend on the complexity of surgery. The surgical fee will probably vary between £2,500 and £4000, this will often cover all postoperative visits to your surgeon and the surgical costs of revision should you experience any problems.

If you are considering surgery choose your surgeon with care. Ensure that he/she is a members of the professional bodies that are recognised by the Royal College of Surgeons for maintaining standards in plastic and aesthetic surgery, The British Association of Aesthetic Plastic Surgeons (BAAPS) and The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), and that they are on the GMC specialist register in Plastic Surgery or ENT surgery.

Simon Withey

Simon Withey, Council Member of the British Association of Aesthetic Plastic Surgeons (BAAPS) and consultant plastic surgeons at the London Plastic Surgery Associates (LPSA)

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