Rhinoplasty

In rhinoplasty surgery, a person’s fundamental appearance is going to be changed. For that reason, communication between the surgeon and patient is critical. The surgeon needs to know exactly what the patient wants to look like. Also, the patient needs to know exactly what the surgeon thinks is possible. To accomplish this, I prefer to draw on photographs of the patients (which we take in the office) to simulate what the person’s nose will look like; I have found this to be a little more accurate than computer imaging. Also, some people communicate better if they show me photographs of people whose noses they like. While it is never possible to re-create another person’s nose, it does help me understand what the patient is thinking. Lastly, I like to show pictures of other patients that I have operated on in order to give people some idea of what I can do with noses similar to theirs.

In the past, rhinoplasty was performed using standard surgical techniques which were virtually the same for every patient. This created results which tended to look similar, and every surgeon seemed to produce a certain “look.” Over the last 20 years there has been a worldwide improvement in rhinoplasty techniques. This has given surgeons more control over the end result and has provided the ability to customize operations for the individual patient.

The surgery is performed at the Vancouver Plastic Surgery Center, under a light general anesthetic. Most of our planning for rhinoplasty takes place before going to the operating room. However, many things happen during the surgery, requiring the surgeon to make constant adjustments during the surgical procedure. For the typical rhinoplasty case, the skin and soft tissue of the nose are separated from the underlying cartilage and bone which make up the framework of the nose. Most of the alteration in nasal appearance is achieved by rearranging this underlying skeleton. For example, if there is a large hump on the nose, the bone and cartilage are reduced in size, and the skin and soft tissue should shrink to the new shape and size. At the end of the procedure, tape and a plaster cast are attached to the outside of the nose.

Rhinoplasty procedures are usually performed under a light general anesthesia, although small procedures can be performed under local anesthetic with or without conscious sedation. Either way, the anesthesia is provided by an anesthesiologist who is certified by the Royal College of Physicians and Surgeons of Canada.

Often confused as different techniques, the open and closed methods refer only to the type of incision the surgeon uses to separate the nasal skin from the underlying cartilage and bone. The closed method involves hidden incisions placed inside the nose, while the open method uses those same hidden incisions combined with a short incision across the columella (the tissue separating the nostrils). The purpose of adding the columellar incision is to give better visibility of the structures which compose the nasal tip.

I use both of these approaches, depending on the situation. Generally, if a person requires alteration to the nasal tip, I prefer the open technique because it gives me greater control and leads to a more predictable result. In fact, most patients undergoing primary rhinoplasty require some alteration to the nasal tip. When the tip is fine, or if the changes needed for the tip are minimal, I will use the closed approach. In the end, there is very little difference, because the columellar incision used in the open approach normally heals invisibly.

Generally, rhinoplasty surgery is not performed until the nose is fully grown – about age 14 or 15 for a girl and 16 or 17 for a boy. A more important consideration, however, is the emotional maturity of a young patient who will have to handle the rigors of surgery, recovery, and the acceptance of the surgical result.

The actual surgery takes anywhere from 1 hour to 2 ½ hours depending on the complexity of the case. You will wake up in the recovery room, with a cast on your nose, breathing through your mouth, but without too much pain. To decrease swelling and discomfort, your head will be elevated and a cold pack will be on your face. You will normally be kept in the recovery room for about 2 more hours before you are discharged home with specific instructions about sleeping position, activities, and when you may shower. We will speak with you by phone the following morning.

Recovery from nasal surgery is not as difficult as most people think. Initially, there is moderate pain which can be treated with simple medication. In many cases, the nose feels numb, with little or no pain at all. The biggest problem most people have after surgery is the inability to breathe through the nose. It’s a lot like having a bad cold, but this problem usually lasts only about a week. We do not use nasal packing, so as soon as the swelling dissipates, nasal breathing will return. When something has been done to the nasal bones, people usually develop black eyes. If so, patients normally look worse than they actually feel. You will be seen at 5 days after your procedure to remove stitches and at 10 days to remove the cast on your nose. We will see you at 2 months to make sure everything is healing normally, and our final visit for photographs is at 1 year.

After about 3 weeks most people no longer look like they had a procedure. However, the nose will be swollen. In general, the end result of a rhinoplasty is not apparent for approximately 1 year. It is important to have patience during this time, because the nose slowly evolves as swelling fades away and the underlying nasal framework settles into place. Ill-conceived efforts to operate on a nose prematurely can make matters much worse in the long run.

Rhinoplasty is considered to be a difficult operation from which to ensure a predictable result; this means that the exact nose created in the operating room may not look the same after it has healed for a year. There are many factors responsible for this, including the nature of the patient’s own tissues, the side effects caused by every surgical maneuver performed, inherent unpredictability in the way noses heal themselves, and the major difference 1 or 2 millimeters can make in a nasal appearance. Also, despite our warnings about swelling, most people do not like the appearance of their nose in the first month or two, and for many people, a year is a long time to wait. In the end, like any surgery, rhinoplasty results are never absolutely perfect, and therefore, the patient who is expecting perfection will be disappointed.