Nose Job | Rhinoplasty

Published: 01/23/18

The nose has a strong impact on the natural beauty the face, affecting its overall character and proportions. If you are concerned about the size or shape of your nose and would like it to be more in harmony with the rest of your facial features, rhinoplasty surgery might be the right thing for you.

The Golden Ratio and Facial Harmony

As the old saying goes, “beauty is in the eye of the beholder.” And that may be true, but if it is, our eyes like math a lot more than you might think.

What does math have to do with looking good? As it turns out, quite a lot actually. A proportionate and symmetrical face has been shown to be at the center of what we consider beautiful, and the “Golden Ratio” is at the center of facial proportions and harmony.

The Golden Ratio is found throughout nature, and has been used in art for centuries. Broken down into the math, the ratio is made of two lengths or quantities, where the two added together, then divided by the larger of the two is equal to the larger of the two divided by the smaller. Written simply as an equation it reads: (a+b)/a = a/b, where “a” is the larger value, and “b” is the smaller. Written as a value it equals about 1.618.

So, what does this mean for how we think about beauty? The distance between the eyes of a face with Golden Ratio proportions is 46% of the width of the entire face. The distance between the eyes and mouth, comprising most of the length of the nose, is about 36%, or 1/3 the length of the face.

Study after study have shown these proportions to be the most visually appealing, ancientists think we might be attracted to faces with this kind of harmony because they suggest good genes and good health.


The Anatomy of the Nose

Your nose is an amazing and complex organ. As the part of your respiratory system that sits front and center of your face, you're able to use it both for breathing, and stopping to smell the roses.

The nose's anatomy is broken into two areas: external and internal. The external anatomy of your nose is made up of all the structure that comprise the visible part of your nose. The internal anatomy is made up of all the structures that are within your nose, and deeper inside your face.

The important external, visible anatomy includes:

Radix

The radix is the highest and deepest part of the nose. This structure separates your forehead from your nose, and is usually about the same height as your pupils.

Dorsum, or “Bridge”

Also known as the bridge of your nose, the dorsum runs down your face from the radix to the tip of your nose, making up most of your nose's length.

Columella

The columella, meaning “small column” in Latin, makes up the skin that separates your nostrils from one another, down the middle on the underside of your nose. Under the skin of the columella are the cartilage structures that support the inside edge of the nostrils, called the medial crura of the alar cartilage.

Alae

Meaning “wings” in Latin, the alae make up the outer support and walls of the nostrils. Beneath the skin of the alae are the lateral crura of the alar cartilage.

The internal anatomy of your nose is primarily made up of bones and cartilage, and can be divided into thirds. The upper third has the nasal bones, the middle third is made up of the upper lateral cartilages, and the lower third is the tip of your nose, comprised of the alar cartilages.

Nasal Bones

The nasal bones are two fairly weak bones that from the “bridge.” These are often moved and repositioned during surgery targeting the nose, also known as rhinoplasty.

Upper Lateral Cartilages (ULC)

Making up the middle third of your nose, you should be able to feel where the nasal bones end and the ULC begins. The texture changes from hard and boney to soft and spongy. The ULC are there to keep your airways open. Weak ULC can contribute to a “pinched” look, while also causing airway problems.

Alar Cartilages

The shape and look of the tip of your nose is determined by the alar cartilages, which support it. Rhinoplasty often involves changing the shape and size of these cartilage support structures.

Septum

Acting as a wall separating the right and left sides of your nose, the septum is your nose's primary support structure.


What is Rhinoplasty?

Commonly known as a “nose job,” rhinoplasty is a cosmetic surgery procedure performed to change the external shape of the nose. It is often regarded as the most difficult cosmetic surgery procedure, mainly because it requires the surgeon to have a mastery of nasal anatomy, specialized techniques, and extensive experience and judgment. Nevertheless, rhinoplasty has becomes one of the world's most popular cosmetic procedures.

A Bit of History

Rhinoplasty has been around for at least 5,000 years, with the earliest treatment for the repair of a broken nose first mentioned in the Edwin Smith Papyrus, the oldest known medical work in the world, dating back to ancient Egypt from 3000 to 2500 BC. Since then the procedure has been written about in ancient India, during the Roman and Byzantine Empires, throughout the Middle Ages, and into modern times.

In Modern Medicine

The first modern rhinoplasty was performed in the U.S. in 1887 by an otolaryngologist, or ear and throat doctor. Dr. John Orlando corrected a “pug nose,” or saddle nose deformity.

The idea that you could choose to change the appearance of your nose took off in the early part of the 1900s, with Dr. Jacques Joseph, an orthopedic surgeon by training. Dr. Joseph went on to become one of the most prolific facial surgeons of all time. The celebrated doctor founded and headed the first Facial Plastic and Reconstruction Surgery Hospital, and many of his concepts and techniques towards nasal septal surgery and rhinoplasty are still in use today.

The 20th century saw a lot of contributions to the development of rhinoplasty techniques. Dr. Maurice Cottle developed many important concepts of nasal physiology and anatomy. Dr. Irving Goldman popularized the “closed rhinoplasty” technique. Dr. Jack Anderson started as an endonasal rhinoplasty surgeon, using the closed technique. After gaining fame, he adopted the “open rhinoplasty” approach, and became a major proponent of the style, speaking regularly about its benefits.

Since the 1950s, rhinoplasty has been considered fashionable, and with the development and evolution of the procedure, it's become more accessible and even more popular. In fact, recent statistics compiled by the American Society of Plastic Surgeons show that over 210,000 people received a nose job in 2015. Perhaps somewhat surprising to some, men make up a significant and growing percentage of patients, with the gender making up 24.43% of all rhinoplasty patients.

The procedure popularity is in great part due to its versatility. Rhinoplasty can either reduce or increase the overall size of your nose, straighten a crooked nose, alter the shape of the tip or bridge, narrow the span of the nostrils, or even change the angle between your nose and upper lip. Rhinoplasty can also help patients who need nasal reconstruction to improve their breathing.

Why You Want a Rhinoplasty

Noses get noticed. How can they not? Because your nose is the central, and often defining characteristic of your face, there are several good reasons you might be considering a rhinoplasty. The most common reasons to undergo this procedure include:

  1. Cosmetics
    Some people are just born with a crooked, bumpy, or otherwise prominent nose. This can lead to feelings of self-consciousness and low self-esteem. Rhinoplasty can reduce, straighten, and smooth out any nose to compliment the face on which it sits. This has the benefit of boosting self confidence as well as overall emotional well being. Some of the most common cosmetic complaints that a patient seeking rhinoplasty states include the following:
    • My nose is too big.
    • My nose is too thick.
    • My nose is too thin.
    • The tip is too pointy.
    • The tip is upturned, or drooping.
    • My nostrils are too wide or flared.
    • There's a bump on the bridge.
    • My nose isn't symmetrical.
  2. Accidents
    Accidents happen, and they have a way of happening to noses. Whether it's from a fall, car crash, or sports injury, rhinoplasty can correct damage to the nose. From an aesthetic perspective, you should have your nose assessed once the swelling from your accident has subsided. That way, you’ll have less of a chance of over-correction.
  3. Breathing issues
    Rhinoplasty can also sometimes be used to help with breathing difficulties. The most common cause of breathing issues is a deviated septum, which can also be referred to as a “nostril collapse.” This often leads to chronic snoring. Rhinoplasty can fix this easily, and in cases like this, is often covered by health insurance.
  4. Sinus problems
    Not only can a deviated septum cause snoring and breathing issues, it can also cause more severe medical concerns. Serious sinus infections and sinusitis, an inflammation of the sinuses, can be caused by a deviated septum. If an issue such as these is discovered, your surgeon will schedule you for a specific type of rhinoplasty, called a septoplasty, to address the problem.

The Different Types of Rhinoplasty

Primary Rhinoplasty

There are a number of different types rhinoplasty, each designed to fill a specific function. The first is simply referred to as a primary rhinoplasty. This can refer to any number of specific techniques and goals because it refers to the first surgery a nose has ever had. No matter what issue you want corrected, your first nose job is considered a “primary rhinoplasty.”

Primary rhinoplasty, before and after. Credits: Dr. Glenn Vallecillos

 

Revision or Secondary Rhinoplasty

Revision, or secondary rhinoplasty is performed to correct the shape or function of the nose after a failed or flawed primary rhinoplasty, which occurs in about 5%-20% of all procedures. This procedure is much more complex than a primary rhinoplasty because it has to deal with scar tissue from the previous surgery. It often requires the nose to be rebuilt using grafts from the nasal septum, ear cartilage, or rib cartilage, as well as synthetic implants if necessary.

Revision rhinoplasty can be used to correct a wide range of problems, including:

Bridge & Middle Third of the Nose Problems

  • Polybeak deformity (also spelled pollybeak deformity)
  • Open roof deformity
  • Tip asymmetry
  • Collapsed middle vault (inverted-V) deformity
  • Persistent bump, or over-resected (scooped-out) bridge
  • Tip knuckling
  • Wide or round tip
  • Pinched tip

Nostril Problems

  • Large or wide nostrils
  • Nostril collapse
  • Nostril retraction, alar retraction
  • Hanging columella

Deviated Nose Problems

  • Crooked nasal bones
  • Crooked septum & breathing problems
  • Crooked tip

Tip Problems

  • Pinched tip
  • Overly short or over-rotated tip
  • Droopy tip or poorly supported tip

General Problems

  • High or low radix
  • Long nose
  • Wide nose
  • Overly narrow nose

Revision rhinoplasty, before and after. Credits: Dr. S. Lin

Ethnic Rhinoplasty

The goal of every nose job is to give the patient a nose that best suits his or her unique face. Ethnic rhinoplasty simply does this while making sure that the patient's ethnic characteristics are preserved.

Most ethnicities have fairly distinct facial characteristics, and in many cases, the nose is one such feature. An “ethnic” rhinoplasty is simply a normal rhinoplasty that aims to give the patient all their desired results while making sure the nose “blends in,” so to speak, with the general look of their face and ethnic background. This is particularly important when considering to what extent the bridge, nostrils and tip should change.

"It has been observed that ethnic groups more often have certain prevalent characteristics that require a more individualized surgical approach," says Boston plastic surgeon and Harvard Associate Professor Dr. Samuel Lin. "Some of these historically noted commonalities among patients of African, Asian, and Hispanic descent include thicker skin, wider nasal bases, and a lower dorsum. It would be a major pitfall to attempt to sculpt the nose without accounting for these factors and may lead to an unnatural outcome. Different techniques than those used in the Caucasian nose to achieve the commonly requested look of a higher dorsum, narrowed tip, and narrowed base would be required. Of course, regardless of ethnicity, each nose must be tailored to the individual, and the term ethnic rhinoplasty is simply to recognize a more generalized observation among a certain population."

Ethnic rhinoplasty, before and after. Credits: Dr. S. Lin

Aging Rhinoplasty

As we age, our nose tends to go through some predictable changes. The skin begins to thicken as the tip starts to droop and stretch, thanks to gravity. This can give some people the appearance of a bump on their nose. In most cases, however, this isn't an actual bump, but rather just the appearance of one as the tip slowly moves away from the top of the nose.

This all happens as the attachments and support structures within the nose, as well as the skin elasticity outside, both begin to weaken. This can happen by the time most people reach 50 or 60. On top of that, the bone under the tip of the nose, and the teeth start to lose their volume, allowing the tip of the nose to droop further. Add to that the usual appearance of lines and wrinkles in the skin as we age, and the overall look of the nose simply deteriorates over time.

A remarkably simple rhinoplasty can correct most of these signs of the aging nose. This simplified surgery is only performed on the tip of the nose, utilizing cartilage grafts. No nasal bones are broken, and most patients recover in only about 5 days.

Aging rhinoplasty, before and after. Credits: Dr. S. Lin

Functional Rhinoplasty (Septoplasty)

A functional rhinoplasty, also known as a septoplasty, is a particular surgical procedure designed to correct a deviated septum and all the side effects that go with it. Your septum is the bone that separates your nostrils, and ideally runs down the center of your nose. When it displaces to one side or the other it can narrow that nostril and cause breathing issues.

During a septoplasty, your septum is straightened, and repositioned in the center of your nose. This should correct any airway problems, and can often correct chronic snoring.

"In less complicated cases, the procedures involved would include surgical treatment of the internal nasal pathway," says Dr. Lin. "These procedures consist of septoplasty (straightening of the septum), turbinate reduction (reduction of enlarged turbinates), or removal of nasal polyps. In more complicated cases, especially in cases of nasal valve collapse (the most narrow part of the nose), alterations to the external nasal framework may be necessary in addition to internal correction. These procedures are all done while maintaining the aesthetic appearance of the nose."


How Much Does Rhinoplasty Cost?

When trying to calculate the overall cost of your rhinoplasty procedure, there are three basic fees to keep in mind:

  • Anesthesia fee
  • Your surgeon's fee
  • Hospital/surgical facility fee

On average, your surgeon's fee for rhinoplasty will make up the majority of the overall price. But this doesn't include either the anesthesia fee or the surgical facility fee, or any other additional expenses for that matter. Anesthesia costs usually range from $600 to $1,200, and facility fees are usually between $700 and $1,100. This brings the total cost of rhinoplasty to an average of between $5,000 and $10,000. Of course, each of these costs can vary depending on your location, the extent of your procedure, and the surgeon you choose.

Other factors also contribute to the overall cost. For example, if you only need a slight reshaping of the nose, the length and therefore the cost of the procedure will be reduced, compared to a full change to your nose's shape. As with most surgical procedures, longer or more complicated operations will be more expensive. Additionally, thanks to the added difficulty, revision rhinoplasty tends to be more complicated, and therefore tends to be more expensive than a primary rhinoplasty. Post-op prescriptions might also add to your end costs.

If you are undergoing a rhinoplasty to correct a deviated septum, any reshaping of the nose might be considered reconstructive, and be covered by your medical insurance. An in depth examination will need to be performed to be sure that a deviated septum is the cause of your problems, and that a septoplasty can fix it.

Luckily, if cost is an issue for your rhinoplasty, most surgeons offer flexible, monthly financing plans. Third-party financing options are also available. These often take the form of “medical credit cards” which work exactly like a normal credit card, except they are specifically designed for elective surgeries.

Rhinoplasty, Mentoplasty… or Both?

Rhinoplasty addresses issues in the nose. Mentoplasty, or genioplasty, on the other hand, is a cosmetic procedure designed to augment a receding chin. To increase the chin's “projection,” or in other words, how far it sticks out, the patient may get either a medical grade synthetic implant, or have their bone structure altered (also known as sliding genioplasty).While it's true that most people focus on the nose when thinking about undergoing a cosmetic facial surgery, it's not the only way to achieve that pleasing profile. More and more patients are either combining their rhinoplasty with a mentoplasty, or are simply choosing to undergo the chin augmentation alone. For the most pleasing profile, your chin should closely line up with your upper lip, and be slightly angular. A weak chin can give the impression of asymmetry in the face, or even make the rest of your facial features seem out of proportion, especially in profile. That means if you have a weak chin, it could be making your nose look bigger than it actually is.

These procedures are often combined, but in many cases that isn't necessary. In fact, depending on the shape and composition of your facial features, a chin augmentation can make your nose seem smaller and more in proportion, completely eliminating the need for a rhinoplasty. Be sure to discuss all your options with your surgeon.


Issues That Can’t Be Corrected With Rhinoplasty

Before you decide on a rhinoplasty, it's important to understand the procedure's limitations so you can have realistic expectations for the results. Rhinoplasty is associated with a higher dissatisfaction rate than other cosmetic procedures, usually because of three reasons:

  1. Misunderstanding of a patient’s aesthetic goals.
  2. Impossible expectations.
  3. Failure to achieve expectations.

This procedure is designed to help patients achieve facial harmony; to make their nose “fit in” best with their other features. Rhinoplasty simply cannot make you look like someone else. Each person has their own, unique facial structure, which plays an important role in determining what nose shape and size will work best for them.

While many surgeons encourage patients to bring in images of noses they both do and don't like as a starting point, it's essential to understand that this procedure can't give you the exact nose as your favorite celebrity. These images simply help your surgeon gain a much better understanding of what you are hoping to achieve. With these images in hand, your surgeon will be able to work with you to find a nose size and shape that is appropriate for your facial features and structure.

When considering a rhinoplasty, it's a good idea to make sure you fully understand what the procedure is and isn't capable of. Rhinoplasty requires such a high level of precision that even a 1 millimeter change either way can impact results.Your goal should be to adjust a single part of your face, not to wake up looking like a different person. Think about actress Jennifer Grey – after she had a nose job, you could barely recognize her as Baby from Dirty Dancing!

Rhinoplasty is an excellent procedure for those with reasonable and realistic expectations, and once you fully understand both what it can do, and it's limitation, you'll be ready to schedule a consultation.

RELATED: Body Dysmorphia - Obsessed with Perfection

Psychological State of Rhinoplasty Patients - Harmony vs Perfection

The success or failure of a rhinoplasty is determined entirely by you, the patient. This is why your psychological state prior to your rhinoplasty is so important. Far too many people are looking for a “perfect nose” and can be quite disappointed with the results when perfection isn't achieved. As stated before, this procedure's goal is to bring harmony to your face by creating a nose that more evenly matches the rest of your features, and better suits your face overall. Understanding this important distinction going into surgery will help you have much more realistic expectations, as well as help ensure a more positive outcome.

Your psychological state is so important in this regard that if your surgeon is under the impression that you don't fully grasp the important differences between perfection and harmony, or what the procedure is and isn't capable of, they may not wish to perform your operation.


Ideal Candidates

Even though rhinoplasty is often considered one of the most difficult cosmetic procedures, it is also one of the most diverse surgeries. The procedure allows nearly anyone who is self-conscious about how their nose looks to have something done to either correct or improve the problem. That said, there are some limitations, so it's best to speak with a surgeon to see if you're a good candidate. In general, ideal rhinoplasty candidates:

  • Are older than 15 (for girls), or 16 (for boys). This is because the American Society for Plastic Surgery (ASPS) recommends waiting until the nose has finished developing before undergoing rhinoplasty. This can be different for everyone, but these ages are a good guideline.
  • Are in good mental and physical health.
  • Don't have any chronic illnesses that might create unnecessary complications during either the surgery or recovery.
  • Don't smoke, or are able to quit a minimum of two weeks before the surgery, and continue to not smoke throughout recovery.
  • Understand the potential risks involved.
  • Are unhappy with their nose's appearance, or have breathing difficulties because of structural issues within the nose.
  • Have realistic and reasonable expectations for the results.
  • Understand that rhinoplasty can improve their appearance, but cannot achieve “perfection.”
  • Has made the decision to undergo a rhinoplasty of their own free will.

Preparing For Nose Surgery

Even though the actual rhinoplasty surgery might be relatively short, often lasting only a few hours, the entire process from booking your initial consultation, through to fully recovered, requires a much larger time commitment. Rhinoplasty might be a popular and common cosmetic surgery, but you shouldn't take it lightly. As a matter of fact, you should begin to prepare yourself for the operation weeks before your scheduled surgery date to make sure you have a speedy recovery, and optimal results.

The very first thing you'll do during your preparation for a nose job, well before any surgery is scheduled, will be to meet with your surgeon to discuss a variety of important factors. This will determine if you’re a good candidate for the procedure to begin with. Your consultation will most likely involve a frank discussion about your motivations for the surgery, and what your end goals are. You'll also be asked about your medical history, including any history of nasal obstructions, prior surgeries, and any medications you're taking. If you have any chronic medical issues, now would be the ideal time to tell your doctor.

This initial meeting will also most likely involve a complete physical exam, including lab tests. The skin and both the inside and outside of your nose will be inspected. This exam helps give your surgeon a better idea of what needs to be changed, and how your unique facial features might affect the results. Sometimes, this physical exam will also include photographs of your nose taken from different angles. Your surgeon might use a computer application to manipulate the photos to show you what kind of results are possible with your features. Don’t take these photos as being concrete proof of how you’ll look after surgery. They’re only a prediction of your results. The most important role these photos play, however, is starting a discussion about the specific, unique goals you have for your surgery.

Once you've met with your surgeon, and you fully understand what rhinoplasty can and cannot do for you, your nose job can be scheduled. From this point the most important thing to do to prepare is to alter your diet, and get active. Ideally, in the weeks leading up to your surgery, you should prepare your body for the changes that are about to take place by doing everything you can to stay healthy going into the procedure. That means nutritious meals in the proper proportions, and raising your level of exercise a bit. Take walks after dinner in the evenings, or bicycle on weekends. The healthier you are going into any surgery, the better equipped your body is to heal afterwards.

 Top 10 Tips To Prepare You For Rhinoplasty 

  1. About two weeks before your rhinoplasty you should stop using any aspirin, ibuprofen, vitamin E, or any other herbal supplements you might be taking. These medications can interfere with your body's natural ability to form blood clots and generally heal. Since your nose is the central feature of your face, you'll want to give it the best opportunity to recover properly.
  2. If you are a smoker, you'll need to stop a bare minimum of two weeks before your rhinoplasty. Nicotine in the blood stream can have a horribly negative effect on healing, prolonging bruising and swelling. Quitting is the best way to ensure your nose heals well and quickly.
  3. Compared to many cosmetic procedures, rhinoplasty's recovery is relatively short. That being said, many people find themselves self-conscious of the facial bandaging immediately after the procedure. So save yourself a little headache, and consider stocking up on household supplies and fill your prescriptions ahead of time so you don’t have to go out in public.
  4. See if you can enlist the help of a relative or friend for the first few days and nights post-op. You might still be a little groggy after the surgery, so it's nice to have someone around to help you out and keep track of when you've taken your meds.
  5. Following your surgery, you'll be breathing through your mouth for a little while. Because of this, your mouth will get very dry, and maybe a little uncomfortable. Before your surgery, stock up on lip balm and beverages to help. A humidifier is also a good idea.
  6. Make sure your doctor understands what you do and do not what done. This is your nose, so now is not the time to be shy. Speak up, or you might regret it later.
  7. Anxiety is normal leading up to a rhinoplasty. After all, your nose is a pretty important part of your face. If the anxiety begins to grow to an extreme, feel free to schedule another appointment with your surgeon. This can help alleviate any lingering doubts or fears, as well as give you another opportunity to ask questions.
  8. Even though rhinoplasty might seem much less involved than, say, a tummy tuck or liposuction, you still won't be able to drive yourself home after the procedure. Make sure you arrange transportation beforehand. In fact, you’ll most likely need a trusted friend or family member to be with you in order to be discharged from the surgical facility.
  9. Have you ever felt pressure in your nose or head when you strain to lift something heavy? Now imagine how that pressure might feel during your rhinoplasty recovery. To avoid this pressure, it's a good idea to get any strenuous work out of the way ahead of your procedure date. You'll want to avoid any heavy lifting for at least three weeks after surgery.
  10. Following the procedure, your nose will be sensitive, and you'll need to avoid bumping it. Wearing loose, comfortable clothing to your operation will help with that. Shirts that button up, and won't need to be pulled over your head are highly recommended.

The Surgery

Thanks to rhinoplasty's ability to adapt to the goals and needs of each patient, the procedures themselves vary widely for each individual. However, they all generally start with the same step: anesthesia. There are two sedation methods available for rhinoplasty: general and IV sedation.

General anesthesia is administered with a mask or IV, and will put you completely to sleep. IV sedation on the other hand, is different. Your doctor will numb your face with a local anesthesia, then give you a powerful sedative through an IV line. You'll experience a “twilight sleep,” and will probably not remember much, if anything, of the procedure afterwards. Which method is better suited for you will be something you discuss with your surgeon ahead of time. Once you're fully sedated, the procedure can begin. There are two primary approaches to the rhinoplasty procedure: “closed” and “open.”

Closed or Endonasal Rhinoplasty

The endonasal rhinoplasty approach gets its nickname, “closed,” from the fact that all the surgical reshaping is made inside the nose, without any visible incisions made to the face. In fact, all the incisions for this approach are made entirely inside your nose, allowing your surgeon access to both the nasal tip and the bridge. Incisions are made along the inside of each nostril, called “marginal incisions,” and are made in an arc shape that follows the curve of the alar cartilage. Next, through the nostril, another incision is made between the alar cartilage and the upper lateral cartilages (ULC), called the “intercartilaginous incision.” Through these incisions both the tip and the bridge of the nose can be reshaped with no external scarring.

In the case of tip reshaping, or structural rhinoplasty, your surgeon will make both the marginal incisions and the intercartilaginous incision together. Once completed, the alar cartilage can be pulled out of the nostril and reshaped. A great deal of nasal tip shaping can be achieved with the closed approach, especially if your surgeon has experience with this technique.

In the case of bridge reshaping, the intercartilaginous incision is the most important, as it allows access to the mid and upper parts of the nasal bridge. Through this incision, the skin of the nose is lifted off the underlying cartilage and bone to allow for reshaping. Once this is done, a retractor is put in place to keep the skin elevated while your surgeon addresses the bone and cartilage. This is all done through your nostrils. The closed approach has had a lot of success in reducing the nasal bridge height, and is used in osteotomies, where the nasal bones are carefully and skillfully broken to narrow or straighten the bridge.

The closed technique can have very successful results, but most surgeons agree this method is more difficult because they can't see what they are doing as well. The surgeon is essentially operating “blind”. Imagine trying to fix some broken pottery under a sheet. It's not impossible, but certainly difficult. Choose an experienced surgeon in this technique for the best results.

Open or External Rhinoplasty

The “open,” or external, approach to rhinoplasty utilizes a small, inverted-V incision across the columella, connecting the nostrils. With the addition of very similar internal incisions as the closed approach, the entire nasal skin can be folded back, almost like the hood of a car. This gives your surgeon a much better view of what they are doing with the internal structures of your nose. With this extended view, your surgeon can assess nearly the entire nasal framework. This allows them to create as much symmetry as possible, since the entire nose is able to be visualized at once, rather than through separate incisions as with the closed technique. Once the nasal cartilages are exposed, your surgeon can reconstruct the whole area by reducing, reshaping, and suturing. Cartilage grafts from other parts of your body can also be used to maintain the shape and form of your nose. Results tend to be more predictable with this approach.

Septoplasty or Deviated Septum Surgery

 

Computer tomography of nasal septum deviation

The nasal septum separates the two sides of your nose. It's made up of bone, cartilage, and the soft tissues that cover everything, like the lining of the nose. If the positioning of the septum is skewed towards one side or the other, it can create blockages in the airways. For patients suffering from breathing issues due to a deviated septum, a septoplasty procedure can help.

The primary goal of septoplasty is to straighten up the septum, restoring its position to the middle of the nose to open the airways. This is achieved by lifting the lining of both sides of the septum through small incisions inside the nose. Through these small incisions, your surgeon can remove part of the septum, as well as reposition it into a straighter alignment. Once the septum has been fixed, nasal splints might be placed inside the nose to help with healing, and the lining of each side of the septum is replaced. Stitching may be used to help the lining heal properly.


Rhinoplasty Recovery

Rhinoplasty can have some pretty dramatic results for a lot of people, but it's important to remember that the recovery period will require some patience. Rhinoplasty often involves making significant changes to bone and cartilage, so it might take some time for your body to fully recover and heal. Usually, the recovery time for a nose job is about two weeks, but because each surgery is tailored to meet your facial structure and goals, the actual recovery time will vary patient to patient. The length of your recovery will depend on a number of factors, including:

  • The extend of the surgical changes to be made.
  • The quality of your post-op care.
  • Your overall health before surgery.

For a lot of patients, the first 24-48 hours of recovery are the most difficult. You'll still likely be feeling some of the effects of the anesthesia, and you might have some mild discomfort. Your surgeon can give you a prescription for pain medication if it gets too bad, but most people need only over-the-counter medications. During your first 24 hours it's common to experience:

  • Headaches
  • Swelling
  • Bruising
  • Nosebleeds

It's best to sped the first 24 hours recovering comfortably in bed with your head elevated. Your nose will ache, you might have a dull headache, and your face will probably feel puffy. Some bleeding is also normal, and can be expected throughout the first 48 to 72 hours. Remember not to blow your nose for a while, because this forceful action too early into your recovery can have a seriously negative impact on your results.

RELATED: Rhinoplasty Preparation and Recovery Advice

About a week after your surgery you'll likely have a follow-up appointment so your surgeon can keep track of your progress. If your procedure involved nasal packing it will be removed at this time, as will any and all splints and stitches. Your bruising should start to fade, and the swelling should be only minor. Most patients are able to go back to work and get back into a normal routine about a week after their nose job. Even if you are able to resume most of your normal activities, it'll still be important that you stay cautious, and avoid and strenuous exercise. You should stay away from activities like sports and weightlifting for at least two weeks, and avoid any other physical activity that might result in a blow to the nose for about eight weeks. It's also highly recommended that you avoid airline travel right after surgery, as the changes in pressure can also have a negative impact on your results.

For most patients, the satisfaction they feel after their rhinoplasty far outweighs any pain or discomfort they might experience during recovery. Nearly all the side effects of this procedure fade relatively quickly. That said, it's important to keep in mind that some minor swelling might persist for much longer, even up to several months. In the end, it might take up to a year for the final, full results to be revealed.

 Top 10 Tips For Recovering From Rhinoplasty 

  1. Swelling is a normal side effect immediately following rhinoplasty. To help reduce this swelling and keep your recovery moving forward you'll want to make sure to keep your head elevated while you sleep and reduce sodium intake.
  2. As your nose is healing it's important to avoid bumping it. That means watching out for pets, small children, and anyone you share a bed with.
  3. A common complaint following rhinoplasty is fluid retention in the tip of the nose. You can minimize this issue by starting a low-sodium diet the day after your surgery, and maintaining it throughout your recovery.
  4. The discomfort and soreness of your nose may radiate into your mouth and jaw. Stick to soft foods for the first week or two to help ease this pain.
  5. Don't wear glasses as you normally would for at least four weeks after your rhinoplasty. Resting glasses on your nose like normal can seriously disrupt its healing, especially if you’ve had bones broken during the surgery. If you must wear glasses, try either taping them to your forehead, or use some sort of foam or pad as a cushion between your glasses and nose. A splint or “frame up” to prop them up off your nose can also help.
  6. Keep your nose out of direct sunlight for a few months after surgery. Sunscreen and hats help promote healing and reduce swelling.
  7. Blowing your nose during your recovery can be a little tricky, especially if you have undergone a septoplasty. Be sure to discuss exactly how you should be blowing your nose with your surgeon, but these guidelines are a good place to start.
    • Rhinoplasty without septoplasty: You can blow your nose gently and with care after about 2 weeks.
    • Rhinoplasty with septoplasty: You'll be able to blow your nose with care after about 4 to 6 weeks.
    • Rhinoplasty with septal perforation repair: You'll need to wait up to 12 weeks to gently blow your nose.
  8. Stay on top of your medication schedule. Pain after a rhinoplasty is usually fairly mild, but it can grow quickly. If you're not staying on schedule with your meds it can be difficult to get it back under control.
  9. Take a nap when you feel sleepy. Sleeping promotes healing, so if you have the opportunity to nap, take it. Just make sure you keep your head propped up on pillows.
  10. During your recovery it's important to remember that the swelling can take between a few weeks and a full year, or more, to completely fade. Try to keep in mind that what you look like right after surgery is not the same as what you will look like once all the healing is finished.

Post-Recovery Results

Rhinoplasty often makes very small changes to the structure of your nose, sometimes changes as small as millimeters. But these small changes can make a huge difference in how your nose looks. That said, the results of rhinoplasty are often more difficult to predict than with other cosmetic procedures, and rhinoplasty results tend to have a higher dissatisfaction rate. In order to make sure you're truly happy with your results, it's important that you and your surgeon agree on your goals ahead of time. Still, in some cases, these slight changes may not be enough, and you and your surgeon may decide on a revision rhinoplasty at a later date.

Once your surgery is complete, your recovery will take up to a full year to completely finish. During this time minor swelling will slowly fade, and your new nose will be revealed. As you move on with your life following the procedure, and your body continues to age, it's natural to see some gradual changes to your face, including your nose, but the overall improvements made should be more or less permanent.

Scarring

Just like all surgeries, there is always the possibility of some scarring following a rhinoplasty. In the case of a closed procedure, all the scarring will be inside the nose, so they will effectively be invisible. For an open rhinoplasty, most of the time the only external incision made is very small, across the columella between the nostrils. Because this incision is so small, and on the underside of your nose, even if it doesn't heal invisibly it won't be noticeable at all.

Maintaining Results

As with most cosmetic procedures, the best way to maintain your results is to make healthy lifestyle choices. Proper diet and exercise are not only good for your new nose, they're good for your whole well being! Unfortunately, even after your rhinoplasty your nose will continue to age, and change accordingly: the skin might blemish from sun damage, pores might enlarge, blood vessels might become more visible. The best way to avoid these subtle changes is to keep your nose and face out of direct sunlight, and use a sunscreen with a high SPF.

Rhinoplasty is often considered one of the most difficult cosmetic procedures, and as such, there is a relatively high rate of revision surgeries. In up to 20% of cases additional modification of the nose is necessary to either achieve, or maintain, your desired results. Be sure to stay in contact with your surgeon during and after your recovery to ensure you stay fully satisfied with your new nose.


Latest Techniques and Scientific Studies

Rhinoplasty is one of the most technically demanding facial cosmetic procedures. As a result, surgeons consistently seek to revise their surgical techniques to ensure the highest possible understanding of nasal aesthetics and soft/hard tissue dynamics to achieve a balance of form and function. Moreover, individual patients’ anatomies mean a customized approach is paramount to ensure any medical factors that may impact on the final outcome are taken into account.

Computer modeling and simulation is a recent development that holds the potential to revolutionize how rhinoplasty is performed. Modeling has been successfully used for decades in fields such as engineering, helping engineers conceptualize and design complex processes. With the development and advance of computing technology, applications for modeling and simulation have gradually expanded to the medical sphere.

A 2017 report in the Facial Plastic Surgery Clinics of North America notes that modeling can now be applied to rhinoplasty techniques to help surgeons make more informed decisions about the most effective maneuvers to achieve an optimal aesthetic outcome. Modeling also takes into account a patient’s specific anatomy while ensuring that any clinical requirements are also considered, thereby promising rhinoplasty closely tailored to the individual.

Another influential development in rhinoplasty is research into the use of silicone-polytetrafluoroethylene (PTFE) implants with a silicone core and PTFE liner. Nasal implants are mainstays of Asian rhinoplasty and also used for individuals with smaller noses wanting greater nasal height. However, silicone and Gore-tex implants sometimes provoke a foreign body response and are prone to migration (movement once inserted).  A 2017 study trialled these composite implants on 177 patients, and revealed promising results. Watch this space.


Frequently Asked Questions

What are the potential side effects and risks of rhinoplasty?

When performed by a qualified and experienced cosmetic surgeon, a rhinoplasty is a very safe procedure, with few, rare long-term complications. Of course, no surgery is completely without risk, so you should be aware of what is possible. Temporary side effects of rhinoplasty usually fade within a few weeks, and include:

  • Bruising around the eyes. This should fade within two weeks of surgery.
  • Soreness and irritation, especially in the areas that have been reshaped or had tissue removed. This is usually easily controlled with over-the-counter medications.
  • Swelling. The majority of this swelling will dissipate quickly, with mild swelling possibly persisting for up to a year. Swelling may interfere with breathing ability.
  • Inflammation of the sinus passages, called “sinusitis.” This is often associated with a temporary change to the voice, and extra mucus production.
  • Nosebleeds are normal for the first 72 hours or so of recovery. Any spontaneous nosebleeds after this time-frame aren't usually serious, but you should alert your surgeon if they happen.

Some of the rare, but more serious rhinoplasty complications may include:

  • Infection
  • Negative reaction to anesthesia
  • Unsatisfactory results, including asymmetry
  • Noticeable scarring
  • Numbness
  • Serious breathing difficulties
  • Chronic nosebleeds
  • Perforated septum
  • Burst blood vessels
  • Hematoma, which is a collection of blood beneath the skin
  • Possible revision surgery

Are there nonsurgical rhinoplasty options?

Recently a nonsurgical alternative to rhinoplasty was developed using dermal fillers to enhance the shape of the nose. Also known as a liquid nose job, this injection treatment is ideal for correcting minor issues like smoothing a bump on the bridge or adding volume to the tip. It generally takes only a few minutes to complete, with results lasting a few months at most depending on the injectable filler product used. Unfortunately, if you are looking for more major changes, need a reduction, or require treatment to correct a deviated septum, surgery is the only viable option.

RELATED: The Pros and Cons of Non-Surgical Rhinoplasty

How important is my surgeon's experience with rhinoplasty?

Because rhinoplasty is widely considered one of the most difficult cosmetic surgeries (if not the most difficult), and there is a higher dissatisfaction rate than with other procedures, it's safe to say that your surgeon's experience with the operation is of the utmost importance. With the rate of revision rhinoplasty hanging around 15%-20% the very best thing you can do to make sure you are happy with your results the first time is to make sure you find a surgeon who is skilled and experienced with nose surgery.

How long does a rhinoplasty procedure take?

Each procedure's length will be fairly unique, determined by your goals. That said, the typical primary rhinoplasty takes about an hour or two, while a secondary surgery can take as long as four hours.

Am I too old for rhinoplasty?

There is no upper age limit for the procedure. That said, to avoid certain risks, you'll need to be in good overall health. Also, for the best results, you should have good skin elasticity in your face, particularly around the nose.

When can I go back to work or school?

You’ll be able to get back to sedentary work and school in about a week. If your job is physically strenuous, then you’ll need to wait longer. Any physical activities, like contact sports, should be avoided for at least two months or so.

It’s important to know that if you’ve had your nose broken, it will be more susceptible to fracture again. Therefore, take care when doing martial arts and playing sports like football, soccer or volleyball.


Glossary of Nose and Rhinoplasty Terms

Ala (plural: Alae): Commonly referred to as the nostril. These are crescent-shaped, and surround the nostril openings.

Alar Cartilages: Also called the lower lateral cartilages, these are flexible arches of nasal cartilage that determine the shape and strength of the columella, nasal tip, and alar rims.

Bulbous Tip: A cosmetic issue characterized by a wide, oversized nasal tip with large alar cartilages.

Cartilage Graft: A piece of cartilage taken from another part of the body (ribs, ear, etc.) custom shaped to strengthen or reshape the nasal skeleton.

Columella: The central “column” that is between the nostrils, as seen from below. It's made of skin, and the paired right and left medial crura.

Dorsal: Having to deal with the nasal dorsum, or bridge.

Intermediate Crus (plural: Crura): The part of the alar cartilage that is above the nostril, but below the nasal dome.

Lateral Crus (plural: Crura): A part of the alar cartilage. This extended above the nostrils.

Medial Crus (plural: Crura): The bottom-most part of the alar cartilage.

Middle Vault: The middle third of the nose. This is made entirely of cartilage, and is formed by the mid-line dorsal septum and the upper lateral cartilages.

Nasal Domes: The hinge-point of each alar cartilage. These define the nose's tip.

Nasal Tip: Also called the “lobule,” this is the forward-most part of the nose, and is formed by the alar domes.

Radix: The nasal root, located between the eyes. This is the upper limit of the nasal bridge, and roughly corresponds to the deepest parts of the nasal bone.

Septum: The dividing wall between the right and left nasal passages. This is formed by cartilage and bone and is covered with a layer of nasal mucosa.

Tip Projection: This term refers to how far from the vertical plan of the face the nose sticks out.

Upper Lateral Cartilages (ULC): The cartilage structures that make up the medial vault.