A rhinoplasty is an operation that changes the shape of the nose.
The name Rhinoplasty is derived from the Greek rhis meaning nose and the Greek plassein meaning to form. (Similarly, the word rhinoceros implies an animal with a large horn on the end of its nose, the Greek word for horn being keras.)
The operation of rhinoplasty is sometimes called a nose job but this is a rather demeaning term for what is often a very difficult and exacting surgical procedure.
Rhinoplasty is a common operation performed by plastic and ENT surgeons in Australia. It may be less commonly performed in USA where plastic surgeons perform an average of only 7 rhinoplasties per year. (Other cosmetic operations have increased in USA with the total number of procedures more than doubling between 1992 and 1998. Liposuction is the most common cosmetic procedure requested by both men and women.)
There are many ways to change a nose. For example, reducing a prominent bridge line, narrowing a broad nose tip and shortening a long nose. The Typical Rhinoplasty Patient requests reduction of a large nose to refined dimensions.
Lifting the nose tip is carried out by trimming the edge of the septal cartilage, trimming the upper edge of the tip cartilages and removal of some lining skin or mucous membrane inside the nostrils. Unfortunately, the tip position may change in the months following the surgery, most commonly a slight drooping of the nose tip while the nostril rims stay elevated. The Miss Piggy deformity is an exaggerated form of this change. Over zealous changes to the nasal pyramid may also weaken the nose too much. Thus, it is better to aim for modest improvement rather than great changes when doing the traditional operation.
The traditional operation is usually carried out in hospital under general anaesthesia. Lines are drawn on the skin of the nose to indicate the desired reductions and incisions are made through the skin inside the nostril openings. A special instrument called a retractor is inserted into a nostril and held by an assistant surgeon or nurse. The skin and soft tissues are dissected away from the cartilaginous and anterior bony skeleton enabling reduction of these structures. Scalpels, scissors, rasps. diamond files and special dissectors are used. When the desired reduction in nasal prominence is achieved it is time to make cuts called osteotomies through the nasal bones (5) with a hammer and chisel so that the width of the nose may be narrowed. The incisions inside the nostril opening are then sutured with dissolving (cat gut) sutures.
The patient returns to the office for splint removal one week after surgery. At that time there will usually be some bruising around the eyes and upper cheeks and this is gone after another week allowing a return to work.
The nose feels rather stiff for approximately three months and then it softens. This is when a slight drooping of the nose tip may occur. Often the nose will have been upturned a little too much at first so the droop is a welcome change!
Swellings are present and are usually soft and easily indented in the first three or four weeks becoming firmer and sometimes hard at six weeks. The commonest site for swelling is just above the nose tip in the supra tip area. It usually takes twelve months for the swellings to subside completely.
The open rhinoplasty has become a popular operation but it also has the size reduction limits of the traditional operation. The name implies a more open exposure of the nasal skeleton by placement of an additional incision across the columella (1) and complete elevation of the skin from the tip cartilages.
The nose tip (2) can be the most difficult nasal structure to modify in a pleasing way. Complete exposure of the cartilages allows new techniques such as folding the cartilages with permanent sutures and accurate reduction of asymmetrical cartilages for greater symmetry.
Tip refinement usually means converting a broad, featureless nose tip into a more angular and pointed shape. In the past, this was often attempted in the closed ("Traditional") operation by removal of much of the tip cartilages. Experience with the open operation has taught surgeons to be more conservative. It is apparent that retention of the tip cartilage is necessary for skin support, preventing the slumping of the skin into a featureless shape.
The open method is particularly useful when extra cartilage is required in the nose tip to increase projection. Cartilage grafts can be sutured to the existing cartilage framework and shaped very accurately. This is a very effective method but it should not be over done.
Delicate cartilage graft "struts" can be fitted and sutured within the columella to strengthen and straighten this part of the nose. A moderate amount of projection of the columella can be achieved in this way. (If a big projection is required it is usually necessary to insert a large cartilage graft, such as that taken from the rib cartilage, behind the columellar base.)
The disadvantages of the open rhinoplasty are the resultant scar across the surface of the columella (1) , the longer operative time which will incur higher fees and hospital charges and more prolonged swelling of the nose tip (2) .
Paul O'Keeffe developed this operation after years of dissatisfaction with the traditional rhinoplasty operation and a study of fresh cadaver nasal anatomy. It is a closed rhinoplasty so there is no external scarring.
Muscle was found in the columella base that acts like a tether, pulling the columella backwards when the columella is made to sit higher on the face by nasal shortening.
Apart from the muscle in the columella base, which could be called the superficial depressor septi muscle, plentiful elastic tissue was found in the mucous membrane above the columella, which pushes the columella forward. Thus, there are balancing forces controlling projection of the nose tip.
There is, in Template Rhinoplasty, a complete elevation of the skin and soft tissue from the nasal pyramid that facilitates its redistribution so thickening of the tissue is hardly ever seen. Thus, accurate pre-op planning becomes an option.
Slackness of the lateral alar ligament can be assessed by pulling the cheeks laterally, tensioning the sides of the nose. If this makes the airway is clearer it is likely that the template rhinoplasty will improve the function of the nose.
A disadvantage of template rhinoplasty is the longer time required for planning and for doing the operation and the corresponding greater expense.
There is a more detailed description of this operation in the Template Rhinoplasty section of this site.
It is uncommon for a patient to notice a slight nasal bend when looking in a mirror. Photographs and the image-reversing mirror will reveal the deviation. That is why many of us do not like to have photographs taken. A person with a more severely bent nose may complain of blockage of the airway.
Paul O'Keeffe modified the septoplasty technique at the beginning of 2001 to include a safe chondrotomy (cartilage cut) shown as yellow lines on the figure. This has greatly improved the septum-straightening results without the previously feared septal collapse that might occur after a different chondrotomy.
Septal bone is often thickened where coloured green in the figure. It is called a spur and would be removed at septoplasty. (NB the caudal end of the septal cartilage is broken away in the figure to show its dislocation off the vomer bone.)
Various implant materials are used to augment the size of the nose. This is particularly so for Asian patients who seem to tolerate the implants better than Caucasian patients.
Silicone has been a popular material for nasal implants over many years. The implants are specially shaped to fit over the skeletal bridge and they resemble a saddle in shape and function. There may or may not be an additional piece for the columella in which case the overall shape is an "L". The advantage of silicone is ease of insertion and ease of removal should problems arise.
Silicone implants have not worked well for Caucasian patients. Too many implants become infected and extrude. Plastic surgeons in Japan report almost none of these problems and some of those surgeons implant hundreds of implants every year. This racial difference is probably due to Caucasians often having a history of trauma, accidental or surgical, when they need nose augmentation.
Some newer implant materials are now in use. Many of these are porous and allow for tissue ingrowth (eg. Medpor). This may have the advantage of better retention for Caucasian patients. A possible disadvantage is the difficulty experienced should the implant have to be removed for any reason.
A rhinoplasty revision procedure may have been predicted from the beginning or be unexpected. Procedures that can be predicted are secondary alar base reductions and nostril sill reductions.
Unexpected revisions may be adjustment to nasal bone and septum positions when a bent nose was incompletely straightened, adjustment of tip tilt if this is wrong and smoothing of persisting irregularities on the dorsum of the nose.
Sometimes the nasal pyramid has widened during the healing process. Internal swellings may have pushed against the bones. Pressing against the bones can help in the early stages. If necessary, the bones can be repositioned surgically after the swelling settles - a new external splint is needed.
It may be necessary to inject a steroid into the nose if there is persisting swelling above the tip. That may be done 6 weeks after surgery.
Sometimes, a little too much cartilage was removed and some cartilage needs to be replaced. This would often be done as an office procedure, taking a cartilage graft from the septum.
Septal adhesions can occur after septal and turbinate surgery. The adhesions are usually very easy to deal with in the office but they can recur. The adhesion could be treated again and a silicone splint placed in the nose for about one week to stop further recurrence.
Sometimes we see patients who have had substandard rhinoplasties. They require more extensive revisions (nasal reconstructions) with cartilage grafts, bone grafts or perhaps the Medpor Nasal Shell.
Cartilage grafts are harvested from various parts of the body. The best source is the nasal septum (4) where a moderately large flat piece of cartilage is normally available. Augmentation of the bridge of the nose (nasal dorsum) can be done with septal cartilage. The graft has to be long enough and flat enough to do the job. The graft may be single or multiple layers sutured together.
Septal cartilage is also excellent for augmentation of the nose tip. Dr Ron Gruber of Oakland, CA, designed a particularly good tip graft comprising two small pieces of cartilage sewn together. The graft is fixed in place with sutures via the open rhinoplasty operation. Placing large pieces of cartilage in the tip is not advised because tip skin will not stretch enough.
The second preference is ear cartilage. The supplies are obviously limited but it is good for reconstructing various parts of the nasal skeleton, especially the nose tip. There would be enough cartilage to make spreader grafts, grafts that are used to reconstruct the normally wider middle third of the nasal dorsum.
Rib cartilage graft from nose tip to mid dorsum has bent forward at top end
Increasing the projection of the whole of the tip structure is a major undertaking. The desired effect can be demonstrated by holding the columella forward between finger and thumb. The nose tip advances and tilts upwards in a pleasing manner, correcting any droop of the nose which may have been caused by previous surgery or just the ageing process. This effect is difficult to achieve surgically because the lip muscles are very strong and pull the advanced columella back. A relatively large graft such as rib cartilage is often required to do the job. The graft is placed as a strut between the anterior nasal spine and the columella base, sometimes via the mouth.
The nasal septum (4) is a good donor site because it is out of sight. The septum may be deviated and removal of the deflected cartilage will correct the septum as well as provide the graft tissue. There is very little discomfort associated with harvesting the graft apart the possible need for packing or intra nasal splinting afterwards. A new cartilage usually forms within the septal tissue. This takes a few years and it is only a thin layer.
The ear is a good donor site provided the cartilage is taken from within the shell of the ear. It is often impossible to tell by looking that cartilage has been removed from the ear. There will be a scar on the back of the ear which looks like a normal crease in the skin. Very rarely will the scar thicken and become a keloid. The alternative is a scar within the shell of the ear. This scar is visible but the quality is much better if there is a tendency to form keloids.
Rib cartilage grafts produce a painful donor site. Pain can be felt with each breath and this can persist for many weeks. However, strapping the ribs is not usually necessary. A scar is present at the donor site and this may become moderately thickened especially if the skin has an elastic property. Taping the scar with paper tape for many weeks improves the scar quality. Keep taping until the scar is becoming a paler pink colour.
Bone may be taken from various sites in the body, eg. nose, hip, skull, rib, elbow, etc.
Small pieces of nasal bone may be removed during the course of traditional rhinoplasty and can be re implanted as a graft. A particularly good use for this bone is as a graft to bone gaps at the lateral osteotomies. The lateral osteotomies are cuts made in the nasal skeleton so the nose can be narrowed.
Hip bone grafts were commonly used for nose reconstruction years ago but are now less popular with plastic surgeons because the bone tends to shrink. This is due to the lack of density of the bone, a feature which was helpful for carving it. A very dense bone is more difficult to work with but it has a much better chance of persisting in the nasal skeleton. Apart from the problem of resorption of the graft, the hip can be a painful donor site.
Skull (also called calvarial) bone is very dense and works well for nasal reconstruction. The skull is formed from two layers of bone which are separated by a type of marrow. The outer layer may be removed and used for grafting. This is a delicate procedure! It is possible to cause a fracture of the skull and there is a remote chance of damage to the underlying brain. The use of skull bone is not recommended after the age of 50 years when the outer layer of bone fuses with the inner layer due to disappearance of the marrow (also called diploe).
Rib bone is quite good for grafting into the nose. The hard outer layer of the bone called cortical bone is used. Problems are that the rib is curved, there will be a scar on the chest and the donor site may be painful.
A strip of bone may be taken from the elbow (also called olecranon) and used to build up the nasal bridge line. The bone is not particularly dense but the small quantity that would be harvested is likely to persist in the nose longer than a block of very porous (cancellous) bone from within the hip bone. This scar and minor bone deformity at the elbow are very acceptable.
Rhinoplasty surgery is difficult so it is not surprising that problems arise from time to time. It has been said that a surgeon needs to have performed one hundred such operations in order to get good at it.
The commonest problem is the unexpected result. It may be a technically satisfactory result but not what the patient requested. Perhaps the nose ended up much smaller than intended. The answer to this is unhurried pre-operative consultations where photographs are viewed followed by accurate surgery (eg. template rhinoplasty).
The result may be less than satisfactory but not technically bad. The drooping tip is a common example of this. As discussed above, the answer to this problem involves the lateral alar ligament as in the template rhinoplasty.
Another example of a less than satisfactory but not technically bad result is supra-tip swelling. This is seen in cases where the nose has been greatly reduced in size. The skin and muscle layers are too big for the smaller skeleton so the tissue bunches up. The answer to this problem is adequate redistribution of the skin and muscle by more than the usual freeing of tissues. The redistributed tissue can be taken up at the junction of nose and cheeks if the nasal pyramid is adequately narrowed.
Partial blockage of the nasal airway is another problem that is certainly not rare. The conventional procedure used to shorten a long nose produces slackness in the soft outer walls of the nose so they suck inwards on inspiration, blocking the airway. The majority opinion is that the obstruction is at the internal nasal valve, defined as the lower edge of the upper lateral cartilages. Spreader grafts that push the upper lateral cartilages outwards are commonly recommended. Paul O'Keeffe disagrees with this idea preferring to believe that the obstruction is due to slackness of the lateral alar ligament and a tightening of the ligament is recommended.
Internal mucosal adhesions between the side wall of the nose and the septum are not uncommon. They would be prevented by placement of silicone splints in the nose for about one week after surgery but they are uncomfortable and difficult to breathe through. It is more comfortable to have no packs or light packs for one or two days only so that is what most patients have. If adhesions occur they are easily dealt with by a minor office procedure.
Post-operative bruising especially around the eyes is not uncommon after rhinoplasty when the nasal pyramid was narrowed. This problem is greatly reduced by the use of a large external splint (not too large!) and eye pads for four hours followed by cold compresses to the eyes.
Post-operative bleeding, also called epistaxis, can occur during the first two or three days. Strangely, a blood clot in the nose often promotes bleeding. Removal of the clot, sitting upright and placing a cold compress on the forehead is often effective. Persistent bleeding may require placement of a pack in the nose or even treatment in a casualty or admission to hospital. Bleeding that commences four or more days after surgery may be caused by infection so an antibiotic should be beneficial.
Infection is a rare complication in rhinoplasty but it can happen if there is haematoma (blood clot) within the tissues or if foreign material (grafts, implants or permanent sutures) has been placed into the tissues. It may be wise to use prophylactic antibiotics for these cases but that is a controversial topic.
Lack of definition at the root of the nose (radix or nasion) might be seen if too much change was intended there. The depth of the skeleton where it is covered by a thick muscle (procerus) is the problem. Changes to the skeleton are not fully reflected in the skin. The situation can be improved if the muscle is lengthened by a procerusplasty.
Bumps on the bridge of the nose are occasionally seen. The thin cartilage that adheres to the under surface of the nasal bones can be difficult to trim because it bends down away from the cutting implement. It can spring back up again during the healing process. Retained cartilage fragments may be present or the bone may have broken in an unfavorable way during the operation. A revision operation is required if the problem persists.
The nasal bones are sometimes overly reduced producing the appearance of a narrow ridge-like bridge. This is caused by the surgeon blindly rasping away the tissues in a narrow pocket and not realising that the bone is being removed while the springy cartilage remains. It is preferable to expose the area more and do the reduction under direct vision, a more time-consuming exercise.
In the past, the alar cartilages were greatly reduced with view to making the tip more pointed and the long nose shorter. In the 1970's very eminent surgeons even recommended complete removal of the alar cartilages. The inadvertent long-term effect was the "Miss Piggy" nose where the nostril rims retract exposing the nostril openings. It is obviously better to have a more conservative approach to surgery.
Sometimes the septal cartilage is overly reduced. If the bottom edge of the cartilage is trimmed too much support is lost for the columella and it retracts while the nose tip retrudes adding to the problem of supra-tip swelling. If too much tissue is removed while trying to correct a severely deviated septum a saddle nose can develop.
Numbness of the nose tip occurs occasionally. There are three nerves on each side of the nose that can supply the tip. If the main nerve is the one coming from the cheek then it is unlikely to be affected. If the main nerve is the one coming from beneath the nasal bone then it will be affected by rhinoplasty. If the nerve coming from the septum is the main one it could be affected if a septoplasty is done. Luckily, numbness persisting longer than one year is uncommon.
A particularly painful complication is ulceration of the cornea that can occur if the eye is sensitive or allergic to the skin prep used to clean the skin before surgery. Ulcers can also occur if the eye is accidentally rubbed during the operation. For this reason the eyes are taped shut for surgery. This painful condition is associated with photophobia and it usually improves significantly next day. Full recovery is expected.
Finally, psychological problems may be present that do not respond to cosmetic surgery. Of particular concern is Body Dysmorphic Disorder characterised by a preoccupation with an imagined defect in appearance, or if a slight physical anomaly is present, markedly excessive concern. This condition should be treated by general practitioners, psychologists and psychiatrists, not plastic surgeons.