What is Rhinoplasty?
Rhinoplasty is a surgical procedure performed to alter the function and appearance of the nose. Although the reasons for surgery may be primarily cosmetic or functional concerns, function and form are closely related and both are considered in every case.
What is Open Structure Rhinoplasty?
Open Structure Rhinoplasty refers to a group of techniques which, taken together, aim to improve both the appearance and function of the nose.
“Open” means an incision is made on the columella (the strut between the nostrils) and the nasal skeleton is exposed. This allows excellent visualisation and access to the cartilage and bone which form the structure and underlying shape of the nose.
“Structure” refers to the use of grafts and other techniques used to reinforce and strengthen the nasal skeleton. The grafts are cartilage which is usually taken from the nasal septum. If this cartilage is unavailable, which occurs mainly in revision surgery, cartilage can be taken from the ear, or occasionally the rib. If this is likely to be required, it will normally be discussed with you before the procedure.
The use of structural grafts allows a predictable aesthetic and functional result which resists change over time due to wound and scar contraction.
Nasal Assessment
Clinical photographs are taken of the nose and, when cosmetic alteration is planned, computer morphing is performed to help plan the desired outcome. It is important to realise that these morphed images are a simulation used to aid communication, and not a guarantee of a particular result.
Endoscopic examination of the nose is performed to aid in assessment of the septum, inferior turbinates and other aspects of the nose and sinuses. CT scans may be requested if sinusitis is suspected.
Surgery
The surgery is performed under general anaesthetic and usually takes between 2-3 hours, but can be longer. When you wake up there will be tapes or a plastic splint on the outside of the nose and silicone splints inside the nose. There are small nylon sutures on the columella and further dissolving sutures inside the nostrils. There may also be small (2-3mm) incisions on the side walls of the nose if osteotomies were needed. If alar base reduction was performed there will also be sutures around the sides of the nose at the groove between the nose and face - this will be discussed in the clinic before surgery. You may get bruising and swelling around the eyes and cheeks.
Rib, ear and temporalis grafts
If there isn’t enough cartilage available in the nose to fashion the necessary grafts, we may need to harvest this from either the rib or the ear – usually the rib is preferable. This is most common in revision surgery or after severe trauma.
Ear (conchal) cartilage is usually harvested from the bowl of the ear, occasionally a composite graft is needed which is cartilage and skin together, and in this situation a small skin graft is taken from behind the ear to cover the graft site. Usually a dressing will be sewn or securely taped in place to provide pressure to the site, and the dressing removed in the clinic.
Rib cartilage is harvested through an incision near the crease under the breast in women, and in a similar location in men. This provides an excellent source of cartilage for structural grafts.
Occasionally we use temporalis fascia, which is the lining over the muscle above the ear. This is harvested through an incision on the hairline or higher, above and behind the ear.
Tissue from behind the ear may be used occasionally for contouring and is taken via an incision in the crease behind the ear.
After Surgery
You may be able to go home the same day, or stay overnight and go home the next morning. There will be some swelling, and ooze of blood and mucus from the nose. Keeping the head elevated in bed and using ice packs can help with swelling, pain and bleeding.
Postoperative cleaning of the nose is very important and should be performed 3 times a day as per the postoperative instruction sheet. Pain relief and antibiotic medications will be prescribed at the time of surgery. The splints and external sutures are usually removed after 5-7 days in the rooms.
Will there be a scar?
The incision on the columella results in a small scar which is red initially then fades. After 2-3 months the scar is usually visible only on close inspection. If alar base reduction is performed, there is a further incision on each side in the groove between the side of the nose and the face. Occasionally external incisions (around 2mm long) are used to aid with fracturing the nasal bones and these are usually not visible once they have healed.
The use of silicone gel (e.g. Dermatix) can help with flattening the scar, and the area should be protected from the sun for up to a year.
Complications and expectations
Bleeding
Bleeding may occur up to 2 weeks after any nasal operation (it is rare for bleeding to occur after 2 weeks). Intermittent oozing of blood is common during the first 2 weeks but you should notify your doctor or go to hospital if you experience a large amount of bleeding which does not settle. In severe cases your nose may need to be packed or you may need to return to the operating theatre. This is not a common occurrence. In rare circumstances you may need iron tablets or even a blood transfusion.
Septal haematoma, abscess or perforation
A haematoma (blood clot) may collect between the layers of the septum, which blocks the breathing. If this occurs it will require drainage.
A septal haematoma can become infected and form an abscess (collection of pus). This could damage the septal cartilage and cause collapse of the nose. It needs to be drained urgently. A sign of septal abscess is severe pain inside the nose, and often fevers. You should contact your doctor if you develop severe pain.
Infection
Infection is a risk following any operation. You will be given antibiotics at the time of surgery and usually for several days afterwards to help reduce the risk.
Nasal obstruction
One of the aims of surgery is to improve nasal breathing, however there is a risk that obstruction persists, or is made worse, particularly if one of the above complications occurs.
Bruising
Bruising is common after rhinoplasty surgery. This is not a complication and usually resolves around 2 weeks after surgery. In very rare occasions, the discolouration may persist for several months.
Numbness, pain and tenderness
It is usual to experience numbness and tenderness of the tip of the nose which persist for many months. In some cases, numbness of the upper lip, gums or front teeth may occur, which usually resolves several weeks after surgery.
Sense of smell and taste
You will usually experience some temporary loss of sense of smell and taste after your nasal surgery due to congestion inside the nose. As the swelling decreases the senses return. It is extremely rare to lose these senses permanently although this can occur. In fact, improving the nasal breathing usually improves the senses of smell and taste.
Pneumothorax (rib cartilage harvest only)
If rib cartilage is used, there is a very small risk of puncturing the lining over the lung and causing air to enter the chest cavity, which is called a pneumothorax. If this was to occur, usually a chest drain would be placed and you would need to remain in hospital until the leak healed, which would usually be a few days.
Unsatisfactory result
Surgery is not an exact science. In most cases we are able to achieve the desired result, however no guarantee can be given that the surgery will be successful or perfect. It is very difficult to achieve a perfectly straight nose or a perfectly straight profile. Sometimes there are minor irregularities, asymmetries, nodules and depressions of the surface of the nose. These often settle themselves over many months after the surgery. Sometimes in operations requiring fracturing of the nasal bones they may not fracture evenly or shift as they heal.
Usually these occurrences are mild and will not cause gross deformity. If asymmetries persist revision surgery may need to be performed. This is usually delayed until 1 year after the initial surgery to allow the healing process to take place. Often such surgery is minor and may consist of simple rasping of an irregularity or placement of a small cartilage graft.
Rarely major revision surgery may need to be performed.
The nose usually looks OK by 2-3 weeks after the surgery but there is some delayed swelling especially around the tip of the nose which improves over 6-12 months after the surgery. This is not a complication but the normal healing process! Sometimes steroid injections are given into the tip of the nose to speed the resolution of this postop swelling.