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Rhinoplasty: Surgery to Improve the Appearance and Function of the Nose

By William D. Losquadro, MD | Facial Plastic & Reconstructive Surgery, Otolaryngology

The term “rhinoplasty” refers to plastic surgery of the nose, and it is one of the most popular plastic surgery procedures in the United States each year.  It is often performed to help people both look and breathe better.

Rhinoplasty can be performed in two different ways. During the closed approach, the entire surgery is performed through incisions made inside the nose. This has several advantages including no external incisions, shorter surgeries, and generally less swelling after surgery.

During the open or external approach, a small incision is made across the narrow bridge of skin between the nostrils called the columella. Connecting this incision to others within the nose allows the surgeon to easily visualize the nose’s internal structure. An advantage of this approach is better exposure that allows more precise correction of deformities. For this reason, many revision surgeries are performed via the open approach.

The external incision may be considered a disadvantage, but it is often imperceptible when closed carefully. The bridge and tip of the nose are commonly reshaped during a cosmetic rhinoplasty. Many patients wish to narrow the bridge or have a bump removed. Some patients with low bridges, particularly Asian or African-American patients, wish to have their bridge raised. Patients are often unhappy with the size or position of their nasal tip. The tip is often narrowed and made less round. Droopy tips are often lifted.

It was common in years past for the same operation to be performed on everyone regardless of individual facial features. Female patients were often left with low, scooped bridges and narrow, pinched tips. Too much cartilage was often removed from the nose resulting in unnatural appearing noses and impaired airways that became more pinched as the years progressed. Modern rhinoplasty techniques emphasize more natural results individualized to each patient’s unique facial features. The internal nasal structures are reshaped and strengthened to maintain both the cosmetic and functional result over time. Computer imaging of the patient’s nose is often performed prior to surgery. This is invaluable in making sure the patient and the surgeon have the same surgical goals.
Patients with difficulty breathing will often have related procedures performed at the same time. A septoplasty is a procedure to correct a deviated septum. The septum is the structure within the nose that separates the two nasal cavities. A crooked septum (often the result of prior trauma) pinches off the airway, causes increased congestion and postnasal drip, and increases snoring. Another common procedure is a turbinate reduction. The turbinates are pillows of tissue that protrude into the airway and help humidify the air. Reducing them slightly helps improve breathing.

It is preferable to wait until the nose has stopped growing before having any type of nasal surgery.  Growth stops in females at approximately ages 15-16 and in males at ages 16-17.  If a child’s shoe size has stopped increasing, this is generally a sign that nasal growth has also ceased.

Rhinoplasty is an outpatient procedure most commonly performed under general anesthesia. Most rhinoplasties will take 1 to 3 hours; complex revision cases will take longer. Patients will wake up with a small cast on the bridge of the nose and a few stitches across the columella if the open approach was used. One common misconception regarding rhinoplasty is that the nose must be packed with gauze after surgery. Although some surgeons still prefer packing, it can be very uncomfortable and is not necessary. Patients without nasal packing will generally have some blood-tinged mucous drainage for the first 24 hours that collects on a piece of gauze taped under the nose.  Pain is often minimal, and many patients require only Tylenol. The cast and any external sutures are removed after one week.

There is a small amount of bruising under each eye that lasts 7-10 days if work was performed on the bridge of the nose. Swelling is variable and decreases rapidly over the first 2 to 4 weeks. Strenuous physical activity and exercise are avoided for the first 1-2 weeks.

Rhinoplasty is considered by many surgeons to be the most difficult of all plastic surgical procedures. It is therefore important to choose a surgeon who frequently corrects both cosmetic and breathing problems of the nose.  A successful rhinoplasty maintains a functional airway, leaves a durable structure, and creates a natural nose that harmonizes with the face.