Rhinoplasty

It is the surgery that changes the shape of the nose by adjusting the bone component, the cartilaginous component, the skin, or all three.  And as we mentioned, it is one of the most common types of plastic surgery. 

Rhinoplasty is one of the most common cosmetic procedures in the world. More than 200.000 procedures were performed in the United States alone in 2018, making it the third most common cosmetic surgery procedure in the country. This surgical technique is regarded as one of the most difficult in plastic surgery.

Nasal dimensions and symmetry are closely related to facial attractiveness since they are a major feature of the face. Even for very experienced surgeons, the technical challenges, the vast range of various procedures mentioned, and the effort to obtain consistent results can be tough.

Indications 

As we said, many people might not be satisfied with the look of their noses. They can change the size or the angle, they can straighten the bridge, reshape the tip, or narrow the nostrils. 

However, aside from the aesthetic purpose of rhinoplasty, it can also be done to: 

• Change the proportions of the nose.
• Repair an injury.
• Repair a deformity.
• Correct a birth defect.
• Improve the breathing ability.

Rhinoplasty can be done for functional, cosmetic, or both reasons. It is crucial to note that patients who are originally seeking functional improvement only frequently express concerns about the aesthetics of the nose during the interview, and postoperatively, they place greater emphasis on the aesthetic outcomes than on their capacity to breathe properly. This is one of the reasons why doing a comprehensive conversation with the rhinoplasty patient is crucial.

Despite the fact that much has been written on the difficulties of selecting the optimal candidate for surgery, there is no established method of properly diagnosing high-risk individuals who will most likely be dissatisfied regardless of the outcome. As a result, the surgeon must assess other non-visible features of the patients and rely on instinct to judge whether or not the operation would be useful.

Interrogation is essential at the initial consultation to determine whether the patient’s expectations are realistic, as patient satisfaction postoperatively is a factor of the surgery’s success. By asking open-ended questions regarding the patient’s life and background (family composition, community relationships, etc.), the physician can listen and interpret nonverbal features that might be valuable in forming an overall picture of the individual.

SIMON (single, immature, male, over-expectant, narcissistic) is a widely used acronym to characterize patients who should be deemed unsuitable for surgery, whereas SYLVIA (secure, young, listens, verbal, intelligent, attractive) has been used to describe the ideal candidate.

Following a general examination, it is critical to address the specific aspects of their nose that they dislike (dorsal hump, nasal deviation, tip problems, etc.) and explain step by step what can and cannot be corrected. This may be accomplished through the use of computer simulation. This is a useful technique for identifying patients with unreasonable expectations by using real-life photographs of the individual and simulating an approximate surgical outcome.

Anterior rhinoscopy is used in the functional analysis to look for frequent reasons of blockage such as turbinate hypertrophy and septal deviations. A nasal endoscopy may be useful in individuals with airway blockage without a visible reason to detect alternative sources of obstruction, such as polyps.

Breathing difficulties in the past, a history of sinusitis, obstructive sleep apnea, previous hospitalizations, pharmaceutical or cocaine use, and a history of mental illness should all be documented.

As with any surgical treatment, informed consent must be discussed seriously with the patient so that he or she completely knows every stage of the process, including its risks and benefits, alternatives, and possible results.

This operation is often performed when nasal components have fully matured and nasal shape will not alter significantly in the future. This corresponds to roughly 15 years of age for girls and 17 years of age for males.

Rhinoplasty to help breathing

For example, there is a well-known nose defect called “Deviated nasal septum”. The cartilage of the nose that separates the nostrils typically sits in the center and divides the nasal cavity evenly. However, some people have uneven septum, which makes one nostril larger than the other does. It is a very common problem that according to The American Academy of Otolaryngology-Head and Neck Surgery, 80% of all septums are deviated to some degree. 

This condition can cause severe symptoms such as: 

• Nosebleeds, 
• Sinus infection. 
• Difficulty breathing. 
• Snoring or loud breathing during sleep. 
• Blocked nostril. 
• Nasal congestion or pressure. 

The challenge of producing “the same nose in every patient” is exacerbated by anatomical differences in inner structures and varying thicknesses of soft tissue envelopes. Furthermore, there is no such thing as a “perfect nose,” because a nasal shape that suits one patient’s face may not fit another’s.

Rhinoplasty is more than just a cosmetic treatment. The procedure also seeks to preserve or improve nasal function if the patient has decreased airflow owing to an obstructive condition. This adds to the operation’s difficulty since interior nasal structures must be changed to remedy functional problems.

All of these variables work together to explain why rhinoplasty is such a pleasant procedure with such positive outcomes.

Correct surgical patient selection, as well as thorough preoperative analysis and planning, are essential stages in improving rhinoplasty outcomes and avoiding subsequent operations.

Well, to me it seems like a pretty bad set of symptoms to live with. However, when you are planning to get a nose job, you should consider many things including your other facial features, the skin on your nose, what you want to change, and the risks of the surgery. 

Rhinoplasty risks

Just like any major surgery, rhinoplasty has risks, including: 

As previously said, rhinoplasty is one of the most difficult surgical operations, and one of the primary reasons for this is its lack of predictability. An immediate positive surgical outcome may not be such one year later.

This is mostly due to the numerous factors involved in the healing process. Individual nasal tissue responses are not always predictable, and as a result, undesirable outcomes might occur.

Although the risk for major complications is low, functional and, mainly, aesthetic complications can cause social and psychological issues and may result in legal problems for the surgeon.

Surgical complications can be defined as hemorrhagic, infectious, traumatic, functional, and aesthetic

• Bleeding. 

Bleeding after rhinoplasty is a common complication. They are typically minor and can be treated with head elevation, nasal decongestants, and compression. If the bleeding persists, an anterior tampon should be performed, and the patient should be evaluated. If the bleeding continues despite the anterior tampon, posterior hemorrhage should be considered, and a posterior tampon should be used. Although significant bleeds are uncommon, an endoscopic approach or angiographic embolization may be required in some cases.

• Infection.

Infections during rhinoplasty can vary from minor cellulitis to serious systemic infectious diseases. As an early complication of rhinoplasty, cellulitis may occur. It typically responds well to cephalosporins, although constant monitoring is required to prevent progression. 

Septal abscesses are a consequence of an untreated hematoma, and the treatment of choice is surgical draining followed by antibiotics. They might occur in the septum, tip, or dorsum of the body. Severe infectious processes are quite uncommon. They occur in fewer than 1% of the cases.

• Adverse reaction to anesthesia.
• Breathing difficulties.
• Permanent numbness in or around the nose due to nerve congestion or injury.
• The possibility of an uneven look of the nose.
• Scarring.
• Pain.
• Discoloration.
• Swelling that might persist.
• The need for additional surgery.
• Septal perforation.
• Intracranial injury 

Intracranial injury is an uncommon condition that can result in a cerebrospinal fluid leak, causing rhinorrhea and migraines. This issue necessitates hospitalization and a neurosurgery assessment.

• Rhinitis: 

This is frequently a transient problem, especially once a blocked airway has been cleared. It might cause nasal discharge, dryness, and breathing problems. Topical treatments are often used to treat it. A CSF fluid leak might be considered if rhinorrhea persists after a few weeks.

• Injury to the Lacrimal Ducts: 

This can result in epiphora, which can be accompanied by bleeding. It is sometimes induced by lateral osteotomies and requires duct intubation to be treated. It is crucial to understand that epiphora may occur in the first few weeks following the surgery as a result of edema compressing the lacrimal ducts, which usually resolves spontaneously.

The appropriate age for a rhinoplasty

Usually, if you are considering the surgery for aesthetic reasons, your surgeon will tell you to wait until your nasal bones are fully grown before considering a nose job. For girls, this is at the age of 15. Boys can be growing until they are older. However, if you are considering the surgery for breathing difficulty, the surgery can be performed at a younger age. 

Rhinoplasty procedure

• If all is well and you have decided to do this procedure already, you need to know how to prepare yourself. 
• Typically, your doctor will tell you all the instructions before and after the procedure. Before the procedure, you will discuss with your doctor if the rhinoplasty will work well for you or not.  Your doctor will investigate and ask you many questions.
• He or she will start with your medical history. This is a very important discussion because your doctor can know your motivation for undergoing this surgery and your goals. Your surgeon will also ask you about any previous nose conditions in your medical history such as nasal obstructions, surgeries, or any medications. 
• He or she will also ask you if you have any bleeding disorder such as hemophilia because if you do, you might not be a good candidate for rhinoplasty. 
• After that, your surgeon will conduct a complete physical examination including examining your facial features and the inside and the outside of your nose. He or she will ask for some laboratory tests such as blood tests as well. 
• This physical examination is very critical and can significantly affect the results of your surgery if done right. It is important to examine  your skin thickness, and the strength of the cartilage because it helps your surgeon to determine what changes need to be done. It will also study the impact of the surgery on breathing.
• Here comes the most famous step, the one that appears to you whenever you are googling the word rhinoplasty, the photography. 
• The surgeon will send someone to take some photographs of your nose from different angles. It makes it easy for your doctor to show you what the results will look like. Using some computer software, the surgeons can manipulate these photos to show you how your nose might look after the surgery. These photos are also important for the before-and-after assessment and reference during the surgery. The specialist might also use these photographs to show his work and get some good reviews after taking your consent, of course. 
• In the end, the surgeon will ask you about your expectations. Based on it, he will tell you what he or she can or can’t do. It might seem a bit uncomfortable for you to talk about something that is making you self-conscious. But, for your own good, you have to be open and honest with your surgeon and tell him or her all your concerns and goals. 
• If a patient has a small chin and is planning for rhinoplasty. The surgeon might advise the patient to have a chin augmentation surgery because a small chin might give the illusion of a larger nose. 
• When everything is set, and you have decided the date of your surgery, your surgeon will advise you to arrange for someone to drive you home after your surgery. 
• If you want to know more information about the different techniques of rhinoplasty, the care after having rhinoplasty, and how the procedure is done in detail, stay with us, we have a surprise for you.                                              

Contraindications

Patients with an unstable mental state at the time of consultation or surgery, patients with BDD or unrealistic expectations, obstructive sleep apnea, active cocaine users, and patients with comorbidities that contraindicate surgical treatments are all common contraindications for rhinoplasty.

• Body Dysmorphic Disorder (BDD): 

Excessive concern with a perceived or barely perceptible flaw in appearance characterizes this mental illness. Patients have greater difficulty socializing, have a lower quality of life, are more prone to depression, and have a higher risk of suicide ideation as a result of these factors.

Because symptoms may develop postoperatively if not recognized, and the patient will be dissatisfied with the results, it is critical for surgeons to notice this sort of patient early. There is currently no validated questionnaire available to properly diagnose these individuals. Referral for mental assessment is required if clinical suspicion emerges.

• Obstructive Sleep Apnea: 

Repeated bouts of airway blockage during sleep define this illness with a high incidence. Perioperative problems are more likely in patients with this disease. The patient’s symptoms might lead to a diagnosis, although it can also be asymptomatic. Although screening questionnaires can be employed, their accuracy is restricted.

Polysomnography is the gold standard for diagnosis. Patients with this condition should be informed of the dangers, and preoperative treatments such as the use of a continuous positive airway pressure device (CPAP) might be used to minimize complication rates.

• Cocaine Abuse:

Patients who misuse cocaine are a distinct category of people. Because of the many contaminating ingredients, inhaled cocaine causes severe vasoconstriction and persistent mucosal inflammation.

Mild inflammation to serious septal holes can be discovered during a rhinoscopy. These individuals are also more prone to experience postoperative problems such as septal collapse or delayed septal mucosa healing, and they should avoid nose surgery.

• Tobacco Smoking: 

Although it appears that cigarette smoking has no influence on the success of septoplasty, patients should be advised to quit smoking before the surgery because of the numerous negative consequences.

• Bleeding Disorders:

Blood clotting problems might arise following surgery. Patients should be asked if they have a history of significant bruising or bleeding, whether they take anticoagulant drugs, supplements, or vitamins, and if they have had past thrombotic events. Any drug, vitamin, or supplement that affects coagulation may need to be discontinued prior to surgery.

Generally, patients that had a previous rhinoplasty and are unhappy with the results should wait at least one year before any evaluation on the definite result or secondary procedure can be performed.