‘Welcome to the Cosmetic Rhinoplasty page, where you will find detailed information about all aspects of cosmetic rhinoplasty. Most people think very carefully before going for a cosmetic rhinoplasty, and the decision as to whether to undergo a cosmetic rhinoplasty can be a difficult and complex one to make. The information here will help guide you through the process from initial thoughts, to details of the consultation, different types of rhinoplasty, the operation itself, what to expect afterwards and also expectations and possible complications.
A rhinoplasty refers to an operation on the nose with the objective of changing the shape of the nose or improving its function (nasal breathing). Most people think a rhinoplasty only means a cosmetic procedure but this is not always the case. People therefore tend to request a rhinoplasty if they are not happy with the shape of the nose in some way, or if the breathing is not optimal due to a problem with the structure of the nose.
A septorhinoplasty is also a rhinoplasty with the addition of a septoplasty.
A septoplasty may be required if the nasal septum is deviated (bent) and if this is causing a difficulty in breathing through the nose. The septum is made of cartilage and bone and is in the middle of the nose, dividing the nose into two roughly equal halves. If the septum is not straight, this can cause a blocked nose.
One of the most common reasons for having a nose that is not aesthetically or functionally ideal is due to a previous nasal injury. This might be an obvious injury such as one sustained in a fight, competitive sport or accident. In this case, the nose will change shape or breathing compared to what it was like before the injury occurred.
In some cases, patients cannot recall any traumatic event. It is still possible that you might have suffered a minor injury during childhood (such as a ball in the face), which might not have been sufficient to break the nasal bones but might have disturbed the septum such that as you continued to grow, the septum and nose may have become more and more deviated. Sometimes, a minor trauma can occur to the nose during childbirth, which in some patients may be the only injury that has occurred.
There can also be some hereditary (inherited) factors. We inherit may good and sometimes some not so wanted characteristics from our parents, and facial and nasal appearances tend to be very consistent from generation to generation.
If you are not happy with the way your nose looks, a rhinoplasty can improve the appearance of your nose. It can also improve your nasal airway if you are suffering with nasal obstruction. Often the two objectives are closely intertwined, such that correcting the cosmetic appearance can sometimes interfere with the nasal breathing, and vice versa (correcting the nasal airway can occasionally affect the shape). It is for this reason that both the appearance of the nose and the way it works should be carefully considered together.
There are of course other reasons why you might have a blocked nose even if your septum is perfectly straight. For example, the structure of the side wall of the nose (the nasal valve) could be weakened and might collapse easily when you breathe in. This is where a functional rhinoplasty might be required to improve the breathing, regardless of the external aesthetic appearance.
There are a number of different specialists who undertake rhinoplasty surgery and you will need to make an appointment to discuss what your hopes and expectations are, and to analyse your nose to see what is technically possible.
Plastic surgeons or ENT surgeons who have subspecialised in rhinoplasty/facial plastic surgery undertake the majority of rhinoplasty operations. Regardless of the background, it is important that your chosen surgeon is experienced in rhinoplasty and has practiced it for many years, with a good track record. It is helpful if your surgeon is a member of a rhinoplasty or facial plastic or plastic surgery organization such as Facial Plastic Surgery UK (FPS-UK), the British Rhinology Society (BRS), British Society of Rhinoplasty Surgery (BSRS), The British Association of Aesthetic Plastic Surgeons (BAAPS), The British Association of Plastic, Reconstructive and Aesthetic Surgery (BAPRAS) or The European Academy of Facial Plastic Surgery (EAFPS). There are also other organisations where membership is only granted after a selective peer reviewed process, such as cosmetic surgery recertification at The Royal College of Surgeons (RCS).
As long as your surgeon performs rhinoplasty regularly and is experienced, then it does not usually matter whether they are a plastic or ENT surgeon. Most ENT surgeons who perform rhinoplasty are also fully accredited in the practice of facial plastic surgery (including the ears).
You will have plenty of time to describe what are the aspects of your nose that you are unhappy with and which you would like to change. We will go into detail about this, as well as what is motivating you to have the surgery – is it for your own satisfaction or have you had comments or pressure from other people to get it done? Is it affecting your everyday life in terms of confidence or is it that you just don’t like how it looks and would like it to look better.
We will take detailed clinical photographs and you will also have an opportunity to try some image manipulation of a photograph to see how your nose might look after the surgery. Please bear in mind that the appearance of the nose after image manipulation is not necessarily how the nose will actually look after surgery. It is more useful as a guide to the surgeon during the surgery to help achieve the appearance that you desire, however it cannot be guaranteed.
You will also be strongly advised to attend for a second consultation on another day, and usually 2 weeks or more from the initial consultation. This is to give you a chance to think over the information covered in the first consultation and to ask any questions that you might have. It also gives your surgeon another opportunity to analyse your nose and to refine the surgical plan in the light of any other issues or requirements that may have arisen. On occasions, a further appointment or more may be required afterwards. There is no set plan for all patients as the preoperative planning process will be tailored to your requirements and concerns.
There are many different types of rhinoplasty depending on what aspect of the nose needs to be addressed and also how the surgery will be carried out as well as what approach will be used. A rhinoplasty can address any part of the nose, for example:
- the dorsum/back of the nose, for example, there may be a big hump or prominence
- the front view, for example the nose may not be perfectly straight or may be too broad
- the tip of the nose, for example the tip might be too prominent (projected) or not prominent/projected enough; alternatively it can be rotated up or downwards, or the width of the base of the nose may not be ideal
An open or closed rhinoplasty refers to how the operation will be carried out. An open rhinoplasty is one where a small cut or incision is made at the base of the nose about half way down the columellar (central part in between the nostrils). A closed approach is one where the surgery is carried out through the nostrils, without any external cuts (a bit like keyhole). In many rhinoplasty operations, wither an open or closed approach could be used although there are some circumstances where an open approach would be preferred, such as in revision cases, or where a graft or implant may be required, or for more complex corrections including the nasal tip.
As the surgery is being undertaken under a general anaesthetic, there is a standard procedure for preparation prior to the anaesthetic, which will be confirmed with you in advance of the day, although usually involves not eating or drinking milk for six hours prior to the surgery. It is usually OK to drink clear fluids (water of tea without milk) up to two hours before the operation. You will then come into the hospital about one to one-and-a-half hours before the start of the theatre list to give enough time for the surgeon, anaesthetist and nursing staff to see you and carry out the necessary preoperative checks, tests and consenting process.
You may already have been contacted by the preadmission team as in some cases there are tests which are required before the day of surgery, such as blood tests, ECG or Chest X-ray.
When it is time for the operation you will be taken through to the anaesthetic room where the anaesthetist will administer the anaesthetic.
Once you are asleep, you will be taken into the operating theatre where the final preoperative checks are carried out. The nose and face will be carefully cleaned with a non-alcoholic sterile solution and the surgical area and draped with sterile towels. A local anaesthetic solution will be injected into the nose, which helps with pain relief afterwards, and you are likely to be given a single dose of an intravenous antibiotic to protect against the risk of infection. The operation will then begin according to the preoperative plan, each aspect of the nose being addressed in a careful sequence. After the operation, it is common for a splint or protective cast to be placed on the outside of the nose. Very occasionally a dressing might need to be placed inside the nose; this is often dissolvable although occasionally it might need to be removed by the nurses before you go home later that day.
After the operation you will be taken to the recovery area where you will wake up. You will not remember much about this time and this is quite normal. Once back on the ward, you should be comfortable with little or no discomfort. The nose and face may begin swelling up with some bruising and the nose will begin to feel quite blocked and will likely get more blocked before it gets better again. You will be able to eat and drink something within an hour or so from coming back to the ward, and after three or four hours you should be well enough to go home.
You will be given some painkillers to take home, to be used as and when required, a nasal decongestant, and occasionally some additional antibiotics (either by mouth or in cream form or sometimes both) depending on the requirements of the operation.
When you are back home, for the first 24-48 hours try to avoid particularly hot or spicy foods, and try to sleep in a slightly inclined position with a few extra pillows. For the first five days try to avoid blowing your nose, and if you have to sneeze please keep the mouth open and let the sneeze come out this way.
If your nose and face gets quite bruised you can use some ice packs on the face or suck on an ice cube (and spit out the water when the ice melts).
For the first two weeks you should stay largely at home, not going into work, although if you can work from home that is fine. You should avoid any exercise, heavy lifting or strenuous activity during this time – a short walk if the weather is nice is fine. It is also advised that you do not fly during this period.
After two weeks you can get back to normal activities although contact sports should be avoided for a further four weeks.
It is also advisable to use a daily moisturizer with sun protection (SPF 15) for the first six months after surgery to reduce the chance of sun damage to the skin.
In the first few days the nose and face will get very swollen and the bruising can be quite dramatic, although the majority of the bruising also settles quickly, having usually disappeared fully by 14 days. The swelling will however take a lot longer to reduce – it usually takes at least eight to twelve weeks for the majority of the swelling to reduce, and occasionally longer.
The nose will continue to heal and change gradually over a period of 12 months after a rhinoplasty, in some cases longer particularly after revision surgery. This is largely due to the gradual reduction in the swelling, although the majority of the swelling has settled by 3 months, and a large part of this by six to eight weeks.
In the immediate postoperative period and for the first two weeks, there will be some bleeding from the nose and the nose will feel very blocked, most likely getting more blocked in the first few days before improving again. There is a risk of infection occurring and some discomfort or pain. Other possible complications include a septal perforation (hole in the septum), recurrent septal deviation in the future, numbness of the upper lip, tip of nose or front top two teeth (usually temporary) and skin discolouration. Very occasionally a rhinoplasty can lead to a reduction in airflow through the nose, which can be felt as a blocked nose or difficulty breathing. This is quite unusual as your surgeon can in many cases anticipate such an outcome and can undertake additional steps during the surgery to try to prevent this from happening. It could still occur despite carefully undertaken surgery. It is another reason to consider undergoing a rhinoplasty with an ENT Surgeon with an interest in rhinoplasty surgery as he or she will understand the function and breathing of the nose in detail and how it can be affected by cosmetic surgery (and what to do to improve it).
Despite very careful preoperative planning and a well executed operation, complications can still occur. It can be a big cause of stress for many patients as expectations often are high at this point, especially so as the nose is at the front of the face and therefore very visible.
Complications could occur because of a change that might have become necessary to the surgical plan during the operation; for example, to protect the structural integrity of the support of the nose, certain technical aspects may not be possible or may have to be adapted. Another reason is that despite the operation going well and according to plan, the outcome may not be exactly what you expected, or it may be that the healing process has been interrupted or negatively affected in some way.
Such complications might include:
- nasal dorsum: not having been reduced as much as you would like, or reduced too much
- nasal profile: nose not perfectly straight
- nasal tip: under- or overcorrection
- irregularities or imperfections: these could appear along any part of the nose
- persisting asymmetry of any part of the nose
Complications are generally more likely to be seen in people with very thin skin, which allows smaller irregularities to show through or where the healing process has been affected by an infection or minor trauma to the nose.
Whatever the problem or imperfection, please try not to worry as in most cases something can be done to rectify the situation and improve the appearance. You will be carefully and regularly reviewed and advised of the progress of the healing as it occurs. In many cases, patients with some concerns raised early on in the healing process often find that as the nose settles, the imperfections disappear or become less noticeable and not a problem.
Any consideration of revision or refinement surgery should be left until at least 12 months have passed since the first operation, to allow sufficient time for the healing process to have completed and any swelling subside fully.