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Rhinoplasty (Nose Job): Basics and Potential Complications

Rhinoplasty (commonly known as a nose job) is an aesthetic surgery to change the form of the nose. It is one of the most challenging procedures in plastic surgery. The surgery may be carried out for a number of reasons such as changing the size or shape of a nose if a person is unhappy with it, repairing a damaged nose, or correcting functional problems. If surgery is only performed on the wall inside the nose called nasal septum to correct breathing problems, it is commonly referred to as septoplasty, while the term septorhinoplasty is used for a combination of septoplasty and rhinoplasty.

Reconstructive rhinoplasty surgery to rebuild the nose can also be performed on a severely damaged nose where part of the nose or the entire nose has been lost. This may be the result of trauma such as a road accident or when nasal tissue affected by a disease such as cancer had to be removed.

Nasal Anatomy

For those who are considering rhinoplasty it is worth knowing a little bit about the structure of the nose to help them understand the ideas behind changing its shape.

The nose is made up of bone at the top (known as bridge) lying between the eyes. Lower down is cartilage, which is the part of the nose that moves when held by a handkerchief. Covering this framework are the soft tissues including muscles, connective tissue, fat, inner lining and skin. The whole arrangement is shaped rather like a pyramid. Plastic surgeons regard the nose as being divided into visible or ‘aesthetic’ units when planning the individual’s surgery.

Reasons for Having Rhinoplasty

There are two main reasons why people consider rhinoplasty – cosmetic and medical. Some people are unhappy with the appearance of their nose, including those who may have damaged their nose in an accident and want to correct it. Others are having problems with breathing. This surgery would usually just be a realignment of the nasal septum (known as septoplasty) but it can be combined with a complete rhinoplasty, if necessary. Hence, the most common reasons for requesting rhinoplasty are to correct:

  • Large nose
  • Unrefined nasal tip
  • Dorsal hump (a ‘beaked’ nose)
  • Change an ethnic nose

What Is Done in a Rhinoplasty?

Rhinoplasty surgery is performed either as closed rhinoplasty, in which cuts are made only inside the nose, or as open rhinoplasty, in which an incision is also made across the bottom part of the nasal septum, allowing the nose to be externalised. The decision, which of the two techniques to use, is partly the surgeon’s preference but for complex nasal tip work the open technique is preferred. Once the nasal framework is exposed to reveal the cartilage bone that makes up the nasal pyramid, alterations can be made. These include:

  • Tip correction where the position of the tip and its size are adjusted
  • Dorsal resection to reduce the ‘hump’ of the nose
  • Septum correction (the septum is the wall that divides the nose)
  • Bone realignment. The bridge of the nose may need to be broken in a controlled manner and manipulated into a new position to give it a new shape. Excess bone can be removed at this stage.
  • Lateral cartilage trimming where the cartilage around the nostrils is reshaped
  • Augmentation grafting. If the nose enlargement is required to build up a better shape, cartilage taken from the septum or from other parts of the body can be cut into the required shape and placed in different areas of the nose.

Once all the necessary corrections have been made the cuts are sutured together leaving gaps between the stitches for fluid to drain. Some surgeons prefer not to use stitches at all and rely on everything falling into place naturally. Then the nose will be packed on both sides with gauze. The outside of the nose is covered with a splint made of plaster, plastic or metal. This cast holds everything in place and is usually kept on for one to two weeks. It is very important to avoid smoking, if at all possible, in order to improve healing.

Potential Risks and Complications of Rhinoplasty

Like all operations, rhinoplasty also involves certain risks. Possible complications include the following:

  • Bleeding. It is common and usually limited to small, occasional nosebleeds within the first week that are easy to control with repeat packing of the nose with gauze. Very rarely, severe, uncontrollable bleeding may occur. This requires a return to the surgery where the bleeding vessel will be cauterised.
  • Hematoma. This occurs when a collection of blood has coagulated. Hematomas disappear naturally with time but they can sometimes become infected. If necessary, a hematoma can be removed with a syringe or swab.
  • Numbness. Numbness is quite common, especially at the tip of the nose. It almost always settles within 6 months.
  • Infection. It rarely occurs because gaps are left to allow drainage of blood and other fluids. Infection is more likely where fluids are trapped as bacteria thrive better in such an environment. Treatment is with antibiotics and the drainage of any collections of fluid. This problem usually settles down within a week.
  • Breathing problems. This is a rare complication resulting from narrowing of the nasal passage. In most cases, it is due to swelling which is temporary. Symptoms settle with time but on rare occasions they may require further surgery.
  • Depression. It is not uncommon to feel depressed after surgery for a short period of time. Occasionally, treatment may be required.

Although most people are eventually happy with their result, a common mistake some people make is to judge the result too soon after surgery. It is normal for the nose to initially appear ‘over-corrected’ but this usually settles over the first few months. Swelling can also persist for a few months, especially at the tip of the nose and again this is quite usual. As this all settles, small lumps and bumps may become visible on the surface. These tend to subside as the nose settles into its new shape which takes between 6-12 months.

Unfortunately, if a person is not happy with the cosmetic result, it is not possible to change their nose back to the way it was. However, they will be offered further surgery to improve their appearance. Repeat operation is more complicated because of scarring caused by the initial surgery. It is usually not considered for the first year after the initial surgery to allow all the tissues to settle in order to adequately assess its result.

Suitability for Rhinoplasty

It goes without saying that a suitable candidate for nose job should be in good general health to undergo this type of surgery. However, that may not be enough. There are several features on a nose that may lead to an unsatisfactory result after the surgery. Rhinoplasty might be more difficult if the following features are present:

  • Inadequate tip projection (hanging or a ‘beak-like’ tip)
  • Low radix (nasal root) and/or low dorsum (the bridge of the nose) where the nose appears to ‘start’ very low down
  • Narrow middle vault (the inside of the nose)
  • Unusual positioning of the bits of cartilage around the openings of the nostrils

In fact, most individuals have at least one of the above features. So, people should not worry too much about whether they have a ‘good’ or ‘bad’ nose for surgery. Nonetheless, there does seem to be a high proportion of individuals with two or more of these features who request another operation after having their first corrective surgery. But, the most important thing affecting whether or not a person will benefit from rhinoplasty is their understanding of what can realistically be achieved.

Where to Find Further Info and Help: American Society of Plastic Surgeons