Introduction
Rhinoplasty surgery is the name for a group of operations. Each component is chosen and modified for the specific nose. Many different three–dimensional problems can be addressed by such sculpting. Some inherit their nasal shape, while others get theirs from trauma and injury. Many patients also need breathing obstruction issues addressed. Not all patients are aware of their nasal obstruction. During the consultation with the surgeon, he will try to learn what the concerns are and help learn what surgery realistically has to offer.

Rhinoplasty – Plastic Surgery of the Nose
Rhinoplasty is the most common cosmetic procedure performed today. Nasal surgery can be done any time after physical growth of a nose is completed. This corresponds with puberty. The only exception is a younger patient with severe nasal obstruction or sinus disease. The surgeons perform rhinoplastic surgery to modify the nose by changing its size and sculpting the nasal structures so that the nose is in harmony with other facial features.When the surgery is done to improve appearance, they re–shape the nose on an individual basis to achieve a more desirable, natural, non–surgical shape. This is in contrast to the unfortunately common and obvious surgical appearance of the scooped–out, turned–up nose with a pinched tip. Surgery may also improve nasal breathing when the septum is deviated or the patient suffers from allergies or sinus problems. Regardless of what is needed, removal of a hump, decreasing the length or width, correcting a deviation, or in some cases building up nasal depressions, surgeons tailor the procedure to meet the individual needs of each patient’s nose and face.

Preparing for the surgery
The doctor will give the patient specific instructions on how to prepare for surgery, including guidelines on eating, drinking, smoking, taking or avoiding certain vitamins and medications, and washing your face. Carefully following these instructions will help the surgery go more smoothly.While making preparations, be sure to arrange for someone to drive the patient home after the surgery and to help the patient for a few days if needed.

Anesthesia for Rhinoplasty
Rhinoplasty can be performed under local or general anesthesia, depending on the extent of the procedure and on what the patient and the doctor prefer.With local anesthesia, the patient will be lightly sedated, and nose and the surrounding area will be numbed; he will be awake during the surgery, but relaxed and insensitive to pain. With general anesthesia, he will sleep through the operation. General anesthesia is usually better for more extensive rhinoplasty or septal surgery. Local anesthesia is usually better for small adjustments or hump removal.

Open vs. Closed Rhinoplasty
Most nasal surgeries are done from inside the nose. Several cuts are made in the nostrils depending on what needs to be done. In open rhinoplasty, the cuts start just inside the nostril and extend over the columella (the post between the nostrils). Most doctors usually make a stair step incision over the columella. This external scar visible from below is usually not significant. When the two nostril incisions are connected, the nasal skin can be elevated exposing the anatomy of the nose. Particularly effective for nasal tip and complex septal problems, the deformity can be addressed with the structures in their natural anatomic position. The cartilage and bone are sculpted under the skin.Closed rhinoplasty depends on incisions inside the nose only. There is no incision made across the skin of the columella. When the tip needs to be modified, it must be delivered through the nostrils and worked on in the delivered deformed position.When the surgery is complete, a splint will be applied to help the nose maintain its new shape. Occasionally soft rubber internal splints are placed inside the nose to stabilize the septum, the dividing wall between the air passages.

The Surgery
Rhinoplasty usually takes an hour or two, though complicated procedures may take longer. During surgery the skin of the nose is separated from its supporting framework of bone and cartilage, which is then sculpted to the desired shape. The nature of the sculpting will depend on the problem. Finally, the skin is re–draped over the new framework.

Rhinoplasty Procedure
The operation generally takes one to two hours. Most incisions are made inside the nose. However, a small incision between the nostrils may be required in difficult noses where there has been previous surgery, in noses with abnormalities of the tip, or noses with severe deviations. This “Open” approach, which was pioneered in this country over twenty years ago by Drs. Fleming and Mayer, provides the opportunity to see what the problem is, to suture parts directly to minimize later shift, to produce better symmetry and, therefore, to achieve results far better than the older closed technique. Though somewhat more time consuming, the results consistently justify the effort. The inconspicuous external incision is easily hidden. In noses with wide nostrils, small external incisions are sometimes made at the base of the nostrils in order to achieve narrowing of this portion of the nose.


Risks with Rhinoplasty
There is a possibility of contour irregularities, but these usually resolve with time. Occasionally, a minor secondary procedure is necessary. Rarely are friends and associates able to tell that surgery has been done. This seems hard to believe, but it is true for two reasons. A natural, non–surgical appearance is achieved and others do not clearly remember that a deformity existed.

After your surgery
After surgery – particularly during the first twenty–four hours– the patient’s face will feel puffy, the nose may ache, and may have a dull headache. The patient can control any discomfort with the pain medication prescribed by the doctor. He should plan on staying in bed with the head elevated (except for going to the bathroom) for the first day.The swelling and bruising around the eyes will increase at first, reaching a peak after two or three days. Applying cold compresses will reduce the swelling and make the patient feel a bit better. The surgeon may use a cool gel mask to gently cool the tissues. In any case, you’ll feel a lot better than you look. Most of the swelling and bruising should disappear within two weeks or so. (Some subtle swelling – unnoticeable to anyone but the patient and the doctor –will remain for several months.)A little bleeding is common during the first few days following surgery, and the patient may continue to feel some stuffiness for several weeks. It is advisable not to blow the nose for a week or so, while the tissues heal.If there is any nasal packing, it will be removed after a few days and the patient will feel much more comfortable. By the end of one or, occasionally, two weeks, all dressings, splints, and stitches should be removed.

Postoperative Period
The minimal discomfort most patients experience after surgery is easily controlled with mild analgesics. A cast is placed on the nose for approximately six days. In the immediate postoperative period, the patient receives medication for swelling and is instructed to place ice on the eyes to keep swelling to a minimum. In most cases, there will be some swelling and bruising around the eyes, lasting six to ten days. When the cast is removed, nasal swelling is present, but this generally goes down quickly and is not obvious to others. However, depending upon the amount of work necessary and the thickness of the skin, the final shape of the nose is not achieved for several months. There will be some stuffiness and nasal obstruction for a short time after surgery, accompanied by a temporary decrease in sensation of the nasal skin. Strenuous activities should be avoided for approximately two weeks.

Getting back to normal
Most rhinoplasty patients are up and about within two days, and able to return to school or sedentary work a week or so following surgery. It will be several weeks, however, before they are entirely up to speed.The patient will receive specific guidelines from the doctor for gradually resuming normal activities. They’re likely to include these suggestions: Avoid strenuous activity (jogging, swimming, bending, sexual relations–any activity that increases your blood pressure) for two to three weeks. Avoid hitting or rubbing the nose, or getting it sunburned, for eight weeks. Be gentle when washing the face and hair or using cosmetics.Patients can wear contact lenses as soon as he/she feels like it, but glasses are another story. Once the splint is off, they’ll have to be taped to the forehead or propped on the cheeks for another six to seven weeks, until the nose is completely healed.The surgeon will schedule frequent follow–up visits in the months after surgery, to check on the progress of healing.

Your new look
In the days following surgery, when the face is bruised and swollen, it’s easy to forget that you will be looking better. In fact, many patients feel depressed for a while after plastic surgery–it’s quite normal and understandable.Rest assured that this stage will pass. Day by day, your nose will begin to look better and your spirits will improve. Within a week or two, you’ll no longer look as if you’ve just had surgery.Still, healing is a slow and gradual process. Some subtle swelling may be present for months, especially in the tip. The final results of rhinoplasty may not be apparent for a year or more.In the meantime, the patient might experience some unexpected reactions from family and friends. They may say they don’t see a major difference in the nose. Or they may act resentful, especially if the patient has changed something they view as a family or ethnic trait. If that happens, one must try to keep in mind the reason for opting for this surgery.