Page:   1,  2,  3

The purpose of this communication is to enhance, not replace the discussion and consultation with your physician so that you can make an informed decision based upon the risks, benefits, and alternatives for your specific needs and desires. After reading this, you will be able to have a more meaningful discussion with your doctor.

It is important to remember that any decision to undergo plastic or cosmetic surgery must involve a commitment on your part to carefully follow the post operative instructions. Failure to follow these instructions can create serious complications and undo the desired surgical result. Optimal results from your procedure require both your patience as well as your active involvement in your recovery by following any treatments or restrictions provided.

Even if you are the optimal candidate for the procedure and have the best technical and artistic surgical care, failure to follow the specific recovery instructions will change the desired result. Remember, your post operative commitment is as an important component as choosing your surgeon and undergoing the right procedure for you.

RHINOPLASTY

Rhinoplasty which is really a procedure to reshape the nose, is a very commonly performed surgical procedure today. With proper execution in appropriately selected patients, it can provide a welcomed change in the outer appearance of the nose. It is often combined with maneuvers inside the nose as well, which can improve breathing in those with difficulty breathing due to structural problems within the nose.

(Fig 1a,b,c) These are before and after photos of a patient who had a rhinoplasty. He is happy that his nose is straighter and the result is natural. On the profile view, he has reduced the noticeable hump on the dorsum of his nose, yet has maintained a masculine appearance. Again, the photos were taken approximately a month after surgery, so he is still very swollen. This gives you an idea of what you might look like at this stage of healing.

Fig-1a	Fig-1b
Fig-1c

(Fig 2 a,b,c) This patient also had the width of her nose decreased and obtained better definition of her tip. In the after photos, you can see the hump on the dorsum was smoothed out and the tip was rotated up slightly. These subtle changes are often all it takes to provide a natural result and improve ones appearance.

Fig-2a	Fig-2b
Fig-2c

(Fig 3 a,b,c ) This is another before and after photo of a patient who has had a rhinoplasty or nasal reshaping procedure performed. These pictures were taken one month after her procedure so there is still a tremendous amount of swelling. On the front view the nose looks much straighter. It is important to note that even though the nose looks straight at this point, healing and the contraction of scar tissue as well as trauma can cause the nose to be crooked again. On the oblique and side views, you can see that the contours of the nose have been dramatically improved specifically along the dorsum and tip. Again, at one month after surgery, there is substantial swelling, and the nose will change over the next year.

Fig-3a	Fig-3b
Fig-3c

(Fig 4 a,b,c) This patient requested a smaller straighter nose with a ski slope type turned up tip. She was happy with the improvement she obtained at this stage of healing. Some patients request a nose and tip with this type of slope while others do not want this. It is very important that you communicate with your surgeon the degree of changes that you are looking for to make yourself happy.

Fig-4a	Fig-4b
Fig-4c

(Fig 5 a,b,c) These are before and 6 month after photos of a patient who has had a rhinoplasty. She wanted a natural looking nose with minimal changes. She wanted the dorsal bump removed as well as bringing up her tip as she felt it was plunging to low. Although her tip was rotated up slightly, just reducing the bump on the top of the nose gives the illusion that the tip is up. Again, it is important to communicate with your surgeon clearly the desired changes you would like to make. Her nose will continue to change and contract over time.

Fig-5a	Fig-5b
Fig-5c

(Fig 6 a,b,c) This patient wanted a subtle change and natural result from her rhinoplasty. It is most evident on the oblique and side view as her hump was reduced slightly. Often just these subtle changes make a big difference.

Fig-6a	Fig-6b
Fig-6c

(Fig 7 a,b,c) These are before and 8 month after photos of a patient who had a conservative rhinoplasty performed. The dorsum and tip were reduced and the nose was slightly shortened and rotated up. Particularly on the oblique and profile view, the removal of the bump on her dorsum has allowed the observer to focus more on her eyes.

Fig-7a	Fig-7b
Fig-7c

(Fig 8 a,b,c) This patient had a rhinoplasty performed with the after photos taken 9 months after her procedure. She wanted to reduce the width of her nose, make her tip more defined, and also reduce the small bump on her profile view. Because the skin on her nose is thick, it will limit the definition she would ultimately like to achieve in her tip. The skin envelope will continue to tighten down over time.

Fig-8a	Fig-8b
Fig-8c

(Fig 9 a,b,c,d) These are before and 10 month after photos of a patient who had rhinoplasty performed, along with a facelift, browlift and eyelid surgery. The changes in her nose are subtle but on the front view, her tip is less boxy, her nose thinner, and on the profile view, her hump has been smoothed out.

Fig-9a	Fig-9b
Fig-9c	Fig-9d

(Fig 10 a,b,c) These are before and 1 year after photos of a patient who had a rhinoplasty performed. She wanted to have her nose straightened and the dorsal bump reduced. She has very pretty eyes and felt that the appearance of her nose was distracting and taking away from her eyes.

Fig-10a	Fig-10b
Fig-10c

(Fig 11 a,b,c,d) These are before and approximately 1 year after photos of a patient who had a Rhinoplasty and chin augmentation performed as well as open neck contouring, browlift and blepharoplasty. He wanted to reduce the hump, straighten his nose, and maintain a masculine appearance. Comparison to postoperative views shows a very nice subtle change. I feel it is usually a much wiser choice to be conservative with surgical changes in order to maintain a natural appearance. This is an even more important issue with men who will not be happy with a feminizing change.

Fig-11a	Fig-11b
Fig-11c	Fig-11d

(Fig 12 a,b,c) This patient had a reduction Rhinoplasty performed with the after pictures taken 1 1/2 years after her procedure. Again, I feel this is a classic example of her beautiful eyes being lost because of the distraction of the excessive projection of her nose. After this is reduced in a natural way, her eyes stand out much more.

Fig-12a	Fig-12b
Fig-12c

(Fig 13 a,b,c,d) These are before and 16 month after photos of a patient who had a Rhinoplasty, chin augmentation and submental liposuction performed. In addition, she had a browlift, eyelid surgery and fat removed from her cheeks. The nose and chin are critical determinants of ones profile and in creating balance and proportion. She wanted to straighten her nose, remove the bump on the dorsum, and improve the position and shape of the tip. She also wanted to achieve more balance in her face and most importantly, look natural.

Fig-13a	Fig-13b
Fig-13c	Fig-13d

(Fig 14 a) Patients often want to know what they will look like early on in the healing process and how presentable they will be. Obviously the amount of swelling varies with patients, doctors, and the procedures performed. This patient as noted previously had 7 different procedures performed on her face so she is very swollen. If you try to concentrate on the nose itself, you can see the degree of swelling during the first 5 weeks. This picture was taken one week after surgery after the nasal splint was removed.

Fig-14a

(Fig 14 b) These photographs show her at 2 weeks and 5 weeks after surgery. Although definitely swollen, she felt comfortable in public, and makeup can usually cover bruises at this time.

Fig-14b

(Fig 15 a,b,c) This is a patient who had a rhinoplasty performed as well as her buccal fat removed from her cheeks. On the front view, you can see that the nose is more narrow and defined in the after pictures, which were taken six years after her procedure. The tip looks natural, and has better projection, position, and definition than previously.

Fig-15a	Fig-15b
Fig-15c

ANATOMY

(Fig 16) To understand how rhinoplasties are performed, it is important to have a basic understanding of the anatomy of the nose. In the most simplistic terms, the nose is composed of skin, bone and cartilage. The graphic here shows the orientation of those structural parts. From the side view, the nose can be divided into the dorsum, the tip, and the nostrils. Bone and cartilage make up the dorsum while the tip is all cartilage.

Fig-16

(Fig 17) In this graphic, the skin has been totally removed to show the underlying anatomy. (Arrow) The hard part of the nose near the eyes is bone. (arrow) The middle more flexible portion of the nose is cartilage commonly called the upper lateral cartilages. If you feel your own nose, you can actually feel where the bone ends and the softer cartilage begins. The tip (arrow) of the nose is also made of cartilage, commonly called the lower lateral or alar cartilages. Obviously, all noses do not look the same. That is because the size, shape, position, relative proportion of these boney and cartilage parts of the nose are variable either from birth, trauma, or surgical change. The thickness of the skin covering the nose is also very different from patient to patient.

Fig-17

These variations in shape, size and proportion of bone and cartilage, as well as varying thickness of skin on the nose provide the basis for noses looking very different. Your plastic surgeon will have to diagnose and decide which anatomical parts are responsible for the visible features you do not like. Your surgeon will also have to design and execute a surgical plan which will modify these anatomical features safely. These bony and cartilaginous parts of your nose under the skin provide a unique shape, but they also provide support and structure. Changes in their size, shape, and position have to be done without losing support and causing instability of your nose. Alterations that cause loss of support or instability can result in problems such as an unappealing visible appearance, and difficulty breathing among others.

CONSULTATION

During your consultation with your plastic surgeon, it is essential that you and your surgeon communicate very well to improve your chances of a good outcome.

You need to know and express exactly what it is that bothers you about the appearance of your nose, not that it just doesn't look good. Your surgeon should be able to point out the underlying source for the problems that you are unhappy with and give you a reasonable idea of the chance for improvement based on your unique tissue qualities.

Many patients will bring in photos of noses that they like. It is unlikely that your surgeon can make your nose look like someone else's. It is important however to convey to your surgeon, what it is about those noses that you do or don't like. Although you should carefully listen to your surgeon's suggestions and opinions, it is you that must ultimately be happy with the plan and results. If you are certain that what your surgeon is suggesting will not make you happy, it may be wise to further delay your operation and/or consult with another surgeon. Your surgeon however may have valid medical concerns which limit the ability to alter your nose in the manner you desire. Prior to scheduling however, you both must be in total agreement with the plan.

(Fig 18) The computer imager may be valuable for that reason. It is an excellent communication tool. It is important for you to know however, that it is just a communication tool. Anticipated results and goals can be drawn on the computer, but that is just a simulation. Although final results often end up looking just like the simulation drawing, often they do not. The value of the computer imaging is that your surgeon and you can explore possibilities and at least decide on what you would or would not prefer. This tool ultimately may provide a clearer picture or plan of what change should or should not be made. It may also convince you that no change should be attempted at all. The computer picture should by no means represent a promise or guarantee of results expected.

Fig-18

TECHNIQUE

(Fig 19) To generalize very simply, most surgical changes are accomplished by removing or adding cartilage or bone or changing their shape and/or orientation. If the dorsum is too high, it can be reduced by rasping down or removing bone and cartilage as is shown in this graphic.

Fig-19

(Fig 20) If the dorsum is to low, it can be raised by the addition of bone, cartilage, or even synthetic materials as shown here.

Fig-20

(Fig 21) Changes in the shape, volume, projection, and position of the tip of the nose can be accomplished by removing cartilage or adding cartilage. These changes can affect the profile and front view of your nose. The graphic on the left shows cartilage being removed to make the tip smaller. On the right, cartilage is added to change the shape or projection of the tip.

Fig-21

Fig 22) By carefully breaking the bones of the nose in a controlled fashion, the width of the nose can also be changed.

Fig-22

(Fig 23) The nostril size and the fleshy portion around the nostrils can also be reduced. This will require an incision on the outside of the nose which usually leaves a scar in the location noted on the right. It is usually difficult to see. Do not expect the shape and size of your nostrils to be exactly the same afterwards. They are often different before surgery anyway if you closely scrutinize them.

Fig-23

Many techniques and maneuvers can be utilized by surgeons to change the appearance of your nose. These surgical techniques can make noses smaller, larger, shorter, longer, more defined, narrower, wider, straighter, and unfortunately, sometimes worse.

GRAFTING

If additional uniquely sized and shaped pieces of cartilage are needed for your nasal surgery, the cartilage can be taken from your nose, ear, or a rib if needed. Additional bone, if needed, can be removed from your nose or from the superficial layer of bone in your skull. (Fig 24) This figure illustrates excess cartilage being removed from a nose during rhinoplasty and harvesting grafting material from the tip and the septum. Additional cartilage is often necessary especially with revisional surgery.

In some cases, if extra material or volume is required, there are a variety of synthetic materials that can be utilized. Synthetic preformed silastic prosthesis are frequently used to provide augmentation to the dorsal area. There are numerous sizes and shapes available. The additional risks of these implants will be discussed.

APPROACH

To perform this operation on your nose, the surgeon has to have exposure and visibility of these anatomic areas in order to change them. Two different surgical approaches can generally be utilized. Sometimes incisions are made inside the nose only. This is called a "closed approach".

(Fig 25) Sometimes, an incision is made outside the nose as well in the flesh between the nostrils to allow even more exposure, as the skin is lifted up away from the underlying nasal structures. This is called the "open approach".

Fig-25

The tradeoffs and advantages of each approach are debated and somewhat controversial. Most surgeons probably will utilize either technique when appropriate. Some surgeons feel they can accomplish everything without having to place a scar on the outside of the nose, and that the open approach causes more swelling. Others feel the scar is a nonissue and the advantages of doing it open are that there can be much more precision especially with nasal tip work and that the better exposure of the tip structures leads to better results. The truth is, that you can have a good or bad result with either technique, and it probably has more to do with your unique anatomic problem, the skill of your surgeon and the variable healing period. The decision should be based on your unique needs, and the comfort level of your surgeon. Be sure to discuss this with them.

SKIN THICKNESS

One of the most important determining factors affecting the chances of a good result is the variability in thickness of skin on the nose. The thickness of the skin of your nose can not be changed.

(Fig 26) This is a helpful way of understanding the contribution of the thickness of your skin to your surgical result. In this picture on the top left, you can see a thin white sheet over a chair with a basketball in it. The cloth represents skin and the basketball represents underlying structures in the nose such as cartilage. You can tell there is a basketball underneath the cloth in the top photo and when it is removed on the bottom left, it is readily apparent that it is gone.

Fig-26

In these photos on the right, the same chair and basketball are now covered by a thicker blanket. You can neither identify the basketball while it is in the chair on the top right photo, or appreciate that it has been removed in the photo on the bottom right.

Thus, for patients with very thin skin, usually any change that is made in the underlying structures is readily apparent through the skin. These patients can enjoy the visibility of very well defined sculpted structures of their nose. The downside is that any flaw or irregularity is also visible. For those with thicker skin, your surgeon's efforts might never be seen to the degree you hoped for. Usually, there is some improvement, but not as much as you would like. Most people have nasal skin which falls somewhere in between very thin, and very thick. You should ask your plastic surgeon about your unique skin quality.

Just as there are countless variations in how noses differ from person to person, there are many variations in techniques utilized by thousands of surgeons. Maybe more than any surgical procedure, nasal surgery is like an art form. Although there are many "so called" standard techniques to change specific parts of the nose, there is certainly room for the surgeon's own artistic freedom of style in modifications. There is probably more room for creativity among surgeons in design and execution of nasal surgery than in other plastic surgical procedures. An innate artistic sense is important as well as a sense of proportion, and balance. Experience performing these procedures is also probably more important in rhinoplasty than some of the other plastic surgical procedures.

HEALING

After the surgeon has performed the procedure, a long healing period follows. The variable degree of healing can dramatically influence the end result and is not under the control of your doctor. This variable healing pattern of each person also influences the overall result of rhinoplasty more than most other plastic surgical procedures. These considerations also make revisional rhinoplasty surgery uniquely more unpredictable compared to other plastic surgery operations.

(Fig 27 a,b) These pictures may help in understanding the visible process of healing in your nose following surgery. After your surgery, your nose will be swollen. (Fig 27a) The shirt sleeve represents skin on the nose that is swollen. The watch underneath the sleeve represents the underlying structures that have been visibly changed. As the swelling goes down, the watch or underlying nasal structures become apparent.

Fig-27a

(Fig 27b) The swelling goes down more and more each month and the overlying skin contracts, until finally; you are able to see the detail of the end result. The extent and period of time that the nose is swollen is variable but usually it takes roughly one year to see a final result.

Fig-27b

(Fig 28) Techniques and timing are variable among surgeons. However, generally, the nasal splint or cast (if one was placed) is removed approximately a week after the operation, and the nose is very swollen. On the right, is a picture of a patient one week after surgery after the splint has been removed with obvious swelling and bruising. The before picture is on the left. This patient had her nasal bones broken, and a lot of tip work which caused additional swelling and bruising. This picture is a fair representation of what a patient may look like a week after an extensive nasal surgery. Most patients will see a positive change in their nose but might be unhappy with the size because of the swelling. You need to be reassured that this is swelling and the appearance will ultimately improve as the swelling slowly goes away. The majority of the swelling may go down over the next few months. However, all the swelling hiding the subtle changes of the nose usually takes about a year. Often, patients will continue to notice changes, and further subtle reduction in size over several years. Usually, during that first year, others are not able to recognize the swelling in your nose.

Fig-28

REVISIONAL NASAL SURGERY

Many nasal surgeries are revisional nasal surgeries or operations to attempt to correct problems from a previous surgery. It is very important to know that each subsequent operation generally becomes more difficult, more unpredictable, and more risky. One of the other significant problems associated with revisional nasal surgery is the unpredictable and excessive build up of scar tissue. Multiple surgeries can result in the compounding or building up of scar tissue on top of scar tissue. This can lead to excessive thickness, volume, and permanent deformities which ultimately are not correctable.

The line between truly needing a revisional surgery and taking that risk, and just wanting a revisional surgery should be clear. Sometimes the degree of precision desired by the patient is simply not obtainable from modern plastic surgical techniques. Chasing perfection in the best of hands can lead to results that sometimes leave a patient wishing they would have stayed put with what they had. Be sure to obtain multiple and thorough consultations with surgeons experienced in rhinoplasty prior to scheduling a revision. Most doctors will tell you to wait at least one year after the initial surgery prior to having a revision. This is an important and valuable bit of advice which requires a lot of patience on the part of the patient. If the swelling has not gone down completely prior to the revisional surgery being performed, it is very difficult for the surgeon to gauge the amount of correction needed. It is difficult to clearly differentiate between the extent of the deformity and the swelling. Thus overcorrection can be the end result of a lack of patience and an over eagerly timed early revision.

NASAL AIRWAY OBSTRUCTION

Besides a cosmetic side of surgery on the nose, there is also a functional aspect of nasal surgery involving nasal airway obstruction and difficulty breathing. There are several areas in the nose that can restrict airflow on its way from the nose to the lungs. These areas can be affected by nasal surgery. First, the nostrils must be large enough to allow airflow, and maintain enough support to stay open when breathing in. Poor surgical planning can lead to instability of this area which can adversely affect breathing. Procedures are also available to improve these types of problems should they exist.

(Fig 29) Inside the nose, the nasal septum is a plate of cartilage that divides the internal nose into the right and the left half. This cartilaginous partition as shown in yellow in this graphic divides and funnels the airflow from each nostril separately into the back of the nose and throat. If the septum is sufficiently deviated, it can obstruct and limit the airflow. Correction of this deviated septum by either straightening it, or removing the obstructing portion of it can improve airflow. Often, a crooked septum is associated with a crooked nose and must be straightened to achieve a straightened nose.

Fig-29

Opposite of the septum on the walls on each side of the inside of the nose, are projecting structures called turbinates which have the ability to expand and contract. They are highlighted in red in this graphic. There are generally three on each side, and excessive engorgement usually of the lower turbinate can contribute also to reduced airflow through the nose. Nasal sprays and decongestants are usually effective in pharmaceutically reducing their size and negative influence on airflow. Surgical reduction or repositioning called outfracture of the turbinates, can also improve airflow in the appropriate patient. (Fig 30) Another area inside the nose which is important for airflow is called the "internal valve" area (arrows). Excessive narrowness of the internal nose or lack of support with inspiration can adversely affect the flow of air through the nose. Surgical modification which causes excessive narrowness of the nose, particularly in patients who have relatively small nasal bones when compared to the length of their nose are at risk (Fig 31) Sometimes, treatment involving the placement of cartilage grafts called "spreader grafts" (white lines) can improve deficiencies in this valve.

Fig-30	Fig-31

ALTERNATIVES TO SURGERY

If you are reading this, you may have already considered the alternatives to having surgery to change the appearance of your nose or to improve your breathing. In most cases, this surgery is elective and you do not have to have the procedure and be subjected to the risks. You should consult with your doctor about available alternatives other than a surgical procedure on your nose. Breathing may be able to be improved with oral medications such as decongestants, antihistamines, various allergy medications, or nasal sprays. External appliances are available for some specific structural problems.

COMPLICATIONS

Each year, thousands of patients undergo Rhinoplasty without complications. Graphic It is a commonly performed surgery, and generally safe for select patients, however complications can and do occur. The rate of complications vary greatly depending on many variables including the skill and experience of the surgeon, tissue qualities of the patient, their compliance to postoperative orders, and the variability and unpredictability of healing among others. Fortunately, the more severe complications are the rarest.

Dissatisfaction with Cosmetic Result: Even in the best hands, adverse events can occur. Always consider that you could be the one having the complication. Probably the most frequent unpleasant result of rhinoplasty is a patient who is not happy with their cosmetic result. Obviously, there are many factors that may lead to this problem. One may be a legitimate poor result however many times, the patient's expectations are very unrealistic. Sometimes the degree of precision desired by the patient is simply not obtainable from modern plastic surgical techniques. Being able to wait while the swelling dissipates is very important to avoid a premature final judgment of your result. Sometimes revisions are necessary. However, sometimes even when a patient wants a revision it is safest to leave well enough alone.

Prolonged Swelling, Bruising, and Healing : These variability's can occur as with any surgery.

Asymmetry: Asymmetry of nasal features as well as the nostrils can occur as a result of surgery on the nose. However many times, asymmetry is present before surgery but not recognized until after by the patient who examines their nose with more detail.

Nose Tip asymmetry

(Fig 32a,b) This is an example of a patient who has previously had a rhinoplasty. The cartilages of the tip of the nose are very asymmetric when comparing one side to the other and there are prominent indentations present. In addition, you can see on the bottom photo that support has been lost causing collapse of the nostrils which makes breathing more difficult.

Fig-32a	Fig-32b

(Fig 33 a,b,c) These are before and 15 month after photos of the same patient following her revision Rhinoplasty. She had extensive cartilage grafting of her nose to provide better support which in turn improved her breathing and provided a more appealing appearance.

Fig-33a	Fig-33b
Fig-33c

Excessive Scarring: Scarring is a necessary part of healing and accompanies all surgical procedures. Scarring worse than expected can occur from a variety of reasons. Sometimes incisions on the nose can be more noticeable than anticipated. It is important that you carefully follow your postoperative instructions.

Numbness: Numbness and pain at the surgical site is common after surgery. Although it is generally only temporary, it could continue indefinitely.

Excessive Bleeding or Infection: These are risks associated with any surgical procedure and the nose is no exception. Although unlikely, it could occur. A hematoma is an unexpected excessive collection of blood at the surgical site after surgery. These problems could require additional surgery to treat.

Difficulty Breathing: Changes in the structure of the nose from surgery, trauma, or scarring can lead to changes in support. These can lead to breathing difficulties. Although some procedures are not intended to affect breathing, and others are intended to improve breathing, your breathing may not be improved and may even be worse after surgery.

Collapsed Nostril

(Fig 34) This is a photo of a patient's nostrils who as a result of surgery and removal of cartilage, lost the necessary support for her left nostril. As a result, she has both a cosmetic deformity as well as difficulty breathing through her left nostril.

Fig-34

Synechia (Scarring)

(Fig 35) This is a photo taken of the inside of a patient's right nostril who had previously had a Rhinoplasty and associated internal nasal surgery performed. Scar tissue has developed which has almost totally occluded her nostril and airway on that side. Obviously, her breathing was worse than before that procedure. Generally, this particular problem can be corrected.

Fig-35

Excessive Dryness and Runny Nose

Sometimes nasal surgery, especially internally on the septum or turbinates can result in problems such as excessive dryness or even a chronic runny nose. These can further add to breathing difficulties and may require medication to treat.

Septal Perforation

(Fig 36) A septal perforation is basically a hole in the septum in the inside of the nose as shown here. These are sometimes seen in people who snort cocaine. This can occur as the result of surgery as well. This problem along with other forms of scarring on the inside of the nose can further restrict your breathing. If a septal perforation is present, surgical attempts can be made to correct it. Perforations can alter the flow of air through the nose and cause excessive dryness, crusting, as well as audible whistling.

Fig-36

Structural Collapse: A saddle deformity is basically a collapse of your nose from loss of so much support. This can happen from extensive reduction or removal of tissues. It is fortunately rare but certainly could lead to the need for additional surgery.

Donor Cartilage Site Complications: If cartilage or tissues are removed from other sites such as the ear or rib, complications of wound healing can occur at those sites as well. Some of them include infection, bleeding, scarring, pain, deformities or other problems. Be sure to ask your surgeon if he anticipates needing tissue from a site other than your nose.

Cartilage Graft and Synthetic Implant Complications: If cartilage grafts or synthetic implants are to be utilized during your nasal surgery, some special considerations exist.

Any graft or implant could possibly become displaced over time. Both cartilage and synthetic implants may also become infected requiring removal, and this appears to me more common with synthetic implants. Although unlikely, it could occur and removal may require replacement of the graft or implant when the inflammation has resolved. Although rare, it is also possible for implants to even erode or come through the surface of the skin. This is called erosion and extrusion, and generally requires removal for an indefinite period of time. This is sometimes caused by excessive tension on the skin by the implant. It is more commonly seen with synthetic implants than from cartilage grafts. Grafts can also twist and become misshapen over time under the steady influence of scarring and contraction of the tissues. This appears to be more likely with cartilage. Be sure to ask your surgeon in detail about these possibilities.

Deformities and need for Revisional Surgery: Any complications can result in deformities, both temporary and permanent. Revisional surgery is sometimes required after nasal surgery and it generally becomes more difficult, unpredictable, and more risky each time. Be sure to be patient and obtain multiple consultations prior to considering revisional surgery.

Changes in Sense of Smell/Voice: A very remote chance of change in sense of smell or a change in your voice could also occur, but is very unlikely. For those who make their living with the tone of their voice such as singers and radio announcers, this potential risk should be discussed in detail.

Other: Although complications are unlikely, they do occur with any operations, and a rhinoplasty is a surgically sophisticated operation involving many variables. Other complications could occur and possibly lead to the need for hospitalization and even death. Be sure to carefully discuss these risks with your surgeon and the possible related financial responsibilities. Financial issues include procedural costs as well as lost work time.

OPERATING TIME AND ANESTHESIA

The time it takes for the surgical procedure, as well as the postoperative instructions varies greatly among surgeons and should be discussed in your consultation.

Rhinoplasty surgery is safely and frequently performed under both local and general anesthesia. With a general anesthesia, you are completely asleep and your breathing is controlled by the anesthesia provider. Under a local anesthesia, usually you are sedated and the areas to be operated on are made numb with a series of injections.

POSTOPERATIVE INSTRUCTIONS

Although postoperative instructions vary among surgeons, the following are helpful suggestions. That being said, it is important however that you defer to and follow the instructions of your surgeon.

Keep your head elevated at home during the early recovery period. Rotating frozen bags of peas make excellent ice packs. Some doctors place nasal packing or a splint inside the nose for a variable period of time. This is often useful as an internal splint to maintain position of the nose and modified structures during healing. Packing is helpful in decreasing any drainage of blood into the throat or stomach which may be a nuisance and cause nausea. It will however lead to a dry throat until it is removed as you will have to breathe through your mouth. Ice chips, lozenges, and popsicles are helpful in keeping the throat moist.

You should not probe inside your nose or blow your nose for about a month, and try to direct sneezing out of your mouth. Vigorous activity should be discouraged that would raise your blood pressure such as exercise for about a month after surgery.

If a splint is placed, it is likely to be on for about a week. It is important to know that if you were to break your arm, a splint or cast would be in place for 6 weeks to allow complete healing. A splint or cast can not be kept on your nose for 6 weeks, so it is important during that time that you do not bump or bend your nose which could adversely affect the final shape and position of your nose.

To have the best chance at an optimal outcome, it is very important that you follow your surgeon's instructions carefully. Show up for all of your postoperative appointments. This gives your surgeon and his staff the opportunity to evaluate your healing and detect early problems if present.

RECOVERY PERIOD

The recovery period also varies greatly depending on the technique, surgeon, and patient. Usually, bruising if present, should be gone within five to ten days. Although your nose will be swollen, you are generally presentable for work after the splint is removed. It has to be emphasized, that in most cases when the splint comes off, you will see a nice improvement in your nose, but not to the extent that you would like. You must be patient during the healing period and know your final result will likely not be identifiable for one year. Pictures at one week, six months, and one year after surgery will show a progressive change.

(Fig 37) These are sample photos of this patient's nose one week after surgery. The appearance is pretty indicative of how many patients look one week after a pretty extensive nasal surgery with the bones being broken.

Fig-37

(Fig 38 a,b,c) These are before and after photos taken 6 weeks after her Rhinoplasty at a time when her nose is very swollen. You can see an improvement on the front view as the nose is more narrow and the tip is smaller and more defined. On the oblique and side view, the tip has been slightly rotated up. The bump on her dorsum will continue to improve as the swelling goes away. People looking at her do not realize that her nose is swollen. Over the next year, the swelling will dissipate and her nose will continue to contract, get smaller and more defined. She understands that she will have to be patient and wait for the final result to appear.

Fig-38a	Fig-38b
Fig-38c

(Fig 39) If open rhinoplasty is performed such as in this patient, this gives an idea of the appearance and degree of noticeablity of the scar six weeks after the procedure. With more time, the scar in most cases will be even less noticeable.

Fig-39

Page:   1,  2,  3

Copyright © 2000-2010 Garth Fisher M.D.®, F.A.C.S. - All rights reserved.
Twitter - Glossary - Facebook - Contact Dr. Fisher

Web Development by Imaginary Trout