Rhinoplasty

This article covers what rhinoplasty involves, why the aims of appearance and breathing are assessed separately, the recovery timetable and the possibility of revision. Returning to work and the nose reaching its final shape are not the same stage; the final appearance of the nose takes months to settle. The surgery of breathing problems and non-surgical procedures are the subject of separate articles.

What is rhinoplasty?

Rhinoplasty is the operation that changes the appearance of the nose by shaping its bone and cartilage structure. The dorsum, the tip, the width and asymmetry can be different parts of the surgical plan.¹ The nose is also an airway; when wishes about appearance are assessed, the passage of air is examined as well.²

The subject of this article is the surgical plan directed at the appearance of the nose and its relationship with breathing. Septorhinoplasty, the surgery of breathing problems, will be covered in a separate article. Although the two aims can be assessed in the same operation, a change in appearance and a change in breathing are separate outcomes.² Non-surgical nose procedures are outside the scope of this article.

Who is it suitable for?

People who want a change in the appearance of the nose, whose facial growth is complete and whose general health is suitable for surgery can be assessed.³ Rather than aiming at a single shape of nose, what the person wants to change, which features they want to preserve and what they expect from the operation are established.²

The decision to have surgery should rest on the person's own wish; having an operation to meet someone else's expectation is not a suitable starting point.³ The examination also assesses how far concerns about appearance affect daily life. Where body dysmorphic disorder is suspected, a mental health assessment is needed; surgery does not substitute for that assessment.²

Previous nose surgery does not automatically rule out a further operation, but a first operation and a revision are not the same patient group.⁴ The report of the previous operation, any current obstruction and the areas from which cartilage has been taken should be declared. The same incision, the same amount of reduction or the same plan of support is not recommended for everyone.¹

What does the examination assess?

The dorsum, the tip, the nostrils, the columella and the skin envelope are examined. The columella is the skin-covered part between the nostrils. The septum is the structure containing bone and cartilage that divides the nasal cavity. The internal examination assesses the areas that affect the passage of air.²

Skin thickness and the strength and position of the cartilages matter for the limits of the change that can be made.² The features the patient wants changed are assessed from the front and from the side. Asymmetry seen at examination and the features to be preserved are recorded; rather than preparing for the consultation with a single photograph of a nose or a single angle, describing the complaint itself is useful.

Breathing complaints: Which side the obstruction is on, whether it is constant or variable, and whether there has been previous trauma or surgery should be described. Nasal sprays in use, allergy complaints and sleep apnoea are reported. Any complaint about the sense of smell before surgery is also recorded.²

The wish about appearance and the expectation about breathing are clarified as separate headings at the examination. Profile features outside the nose can also be discussed; the position of the point of the chin, for example, can be assessed together with the appearance of the dorsum. This assessment does not mean an additional facial operation is needed. The decision is not made in order to fit the person to a predetermined facial measurement.

How is the operation planned?

Is it done open or closed?

In the open technique there is a small skin incision on the columella, used together with incisions inside the nose. In the closed technique access is gained through incisions inside the nose.¹ The approach used is determined by the surgeon's preference and the person's needs; in this practice neither of the two methods is the default for everyone.

In the 12-study meta-analysis of a systematic review examining 20 studies, 1,067 people were assessed, 539 open and 528 closed operations.⁵ No significant difference was found between the methods in the results of the ROE scale, which concerns appearance and satisfaction, or the NOSE scale, which concerns nasal obstruction.⁵ Because the patient groups and outcomes of the studies varied, this finding is not proof that the methods are equivalent for every patient and every problem.⁵

The name of the incision route does not describe everything done in the operation. Which changes are needed for the dorsum or the tip is planned separately.¹ In choosing the open or the closed method, the external incision, the existing structure, any previous operation and the change to be achieved are assessed together.

How are bone, cartilage and support addressed?

The plan may not consist only of removing tissue; while bone or cartilage is being shaped, cartilage may need to be added in some areas.¹ Collapse and contour problems associated with removing too much tissue from the dorsum have been reported; a wish for reduction therefore cannot be considered apart from preserving the supporting structures.⁶

The shape of the tip and the appearance of the dorsum are assessed separately. The effect of the intended change on the passage of air inside the nose is also part of the plan.² The source of a breathing problem is not divided into detailed surgical techniques in this article; where an accompanying functional procedure is needed, it is explained on its own grounds.

Where is cartilage taken from?

The need for cartilage varies from person to person. Where possible the septum inside the nose is used; where that is not sufficient, ear or rib cartilage can be assessed.¹ This does not mean ear or rib cartilage will be taken from every patient. Any possible need is discussed before surgery.

Taking cartilage from another area creates a surgical site there as well. The risks of the donor area for rib cartilage, such as pain and scarring, and the warping or resorption of the cartilage placed in the nose are separate problems.⁷⁸ The source of cartilage is chosen by looking not only at the need in the nose but also at the additional burden the donor area brings.

How are anaesthesia, duration and supports planned?

In this practice the operation is carried out under general anaesthesia and takes 2-4 hours. A hospital stay of 1 night is planned. The decision to discharge is made after checking the extent of the operation and the person's recovery.

Splint and packing: The timetable for removal in this practice is planned as 1 week. The splint outside the nose and the support inside it are not in the same place. The surgical team explains the care of the supports used and how they will be removed at the check-up; they are not removed at home on your own initiative.

Stitches: In the open technique the stitches on the columella are removed after 1 week. In the closed technique there are no stitches to be removed on the outside. The fact box carries the splint and packing information; whether there is an external stitch depends on the incision route used.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.⁹ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹⁰ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹¹ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹² The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹³ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹³ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

Sprays used regularly inside the nose and any previous nose operations are also reported. If ear or rib cartilage has been taken before, this is stated at the examination. The instructions to be given on discharge about the splint, taping, glasses and returning to work are reviewed beforehand.

What is recovery like?

The first check-up is after 1 week. Bruising is expected to settle in 7-10 days and marked oedema to subside in 2-4 weeks. These are the care timetable of this practice; a check-up is not carried out by looking at the calendar day alone. Where there is an unexpected complaint, the scheduled check-up is not waited for.

While a full return to daily life is planned at 2-4 weeks, the first assessment of the shape is made within 2-3 months. Residual slight swelling can last 3-6 months. The final shape of the nose settling can take 6 months to 1 year. Looking less swollen from the outside in the early period does not mean the tissues have taken their final shape.¹⁴

Having returned to work or being able to carry out daily tasks, and being able to assess the final appearance of the nose, are different stages. The first follows the return of everyday function, the second the resolution of swelling and the emergence of the shape.¹⁴ A decision about final symmetry or revision is not made on the appearance in the first months; the direction of change is assessed at the check-ups.

The first stage of breathing: When the packing is removed, breathing through the nose becomes easier. This first relief is not assessed as the final state of breathing.

The intermediate period of breathing: After a time, the passage of air can decrease again because of oedema in the mucosa lining the inside of the nose. In this period your surgeon may advise a spray. Feeling obstructed again after the relief that followed removal of the packing does not by itself mean the operation has failed; the follow-up plan of this practice also assesses oedema inside the nose.

Assessing breathing: The final result for breathing is assessed after 3-6 months. Even so, the end of this period is not waited for where obstruction is steadily increasing or does not follow the expected course. Follow-up of appearance and of breathing are carried out separately; improvement in one should not lead to a complaint about the other being disregarded.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

Nasal cleaning and taping: During the first week an ointment is applied to the areas of the stitches and a moisturising spray is used inside the nose. Taping is planned for 2 weeks. The area the product is applied to and the way tapes are changed are determined by the instructions given on discharge. Crusts inside the nose are not forcibly picked off; the method given for cleaning is not departed from.

Glasses: The use of glasses that rest on the nose varies with the technique; they are usually restricted for at least 1-2 months. Where glasses are needed for vision, how they can be used without pressing on the nose is planned in advance with the surgical team. The end of the restriction is not decided merely by the person feeling well.

Blowing the nose: The restriction varies with the technique and usually lasts at least 4-6 weeks. The nose is not blown forcefully to clear obstruction. Cleaning and the use of spray are carried out according to the plan given; where obstruction persists, assessment by a doctor is sought rather than adding a new product on your own initiative.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: The treatment prescribed for pain is used. Pain that increases in a way that differs from the expected course, becomes marked despite the treatment given, or is accompanied by swelling and bleeding is reported to your doctor. Where cartilage has been taken from the ear or the rib, pain in that area is also described separately.

Returning to work and sport: A return to work is planned at 1-2 weeks and a return to sport at 2-4 weeks. The physical demands of the job and the type of exercise are assessed. Separate approval from your doctor is obtained for a return to activities in which the nose could be struck or pressed; the general interval for sport is not automatic permission for every activity.

Driving: A return can be assessed within 1-3 days. Where there is grogginess, reduced attention or a problem affecting vision, driving is not undertaken. Medication in use and the comfort of movement are taken into account; the interval given does not by itself show that you are ready to drive.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the nose and face, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: In the early period swelling, bruising, nasal obstruction and numbness can occur.² The course of these findings is assessed at the check-ups. Rather than repeatedly pressing the nose to check it or trying to shape it, the site of the complaint, when it began and how it is changing are described to your doctor. Increasing pain or bleeding is not folded into ordinary swelling and passed over.

How do the scars change?

In the open technique the skin incision on the columella can leave a scar on the outside; access from inside the nose in the closed technique leaves no visible external incision scar.¹ The absence of an external scar does not mean there is no tissue healing inside the nose, or that the operation is without risk.¹⁵

In this practice the maturing of the skin scar is assessed as 6 months to 1 year. For the skin incision on the columella in the open technique, silicone gel and massage are advised; the decision to begin is made by your surgeon according to the healing of the wound. Silicone gel and massage are not applied to incisions on the inner surfaces. The care of the external skin scar in the open technique is not carried over to the closed technique.

Where cartilage has been taken from the ear or the rib, the skin incision of that area is assessed separately. The care instructions should make clear which product is given for which incision. A product given for a skin incision is not applied inside the nose; the ointment advised for the area of the stitches in the first week and later scar care are not used in place of one another.

The visibility of a scar and wound healing can vary from person to person; it cannot be guaranteed that the scar in the open technique will go unnoticed.¹⁵ A check-up is arranged for persistent redness, opening, or a scar that becomes prominent.

Risks and complications

An unwanted result or a need for further treatment can arise after nose surgery.¹⁵ In the 36-study review covering primary aesthetic, functional and combined rhinoplasty, bleeding, infection, dehiscence, septal perforation and the need for further surgery were assessed.¹⁶ The results of different techniques and patient groups should not be read as a percentage showing all the risks for one person.¹⁶

Problems with shape, symmetry and support

Asymmetry, irregularity of the dorsum or the tip, and an appearance different from that expected can occur.¹⁵⁶ One of the problems associated with loss of support is the collapse of the dorsum known as saddle nose; excessive or insufficient intervention on the structures of the dorsum can also lead to other contour problems.⁶

Warping, displacement or resorption can develop in a cartilage graft.⁶⁸ These possibilities do not mean the same problems will occur in everyone who has cartilage added.⁸ Where there is a lasting problem of shape, a further operation can be assessed; early oedema and lasting irregularity are distinguished at the check-ups.¹⁵¹⁴

Breathing difficulty and septal perforation

Breathing difficulty present before the operation can persist, or new breathing difficulty can develop afterwards.¹⁵ It is therefore taken into account that new obstruction is not merely a complaint about appearance. Where the complaint worsens, the routine check-up date is not waited for.

Septal perforation is the formation of a hole in the partition inside the nose. The American Society of Plastic Surgeons lists it as a rare risk, and states that further surgery may be needed for repair and that not every perforation can be corrected.¹⁵ In the 36-study review, the study rates reported for septal perforation range from 0 to 2.6 per cent; this too is not a single pooled probability but the range between studies.¹⁶ Temporary mucosal oedema and a lasting structural problem are not the same; the distinction is made by examination.

Changes in smell and sensation

A change in the sense of smell and numbness in the nose can occur; a persistent change in smell or taste, and persistent numbness, are also among the reported complications.² No verified frequency for permanent loss of smell is given in this article. A pre-existing complaint about smell and a change beginning after surgery should be described separately, and prolonged complaints should be assessed by a doctor.

Bleeding, wound problems and infection

Bleeding, dehiscence or infection may call for further treatment.¹⁶ Where bleeding increases, the wound opens, there is foul-smelling discharge, or pain increases together with fever, the surgical team is informed. Where there is a problem with the internal support, the splint or the tape, no attempt is made to correct it at home.

Risks related to the area cartilage is taken from

Where cartilage is taken from the ear or the rib, pain and scarring are assessed separately.¹⁷ In a 21-study review of rib cartilage harvesting, the pooled rates of donor site problems were reported as 0.1 per cent for pneumothorax, 0.6 per cent each for pleural tear, infection and fluid collection, 2.9 per cent for scar-related problems and 0.2 per cent for severe donor site pain.⁷ Pneumothorax is the entry of air between the lung and the chest wall; where there is chest pain and shortness of breath, urgent assessment is needed.

In an updated meta-analysis covering 20 studies and 1,648 patients, the pooled rate of pneumothorax was reported as 0 per cent, with a 95 per cent confidence interval of 0-0.46 per cent.⁸ This finding does not prove the risk is zero; it shows that uncertainty remains for rare events.⁸ The values of 0.1 per cent and 0 per cent given for pneumothorax by the two reviews are estimates from separate sets of studies and are not in conflict; 0.1 per cent falls within the 0-0.46 per cent confidence interval of the other review.⁷⁸

Nor can it be said that pain will be severe in every patient. In a prospective pilot study of 55 people undergoing rhinoplasty and nasal reconstruction, assessments were planned at 1, 4 and 12 weeks, and no significant difference was found between the pain scores of the ear and rib donor areas.¹⁷ This small series, covering different operations, is not a guarantee of freedom from pain.¹⁷

Anaesthetic and general surgical risks

The risks relating to general anaesthesia and the person's coexisting illnesses are addressed in the preoperative assessment.¹⁵ The measures to be used are determined according to the person and the procedures planned.

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

When does the result settle, and when is revision assessed?

The 2-4 weeks given for a full return to daily life is not the time it takes to see the final state of the nose. While the shape becomes suitable for a first assessment within 2-3 months, residual slight swelling can last 3-6 months; the result is expected to settle in 6 months to 1 year. The nose is therefore still in its healing period at the time of the return to work. The American Society of Plastic Surgeons likewise states that the contour becoming defined takes longer after the initial swelling has subsided.¹⁴

A revision is a further operation carried out to correct a problem that remains or develops after the first operation. In the study by Spataro and colleagues, drawn from the health records of 3 states in the United States, a total of 175,842 septorhinoplasty records were examined.⁴ Revision was recorded in 5,389 of the 172,324 people undergoing a first operation, that is 3.1 per cent; operations between 2005 and 2009 were followed to the end of 2012, giving a minimum follow-up of 3 years.⁴ This series covers septorhinoplasty carried out for both aesthetic and breathing purposes; the rate is not the rate for aesthetic nose surgery alone, nor a percentage of dissatisfaction.⁴ In the same study, revision was reported in 340 of the 4,289 operations coded as being for cosmetic reasons in the health records, that is 7.9 per cent; cosmetic coding is among the characteristics reported together with a higher rate of revision.⁴ This subgroup rests on a much smaller number and is separated according to the coding in the records; its result does not directly show the revision rate an individual considering aesthetic nose surgery should expect.⁴

In the other review, of 36 studies, study rates of 0 to 10.9 per cent were reported for revision.¹⁶ This range is the range of results across different studies; it is not a single pooled probability, nor a lower and upper limit a person should expect.¹⁶ It would not be appropriate to make a direct comparison of safety with the 3.1 per cent of the records series; the patient groups and the scope of the outcomes measured are not the same.⁴¹⁶

While there is oedema in the early period, a definite decision about revision is not made on appearance alone. The course of the swelling and the nature of the remaining problem are assessed first. This approach does not mean waiting where there are problems that call for early assessment, such as bleeding, infection or marked breathing difficulty. Whether a further operation is needed, and when, is determined for each person.¹⁵

What can be expected from the result?

The change expected is assessed together with the aims for appearance established before surgery. Although the result can be preserved for a long time, changes due to ageing continue; it cannot be said that the shape of the nose will never change.¹⁸ Full symmetry, or that no further procedure will be needed, cannot be guaranteed.¹⁵

A shape one person likes does not have to be a surgical aim for another. Differences in nasal shape associated with individual and ethnic features are normal variations and are not, by themselves, problems requiring correction. At the examination, not only the features to be changed but also the features to be preserved need to be stated clearly. The assessment of the operation is not reduced to a single measurement or to a description of appearance valid for everyone.

The aim for breathing is followed separately. The first relief provided by removing the packing, the intervening period of oedema and the assessment after 3-6 months are considered together. The timetable for assessing appearance and the follow-up of a breathing complaint are not the same thing; a continuing complaint should be reported to your doctor even where the external appearance is satisfactory.

When should you contact a doctor?

Urgent assessment is needed without delay in the following situations:

• Bleeding that does not stop or increases markedly.
• Marked breathing difficulty together with rapidly increasing swelling.
• Sudden shortness of breath, chest pain or fainting.
• One-sided leg pain and swelling.

The surgical team should be informed in the following situations:

• Fever, foul-smelling discharge, the wound opening, or steadily increasing redness and pain.
• Displacement of, or marked pressure from, the splint, the packing or the tape.
• Nasal obstruction that does not follow the expected course, or that increases or persists.
• A change in the sense of smell that becomes lasting, or increasing complaints of sensation in the nose.
• Increasing pain, swelling or discharge in the ear or chest area from which cartilage was taken.

With these signs the scheduled check-up date is not waited for. Where rib cartilage in particular has been taken, chest pain and shortness of breath should not be assessed as pain of the operated site alone. Which department to attend is determined by the contact and emergency plan given on discharge.

About the numbers in this article

The periods in the fact box, and the check-up, care and recovery timetable, are the framework set by the surgeon for this practice. They are reassessed according to individual healing and the extent of the operation. Returning to daily life, the swelling passing completely and the result settling are different measures.

The research figures belong to their own patient groups. Revision records, the scale scores of technique comparisons, and the donor site risks of patients in whom only rib cartilage was used do not come from the same denominator.⁴⁵⁸ That no significant difference was found in one study does not show that the methods are equivalent, and that 0 per cent was calculated for a rare event does not show that the risk is absent.⁵⁸ These figures are given to explain the uncertainties to be assessed at the examination, rather than as a promise of an individual result.

References

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