Rhinoplasty (Nose) – Dr. Ina Isac

Rhinoplasty, or rhinocorrection, is a very popular surgical procedure that improves not only the appearance of the nose but also that of the entire face, and which also leads to increased self-confidence. A plastic surgeon can alter the shape of the nose by making it smaller or larger, as appropriate, and by modifying the bridge, tip, and nostrils. In addition, rhinoplasty can also address functional issues, such as difficulty breathing (surgery for a deviated septum). As a result of the surgery, the patient will have a pleasing and as natural-looking a nose as possible, as well as normal breathing.

Patients must be at least 15 years old for girls and at least 18 years old for boys. By these ages, the shape of the nose has already stabilized and the bones have matured. There is no maximum age for rhinoplasty; in other words, the surgery can be performed at any time after the ages mentioned above. Patients must have realistic expectations regarding the surgery; therefore, it is very important for the surgeon to understand what the patient expects and what their goals are in this regard. The patient’s hopes and desires must largely align with what can be achieved through surgery.

Even minor changes to the nose can lead to excellent results. Rhinoplasty is considered one of the most difficult and meticulous procedures in cosmetic surgery, as the difference between a satisfactory and an unsatisfactory result can be as little as a few millimeters! The procedure is one of the most difficult and delicate in cosmetic surgery. That is why the consultation(s) with the surgeon are very important. The patient must be well-informed about all aspects of the surgery, and any questions should be addressed to the doctor.
First, you should describe to the surgeon what bothers you about the current appearance of your nose and roughly how you’d like it to look after the surgery. If you have photos of noses that are close to your ideal, it’s a good idea to bring them to the consultation. Your doctor will tell you whether your desired results are achievable and may perform a computer simulation to give you an idea of what you would look like with your new nose shape.

You must tell your doctor about any other medical conditions you have, previous surgeries involving the nasal pyramid, and any drug allergies. Before the surgery, the doctor will recommend routine blood tests, a skull X-ray, and any necessary treatments for rhinitis or sinusitis that you must complete before the procedure.

It is important that you do not have a cold before surgery and that you avoid taking aspirin for at least 2 weeks beforehand, as this increases the risk of bleeding. Vitamin E and homeopathic medications (such as spirulina and ginseng) should also be avoided for the same reason. You may take Arnica montana tablets before surgery, as they help reduce postoperative swelling and bruising.

The evening before surgery, it’s a good idea to wash your face thoroughly with soap to prevent infections that may arise from germs on your face. You must not eat anything for 6 hours before the surgery and must not drink anything for at least 4 hours before the surgery.
After the surgery, it’s a good idea to arrange for a family member or friend to drive you home, since you won’t be able to drive.

Do not use any facial cosmetics or makeup. In the days following the surgery, your face will be swollen, you will have bruises around your eyes, and you will need to spend more time in bed. For this reason, it’s a good idea to stock up on food and get your affairs in order before the surgery, and ideally have someone available to take care of you. The benefits of the surgery are both aesthetic and functional. The aesthetic benefits aim to improve the appearance of the nose so that it has as natural a shape as possible and harmonizes with the patient’s face. Rhinoplasty is also performed on noses that have suffered previous trauma and exhibit deviations. The functional benefits consist of improved respiratory function.

Sometimes rhinoplasty can be combined with other cosmetic procedures (chin implants in cases of micrognathia—a chin that is too small, which creates the illusion of a larger nose—facelifts, etc.).

- Aesthetic Benefits
  - Symmetry—people generally respond very positively to anything symmetrical, especially on the face; even a slight asymmetry in the nose makes a noticeable difference. One of the major benefits of rhinoplasty is that, when performed by a competent and experienced surgeon, it can achieve facial symmetry for the patient (a nose centered on the midline, without deviation, a harmonious, symmetrical, and symmetrical nostrils).
  - Shape—the bridge of the nose can be altered (it can be made straight or slightly arched by removing the hump), the base can be narrowed, the nostrils can be narrowed, and the angle between the nose and the upper lip can be adjusted (i.e., the tip can be raised or lowered).
  - Size – it can be enlarged or reduced, as appropriate
- Functional benefits

It can be performed in two ways: closed or open. The surgeon decides which of the two types is appropriate for each case.

1. - Closed rhinoplasty—is indicated only in certain cases, specifically those in which the necessary changes are minor, since the procedure allows for fairly limited access. Closed rhinoplasty does not allow for as many modifications as open rhinoplasty. Thus, it is recommended for patients whose nasal tip is within normal limits and does not necessarily require modification, as well as for those whose nostrils are large enough to allow access. It allows for the removal of a hump, raising or lowering the tip (but not by much), and procedures involving the septum and turbinates. The advantages of closed rhinoplasty include the absence of external scars (incisions are made only on the inside), as well as less severe swelling that resolves more quickly.
  - Open rhinoplasty—is recommended in most cases. It allows for broad access and multiple modifications, since everything is performed in plain view. It is also the procedure of choice for secondary rhinoplasties (i.e., second, third, or fourth surgeries). The disadvantages include a small scar on the columella (which, however, usually heals very well and becomes barely visible within a few months) and more prolonged swelling of the nose.

In most cases, the surgery is performed under general anesthesia, so the patient will not feel anything.

At the end of the surgery, packing is inserted into the nose to help prevent bleeding and promote adhesion of the mucosa to the septum. Some surgeons use silicone tubes instead of packing, allowing the patient to breathe through them postoperatively, unlike with packing, which requires breathing only through the mouth. The packing or tubes are removed 48 hours after surgery.

Immediately after surgery, you’ll need to apply ice packs to your eyes and keep your head elevated on pillows to reduce swelling.
The splint is kept in place for 7 days, and the external dressings (adhesive strips) for 10 days. The sutures are removed after 7 days (the external ones) and after 10 days (the internal ones). In the first few days after surgery, you will most likely have a stuffy nose. Your doctor will prescribe nasal drops, as well as antibiotics and anti-inflammatory medications.

You should avoid blowing your nose for the first 2–3 weeks. Also, wearing glasses is prohibited for the first 45 days (during which time it is recommended to wear contact lenses).
In general, rhinoplasty is not a painful procedure. In the first few days after surgery (4–5 days), your face and eyes will be swollen, and you will have bruising around your eyes. The severity of the swelling and bruising varies greatly from patient to patient, though it also depends on the surgeon’s technique. Your doctor will prescribe creams to help reduce the bruising.
The nose is an organ that swells quickly but takes a long time to go down.

You can generally resume daily activities in 10–12 days (since, for the most part, the swelling in the nose subsides within 2 weeks), and intense physical activities (sports such as soccer, swimming, and basketball) can be resumed only after at least 2 months.
Swelling in the nose can last quite a long time, up to several months, depending on the patient’s skin type and complexion. The thicker and more acne-prone the skin, the more pronounced the swelling will be, and the longer it will take to subside. Minimal changes can be observed from week to week, but the final result can only be fully appreciated after 3 months (sometimes 6–12 months).

Below is a complete list of instructions that patients must follow after rhinoplasty:

1. When sleeping, prop your head on 2 or 3 pillows for at least the first 7 days after surgery; this will help the swelling subside more quickly.
2. Apply ice to your eyes (but not in direct contact with the skin) for the first 3 days after surgery.
3. It is normal for swelling to continue even after the first 48 hours following surgery. Swelling peaks 48–72 hours after surgery.
4. If you are not in pain, there is no need to take pain medication. Do not drink alcohol while taking medication.
5. If you feel anxious, take Xanax as an anti-anxiety medication every 8 hours for the first 24–48 hours, but only as directed by your doctor. Do not take sleeping pills together with Xanax!
6. On the day of surgery, consume only liquids. The next day, you may start with a light diet, but for the next 2 weeks, avoid foods that require excessive movement of the lips, such as crackers, apples, etc.
7. You will likely have bloody discharge for the first 3–4 days after surgery; change the nasal pack as often as needed, but do not rub or blow your nose, as this may displace the bones or cartilage.
8. To prevent bleeding, avoid sneezing or blowing your nose for the first 2 weeks. If you cannot avoid sneezing, sneeze through your mouth.
9. As long as you have the splint on your nose, avoid getting it wet when washing your hair. You can have your hair washed at a beauty salon.
10. You can clean the inside of your nostrils and the columella area, where the stitches are located, using cotton swabs dipped in hydrogen peroxide. Afterward, you can also use the swabs to apply Betadine ointment. Your doctor will show you how to do this so that you do not damage anything inside your nose.
11. Avoid intense physical exertion (which raises your heart rate above 100 beats per minute), such as aerobics, fitness workouts, bending over, or lifting weights, for the first 3 weeks after surgery.
12. Avoid any trauma to the nose during the first month after surgery.
13. After the splint is removed, do not wear glasses for 45 days; instead, wear glasses that rest on your forehead or contact lenses, which can be worn as soon as the swelling has subsided.
14. The skin on your nose is extremely sensitive to sunlight. Avoid sun exposure for at least 6 months. If you are exposed to the sun, wear a wide-brimmed hat and use sunscreen with an SPF of at least 20 that protects against both UVA and UVB rays.
15. The splint is removed 7–9 days after surgery.
16. Once the splint is removed, you can gently wash the skin on your nose with a moisturizing soap. It is recommended that you apply a moisturizer twice a day, as the skin on your nose will remain dry for several weeks.
17. After rhinoplasty, it is very likely that the tip of your nose will remain numb for several months. Your front teeth (incisors) may also feel numb. These sensations are normal and will disappear over time. During the winter, you should avoid exposing your nose to cold temperatures; since you cannot feel it normally, there is a risk of frostbite.
18. Most of the swelling will subside within the first 3–4 weeks after surgery. It is possible that some parts of the nose will be more swollen than others, and it is also possible that some swelling may shift from one part of the nose to another. Each person experiences swelling differently. Thus, some people may have minimal swelling around the nose and eyes. Others, however, experience significant swelling, extensive periorbital bruising, as well as bruising of the sclera. The severity of these phenomena depends in part on the quality of the surgical procedure, but the patient’s biology and vascular fragility also play a major role. Often, there is swelling on the sides of the nose caused by periosteal reactions resulting from nasal bone fractures. These reactions are normal; they may be asymmetrical and resolve over time. The nose is an organ that swells easily but takes a long time to subside, with the recovery process varying significantly from patient to patient. The final result of rhinoplasty can be assessed after at least 6 months; often, the last 10 percent of the swelling does not subside until after 1 or even 2 years. The extent of swelling also depends on the quality of the patient’s skin and complexion. Patients with thick, acne-prone skin typically swell much more and take much longer to subside than those with dry, thin skin.
19. You may experience a sensation of a “stuffy nose” for a few weeks after surgery; this sensation will go away and is not noticeable to those around you.
20. It is absolutely normal to have a stuffy nose and difficulty breathing for 2–3 weeks after surgery, even if the procedure also involved correcting a deviated septum that was causing breathing difficulties. After surgery, the nasal mucosa is extremely swollen and will make breathing difficult until the swelling subsides. Once the swelling has gone down, and with the nasal passages now clear following the surgery, there will be no further obstacles to breathing easily. To help the nasal mucosa decongest more quickly and to breathe properly, it is recommended that you use Bixtonim drops (1–2 drops in each nostril, up to 3–4 times a day) for the first 5 days after surgery. After that, you can use Pinosol as often as needed; in addition to its decongestant effect, it softens crusts and makes them easier to remove. Another way to maintain proper nasal hygiene is the daily use of sea salt (available at pharmacies as an easy-to-use spray under various brand names).
21. Your doctor will prescribe antibiotics and anti-inflammatory medications that you should take for at least 5 days after surgery.
22. Do not attempt to massage your nose—neither the cartilage nor the bones—as there is a risk of displacement or suture breakage during the first 3 weeks after surgery.
23. You may apply healing creams to the columellar scar (if present).
24. External sutures are removed after 7 days; internal sutures after 10 days.
25. You will wear adhesive strips on your nose for 10 days. Afterward, if your doctor instructs you to do so, you will apply these strips yourself at night for several weeks, as recommended.

Today, and quite rightly so, more and more men are seeking to correct the shape of their nose and improve their respiratory function.

- Candidates for rhinoplasty must be at least 18 years old, the age at which the nose stops growing. It is important that the patient wants to improve the appearance of their nose, but not to achieve a “perfect” nose, which does not exist. Realistic expectations are very important and must be thoroughly understood by the patient. The patient may complain that their nose is too large or too small in comparison to the rest of their face, that the tip is too bulbous, too long, or too droopy/upturned, or that they cannot breathe properly.
- Benefits—These include achieving a masculine, straight nose without a hump or a pointed tip, and with an angle of approximately 90 degrees between the nose and the upper lip. It is very important to avoid feminizing the male nose.
- Specifics – In general, men are more prone to intra- and postoperative bleeding; additionally, the nose swells more severely and takes longer to subside than in women.

The key to achieving satisfactory results is for the patient to understand exactly what can and cannot be achieved through surgery. The current shape of the nose limits the outcome in many ways; it is very difficult, if not impossible, to drastically alter the shape of the nose and achieve the nose the patient dreams of while maintaining a stable and sturdy structure. The patient must understand that the result depends largely on the initial shape of the nose, and even minimal changes—on the order of millimeters—can have a positive impact on the entire nasal pyramid.Like any other surgery, rhinoplasty involves risks, and various complications can arise at any time that must be prevented and treated. These include:

- bleeding
- the formation of a hematoma, especially in the nasal septum, which must be drained when it occurs
- infections
- failure to meet the patient’s expectations—including postoperative sequelae, overcorrection or undercorrection, unresolved breathing problems, and asymmetry, all of which may require subsequent revision or secondary procedures

Adverse effects are normal, temporary, and resolve over time; their severity varies from patient to patient and is part of the normal recovery and healing process. It is important for the patient to be aware of these effects and to understand that, until the desired new appearance is achieved, they must go through certain phases that may be unpleasant to look at but are an inherent part of the process. Many patients feel disappointed and depressed immediately after surgery due to swelling and bruising. The initial appearance is very different from the final result, and the key to getting through this phase is patience. Patience following rhinoplasty must be incomparably greater than after other cosmetic procedures.

- Swelling occurs mainly around the eyes and on the nose; it peaks on the first and second days after surgery and begins to subside after day 3; It generally disappears after 2 weeks; after this period, it gradually subsides over 6–12 months, though it will not be noticeable to others, only to the patient and the doctor; after one year, the full results of a rhinoplasty can be fully appreciated.
- Periorbital bruising varies in intensity from patient to patient depending on skin color and skin type; regardless of how intense or widespread it is, it will disappear within 5–7 days and does not constitute a complication.
- A stuffy nose and difficulty breathing are common in the first few days and may last up to 2–3 weeks.

Anyone undergoing rhinoplasty expects to achieve the nose they desire, especially since the procedure requires significant effort on the part of the patient (both financial and emotional, as well as a two-week hiatus from daily activities and social isolation), but also from the surgeon to an equal extent. Unfortunately, the results do not always meet expectations, especially when it comes to rhinoplasty. The results can be highly unpredictable regarding the nose, as the healing process of bones and cartilage is very difficult to influence. It is possible that the patient has unrealistic expectations or that the surgeon does not perform the surgery in accordance with standard practices or the patient’s expectations. That is why it is extremely important for the patient and the surgeon to be on the same page before surgery—meaning that the surgeon understands exactly what the patient wants, and the patient knows exactly what to expect, what can be achieved, and what cannot.

There are cases where the patient, dissatisfied with the outcome of the procedure, requires a secondary revision rhinoplasty.

Secondary (or tertiary, etc.) rhinoplasty is always much more difficult than the initial procedure for several reasons:

1. - the healing process produces significant scarring and fibrosis, which makes reoperation difficult.
  - If the patient was not operated on by the same surgeon, it is unclear how the previous procedure was performed, which structures were altered, or whether any septal cartilage remains that can still be used.
  - In secondary rhinoplasty, cartilage is almost always needed for various grafts (to reconstruct certain structures, stabilize the tip, or augment the bridge); If the previous surgery required septal cartilage and none remains for the second surgery, cartilage must be harvested from other sources (the ear or a rib), which entails new incisions, a longer operating time, an increased risk of complications, and additional sources of pain for the patient.

Swelling following secondary rhinoplasty takes much longer to subside (up to 2 years), recovery takes longer, and the final result cannot be fully assessed until after this period has elapsed.