Rhinoplasty, more commonly known as a nose job or nose reshaping surgery, comprises a group of operations designed to improve nasal aesthetics, while preserving (or improving) nasal airflow and breathing.
Noses come in an endless variety of shapes and sizes. Hence there is no one standard rhinoplasty operation that can be applied to every patient. Broadly, there are 2 operative approaches that can be used for rhinoplasty – a so- called “open or open tip” or a “closed” rhinoplasty. For the better part of the past 15 years, I have most often employed the “open rhinoplasty approach” which allows the surgeon binocular visualisation of the entire nasal skeleton.
This leaves one with a small scar across the columella, which usually fades to be come barely visible over time. Still today, I make use of this approach in complex secondary nose-jobs (where patients have had prior rhinoplasty) Over the past 2-3 years I have been very fortunate to begin the journey of moving away from traditional open approach, reduction rhinoplasty to a new movement in rhinoplasty surgery – that of Preservation Rhinoplasty. Where possible nowadays, I will try, in suitable primary patients, to use part or all of the preservation rhinoplasty philosophy.
Preservation rhinoplasty is a “new” philosophy in rhinoplasty, based on tissue preservation rather than resection / reconstruction which is currently the standard. It is conceptually the opposite of the septal L strut concept, in that most of the septum is preserved and manipulated, rather than being resected. The skin and soft tissue envelope is largely preserved as the plane of elevation is done at a true sub-perichondrial / sub-periostial level, using (ideally) a closed approach; although many proponents do it open too. Ligamentous structures are also preserved or if breached, are formally repaired. The dorsum is preserved where possible, with or without some manipulation, and a let- down or push- down procedure is done, hence preserving the integrity of the midvault and the keystone area, and so avoiding the need for midvault reconstruction. Osteotomies are done very accurately with either ostetomes, piezo, specifically designed micro-saws or micro-power tools. Lastly, the alars are largely preserved and manipulated using sutures. In short, there is minimal resection in the true sense of the term. Like in all of rhinoplasty, patient selection is important – this is not a procedure for all patients, but rather for a select group of primary rhinoplasty patients. Whilst the term preservation rhinoplasty is a new one, it is really a constellation of older techniques that have been refined as more of the anatomy is defined. I have been been fortunate to learn this evolving technique from colleagues abroad and am pleased to be able to offer it to selectd primary patients.
The operation is performed under general anaesthetic. Once asleep, local anaesthetic is injected in to the nose to limit bleeding and enable better visualisation. I do some surgeries “open” and others “closed” using preservation techniques. All elements are addressed to varying degrees to include tip manipulation, bridge adjustment and narrowing of the nasal bones when indicated.
Over the past several years, increasing importance has been placed on the functional aspect of rhinoplasty – the idea being to have an aesthetic nose that functions (breathes) as well, or better than pre-operatively. As such, we often have to address the nasal septum (internal cartilage) by septoplasty, and use some of this septal cartilage to support certain structures, notably the adjusted tip . Previously somewhat neglected, this type of functional surgery is currently commonly performed as part of a modern rhinoplasty.
The surgery may take 2-4 hours – depending on what is required. Secondary surgery is more complex and takes longer.
Either way, the surgery is often done as a day case (occasionally an overnight stay is needed). A splint is placed over the nose at the completion of the surgery, and is generally worn for the first week or so.
External sutures (across the columella) are removed at a week post op. Bruising is variable and always more in men than women. I usually recommend Arnica to be taken post op to assist with the resolution of the bruising and swelling, but not pre operatively. As regards to pain, rhinoplasty patients have remarkably little pain post op – just some stuffiness.
Although some result will be seen at about a week when the cast is removed, it is important to realise and understand, that it takes about a year to 18 months before the final result can be appreciated. This time is needed for the skin envelope to contract and re-contour to the cartilage framework that was adjusted at the surgery, and the thicker one’s skin, the more protracted this process.