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Nose Surgery (Rhinoplasty)

What is a Rhinoplasty?

A “Rhinoplasty” (“Nose Job”) is a facial surgery designed to reshape the nose. Rhinoplasty can be done for corrective (“functional”) problems (such as nasal airflow obstruction causing breathing problems or a deviated septum), to correct a structural deformity (such as a crooked nose or prominent bump), or to improve the appearance of the nose by making subtle changes to its size, shape, width or tip.

The goal of rhinoplasty is to improve the proportions and the appearance of the nose, potentially improving self confidence and overall facial balance. Rhinoplasty can enlarge or reduce the nose, or reshape the bridge and nasal tip. Nose reshaping can also adjust nasal width, change the profile of the nose or reduce nostril width. Rhinoplasty can additionally correct nasal asymmetry, straighten the nose if there is significant deviation, and correct other features of the nose such as a bulbous tip, hooked shape, large dorsal hump or excessively upturned nose.

Rhinoplasty reshapes the nose for both aesthetic and reconstructive purposes. Whether the concern is a congenital feature of the nose you would like to modify, a past injury causing a post-traumatic nasal deformity, or other issues related to the appearance of your nose, rhinoplasty can help provide balance and create better proportion to your nose and face overall.

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Who is a Good Candidate for Rhinoplasty Surgery?

Good candidates for a rhinoplasty include males and females who are healthy, in good physical shape, emotionally stable, with realistic expectations about what rhinoplasty surgery can and cannot achieve.

Potential rhinoplasty patients are at least 14 or 15 years of age (to ensure facial growth is complete), are nonsmokers, with specific but practical goals for seeking a change in the appearance of their nose. As long as one is in excellent health and understands all potential risks and benefits of surgery, there is no upper age limit for having nose reshaping done.

Individuals seeking rhinoplasty often feel their nose is too large for their face; they may dislike a bump on the nasal bridge when in profile, feel their nose is too wide when viewed from the front, wish to change a drooping, broad, “boxy” or thickened nasal tip, or feel self-conscious from enlarged or excessively flared nostrils. Others notice their nose is asymmetrical or off-center from previous injury, and yet others have difficulty breathing due to internal nasal issues or septal deviation.

Reasonable patients with physical and emotional maturity and realistic expectations of rhinoplasty surgery are usually very satisfied with the decision to reshape their nose. Even slight changes to the shape of the nose can have a dramatic and positive effect on appearance and body image, if done in the right setting. Ideal rhinoplasty candidates are well-adjusted and otherwise happy with their lives and do not expect rhinoplasty to transform them into someone else. The best nose reshaping candidates simply want to improve their nose appearance, but do not seek absolute perfection.

Smokers, patients with multiple or untreated medical problems, and individuals who have unrealistic expectations or who are psychologically unprepared for surgery are not good candidates for a rhinoplasty. Learn more about Preparing for Plastic Surgery in our Preoperative Instructions section.

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What Are the Different Types of Rhinoplasty?

Closed Rhinoplasty

A “closed rhinoplasty” involves making small incisions inside the “mucosa” (internal lining) of the nose to access its internal structures. The skin of the nose is separated from the bone and cartilage to remove, reshape, augment or rearrange these components of the nose framework. The closed rhinoplasty technique is used primarily for “primary” rhinoplasty or simple nose reshaping.

Open Rhinoplasty

An “open rhinoplasty” makes an incision in the skin of the “columella”, the vertical segment of skin separating the nostrils at the base of the nose. The open rhinoplasty technique enables full visualization of all internal structures including cartilage, bone and internal lining and is used for most major nose reshaping procedures and revision or “secondary” rhinoplasty.

Revision Rhinoplasty

A Revision or “Secondary Rhinoplasty” can further improve the appearance of the nose if necessary after a “primary” rhinoplasty procedure. Patients may choose revision rhinoplasty if they are unsatisfied with the way their nose looks or functions. They may feel the overall effect is either too subtle or too dramatic, or they may believe their results are asymmetrical or uneven, usually due to postoperative scarring inside the nose or other healing abnormalities. Others may be concerned about residual nasal airflow obstruction or related breathing difficulties.

Revision rhinoplasty is significantly more complicated and has a much higher risk of complications than primary rhinoplasty. It is recommended that at least a year pass after a primary rhinoplasty before any secondary surgery is attempted, as it takes at least a year or longer for the final nasal form to emerge after nose reshaping.

Nonsurgical “Liquid Rhinoplasty”

A nonsurgical technique sometimes called a “Liquid Nose Job” uses injectable fillers to fill in depressions or irregularities on the nasal surface to create better symmetry, smooth out the nasal dorsum, or produce other subtle changes to the nasal tip. Also called a “Lunchtime Rhinoplasty”, this procedure does not actually involve surgery. The results of nose reshaping using fillers can last for six months up to two years. Learn more about the “Liquid Rhinoplasty” in our Minimally Invasive Cosmetic Enhancement section.

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What Really Happens During a Rhinoplasty?

Please see our Preparing for Surgery section to learn about what happens in the operating room on the day of surgery.

A rhinoplasty is usually performed in the operating room under general anesthesia for optimal comfort, control and safety. Surgery of the nose is performed either using the “closed” technique (where incisions are hidden inside the nose), or as an “open” procedure (involving incisions in the skin at the base of the nose). Through these incisions, the soft tissues that cover the nose are gently raised, allowing reshaping of the framework of the nose.

Prior to making incisions, local anesthesia is injected to ensure the nose is numb upon awakening but also to help “vasoconstrict” the blood vessels of the nose and minimize bleeding. Incisions are made to access the internal structures of the nose, and modifications are made to the framework (cartilage and bone), the lining (mucosa) and the external cover (the skin). Sometimes the nasal bones are brought closer together or moved farther apart using “in-fracturing” or “out-fracturing”. Bony work will usually create significant bruising that often spreads to the eyes (creating “black eyes”).

A prominent bump can be gently reduced using a “rasp” (file). The size of the nose can be reduced by removing bone and/or cartilage, or it can be augmented by adding bone or cartilage “grafts” from the nose or other parts of the body such as the ear or rib. A deviated septum is straightened, and nasal airflow can be improved by trimming protruding projections of mucosa inside the nose (called “turbinates”). Flaring nostrils can be reduced using small incisions in a natural crease at their base and other surgical details as appropriate.

Rhinoplasty is truly a three-dimensional procedure: Following sculpting of the underlying bony and cartilage framework of the nose, the nasal skin and soft tissues is redraped over the nasal scaffold and incisions are closed using dissolving sutures wherever possible. Nasal “packing” (absorbent gauze) is applied to the inside of the nostrils to help reduce swelling and bleeding after surgery. A firm external “splint” is applied over the nasal skin for support and protection for approximately one week after surgery.

When you awake from a rhinoplasty, you will be comfortable from local anesthetic that has been injected in the nose but will feel very “stuffy”. It is important not to blow your nose for up to a week after nasal surgery. Rhinoplasty is usually done as an outpatient procedure and can take 2-4 hours to perform, depending on the details of surgery.

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What is the Recovery After Rhinoplasty Surgery?

Following a rhinoplasty, some bruising and swelling is expected for a few days to weeks, and you may even develop two black eyes! Glasses should not be worn for a week or two after rhinoplasty to avoid pressure on the nasal bridge. Any initial asymmetry from swelling or an uneven appearance to the nose is quite common and will normalize as healing progresses.

After approximately two weeks, obvious signs of surgery such as puffiness or discoloration should dissipate; however, it can take up to a full year for your final results and your new nasal contour to be evident. Sleeping with a few extra pillows to elevate your head can help speed the resolution of postop swelling. Open rhinoplasty incisions tend to heal very well with good quality scars, while closed rhinoplasty incisions are completely hidden inside the nose.

As a component of Scar Therapy, it is important to minimize direct sun exposure to the nose not only during healing, but as a life-long behavior to help maintain your good skin quality and to minimize future “photo-aging” (sun damage). Strict sun avoidance and the regular use of sunblock of at least SPF 30 are vital to prevent “hyperpigmentation” (darker color to the skin and incisions) and sunburn. Wearing makeup over sunblock is permitted at a week postoperatively and should continue as part of your morning routine. Products that are recommended for postoperative skin protection are available at our office as part of our Medical-Grade Skin Care regime.

Any sutures that do not dissolve on their own will be painlessly removed in the office within a week or two. Please see our Postoperative Instructions section and Special Instructions for Facial Surgery for additional information pertaining to recovery from a rhinoplasty.

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What Are Potential Risks and Complications of Rhinoplasty Surgery?

When you are considering any type of surgery, you should be fully educated about potential risks and complications. Please see our Preparing for Surgery section to learn about general risks and potential complications, Special Considerations for Facial Plastic Surgery, and our section on Postoperative Instructions for additional information pertaining specifically to rhinoplasty surgery.

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Before and after rhinoplasty surgery results will be reviewed during your consultation.

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Is Rhinoplasty Surgery Covered by Insurance?

A rhinoplasty is usually considered cosmetic, particularly if it is being done to improve the appearance of the nose.  However, if there is a history of trauma to the nose with documented breathing problems, insurance may cover some of the procedure costs.  Our Patient Coordinator Mary will speak with you in detail after your consultation about estimated fees for rhinoplasty.

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As women Plastic Surgeons, we intimately understand how an individual’s looks and their feelings about their appearance can influence self-image and self-esteem. At your rhinoplasty consultation, your surgeon will spend a great deal of time with you to get to know you personally and take a complete medical history.

Important details of your history include prior nasal trauma, nasal deformity and nasal surgeries, a history of difficulty breathing through the nose, nasal allergies or stuffiness, and use of nasal sprays, antihistamines, decongestants and other medications and drugs that affect the nose.

A complete nasal examination will be done, including the external appearance and the internal structures of the nose. The quality of your nasal skin, the size and shape of your nose, its symmetry and relationship to your other facial features will be carefully examined. We will explore in detail your reasons for seeking a rhinoplasty, and if you are an appropriate candidate for surgery, your options will be described in detail.

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Dr. Karen M. Horton, M.D. - Plastic Surgery, Physicians & Surgeons - Medical-M.D., San Francisco, CA