Am I a good candidate for rhinoplasty?

The best candidates for rhinoplasty:

• Are at least 13 years old;
• Have finished facial growth;
• Are generally healthy;
• Do not smoke;
• Are seeking rhinoplasty for personal reasons, not pressure from others; and
• Have realistic goals for the procedure.

How is the procedure performed?

Rhinoplasty is usually an outpatient procedure performed under IV sedation or general anesthesia.

Surgeons use one of two techniques when performing nose surgery. In a closed rhinoplasty, incisions are made within the nostrils. In an open rhinoplasty, the incision is made across the columella, the tissue between the nostrils. With both methods, the surgeon gently lifts the soft tissues covering the nose. He or she sculpts the bone and cartilage to the desired shape. Any additional cartilage needed to augment the nose can often be taken from the septum.

If the patient has a deviated septum, the surgeon will adjust the septum and the inner structures of the nose to improve breathing. Then the tissues are re-draped and stitched closed. If the patient desires nostril reshaping, this is done as the final stage of rhinoplasty. The entire procedure generally lasts one to two hours.

Last year, 152,434 rhinopplasty procedures were performed in America (Source: ASAPS).  People who are interested in improving the appearance of their noses seek consultation with plastic surgeons and otolaryngologists for this popular procedure. Some are unhappy with the noses they were born with, and some with the way aging has changed their nose. For others, an injury may have distorted the nose, or the goal may be improved nasal breathing. Because the nose is the most defining characteristic of the face, a slight alteration can greatly improve one's appearance.

Successful rhinoplasty surgery is a result of good rapport between patient and surgeon. Trust, based on realistic expectations and exacting medical expertise, develops in the consulting stages before surgery. As with all elective plastic surgery, good health and realistic expectations are prerequisites. Understanding nasal surgery is also critical and since there is no ideal in rhinoplasty, the goal is to improve the nose aesthetically in order for it harmonize better with other facial features.

Skin type, ethnic background, and age are important factors to be considered prior to surgery. Before the nose is altered, a young patient must reach full growth, usually around age fifteen or sixteen. Exceptions are cases in which breathing is severely impaired.  The definition of rhinoplasty is, literally, “shaping the nose”. First, incisions are made and the bone and cartilage support system of the nose is accessed. The majority of incisions are made inside the nose, where they are invisible. In some cases, an incision is made in the area of skin separating the nostrils along the columella. Next, certain amounts of underlying bone and cartilage are removed, added to, or rearranged to provide a newly shaped structure. For example, when the tip of the nose is too large, the surgeon can sculpt the cartilage in this area to reduce it in size. The angle of the nose in relation to the upper lip can be altered for a more youthful look or to correct a distortion.

While a surgeon must master a number of individual techniques for rhinoplasty, she or he must also have the judgment, skill and natural ability to choose the right techniques for each individual situation.  The different techniques and approaches used in rhinoplasty are detailed here:

Reducing the hump:
Cartilage and bone make up the nasal hump. One approach for taking down the hump is described here, but there are several methods that can be used.  The surgeon may also have in the operating room the photos of the imaging goal derived from computer imaging to use as a guide.  My preferred approach is the en bloc ('in once piece') resection of the nasal hump. A scalpel is used for this method to incise the cartilage of the hump in order to create, as shown below, a 'joint' at the junction of the cartilage and bone.
Then the osteotome (bone knife) is situated at the bone-cartilage junction, and the osteotome can easily cut through bone because it is extremely sharp. The osteotome advances through the bone in the desired path with a gentle tapping technique, then the bone-cartilage hump is removed in one piece.  A surgical file or rasp is often commonly used to reduce or smooth the bony hump once resection has taken place.

Osteotomies:
Though not necessary in all rhinoplasties, osteotomies involve controlled fracturing of the nasal bones. Osteotomies are usually required when reducing the nasal hump and are also often used to improve a crooked nose or narrow an overly wide nose.  The bone is cut in the middle with a "back cut" if  a medial osteotomy is done. Then, the osteotome is placed at the edge of the bone from an internal approach along the piriform aperture. A gentle tapping technique is used to advance the osteotome along the planned path of the lower nasal bone and maxilla as outlined in the Gunter diagram below.  After this, the bone may easily be shifted as needed.

Spreader Grafts:
Rectangular strips of cartilage known as spreader grafts are placed between the septum and the upper lateral cartilages.  Cases requiring widening of the middle third can benefit from spreader grafts. In certain patients, spreader grafts can also provide additional support of the middle third of the nose to aid in alleviating internal nasal valve collapse. An example of that type of patient would be one with short nasal bones, long weak upper lateral cartilages, thin skin and a narrow nose. Another type of patient would be one who requires a large hump reduction and thus needs the additional support of the spreader grafts.

Suture techniques:
Suture techniques: One reliable yet conservative way to make changes to the nasal tip is through the use of suture techniques. These can be used when refining a bulbous nasal tip or doing a tip elevation (projection and rotation).  Suture techniques are reliable and in past decades have become increasingly popular. The nasal tip can be elevated and projected by applying sutures to the tip cartilages in a specific way. The sutures borrow cartilage from the side part of the cartilage (lateral crura) and redirect the cartilage so that it becomes part of the medial part of the cartilage (medial crura).

Cephalic resection:
A resection of a portion of the tip cartilage can be undertaken to help achieve refinement or 'narrowing' of the nasal tip. This technique is known as cephalic resection and it is another useful method for refining the bulbous tip.  It is crucial to leave a rim of cartilage that is wide enough to support the nasal ala after cephalic resection.

Tip grafts:
Tip grafts: According to how the surgeon shapes and places a tip graft, these can be used to achieve several different effects. The patient's own cartilage, preferably taken from the nasal septum during septoplasty, typically comprise the tip graft. Tip grafts can be helpful in creating additional nasal tip refinement and in projecting the nose, lengthening the nose, or both.  Surgeons often use a columellar strut, which is a rectangular piece of cartilage placed between the medial crura of the tip cartilages, if additional support or strength is needed in the nasal tip. Additional strength to the tip and sometimes some amount of tip elevation (projection and rotation) can be achieved with a strut.

At the conclusion of the rhinoplasty procedure, the tissues are then redraped over the new frame and the incisions are closed. A splint is applied to the outside of the nose to help retain the new shape while the nose heals. Go to the next page to learn about recovery.