Rhinoplasty is a surgical procedure designed to reshape the appearance of the nose. There are many changes that can be made to the nose. The bridge height may be reduced or the bridge of a wide nose narrowed, a crooked or poorly aligned nose may be improved, the bridge height may be elevated, the middle one-third of the nose may be reduced, or the tip may be altered. However, it must be emphasized that every nose is different and requires a tailored plan when deciding on the appropriate technique to be used. Rhinoplasty is one of the most challenging plastic surgery procedures to perform successfully with stable, long-term X Trusted Source American Society of Plastic Surgeons Chaffoo R Go to Source results.

Most rhinoplasty procedures are performed in the outpatient surgery center.

Deep sedation or general anesthesia can be used in most rhinoplasty procedures.

Rhinoplasty surgery involves a multitude of surgical techniques that can be used to reshape the nose, the choice of which is based on a thorough preoperative nasal analysis that includes an assessment of the external and internal nose. The two main approaches in rhinoplasty are the “closed rhinoplasty technique” and the “open rhinoplasty technique.” The closed rhinoplasty technique utilizes hidden incisions that are made on the inside of the nose. The skin (overlying soft tissue) is lifted off of the underlying framework of the nose which consists of cartilage and bone, and these are then carefully altered to achieve the desired new shape. The upper two-thirds of the nose (consisting of the bony vault and cartilaginous middle vault) is often reshaped in situ, or in its native position. In contrast, altering the tip of the nose with the closed technique requires the cartilage to be withdrawn outside of the nose before it is reshaped. Appropriate changes are made to the cartilage while it is outside of the nose, then it is replaced back into the nose.

The open rhinoplasty technique utilizes the same internal incisions made with the closed technique, but it also includes a short incision made across the columella, or the skin between the nostrils. This external incision allows the surgeon to lift the skin off of the underlying cartilage and bone, allowing for complete and direct exposure of the entire framework. In comparison to the closed technique, open rhinoplasty affords a much wider visualization of the underlying structures, particularly the nasal tip region. This allows for more predictable and accurate alterations to the cartilage and bone.

There are a number of alterations that may be made to the nose including changes in the bridge height and bridge width, improvement of a crooked or poorly aligned nose, and changes to the tip of the nose. Once the desired changes are achieved, the incisions are then closed with meticulous technique and the nasal skin is then taped to minimize soft tissue swelling. If the nasal bones have been reshaped, an external nasal cast will be placed for additional stabilization.

In cases where the nose skin is relatively thin, Dr. Hilinski will often recommend the use of a fascia graft to help thicken the overlying nose skin from the inside. He prefers the use of temporal (temple) fascia as opposed to other materials such as Alloderm (acellular dermis) because fascia is your own tissue and it provides a more reliable, durable result. Temporal fascia harvesting involves the use of a hidden incision within the hair-bearing scalp (without shaving the hair) that heals relatively quickly. After the nose has been reshaped, the fascia is placed over the bone and cartilage framework and below the skin. This helps to provide an additional “cushion” layer that aids in making the nose look smoother and more natural as it heals. Patients with thicker skin usually do not require fascia grafting during rhinoplasty.

Closed rhinoplasty is a rhinoplasty approach in which hidden incisions are made on the inside of the nose, as opposed to open rhinoplasty which involves incisions on the inside of the nose as well as a small incision between the nostrils on the underside of the nose.

Open rhinoplasty is a rhinoplasty approach which utilizes the same internal incisions as with the closed technique, though an additional short incision is also made on the underside of the nose between the nostrils.

Every nose is different and requires a tailored plan. However, the following will help to summarize the most common techniques used in both closed and open rhinoplasty. In most cases a combination of techniques will be required to achieve the desired results. When reshaping the bony vault (the upper one-third of the bridge), it is common to “reduce” the bridge height by contouring down the bony prominence. Narrowing the bridge (for a wide nose) utilizes techniques to cut the nasal bones near the attachment to the cheek, which helps to bring the two sides of the nose closer together. When addressing a crooked nose or one with poor alignment, the bone is mobilized, or fractured, to allow for repositioning of the bones into better alignment.

In many cases, the middle one-third of the nose (the middle vault) requires a reduction in height to maintain balance with the upper one-third. The middle vault of the nose is made of cartilage and, therefore, requires additional consideration. Rhinoplasty surgeons should make every attempt to avoid over-reduction of the middle vault as this can lead to long-term problems with nasal breathing (termed internal valve collapse) and the clichéd “ski slope” deformity. This collapse of the middle vault is often not seen within the first nine to twelve months following surgery and typically manifests sometime beyond this period as an external deformity (pinching of the middle vault region and a scooped out appearance) and functional compromise. Techniques that help to avoid these unwanted complications include the use of spreader grafts which are hidden grafts made out of the patient’s own cartilage that are strategically placed after reducing the bridge height. Spreader grafts help to reinforce the middle vault region by compensating for the removal of the bridge cartilage. They are also commonly used to help reshape the bridge when there is an asymmetry between the left and right sides.

In some patients, the bridge requires augmentation, or elevation of the bridge height, in order to bring the nose into better balance with the face. In these cases, it is best to use the patient’s own cartilage if possible. The choices for cartilage grafts include the septum, the ear (auricular), and the rib (costal). If these are not an option for harvesting the cartilage, one may consider the use of cadaveric cartilage (taken from a cadaver) or alloplastic implants (such as Gore-Tex®).

When reshaping the nasal tip, every attempt should be made to preserve as much of the native cartilage as possible. This is typically accomplished by altering the tip contour using specific suture techniques that permanently bend the cartilage into the desired shape. In some cases it is still necessary to remove or shave excess cartilage in order to achieve the desired tip definition. In these cases, it is imperative that the rhinoplasty surgeon be more conservative as to avoid compromising the support of the tip. When over-aggressive techniques are used to achieve maximal definition, it is usually at the expense of tip support which can lead to postoperative pinching and collapse of the nasal tip. In still other cases, it is necessary to add cartilage (such as shield grafts and lateral strut grafts) to the tip in order to achieve the desired shape.

Surgical times for rhinoplasty may range from two to two and a half hours.

The location of the rhinoplasty incisions will depend on whether a closed or open approach is used. If a closed rhinoplasty approach is chosen, the incisions are hidden entirely inside of the nose along the inner nostril rim and the septum (the wall separating the left from right nasal passage). If an open rhinoplasty approach is chosen, a short incision is made in between the nostrils half way between the nasal tip and the upper lip. This incision is shaped as an inverted V which is less visible than a straight line. With proper technique, this incision is virtually undetectable after the healing process.

If a closed rhinoplasty approach is chosen, the incisions are hidden entirely inside of the nose, resulting in no visible scarring. If an open rhinoplasty approach is chosen, a short incision is made on the skin between the nostrils halfway between the nasal tip and the upper lip. Because this incision is shaped as an inverted V, it is less visible than a straight line. Furthermore, with proper technique, this incision and resulting scar are essentially imperceptible once healed.

Pain is not a significant component of the healing process after rhinoplasty.

Patients can expect five to seven days of initial recovery where bruising and swelling may be more noticeable. We have all of our rhinoplasty patients use Arnica Montana before and after surgery which significantly helps minimize bruising after rhinoplasty, as well as the degree and duration of swelling. Most patients will begin to look presentable in public within seven to ten days after surgery, though a majority of the soft tissue swelling will take several months to disappear. The nose continues to undergo healing and remodeling of the shape for upwards of a year and beyond in some cases. Patients with thinner skin will often see a resolution of their swelling faster than patients with thicker skin, as thicker skin does not “shrink wrap” around the new nose as quickly. Patients who undergo realignment of the bridge for a crooked nose deformity or narrowing of the bones should be seen more frequently during the first six to eight weeks after surgery. In some cases, patients will be instructed on how to perform “digital exercises” that help to maintain the proper alignment and position of the bones.

Patients are usually able to return to work within seven to ten days after rhinoplasty.

Patients may resume aerobic activity (reconditioning) within ten to fourteen days after surgery while more strenuous activity (resistance workouts) can be resumed within three to four weeks. Some patients will note a temporary increase in swelling after resuming their workout routine.

The stitches are removed within five to seven days after the rhinoplasty procedure.

As with all types of surgery, there are potential risks associated with rhinoplasty. Rhinoplasty risks include infection, bleeding, functional difficulty, suboptimal results, and general anesthesia X Trusted Source Who is a good candidate for rhinoplasty? American Society of Plastic Surgeons Go to Source risks. Because of his advanced training and experience in revision rhinoplasty, Dr. Hilinski finds his average of patients who require revision surgery to be much lower.

Insurance usually does not cover rhinoplasty procedures which are performed for cosmetic purposes. Some coverage may be available when treating breathing problems or deformities. Patients should check with their own insurer. For additional assistance with the total cost of rhinoplasty, please ask us about financing for facial plastic surgery procedures.