Rhinoplasty - Toronto Rhinoplasty Surgery by Dr. Oakley Smith

Rhinoplasty

Consultation with Dr. Oakley Smith

At your appointment you will meet with Dr Oakley Smith for the initial consultation during which symptoms and goals will be discussed. Your face and nose will be examined and your questions regarding rhinoplasty answered.

The possible aesthetic/cosmetic changes and functional improvements will be discussed. If you are interested in cosmetic rhinoplasty surgery, pictures are taken and the possible cosmetic changes can be shown to you using computer graphics.

If you wish to proceed, another meeting to answer any last minutes questions occurs shortly before surgery. Out of town patients can be seen the day before surgery.

Dr. Oakley Smith Standing in Toronto Operating Room

Rhinoplasty Surgery

Your rhinoplasty takes usually between two to three hours and occurs under a general anesthetic. Less time is needed to correct only internal breathing issues, while more time is required for cosmetic changes, and much more time is required for badly damaged noses such as those previously operated on or seriously injured. Surgical time increases here to five to seven hours. Noses that have been broken, traumatized or previously operated always require longer surgical time to reconstruct as they frequently require the addition of cartilage. Regardless of the length of your surgery, you don’t require overnight stay, unless there are other unrelated medical issues.

After rhinoplasty or any nose surgery, you remain in the recovery room till fully awake. This varies from half an hour to two or even three hours. Then you return to the day surgery area where you stay for a few more hours while a nurse monitors your progress before leaving. Many people feel nauseous and a minority (<20%) vomit up old blood which had drained into their stomach during surgery while asleep. You will be given a prescription for pain medication which conveniently may be filled at the hospital pharmacy before leaving and a follow up appointment to see Dr Smith at the hospital clinic in a few days time. You must have someone to help take you home. In spite of feeling wide awake and normal after rhinoplasty surgery, your judgement is still impaired.

Types of Nasal Surgery

Your nose surgery usually falls into one of two categories. Nasal surgery can be either a septoplasty or rhinoplasty. The beginnings of rhinoplasty started over 5,000 years ago in India. In fact there is still a type of rhinoplasty called the India or Hindu forehead flap rhinoplasty practiced today. Click here if you would like to read more about the history of rhinoplasty.

A septoplasty is internal nasal surgery only. Click here if you would like to read more about Septoplasty surgery. It is the least traumatic and invasive procedure. There is no external bruising and rarely any visible swelling. There is little and usually no external change to the shape of the nose. If the nose has a bend, it usually remains after surgery. People often find this difficult to understand. The explanation is it’s the internal bend (deviated nasal septum) that is responsible for the difficulty breathing and this is what is corrected during septoplasty. Although the external bend is often due to the internally twisted septum, it most commonly doesn’t become straight when the internal twist is corrected because it is held in place by the two plates of surface cartilage which aren’t changed. A rhinoplasty is needed to correct these plates. Frequently partial inferior turbinectomy (click here if you would like to read more about Turbinectomy) is done along with septoplasty. This minor procedure trims the fleshy swellings of the inner sides of the nasal passages. It improves nasal breathing by increasing the cross sectional area of the nasal channel.

Rhinoplasty is required to change the external appearance of the nose. Rhinoplasty is also known as Septorhinoplasty, as the internal foundation and cartilaginous support of the nose very often needs modification too. Rhinoplasty can be further divided into reduction rhinoplasty, augmentation rhinoplasty, blended rhinoplasty or revision rhinoplasty. Click here if you would like to read more about the revision rhinoplasty.

If you have never had a recognized injury or prior nasal surgery, you are likely going to have a reduction rhinoplasty. Cartilage and bone are removed, hence the word ‘reduction’. In addition, the nasal bone is filed down to reduce or smooth it. In the same way, your nose cartilage is reshaped or shifted, in addition to possibly being partially removed. There are also uncommon problems where a surgeon will actually shave down the nasal skin. One of these is called rhinophyma. Click here to read more about rhinophyma.

Most people know about nasal casts after rhinoplasty or a ‘nose job’, and many are aware of nasal packing. Less commonly known is the use of internal nasal stenting. This method has mostly replaced nasal packing. After Rhinoplasty your nose is weakened and has much reduced intrinsic strength. This fragile state slowly improves over many months after your rhinoplasty. Your nose is supported from the inside by thin plastic sheets. They can’t be seen, unless you tilt back your head and look carefully up your nostrils, then the leading tips of the stent can be seen about half an inch inside your nose.

As the name suggests, tissue is added to your nose when augmentation rhinoplasty is required. These surgeries are often more complex and require more surgical time. When your nose has been damaged, the addition of either cartilage and/or bone becomes necessary. Previous surgery and nasal fractures are most often the cause of the loss of support to your nose. Overly aggressive cosmetic rhinoplasty can weaken and/or remove too much of the natural internal support. Most often the nasal symptoms are; difficulty to breath, nasal pain and nose crusting, along with the external nasal deformity. Externally this loss of nasal support causes your nose sometimes to twist, shrink, collapse or sink in.

Chest incision after rhinoplasty

The chest incision heals well and seldom is an issue. With women it is placed directly below the breast, hidden in the crease.

The area just above the tip of the nose, the supratip, can collapse causing a deformity called a ’boxer’s nose’. Its similar to the changes to a boxer’s ears where there has been many cartilaginous breaks resulting in a ‘calliflower ear’. Another name for this nose deformity is a ‘saddle nose’. Just under the nose, the area called the columella can retract, resulting in unpleasant look we surgeons call, not surprisingly, columellar retraction. Again this arises from loss of nose tissue. Here its the cartilaginous septum that is gone, usually due to again aggressive nose surgery. Usually in the form of a septoplasty. Another problem after rhinoplasty is a septal perforation. Internally tissue loss can cause a hole to form in the center partition of the nose called the septum. This can produce a spectrum of symptoms from, if you are fortunate, nothing; all the way to chronic, difficult to treat nasal pain, nose crusting and bleeding.

Incision in ear after rhinoplasty

The incision around the inner rim of the ear can barely be seen months after surgery.

Tissue can be found from several places in your body and used to replace what is missing. A principle of plastic surgery is to replace ‘like tissue with like tissue’. That means cartilage is replaced with cartilage and bone with bone. Most commonly it’s cartilage that is needed. The best cartilage is nasal cartilage. However sadly it often not available, as loss of this is the problem to begin with.

The next place nose surgeons use is either your ear or rib. The cartilage here is of a different quality and this can pose some technical challenges. The harvesting of your ear cartilage is surprisingly not noticeable afterwards. The cartilage removed is from an area that fortunately causes very little change to the shape of your ear and has no effect on your hearing. Rib cartilage leaves a scar undcer your breast from 2 to 3 inches long. Less commonly bone is needed. It can be take from your hip, rib or skull. By the very nature of harvesting it, the surgery leaves you a scar and sometimes a slight skin depression at the donor site.

Post Operative Rhinoplasty Course

There is seldom pain around the nose after rhinoplasty, rather discomfort and pressure. Most people need moderate strength pain medication for the first few days. We prescribe Tylenol with codeine. You should remain at home for the week. You are not ill, but you will be tired and uncomfortable.

Six months after rhinoplasty

If you have had a Rhinoplasty, the three black visible stitches under your nose are removed four days later. Your nose will be cleaned of crust and old blood at this time also. Your nasal cast comes off your nose at the next meeting with Dr Smith at a week. You may be given nose exercises to perform for two weeks to maintain the shape of your new nasal bridge. Plastic internal nasal stents remain supporting the nose from the inside for one to three weeks, longer if the nose was badly damaged and has been weakened.

Your nasal breathing unfortunately won’t be normal till these stents are removed. After they are removed your breathing will continue to improve for the following four months. The bruising, if you have any, is gone at two weeks. Surprisingly it isn’t often on your nose but appears mostly under your eyes. Bruising is the result of the nasal bone osteotomies or fracturing of the nasal bones during rhinoplasty. Surgical manipulation of the nose skin and nasal cartilages don’t cause much brusing to appear. There are several techniques at the time of your rhinoplasty surgeons use to reduce the brusing. Swelling unfortunately remains much longer than bruising, after rhinoplasty its present for six months. It usually masks the changes to the underlying structure of your nose after rhinoplasty. Its one of the most difficult things for patients following a nose job. Everyone wants immediate results with rhinoplasty and its hard to have to wait many weeks to start to see the new nose appear through the swelling. Just like rhinoplasty, septoplasty causes swelling also. However here it is internal and not often noticable externally. It too follows the same time line and patients need to wait for it to resolve to feel the improvement to their nose breathing. Approximately half the swelling has resolved at six weeks.

Most people can return to their usual activities and lifestyle by two weeks after rhinoplasty. Strenuous physical exercise where you sweat, increase your blood pressure or heart rate, is discouraged for six weeks, as it can delay or even reverse the resolution of the post rhinoplasty swelling. A short series of injections are used to obtain further small improvements or ‘touch ups’ in many noses. The nose continues to subtlety change as the tissues shift and settle for a full year after rhinoplasty. However these changes after rhinoplasty are very subtle and few people other than you and Dr Smith would notice.

Lateral Nasal Wall Obstruction

There are some nasal conditions that can be treated non-surgically and neither a rhinoplasty or septoplasty are needed. Nasal allergies and chronic sinusitis are two well known examples. Less well known however is that certain types of noses can also be reshaped effectively without rhinoplasty. These are noses where the narrowing is from the outer external wall, either collapsing or bending inwards and not from a deviated septum.

Sometimes its because these nasal cartilages are naturally thin and weak, but mostly its secondary to previous rhinoplasty surgery. The treatment is to move this nasal wall outwards. Rhinoplasty surgery can fix the problem. In fact there are two surgical methods. A classic rhinoplasty can replace the weaken collapsed nose cartilages with new cartilage or sometimes a suspension suture can be used underneath the cheek to pull the nasal side wall outwards. This is preferable to rhinoplasty as the post surgery recovery is much reduced. Other times non-surgical methods are used. The best known method is the external nasal strip that is marketed for the relief of snoring. It doesn’t really work well for that, as only about 5% of people find their snoring is reduced or eliminated, but it works very well in opening the nasal passages by pulling them outwards. However it is visible and single use only. There are also internal nasal stents that open the nasal passage by pushing the outer wall open. They can’t be seen and are reusable. A small group of people never can adjust to feeling them in their nose; just in the same way certain people can’t tolerate contact lenses, however most people learn to manage. There are several comercial companies producing these internal nasal stents. There are inexpensive and can be bought over the internet. Click here to be directed to their web page.

The usual surgical means of improving nasal breathing from narrowing produced by collapse of the nasal side wall very frequently involves augmentation rhinoplasty. Cartilage is obtained from elsewhere and used to replace or occasionally support existing but weakened tip cartilage. The new cartilage is placed at the side walls where there is usually pinching of the overlying skin. This is technically challenging surgery and the success rate suffers as a consequence. The sides of the nose are almost always widened sometimes helping the appearance other times making a nose less attractive. Preoperatively patients need to understand it’s often a question of one (breathing) or the other (appearance).

A small percentage of the time and several months afterward surgery, a tissue filler like Juvederm or Restylane can be used to get a final 2 or 3% cosmetic improvement. These are the same fillers used elsewhere on the face to reverse the signs of aging. The use here in the nose has expanded the improvements achievable by nose surgery alone. They are suitable for minor surface irregularities, small nasal humps and mild dorsal nasal bridge deviations. Often they are added sequentially, as one can always add more while the opposite isn’t true. A trial of absorbable fillers is used initially. Unlike elsewhere on the face, where facial expressions from muscle contractions accelerate the absorption, tissue fillers in the nose last longer than the usual 3 to 6 months. At a later date and usually when the first tissue filler has nearly completely absorbed, a semi permanent filler can be substituted.

For some noses, tissue fillers are all that is needed and rhinoplasty can be avoided. I call this “injectable rhinoplasty” or“non-surgical rhinoplasty”. The procedure is done awake and the improvement can be monitored by a mirror such that you have control over the changes. The recovery time is at most a day or so and usually immediate. Permanent complications are very rare. The commonest issue is adding too much filler. Even this is very unlikely, and if it does happen, like a bad haircut, its only a matter of waiting and things return to as before. At a later date, usually several months later, a semi-permanent or permanent tissue filler can be used. Cosmetic dermatologists have seen this technique as a means to expand their scope of practice. The term ‘non-surgical nose job’ has become a recognized phrase and is used for marketing practices in the United States. However like all medical procedures, there are indications and limitations. Facial Plastic Surgeons are best positioned to offer the appropriate technique, surgical or non-surgical, to reach your aesthetic goals.

Risk & Benefits

Dr. Oakley Smith

Nose surgery is usually successful. Restoring normal nasal breathing and cosmetic appearance occurs between 50 to 95% with the average around 85%. Factors that influence the success include revision rhinoplasty surgery, previous trauma, quality of the nose skin, general health of the patient, non-structural causes of difficult breathing like allergies and, probably the most important, the choice of rhinoplasty surgeon. In about 1% of rhinoplasty, the nose is unfortunately made worse.

This possibility can be kept as minimal as possible by choosing an experienced rhinoplasty surgeon. When a complication unfortunately happens, it can be due to many reasons. Sometimes a hole in the septum is created. Doctors call this a septal perforation. This creates an internal passageway between the two nasal channels and may cause no symptoms to varying degrees of chronic nose crusting, bleeding and nasal blockage.

Another cause of an unsatisfactory rhinoplasty result is the removal of too much cartilage and/or bone. This can result in a misshapen nose with a depressed nasal bridge. It is commonly referred to as a ‘saddle nose deformity’ and reminds people of a boxer’s nose. Other areas can suffer from excess cartilage removal: the nasal tip can appear pinched or become twisted over time. The flesh below the nose (columellar) can retract upwards, the rims of the nostril can also be pulled up exposing too much of the columellar.

Numbness of the tip of the nose is expected while infrequently the front of the teeth become numb. This can last several months, although it is rarely permanent. Post operative rhinoplasty infection is low, occurring in less than 1%. While nasal bleeding into the mustache dressing under your nose usually happens for the first day or two after rhinoplasty, its mild and not really considered a complication. Bleeding such that the dressing becomes soaked through in a few minutes or the blood flows freely however, is a complication and happens in 1% of rhinoplasty. The need for intervention, like repacking the nose or even further surgery, is rare.

The commonest issue following rhinoplasty is an unsatisfactory result. Depending on the nose and the surgeon’s skill and experience, this can occur in 5 to 40% of cases. When the initial problem was functional not cosmetic, an unsatisfactory result means the breathing remains unimproved or minimally better, such that in retrospect the rhinoplasty wasn’t worth the effort or time. When the rhinoplasty was undertaken for cosmetic enhancement, the agreed upon goals weren’t achieved and/or there remains an irregularity or asymmetry. People often wonder why this can happen. If you exclude poor surgery or an inexperienced rhinoplasty surgeon, the explanation is usually found in the nasal tissues. The material we surgeons work with during rhinoplasty consists of the overlying skin, internal mucous membranes, bone and cartilage. All four tissues are altered during rhinoplasty. However they each heal differently, and its the skill and experience of your rhinoplasty surgeon to understand the differences and learn and understand the means of creating a predictable result. It is as much an art as a science and years to master. Click here if you would like to learn more about the types of doctors who perform cosmetic surgery.

Nose cartilage, for example, has a memory and tends to return to its original shape. This inherent characteristic is the underlying cause of a large number of rhinoplasty failures. The more rhinoplasty techniques a surgeon has mastered and the more noses he has seen and treated, the less likely this property of cartilage will defeat the hoped for rhinoplasty outcome.

In spite of all the above, fortunately rhinoplasty usually is a happy experience with a successful result. Over 7,000 septoplasty and 800 rhinoplasty occur each year in Ontario, with the majority of people satisfied and glad they proceeded. If you would like to learn more about nose surgery, we are happy to meet with you and discuss whether rhinoplasty would be of value in your particular situation.