Rhinoplasty surgery is performed to refine the nose's size and shape. It is often combined with surgery on the nasal septum to correct obstructed breathing (septorhinoplasty). It is the most frequently requested and performed facial procedure in Mr Paun’s practice.
The nose is perhaps the most defining characteristic of the face. With its central position it is often what the observing eye is first drawn to when looking at a face, particularly when prominent. Many patients are unhappy with the general look of the nose they were born with but for others trauma may have distorted the nasal appearance. The most common requests for cosmetic correction in our London clinic include:
Hump on the bridge of the nose
Deviated nose
Wide appearance
Large or unpleasant looking tip
Most patients request that the nose is made smaller and in female patients this is often the ideal; usually associated with making the nose look more feminine. In male patients (incidently approximately 30% of all our patients) such reduction in the size needs to be more limited and often refinement is what is required. In all patients it has to be remembered that the function of the nose is of extreme importance and that any surgical intervention does not compromise this. Indeed in many patients, cosmetic concerns are associated with breathing difficulties or sinus problems and these can be addressed concomitantly with related procedures.
Many patients considering rhinoplasty have associated nasal blockage and/or sinus problems. This is particularly common after trauma to the nose. It is important to correct any such problems at the time of surgery. Deviation of the midline partition of the nose (nasal septum) can give rise to breathing difficulty but equally can be responsible for deviation of the nose externally and correction is important for both reasons. Equally it is important to remember that the nose has a function and there are times when aesthetic changes could compromise breathing. Mr Paun - the best rhinoplasty surgeon in London, spends much of his time correcting prior operations performed by other surgeons where such postoperative problems were not anticipated and dealt with. We carefully take into account any medical and cosmetic reasons for a request for surgery and work with patients to achieve the best outcome for both.
Accurate assessment for this surgery is of paramount importance at our clinic. With his specialist training in functional and aesthetic aspects of nasal surgery, Mr Paun examines the nose both outside and inside, often using specialist endoscopy. A discussion about the patient’s likes and dislikes form the basis upon which recommendations are made for correction. As part of any assessment for cosmetic nasal surgery, photographs are taken. These are transferred to an advanced 3 dimensional computer imaging program and the patient is shown what can be realistically achieved with the surgery.
The patient can expect a thorough explanation of the expectations and risks involved in surgery.
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 more complex cases such as with difficult nasal tip or revision surgery, an incision is made in the area of skin separating the nostrils at the bottom of the nose. This ‘external approach’ may also be required in cases of traumatic rhinoplasty or where a nose is very deviated. 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 cartilage can be sculpted 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. The width of the nose is addressed as a final step and reduced if required with small external incisions at the bases of the nostrils.
The skin and soft tissues are then redraped over the new frame and the incisions are closed. A plaster cast is applied to the outside of the nose to help retain the new shape while the nose heals. Soft, absorbent packing material may be used inside the nose to maintain stability along the nasal septum and to stop minor post operative bleeding although this is usually not required. Very occasionally, soft Silastic splints may be left within the nose for a week or two to help prevent scar tissue formation inside the nasal cavity.
The majority of our patients seek reduction in the size of the nose. This might involve taking down the hump of the nose as well as reducing the volume of the nasal tip to keep the nose in balance. Once the hump is removed, the nasal bones normally need to be reposition to narrow the nose to keep things in proportion. Keeping the nose looking normal and natural looking is the key to a successful unoperated look.
Deviation of the nose is common after trauma but may occur naturally, perhaps after an injury in childhood that went unnoticed. Correction normally involves repositioning of the nasal bones and cartilage into the midline and may require additional cartilage being added to help keep the nose straight in the longer term. Such procedures are often the most challenging as the nose has a tendency to want to redeviate and a variety of complex procedures may be needed.
Certain ethnic groups tend to have smaller noses that have rather a flat nasal bridge. Such patients benefit from building up (augmentation) of the bridge and tip region. Other cases may include patients having had trauma to the nose where the nasal bridge was flattened or in revision cases where the cartilage of the nose may have been taken down too much or after septoplasty surgery. A ‘saddle’ nose similar to those often seen in boxers or rugby players may occur. Correction normally involves addition of cartilage to the nose, which normally is harvested from the septum of the nose but may involve taking it from other areas of the body including the ear or rib. On occasion, specific implants may be required – details of the options are discussed on a case to case basis by our expert surgeon.
The vast majority of patients will require General anaesthesia. This is given by highly qualified Consultant Anaesthetists that are specifically chosen for their expertise in the Face and Head and Neck area. Patients are given the opportunity to speak to the Anaesthetist in advance of the surgery to allay any concerns or fears. The procedure is often done as a Daycase procedure but may require an overnight stay in hospital.
The vast majority of patients will require General anaesthesia. This is given by highly qualified Consultant Anaesthetists that are specifically chosen for their expertise in the Face and Head and Neck area. Patients are given the opportunity to speak to the Anaesthetist in advance of the surgery to allay any concerns or fears. The procedure is often done as a Daycase procedure but may require an overnight stay in hospital.
The plaster cast placed on the nose to protect it and to keep the structure stable will be left for about a week. In the unlikely event of packing being placed inside the nose during surgery, it is removed a few hours following the operation. The face and eyes will feel puffy and there is likely to be a degree of bruising, especially the first day or two after surgery. Cold compresses help reduce the bruising and discomfort. Mild painkillers are occasionally required although these are rarely needed beyond the first few days. Blowing of the nose should be avoided for the first few days after surgery. Absorbable stitches that do not have to be removed are used inside the nose but if there are any external incisions, these are closed with permanent stitches that are removed after a week. The plaster cast is usually removed six or seven days after surgery.
It is crucial that postoperative directions are followed. Some activities will be prohibited in the weeks after the procedure. Sun exposure, exertion, and risk of injury must be avoided. Tape and other devices are sometimes used to permit wearing glasses without stressing the area where surgery was performed.
Follow-up care is vital for this procedure to monitor healing. Obviously, anything unusual should be reported to us immediately. It is essential that to keep all follow-up appointments with Mr Paun.
Swelling around the nose should settle rapidly in the first few weeks after surgery but it is important to note that the healing process continues for some time after. As an approximate guide, there will be a subtle change in the appearance of the nose (almost always for the better) for some months after the operation, although most scar maturation has occurred within a year of surgery. Most patients can get back to a normal working life after 2 weeks and perhaps earlier with application of some make up. Massaging the nose gently can reduce swelling and prevent scar formation under the skin.
All surgery carries risks complications. These complications are thankfully rare and usually only minor in surgery.
Prolonged nasal bleeding is unusual. Whilst it is normal to get some minor bleeding from the nose in the first few days after the operation, heavier bleeding is possible. Rarely, if simple measures don’t settle the problem, medical treatment may be required.
Postoperative infection is rare but can be uncomfortable when it occurs. It will usually settle with antibiotic treatment which is sometimes given at the time of surgery and as part of the post op management as a prophylactic measure, particularly in more complex cases.
After the swelling has settled, there is an unlikely risk of developing small irregularities in the supporting structures underlying the skin. These may only be felt but are sometimes visible and if conservative, simple measures don’t resolve matters with time, an additional procedure may be required. The skin itself may rarely become mildly reddened in certain areas, most commonly over the bridge of the nose. Once again this will improve with time but permanent discolouration may require treatment with a laser. Such complications are more common in patients with thinner skin.
Whilst it is the aim of surgery to try and get the nose straight and symmetrical, the unpredictable nature of healing and scar tissue formation does not always allow this to occur. In markedly deviated noses and after severe trauma in particular, a residual deviation is possible but the likelihood of this will be discussed prior to the operation. Overall, approximately 6% of Mr Paun’s patients may need an additional procedure – most commonly a minor ‘touch up’.
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