Reshaping Noses

Posted Thursday, September 13, 2007 to PROCEDURES > Face

Posted by The Original Anti-Aging & Cosmetic Surgery Magazine

Jennifer Barnes asked Sherman Oaks plastic surgeon Peter Grossman, MD the most common questions about cosmetic nose surgery.

What rhinoplasty techniques do you use in your practice?

For cosmetic rhinoplasty, there are two basic surgical approaches. The closed (internal) approach is performed with all incisions on the inside of the nose. Dissection of the anatomy of the nose is all done internally. The advantage to this is there is no external scar.

The open approach to rhinoplasty involves making a small incision in the narrowest portion of the skin between the nostrils known as the columella. Intraoperatively, the tissue is pulled back, exposing the structural framework of the tip of the nose.

In my practice, I individualize my approach based on the patient's needs. For some patients, I believe a closed approach is best, while for others the open approach is a better option. The advantage of the open approach is that it gives the surgeon the ability to visually inspect the framework of the nose and allows a more accurate diagnosis of the cause of the external deformity. Additionally, the increased visualization makes it easier for the surgeon to perform certain technical maneuvers. The disadvantage to the open approach is that it requires a longer operative time, and it will result in a minimally noticeable scar under the columella.

In my practice, if a patient requires minimal corrections to the tip, then a closed approach is performed. However, if delicate restructuring of the tip of the nose is needed, as is often the case, then I will do this through an open approach.

What does the procedure entail?

Whether the approach is internal or open, cosmetic rhinoplasty involves evaluation of the anatomy of the nose and its proportionality to the patient's face as a whole. This may involve narrowing the width of the nose by fracturing and realigning the bony structure, refining the dorsom (top) of the nose by either augmenting or reducing the bony or cartilaginous framework, correcting any deviations that may exist in the septum (the portion of the nose that separates the two nostrils), and refining, if necessary,the tip to create a smooth triangular Shape that is neither too bulbous nor too sharp in its angular configuration. Equally as important as the cosmetic improvement is the need for the surgeon to pay careful detail to maintain maximal airway function.

What problems can be addressed?

Rhinoplasty involves both cosmetic and functional correction of the nose. Airway obstruction due to deviated septum or hypertrophic turbinates can be addressed at the same time as a cosmetic procedure.

Common cosmetic problems corrected with rhinoplasty include: reduction or augmentation of the nasal dorsum; correcting a drooping tip; correcting a tip that is too wide, too narrow, too sharp, or deviated. Each nose has to be individually assessed. Many different problems can be corrected, but some noses are better off left untreated.

What patient is not a candidate?

Dr Jack Sheen, perhaps the foremost rhinoplasty surgeon in the world, has laid out some excellent guidelines of those patients who should not be operated on. These include:

1. Patients with unrealistic surgical expectations.
2. Patients who are unsure of what bothers them about their nose.
3. Patients going through a life crisis often want surgery as a form of distraction or false resolution of their problems. Surgery in this circumstance often worsens the situation rather than making it better.
4. Patients who are facing external pressures to have their nose done. A patient who comes in and says, "1 like my nose but my boyfriend doesn't like this bump" should be counseled that the decision for surgery should be a personal one. Often times patients can be disappointed if they undergo a surgery that they don't really want.

Do you recommend visual imaging, and how is this beneficial for the patient?

Computer visual imaging allows the patient to have a general idea of what they may look like after surgical correction of the nose. Many surgeons feel that this is a very helpful tool to explain to the patient the areas that need refinement and to make sure that the patient and the surgeon have mutual expectations.

Other surgeons feel that despite any written disclaimer stating that the computer image is just a guide, the visual image generated by the computer can be very misleading to the patient. The computer does not take into account the technical aspects of the surgery and the patient's individual healing process. It is for those reasons that I personally do not use computer visual imaging.

What is the recovery time?

Recovery time varies from patient to patient based on the extent of the procedures performed and the individual's ability to heal. For the most part, the patient will look quite bruised and swollen for the first week. Within two to three weeks, however, most patients' swelling and bruising have resolved considerably. The healing process of the nose is a dynamic process that will continue for the better part of a year. After three weeks, however, the patient has a good idea what the nose is going to look like, and all further changes will be subtle.

As far as pain goes, the worst discomfort usually subsides in the first 48 hours. Most normal activity can be resumed within ten days to two weeks, although contact sports should be avoided for a minimum of six to eight weeks.

The patient can return to work within 5-7 days for sedentary work, 1-2 weeks for active work, and 2-3 weeks for strenuous work.

What are the possible complications?

The nose is a three-layered complex structure consisting of the inner lining, known as the mucosa; the cartilaginous and bony framework; and the overlying skin and subcutaneous tissue. All three layers are subject to the possible development of scarring during the healing process after surgery This can lead to delayed development of distortion of the nose that was not noted or anticipated at the end of surgery Although there is a small possibility of the need for revision surgery, in general, patients are happy with the outcome of their rhinoplasty surgery.

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