Rhinoplasty commonly known as a ‘nose job’, is a delicate operation that changes the shape and size of the nose. It is one of the most common plastic surgery procedures carried out in the world.
Rhinoplasty is considered one of the most delicate and complex cosmetic surgeries to master, given the complex structure of the nose and the balance it provides to a face.
Rhinoplasty is frequently performed in combination with Septoplasty (called Septorhinoplasty) to correct a deviated nasal septum (the cartilage in the nose that separates the nostrils) causing a blocked nose and/or to harvest septal cartilage and use it as a graft to improve nasal support or shape.
The nose is at the very centre of the face and is the key to facial harmony and balance. Therefore, it has a great impact on how a person looks in addition to all important function, breathing.
It is a common misconception to think that the nose can be sculpted as if it was a piece of marble, or that one can choose a “perfect” celebrity nose from a magazine. In reality a surgeon must take account of the underlying nasal structure, which ultimately determines what is available to work with, what is possible and what is right for each patient. Therefore, rhinoplasty is about making improvements and not to achieve perfection.
Many people feel their confidence and self-esteem is undermined because the shape of their nose detracts from their overall appearance.
Only you can know the impact of having a nose that you feel is not the right shape. If your nose is making you feel self-conscious and holding you back in life, it may be time to consider nasal plastic surgery.
Rhinoplasty is not a surgery that you must have but an operation that you wish to have to improve your nasal appearance and confidence. Therefore, it is paramount that you have a realistic expectation before proceeding with this cosmetic surgery. You must trust your surgeon and feel comfortable and confident with your treatment plan.
Mr Elmiyeh feels that an honest and confidential consultation is the key, and this should provide a clear surgical plan and understanding of the likelihood of achieving them. He will also discuss the option of having a non-surgical rhinoplasty if appropriate. The use of manipulated (morphed) digital clinical photography provides a platform for discussion as to the patients’ desires and realistic expectations. Such images are not a guarantee of exact results, but a great tool to ensure that you and your surgeon are on the same wavelength.
- to improve the aesthetic appearance of the nose, self-image, confidence
- reduction of nasal hump or size
- augmentation/increasing and contouring the nasal tip of bridge
- straightening of the nasal bones
- refinement of the tip of the nose (narrowing, reshaping, altering length/projection, too flared/big nose, bulbous tip, improve symmetry)
- correction of birth defects or broken nose
- to produce a nose that is in harmony with the face( Your ideal nose may only suit someone else’s face and not yours)
- to produce a result that has a natural (Non-operated appearance)
- improve function (breathing) by treating a deviated nasal septum( the cartilage in the nose that separates the nostrils)
Limitations of a nose job surgery are due to the unique tissues and structure of the nose. There is no perfection in rhinoplasty and it is impossible to replicate another person’s nose perfectly.
Those contemplating to have a substantial amount of bone or cartilage in the nose removed (Excisional Rhinoplasty) must appreciate its considerable long-term complications. Excisional surgery is technically easy to perform. However, the nose due to lack of structural support eventually, over many months or years, becomes deformed.
Inverted ‘V’ result of excessive excision
As a cosmetic surgeon and a nose specialist, Mr Elmiyeh aims to achieve the best cosmetic outcome without compromising the nasal structural support and airway (breathing).
- Nasal Septum: Septum (the cartilage in the nose that separates the nostrils) is the key supporting structure of the lower two thirds of the nose. The nasal septum is involved in almost every rhinoplasty operation. Deviated noses have an underlying twisted septum which may also cause nasal blockage. The anatomy of the septum and its peripheral attachments are key in performing rhinoplasty.
- Previous nasal surgery or trauma: The presence of scarring, absence of cartilage tissue for grafting purposes and in some cases poor blood supply make any revision surgery much more difficult with greater risk of complications. Such surgeries often require additional graft material such as those harvested from the ear or rib cartilage.
- Texture and thickness of the skin: Thin skin makes it is easier to achieve fine refinement, but it also makes irregularities more visible. On the other hand, thick skin is great in covering up minor irregularities but since it does not shrink well, it will not show fine underlying refinements.
- Age: Age is a consideration, it is not advisable for teenagers to undergo rhinoplasty before they have completed their growth spurt at about the age of 16 for girls and 17 for boys. Younger patients with a smooth complexion are better candidate for surgery since their skin has more elasticity and can mould onto underlying structures.
- Ethnic nose: It is important to respect patients’ wishes to alter or enhance the nasal feature while staying true to their ethnic origin or cultural group
- Facial harmony:
The challenge is not just to improve the nose’s cosmetic appearance but also to ensure that it is in harmony with the patients’ unique facial structure. Balance among different aesthetic units of the face also plays a very important role in creating facial harmony. Horizontal and vertical anatomical ratios can provide a useful framework for cosmetic interventions and what can be considered as aesthetically pleasing. Of course there is ethnic and gender variations.
- Nasolabial angle: The ideal nasolabial angle for men is about 90 – 95 degrees and for women is about 95 – 105 degrees.
- Facial features: It is not realistic to get a perfect result in presence of another facial asymmetry. A small chin can give an impression of a large nose. In these photos, you can see correction of the chin size (genioplasty or chin implant) makes the same nose look less prominent and more proportionate to the rest of the face.
Rhinoplasty is carried out under general anaesthetic and usually takes 2 to 3 hours to complete.
Rhinoplasty can be achieved through either the ‘closed/ internal’ or ‘open/ external’ approaches, depending on your needs. Mr Elmiyeh will discuss the right approach for you during your consultation.
Closed approach rhinoplasty
This approach is generally used for less complex operations on the nose. In this approach cuts are placed inside the nose where they cannot be seen.
Open approach rhinoplasty
This approach is considered for more complex surgery such as revision (secondary) surgery. In this approach, a small incision is also made across the skin bridge between the two nostrils, in order to gain greater exposure and access to the internal nose structures and hence improve precision in surgery.
The scar across the skin between the two nostrils usually fades away in one year. Here are two sets of photos before and after an open (external) rhinoplasty.
Complications are infrequent and are usually minor. However, as with any surgery, there are some risks associated with a rhinoplasty. The procedure is kept as minimally traumatic as possible to reduce risks even further.
- Infection: Rarely an infection may occur during the healing process of patients. In those individuals with higher risk of infection, prophylactic antibiotic will be provided to reduce the risk. Routine use of antibiotic is not advised.
- Bleeding: It is common to notice a little bleeding for the first few days after surgery and it generally settles on its own. More severe nosebleeds should be treated by sitting upright, leaning forward, applying cold compresses over forehead and taking gentle and deep breaths through the mouth. The vast majority of nosebleeds will stop in 15 minutes. Very rarely would the nosebleeds be severe enough to warrant packing or dressing inside the nose.
- Bruising & swelling: These are a normal part of healing and occur around the eyes and the nose to a various extent between individuals but should largely subside within a few weeks. Minor swelling particularly around tip of the nose can be present up to 12 -18 months post-surgery.
- Poor wound healing or scarring: In closed rhinoplasty all scars will be hidden inside the nostrils. In an open rhinoplasty, there will be a small scar across the skin between the nostrils. This cut usually heals very well and is barely noticeable a year post-operation. When the flare or size of the nostril is reduced, there may be a small scar in the corner of the nostrils. Permanent outward marks are hardly discernible, though any kind of surgery and healing process can be unpredictable, so it is wise to remain realistic and be prepared.
- Irregularity on the nose: Unpredictable healing or responses to surgical steps may cause new irregularities or asymmetries that can appear weeks or months after surgery. These irregularities may be felt or could be visible.
- Discomfort or pain: Rhinoplasty is surprisingly pain-free, very few patients experience any pain only some discomfort.
- Change in skin sensation (numbness): This is a common occurrence and subsides over a few months. However, this may persist up to one year after surgery particularly around the tip of the nose.
- Skin discolouration: Skin over nasal bone is particularly thin and more prone to get red and inflamed following surgery. Pre-existing scars over the nose are more likely to become discoloured.
- Difficulty breathing through your nose: Congestion and nasal blockage due to internal bruising is common initially. Persistent breathing disturbances is less common and tends to be more in reduction rhinoplasty and revision rhinoplasty patients. One has to be aware that scars and loss of mucosal-sensation can also give the feeling of a “blocked nose”.
- Nasal septal perforation (a hole in the nasal septum): There is up to 5% risk of developing a hole (perforation) in the nasal septum after a primary surgery that maybe amenable to a surgical repair if symptomatic. In Smokers or those undergoing a revision or complex surgery risk is up to 10%.
- Unsatisfactory nasal appearance: Unacceptable results are rare and most concerns are resolved by the time the nose is fully healed in 12 -18 months after surgery. Therefore, it may require a lot of patience from you. After this period of time only about 1 in 20 patients who had their first (primary) surgery may require a second (revision) surgery.
- Risks associated with anesthesia: General anaesthesia is usually very safe. Risk level varies depending on your medical conditions. Our skilled anaesthetic Consultant will discuss this with you and ensure that you are well informed, confident and comfortable to proceed.
- Septal deviation: Septal cartilage has memory and wants to go back to the origin shape, hence there may be some remnant septal deviation causing some nasal blockage.
The majority of patients are extremely satisfied with their result and report an raised self confidence. A small group of about 7% of patients may require more surgery to correct an irregularity. This risk is higher in patients that have had previous nasal surgery or have severe deformities. It is important to appreciate that surgery cannot guarantee a perfect result, although every effort is made to achieve the best outcome possible.
- It is paramount that you explain the exact changes that you wish to make on the appearance of your nose.This is to ensure that you and your surgeon are on the same wavelength and can discuss what is possible to achieve and the appropriate surgical or non-surgical approach.
- During your first consultation, a thorough medical history is obtained. The external and internal nose is examined.If there is a medical indication such as nasal obstruction and sinus disease, a small endoscope will be used to examine the inside of your nose. Digital clinical photographs of your nose and face are taken and you can expect a thorough explanation of the risks vs benefits of the surgery.
- At your second consultation, you will review your manipulated (morphed) digital images which provides a platform for having a more in-depth discussion of your desires and realistic expectations. Such images are not a guarantee of exact results but a great tool to ensure that you and your surgeon are on the same wavelength.
- Mr Elmiyeh suggests that you bring a family member or a friend for this consultation to help you in your decision making if possible. They may also ask important questions that you had not thought of.
- Please use this opportunity to ask all questions you may have and ensure that your questions have been answered satisfactorily.
- The bottom line is that you need to feel comfortable that the likely benefits to be gained by the operation outweigh the small, but definite risks of developing any problems following the surgery. Mr Elmiyeh will guide you through this process so that you have a grounded acceptance of what your ‘new’ nose may look like. Only then can you make an informed decision and proceed with your surgery.
- Smoking significantly increases risks of your surgery and you must stop smoking at very least 2 weeks prior to your surgery and ideally much sooner.
- Avoid taking nonsteroidal anti-inflammatory drugs such as Aspirin and Ibuprofen/ Neurofen 7 days prior to your operation.
- Stop taking all vitamins, herbs and diet supplements 7 days before surgery as they may increase bleeding during surgery. In particular primrose oil, garlic, Omega 3 fish oil, St John’s wort, ginger, turmeric, cumin and vitamins C & E.
- Arnica is one of the most popular homeopathic medicines may help to reduce swelling and bruising. Arnica taken by mouth, can cause side effects such as irritation of the mouth and throat, stomach pain and skin rash.
- Bromelain is a mixture of enzymes found in the pineapple plant. Pineapple has anti-inflammatory properties and may help reduce bruising. If you are considering taking any supplements, please discuss it with Mr Elmiyeh.
- You are advised to purchase a couple of saline sprays such as STERIMAR Breathe Easy and also a NeilMed Sinus Rinse device with 120 premixed sachets.
- You will also need to arrange someone to drive you home from hospital and help you out for a few days after surgery.
- You may wish to get your home cleaned and stock up your fridge so that you have a stress-free recovery.
- Do not wear any make up on the day of the surgery.
- Bring your glasses along as you will not be able to wear contact lenses for about one week after surgery.
- Do not wear any make up on the day of the surgery.
- On arrival, nurses will check you into your room and fill in the appropriate forms.
- Mr Elmiyeh will see you in your room and explain your surgery again and will answer any questions that you may have. He will then get you to sign a consent form.
- Anesthetist Consultant will also meet up with you to review and discuss everything you wish to talk about anesthesia.
- In the operating room, our calm and reassuring team will ensure that you are feeling relaxed and comfortable, as the general anesthetic takes effect.
- Once you are asleep, the operation will be carried out.
- At the end of the surgery, you will have a small cast over your nose. You may have some very fine, dissolvable stitches in the skin bridge between your nostrils.
- If gentle packs are inserted inside your nose, they will be removed before you go home.
- After the surgery, you will feel slightly drowsy. Your nose will feel blocked and mouth breathing will make your throat dry. sipping water on regular basis would certainly help.
- Your nose may ache, and you may have a dull headache. Blood stained mucous discharge through your nostrils and at the back of your throat is to be expected and lasts for a few days. There may be bruising and swelling around your eyes and this may peak in the first couple of days.
- Patients either go home on the same day or stay overnight for social and/or medical reasons.
- You will be provided with detailed and careful guidance about your aftercare including the appointment time for your follow up.
- Once you are comfortable and reassured, you will be discharged home.
- It is advisable that you take the painkillers provided at least for the first 24 to 48 hours even if you do not have any pain.
- Use antibiotic ointment provided regularly.
- To reduce bruising and bleeding in the first few days apply ice packs over the forehead (15 minutes each time).
- Sleep in a semi-upright position.
- Avoid bending down and lifting objects.
- You may continue to feel some nasal congestion and ‘stuffiness’ for several week. it is best to avoid blowing your nose for about two weeks.
- Sip water regularly as mouth breathing may make your throat dry and sore.
- You are advised to use saline spray such as STERIMAR Breathe Easy on a regular basis (10 to 20 times per day) for 5 days after your surgery. You will then require to use NeilMed Sinus Rinse device (4 to 8 times per day) for minimum of 6 weeks. This is extremely important and must be performed gently and diligently. You may blow your nose gently.
- Dissolvable stitches may be visible and will drop out of the nose within a few weeks.
- Nasal sesame seed oil spray e.g. Gelositin/Nozoil can sooth and minimise crusting.
- After removing the nasal cast, steam inhalation 2-3 times a day will reduce nasal congestion which can last up to 6 weeks.
- While your nose is healing, it is very mobile and may easily move and become deviated ‘bent’. You must protect your nose against any trauma.
- Do not get the cast or your face wet as warm environment harbours bacterium and may lead to possible wound Infection.
- Your cast should continuously remain secure over your nose until is removed on your first post-operative appointment. Your nose can get deviated if the cast falls or is removed.
- If you are advised to massage your nose, place your index finger on either side of the nose just below the bridge and sweep down the cheeks. Work your way down to the tip. Do this for 2-3 minutes a day please.
- Avoid putting cotton buds or your finger into your nose to try and clean crusts.
- Avoid activities such as housework.
- You may be able to wear your contact lenses after 5 to 7 days.
- During spring and summer time, apply a SPF 50 sunscreen on your nose for a couple of months.
- Gentle exercise between 2 to 4 weeks after surgery.
- Avoid contact sports for 6 weeks.
- Refrain from flying for about 2 weeks.
If you have low pain threshold take some paracetamol prior to your visit. Your cast will be removed, and you will see your ‘new’ altered yet swollen nose for the first time. You can use minimal make up to cover up any residual bruising on your face if present. You may be able to fly at this point if there are no concerns. You need to discuss with your surgeon exactly when and if you can fly based on the outcome of the examination.
Second Post-operative appointment (6 – 8 weeks)
Your nose will be examined, and any aftercare concerns are dealt with. Significant reduction of swelling is expected both externally and internally. You may be able to return to more vigorous exercise.
Third Post-operative appointment (4 – 5 months)
Your nose will be examined and any aftercare concerns are dealt with. Some swelling and altered sensation/ numbness particularly around the tip of your nose can continue until 12 – 18 months post-surgery. It is important to be extremely patient and sit back and allow for all swelling and healing to occur. That is why the fourth visit is planned around 12 – 18 months after surgery.
Fourth Post-operative appointment (12 – 18 months)
Final visit and check up
|Procedure time||1 – 4 Hours*|
|No. of nights in hospital||Day case or 1 night|
|Avoid driving||1 week|
|Avoid flying||2 weeks|
|Avoid smoky, humid and dusty environment||2 weeks|
|Restrict activity||2 – 3 weeks|
|Break from wearing glasses||6 weeks|
|Avoid vigorous exercise||2 months|
|Avoid contact sports||4 months|
|Protect against direct sun exposure (Hat & SPF 50+ cream)||3 months|
*Depending on complexity