Rhinoplasty

Rhinoplasty (nose reshaping), nasal cosmetic surgery, is performed to improve the nose aesthetically – making it harmonize better with the other facial features – while maintaining or improving function. Because it is the most defining feature of the face, the size and shape of the nose has a significant impact on a person’s appearance.
Some patients want their nose to be straight, others want the nostrils narrowed, others say their nose sticks out to far from their face. Because the nasal tip loses support as we age, some patients are surprised to realize how significantly rhinoplasty contributes to a more youthful appearance. Once thought a beauty procedure sought by only wealthy women, men in today’s competitive corporate workplace are increasingly seeking rhinoplasty to improve self-confidence and restore a younger look.
When discussing rhinoplasty the best place to start is by looking at before and after photos to see just what can be accomplished. As you will see in the photos, patients often ask to combine a rhinoplasty with a brow lift for correction of frown lines between the eyes or blepharoplasty for improvements in bags under the eyes. Chin implants, cheek implants, otoplasty (ear surgery), lip surgery and facelifts can also be performed in conjunction with rhinoplasty. Many patients seek information about improving superficial skin wrinkles with a chemical peel, laser surgery or similar skin resurfacing procedure.
When patients come to our office seeking facial plastic surgery, it’s not uncommon for them to focus on a single aspect of their appearance rather than the overall picture. A board certified facial plastic surgeon, trained to perform cosmetic and reconstructive surgery exclusively on faces and necks, knows that his responsibility is to evaluate not only the areas of concern but also the motivation behind the requests. It goes without saying a rhinoplasty won’t save a failing marriage. Similarly some patients not ready for cosmetic surgery are better served with conservative measures, such as Botox for fine lines and wrinkles or Collagen for crows feet. Patients who educate themselves know when and if the time is right to proceed.
At your initial consultation, we will evaluate the soft tissue and bony architecture as well as the form and function of your nose. An overall assessment of the face provides the basis for what one may expect from rhinoplasty. Skin type, ethnic background and age, along with the degree of deformity and function are important factors influencing the outcome of surgery. As with all facial plastic surgery, a thorough health assessment and realistic expectations are prerequisites.
Your understanding of procedures and routines is essential to a successful final result. Before we proceed to preoperative routines, we want to take a moment to include those patients who are referred to us for revision rhinoplasty. Revision rhinoplasty – a term no one wants to hear! Whether due to trauma following original rhinoplasty, disease, pre-existing conditions or surgeon error, revision rhinoplasty occurs from 2-5% in any surgeon’s practice.
Although the preoperative and postoperative instructions for revision rhinoplasty are the same as for the primary (first-time) rhinoplasty patient, revision rhinoplasty has it’s own set of special considerations. If you are a patient seeking revision rhinoplasty, please a moment to scroll to review special considerations for revision rhinoplasty. Including revision rhinoplasty in our procedure instructions also brings up a very important point.
Facial plastic surgeons (board certified reconstructive and cosmetic surgeons that concentrate exclusively on the face and neck) are specialty trained to perform rhinoplasty, the most challenging of all cosmetic surgery. Not every cosmetic surgeon is trained in rhinoplasty and not all surgeons have the skill to perform rhinoplasty. More than any other cosmetic surgery, we highly recommend that you do your homework in selecting a surgeon that specializes in rhinoplasty. And if you are seeking revision surgery, your thorough investigation before selecting a surgeon is critical. How do you do this? Start with our how to Select a Surgeon

BEFORE RHINOPLASTY SURGERY

At your preoperative appointment our nurse will provide all the instructions for you to follow before and after surgery. On the business day prior to the operation we ask you to call to confirm your arrival time for surgery. Upon arrival for your surgery, you will talk with a nurse (who will start an IV), discuss anesthesia (local anesthesia with IV sedation keeps you asleep and comfortable) and meet with your doctor before going to the operating room. Rhinoplasty takes about an hour depending on the structure and amount of change you are seeking. Revision rhinoplasty generally takes longer, especially if you need grafts as we previously discussed. Also, if you are having a combination of procedures your surgery will take longer. Recovery time from the anesthetic takes about an hour and you will be discharged about four to five hours from the time of admission.

PREOPERATIVE RHINOPLASTY SURGERY INSTRUCTIONS

Please avoid any aspirin, aspirin-containing products, or ibuprofen (Advil, Aleve, etc.) for one week prior to and two weeks following your surgery. See our “Medication List” for products to avoid prior to and immediately following surgery. If you are on any medications that affects bleeding (such as coumadin or warfarin) please notify the office immediately.
Please notify us of all routine medications and significant health history. We ask that you remain on your daily medications unless instructed otherwise. At the preoperative appointment, our nurse will tell you which daily medications to take with just a sip of water on the morning of surgery.
At your preoperative appointment you will be given prescriptions for use following surgery including an oral antibiotic, swelling and pain medications. You will be instructed to take Vitamin C (ascorbic acid), which helps promote healing, one week before and two weeks following surgery. Please take Arnica, a natural herb that significantly decreases bruising, as instructed before and after surgery. We will also ask you to obtain an antibiotic ointment and saline spray for use following surgery. Please obtain these prescription medications and items before your surgery so you will have them ready for use when you return home after your surgery has been completed.
Please call the Lindsay House Surgery Center at (585) 244-1135 before noon on the business day prior to your procedure to confirm your arrival time.
You may not eat or drink after midnight the evening before the procedure unless instructed otherwise. This includes all food, liquids, water, candy, mints or gum. You may brush your teeth. Your procedure will be cancelled if you do not follow these instructions.
Do not bring valuables (cash, credit cards, watches, jewelry, etc.) to the Lindsay House on the day of surgery. Remove all make-up and nail polish before arriving for your procedure.
It is not required that a family member or friend stay at the Lindsay House during your surgery. However, someone must be available at all times while you are here at the Lindsay House for surgery. Someone will need to drive you home after your surgery and stay with you that evening. Transportation to the office for packing removal the day following surgery is also required.

AFTER RHINOPLASTY SURGERY

After surgery your nose will be packed with soft nasal packing. There will be soft silastic splints along each side of your septum (divider of the inside of the nose). Splints reinforce the newly shaped cartilage. You may notice that tears run down your cheeks. This is due to swelling and will subside during the first week following surgery.
The nasal packing will prevent breathing through your nose so you will have to breathe through your mouth. Your mouth will become very dry. Please drink as much fluid as you can which will help you from becoming dehydrated. Drinks at the bedside along with a humidifier (cool or warm) may help.
Following nasal surgery, mucous membranes can produce extra mucous. Draining of red-tinged mucous through your packs onto your drip pad is normal. Many people ask, “How much drainage is too much?” If you are completely saturating the drip pad with bright red blood every five minutes by the clock for an hour, notify us at the telephone numbers provided below. This is uncommon and can routinely be treated over the telephone or with a visit to our office.
Following your procedure the nurses will ask assist you to meet the discharge criteria: to drink liquids, walk with a steady gait, void, manage your discomfort, and to have your nasal drainage under control. The nurses will teach you how to change the drip pad under your nose, which you will need for about 24-48 hours.
You will be asked to come to our Lindsay House office (not the Surgery Center) the following day for packing removal. Although removal of nasal packing has been described by most patients as discomfort rather than pain, you are encouraged to take your pain medication about an hour prior to packing removal. Packing removal will help relieve some of the pressure. However, due to swelling, you will not be able to breathe well through your nose for one week.

POSTOPERATIVE RHINOPLASTY SURGERY INSTRUCTIONS

Activity

Sleep with head of the bed elevated or use two to three pillows. Sneeze with your mouth open and do not blow your nose of sniff for seven days. Absolutely no bending, lifting or straining. If you have little children, bend at the knees or sit on the floor and let them climb on to your lap. One week off work is recommended following rhinoplasty. Avoid long steamy showers for one week postoperatively or the cast may become loose. Taking care to keep the cast dry while bathing is important.

Diet

Advance diet from liquids to soft food to your regular diet as tolerated. In the immediate postoperative period, avoid extremely hot liquids or foods if you experience temporary numbness on the roof of the mouth.

Wound care

Keep ice-water soaked pads on eyes until bedtime, changing pads every 20-30 minutes. Pads should be soaking wet – do not wring out completely. It is the weight of the water as well as the temperature that helps minimize bruising. A small bag of frozen peas or corn may also be used on top of the eye pads. Make sure the bag is not placed directly on the skin. Use a washcloth or towel between the bag and your skin.
You will have a gauze drip pad placed beneath your nose. Change this as needed for the first 24 hours following surgery. It is not uncommon to change this every 15 minutes for the first several hours following rhinoplasty. If you completely saturate the pad with bright red blood every five minutes for one hour by the clock, please call your surgeon at the numbers provided. Ice packs to the forehead and/or back of the neck may help decrease bleeding. Do not place ice packs directly on your skin. Do not swallow any drainage from your nose as it may make you nauseated. Cough it up and spit it out.
Following removal of the packing, the drainage will eventually subside and the drip pad will no longer be required. Do not use saline nasal spray until the night following packing removal.
The cast must remain on your nose for one week. It must be kept dry or it could become loose. Notify your surgeon immediately if the cast falls off.

Medications

Most patients complain of pressure from swelling and congestion more than pain. Use pain medication (most commonly Vicodin/hydrocodone) as directed/as needed. Vicodin contains Tylenol. Do not take additional Tylenol or acetaminophen while taking Vicodin. Do not drive or drink alcohol while taking pain medication. Side effects of pain medications can include nausea and constipation. Taking pain medication with food can minimize nausea. Over-the-counter laxatives are indicated if constipation persists.
Although packing removal has been described as pressure rather than pain, we recommend taking pain medication about one hour before coming to the office for packing removal.
Start your antibiotic (Keflex/Cephalexin) when you arrive home following the procedure. During your surgery you received antibiotics through your IV. Take antibiotics as directed until gone. It is not uncommon to have a low-grade fever for 24 hours following surgery.
Start the prescription for swelling medication (most commonly Medrol Dosepak/methyl prednisolone) when you arrive home following surgery. At your preoperative appointment, our nurse will provide specific directions for use of this medication following surgery.
The evening following packing removal, start using the ointment (most commonly polysporin/bacitracin) two times a day (morning and evening) inside the base of each nostril. Insert only the cotton part of the Q-tip into your nose. Ointment is applied after the morning and evening saline rinses.
Salt water rinse and ointment
Following nasal packing removal, start your saltwater rinses in the evening. Salt water rinsing is very important for your postoperative healing. The salt water moisturizes, cleanses and facilitates healing.
You can make your own salt water by mixing one tablespoon of sea salt (not table salt) and 12-16 oz. lukewarm water in a small plant mister bottle. Place the tip of the mister gently near the opening of the nose and spray your nose. If you prefer you can purchase saline spray in your drugstore without a prescription. Please rinse your nose with salt water five to six times per day until your splints are removed. You may then decrease your rinsing to three times per day.

Please Remember!

Nasal congestion, facial fullness, headache and disrupted sleep are very normal postoperative symptoms and will decrease as the healing process occurs. It is not uncommon to have numbness on the roof of the mouth (palate) behind the front teeth. Therefore avoid extremely hot liquids or food in the immediate postoperative period.

Final Result

Following rhinoplasty, it takes time for the swelling of the mucus membranes to subside and for the skin to adhere to the new framework. Most patients return to work one to two weeks following surgery, depending on temporary bruising and swelling. At that time, swelling is still apparent to you but not to many of your coworkers and closest friends.

Final results following rhinoplasty are not apparent for one full year following surgery. After three months, the changes are ever so subtle, although still important. Being perfectionists about our work, you may tell us you are pleased long before the one year anniversary. However, we request that you follow-up with us at that time for postoperative photographs and so that we can enjoy your final result.

REVISION RHINOPLASTY (Nasal Reshaping)

Revision rhinoplasty is more challenging than primary rhinoplasty for several reasons. First is the altered “geography” of the nose. At the time of the primary rhinoplasty, distorted cartilage was removed to make the nose straight and restore function. Therefore, in revision rhinoplasty, the cartilage needed for reconstruction is no longer available. Depending on the amount of cartilage that remains, the need to borrow cartilage from behind one ear (an auricular graft) to restore nasal form and function is not uncommon. Although the ear incision is camouflaged well and does not change the shape, size, form or function of the donor ear, the need to borrow neighboring cartilage means an extra incision.
Nasal lining that has undergone surgery is now subject to scar tissue, which also increases the complexity of revision surgery. Therefore, amount of surgical time required to perform revision rhinoplasty typically is longer than primary rhinoplasty.
One risk of primary rhinoplasty is the appearance of telangectasias – little spider like veins that are typically present prior to surgery but become more noticeable after rhinoplasty. This is not commonly an issue and the overall improvements far outweigh the appearance of these. However, in revision rhinoplasty, the appearance of telangectasias can be more pronounced. This point should be discussed prior to revision surgery so your doctor can provide his opinion depending on your individual skin type, texture and thickness.
Revision rhinoplasty may have its own set of special considerations but it also can be the most rewarding. If you are considering revision rhinoplasty (regardless of where you elect to have the surgery performed) it is essential that you consider a board certified facial plastic surgeon. Why? Because facial plastic surgeons have unique board certifications in both head and neck surgery and cosmetic and reconstructive surgery. Please ask to see before and after pictures of patients who have been referred to Lindsay House for revision rhinoplasty.