rhinoplasty

Rhinoplasty

Introduction

Rhinoplasty or nose reshaping is one of the most common cosmetic surgical procedures sought by men and women. Concerns range from a crooked nose to a hump on the bridge, a large or boxy tip to depressions or difficulty breathing. Often patients consult me having had a previous rhinoplasty and just seek a subtle contour refinement. Changing the nasal shape does not have to be a huge ordeal. I authored the first papers in the UK on Injection rhinoplasty, using fillers to resculpt the nasal form and have since been an invited expert to author the non-surgical rhinoplasty chapter in the latest textbook on advanced rhinoplasty.

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Consultation

The initial consultation is an opportunity for you to talk and me to listen. I like to understand what has led to my patients seeking advice on improving their appearance. During the consultation process, I thoroughly examine the nose in all dimensions. I like to feel the thickness of the skin and position of the underlying cartilages. I carefully measure, document and photograph the nose in 6 different positions, then with the help of 3D imagery can modulate the images to suggest what might be achievable. Occasionally, I will suggest that surgical treatment may not be necessary and, if appropriate , suggest less invasive alternatives such as filler injections. I will ask you to show me historical photos so that we can really discuss what may be achievable, and only when you really understand the options available, their respective costs and associated downtime will we embark on a treatment path together.

Jane 3 weeks after face, neck lift and Rhinoplasty


Types of Rhinoplasty

Surgical -

Closed Rhinoplasty

This is a rhinoplasty without any external incisions. Access to the nasal structures is gained through incisions inside the nostrils. During the procedure, the skin of the nose is gently elevated off the underlying cartilage and bone so that they can be modified, altered and reset into a more aesthetically appealing framework. The skin is then redraped and the incisions are closed with dissolvable sutures. If the bony bridge has been altered a small plaster splint is applied and fixed with sticky plaster.

Open Rhinoplasty

For more complex nasal alteration, more commonly in revision rhinoplasty or where intricate changes to the nasal framework such as cartilage grafts are necessary I use what is called an open approach. This is identical to the closed approach above except I make small incision across the collumela. This is the thin firm structure between the nostrils. This transcollumellar incision enables me to lift the nasal skin off the whole nose much like opening the bonnet of a car and gives a perfect view of all the underlying bony and cartilage framework. After modification the collumelar skin is stitched back together with ultra fine sutures and heals invisibly. There can be more swelling with this approach but the access is second to none.

Tip Plasty

Occasionally, it is just the nasal tip that needs refinement. If you feel on your own nose, the mobile compressible part of the nose is the tip. The tip can be delivered out of the nostril through incisions inside the nose and refinements to the cartilage are made before it is popped back into position.

Non surgical -

Injectable Implants

Injectable implants have revolutionised fine aesthetic refinement of the nose. Profile irregularities such as a hump or saddle, an under projected or drooping tip, contour depressions, irregularities or pick scarring are all perfectly treated with filler. Whilst the result isn’t as permanent as surgery, the use of Radiesse® filler has increased the longevity of correction significantly. I have patients who maintain the correction 3 years out.

Preparation

This is a vital part of my surgical philosophy. When setting out my practice I wanted my patients to ENJOY their surgical experience. This is after all surgery they have chosen to have! I could have followed convention and operated out of leased theatres in large private hospitals but this didn’t fit with this philosophy. Overflowing car parks, receptionists I didn’t know, bank staff, theatre overruns and management dictat over patient experience. I travelled throughout Europe and the US to refine the model and my surgery is the result of this research. Custom built and registered facilities for facial cosmetic surgery, an environment that is a clinical home from home, sta! hand picked not only for their expertise but their approach and interpersonal skills, and surgery that is natural, contemporary, safe and individually planned and performed by me for each and every patient from initial consultation through surgery to final follow up visit. I am constantly refining the model to give my patients the very best experience.

I believe that a patient that is relaxed, calm and comfortable, not starved for general anaesthetic, and who is familiar with the environment has lower blood pressure, lower circulating stress hormones and is in a far better place to start recovering from surgery.

My assistant Lucy discusses preoperative preparation with all my patients, and everything is considered. From hair colouring to diet sheets, pre operative medications, supplements and specifics to avoid such as blood thinners - Non steroid anti-inflammatories (Ibuprofen, Neurofen, Volatarol), Aspirin and Vitamin E.


Recovery

My patients literally walk out of the operating theatre into the recovery room and are back home (if local) or at the hotel within an hour accompanied by a family member or friend. It is quite normal to have some swelling and for the nose to feel blocked and stu!y for a few days. Sleeping propped up on pillows helps take down the swelling. Bruising varies depending upon the procedure performed but if the nasal bones have been reset, black eyes are inevitable for about a week. I see may patients again at a week to remove the plaster and/or stitches if necessary. The soft tissues of the nose can be still be swollen at this stage but this rapidly improves after the plaster is removed. Most patients can be back at work by 10-14 days. The nasal bones as still very delicate at this stage so strenuous activity and/or contact sports are forbidden! I advise my patients that it can take up to 9 months from all the skin swelling to settle completely after rhinoplasty.

Procedure

Rhinoplasty surgery begins at the initial consultation. I want my patients to truly understand all the options available and the risks before undergoing surgery. I take written consent for the procedure(s) we have mutually agreed and give a copy to take away and read at leisure. Any queries that might arise are welcome to be clarified at a second preoperative consultation. On the day of surgery patients are escorted to the surgical suite where they are given their own temperature controlled warming gown and thick comfy socks.

After a relaxation tablet, I spray anaesthetic spray inside the nostrils and put anaesthetic jelly on the nasal skin. My anaesthetist then gives a little sedation through a drip and you go off to sleep. I then inject the already numb nose with local anaesthetic to leave it temporarily completely numb. I then perform the rhinoplasty according to our preplanned approach. Incisions are made inside the nostrils and the skin is lifted from the underlying bone and cartilage. If the nose has been blocked I straighten the internal cartilage partition between the nostrils. If the nose needs straightening, I gently file down the bump and then fracture and reset the bridge. The nasal tip cartilage is then refined if necessary. A small plaster cast is stuck to the nose to the protect the healing bones for a week.


Risks

Risks are minimised with adherence to pre and post operative guidance They are fortunately extremely rare with recent anaesthetic and surgical innovation and when they do they are usually a temporary inconvenience rather than a permanent problem. I do literally everything I can to minimise risks but when they occur I treat them with first class care and attention. The single biggest risk factor in facial cosmetic surgery is smoking. So much so, I do not operate on anyone who has smoked for 2 weeks before surgery.

Bleeding

A little bleeding from the nose is quite common after rhinoplasty but settles on its own with sitting upright leaning forward and like pressure on the soft part of the nose.

Non perfect result

There are a minority of patients (and their surgeons!) - about 5% reported - who after waiting a period of 9-12 months are not happy with their result. These are most commonly revision rhinoplasties or patients who have had previous significant trauma to their nose. If I agree that the result is not ideal, it is my policy to revise the work for free if I feel I can improve the result.