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Rhinoplasty (Nasal Deformities)

Procedure: Rhinoplasty
Surgery Length: 3-6 hours
Anesthesia: General with local
Where: Outpatient Hospital
Recovery:  Acute nose bleed can occur immediately post-op, temporary swelling and bruising, temporary stuffiness and drainage, Pain in nasal area subsides after several days, Must sleep on 2-3 pillows to limit swelling, Possible Nausea and Vomiting for first 24 hours, Splint on nose for one week
Back to work: 2-3 weeks
Full activities: No contact sports or wearing of glasses on bridge of nose for 1 month
Risks: Need to pack nose related to bleeding, loss of mucosa in central strut (nasal septum) can result in hole between nasal vestibule (extremely rare), Residual nasal deformity

PROCEDURE:  This is a procedure designed to alter the exterior appearance of the nose to correct deformities which are congenital or traumatic. Some patients have distortion and asymmetry of the nose owing to a cleft lip. Others have a prominent inherited nasal hump or nasal tip. Traumatic injuries (such as nasal fractures) can change the appearance of a nose, causing curving of the cartilage as well as distortion of the bones at the bridge of the nose.

Traumatic injuries can change the appearance of a nose drastically. Broken noses (nasal fractures) can cause curving of the cartilage of the nose, as well as distortion of the bones at the bridge (where the nose meets the forehead). Such trauma does not have to be extensive nor recent. Often it has occurred in childhood and becomes more noticeable as the patient enters puberty and grows into the deformity. (The facial features grow and become more defined). Traumatic changes can also be seen months or even years after the injury in both adults and children. Scar tissue or calcified bone may deposit at the bridge, making the bump larger or the nasal bone may be displaced off center. This crookedness may be observed at the tip of the nose as well as at its base or bridge. If the spongy cartilage of the nose has been injured, there can be bending of the nasal tip and even the septum or central strut of the inner nose. A deviated septum can occur from this sort of injury, causing obstruction of nasal breathing. It is often necessary to correct the curvature in order to straighten the bent nasal tip as well as improve the airway. Fractured noses should have an attempt at reducing the fracture fragments to their normal anatomical position. This can often avert the need for later correction of external or internal deformities (nasal obstruction). However, poor nasal breathing may be secondary to one or more factors. In cases of severe allergy, the lining of the nose becomes irritated and swollen, particularly with seasonal pollen changes or other exposures to sensitive aromatic compounds. In the presence of a crooked nasal septum, these allergies can further complicate a partially obstructed nasal airway. For that reason we advise:
Avoidance to allergic exposure.
Prescribed use of nasal cortisone sprays.
The use of oral antihistamines (Chlor-Trimeton) and decongestants (Sudafed).
With the failure of these measures, we may refer the patient to an allergist or an ear, nose and throat specialist who specializes in nasal allergies. Oftentimes such allergic patients will have thickening of the lining of the nose (the mucosa). This mucosal thickening forms polyps which can obstruct nasal breathing and even cause an increase of sinus drainage into the nose. These polyps may have to be removed surgically.

Allergic type patients are also prone to larger than usual turbinates. (Turbinates are bony structures in the nasal passage which warm and moisturize the air that you breathe). These turbinates can become thickened with allergy and may require injection with steroids (cortisone). In extreme cases turbinates may require excision. This turbinectomy procedure is often done at the time of septal surgery.

A rhinoplasty is a procedure designed to alter the exterior appearance of the nose by manipulating the nasal bones and the soft spongy cartilage in the nasal tip. A septoplasty is an operation to further enhance the external appearance of the crooked nose by straightening a bent nasal septum. The septum is made of cartilage which when bent or deviated can cause problems in nasal breathing as well as with the nose's outer appearance.

In regard to the various nasal operations, they can be performed individually or oftentimes together, depending upon the indications and findings at surgery. A septoplasty (straightening of a bent septum) and possibly submucous resection (removal of damaged septal cartilage) can be done in order to improve the nasal airway. A turbinectomy (removal of excessive turbinates) is sometimes indicated when septal surgery is required. These procedures are usually covered by your insurance carrier and best clarified by sending a letter of pre-authorization in order to get approval prior to the operation. If second opinions are needed we can coordinate these examinations for your insurance.
Aesthetic reconstruction (rhinoplasty) of the contour of the nose may also be insurable if proof of trauma and a change in contour can be supplied to your insurance company. We recommend that patients supply some documentation of their trauma, plus photos taken before and after the injury. In some cases insurance will pay for septal surgery, but not for the cost of the cosmetic nasal reconstruction (rhinoplasty).

As to the procedure itself, the septoplasty brings the deviated septum (which is the cartilaginous strut of the nose) back into the proper mid-line position. However, the inherent difficulties of that procedure are that cartilage has a memory and tends to reform into its previously traumatized contracted state. This can happen despite all attempts at scoring the cartilage or bringing it into proper contour with physical adjustment. This difficulty is in part sometimes aided by doing a submucous resection or removal of a portion of that cartilage which is so badly deformed or bent that it cannot be straightened.

One problem of doing such a procedure is the chance of a nose bleed following the operation. This bleeding usually stops with application of pressure. In rare severe bleeds, the nose must be packed to stop the bleeding. The other problem is that the mucosa covering the cartilage could be injured in the course of resection and such injury could cause loss of the mucosa in the central strut and a potential hole communicating between one nasal vestibule and the other vestibule. Usually such perforations are not noticeable, but occasionally they can bleed and give a whistling sound when breathing through the nose. Another operative procedure may rectify this problem but standardly many surgeons either cauterize the bleeding site and/or enlarge the perforation to obviate the whistling of air. Again, this is a rarely seen problem, but one which should be mentioned in terms of a septal surgery.

Likewise, in terms of discussing a septal operation, one must consider that if the patient has a history compatible with allergies, then antihistamines and other approaches to control the allergies may be necessitated following septal surgery. If there is a strong seasonal history of nasal disturbances, it is imperative that prior to surgery the patient seek the services of a competent allergist or other specialist to attempt a trial of oral and topical antihistamine therapy to the nasal mucosa in order to see what benefit might be gained

In regard to the recovery period from the turbinate or septal operations alone, patients will have some swelling and residual stuffiness of the nose for several weeks after the operation from the manipulation of the tissues. This holds true when a rhinoplasty alone is done or when a rhinoplasty is done in addition to a septal surgery. The obstruction is such that you may well benefit from having the rhinoplasty done as a separate procedure to the septoplasty, submucous resection, and possible turbinectomy. Only in rare instances is this necessary, and it is usually a decision made at the time of surgery when a serious deviation of the septum is found or a difficult bony obstruction is observed proximal to what could be seen on a preoperative basis. When such a presentation occurs, it is best to back off doing the rhinoplasty and leave the septum and inner nose to heal on its own. Again, both the rhinoplasty and the other septal surgeries are usually done at the same time unless these other problems are found at the time of surgery.

The down time from the septal operations alone would be approximately one week. You could then return to non-strenuous duties without great difficulty. If, on the other hand, a rhinoplasty were performed at the same time, there would be some black and blue, and swelling which would not resolve for an additional week. You would have to consider the down time from the standpoint of your need to meet the public. There may be some black and blue residual up to and over two weeks.  You might have to consider doing the surgery to coincide with a vacation that may leave you beyond three weeks from seeing the public. As far as the discomfort after surgery, there usually is some aching in the nasal area after the septal surgery and some further discomfort if the rhinoplasty is done. This discomfort can easily be managed with oral analgesics and is further helped with elevation of the head, sleeping in a position on two or three pillows to further improve the swelling and inner nasal drainage.  Ice compresses also help to resolve swelling and black and blue as well as decreasing post operative pain. 

The rhinoplasty procedure is done with incisions entirely within the nose plus one small incision across the base of the nose.  This approach allows resection of excess cartilages in the nasal tip, trimming of the cartilages on the dorsum or top of the nose, and chiseling away of the bony hump. Following these maneuvers, the nasal bones are fractured at their lateral aspects as if at the base of the tilted sides of a roof so that both sides of the roof are brought together to meet over the new re-contoured midline or central strut, which has been trimmed of its bony hump. The resulting effect is not helped when there is a tendency to thick skin. A thick skin, when draped over an underlying bony or cartilaginous superstructure, tends to not highlight the basic outline of the nose, but rather tends to make it rounded and less pronounced.
The rhinoplasty procedure yields some swelling which is basically resolved by the first month, but may persist up to several months after surgery. Further improvement in this swelling is obtained by massage and maintenance of some elevation with one or two pillows at night.

The operation (whether septal surgery alone or the rhinoplasty and septal surgery being done together) is best done under general anesthesia at the outpatient surgical unit.  We ask that patients refrain from Vitamin and aspirin products at least two weeks prior to surgery as these medications tend to thin the blood and increase the chances of bleeding. We also recommend that patients have a shower and shampoo the morning of surgery and that they eat or drink nothing after the midnight before their operation.

After the procedure, there is a limited recovery period in the post anesthesia recovery area.  The patient must then return to the care of another person to observe you for the initial 24 hours. Someone will have to obtain medications for you and see that your basic needs are cared for.

Ice compresses are placed over the areas of the eyes as well as a small drip pad beneath the tip of the nose for catching any drainage. Some nausea and vomiting can occur in the first 24 hours inclusive of some old blood from the operative procedure. The chances of bleeding, as mentioned, are small, but should this happen patients are asked to pinch the tip of the nose and wait fifteen minutes by the clock in an erect position while remaining calm. If the bleeding persists, the patient is seen and the bleeding site cauterized. Packs are occasionally used in the nose at the time of surgery and are maintained after the operation. Oftentimes they are omitted, but may be required if such bleeding occurs.

A nasal splint is kept in position approximately five to seven days. There may be additional lighter splints applied to the nose for an additional week after its removal. The nasal drip pad is usually not needed after a few days. Decongestants and saline nose drops are ordered postoperatively at a time when most of the drainage has subsided or is subsiding. Prophylactic antibiotics are also administered along with your pain medications. The base of the nose may have some small resections at the base of the nostrils, but this is oftentimes elected for another procedure if the desire is to narrow the nasal base. With any operative procedure, the hallmark of a rhinoplasty is conservatism. One must be careful not to remove too much cartilage or bone as it is more difficult to replace it than to remove it. For this reason, any bony callus development at the fracture sites should not be addressed for at least one year. Likewise, any scar tissue formation at the dorsum or tip of the nose should not be addressed until the scar tissue has had a chance to subside over a one year period. These adjustments along with adjusting the nasal septum can be contemplated pending the results of the surgery and are necessary in a small percentage of rhinoplasty patients. 

We ask all nasal surgery patients to refrain from smoking two weeks prior and one week after their operation. We also ask that there be NO contact sports or the resting of eye glasses on the nasal bridge for up to one month after surgery.

The charges for the septoplasty and submucous resection procedures are usually insurable. Similarly, if excessive turbinates of the nose require cortisone injections or excision, your insurance company will customarily cover these fees. The rhinoplasty procedure, in some cases, is also insurable if trauma can be verified with pre-injury photos.

The surgical fee is paid at least two weeks prior to surgery in its full amount. Upon receipt of payment from your insurance carrier, the amount will be forwarded to you. I recommend that patients allow at least one month in advance for scheduling their procedure.

Fractured noses are also considered traumatic and usually insurable. Fractures are set 3 to 14 days after the trauma in a maneuver similar but not as extensive as a rhinoplasty. Recovery complications and precautions are identical to rhinoplasty cases.  These nasal fracture patients may later require a definitive rhinoplasty or septal surgery.

Please feel free to ask Dr. Kennedy or any member of the staff questions on any of the points raised.