New Techniques for Rhinoplasty: Everything You Need to Know

What is a Rhinoplasty?

Rhinoplasty, or in layman’s terms a nose job, is a plastic surgery procedure that aims to reconstruct and alter the shape of the nose, to provide facial harmony. Rhinoplasty can be done either to better the function of the nose using reconstructive surgery or to alter the structure of the nose for cosmetic reasons using cosmetic surgery. Surgical rhinoplasty is usually done either as open rhinoplasty or closed rhinoplasty.

Rhinoplasty. Image Courtesy of Paravis Michael S. Schwartz, M.D

In open rhinoplasty, the surgeon makes a small incision at the columella, the base of the nasal septum. In closed rhinoplasty, the surgeon performs the entire procedure without making an outside incision.

Considerations before a rhinoplasty

A plastic surgeon needs to take multiple things into consideration during the consultation before going forward with surgery. The doctor needs to care for factors like:

The underlying framework of the nose
Skin thickness
The other facial features. Furthermore, the surgeon needs to take into consideration the ethnicity of the patient, as it is a major factor that can affect the results of the surgery.

Difficulties associated with rhinoplasty

Rhinoplasties can result in a self-esteem boost for the patients and are one of the most common surgeries performed in plastic surgery. However, it is also one of the hardest surgeries for doctors to perform, especially since a slight change can result in big results. The more challenging part of rhinoplasty is the fact that there are no specific steps to this surgery, instead, every surgery is tailored according to the case. The nose is the most prominent part of the face and a nose job can either harmonize your facial structures or ruin them completely depending on the quality of the surgery.

Risks of Rhinoplasty

Rhinoplasty is a surgical procedure and is associated with risks common to all surgeries:

Bleeding
Infection
An adverse reaction to the anesthesia

However, other risks specific to rhinoplasty are:

Difficulty breathing through your nose
Permanent numbness in and around your nose
The possibility of an uneven-looking nose
Pain, discoloration, or swelling that may persist
Scarring
A hole in the septum (septal perforation)
A need for additional surgery

It is important to note that accurate results of rhinoplasty may not be visible immediately after the surgery. Sometimes, the right shape of the nose may be visible almost a year later.

How is a rhinoplasty performed?

Rhinoplasty is the most individualized surgery in the surgical world, and focuses on the following:

The bridge of the nose—width, height, bump
The tip of the nose and how the cartilage is shaping the tip
The base of the nose, how wide it is, and how much projection the tip has

It can be performed in one of three ways:

Open Rhinoplasty: Due to the presence of an incision resulting in a scar, this method is not preferred by patients
Closed Rhinoplasty: It has many benefits over open rhinoplasties, like reduced post-operative edema, reduced scarring, and an overall reduction in recovery time. This method also involves fewer risks of iatrogenic damage to the nose during surgery.
Ultrasonic Rhinoplasty: It is performed using piezoelectric instruments like those used in dental practices. This method only recently gained popularity in the US. , Dr. Laurence Berkowitz, was the first doctor to use this high-speed modality in the US

Dr. Berkowitz tried to use this modality in the US in 2010, however, it wasn’t available for cosmetic surgery purposes. It wasn’t until 2015 that the technology was available in the US, thanks to the medical equipment company Synthes.

Speaking of ultrasonic rhinoplasty, Dr. Berkpwitz said. ‘This new technology will finally move rhinoplasty techniques into the 21st century. It gives surgeons more control and precision, patients more predictable results, dramatically decreased bruising and pain, and rapid recovery. We can routinely return our patients to work or school within one week.’

Furthermore, doctors now do not use historical surgical techniques that focused on removing tissue for size reduction and adding implants accordingly. Instead, they use techniques called structural rhinoplasty, in which the rearrangement of structures rather than removal or addition takes place. This is extremely useful because historical techniques often resulted in excess tissue becoming fibrotic and scar tissue. This scar tissue would obstruct nasal passages and cause difficulty breathing and the saddle-shaped nose is often associated with rhinoplasties.

According to Dr. Jason Roostaeian, UCLA Associate Professor of Plastic Surgery, ‘The biggest difference between historical surgical technique and modern rhinoplasty technique is the shift from a reductive to a structural approach. With structural rhinoplasty, we utilize what’s already there – the nasal bones and internal cartilaginous framework – but rearrange and sculpt it so that we end up with a more stable and predictable result that stands the test of time.”
Recently, there has also been an increase in the use of cartilage grafts that provide structural tip support and help with the straightening of the nose. The spreader graft is the most important graft used in rhinoplasties as it helps straighten the lower third of the nose.

Post-surgical edema can cause breathing difficulties and this aspect of a nose job has been discouraging many from getting a nose job. However, Dr. Dutton from Chicago found the solution to this problem by performing minimally invasive rhinoplasty and 3-D imaging. 3D imaging has been used by surgeons for a long time to help patients visualize the changes that will be visible after the surgery, and before the surgery. In minimally invasive rhinoplasty, Dr. Dutton uses several tools and makes multiple incisions inside the nose for better visualization and alteration of the nose. According to him, the patients can breathe through their nose immediately after they wake up in the recovery room. Furthermore, he claims that minimally invasive rhinoplasty can reduce the post-surgery recovery time, and the post-surgery edema greatly. Also, there are no external incisions, making this method very popular among patients.

As mentioned above, the shape of a person’s nose plays a big role in their self-image and self-esteem. This is why rhinoplasties still remain the most performed plastic surgery with 207,284 of those performed in 2019 alone. However, nose jobs are not always related to positive results. Sometimes, a botched nose job can negatively affect the individuals’ psyche (depression) more than the original nose structure that they were unhappy with.

What causes a botched nose job?

There are many reasons for a botched nose job, the main reason being the fact that rhinoplasty is a very difficult and complicated process. A surgeon needs to be highly qualified and skilled for the surgery to produce positive results. Furthermore, intricate nasal anatomy can pose another problem. Anatomy of the nose can be a problem even for the most skilled surgeon.

Some of the most common reasons for a ‘botched’ nose job include:

Poor pre-operation planning
Lack of precision in placing incisions
Excessive extraction of cartilage and bone from the bridge of the nose
Damage to nasal tip cartilage
Excessive extraction of septal cartilage
Unnecessary or poor use of skin grafts

According to Dr. Andres Bustillo, a plastic surgeon from Miami, ‘A failed rhinoplasty can be one of the most devastating experiences a patient undergoing plastic surgery can have. Correction of a botched nose job is even more difficult than the initial rhinoplasty. There is scar tissue, deformities from the first surgery, and an overall ruined framework which complicates the entire process of revision rhinoplasty difficult. Furthermore, the recovery time of revision rhinoplasty is greater than the first rhinoplasty.

References

Daniel, Rollin K. “The Preservation Rhinoplasty: A New Rhinoplasty Revolution.” Aesthetic surgery journal vol. 38,2 (2018): 228-229.

Hopping SB, White JB (2009). “Ethnic Rhinoplasty: a Universal Preoperative Classification System for the Nasal Tip”. The American Journal of Cosmetic Surgery. 26 (1): 35–39.

Daniel, Rollin K.; Pálházi, Péter (2018). Rhinoplasty: An Anatomical and Clinical Atlas. Springer. p. 138.

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