The structure of the nose and the logic of the operation
The nose is made up of a bony vault at the top, the upper lateral cartilages in the middle and, below them, the lower lateral cartilages that form the nasal tip. The septum, which runs through the middle of this framework, both separates the two airways and forms the main support that carries the nasal tip. In rhinoplasty these structures are reduced, reshaped or supported with cartilage grafts. This is why aesthetics and function cannot be separated: removing a hump or making the nose smaller can narrow the airway if appropriate supports are not added. The current approach is “structural rhinoplasty”, which preserves or rebuilds structural support while improving appearance.
Preparing for surgery
At the examination the inside of the nose is assessed endoscopically; septal deviation, turbinate enlargement and narrowing of the nasal valve are noted. In patients with breathing complaints, the severity of the complaint is recorded using standard questionnaires such as NOSE; this makes it possible to show improvement after surgery objectively. Photographs are taken from standard angles and a digital simulation may be done; the simulation is not a target but a communication tool that helps the patient and the surgeon speak the same language.
Cigarettes and nicotine-containing products impair tissue healing and can cause problems with the blood supply of the skin; stopping them in the period around the operation is recommended, and how long before to stop is planned according to the instructions of your surgeon and the anaesthesia team. Do not stop medicines that can affect bleeding risk, such as aspirin and ibuprofen, or vitamin E, fish oil and herbal supplements, on your own; plan this before surgery together with your surgeon and, where necessary, with the doctor who manages the medicine and the anaesthesia team. Medicines taken regularly for chronic conditions are continued with the knowledge of the surgeon and the anaesthesia team. The day before surgery, blood tests, an ECG and a chest X-ray are done and the anaesthesia assessment is completed.
Surgical techniques
Closed (endonasal) rhinoplasty: All incisions stay inside the nostrils. There is no external scar, there is less swelling and recovery is somewhat faster. It is suitable for hump removal, narrowing of the nasal bones and limited tip work.
Open rhinoplasty: A small incision of a few millimetres is added across the columella, which separates the nostrils, the nasal skin is lifted and the whole framework is seen directly. It is preferred for marked deviations, complex tip reshaping, cases requiring grafts and revisions. The columellar scar usually becomes almost invisible within 6–12 months.
Preservation rhinoplasty: Rather than removing the dorsal hump piece by piece, this approach preserves the natural structure of the nasal dorsum and lowers it by reducing the bone and cartilage beneath it. In suitable noses it gives a more natural dorsal line and a lower risk of irregularities; however, not every nose is suitable for this technique.
Piezo (ultrasonic) surgery: Instead of a classic osteotome, tips that work with ultrasonic vibration are used to shape the bone; because it does not damage soft tissue, bruising and swelling may be less.
Accompanying procedures: Septoplasty (correction of a deviated septum), turbinate reduction (radiofrequency or partial resection) and cartilage grafts that open the nasal valve are performed in the same session to widen the airway.
The day of surgery
The operation is performed under general anaesthesia and takes 2–3 hours. The silicone packs placed inside the nose have channels that allow breathing and are usually removed within 2–5 days; in many patients no packing is used at all. A thermoplastic splint is placed on the nasal dorsum. Patients spend the night of the operation in hospital and are discharged the next day.
Recovery — week by week
First week: Bruising and swelling around the eyes, nasal congestion and slight oozing are normal. Keeping the head elevated, cold compresses and the prescribed painkillers are sufficient; pain is usually milder than expected. Do not blow your nose, and sneeze with your mouth open. Light walking is fine from the first day. On days 5–7 the splint is removed; absorbable stitches are generally used, and any stitch that needs removing is taken out at your check-up.
Weeks 2–4: The bruising disappears and most of the swelling goes down; patients return to social life and desk work. When glasses that press directly on the nasal bones can be worn depends on whether osteotomies were performed, on bone healing and on the surgical technique; unless your surgeon gives a different period, such glasses should not be worn for 8 months, and if needed they can be worn taped to the forehead during this time. Cleaning the inside of the nose with saline sprays continues. From week 3, cardio exercise such as brisk walking or light jogging can begin, and you can swim in the sea.
Months 1–3: The pool is allowed after 2 months and weight training after the 3rd month, while sports with a risk of nasal trauma are resumed with your surgeon’s approval — individual surgical instructions take priority. The nasal tip may still feel slightly swollen and firm; swelling is more noticeable in the mornings. Sun protection and a high-factor sunscreen are recommended.
Months 6–12: The last swelling at the nasal tip slowly resolves and the fine details become clearer. The final result is assessed at the first year, and up to 18 months in people with thick skin. Follow-up visits are planned at 1 week, 2 weeks and 1 month; the timing of the next visit is decided at the 1-month check-up.
Possible problems
Bleeding, infection and anaesthesia-related problems are rare. A temporary reduction in skin sensation, numbness of the nasal tip that can last for months and a temporary change in the sense of smell may occur. In the long term, revision surgery may come up in about 5–15 per cent of patients because of small irregularities, slight asymmetry, narrowing of the airway or expectations not being fully met. Revision is usually planned at the earliest 12 months later so that the tissues can settle, and it often requires grafts taken from rib or ear cartilage.
Frequently asked questions
Is the operation painful? The great majority of patients describe the pain as mild to moderate; simple painkillers are sufficient in the first days. The main discomfort comes from nasal congestion.
When can I fly? Flying is possible once the splints have been removed, usually one week after surgery.
Will the nasal tip drop later? During surgery the nasal tip is positioned taking into account that it will come down somewhat as the swelling subsides; this is an expected process. Permanent supports keep this change under control.
Can it be corrected with Botox or fillers? A small hump or mild irregularities can be temporarily camouflaged with filler; however, the nose cannot be made smaller and the airway cannot be corrected. Filler may make a later rhinoplasty more difficult.
Will the result look natural? A natural look is achieved through proportions that are in harmony with the rest of the face and preserved structural support. The aim is not a nose that “looks operated on”, but one that looks as if it belongs to the person’s own face.
For the summary:
Back to the short article- Ishii LE, et al. Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty. Otolaryngol Head Neck Surg 2017. PubMed
This article is for general information; please consult your physician for diagnosis and treatment.