Rhinoplasty

Rhinoplasty

[rahy-nuh-plas-tee]

Rhinoplasty (Rhinos, "Nose" + Plassein, "to shape") is a surgical procedure which is usually performed by either an Otolaryngologist, Maxillofacial Surgeon, or Plastic Surgeon in order to improve the function (reconstructive surgery) and/or the appearance (cosmetic surgery) of a person's nose. Rhinoplasty is also commonly called a "nose reshaping" or "nose job". Rhinoplasty can be performed to meet aesthetic goals or for reconstructive purposes to correct trauma, birth defects or breathing problems. It can be combined with other surgical procedures such as chin augmentation to enhance the aesthetic results.

History

Rhinoplasty was first developed by Sushruta, an important physician (often regarded as the "father of plastic surgery") who lived in ancient India circa 500 BC, which he first described in his text Sushruta Samhita. He and his later students and disciples used rhinoplasty to reconstruct noses that were amputated as a punishment for crimes. The techniques of forehead flap rhinoplasty he developed are practiced almost unchanged to this day. This knowledge of plastic surgery existed in India up to the late 18th century as can be seen from the reports published in Gentleman's Magazine (October 1794).

The first intranasal rhinoplasty in the West was performed by John Orlando Roe in 1887. It was later used for cosmetic purposes by Jacques Joseph (b. Jakob Lewin Joseph) in 1898 to help those who felt that the shape or size of their nose caused them embarrassment and social discomfort. His first rhinoplasty patient was a young man whose large nose caused him such embarrassment that he felt unable to appear in public. He approached Joseph because he had heard of a previous successful otoplasty, or "ear reshaping," which the surgeon had performed.

How rhinoplasty is performed

It can be performed under a general anesthetic or with local anesthetic. Incisions are made inside the nostrils (closed rhinoplasty). Sometimes, a tiny, inconspicuous incision is also made across the columella, the bit of skin that separates the nostrils (open rhinoplasty). The surgeon first separates soft tissues of the nose from the underlying structures, then reshapes the cartilage and bone. Most people remain at home for a week. If there are external sutures, they are usually removed 4 to 5 days after surgery. The external cast is removed at one week. If there are internal stents, they are usually removed at one to two weeks. The periorbital bruising usually lasts two weeks. Due to wound healing, there are minor and subtle shifting and settling of the nose over the first year.

In some cases, the surgeon may shape a small piece of the patient's own cartilage or bone to strengthen or change the structure of the nose. Usually the cartilage is harvested from the septum although if there isn't enough which can often occur in revision rhinoplasty, cartilage can be taken from the concha of the ear or rarely the ribs. In the rare case, again usually revision rhinoplasty, where bone is required, it is harvested from the cranium or ribs. Sometimes a synthetic implant may be used to reconstruct the nose. This is most common when augmenting the bridge of Asian noses.

To improve nasal breathing function, a septoplasty may also be performed. If there is turbinate hypertrophy, an inferior turbinectomy can be done.

There are several complications that can arise in rhinoplasty, although it is usually considered to be safe and successful. Post operative bleeding is uncommon and often resolves without needing treatment. Infection is rare and can occasionally progress to an abscess that requires surgical drainage under general anesthetic. Adhesions, which are scars that form to bridge across the nasal cavity from the septum to the turbinates, are also rare but cause nasal obstruction to breathing and usually need to be cut away. A hole can be inadvertently made at the time of surgery in the septum, called a septal perforation. This can cause chronic nose bleeding, crusting, difficult breathing and whistling with breathing.

If too much of the underlying structure of the nose (cartilage and/or bone) is removed, this can cause the overlying nasal skin to have little shape resulting in a 'polly beak' deformity. Likewise if the septum is not supported, the bridge of the nose can sink resulting in a "saddle nose" deformity. The tip of the nose can be over-rotated causing the nostrils to be too visible and creating a "Miss piggy" look. If the cartilages of the tip of the nose are over-resected, this can cause a pinched look to the tip. If an incision is made across the collumella (open approach rhinoplasty) there can be variable degree of numbness to the nose that may take months to resolve.

The cost of rhinoplasty varies regionally and between surgeons. If it is for functional reasons, like breathing correction, it can be covered by many health plans. For example in 2006 in Ontario, Canada the provincial health insurance carrier paid $480, while the cost for cosmetic rhinoplasty varied between $1000 and $10,000.

In the entertainment industry

The Los Angeles Examiner of May 5, 1930, stated that:

"Having one's nose shaped to fit the talkies is the most popular thing in Hollywood now. Hollywood plastic surgeons agree that more than 2000 facial beautification operations have been performed among film players within the past few years."

Siblings Michael, Janet and La Toya Jackson's are among the most prominent rhinoplasties in show business with a dramatic reduction of nose size and change of shape. Like many starlets, a young Marilyn Monroe had work carried out on her nose before her first film roles at the advice of her mentor Johnny Hyde. Jennifer Grey is another famous movie star whose looks transformed completely after a nose job, which actually damaged her career. Japanese pop star Ayumi Hamasaki had a nose job sometime of A Song for XX and Loveppears.

It should be noted that there is some controversy as to whether Monroe ever had a rhinoplasty. Her friend and biograher James Haspiel has stated "Monroe never had a nose job" , although according to him she did have some modifications made to her chin. If this is true then the differences in size that have been observed in various pictures may be explained by the length of the lens used by the photographer.

Ethnic rhinoplasty

Although techniques and methods employed during rhinoplasty surgeries are the same regardless of race, there are some trends that apply to patients of certain ethnic backgrounds.

East Asian patients often want their noses to appear narrower. This can be done through the use of infractures, where the nasal bones are broken and moved in or reset to thin out the nasal area and add projection in the process. Outfractures, where the nasal bones are broken and moved outwards, are used to widen a too-narrow dorsum. East Asian patients typically seek augmentation (adding material) of the bridge of their nose which will make the nose appear narrower as well. In Asia, patients typically use a variety of alloplastic implants including Gore-Tex, Med-Por, or silicone. Due to the risks of alloplastic materials, natural materials to the bridge of the nose, such as rib cartilage (costal cartilage) or ear cartilage (auricular cartilage) are being used more commonly.

Patients of African descent commonly seek narrowing of wide nostrils. This procedure may include removing sections of the base of the nostrils or sections of the nose where it meets the face. The tip of the nose can be restructured by removing tiny sections of cartilage to give the nose more shape, or even adding cartilage to provide additional structure to the nasal tip.

Revision rhinoplasty

Revision rhinoplasty is a nose operation carried out to correct or revise an unsatisfactory outcome from a previous rhinoplasty. It is also known as secondary rhinoplasty. Occasionally there can be a third or even more surgeries. An unsatisfactory outcome occurs from 5 to 20% of rhinoplasties. There are two main reasons for performing secondary rhinoplasty. The first is purely cosmetic. A patient may be unsatisfied with all or part of a previous "nose reshaping”. A nasal fracture may not have been reduced enough, or too much. A prominent or bulbous nasal tip may have not been addressed appropriately, or over-aggressively. The nose may looked pinched, it may look like a parrot’s beak, or like a boxer’s nose. There are many ways in which previous nose surgery may have left a nose aesthetically unappealing to a patient. The second reason is functional. The original nasal surgery may have been carried out to help with difficulties in breathing, and the outcome may have been unsatisfactory. Alternatively, the original surgery may have been performed for cosmetic reasons, but may have disrupted a normal physiologic mechanism involving the inspiration or expiration of air, making it difficult to breathe. Secondary rhinoplasty, and especially tertiary rhinoplasty, are extremely complicated procedures. This is self-evident because it is clear that even when the patient was operated upon for the first time, even when the tissues were “virginal,” and untouched the desired result could not be obtained.

Non-surgical rhinoplasty

Non-surgical rhinoplasty refers to a procedure in which fillers are used to alter and shape a person's nose without invasive surgery. This procedure has been performed by doctors since 2003. By filling in depressed areas, lifting the angle of the tip or smoothing the appearance of bumps on the bridge of the nose, it can create a symmetrical nose that goes in harmony with the rest of a person's face, creating a better balance, and give the appearance of a smaller nose.

Although the procedure is usually performed for aesthetic purposes, it can also be used to correct some birth defects. Because the procedure is not invasive, the bruising and swelling are minimal. Duration of results depends on the type of filler used. Radiesse (calcium hydroxyapatite) lasts for 8 to 12 months and this is the filler that is ideal. Hyaluronic acid fillers usually last for 5-6 months. Artefill, a permanent filler was recently approved by the FDA.

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