Rhinoplasty

Rhinoplasty simply means “moulding the nose”. It is a procedure which is mainly surgical in nature and is used with different intentions. Rhinoplasty is often referred to as “nose job” in layman’s terms.

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Rhinoplasty

Functional vs Cosmetic rhinoplasty: Function and form go hand-in-hand in rhinoplasty and as a result the changes to the nasal shape could result in changes in the functional aspects and vice versa.

Cosmetic rhinoplasty: This procedure is mainly aimed at changing the shape of the nose. The general perception of the term “rhinoplasty” is the cosmetic aspect of this procedure.

Functional rhinoplasty: This procedure is aimed at improving the nasal breathing problems. It is often perceived that “rhinoplasty” equals “cosmetic nasal surgery” but modern rhinoplasty is used to improve the nasal airway as well as correcting the nasal blockage (or at least using modern techniques so that nasal blockage is not created as a result of the cosmetic changes).

Closed vs Open rhinoplasty: This refers to the method of approach to the nasal structure.

Close rhinoplasty: In this technique, the approach is through the nostrils and there are no cuts on the skin.

Open rhinoplasty: In this technique, a small incision is made at the bottom of the nose to be able to open up the nose to have better access to the internal elements.

Surgical vs medical rhinoplasty: The term rhinoplasty refers to the surgical procedures involving the nasal skeleton however nasal shape can be changed in certain circumstances by non-surgical methods.

Medical rhinoplasty: This term refers to the use of fillers and botulinum toxin in reshaping the nose. The indication is purely for cosmetic reasons and this method cannot correct functional problems. Medical rhinoplasty can be used for limited areas to change the shape and it cannot be used to make the nose physically smaller (however it can bring temporary balance to the nose).

Surgical rhinoplasty: This term is what is commonly understood by the term rhinoplasty. The information provided on this page refers to the surgical rhinoplasty.

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Surgical procedures in Rhinoplasty

Rhinoplasty is mainly a surgical procedure which addresses the nasal skeleton with the aim of improving the nasal shape and nasal breathing.

Rhinoplasty is described in variety of names depending on the nasal area being operated on:

Rhinoplasty: it is a general term for addressing the nasal skeleton but it can refer to the outer nasal skeleton excluding the nasal septum. The surgery can be performed through the nostrils (closed rhinoplasty or internal rhinoplasty) or by opening by the nose (open rhinoplasty or external rhinoplasty).

Septorhinoplasty: It is all aspect of rhinoplasty but the nasal septum is addressed too. It often refers to the septal surgery as part of the operation. Septorhinoplasty is used in primarily functional problems due to septal deformity where the septal deformity cannot be easily addressed through traditional septoplasty (ie nasal septum surgery). In very complex cases of septal deformity, the open approach septorhinoplasty is used to be able to remove the crooked septum and reconstruct it and then re-insert it in the nose; this is known as “extracorporeal septoplasty”.

Tip rhinoplasty: It addresses the cartilages in the nasal tip area.

Alar base rhinoplasty/nostril surgery: It addresses the shape and width of the nostrils. This procedure often requires incisions on the outer nasal skin which can be hidden in the creases around the nasal base.

Reduction rhinoplasty: The aim is to make the nose smaller

Augmentation rhinoplasty: The aim is to make the nose or parts of the nose larger.

Revision rhinoplasty: It is when the nose has been operated on before. It is often much more difficult to perform as the planes of surgery are scarred up after the previous rhinoplasty. The rate of revision surgery worldwide is something around 7-10%. There is no doubt that the rate is affected by the surgeon’s factors (ie skills etc) and the patient’s factors (ie how they heal etc). The revision rate refers to the cases that ended up having a revision surgery. It goes without saying that a higher percentage of patients must have unsatisfactory results which might have needed surgery but either the surgeon or the patient was not happy to go through another surgery. Generally, it is difficult to achieve a perfect nose. It is important to have realistic expectations. If you are happy with improvement rather than perfection then you are in a good starting position.

Nasal valve surgery: This entails certain techniques and procedures that are mainly used during modern rhinoplasty to improve the nasal airway.

Turbinate surgery: Turbinates are the structures on the outer nasal wall responsible for humidification and warming up the air we breathe in. Often these structures narrow the nasal airway and they need to be treated at the same of time of performing rhinoplasty.

 

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Rhinoplasty complications

No surgery is without complications. The more complex the surgery, the more chance of complications occurring. However, it does not necessarily means that you will have a complication after rhinoplasty.

The following are the side effects and the complications that you may experience after septorhinoplasty:

Nasal blockage due to surgery which lasts a few weeks. If the turbinates have been operated on, the tissue will fall off after 2-3 weeks; until then the nose is fully blocked.

Minor nasal bleeding/oozing and discharge which lasts a few weeks. Risk of significant bleeding is not high but it can happen up to 3 weeks after the operation; if this happens you need to attend the A&E department close to where you live.

After the operation, minor asymmetry and irregularity may be present. These can be seen or even felt on some cases. This can be noticed especially when the nasal bone are broken and readjusted. Whether to perform revision surgery for irregularities and asymmetries is judged based on individual cases and with taking risks and benefits into account.

Unsatisfactory aesthetic outcomes. Generally aim for improvement. Perfection is difficult to achieve.

Persistence or deterioration of the nasal blockage. Sometimes the nasal blockage is not improved; some of this can be due to late changes in the nasal cartilages especially the septal cartilage where it can warp and change shape months after surgery.

You might notice numbness to the tip of nose (especially if the nasal skin has been opened up; ie open rhinoplasty). This can take up to 18 months to settle down.

In rare cases you may notice subtle skin colour changes to at the nasal tip. In most cases, this will improve with time but in some cases the colour changes do not settle down.

You might notice numbness and tenderness at centre of the upper lip or at the upper incisor teeth. These can take up to 12-18 months to settle down. Vary rarely, this can be associated with discolouration of the middle upper teeth which is not reversible.

There is a risk of septal perforation (a hole in the middle partition of the nose). This is not common but it is not rare either. The chance is more if you have had previous septal surgery or you have a badly fractured nasal septum. If this occurs and you are troubled by it, then further surgery/treatment can be considered.

Certain aspect of the healing process, including appearance of the scar, is to some degree out of surgeon’s control and it very much depends on your skin type and how you heal.

The majority of the nasal swelling will settle after 3 weeks. Further swelling will take 6-12 months to settle.

After the operation your nose will feel different to touch; this will settle with time. You might notice a different feel to your breathing, this is usually due to good flow of the air through your nose; you will generally get used to it within a few months.

You might develop some bruising around the nose and eyelids. This might be different between right and left side. It is usually worse when nasal bone has to be broken but it can even be seen when no bony work has been done. Very rarely the skin discolouration will not fade fully; this is more relevant if you have a very thin and pale skin type.

Like any other operation, there is always a risk of postoperative infection. You will be discharged with a course of antibiotics but despite this you might still develop an infection. If this is severe, you might require admission to the hospital for intravenous antibiotics (ie through the veins rather than taking tablets). In cases of severe infection, the nasal septum can get badly damaged and as a result it might collapse leading to significant nasal deformity.

Some patients notice they develop runny nose after rhinoplasty. You may require nasal sprays to address this if it does not settle spontanously in due course.

If the results are such that the patient and surgeon both are unhappy and a revision surgery is considered, this will be offered after 12 months. This time is to allow the tissue to heal fully.

 

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What to do before rhinoplasty

If you are on blood thinning tablets (eg Aspirin, Warfarin, Clopidogrel), inform the surgeon. If it is decided to proceed with surgery you need to be advised on these medications (ie when and how to stop them prior to the operation).

Do not take any vitamins (especially Vitamin E) four weeks prior to operation.

Do not take herbal remedies like Ginkgo biloba, Ginseng and Garlic four weeks prior to operation.

Do not have Curry two weeks before the operation.

Inform the surgeon of any head cold or other infections within two weeks prior to the operation. The operation will be cancelled if you have a nasal infection close to the time of operation.

Have a replacement plan if you wear glasses. You will not be able to wear your glasses for a few weeks after the operation.

Do not use any facial cream 2-3 weeks prior to the operation.

Take a shower before the operation and wash your hair.

Do not wear any make up on the day of operation.

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What to do after rhinoplasty

 

You need to rest for the first few days. Avoid strenuous activity for the first 3-4 weeks.

Be gentle with your nose; it takes on average 6 weeks to be relatively stable.

Make sure to dab to clear the nasal discharge. Do not rub your nose; you are likely to dislodge the sutures or move your nose.

If there is excessive active bleeding and it is not stopping spontaneously, you need to attend the A&E department close to you. Do not attend the private hospital as there is no emergency service available.

After the operation, you will need to take oral antibiotics (tablets) and insert antibiotic cream inside the nose for a week or two. Insert the nozzle of the cream into each nostril and squirt a small amount into the nose; sniff it up gently if possible. Do not rub your nose and do not insert the cream with your finger or any other applicator.

You will be given a course of nasal salt-water rinse after surgery too. Use a salt-water rinse system such as Sterimar spray so that you can apply the salt-water without pressing on your nose.

Do not blow your nose in the first week after the operation. After removal of the internal splints, you need to continue rinsing your nose. If you have to blow your nose then do so gently. If the tissues are ready to be dislodged, they will do so with gentle blowing. When blowing your nose, hold your nose gently with both hands; do not push your nose to one side when blowing.

If you sneeze, try and sneeze through your mouth. This would exert less pressure and reduces the chance of bleeding or dislodging the splints.

It helps if you sleep with the head elevated for the first 2 weeks. Be careful not to sleep on your side for the first few weeks as the weight of the head and pressure exerted by the pillow can move the nose.

Avoid wearing your glasses in the first 2-3 weeks. You can wear them as normal after 6 weeks. In between these dates, wear them sparingly as and when needed.

You will have a plaster on your nose which is there to protect your nose during the initial phases of healing. This will be removed 1-2 weeks after the operation.

You can wash your hair after the operation but be careful not to get the cast and the tapes wet.

After the surgery you will have plastic sheets inside the nose so that tissues do not get stuck to one another. These will make your nose feel even more blocked. These will be removed 1-2 weeks after the operation.

After removal of the internal plastic splints, you need to perform nasal douching (rinsing the inside of the nose with salt water) for a couple of months to prevent adhesion and to help clearing the debris. You can buy over the counter nasal douching devices such as Sterimar (salt-water spray).

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Rhinoplasty Journey

 

The initial consultation

The initial consultation is the opportunity for both the surgeon and the patient to get to know each other. Use this session to tell the surgeon what you want to achieve.

Consider the following in the initial consultation:

Establish if the surgeon is the one for you. You are looking for somebody skilled to do the operation and also caring to look after you in case things go wrong.

Have a clear aim in what you want to get out of surgery. Be detailed in what changes you want to achieve in the nasal shape. Using other peoples’ photographs is a way of relaying the message but do not expect to have their nose; each nose is unique and you will have an altered shape of your nose.

If your nose has changed shape and you are aiming to achieve the previous shape, do bring and old photograph so the surgeon can see what your nose looked like.

At the initial consultation, a full history will be taken and a thorough clinical examination will be performed. As part of examination, you may need to go through a nasal endoscopy. Nasal endoscopy carries a fee which is separate to the consultation fee.

Your photographs will be taken on the first consultation. If you are having cosmetic rhinoplasty, the photographs will be modified and shown to you at the second consultation.

The initial consultation lasts 30 minutes.

All cosmetic rhinoplasty patients are encouraged to attend the second free consultation.

There will be at least two weeks gap between the time that you decide to proceed with the operation and the operation date.

 

The second preoperative consultation

All cosmetic rhinoplasty patients are encouraged to attend the second consultation. This consultation is free of charge and it provides a chance for you to ask any questions and to see the changes that have been made on the photographs. These photographs are only there to help you visualise what you may achieve and they can help the surgeon understands your needs ; they are not a guarantee of what your nose would look like.

 

Cooling off period

There will be at least a two week gap between the time you agree to go ahead with surgery and the actual date of the surgery. This will allow you to rethink your decision. If you have any doubts, come back for further consultations. If you are not sure, it is always better not to proceed with surgery.

 

Pre-operative assessment

You will be seen by one of the nurses in the preoperative assessment clinic a few weeks before the surgery to make sure you are fit and healthy for the type of operation you are having. You should have told your surgeon any medical conditions that you may have or any medications you take (prescribed or over-the-counter). If by any chance, you forgot to tell your surgeon any of your medical history and medications, then tell the nurse at this clinic.

 

Day of the surgery

On the day of surgery, Mr Anari and the anaesthetist will visit you before the surgery to go through the procedure and the consent form. This will be your final chance to ask any questions. Ideally there should not be any major questions left unanswered at this stage.

You will get checked and admitted by the nurse and will get ready for surgery.

The time of your admission is not the time of surgery. The surgery is often taking place a few hours after your admission.

Come prepare to stay overnight but in certain situations and depending on when the procedure is performed and how you recover, then you may be discharged the same day. Those who do not live locally are encouraged to stay overnight.

 

Discharge from the hospital

Upon discharge from hospital, you will receive your post-operative course of medications which will generally include a course of antibiotic tablets and cream along with painkillers and a canister of salt-water for nasal rinsing. A follow-up date will be arranged for you to attend the clinic in 7-10 days to see Mr Anari.

 

What to expect in the recovery period

Rhinoplasty is not a painful operation but your nasal lining will swell up after the operation and your nose will be blocked as if you have a bad cold. You will have some slight ooze and bloody discharge from your nose which you will need to dab (do not rub your nose). You will need to apply the antibiotic cream and the salt-water nasal douching on a regular basis in order to help the healing process and to keep the nostril clean. Do not try to blow your nose to clear it in the first week or so, you will only make it bleed.

You may notice some bruising around the nose and eyes. These will change in colour and finally settle within a few weeks. Most of the time, the bruising is minimal to none.

Your nose from outside will also be swollen. This is only slight and will be more prominent around the nasal tip. Most of the swelling will settle after the first few weeks. Minor swelling can take several months to a year or so to settle fully.

Your nasal tip skin can feel numb to touch if your nose was opened up (ie open rhinoplasty). This will generally settle down after several months.

 

First post-operative review

At this appointment, Mr Anari will remove the stiches and the splints from the inside and the outside of the nose. Your nose is not fully set in stone at this stage so you will still need to be gentle with it and do not insert any pressure for the first few weeks. Your nasal lining will take several weeks to heal so you will need to continue with your nasal douching for several weeks.

 

Further post-operative reviews

You will be reviewed at several sessions (often a month, six months and 12 months after the operation). Any further follow-ups are dictated by the clinical need. Patients are often discharged if all is well after one year (or sooner if indicated).

 

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Frequently Asked Questions

 

Open vs Closed rhinoplasty?

There is no right or wrong approach to rhinoplasty. The choice of open or closed rhinoplasty depends on the location of the deformity, degree of deformity and the surgeon’s skills.

Each technique has its own advantages and disadvantages. The most important point is the fact that your surgeon should be able to address the area of concern through the method of his/her choice in agreement you. For example: there is no point in opening of the nose if there is only small amount of bony work involved as the morbidity of the open surgery most likely outweighs the benefits. On the other hand, a few millimetres of well-hidden scar the bottom of your nose is a reasonable compromise if the surgeon decides to open up your nose to correct a very badly deformed septum.

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Who should operate on my nose? An ENT surgeon or a Plastic surgeon?

In the United Kingdom two main specialities are involved in rhinoplasty: Ear, Nose and Throat (ENT) surgeons and the plastic surgeons; to a lesser degree and in some areas maxillofacial surgeons are becoming more and more involved in this surgery too. (Worldwide, general surgeons are the fourth group who perform rhinoplasty. Those who are involved in application of fillers and Botox may be involved in medical rhinoplasty too.)

Historically there has been a difference between the way ENT surgeons and plastic surgeons perform rhinoplasty: ENT surgeons deal with the airway and the plastic surgeons deal with the cosmesis and shape. Nose is one of the areas in the body where the form and function are closely related to one another. Ideally, someone who has been trained in both the functional and cosmetic aspects should be operating on your nose.

Therefore, ask the surgeon what training they have had. Ideally you want somebody who has been trained in a well-recognised system. In the UK, you can check that the surgeon is on the GMC specialist register by clicking on this link; this way at least you have checked that they have been through specialist training. Unfortunately, this does not guarantee anything!

Ask what kind of training they have had with the special attention to rhinoplasty. A fellowship in this area is another level of security and further reassurance for you.

Do ask how many cases and what type of cases they do and how often they do rhinoplasty.

Do not get influenced by the membership of associations. Abbreviations such as BAAPS, BAPRAS, and FPS-UK are all abbreviations which refer to the affiliation of the surgeon to those societies; they are not qualifications. They suggest that the surgeon has been through a recognised training programme and possibly works or has worked in the NHS but per se they do not endorse the surgeon's capability in performing a particular operation.

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Who is the best rhinoplasty surgeon in the UK? Who is the rhinoplasty expert in Birmingham?  Who is the top rhinoplasty surgeon in London?

Do not get influenced by the titles. Fortunately or unfortunately there is no organisation to recognise who is the best or worst in the field. You need to do your research to find who is best for you. Remember even in the best hands the results are not always favourable. You need to find a surgeon whom you can build a rapport with and you can be sure that he or she will look after you in case things go wrong!

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Reduction vs Augmentation rhinoplasty?

Modern rhinoplasty is not about making a nose smaller or larger. A well-thought rhinoplasty is about brining balance to the nasal shape and fitting it in with the rest of the nose. In modern rhinoplasty, the surgeon often uses both techniques at the same time (ie making some part of the nose smaller and making some other parts larger). The whole idea is to give balance to the nose and make sure that you can breathe through it.

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Medical vs Surgical rhinoplasty?

Medical rhinoplasty can be used to change the shape of the nose in certain areas. Fillers and botulinum toxin are used to achieve the desired result. Make sure non-permanent fillers are used; even in the best hands the injections can go wrong. Medical rhinoplasty cannot make the nose physically smaller. However it can bring the balance back to the nose by making some parts of the nose larger. Medical rhinoplasty cannot address the functional aspects’ so if you have nasal blockage, you will need a surgical rhinoplasty to address the structural problem. The effects of medical rhinoplasty last on average 12 to 18 months. Those who are not sure if they want to go ahead with a surgical rhinoplasty can benefit from a medical rhinoplasty to see the effects on a temporary basis.

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Do you use grafts in rhinoplasty?

Modern rhinoplasty is about balance and support. Grafts are often required to reconstruct the nose, give support to the nasal structure and re-shape the nose. The best graft is the cartilage taken from the patient’s nose but in certain cases (eg revision surgery) extra cartilage from the ear or rib may be required. Generally it is best to avoid implants if possible as they invariably can cause problems.

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When can I go back to work?

As a general rule, the more extensive the surgery, the more time needed for recovery. For example, if you have undergone nasal tip surgery only, you can return to normal activity within a few days whereas if you have undergone extensive open septorhinoplasty and turbinate surgery, you may require more time (sometimes up to three weeks). Generally, septal surgery and turbinate surgery result in internal nasal swelling and nasal blockage and this aspect of the surgery adds to the recovery period. For an average rhinoplasty or septorhinoplasty most people take a week or two off before they go back to work but this may vary depending on the type of operation, your personal circumstances and the type of job you do. It is generally advisable not to go back to work before your first post-operative review. Mr Anari will be able to advise you on your recovery period during the consultation.

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Is rhinoplasty painful?

Rhinoplasty is not a painful operation. You will mainly notice nasal blockage as if you have a bad cold. This will take a few weeks to fully resolve. You may have some discomfort for which you will be given appropriate pain relief.

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Will I bruise much after rhinoplasty?

Most of the bruising after rhinoplasty is because of osteotomy (ie breaking of the bones). This bruising changes colours over a few weeks and then it generally fully settles down. In very rare cases a hint of discolouration may persist. You may also get some bruising even if no bony work has been done. Mr Anari uses special techniques to reduce the amount of bruising during the operation on your nasal bones; most patients have minimal to no bruising which is mostly settled within a week.

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Will my nose be packed after rhinoplasty?

Mr Anari does not use any packs in the nose. You will have thin plastic sheets inside the nose and a splint outside your nose to keep things in place. These will be removed when you attend for your first post-operative visit.

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Where are the clinics held?

The clinics for preoperative assessment are held at Spire Parkway Hospital in Solihull, West Midlands, UK and also in Spire Little Aston Hospital in Sutton Coldfield, West Midlands. Both clinics are within easy reach of Birmingham. Patients from London often travel to Spire Parkway Hospital as they find the route and travel more straight forward. Spire Parkway Hospital is within a few miles of Birmingham International Airport and Birmingham International Train Station.

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Where is the operation taking place?

The operation takes place at Spire Parkway Hospital in Solihull, West Midlands, UK.

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Can I be discharged the same day?

Yes. If you live locally (eg in the Birmingham area) and we have done your operation at a time that you have had enough time to recover from anaesthesia then you can go home the same day. If you live more than one hour drive away (eg London) or if you need more time to recover from anaesthesia, then it is best to stay overnight and go home the next day.

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How much does rhinoplasty cost?

The price of rhinoplasty can range from £4500 to £8000.

The price of rhinoplasty varies depending on several factors:

1. Extent of the surgery: This is the main factor. A small operation to address a minor tip defromity costs less than an open approach septorhinoplasty to correct a significant deformity.

2. Primary vs Secondary surgery. If your nose has been operated on before by a different surgeon and you are going through further surgery to correct the defromity or to improve the nasal breathing, the operation will cost more due to technical challenges faced in these cases.

3. Type of anaesthesia (local vs general): Mr Anari performs most of his rhinoplasty operations under general anaesthesia. Certain minor cases can be done under local anaesthesia. Local anaesthesia will cost slightly less than the general anaesthesia but by the nature of the operation, the smaller the operation, the lower the cost.

Mr Anari will be able to advise you on the cost of your operation after he has examined you.

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