How is a rhinoplasty done?

Rhinoplasty surgery can be performed from 2 approaches. The external approach uses an incision along the undersurface of the nasal columella (between the nasal openings). This will lead to a small scar that usually goes unnoticeable. The internal approach is performed inside the nose with no nasal external incision. In general, there is less swelling when the internal approach is performed as there is less dissection of cartilage from the underlying tissue.

In a rhinoplasty, typical steps include rasping down the bony hump, shaving the cartilaginous hump, sculpting the tip cartilage, and making cuts in the bones and pushing them inward. Cuts can be made from inside or outside of the nose. Some noses require removal of fat from the tip, and some require removal of skin from the nostrils. Various steps may be performed to improve the breathing, such as operating on the septum between the nostrils or the turbinates (the air baffles of the nose).

With hundreds of possible steps, rhinoplasty is the most individualized operation in plastic surgery. No two noses are alike, and no two will need exactly the same procedure. The rhinoplasty demands creativity, since the actual structures of the nose often turn out to be different than expected. The plastic surgeon has no x-ray to give him a look at the cartilage prior to surgery, so he must be able to think on his feet. Surprises such as cracked or buckled cartilage and scar tissue make this operation challenging to even the most experienced surgeon.

The way a rhinoplasty is done depends on the problems the person sees with the nose. There are many things that have to be looked at before the surgery. Generally, the areas focused on are:

• 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 

The other difficult thing is how to project what the nose will look like after surgery. There are specialized computer programs that can help predict that but it’s just an estimate. The best predictor is having the surgery done by a plastic surgeon who has done a large number of rhinoplasties. The surgeon will be better able to predict the outcome based on his or her experience.

There are a number of things that must be considered when creating your rhinoplasty experience. Rhinoplasty can be performed in a number of different ways. The surgery can be done using general or twilight anesthesia. It can also be done using an "open" approach (with a small external incision) or a "closed" approach (no external incision). "Non-surgical" office-based rhinoplasty can also be done in certain cases.

Rhinoplasty surgery is generally performed as an outpatient procedure and, surprisingly, most patients don't have a lot of pain after surgery -- it's really more of a "congested" feeling. What needs to be done during rhinoplasty surgery depends on the patient's concerns, the deformities involved, and what can be accomplished from the surgeon's perspective. The best way to figure out what your specific surgery will involve is to have a consultation with a rhinoplasty surgeon and develop a plan that is right for you.