Surgery to reshape the nose (augmentation rhinoplasty) is a very common plastic surgery procedure and it can both increase and decrease the size of the nose. The size of the tip, the bridge and the nostrils can also be changed as can the angle between the nose and the upper lip. Sometimes breathing difficulties can be corrected at the same time. The nose is the central feature of the face, many people are self-conscious of shape, which they may regard as too big, too small or have some other feature, which they dislike. The characteristics of the nose are inherited from parents and develop during adolescent years. They continue until the age of 16, when the nose stops growing. It is therefore, unwise to operate before this age. Injury to the nose is a common cause of flatness. Occasionally, it is a characteristic, which is inherited. This can also develop after surgery to the interior framework of the nose (septoplasty to improve the breathing). The owner of a flat nose may acquire the reputation of the profession of a fighter as opposed to a sports person, which may have an adverse effect to self-esteem.
What can be done?
To improve the appearance of a flattened nose it is necessary to introduce some additional framework underneath the skin to raise and straighten the bridge line. The operation is called Augmentation Rhinoplasty. Various materials are used for the additional framework such as bone; cartilage (gristle) and a range of artificial materials. Each has its advantages and disadvantages which are too complex to discuss on this page. The additional framework is usually introduced into the nose through a cut either inside the nostrils or in the strut of skin between the nostrils(The Columella). If a bone graft is used for the additional frame it is either taken from the crest of the hip, from a rib, from the back of the elbow or from the outer surface of the skull without causing any weakness to the ‘donor’ bone. If cartilage is used, it is usually taken from the shell of one or both ears or from cartilage inside the nose, which is spare. When the nose has been flattened by injury, it is quite common for the plate of bone, (The Septum) which separated the two halves of the nose to be buckled as well. This makes breathing difficult. It can often be corrected at the same time as an augmentation rhinoplasty by straightening the buckle out but sometimes it is advisable to have this done as a separate operation beforehand. In cases of severe collapse of the nose, skin grafts may also be necessary to achieve a satisfactory reconstruction. This is highly complex plastic surgery and outside the scope of this factsheet.
What are the consequences?
You can expect to have bruising and swelling of your face, particularly around the eyes, which will take up to 3 weeks to settle and during part of this time your nose is likely to be covered by a firm splint. Once the initial swelling has settled, you will find that your nose feels rather stiff and numb. The numbness will disappear slowly during the next few months but the stiffness is likely to be permanent. If it has been necessary to take a bone graft from another part of the body, you will be left with a scar, which may be noticeable, if it is on your hip or chest.
What are the limitations?
Although it is usually possible to make a substantial improvement to the appearance of the nose with the operation, the new frame may feel unnaturally hard. This is because it does not have the consistency and flexibility of the natural frame of the nose. You may also find that the additional frame can be moved about under the skin if it does not become fixed to the existing bony framework of your nose. These limitations need not worry you provided you bear in mind that the operation is done for the sake of your appearance. Particularly if a bone graft has been used, there is a tendency for it to gradually shrink in size during the first year or two after the operation. To help compensate for this, your surgeon is likely to put in more graft than you actually need so that to start with your nose may look over-bulky. There may be technical limitations to the perfection of appearance that can be achieved. For example, perfect symmetry may not be possible and it may not be possible to make the nose as large as might be desired. An experienced surgeon will be able to advise you what is possible in your own case.
What are the risks?
Like any operation that is carried out under a general anaesthetic, there is a small risk of chest infection, particularly among people who smoke. Very occasionally the operation can be complicated by heavy nose bleeding either shortly afterwards or, after a week to 10 days which may require treatment in hospital. There is a small risk that infection could adversely affect the success of the operation. Were it to happen, it may be necessary to remove the implant or graft of bone or cartilage. In either event, it should be possible for you to have a further reconstuctive operation once the infection has cleared. Rarely, artificial implants can extrude through the skin of the nose or its lining and need to be removed. This can happen months or years later, and is more likely if a large implant has been used or if the nose is accidentally injured.
Altogether, you can think in terms of there being about a 10% risk that you may need further surgical treatment for one or more of these complications were you to have this operation done.
What you can expect at the time of your operation?
If you need only a small implant, it may be possible to do the operation without a general anaesthetic, in which case you would have injections of local anaesthetic into your nose to make it numb and you would not need to stay in hospital. For larger reconstruction’s and if a bone graft from the hip or chest is needed, you would probably need a general anaesthetic and, maybe up to a week in hospital. After the operation you will probably have dressings in your nostrils for a day or so which will prevent you from breathing through your nose. You will also have a firm splint over your nose for the first week or two. There should be very little pain in your nose but, if you have had a bone graft taken from your hip, you can expect this to be quite painful for about 10 days, particularly when you walk. You will be given appropriate painkillers to help with this.
What should you do when you go home?
You can expect to have some minor bleeding from your nose for the first day or two and you can gently dab this away with a gauze swab or clean handkerchief. Unless you are advised otherwise, it is best for you to leave any crusts in your nostrils for the first week and then gently cleanse them away with cotton buds. You should keep your head up as much as possible and avoid hot baths. Do not blow your nose and try your best not to sneeze through your nose. If you are going to sneeze, cough it out. It is safe to clear your nose by sniffing into the back of your throat. Stitches inside your nose will be of the absorbable type and do not need to be removed. If your stitches are outside your nose, your surgeon will advise you on their care and the time for their removal. You will also have a firm splint over your nose in order to protect the new frame and keep it stable whilst it is settling in. Once the splint has been removed, this protection is gone and you will have to be very careful in the way that you handle your nose for the first six weeks. You should avoid any activities where you might knock your nose and you should not move it from side to side between your finger and thumb. Try your best to sleep on your back. How long you will need off work will depend on the extent of your operation. The initial swelling and bruising will probably have disappeared within the first two weeks sufficiently for you to feel confident to show your face in public again. However, it will take at least three months for the reconstructed shape of your nose to mature and maybe a lot longer if you have had a lot done. Do not be too critical of your nose too early. Minor unevenness of contour is common during the first few months and usually settles with time.
You should by now understand that this is a delicate and complex operation, which needs to be designed for the needs of the individual patient. You should only consider augmentation rhinoplasty for yourself if you are genuinely self-conscious of the nose you have at present. Do not think of having augmentation rhinoplastyt done either for someone else’s sake or if it is just a whim. If you do decide to go ahead, only go to a surgeon who is properly trained, and be guided by his or her advice as to what is possible in your own case.
Professor Simon Kay, Consultant Plastic Surgeon