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Rhinoplasty is usually done under general anesthesia. This keeps the airway safe and the patient completely still, which is important for the precise work needed. A board-certified anesthesiologist watches the patient’s vital signs during the whole surgery.
A throat pack is often placed to prevent blood from draining down the back of the throat. Local anesthesia with epinephrine is injected into the nose to constrict blood vessels, minimizing bleeding and keeping the surgical field clean for precise dissection.
The surgery begins with the incision. In an open approach, a small inverted-V or stair-step incision is made across the columella. This allows the skin to be lifted off the tip. In a closed approach, incisions are made inside the rim of the nostrils.
The skin envelope is carefully elevated from the underlying cartilage and bone. This dissection must be in the correct plane (sub-SMAS) to preserve the blood supply to the skin and prevent damage to the soft tissues.
The surgeon addresses the septum first. The mucoperichondrium (lining) is lifted off the septal cartilage. Deviated portions of the cartilage and bone are removed or reshaped to straighten the airway.
The cartilage that is taken out is saved and shaped into grafts, such as struts, spreaders, and shields, to rebuild the nose later. Using this tissue is a key part of structural rhinoplasty.
If a hump is present, the surgeon reduces it. The cartilage portion of the hump is trimmed with a scalpel. The bony portion is reduced using a rasp (file) or ultrasonic Piezo device.
The goal is to lower the bridge to the desired profile height. Following reduction, the “open roof” deformity (a gap between the nasal bones) is closed by fracturing the bones inward. This restores the nasal dorsum’s natural pyramid shape.
Osteotomies are controlled bone fractures used to narrow the nose or close an open roof. The surgeon makes precise cuts in the nasal bones using fine chisels or ultrasonic tools.
Lateral osteotomies allow the side walls of the nose to be moved inward, narrowing the width. Medial osteotomies separate the bones from the septum. This resetting of the bony vault is crucial for correcting a crooked nose or widening caused by hump removal.
To prevent the middle third of the nose from collapsing after hump removal, spreader grafts are often used. These are long, thin strips of cartilage placed between the septum and the side walls.
These grafts work like small spacers to widen the internal nasal valve and help breathing. They also make the bridge look smooth and straight, and prevent the inverted V deformity, where the bones and cartilage look separated.
The surgeon shapes the nasal tip using sutures and grafts. The lower lateral cartilages are trimmed (cephalic trim) to reduce bulbosity. Domal sutures are placed to bind the tip points together, refining the definition.
A columellar strut graft is often placed between the medial crura to support the tip and maintain projection. Tip rotation is adjusted by suturing the tip cartilages to the septum (tongue-in-groove technique) or using a septal extension graft.
If the nostrils are wide or flaring, an alarplasty is performed. The surgeon marks a wedge or crescent of tissue at the nostril sill and excises it. The edges are sutured together to narrow the nasal base.
This step is performed last to ensure the nostril size is balanced with the new tip projection. The incisions are hidden in the natural crease where the nostril meets the cheek.
Once the reshaping is complete, the skin is redraped. The columellar incision is closed with fine, non-absorbable sutures. The internal incisions are closed with dissolvable stitches.
A thermoplastic cast or splint is placed on the outside of the nose to protect the bones and hold them in their new position. Silicone splints (Doyle splints) may be placed inside the nose to support the septum and prevent scar bands (synechiae) from forming.
Many modern surgeries utilize the Piezotome. This device uses high-speed ultrasonic vibrations to cut bone. It is precise enough to sculpt the bone without breaking it, and it does not cut soft tissue.
This technology results in significantly less bruising and swelling compared to traditional hammers and chisels. It allows for the “preservation” of the bone’s structural integrity while changing its shape.
The patient is transferred to the recovery room (PACU). The head is kept elevated to reduce swelling. Nurses monitor for excessive bleeding or hematoma formation. The throat pack is removed before the patient wakes up.
Pain is typically mild to moderate, often described as a “stuffy head” feeling similar to a severe cold. Nausea is aggressively treated to prevent vomiting, which could increase intracranial pressure and cause bleeding.
Rhinoplasty is an outpatient procedure. Patients are discharged once stable. They are given a “drip pad” to catch minor nasal oozing, which is normal for the first 24 hours.
Detailed instructions are provided: change the drip pad as needed, use saline spray to keep the inside moist, and apply ice packs to the cheeks (not the nose). The patient is instructed to sleep with the head elevated on pillows.
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Bruising under the eyes is common after rhinoplasty, especially if the nasal bones were broken (osteotomies). However, with modern techniques such as ultrasonic (piezo) surgery, bruising is significantly reduced. It usually resolves within 7 to 10 days.
We rarely use traditional “packing” (long gauze strips) anymore. Instead, we use soft silicone splints that allow you to breathe. These are easily and painlessly removed in the office during your one-week visit.
You cannot blow your nose for at least 2 to 3 weeks after surgery. Blowing your nose can create pressure that can cause bleeding or disrupt healing tissues. If you need to sneeze, do it with your mouth open.
Most patients are surprised that rhinoplasty is not very painful. It is more uncomfortable due to the congestion and the cast. Most patients stop taking prescription pain medication after 2 or 3 days and switch to Tylenol.
Yes, but be gentle. Use a soft toothbrush and avoid moving your upper lip too much, as it is connected to the base of the nose. Aggressive brushing can pull on the internal stitches.
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