The nose occupies the central part of the face and is the most prominent component in the face. Hence, it has an overbearing influence on the balance and beauty of a face. A nose that is out of proportion can seriously affect facial beauty.
"The art and science of altering the appearance of the nose to enhance facial aesthetics” are called Rhinoplasty. The surface appearance of the nose is the result of certain lines, proportions and ‘light play’ (shadows & reflections resulting due to incident light). This appearance is linked to underlying anatomic structures i.e. the bone & cartilages that form the framework of the nose. Altering this framework changes the surface appearance of the nose.
Planning a Rhinoplasty starts with a detailed assessment of surface aesthetics and functional assessment of the nose.
During the consultation, a detailed history of the patient is taken. An effort is made to understand the aesthetic goals of the patient. This is followed by an assessment of nasal anatomy and function. Finally, aesthetic goals are set and changes to make during a Rhinoplasty are listed.
The patient is generally assessed clinically and by laboratory investigations for fitness for surgery. A large majority of the procedures are performed under general anesthesia, i.e. the patient is unconscious and unaware of the procedure being done. Once the anesthetic is administered, the surgeon starts by exposing the nasal framework and making the required changes to it.
Each patient presents with a different set of complaints, requiring different manipulations of their nasal framework. For example -
Dorsal Hump - Treated by bony reduction and component reduction of the upper lateral cartilages. May also require lateral osteotomies.
Saddle Nose - The dorsum of the nose is shallow and concave. These patients have a depressed bony vault and cartilaginous vault along with a deficient septum. They may or may not be suffering from airway obstruction. Such a problem can occur by birth (binders syndrome) or may be acquired due to injury, septal surgeries, etc. Correction of these deformities involves reconstructing the septum with cartilage grafts and augmentation of dorsum with cartilage grafts. These grafts are sourced from the patient's ear (conchal cartilage) or the ribs (costal cartilage grafts). These cartilages are surgically shaped to suit the requirements and secured in place.
Crooked Nose - These noses are deviated or curved and present visible asymmetries. This problem may be congenital or acquired due to injuries.
Underlying structural deformities like – curved or ‘s’ shaped septum, asymmetrical attachments of cartilages, asymmetrical sizes and strength of lower lateral cartilages are usually found. The treatment is aimed at the correction of deformities and restoration of symmetry.
Broad Nose & Bulbous tip - This is a common feature of Indian noses. The problems seen are overtly thick skin at the tip resulting in the amorphous tip, broad and bulky lower lateral cartilages, poorly supported tip, broad bony vault, etc. The corrections are aimed at narrowing the nose and giving a more defined tip. The changes include debulking the nasal skin, trimming of lower lateral cartilages, columellar support, tip grafts, lateral osteotomies, etc.
Other encountered defects in the nose include the short and overly rotated nose, drooping nasal tip, retracted alae, retracted columella, etc. These deformities are suitably dealt with during Rhinoplasty. Apart from aesthetic concerns, Rhinoplasty on occasion deals with airway issues resulting due to narrow internal or external valves of the nose, deviated septum, etc.
Septoplasty is a common component of a Rhinoplasty, especially when dealing with crooked or deviated noses. This can benefit a patient suffering from concomitant airway obstruction.
Patients suffering from saddle nose and airway obstruction benefit from the reconstruction of the septum that is done as a part of their Rhinoplasty.
Patients suffering from a collapse of internal value benefit from spreader grafts.
Rhinoplasty can be performed through an external approach (open tip) or endonasal approach (closed tip). There are also numerous incisions such as inter cartilaginous Trans cartilaginous, Trans columellar, etc., each of these has been designed as an approach to a particular area of the nasal anatomy. These incisions may be used by the surgeon in combination or alone to achieve the optimum results. The incisions for Rhinoplasty do not leave conspicuous scars.
Revision Rhinoplasty - Sometimes, optimum results may not be achieved by the Rhinoplasty surgery and the patient may express a desire to undergo a second procedure to make the corrections. This is technically feasible but it is advisable to observe certain precautions. The most important is to give the adequate time of recovery i.e. a year at least from the time of the first surgery. It should also be noted that every surgery results in fibrosis in the tissue planes which makes the second procedure technically challenging.
The preferred minimum age is at about 18 years or whenever the growth of midface is complete. It is not advisable to perform aesthetic Rhinoplasty in a growing age or while the facial proportions are continuously changing. Moreover, the mental maturity of the
patient should be considered and assessed for their ability to make proper decisions. The results of Rhinoplasty are observable as soon as the dressings are removed. However, patients are advised to wait for the final results to be apparent in about 9 months to 1 year's time. The reason for this is different anatomical regions of the nose take different amounts of time to settle down from the effects of surgery.
The swelling in an osteotomy plane takes about 3-4 weeks to completely subside.
The tip takes about 9 months to completely settle down after an open tip Rhinoplasty.
The results once settled may remain for a long time but are subject the natural process of ageing similar to an unoperated nose.