Facial Rejuvenation Procedure
Nasal Airway Reconstruction
Define Rhinoplasty:
Cosmetic correction of the nose
Define Septoplasty:
Corrects airway obstruction
Procedure:
Reshape nose by reducing or increasing size, removing hump, changing shape of tip or bridge, narrowing span of nostrils, or changing angle between nose & upper lip. May also relieve some breathing problems.
Length:
1-2 hours.
Anesthesia:
Local with sedation or General Usually Outpatient.
Side Effects:
Temporary swelling, bruising around the eyes, nose and headaches. Some bleeding and stiffness.
Risk:
Infection. Small burst blood vessels resulting in tiny, permanent red spots. Incomplete
improvement, requiring additional surgery.
Recovery:
Back to work 5-7 days.
Exercise:
1/3 Intensity at 3 weeks, 2/3 Intensity at 6 weeks, Full Intensity at 8 weeks.
Bruising:
2-4 weeks.
Swelling:
Moderate/significant for up to 4 weeks. Subtle/mild for 2 to 3 months. All of which are dependent upon extent of procedure(s).
Avoid Hitting Nose or Getting a Sunburn:
8 weeks.
Final Appearance:
1 year or more.
Duration of Results:
Permanent
Office Visit:
1st 7 days / 2nd Visit 4 weeks. Anticipated office visits: 2-3 the first 3 months, 6 months then yearly.
Splints or Tape:
Wear for 7 days.
Pain Meds:
Ibuprofen or Narcotics.
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More Information About
Cosmetic External Nasal Surgery/
Internal Functional Reconstruction
The nose is one of the most prominent and noticeable of all the facial features. Its proportion and shape in relation to other facial features has an immense effect on your overall appearance. In addition, the nose performs critical functions allowing passage of air for breathing and controlling the conditioning and flow of the air before it reaches the lungs.
Visually apparent external nasal deformities are frequently but not always associated with internal nasal deformities which affect airway obstruction. Nasal deformities can result from previous traumatic injury to the nose, or may result from hereditary or other causes.
Structurally, the nose can be envisioned as a tripod if viewed with the head tilted back. The side walls of the nose form the outsides of the tripod, with the septum (which divides the nose in half internally) being the central support of the tripod. When the nose is broken or damaged by trauma, very frequently there is disruption of both the outer wall of the tripod (nasal bone) as well as the central internal strut (nasal septum). When the nasal septum is bent, broken, or otherwise deviated or damaged, it can produce obstruction of the nasal airways which pass between the limbs of the tripod. To achieve adequate straightening of the septum surgically, it is frequently necessary to reposition external and internal structures.
Operative procedures to modify or correct septal abnormalities are called SEPTOPLASTY or SUB MUCOUS RESECTION. Their purpose is to correct deformities of the nasal septum to improve or alleviate airway obstruction.
Another major category of nasal surgical procedures is directed toward improving the external appearance of the nose, and these are termed RHINOPLASTY. The purpose of these procedures is to improve specific nasal characteristics which detract from nasal and facial appearance in order to obtain a more harmonious aesthetic balance of the nose with other facial features.
In addition to the information contained here, during your consultation and examination, we will review specific factors which pertain to your individual case. (As you review this information, please write questions in the margins that we can address during your consultation.)
RHINOPLASTY, SEPTOPLASTY, and SUB MUCOUS RESECTION are operations which are accomplished through small incisions inside the nose; sometimes small external incisions are also needed. RHINOPLASTY may be performed separately or in conjunction with SEPTOPLASTY or SUB MUCOUS RESECTION depending on the nature and extent of the deformities involved.
The nose is an extremely complicated facial feature structurally, and is unique in each individual. Its aesthetic contribution to the overall appearance of the face is immense, both in desirable and undesirable characteristics. DUE TO THE UNIQUE STRUCTURE AND APPEARANCE OF YOUR NOSE, IN RHINOPLASTY PERHAPS MORE THAN ANY OTHER AESTHETIC OPERATION, THE INDIVIDUALITY OF YOUR NASAL STRUCTURES AND THEIR RELATIONSHIP TO OTHER FACIAL FEATURES MUST BE RECOGNIZED AND RESPECTED. IN FORMULATING YOUR OPERATIVE PLAN, I WILL ALWAYS TRY TO PRESERVE THOSE POSITIVE CHARACTERISTICS WHICH MAKE YOUR NOSE INDIVIDUAL AND UNIQUE AND MODIFY OR IMPROVE ONLY THOSE CHARACTERISTICS WHICH DETRACT. It is illogical to envision the perfect nose and try to create this image on your face. This approach ignores the essential balance between your nasal and facial characteristics and predictably concludes in a result which does not fit your face. Modifications of specific, limited, undesirable characteristics to achieve a more harmonious balance of nasal and facial features is my goal in RHINOPLASTY.
Disregard of these principles also results in a nose which is over operated and looks over operated. PERHAPS IN NO OTHER AESTHETIC PROCEDURE IS THE PRINCIPLE OF CONSERVATISM AS IMPORTANT AS IN RHINOPLASTY. For this reason, considerable time will be spent in discussing with you those nasal features which you consider undesirable and the limits of a safe operative approach to correct them without producing the operated look so frequently seen following RHINOPLASTY.
In approaching operative correction of nasal deformities, judgments will be made on the conservative side in all cases. Minor adjustments or additional removal of small amount of tissue following initial RHINOPLASTY may be necessary in 5% of my patients, but these are minimal compared to the major problem of dealing with an initial procedure which was too aggressive in its approach. The structural elements of the nose are unique in their characteristics and arrangement, and extremely difficult to reconstruct when excessively removed.
Rhinoplasty/septoplasty can sometimes be combined with other surgical procedures, usually producing slightly greater, but nevertheless acceptable risks. A decision in this regard must be strictly individualized, depending on the type of other surgical procedures being performed as well as other medical and surgical factors.
The purpose of all types of cosmetic surgery is to improve your appearance as much as possible. This change will hopefully improve your quality of life by improving your self image in a very positive way. By addressing and improving those specific areas which detract from your appearance, leaving the positive aspects of your appearance undisturbed, this type of surgery results in an overall improvement in your appearance. Cosmetic surgical procedures are not magic. They are detailed procedures designed to improve specific aspects of your appearance. They can do no more than that. Whether you are happy with the results of cosmetic surgery will depend largely on how well you communicate to us which specific aspects of your appearance you are unhappy with and how well we communicate to you what a surgical procedure can and cannot do toward alleviating the problem. Plastic surgery does not perform transforming miracles. A combination of art and science, plastic surgery is not an exact science. Some of the factors involved in producing the result (such as your healing characteristics) are not totally within your or our control, and therefore, it is impossible to warrant or guarantee the results of your surgery.
After talking with you and examining you, I will make every effort to clearly and precisely give an opinion about whether a specific surgical procedure can significantly improve your areas of concern with a high degree of reliability and a minimal level of risk. All cosmetic surgical procedures involve some trade-offs. I will try to outline these clearly for you and answer any questions you might have. The final decision regarding having the surgery is yours, and I encourage you to consider it carefully and deliberately.
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AT YOUR INITIAL CONSULTATION:
At your first visit your previous medical history will be discussed, especially any history of previous trauma (injury), allergic conditions, and previous surgical procedures which may have been performed on your nose. We will review in detail the specific problems you are experiencing with your nose or any aesthetic qualities which you consider undesirable and would like corrected. After examining the external features and internal configuration of your nose, we will discuss in detail your desires regarding correction of specific areas, and the degree to which I feel these desires can be met by a surgical procedure.
In this consultation, I would expect you to be frank in discussing your expectations with me. Do not hesitate to ask any questions that you may have. I will be equally frank with you, explaining the factors that could influence the procedure and the results.
I cannot make the decision for you regarding whether to undergo surgery or not. I can only advise you regarding the surgical options and anticipated outcomes I would expect for you based upon your individual anatomy, desires, and realistic expectations. I will define goals in a surgical plan at this initial consultation. Follow up appointments will include time to ask further questions or review the procedure so that you are comfortable with its nature and implications. I will educate you and define the operative scenarios and choices available to you, but you must make the final decision regarding the surgical procedure.
When a decision is made to proceed with surgery, preoperative photographs will be taken. These photographs are essential to the planning, execution, and follow-up of your procedure.
Surgical fees for the procedure will be discussed with you. They depend upon the nature and the extent of the procedure being performed. All fees for cosmetic surgeries are payable in advance and include the cost of surgery as well as all postoperative follow up care. Additional fees are required for the surgical facility and anesthesia care, and will be collected on the day of your preoperative visit at the surgery center.
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BEFORE YOUR RHINOPLASTY/SEPTOPLASTY:
Our nurse and office manager will make all arrangements regarding scheduling of your surgery and will give you specific instructions as well as reconfirm these with you by telephone and/or letter. Since both of our schedules must be coordinated with the surgical facility and anesthesia schedules, please allow our personnel a reasonable amount of time to make these arrangements. They will make every attempt to accommodate your requests.
Good general health is mandatory for a problem free and predictable recovery from any surgical procedure. Wellness and good general health result from proper diet, regular exercise and appropriately timed medical evaluations focused on preventative medicine. Good nutrition, vitamin and herbal supplements, as well as adherence to holistic health principles are important concepts in maintaining wellness. Certain supplements, although generally beneficial, may have adverse effects during surgery. Please advise us about all your medications and supplements, so we may advise you regarding their safety in regard to your surgical procedure.
We believe that good nutrition is an important component to excellent surgical outcomes. Multiple studies show that most Americans aren’t getting the recommended daily intake of necessary vitamins and minerals, much less the optimal amount. These suboptimal levels of nutrients have been linked with major diseases from heart disease to cancer.
We use a three phase healing program with nutritional supplements to help you recover more quickly and with less downtime. We have you start this a week or so ahead of time to ensure that you are boosting your body’s immune system and removing anything that could interfere with anesthesia or increase bleeding. Immediately following surgery we give you nutrients that help reduce pain and inflammation and detoxify the anesthesia and other medications. The third phase has additional healing nutrients to support your recovery.
Routine laboratory tests including blood counts and blood chemistries, a pregnancy test when applicable, and an electrocardiogram if you are over 50 years old, will be performed prior to surgery. These tests are performed routinely to screen for any abnormalities, which might complicate your anesthesia or surgery.
Do not take aspirin or any drug containing aspirin for at least two weeks prior to your surgery. Aspirin may retard platelet function, a blood component that is important to normal blood clotting mechanisms. There are many drugs which contain aspirin. Before taking any drug, check the label carefully to assure that it contains no aspirin.
Do not eat or drink anything 8 hours prior to surgery. Safety in the administration of anesthesia or sedation requires that your stomach be absolutely empty for this interval of time before surgery.
Shower or bathe normally the evening prior to surgery.
You should wear loose fitting, comfortable clothing the day of surgery. A loose fitting shirt with buttons in front is preferable to any type of clothing which must be put on over the head. Pleases be sure that you have all of your questions answered prior to going into the surgical facility. I prefer that you make an additional appointment in the office if necessary to answer questions regarding your surgery. On the day of surgery, I will visit with you briefly immediately prior to surgery. Any final questions will be answered at that time.
Arrange for someone to drive you home at the appropriate time following your procedure, and arrange for someone to stay with you the night of surgery.
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THE DAY OF SURGERY:
I usually prescribe sedation or pre medication prior to your being brought to the operating room. In order to minimize total necessary doses of drugs, sedation is best administered through an intravenous line rather than given in shot form into your muscle. It is normal to be slightly excited or apprehensive immediately prior to the surgery, and this will be alleviated quickly once your intravenous line is inserted. Our anesthesiologist will speak with you and answer all of your questions regarding your anesthetic.
Rhinoplasty and septal procedures may be performed using either local or general anesthesia, depending on the nature and extent of the procedure. Following your examination and evaluation of the indicated procedure, I will discuss these options with you. When local anesthesia is chosen, you will receive heavy sedation prior to any manipulation or injection of local anesthesia. You will experience no pain and will have no recall of the procedure. An anesthesiologist or I will administer the medications, and when the proper level of sedation has been achieved, injections of local anesthetic into areas of the nose are performed both to render the area pain-free and to control bleeding during the operation. Small cotton packs moist with a solution to constrict the nasal membranes and limit bleeding are then placed within the nose and appropriate modification of the nasal structures is carried out.
At the completion of the procedure, if septal surgery has been performed, plastic splints will be placed within the nose and left in place from five to ten days, depending on the nature of the procedure performed. Due to drainage of material and fluid following surgery, some degree of blockage of the nasal airways is normal, but you will be able to partially breath though the nose. I DO NOT PACK THE NOSE SO THAT YOU ARE UNABLE TO BREATHE THROUGH IT. A thin external splint of aluminum or plaster will be applied to the outside of your nose if we have repositioned nasal bones. The external splint is fixed in place by tape and usually remains in place approximately one week.
At the completion of your operation, you will be transferred to the appropriate recovery area where you will remain until you awaken. I purposely like for you to remain drowsy, since you will be much more comfortable. After an appropriate interval of observation, usually a few hours, you will be allowed to leave with someone to drive you home and stay with you the evening of the surgery.
You will have been given prescriptions for pain medication and antibiotics with instructions for each at your preoperative visit.
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AFTER YOUR RHINOPLASTY/SEPTOPLASTY:
Since I want you to remain drowsy and comfortable the evening of your surgery, fill your prescription for pain medication before surgery and take one immediately on arrival at home. Pain medication is best taken with a small amount of food and not on an empty stomach since nausea may occasionally occur. Make yourself comfortable, not necessarily in bed; a couch or comfortable chair is fine. You will continue to be drowsy and will awaken intermittently during the evening. Use the pain medication as directed to remain comfortable. Intermittent cold compresses for the first 48 hours after surgery will help with swelling and discomfort.
Do not try to eat any heavy foods the evening of surgery. Liquids or light foods are preferable. You may resume a soft diet the next morning, and continue with soft foods for
4-5 days. Should you experience any nausea the evening of surgery, drink small amounts of liquids only: no food until morning. Anti nausea medications are generally not needed; any nausea experienced from the medications used in surgery will usually be gone the next morning. If you have a history of nausea after anesthesia, please inform your anesthesiologist the morning of surgery and you will be given anti-nausea medications during the procedure that will help minimize this occurrence after surgery.
Drainage from the nose is normal for at least 72 hours following surgery and possibly longer. For the first 24 to 48 hours, the drainage will be reddish in color and will decrease in amount day by day. If drainage is significant, you may use a small gauze pad taped beneath the nose, or simply blot beneath the nose with tissue. Your nose will not be packed, and if you keep it clean as directed below, you should be able to maintain some degree of airflow, even if splints are in place.
Drainage will tend to accumulate near the nostril openings and can be easily removed by dipping cotton tipped applicator stick (Q-tips) into half strength hydrogen peroxide and gently cleaning inside the nose. THIS WILL NOT HARM THE OPERATIVE INCISIONS IN ANY WAY. Following the cleaning, apply a small amount of antibiotic ointment or Vaseline into the nostril to avoid drying and crusting.
If you have had an operation done which involves the septum, small plastic splints will be in place in each nostril. Each of the splints has a small tube attached, which if kept clean, will provide airflow through the nose. It may be necessary to clean the nose two to three times daily for the first 24 hours and then usually once or twice daily is adequate when drainage decreases.
Tape without a splint is placed over the nose if the nasal bones have not been modified to assist in having the skin adhere to the nasal framework and to minimize postoperative swelling. The tape should be kept as dry as possible, but cautious face and hair washing may be carried out immediately. If the nasal bones have been repositioned, a small aluminum or plaster splint will also be in place over the upper portion of the nose and held in place with tape. The tape and splint are usually left in place five to seven days depending on the nature of your procedure. A liquid adherent material is painted on the skin before the tape is placed to improve its adherence. Depending on the amount of perspiration and oiliness to your skin, the tape may begin to loosen at three to five days. This is normal and loose ends of the tape may be trimmed.
If the nasal bones have been modified or moved during the procedure, you may wear light glasses only briefly for about three weeks. Inadvertent blows or pressure on the rims or any other portion of the glasses is transmitted to the nose pieces, and can cause displacement of the nasal bones. After three weeks, glasses must be worn with caution for an additional three weeks to avoid displacing the nasal bones. Contact lenses may be worn as tolerated.
Bruising is normal following rhinoplasty procedures. The degree of bruising and the time required for resolution vary widely, but bruising is usually mild to moderate and resolves within ten to fourteen days. Bruising can usually be hidden with makeup in three to five days. Some minor degrees of swelling will remain in the nose for up to one year. Nasal modifications are visually apparent immediately following surgery, but certain areas of the nose, especially the nasal tip, will continue to improve in appearance as the minor amount of swelling resolves over several months. These changes are quite subtle after the first six to eight weeks.
Following nasal operations, there are often noticeable changes in the amount and direction of airflow through the nose. The difference in sensation while breathing may be significant, especially the first few days postoperatively. Often, the amount of air moving through the nose is significantly increased, and several weeks are required to fully adjust to the new sensation. The membranes may also be irritated and require several weeks to equilibrate. These adjustments are usually minor in degree and require no medications.
If you are given a prescription for antibiotics following surgery, take the prescription until ALL of the antibiotics are completed.
Strenuous exercise should be minimized for at least three weeks following surgery. Activities such as stooping over and lifting heavy objects or having the head lowered below the level of the rest of the body for any extended periods should also be avoided to minimize the chance of postoperative bleeding.
Resume normal tasks of daily living as rapidly as possible. The pain from the procedure decreases to about half of its intensity each 24 hours following surgery. Postoperative discomfort is most marked only during the first 24 hours and regresses rapidly thereafter. Resumption of normal activities, for example, lifting the arms to comb the hair and lifting objects of normal weight, speeds the recovery process and reduces the pain more rapidly. Most patients are back at work in 7-10 days. Call the office for an appointment to be seen as directed following surgery.
You may resume light exercise at 3 weeks following surgery. This includes low impact activities at 1/3 duration of exercise, repetitions, amount of weight, and pulse rate. Your exercise tolerance should gradually increase to 2/3 intensity at 6 weeks, and be at full intensity by 8 weeks. This includes high impact activities such as running, horseback riding, and high impact aerobics.
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LIMITATIONS, RISKS AND POSSIBLE
COMPLICATIONS OF RHINOPLASTY:
With any surgical procedure, a very small percentage of untoward complications can occur. These complications are rare, and I mention them not to alarm you, but only to inform you.
It is possible to have untoward side effects to any drug which is administered during surgery. Severe side effects are extremely rare, but can be life threatening. It is for this reason that I insist on performing your surgery in an optimal setting where all conceivable equipment and medical backup are available should you have an unexpected reaction. Anesthetic or sedation risks are extremely minimal. The media has vastly over publicized many cases, and most have occurred in settings where less than optimal facilities, equipment and personnel are present.
Discomfort following operative procedures on the nose is usually minimal.
The primary inconvenience usually results from partial blockage of the nasal airways due to secretions initially following operation, and will subside in a matter of days.
Following operations to correct the septum (septoplasty or sub mucous resection), increased airflow through the nose may feel strange initially and require a few weeks for you to adjust to the feel of the new airway. The mucosa or lining of the nose also requires time to adjust as swelling and irritation subside in the first six to eight weeks. I encourage you to allow normal body mechanisms to adjust without using nasal sprays or medications in most cases.
Excessive bleeding following nasal operations occurs rarely, in less than 5% of cases. Should this occur, additional packing of the nose or examination and control of the bleeding point may be necessary. Sometimes this requires a return to the operating room.
Slight irregularities or under correction of small areas of the nose may result following rhinoplasty and may require future correction. As explained above, additional minor correction is far preferable to excessive operation at the initial procedure. Most secondary procedures are minor in nature, but may require a return to the operating room to perform them.
Infection is a possible complication of any surgical procedure and is extremely rare in the nose. Occasional cases of infection have been reported, but the chance of this occurring is less than 1%. Severe infection can result in damage or loss of nasal tissues. An additional procedure may be necessary if severe infection occurs in a localized area in order to accomplish adequate drainage.
Inadvertent blows or manipulation of the nose following surgery may produce movement of
nasal structures which might result in a loss of the desired configuration or symmetry of the nose. If recognized early, these abnormalities may be satisfactorily corrected without an additional operative procedure.
The cartilage of the nasal septum is like a spring and when moved tends to return to its original position to correct abnormal position. We must weaken the spring. Since the septum also performs support function in the nasal tripod, there must always be a balance between weakening the spring to correct abnormal positioning while preserving support functions. For these reasons, incomplete correction or recurrence of deformities can occasionally occur.
There are certain aspects of your healing process over which we have no control. If areas fail to heal properly or excessive scar tissue forms, visible external or internal deformities can occur. Rarely, perforation or holes in the nasal septum may occur due to incomplete healing. These are very rare and unusual, and can usually be improved or corrected by a secondary procedure.
All of the above-mentioned complications of rhinoplasty/septoplasty are unusual but occur occasionally despite the most vigorous standards of surgical practice. They are mentioned not to alarm, but to adequately inform you.
CONCLUSION:
Rhinoplasty/septoplasty can be one of the most rewarding aesthetic procedures both to the patient and the surgeon. Achieving the desired result in rhinoplasty/septoplasty demands a thorough understanding and communication regarding your desires and my ability to produce the desired changes within the limits prescribed by your individual nasal structures.
During your office consultation, additional and more detailed information regarding all of the areas mentioned in this information sheet will be provided you, as well as an opportunity for you to ask in-depth questions. Please review this sheet carefully and write down any questions you may have.
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