NOSE
Who
hasn't heard of the nose bob or the nose job? Cosmetic surgeons, rather more
sedately, call it rhinoplasty. It's the most-requested procedure for the face,
the one that can make the most dramatic difference on some faces -- and, unfortunately,
also the one with the highest rate of post-op dissatisfaction (either because
of over-expectations on the part of the patient or over-correction on the part
of an ambitious surgeon, or because tricks by Mother Nature or due to constitutional
factors can distort the intended result).
The first nasal
surgeries are credited to the great Indian practitioner, Sushruta, in the 6th
century B.C. In modern times, the development of nose correction procedures
has closely paralleled the advancement of cosmetic surgery itself. In fact it
was the nose bob that first made plastic surgery a household word. Until the
early part of the 20th century, however, the surgical incisions were mostly
placed outside the nose; today, they are placed inside the nose so that scars
are not visible.
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Additionally, techniques are far more refined
today. While the earlier corrected noses had a "surgical look", today's
new noses are more natural in appearance. The first rhinoplasty operations in
recent times were directed at reducing the size of the nose; today, noses can
be made smaller or larger, turned up, pushed back, have their nostrils thinned,
their profiles made aquiline and much more.
Nose jobs may be
requested for a number of different reasons:
i.) Congenital malformations including deviated septum, saddleback deformities,
double humps etc.
ii.) Aesthetic purposes such as refining a bulbous tip, trimming a long
nose, narrowing down flared nostrils, etc.
iii.) Reconstruction of the nose (or a part of it) which may be required
following severe injury, an accident or cancer surgery.
The surgery therefore
basically involves altering or restoring nose shape by one or more of three
approaches:
i.) removing underlying bone or cartilage
ii.) moving and reshaping this underlying structure
iii.) adding to it through the use of silastic implants. The skin is
then re-draped over the new contours.
The procedure is
essentially akin to raising or lowering the central support of a tent, thus
altering its external appearance.
PRE-SURGERY
PREPARATION
Perhaps
no other cosmetic procedure calls for as much planning, aesthetic judgement
and careful preparation as nasal surgery.
At your pre-op
clinic visits, your surgeon -- if he's a skilled and ethical practitioner --
will lead you through an extended amount of groundwork: discussions, photograph-taking,
detailed examinations of not only your nasal profiles but also of the other
features of your face. His efforts will be directed at not just correcting the
obvious defect in the nose or refining and redefining its shape, but also in
ensuring that -- taken in conjunction with the other features of your face --
the final look will be balanced and pleasing to the eye. One reason for the
"something's missing" look in the results of earlier rhinoplasty was,
that, while noses were corrected, chins were left intact; today, we know that
many patients undergoing nasal surgery can also benefit from having their chins
altered. (For instance, those with large noses unfortunately, but commonly,
have weak or small chins).
Sometimes alterations
in the area of the upper lip -- which is contiguous with the nose -- are also
required along with the nasal correction.
Even in planning
the correction of the nose alone, the surgeon must consider the fine aesthetic
balance that he needs to maintain among its various aspects: the bridge, the
tip, the nostrils, the root of the nose (i.e. the area where the nose joins
the forehead). For this reason, he will need to take, and to show you, professional
photographs which should include the full face, two profiles, a smiling view
and a basal or "worm's eye-view" taken from a low angle.
Your intended surgeon
will try to determine your motivation for altering the shape or size of your
nose, and whether your expectations are realistic. This is the time you must
express yourself fully so that he can tell you not only what is possible in
your case, but also what is not. He can show you this more precisely by inking
in alterations on your photographs or, more commonly today, with "computer
imaging" which allows you to electronically preview the expected post-op
results. But remember, all these are approximations, there are no guarantees.
So, too, with the 'before' and 'after' pictures of his previous patients that
a surgeon might show you: they give you a sense of his aesthetics, and of what
is possible in nose correction surgery, but they won't tell you the exact result
you can expect on your own nose.
Some expectations
are clearly unrealistic: to expect a surgeon to alter a large bulbous, thick-skinned
nose into a finely-chiselled feature, for instance. An extent of improvement
can definitely be expected, but not a total transformation, and as the patient
you should know this before the operation, not after.
Though standardized concepts of the "ideal nose profile" do exist,
the wise surgeon will use this only as a general aesthetic guide, and not try
to make every patient conform to the mould; in the end, it is the harmonizing
of the individual patient's features that will make for the "best"
result.
The pre-op examinations
will include inspection of the intra-nasal area, especially if a nasal obstruction
or inside growth exists.
Also important
is checking the thickness of the nasal skin. Thick, rigid skin does not drape
as well over the re-modelled nose as fine textured skin (the rhinoplasty surgeon's
delight, especially if it accompanies a long, thin nose).
At what age can
you have your nose done? Most cosmetic surgeons agree that nasal surgery can
be undertaken once the nose has attained about 90 per cent of its adult size,
at about 13 years for girls, and 15 for boys. (The exception, of course, is
the correction of a serious birth defect which interferes with breathing and
may stunt the development of the lungs and needs to be tackled urgently). What
is more important is that an adolescent should have attained the emotional maturity
necessary to handle the implications, and especially the aftermath, of the surgery.
In fact, the `cope-able' adolescent patient is often the best candidate for
nasal surgery; greater prudence on the part of the surgeon is called for, in
undertaking corrective surgery in the older patient in whom the skin is also
less elastic and will not settle down as easily into its new shape. On the other
hand, this does not mean that 50 or even 60 is "too late" to have
nasal surgery. Only, healing will take slightly longer.
OPERATION
Either
local or general anaesthesia can be used, coupled with an intravenous sedative.
An adequately-sedated patient is likely to experience less bleeding during the
surgery than a nervous one. The surgery takes from an hour to two hours, depending
on what needs to be done. Different deformities require different approaches
and procedures; most surgeons, however, find it useful to follow an "order
of procedure", especially in treating the most common nasal deformity,
the nose with a hump which may be too long or too large and generally accompanied
by some kind of abnormality of the nasal tip.
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Often, correcting one type of deformity requires
accompanying alterations to be made in one or more other nasal features in order
to maintain a balanced nasal profile. Thus, if the contour of the bridge is
corrected, it may be necessary, to also alter the tip surgically, so that it
fits well over the new bridge; to neglect to do this may bring on what is known
as a "polly-tip" deformity.
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In most rhinoplasty procedures today, the incisions
are placed inside the nose. There are exceptions, such as surgery to reduce
the flare of the nostrils, in which case the incisions are made in the groove
of each nostril. These are rarely visible and, even they fade with time.
POST-OPERATIVE
CARE
When
the surgery is complete, a Plaster of Paris or a metal splint is applied to
the nose to keep the new structure in position and to limit swelling; it stays
on for five to seven days. In some nasal procedures, a small amount of surgical
packing is inserted inside the nose at the end of the operation and kept in
for the first 24 Hours. It helps to control post-operative bleeding, and-though
it is a source of annoyance to the patient-the longer it is kept in, the easier
it is to remove, without disturbing the healing tissues.
Medications and
antibiotics are routinely given to control the pain, infection risk and inflammation.
Bleeding is less, and healing faster, if the patient is left undisturbed.
On average, you'll
need to stay in the hospital for about 6 hours. In the early post-operative
period, you will be advised to sleep with your head raised, so as to minimize
oozing. Ice compresses may be placed over your eyes. They chiefly have a soothing
effect: they do not lessen the swelling and discoloration that appear around
the eyelids, nor hasten their disappearance.
You will also be
asked to observe a whole set of cautionary do's and don'ts, all aimed at preventing
loosening of the splint, avoiding distortion of the newly-created structure
and promoting healing. They include:
1.) Stay on a liquid/soft diet during the first two days after surgery
to minimize mastication (which could pull on the operated nose).
2.) In the initial period, breathe through your mouth until the nasal
passages clear sufficiently to permit breathing through the nose.
3.) For about a week after the splint has been removed, avoid blowing
your nose: it could provoke hemorrhage as well as pain.
4.) When you sneeze, keep your mouth wide open, exhale as much air out
of your lungs as you can before you actually sneeze to reduce the intensity
of the sneeze .
5.) After the splint has been removed, clean your nostrils three to four
times a day with cotton buds, and apply cold cream or Vaseline inside the nose
to soften the blood clots or crusts.
6.) Avoid compressing the nostrils, playing around with the new shape
of your nose or inserting objects inside the nose: this could bring on trauma
as well as scarring.
Expect swelling
and discoloration around the eyelids to continue for seven to ten days. Sometimes
the whites of the eyeballs appear red due to the blood, that has escaped from
the nasal area into the eyeballs. This is known as a sub-conjunctival hemorrhage
and will also spontaneously disappear, by around the tenth day.
Swelling around
the nose takes a much longer time to settle down. About 90% of it will have
disappeared within a fortnight but a minimal amount of swelling may persist
even upto a year, especially in the area above the tip of the nose or at the
root of the nose (i.e. the area where the nose joins the forehead). The older
the patient, and the greater the amount of reduction in nose size, the longer
it will take for the swelling to subside. This residual swelling is not conspicuous;
it exists more as a feeling of tissue firmness.
The tissues lining
the inside of the nose will also be swollen post-operatively, resulting in some
degree of nasal blockage and therefore mildly obstructed breathing for about
three months.
You will definitely
need to take time off from work for two to three weeks to avoid exposing your
nose to external hazards. You'll also be instructed not to over-expose your
face to the sun for the first few months since its strong rays can burn the
skin of your nose at a time when the blood supply has not completely returned
to normal.
Although the nasal
chiselling performed at the time of the surgery takes about six weeks to completely
heal, you can get back to routine activities in about two to three weeks. However,
you'll need to avoid contact sports such as football and wrestling because of
the risk of dislocating the healing nasal bones.
A deformity caused
at this stage of healing can be repaired, though.
RISKS
AND COMPLICATIONS
1.) Post-operative bleeding :
Hemorrhage is an infrequent complication of rhinoplasty, is usually not severe
and is easily controlled by removing clots and re-packing of the nose with gauze.
Bleeding is a more likely occurrence if a procedure involving the nasal septum
(the partition between the two sides of the nose) has been done. It can also
be provoked by picking the nose post-operatively or by exertion.
2.) Infection : If hematoma (collection of blood clots) has been carefully
avoided by the surgeon, and if he has removed fragments of bone or cartilage
at the completion of the procedure, infection is unlikely. The rare abscess
that does occur is tackled by its incision and drainage and with antibiotics.
3.) Malfunctioning of the nose (that is, breathing difficulties, may
result from faulty surgery, such as destruction of part of the musculature of
the nose in an effort to thin the nose, or through excessive removal of the
cartilage (which is the framework upon which the muscles rest and act). Since
the nose is not just a static facial "feature" but an organ of breathing,
it cannot simply be shaped at will on the operating table; the surgeon must
take great care to preserve the dynamics of its normal functioning.
Excessive removal
of the cartilage of the nose-tip may result in a 'pinched-tip', which may not
become apparent until two or three years after the surgery.
4.) Drooping of the tip: Due to the dressings as well as the initial
swelling, the tip of the nose is temporarily elevated in the immediate post-surgery
period; as the swelling subsides, the tip resumes its position,. But the patient
often interprets this as a downward drooping of the tip. The surgeon's assurance
is needed at this stage so that the patient knows that the early droop is in
fact intentional.
At times, however,
drooping of the nose tip may in fact be caused by poor surgical judgement or
execution, resulting in over-correction. This can undermine an otherwise satisfactory
outcome.
5.) Poor Healing : Some of the most unfortunate effects of nasal surgery
result from the fact that the process of healing is so unpredictable. Excessive
scar tissue may form inside causing tissues to be pulled into abnormal positions.
Some patients scar badly. (Darker skins are more prone to poor scarring). Poor
blood supply can cause temporary or permanent discoloration of the skin. In
thin-skinned persons, this can result in dark rings under the eyes. If there
is abnormal absorption or re-setting of the nasal bones at the places where
they have been cut, the new nasal framework can collapse.
Much of the healing process is controlled by Nature, and sometimes Nature does
play cruel tricks.
6.) Patient dissatisfaction : This is perhaps the main risk in nasal
correction: that the patient is unhappy with the result. Most frequently it
arises from a combination of over-expectations on the part of the patient and
over-ambition on the part of the surgeon. When an effort has been made to accomplish
more than the local tissues will permit, dissatisfaction is inevitable. It is
often better to settle for less-than-perfect results rather than to reach for
the unattainable and be foredoomed to failure.
To a lesser degree,
temporary dissatisfaction may be caused by minor irregularities in the contours
of the new nose. Generally these are not obvious to the rest of the world, only
to the patient and to the surgeon and that only on palpiation of the area.
Many of these irregularities
settle down in time, generally within three to six months. In fact, the virtue
most demanded by nasal surgery is patience. If you expect to see your "new
nose" immediately after the dressing is removed, you're being far too precipitate,.
The nose is notorious for taking the longest time to settle into its new shape.
One famous cosmetic surgeon has described the "settling-in" process
as akin to the development of a Polaroid picture: it gets better and brighter
all the time. Although the new nose is 90 percent "there" within about
three months, you might need to wait upto eight to eighteen months, to see the
absolutely final result.
You'll know your
plastic surgeon has done a poor job if you hear comments such as "Have
you done something to your nose?" You'll know he's done a great job if
people comment that "Your face is looking better", but cannot exactly
say Why : that's something only you and your surgeon should be able to tell
!

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The
Nose
"If
the nose is right, everything about the face appears right"
-ANTHONY ERIAN
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