The Day Of Surgery
The big day has arrived. No doubt you’re excited and most likely a little anxious about undergoing your rhinoplasty procedure. Thanks to modern medicine, surgeons have fine-tuned the process of rhinoplasty, resulting in less discomfort and quicker recovery times. And although it may have been easy to spot “nose jobs” in the past, current trends in rhinoplasty have led to more natural-looking results that blend harmoniously with the rest of your face.
Arriving at the Surgery Center
When you arrive at the surgery center, you’ll complete any required administrative paperwork. Part of this paperwork will include “informed consent” forms, which you’ll be asked to sign. What is an informed consent form? Prior to surgery, you should receive an explanation of the procedure you’re having, any risks, and the expected outcome. The informed consent form states in detail that you understand everything involved with your surgery. You should read through the consent form carefully before signing it. If you have any questions or need more information, ask your physician.
Informed Consent Forms
Informed consent forms typically cover the following:
- Authorization for the surgeon to perform the procedure
- Authorization for anesthesia to be administered
- Authorization for the surgeon to perform any additional procedures deemed necessary in case of emergency or to achieve the desired results
- Authorization for the surgeon to take before-and-after photos and/or video
- Acknowledgment that you’ve been fully informed about your procedure
- Acknowledgment that you’ve been fully informed about the possible risks involved
- Acknowledgment that there are no guarantees about the results
- Acknowledgment that any computer imaging you were shown isn’t a guarantee of the results you’ll achieve
- Certification that you have truthfully disclosed all medical conditions, allergies, medications taken, and smoking habits
- Certification that you agree to follow the surgeon’s instructions
Once you’ve completed the necessary forms, the preparations for surgery begin. You’ll be given a hospital gown, a hairnet, and perhaps surgical booties or socks to wear. Most surgery centers have a designated area where you can leave your clothing and personal belongings. At this point, a nurse may give a sedative to help you relax.
Meeting with Your Surgeon
At some point during your surgery prep, you can expect to have a brief meeting with the surgeon to go over the procedure. This is your chance to ask any last-minute questions or to make any modifications to the wishes you had previously discussed. As part of the preparation for your surgery, some surgeons use a special surgical marking pen to draw on your nose as a blueprint for changes to be made during surgery. These markings are usually made while you’re sitting or standing rather than while you’re lying down.
Meeting with the Anesthesiologist
You may also receive a brief visit from the anesthesiologist during the preparations for surgery. He or she will verify that you haven’t had anything to eat or drink other than a few sips of water with any necessary medication. Your anesthesiologist will also check that you haven’t been taking any of the medications your surgeon instructed you to avoid. A quick review of your medical history may also be part of this visit. The anesthesiologist may ask you about certain medical conditions, any allergies to food or medications, and whether you or a family member have ever had any allergic reactions to anesthesia. What do food allergies have to do with anesthesia? Some anesthetics contain components of foods, such as eggs, so it’s important to inform the anesthesiologist of any food allergies. And although adverse reactions to anesthesia are rare, they can run in families. You should also inform your anesthesiologist about any allergies to latex. Even though you’ve already included this information in your medical history, it’s important to review it with the anesthesiologist. This review is done to ensure your safety during your procedure, so be sure to bring up anything you may have forgotten to include in your history. If you have any last-minute questions about anesthesia or pain control during the procedure, ask the anesthesiologist.
Placement of IV
Surgery prep will continue with the placement of an IV. The IV is usually placed in your arm or in the top of your hand and will be used to administer anesthetics, antibiotics, and other medications. Other than a slight stinging sensation when the IV is first inserted, you shouldn’t feel any pain. The IV is usually taped in place with surgical tape to prevent it from moving.
Before your rhinoplasty surgery begins, some form of anesthesia will be administered to keep you pain-free during the procedure. If you feel somewhat nervous about being “put under” with anesthesia, you’re not alone. It’s common to experience some anxiety about undergoing anesthesia. However, you should know that anesthesia is safer than ever before. In fact, a 1999 report from the Institute of Medicine states that anesthesia is fifty times safer today than it was in the early 1980s. What makes it so much safer today? It’s due to improvements in the drugs used in anesthesia, in the education of anesthesia providers, in technology, and in the techniques used for monitoring patients during surgery. For rhinoplasty surgery, sedation anesthesia combined with local anesthetics is commonly used. However, general anesthesia may be recommended depending on the complexity of your procedure, your physical condition, your reactions to medications, and whether you smoke. The anesthesiologist or surgeon makes the final decision about the type and level of anesthesia you receive.
Sedation anesthesia, delivered by IV, uses pain relievers and sedatives to minimize discomfort and to induce relaxation and drowsiness. Sedation anesthesia is often combined with local anesthetics to provide additional pain relief. With sedation anesthesia, you can breathe on your own, so there is no need for a breathing tube down your throat. Sedation anesthesia agents do not remain in the body long, and you can expect to feel normal within a few hours after surgery. Sedation anesthesia is also referred to as monitored anesthesia care (MAC), twilight sedation, or conscious sedation. Sedation anesthesia may be administered in varying levels: minimal, moderate, or deep. The anesthesiologist makes the decision about which level of sedation to administer. Minimal sedation: With this level of sedation, you remain awake but relaxed during your procedure, and you don’t feel pain or discomfort. Your memory of the procedure isn’t affected. Moderate sedation: You’ll feel drowsy and may sleep through portions of or all of your procedure with moderate sedation. However, you can be awakened if touched or spoken to. You may or may not remember what happens during your procedure. Deep sedation: You’ll sleep through your procedure and most likely won’t remember much, if anything, about it. This is often referred to as TIVA—total intravenous anesthesia. A laryngeal mask airway (LMA) may be used with TIVA as a way to keep your airways open during your procedure. The LMA consists of an inflatable silicone mask and a rubber connecting tube.
Local anesthesia numbs a small portion of your body, preventing you from feeling any pain in that area. Local anesthesia, when used alone, leaves you fully alert and allows you to breathe on your own. For rhinoplasty procedures, local anesthetics aren’t used alone, but are often combined with sedation anesthesia. Local anesthetics remain in the body for a very short time and don’t cause any feelings of sleepiness or grogginess.
The deepest form of general anesthesia produces a loss of sensation throughout your entire body and blocks your memory of the procedure. Basically, you won’t see, hear, or feel anything during your procedure. Because general anesthesia renders you unconscious, you may or may not be able to breathe on your own. For this reason, the anesthesiologist may place a breathing tube down your windpipe (trachea). General anesthesia agents remain in the body for up to twenty-four hours, so you won’t feel like you’re back to normal until these agents have been completely eliminated from your system.
Monitoring During Surgery
To ensure your safety, the anesthesia professional will monitor your body’s vital functions the entire time that anesthesia is being administered. While the facial plastic surgeon concentrates on making refinements to your nose, the anesthesiologist will focus on equipment that monitors your heart activity, breathing, circulation, and oxygen levels. EKG: The monitors that were attached to your chest, arms, and back during surgery prep are connected to an EKG (also known as an ECG) machine that monitors your heart activity. The EKG machine alerts the anesthesiologist to any changes in your heartbeat. Blood pressure cuff: A common blood pressure cuff is used throughout surgery to inform the anesthesiologist of any change in your blood pressure. Pulse oximeter: The pulse oximeter is clipped to the tip of your finger during surgery prep to monitor the amount of oxygen in your blood. The device is linked to a computerized unit, which sounds an alarm if there’s a drop in your oxygen levels. Ventilator monitor: If general anesthesia is used during your procedure, the breathing tube that is placed down your windpipe is connected to a ventilator, or artificial breathing machine. The ventilator breathes for you while you are under the effects of the anesthesia. To ensure that the breathing tube is placed correctly and that your ventilation levels are normal, the anesthesiologist will check the ventilator monitor.
Undergoing Your Rhinoplasty Procedure
If you’re having closed rhinoplasty, your procedure will probably last approximately one to two hours. If you’re having open rhinoplasty, your procedure will take about two to three hours. More complex cases may take even longer. Once you’re sedated, your surgery will begin with the surgeon making small incisions just inside the rim of each nostril. If the open rhinoplasty technique is being used, an additional incision is made on the columella, between the nostrils. This incision may be made in the shape of an inverted V, a W, or a zigzag, which is referred to as a “step off” incision. If your surgeon is using the open technique, the skin is lifted away from the underlying nasal structures so that they are clearly visible. In the closed technique, the skin is separated, but not lifted away, from the underlying tissues. Depending on the characteristics of your nose, your rhinoplasty may involve reshaping one, some, or all of the following: the bridge of your nose, the upper portion of your nose, the cartilage at the tip of your nose, and the nostrils. If it’s necessary to improve the function of your nose as well as its appearance, your surgeon may perform additional reshaping of the septum and other tissues within the nose. It’s important to note that each of these steps may be performed using a variety of surgical techniques. The techniques your surgeon chooses depend largely on your anatomy and his or her personal preferences. Likewise, surgeon preference often dictates the order in which the steps of the procedure are performed.
Reshaping the Bridge
Shaping the bridge of the nose may involve reducing or augmenting its size or refining its shape. The bridge of the nose consists of both cartilage and bone. To reduce a hump on the nose, a surgeon will remove excess cartilage and bone and then refine the remaining tissues with a rasp, an instrument similar to a nail file. When removing a hump, most surgeons take a conservative approach, removing less cartilage and bone than they think is necessary and then making minute refinements until the desired result is achieved. When a hump is removed, the remaining bone may have what’s called an open-roof deformity, or a gap between the two sides, that needs to be closed. This is done in a controlled manner by making fine cuts, small fractures called osteotomies, in the bone. These cuts are made with a small chisel, called an osteotome, and a surgical hammer. After the bone is cut, it is gently guided into the desired position. If the bridge of your nose requires only refinement, your surgeon may simply use a rasp to make slight improvements in its shape. To augment the size of the bridge, a surgeon may be required to add cartilage, soft tissue, or alloplastic material. (See the sections on “Cartilage Grafts”, “Soft-Tissue Grafts”, and “Alloplastic Implants” in this chapter for more information.) Augmenting the bridge of the nose is especially common in certain ethnic rhinoplasty procedures. Added cartilage is generally sutured in place within the nose and then refined.
Reshaping the Upper Portion of the Nose
The upper portion of the nose, which is made of bone, is commonly reshaped in rhinoplasty procedures. To narrow the nose, a surgeon must move the bones closer together. If a hump is removed from the bridge of your nose, your nose will most likely require narrowing as well. To correct a crooked nose, the bones must be realigned in a straight fashion. Narrowing and straightening the nose are both accomplished in a controlled manner by making osteotomies in the bone.
Reshaping the Tip of the Nose
The tip of the nose is made of cartilage. Reshaping it may involve reducing its size, refining its shape, augmenting its size, shortening or increasing its projection, shortening or increasing its length, or changing the angle between the tip and the upper lip. To reduce its size, shorten its projection, shorten its length, or raise its angle, your surgeon may remove or refine excess cartilage using a number of surgical techniques. In some instances, sutures may be placed in the cartilage to help achieve the desired effect. When the tip of the nose is too small and requires augmentation, a cartilage graft, a soft-tissue graft, or a combination of both may be necessary. In some instances, when the tip of the nose is the only portion of the nose that requires refinement, the procedure is called tip-plasty.
If your nose lacks adequate cartilage to achieve a satisfactory outcome, a cartilage graft may be necessary. When cartilage in the bridge of your nose or in the tip of your nose needs to be built up, your surgeon will most commonly use cartilage from your own septum. Cartilage is also commonly taken from your own ear. In rare instances, cartilage may be harvested from a rib, or it may come from donor tissue. When taking cartilage from the septum, the surgeon removes a portion of your septum that doesn’t affect the overall support of your nose. To take cartilage from your ear, the surgeon will make a well-hidden incision in the back of your ear, and remove a portion of the cartilage within. Removing cartilage from the ear may cause your ear to lie closer to your head, but will have no effect on your hearing. Taking cartilage from a rib requires an incision in the rib cage. The harvested cartilage is shaped and sutured strategically into your nose to achieve the desired result. When the cartilage comes from your own body, there’s no risk of rejection. In the rare instance that the cartilage comes from donor tissue, there is some risk that your body will reject it.
When augmentation is required in a rhinoplasty procedure, a surgeon may use soft-tissue grafts in lieu of or in addition to cartilage grafts and alloplastic implants. When cartilage grafts are added, there’s a possibility that these structures may eventually become visible under the skin. This is especially the case if you have thin to medium skin, if you’re having ethnic rhinoplasty, or if you’re having revision rhinoplasty – a follow-up procedure to refine a previous nose surgery. Revision rhinoplasty can cause the skin to thin and to contract more tightly around the underlying structures, creating a “shrink wrap” effect that can make the underlying cartilage grafts visible. By covering the cartilage grafts with soft tissue, a surgeon can often prevent them from becoming visible. Soft-tissue can be harvested from the nasal tip or from the deep temporalis fascia, which cover the mastication (chewing) muscles on the side of the skull. When deep temporalis fascia is used, the incisions are hidden within the hairline.
In some instances, alloplastic implants may be used in addition to or in place of cartilage grafts and soft-tissue grafts. For instance, if you would prefer not to use your own cartilage or soft tissue, your surgeon may use an alloplastic implant instead. These implants are pliable and easy to mold to the desired shape. However, the implants have been noted to have higher infection rates than when your own tissue is used. Alloplastic implants are more commonly used in revision rhinoplasty and ethnic rhinoplasty.
Reshaping the Nostrils
During your rhinoplasty procedure, your surgeon can change the shape or size of your nostrils. If your nostrils are too large or too wide, your surgeon can remove a wedge of tissue where your nostrils join your face. This technique, in which small incisions are made in the natural creases where the nose joins the face, is known as a “Weir excision.” Depending on the shape of the wedge removed, this technique can reduce either the width or the length of your nostrils. The resulting scars from these incisions are usually hidden in the natural creases of the nose and may be invisible or barely visible when fully healed. Another surgical technique used to reduce the size or flare of the nostrils is called “nostril sill incisions.” With this technique, small incisions are
Reshaping the Septum
The septum, the dividing wall between the two sides of your nose, is commonly reshaped during rhinoplasty. For instance, if you have a long nose, the surgeon may remove a portion of the septum near the base of your nose to shorten it.
Correcting a Deviated Septum
There are a number of ways to correct a crooked or deviated septum. Your surgeon may simply remove the portion of the septum that is crooked and blocking the airway. If that isn’t the best option, your surgeon may make small cuts or fractures in the septum and realign it to make it straighter. When this procedure is performed alone without any cosmetic reshaping of the nose, it’s called septoplasty.
Other Functional Improvements
If necessary, your surgeon may make additional functional improvements to other tissues within the nose. These improvements are made using a variety of surgical techniques.
Redraping the Skin
When your surgeon has finished reshaping the structures within your nose, he or she will redrape the skin over the new framework. If your nose has been reduced in size, your skin will contract to fit the size of the new framework. In general, it isn’t necessary to remove any skin during rhinoplasty. If cartilage grafts were added, the skin will likely be redraped over soft-tissue grafts to prevent the cartilage from becoming visible in the future.
Once the best results possible have been achieved, your surgeon will close the incisions. The incisions inside the nose and across the columella are closed using very fine sutures that are about as thick as a single hair. The sutures used in rhinoplasty may be absorbable, nonabsorbable, or a combination of both. Absorbable sutures dissolve on their own and don’t require removal in your surgeon’s office. Nonabsorbable sutures require removal in your surgeon’s office.
Once your surgery has been completed, dressings will be applied to your nose. Surgical tape is applied tightly to the skin across the bridge and, in some cases, under the base of your nose. The tape serves a dual purpose: it protects the skin and helps reduce swelling. A small splint is then placed on the bridge of your nose to stabilize the reshaped nasal bones and tissues. Nasal splints come in a variety of materials, including metal and plaster of Paris. The type of splint used is usually a matter of your surgeon’s personal preference. For added comfort, the underside of the splint may be lined with soft cloth. The splint may be self-adhering or may be kept in place with additional tape. Gauze pads are applied below the base of your nose and are taped into place. The gauze pads are used to absorb any postoperative nasal discharge. Cold cloths may be placed on your forehead to reduce swelling.
In the past, long strips of gauze coated with antibiotic ointment or petroleum jelly were used to pack the nostrils to minimize bleeding and support the nose following surgery. Although this nasal packing used to be commonplace, a growing number of surgeons have stopped using it because it increases discomfort, contributes to added swelling and bruising, and prolongs the recovery period. In addition, while nasal packing is in place, it’s impossible to breathe through the nose. Instead of using packing, surgeons now use special surgical techniques to control bleeding and provide nasal support. Some surgeons may insert a small pack of absorbent gauze inside the nostrils which will be removed the following day. It’s important to note that even if you don’t have any packing in your nostrils, postoperative swelling may make it difficult to breathe through your nose for a few days after your surgery. Some surgeons may place pliable nasal splints made out of silicone inside the nostrils, especially if the septum was severely deviated. These splints are usually removed in your surgeon’s office in approximately one week. Although the splints have tubes attached that allow you to breathe through your nose after surgery, they are usually considered uncomfortable. Most patients prefer not to have anything inside the nostrils following surgery.
If your surgeon has determined that chin augmentation, in addition to rhinoplasty, will help you achieve a more balanced profile, the augmentation is often performed at the time of your rhinoplasty procedure. The chin implant is usually performed first and takes about thirty minutes. During this procedure, an incision is made either underneath your chin or inside your mouth where your lower lip meets your gum. The surgeon then inserts the chin implant. Chin implants come in a variety of shapes and sizes and are made of natural-feeling synthetic material, such as solid silicone. Once the implant is in place and the desired chin projection is achieved, the surgeon closes the incision with fine absorbable or non-absorbable sutures.
In the Recovery Room
After your rhinoplasty procedure, you’ll be taken to the recovery room. During your stay in the recovery room, your vital signs will continue to be monitored closely. You can expect to feel drowsy while you’re in the recovery room. This drowsiness will soon dissipate; how long it lasts depends on the type of anesthesia used, your individual response to the anesthesia, and whether you received other medications. If you’re like most patients, you may be worried about feeling pain immediately following your procedure. Rest assured that there is generally little or no pain following rhinoplasty.
Side Effects of Anesthesia
You may experience some side effects as the anesthesia wears off. The degree to which you experience side effects is highly individualized and may depend on the type of anesthesia used. In general, side effects from sedation anesthesia, commonly used for rhinoplasty, are minimal. It’s common to feel confused and disoriented. Mild reactions to anesthesia also include nausea, sore throat, and dry mouth. However, thanks to anti-nausea medications, the risk of nausea and vomiting following surgery is very low. Allergic reactions to anesthesia are rare and are usually preventable. By informing your surgeon and anesthesiologist of all known allergies, you can help prevent an allergic reaction. Based on the information you give them, your surgeon and anesthesiologist will select the anesthesia drugs least likely to produce a reaction.
Leaving the Surgical Facility
You’ll continue resting in the recovery room until the staff decides that it’s safe for your caregiver to drive you home. Most Beverly Hills rhinoplasty patients are ready to go home within a few hours after surgery.