Cosmetic & Functional Rhinoplasty Surgeon, Ear Nose, Throat, Head & Neck Surgeon

Overview

Rhinoplasty is surgery on the nose that will impact on its external appearance. This may be a cosmetic rhinoplasty with the goal of improving one or several elements of the noses appearance such as straightening the bridge (dorsum), improving the profile, correcting tip asymmetry and projection or correcting irregularities of the nostrils (alar). Functional rhinoplasty has the primary goal of improving the ability to breathe through the nose (improve nasal airway). In many individuals the nasal airway can be improved without a rhinoplasty, but in some, the structural components contributing to the blockage require a rhinoplasty such as: The side walls of the nose being sucked in with inspiration (nasal valving), crookedness of the nasal septum high in the nose, loss of tip or alar support or just severe external deformity (a very crooked nose) sometimes secondary to trauma. Like cosmetic rhinoplasty, functional rhinoplasty looks to improve the appearance of the nose but it is performed in individuals whose primary concern is nasal blockage. Some people who have a functional rhinoplasty are happy with the appearance of their nose but require this surgery as the cause of their blockage requires this surgical approach.

I perform both cosmetic and functional rhinoplasty.

Rhinoplasty is often combined with septoplasty and turbinoplasty. Septoplasty is straightening of the internal nasal septum (the midline wall between the two nostrils). This helps with the nasal airway as well as can improve nasal support and in some instances external straightness. Turbinates are vascular pads on the internal sidewalls of the nose that fluctuate in size over the day to regulate airflow. Turbinoplasty is surgery to reduce the size of these pads to aid the nasal airway. It is commonly combined with septoplasty. I perform turbinoplasty endoscopically (with the use of a small fibreoptic telescope and camera).

FESS (Functional Endoscopic Sinus Surgery) is surgery to aid in drainage of the sinuses in people who suffer from various symptoms such as facial pressure or infected nasal discharge. If limited this can often be combined with the above surgeries. However, if sinus work is more involved it may need to be performed at a separate time to your rhinoplasty (usually before) as the packing in the nose for a few days after rhinoplasty can otherwise lead to a sinus infection that may impact on your surgical recovery and result.

Expectations

Depending on the complexity of the rhinoplasty, I will usually see most patients twice before their eventual surgery. We will discuss what our goals of surgery are. I will ask you what you are hoping to achieve (the look you are after), discuss the achievability of this and how we would go about it as well as possibly recommend other minor elements to refine to balance out this look. We need to both be on the same page before proceeding further. Occasionally, even after lengthy discussion, patient’s cosmetic desires are in conflict with what I think is achievable or what would look aesthetically pleasing. In these instances, I would not proceed to surgery. Not every nose will suit every face and not all nasal aesthetics are achievable. I am quite clear on these issues during the consultations and document clearly our agreed goals of surgery. If you change your mind or have some new ideas DO NOT bring these up when I pop in to say hello immediately prior to your surgery. Let my staff know and I will arrange another pre‐op consult.

The skin envelope covering your nasal cartilage and bony framework is one of the biggest factors in determining your potential cosmetic rhinoplasty outcome. Very thin skin and very thick skin each pose their own challenges and I will discuss this pre-op as needed. How well we look after the skin in the post-op period is very important especially in these very thin and thick-skinned individuals. Smoking compromises blood flow and healing especially in small vessels such as those that supply the nose tissues, internal lining and skin envelope. For any significant rhinoplasty I will strongly recommend cessation of smoking for 2 months pre-op and as long as possible post-op. Post-operative nasal infection can be disastrous in major nasal reconstructions and poor blood supply via scarring (from multiple previous surgeries or trauma) and smoking are major contributors.

Photos will be taken pre‐operatively in my office and at certain stages post‐operatively.

The surgery itself is done under general anaesthetic (fully asleep) and can take between two and six hours depending on surgical complexity. You will see your anaesthetist immediately before your surgery who will discuss the anaesthetic process and at this stage, you can raise any minor concerns you have. If you have significant health or other concerns in regard to the anaesthetic please raise these with me during your consults so I can notify the anaesthetist, if needed, well in advance. I like to keep rhinoplasty patients in hospital overnight to minimise activity, monitor blood pressure to reduce bleeding, manage pain as needed and keep cool packs on the cheeks and eyes to reduce potential swelling. I will see you the next morning at which stage most patients go home with discharge pain medication and antibiotics.

Rhinoplasty may be performed as an Open (single small external incision [cut] on the narrow bridge of skin between the nostrils under the nose) or closed procedure (no external incisions). Both types of rhinoplasty involve internal nasal incisions. All internal incisions have dissolving stitches while for an open rhinoplasty the small external incision under the nose is closed with 5‐7 tiny stitches that may be dissolving (with skin glue applied over them) or need to be removed 6‐8 days post op. Nearly all rhinoplasties I perform are done in the open manner as this allows much better exposure/ access to the nasal framework to not only (much more accurately) achieve the desired cosmetic result but better access the nasal septum from above to improve the airway, source cartilage for grafts if necessary and allow better visualisation for stitches to shape and support the nose. Apart from the small incision externally under the nose (that should be expected to heal very inconspicuously), the open approach is well recognised as offering greater advantages in accurately shaping and supporting the nose.

In some cases, grafts (of usually cartilage) may be required to strengthen and shape your nose. I will usually know this in advance and discuss it during our pre‐op consults. This cartilage is usually taken from the nasal septum, but in some cases a graft may need to be taken from your ear or, where a larger reconstruction is necessary, your rib. Again, this would be outlined pre‐op if needed. I very commonly use rib cartilage.

Aftercare Instructions

I will usually briefly discuss how your surgery went with you on the evening of surgery but leave more detailed discussion until the next day as many people do not remember the details (or often even seeing me at all) on the day of surgery after their anaesthetic. I will usually speak to a nominated family member or friend after your surgery (if desired).

When sleeping, keep your head elevated on 2 pillows for the first 7 days after surgery. During the day for the first 72 hours, apply crushed ice in an ice bag to your cheeks and eyes to minimise swelling and bruising as much as possible. Do not put pressure on the splint on your nose.

It is normal to continue to swell for several days. It usually reaches its peak 48‐72 hours after surgery.

Pain Medication

For moderate to severe pain you will usually be supplied with paracetamol (2 tablets 4 hourly as needed) to take with Oxycodone (Endone) (5‐10mg 4 hourly as needed). The endone will make you drowsy and in some may produce nausea. If I have taken a rib graft you may also be supplied with a slow release opioid painkiller (Targin or Palexia SR) to use in addition to the above medications. If you have no pain ‐ do not take anything. For mild pain take paracetamol only. Do not exceed more than 8 paracetamol (Panadol) per day. Endone is strongly constipating, if consumed regularly you should also start a regular laxative (e.g. Coloxyl and Senna, Metamucil or lactulose).

If you have pain despite the above regular medications or have a reaction to any of the above let me know.

I will sometimes supply you with a short (3 day) course of tranexamic acid tablets to help bleeding or bruising in those who required a lot of bony work in the reconstruction.

DO NOT take non‐steroidal anti‐inflammatory medicines such as ibuprofen (Nurofen) within 2 weeks of surgery as this can promote post-operative bleeding.

DO NOT drink alcohol while taking strong pain medication.

After surgery, begin on that day with a light diet of fluids only. The next day you can begin a soft, regular diet but for 2 weeks avoid foods that require excessive lip movements such as apples or corn on the cob, etc. Avoid hot foods for 3 days.

I will usually see you between 6 an 8 days post‐op to remove your external nasal splint, stitches and any internal splints. You will feel much better after this visit. Removing the internal splints is not overly painful. In many instances, I may leave the external cast for 2 weeks or apply a new cast or just taping after 1 week to help swelling and skin smoothness. My staff will contact you for this first appointment. Prior to this, you should expect some light bloody discharge from the nose.

Antibiotics will be provided for the first 10-14 days after surgery. After your first appointment with me at day 6‐8 you can commence nasal douches or sprays. I will advise you of this.

If you need to sneeze in the 2 weeks post‐op do so through your mouth.

With your nasal splint on you may wipe your face with a moist face cloth. Do not splash water on your face and do not get your splint wet. You may wash your hair with assistance (hairdresser style) keeping your splint dry but best to wait until after your first consult.

You will be supplied with some kenacomb (Otocomb) ointment from the hospital. Apply this on a cotton tip/ bud and place it just inside your nostrils (just to the depth of a cotton bud head) twice per day to keep it from getting crusty. Start this the first day after your surgery and usually continue for a couple of weeks until no longer crusty.

General Instructions

Avoid strenuous activity (anything that gets your heart rate more than 100 beats/ min) for the first 3 weeks after surgery. Normal activity after 3 Weeks.

Avoid bumping your nose for 4 weeks after surgery. If you get a bump on the nose and it becomes crooked or changes then contact me for review.

After the splint is removed avoid wearing sunglasses for 4 weeks. For corrective eyewear, these may be worn but for the first 2 weeks apply some tape between your glasses and your forehead to take the weight of the glasses of your nose. If your glasses are leaving prominent impressions on the sides of your nose, avoid using them. Wear contact lenses if possible.

The skin on your nose is sensitive to sunlight after your surgery. Protect your nose from excessive sunlight for 6 months. Usual measures of a broad-brimmed hat and quality sunscreen recommended. Don’t apply makeup, moisturiser or sunscreen to your nose for the first 2 weeks.

After your splint is removed you may wash the nose gently with a mild bland soap. No special deep cleansing products for 2 weeks as your nose skin will be quite sensitive.

The tip of your nose will feel numb after rhinoplasty and your upper lip and front teeth may feel a bit ‘funny’. These sensations will slowly resolve. The tip numbness usually takes several months (3-4) to totally disappear.

Much of the swelling will be gone 2‐3 weeks after surgery. It often takes approximately 1 year for the last 10% of the swelling to settle. Thin skinned people quicker, thick-skinned longer than this. Your nose may feel stiff when you smile and not as flexible as before surgery. This will be especially so over the first 3-4 months after your surgery and is a normal healing phenomenon. It is not noticeable to others and things will gradually return to normal. Your nose may remain stiffer if increased support was one of the goals of surgery.

Contact

I am very particular about rhinoplasty surgery. Your outcome is very important to me. An excellent result is not just about concise pre‐operative assessment, clear expectations, discussion and skilled operative techniques but also close adherence to postoperative recommendations.

If you have concerns:

If a public hospital patient please contact the ENT registrar at either Monash Health or Alfred Health where you had your surgery. You can ask for them through the hospital switchboard. They will contact me if needed.

If a private patient please contact my office with any concerns. If this is out of hours and you feel the concern is urgent then the message bank in the office will direct you to contact the nurse manager at the hospital where you had your surgery. They will then contact me if needed.

This may be for any significant or persistent bleeding, significant medication reaction rash or swelling), nausea, vomiting, wound concerns, trauma to the nose, persistent fever above 38.5°C, redness, shortness of breath or increasing pain.

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