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Nose Enhancement
Corrective nasal surgery is
near the top of the list as one of the most common
aesthetic surgical procedure. This operation has its
origin centuries ago when Indian surgeons
reconstructed the noses of women who had been
disfigured as punishment for adultery. Children with
birth disorders (cleft lips) have also undergone
nose and lip reconstructions for centuries. In the
early part of this century, a European orthopedic
surgeon, Dr. Joseph, first performed the landmark
operation of aesthetic reduction rhinoplasty (nasal
surgery) to improve the appearance of an unmarried
female relative. Since that time, dramatic
refinements in technique have occurred. Rhinoplasty
today can improve both appearance and function of
the nose.
There are numerous nose
procedures that people desire. Some persons may wish
to reduce the size of their nose, while others have
a bump on the top of the nose that appears prominent
from a profile view. Still others want the tip of
the nose to be narrowed and less prominent. This is
the so-called tip procedure. It is this procedure
that benefits the aging nose, since one of the
telltale signs of aging is a sagging nasal tip.
Often rhinoplasty is considered as a midlife
improvement for self-esteem or nasal breathing. The
desire for correction may have been present earlier
in life, but the operation may have been postponed
because of financial or other considerations.
Most people today are aware of the
benefits that a nose operation offers them and what
can be achieved if you are not timid about altering
appearance. Although society in general thinks
favorably of aesthetic surgery, some people may wish
to remain low key about their surgery. In many cases
your friends and family may not even notice that
you’ve had a nose operation, but for the most part
simply think you look "better."
It is important to realize that
the goal by today’s standards is to achieve a
natural-looking nose that fits the face, not a "nose
job" that looks unnatural. When the nose fails to
look natural or fit the face, it presents an element
of distraction, preventing the natural focus of
attention to the person’s eyes. It is extremely
important for the surgeon to strive for balance of
the face to achieve natural appearance. The move has
been away from the turned up "Hollywood nose" of
yesteryear to a stronger nose and, more importantly,
one that suits the remainder of the face for
complete harmony.
Structure of the Nose
To understand surgery of the
nose, it is important to understand the structures
of the nose and some terminology. The top of the
nose that extends from the forehead to the tip of
the nose is the dorsum. Nostrils are the opening
through which air passes to the lungs. The center
divider, which separates each nasal passage from the
other, is called the septum.
Underneath the skin, the front
part of the nose is made up of cartilage, a
"springy" material also found in the ear. The
cartilage of the nose can be surgically reshaped. If
you grasp the front part of the nose, it is the part
that wiggles back and forth. The top part of the
nose that cannot be wiggled back and forth is made
up of bone. These are the bones that join with the
forehead at the top of the nose and with the
cheekbones.
The nose is like a tent.
Cartilage and bones join to form the sides and top.
The septum or center divider of the nose forms the
wall between the nasal passages. This center divider
may be pushed off to one side or the other, or it
may take several bends, blocking both sides of the
nose. Operations to clear the nasal air passages
often involve moving the components of the septum
back into the middle of the nose to create an equal
airway on both sides. Procedures on the nose may
also involve the turbinates, which are folds that
grow off the inside of nasal bones. They are highly
vascular and are lined with mucus membrane.
Sometimes, because of allergy or irritation, these
folds will become overly large and must be trimmed.
Should there be more than one cause of nasal
obstruction (e.g., allergies), this too must be
dealt with after appropriate diagnosis and
prescribed medication. Frequently, correction of
breathing problems is covered by medical insurance.
It is obvious that if the
top of the tent is shaved off, there is a
separation, at the top, between remaining sides of
the tent. This is true for the nose as well so when
the dorsum is reduced significantly, the sides have
to be moved in order to make the nose more narrow
and with a pleasing, straight dorsum. In order to do
this, the bones of the nose must be repositioned.
This is done by scoring and breaking the bones and
then moving them as needed. Although this sounds
rather rough, the bones of the nose are very fragile
and is not unduly traumatic.
The tip of the nose extends
past the top of the nose in profile. This look to
the nose is one of the features that differentiate
an attractive nose from one not so attractive. The
tip is formed from other cartilage called alae.
These alae are worked with in a variety of ways from
suturing to placing grafts on them to trimming them
depending on what is present structurally and what
is desired as a final result of the surgery. This
tip work is best done (when extensive) through what
is called an open rhinoplasty. This is where a tiny
incision is made at the bottom base of the nose (the
columella) and the entire structure of the nose is
laid open to be worked on in plain site. For the
precision of the tip work often required, the tiny
scar is an excellent trade. Your surgeon should
discuss these options with you prior to the
procedure and make his preference and reason for
incisions and approach clear to you.
Making incisions and reducing
their width can narrow the base of the nostrils,
where they join the cheek. This leaves tiny scars
but the crease largely hides where they lay. This is
a very useful adjunctive procedure in those who have
very wide, flaring nostrils. It also gives the
illusion of a longer nose by making it narrower.
So far, we have been
discussing reduction rhinoplasty, i.e.. Making the
nose smaller. There is also a huge group of patients
who desire to have their noses made larger. This
usually involves making the dorsum higher and the
tip project more away from the face. In many
instances the nasal dorsum can be made higher by
simply inserting a silastic or polymeric implant.
This is not possible in areas of the nasal tip since
these do not do well when there is skin tension on
them. By and large, it is best to build up the tip
with the patient’s own tissue; usually a small piece
of cartilage borrowed from the septum. In some
instances, the dorsum should also be built up with
the patient’s own cartilage and/or bone. It is best
to discuss all of the options, benefits and
downsides of each substance or technique with your
surgeon.
Under no circumstances should you
allow anyone to inject any sort of silicone,
paraffin, oil, etc. into your nose in order to build
it up. Cosmetic surgeons have seen many disasters
from these injections and, once done, it is
essentially impossible to remove. This is a common
practice in Asia and is mentioned here only to be
condemned.
Surgery
Operations on the nose are
often performed with incisions placed inside the
nose, out of sight. Under certain circumstances,
however, incisions may be placed on the outside of
the nose. These incisions will be carefully located
in natural folds of the skin so as to be hardly
noticeable.
Modeling of the tip of the nose
involves working on the tip cartilages. Two
cartilages that make up the nostril and wrap around
to the top of the nose are often trimmed and/or
rotated to form a finer, more sculptured tip. Bumps
on the nose often involve removing portions of the
upper cartilages and nasal bones that form the
dorsum of the nose. After a nasal operation, tape
will be applied to the outside to hold the skin to
the new bony and cartilaginous framework that has
been provided by the surgery and is responsible for
the new, improved appearance. A splint may be placed
over the tape to help hold the bones in position
during healing. This cast may be in place from five
to seven days.
It is best to discuss with your
surgeon exactly what procedure will be necessary to
remove a hump, decrease the length or width of the
nose, correct a deviation, or build up depressions
of the nose. The doctor will also be able to tell
you if you require work on your septum or turbinates,
especially if you suffer from a stuffy nose,
snoring, or sinus problems.
Before and After Nose Surgery
Most patients want a pleasing natural
look to the nose. Discuss in detail what you wish to
have done to your nose with your physician before
the surgery. Often, particularly for nasal surgery,
I find that computer aided imaging is useful as a
format in order to clarify exactly what my patient
desires prior to surgery. It is also an excellent
means for me to communicate what is and what is not
possible for a given patient based on their anatomy.
Postoperative
It is important to limit strenuous
physical activities in the immediate postoperative
period. You may return to light work in a few days,
but no activity which might be strenuous for two to
six weeks. Again, discuss this with your surgeon,
because there are individual variations in allowable
activity.
After surgery on your nose, you
may expect to have some stuffiness in the nostrils,
especially if packing is used. There is very little
pain associated with the procedure. You may have
"black eyes" which will clear in a week or two, but
most people have only mild swelling and/or mild
bruising.
When the splint is removed,
there will be some swelling of the nose, both inside
and outside, but this usually dissipates within two
to six weeks. It will, however, be several months
before every bit of the swelling is gone from the
nose and the final result can be appreciated.
Swelling around the tip may take somewhat longer to
dissipate, sometimes up to one year, although this
is not obvious to the observer.
Complications
Due to individual differences
in the way the bones and cartilages of the nose
heal, it is possible to have a surgical result that
is not as pleasing as desired. In this case,
touch-up operations or "fine tuning" may be
necessary. These are usually minor procedures that
are often performed under a local anesthetic. If you
notice problems in the healing process, return to
your surgeon who will give the appropriate
treatment. Your surgeon may suggest at the time of
your postoperative visit any corrective or "fine
tuning" procedures that in his opinion would further
enhance your appearance.
Once again it will be most
pleasing and life enduring to have as natural a nose
appearance as possible. One that fits your profile
from brow to chin.
Some numbness and swelling in
the tip of the nose generally persists for several
months. Healing is a gradual process that cannot be
hurried. Often, residual bumps will resolve as the
healing progresses. Thick skin of the nose may also
affect the end results.
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