Rhinoplasty

The nose is a central and prominent feature. Its size and shape are largely determined by genetics. Where the nose is larger or smaller than the rest of the face will carry, or is asymmetric, people may feel self-conscious about it; and a nose with structural problems may also cause difficulty breathing.

Rhinoplasty is one of the most common operations performed at EIPS. It is designed to improve both the appearance and the function of the nose. It is also a demanding procedure. During nasal surgery the surgeon has to think in three dimensions at all times, and a few millimetres can make the difference between a good result and an average one.

What rhinoplasty does

Rhinoplasty improves the appearance of the nose and its relationship to the rest of the face. It can involve subtle or substantial changes to the shape, size, length, bridge, tip and nostrils.

It also treats breathing problems caused by a deviated septum, including sleep apnoea and snoring. In these cases the surgery is combined with a procedure on the nasal septum or the turbinates.

Some patients have suffered an injury to the nose, such as a nasal fracture from an assault or an accident.

The operation suits people whose nose is overly large or too small, or which moves during speech and smiling. The proportions that work are the ones proportional to the rest of that person’s face.

Types of rhinoplasty

The nose is built on a supportive skeleton. The lower two-thirds are the nostrils — flexible cartilage, like the cartilage of the ear. The upper third is bone. A further midline cartilage partition, the septum, divides the two airways behind the nostrils. The septum supports the cartilaginous part of the nose and prevents it collapsing. Surgery on Caucasian noses generally aims to reduce size by reducing both the cartilaginous skeleton and the bone.

Open rhinoplasty

The open technique allows comprehensive visualisation of the cartilaginous and bony skeleton and so facilitates precise correction of nasal deformity. A subtle incision is made at the base of the nose, across the columella between the two nostrils, with additional incisions inside the nose. Open rhinoplasty suits patients with more severe deformity or with injured noses. Revision surgery is typically performed only with an open technique.

Closed or endonasal rhinoplasty

Closed rhinoplasty uses incisions inside the nostrils, in the mucous membrane. No incision across the outer skin is necessary. The surgeon does not have a clear view of the nasal skeleton, which makes the technique more difficult. The advantages are reduced healing time and no visible scars.

Ethnic rhinoplasty

The shape and size of the nose vary with ancestry. Conventional reduction techniques are often unsuitable for wider nostrils or flatter noses. For a small nose, cartilage is taken from another site — the rib, skull or ear — and reshaped to fit the recipient area, for example the bridge line. Changes to the nasal bridge, adjustment of the angle of the nose and the size of the nostrils are typical. The aim is a nose that harmonises with the patient’s own heritage rather than one converted to a different template.

Non-surgical or liquid rhinoplasty

Non-surgical rhinoplasty makes minor, temporary changes to the nose. Soft tissue fillers with hyaluronic acid are injected to reshape subtle nasal irregularities. The fillers may last up to a year. Liquid rhinoplasty is a medium-term solution, commonly used as a test before a patient opts for surgery, which is permanent. It cannot correct all types of nasal abnormality; it suits patients who need minor correction of the tip or the nasal bridge.

Septorhinoplasty

Septorhinoplasty addresses both the functional and the aesthetic problems of the nose in one operation. Its primary objective is to improve breathing through the nose by straightening the septum — the partition inside the nose that divides the nostrils. It suits patients with a deviated septum.

Rhino-tip surgery (tipplasty)

Tipplasty modifies the structure of the underlying cartilage to improve the shape of the nose. It reduces the width of the nose and lifts the tip. The nose is reshaped from the inside to keep scarring minimal, though depending on the nasal structure it can also be performed with an open technique. Tipplasty involves no bone work, so it suits patients who do not need a dorsal hump removed.

Cases suited to rhino-tip correction include:

• Big boxy tip — a large, rounded tip due to thick skin.
• Bent or crooked tip — one nostril looks bigger than the other, causing nasal asymmetry.
• Hooked tip — tip rotation problems, such as an over-projecting tip.
• Large and wide nostrils — flared nostrils that make the nose look flattened.

Ultrasonic rhinoplasty

Traditional methods use bone files, chisels and mallets, which lead to bruising and swelling and a longer recovery. EIPS is one of the few centres in Cyprus, Greece and Malta using the piezotome, or ultrasonic, method. Concentrated, high-frequency ultrasound sculpts the bony skeleton without injuring the nasal soft tissues, which reduces swelling, bruising and discomfort, and recovery is quicker than with conventional techniques.

Revision or secondary rhinoplasty

Where a primary rhinoplasty has not produced the intended result, patients may opt for revision surgery. It is more complex, and some surgeons decline to perform it. Patients must have fully recovered from their previous nasal surgery before a revision is considered.

What it improves

Aesthetically:

• Smooths bumps on the dorsum
• Reduces the size of the nose
• Narrows the bridge
• Shortens a drooping tip
• Reshapes and refines an asymmetric tip
• Improves overall facial symmetry and proportion

Functionally:

• Improves difficulty breathing
• Corrects traumatised and damaged noses
• Corrects anatomical defects such as a bent nose, septal deviation, turbinate hypertrophy and nasal valve collapse
• Improves the quality of sleep and reduces sleep apnoea
• Relieves symptoms such as allergy and congestion

What the operation involves

On the day of surgery, nursing staff record the patient’s vital signs. The anaesthesiologist then meets the patient for a pre-operative airway assessment, and the surgeon marks the sites of the nose to be treated.

Anaesthesia General anaesthesia, performed by a certified anaesthesiologist.

Incisions The number and type of incision depend on the rhinoplasty designed for the individual patient. In an open rhinoplasty, a subtle incision is made at the base of the nose, across the columella between the two nostrils. In a closed rhinoplasty the incisions are inside the nostril.

Closure The incisions are closed with close attention to detail.

A primary rhinoplasty takes roughly two to four hours. A revision rhinoplasty may take longer.

Recovery

After the procedure the patient recovers in the recovery suite. A few hours later the surgeon gives post-operative advice. A gauze dressing is strapped under the nose, which the patient changes at home, and a splint is worn for up to ten days. Bleeding from the nostrils over the first few hours is common where the septum or turbinates were treated. Oral analgesia relieves post-operative pain.

A responsible adult must accompany the patient home and stay with them for the first 24 hours. The EIPS post-operative team is available round the clock during that period and calls regularly to check that recovery is proceeding normally.

Over the first week there is discomfort, with bruising and swelling in the treated area and under the eyes for the first seven to ten days. These are more pronounced in complex rhinoplasties involving resetting the nasal bones. In general, recovery depends on the extent of surgery and on any accompanying procedures.

The splint is removed at the follow-up visit, seven to ten days after surgery. The nose is usually still swollen at that point. The final shape takes from six months up to a year to settle.

Sunlight should be avoided to prevent pigmentation of the skin, and smoking should be avoided. Intense exercise and heavy lifting are not permitted for at least four weeks, though walking and similar gentle exercise help reduce the risk of blood clots.

Although the result is permanent, the soft tissue and cartilage of the nose may change over time.

Who it suits

Healthy people with no serious medical history are candidates for rhinoplasty, provided they have realistic expectations of what the surgery can achieve. Patients should be at least 18 years old: an immature nasal skeleton makes the result less reliable. Objectives and concerns are discussed in depth at the initial consultation.

Where the surgery takes place

Dr. Stavrou performs rhinoplasty in accredited medical centres in Nicosia, Limassol, Athens and Sliema. After the procedure the patient is transferred to the recovery suite and monitored by the medical staff.