What is a rhinoplasty?
The term rhinoplasty comes from 2 Greek root words: ‘rhis‘ from which we get ‘rhino’ which means nose; and ‘plassein’ from which we get ‘plasty’ or to reshape. In English, a rhinoplasty is a surgical procedure to alter the shape of the nose. As simple as this sounds, it is a delicate, intricate, and complex procedure that relies on principals of architecture and artistry to reshape cartilage and bone to create beautiful and long-lasting outcomes.
Many of the maneuvers traditionally used by surgeons during a rhinoplasty are performed to create a smaller or refined nose. While these changes will look beautiful in the operating room, they can result in collapse of the nose over time leading to worsening nasal obstruction and poor aesthetic outcome. When choosing a surgeon, ensuring they have advanced training in rhinoplasty and ample surgical experience with hundreds of rhinoplasty cases can minimize these risks and the risk of requiring revision surgery. Surgeons with advanced cosmetic training through accredited facial plastic surgery fellowships and double board certification are rhinoplasty experts.
Types of rhinoplasty
There are 3 main approaches to rhinoplasty.
- Endonasal or ‘closed’ rhinoplasty use invisible incisions inside the nose.
- External or ‘open’ rhinoplasty uses a small incision on the skin between the nostrils and below the tip of the nose.
- The third type of rhinoplasty is a ‘liquid rhinoplasty’ and is not surgery at all. This approach uses hyaluronic acid fillers to temporarily camouflage bumps and create illusions of rotation and projection.
At our office in Guelph, just a short drive from Kitchener or Milton, rhinoplasty begins with an in-person consultation wherein Dr. Brace will perform a detailed examination of your nose to determine which approach is the most appropriate for each individual.
Cosmetic vs. Insured Rhinoplasty
Another commonly asked question in our clinic is whether or not insurance (OHIP here in Ontario) will cover all or part of a rhinoplasty (nose job) procedure.
Here is a breakdown of what is covered and what is paid for out-of-pocket by the patient:
- OHIP-covered rhinoplasty – A rhinoplasty or septorhinoplasty is covered by insurance when there is a functional issue with the nose (i.e. deviated septum, trouble breathing, nostril collapse) or if trauma to the nose has occurred and it is causing functional impairment. In order to be covered, a referral from your physician to the surgeon (Dr. Brace) is required. Any cosmetic changes to the shape of the nose are not covered by insurance.
- Out-of-pocket rhinoplasty – A rhinoplasty is paid for by the patient as soon as any cosmetic changes are desired (i.e. removal of bump, change in width, tip work, altering nostril shape/size, etc).
Since Dr. Brace is a trained ear/nose/throat specialist, he will always address any functional (breathing, etc) issues at the same time as the cosmetic concerns.
We do not offer combined rhinoplasty cases, where part of the surgery is covered by the patient and part covered by OHIP. Because cosmetic cases are performed at a private surgical centre (and not at an OHIP-funded community hospital) the patient needs to cover the cost of renting the facility and we cannot bill OHIP for a portion.
Who is a Candidate for Rhinoplasty?
The nose plays both a central aesthetic role in facial beauty and a functional role in breathing. You may be considering a rhinoplasty if you feel the shape, size, or symmetry of your nose distracts from the overall aesthetic balance and harmony of your face. If you also have difficulties with nasal breathing, altering the shape of the nose will often also improve nasal airflow and breathing. In some cases, the septum (the middle wall on the inside of the nose) is also reshaped and straightened in which case the surgery is referred to as a ‘septorhinoplasty’.
Men and women of every ethnicity and background pursue rhinoplasty for a variety of reasons. Age plays a factor and, in general, a young adult should be finished growing before pursuing surgery. There are familial, cultural, and ethnic considerations for every person and every nose. Techniques vary for each type of nose. A consultation to determine your personal aesthetic goals and an exam of your nose is required to create an individual and specific surgical plan.
Rhinoplasty by Dr. Brace
Dr. Brace is a rhinoplasty expert trained through the American Academy of Facial Plastic and Reconstructive Surgery. He is double board-certified in facial plastic surgery, by the Royal College of Surgeons of Canada and the American Board of Facial Plastic and Reconstructive Surgery. The process of gaining his Board Certifications required 5 years of surgical training in Canada, 1 year of dedicated facial plastic surgery training at the Ohio State University, and 2 years of surgical practice with peer review of his results. This is in addition to passing both written and oral board exams. After thousands of hours in the operating room under the tutelage of his fellowship director, and hundreds of rhinoplasty cases, Dr. Brace’s skill and expertise in creating natural, beautiful, and functional rhinoplasty results attracts patients from across Canada.
Whether your nose requires minor modifications or major reconstruction, Dr. Brace can help you achieve long lasting, natural looking, results with optimization of your nasal breathing. Dr. Brace is a nasal airway specialist and regularly teaches rhinoplasty and nasal airway surgery to surgical residents. He has presented advanced surgical rhinoplasty techniques at national and international surgical meetings to fellow surgeons and trainees from around the world.
The consultation is the first and most important step in achieving a fantastic rhinoplasty result. During this visit Dr. Brace will assess your general health, your facial balance and your nose. He will then discuss your aesthetic goals and desires. Dr. Brace uses 3D computer imaging and morphing software to alter images of your consultation for nose surgery. Milton and Kitchener residents are just a short drive from our office in Guelph and rhinoplasty consultations are always done in person so the doctor is able to ensure that the nose you desire is clearly communicated. From this discussion and these images he will explain the approach and surgical plan to achieve the best rhinoplasty result.
Before & After
Dr. Brace currently performs rhinoplasty surgeries in the hospital under general anesthetic. The surgery is a day surgery procedure and usually takes 1-4 hours to complete depending on the complexity of the case. Sometimes additional cartilage is needed and cosmetic incisions may be made to access rib or ear cartilage. If needed, this will be discussed and pre-planned at the time of consultation.
Patients are able to go home the same day of surgery after a period of observation in the recovery room. After a rhinoplasty, you will require a ride home from a friend, family member or other caregiver. After a rhinoplasty Dr. Brace dresses the nose with surgical tape and a nasal splint. If an external approach rhinoplasty was performed there will be 5-6 fine small sutures below the tip of the nose. There are also fine absorbable sutures inside the nose. Dr. Brace uses gentle and light packing in the nose using Telfa gauze. This is to absorb any bleeding from the incisions inside the nose and to provide light pressure overnight. It is removed the next day. Regular gauze ‘moustache dressing’ is gently taped to the cheeks and suspended under the nose to catch any drips of blood from the nostrils. A prescription for pain medication (and antibiotics if required) is provided.
RECOVERY AFTER SURGICAL RHINOPLASTY
Bruises: After leaving the hospital it is not uncommon to start to notice bruising around the eyes. This occurs if the nasal bones were broken as part of the surgery. Dr. Brace uses very small and fine instruments for this portion of the surgery to minimize bruising whenever possible. Gentle application of ice packs help decrease the bruising. Anti bruising treatment with Arnica supplements will be discussed preoperatively and provided if desired.
If rib or ear cartilage was required there may be bruising in the skin of the right chest or ear and neck respectively. Ice can be used here as well.
Bleeding: a small amount of dripping from the nose onto the ‘moustache dressing’ is common and of no concern. Change the dressing as needed but leave the gauze inside the nose.
Swelling: The tip of the nose will be visible below the splint and this along with the columellar skin (under the tip with the stitches) will be swollen. If ear cartilage was used the conchal bowl of the ear will be swollen.
Nausea: some people develop nausea as a reaction to the anesthetic medication. IV medicines are given to minimize this. Gravol can be taken at home if it persists. The nausea does not usually persist beyond the first day after surgery.
Discomfort: Most people report the majority of discomfort to come from the inability to breathe through the nose from the gentle packing. Nasal tenderness and a mild ache in the upper lip and teeth is common but is usually controlled with a regular acetaminophen. Dr. Brace provides stronger medication as a back up pain reliever but most people report minimal to no use required.
Numbness: some people report a numb sensation in the central upper teeth, central upper lip and nasal tip. Sometimes it feels like your upper lip doesn’t move well with smiling. This is temporary from bruising of the local nerves and muscle. The lip and teeth generally regain normal sensation with 2-4 weeks. The nasal tip will take months to regain normal sensation if an external incision was made.
Bruises: if you bruise, they will look purple and dark red on the inside portion of the eyelids close to the nose. Ice in the first 72 hours helps minimize these
Bleeding: remove the ‘moustache dressing’ and the Telfa gauze from inside the nose the morning after surgery. The gauze inside the nose will often have a clot of blood stuck to it. This is normal. Expect some dripping or brief flow of blood tinged mucous after the Telfa is removed. Our noses make about 2L of mucous every day and the Telfa can trap this in the nose. Once the Telfa is out, nasal saline rinses can be done to gently wash out blood clots and mucous and help the nose heal. The incision, if present, can be cleansed with a Q-tip and peroxide.
Post-operative care instructions detailing this will be provided.
Brisk constant flow of blood is not normal, and thankfully not common. Instructions will be provided for what to do in this situation.
Discomfort: expect tenderness of the nose and upper lip and teeth. Acetaminophen is usually all that is required.
Swelling: usually peaks in the first 1-3 days but is only visible on the tip and columellar and around the eyes.
Bruises: present but beginning to fade
Bleeding: there should be little to no bleeding. Blood tinged mucous may be present. Avoid nose blowing and use gentle nasal saline rinses.
Incisions: clean any incisions according to instructions
Discomfort: tender to touch. Acetaminophen as required.
Dr. Brace will see you back for removal of the splint and sutures and to examine your healing.
Bruises: most bruises will already be lighter and fading. If there is a red or purple discolouration present Dr. Brace will offer pulse dye laser treatments to accelerate the resolution of these bruises.
Bleeding: there may be a small amount of bleeding around the skin edges if sutures are removed. This will scab over within the first hour. The scabs can be gently removed with a Q-tip moistened with peroxide.
Discomfort: removing the sutures does not hurt but can feel like the pinch of plucking a hair. Many people are anxious about this part of the follow-up and are pleasantly surprised at how easy and quick it is.
Removal of the splint is a gentle process and does not typically produce any discomfort beyond the pull of tape on the skin.
Swelling: once the splint and sutures are removed Dr. Brace will reveal your nose to you. It will look bigger than expected from the swelling. As a general rule the swelling in the upper 2/3rds of the nose rapidly decreases in the first 6 weeks or so. However, after removing the compressive splint the upper 2/3rds may initially swell MORE before beginning to shrink down to size. The nasal tip will undergo a slower resolution of swelling. This can take up to a year in primary rhinoplasty cases or longer (2 years) in revision rhinoplasty cases.
Follow up with Dr. Brace to assess the early resolution of swelling, the healing of the incisions and the patency of the nasal airway.
Bruises: these should all be resolved.
Bleeding: some people may have a dry and inflamed septum after surgery with remnants of suture material. This can lead to scabbing and occasional bleeding. Dr. Brace will remove any large suture remnants at this time and recommend nasal moisturizers if required.
Discomfort: minimal if any at all.
Swelling: Most of the upper 2/3rds of the nasal swelling is resolved. The nasal tip still looks swollen. Gentle pressure with a finger tip will show 1-3mm of ‘pitting’. Dr. Brace will discuss nasal tip injections if the swelling is excessive.
Follow up with Dr. Brace
Swelling: significant decrease in tip swelling at this point with refinements beginning to show. Injection of anti-inflammatory medications into the tip may be discussed depending the appearance.
Early ‘After’ pictures will be taken to assess early changes.
Follow up with Dr. Brace
Swelling: At this point usually 80-90% of the swelling is resolved and there is 0.5-1mm of ‘pitting’ detectable in the tip. ‘After’ photos will be taken and possible discussion of nasal tip injections.
Follow up with Dr. Brace
Swelling: essentially resolved unless surgery was a revision case. Final ‘After’ photos taken and compared to ‘Before’ pictures. Assessment of achievement of aesthetic goals. Discussion of any minor modifications or revisions if necessary.
In every aesthetic procedure, there will be a small subset of patients who do not achieve the complete aesthetic goals of the surgery. This can be for a host of factors including surgical maneuvers used, limitations of the anatomy, healing complications, or even unexpected trauma during the healing process. In rhinoplasty, the factors working against a perfect result are generally scar tissue contracture, cartilage memory, imperfectly healed bone, or minor post-operative traumas to the nose. In Dr. Brace’s practice, the revision rate is less than 5%. This means that at 1 year, 1 in 20 rhinoplasty patients will want to refine a small aspect of their surgery. This is usually a minor procedure that is often completed under a local anesthetic. The most common reasons for a revision would be a small bump along a bone cut where new bone is formed creating a firm nodule or an alteration of a nostril scar if the nostrils are reduced in size. Revision surgery is best avoided by seeking a skilled experienced rhinoplasty surgeon with meticulous and thoughtful technique.
Book an appointment with Dr. Brace to discuss your specific nasal concerns.