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Rhinoplasty Surgery (Nose Job)

THINKING OF A NOSE JOB

Look around. You will like some faces and noses more than others.  But why? What is the source of your like? A nose can also be divided into different esthetical parts in itself such as nasal tip, nasal dorsum and nasal alars. Their proportion to each other, harmony of them with other facial features, maybe their correlation with the shape of your eyebrow, oval shape of your forehead, your cheekbones, and chin… And more reasons to be found… This is why some faces and some noses are prettier than others. “The art of creating noses perceived prettier”, this is exactly what we call a nose job, or rhinoplasty surgery in a more professional way. When we look at a person, nose is the first thing we see.  This organ which is right in the middle of face is really the center of our beauty perception. This is why we are usually aware of a visual problem of our nose while we cannot make sure whether there is a sagging problem with our middle face or eyelids. The things disturbing our esthetical nose perception may be derived from the problems related to bone shape, cartilage structure or skin. What we do is sometimes removing the excessive ones, sometimes patching grafts of cartilage or dermis from other parts of the body, or sometimes reshaping existing tissue. These tissues in terms of shape have a three dimensional special design. Reshaping by making changes on this design requires special techniques.  Besides, in the future in order to sustain the good appearance gained on the operation table, a lot of precautions have to be taken. Yet, due to their self-elasticity, perichondrium cells on cartilaginous tissues have the tendency to turn back to their previous shape. Therefore, nose job is a type of surgery that knowledge, skill, and experience all have significance. Nevertheless, a possible complication is just a matter of time, and a nose job may always surprise you, no matter what your experience level is. Internationally approved publications announce that average risk level of a nose job is 10%. At this point, instead of having no risk expectation from the surgeon, it is very important to expect him to have the skill of solving all possible complications and to know that he will not hang you out to dry. In fact, it is the rightest thing to do. You look at the mirror (actually you have been doing it for a very long time), and say “it is the time”. Then you are ready to have nose job. Now, below a long list of questions and answers wait for you. Let me answer some of your questions for you.

Who should perform the nose job (rhinoplasty surgery)? A plastic surgeon or an ENT surgeon?

If I tell you that you need to consult a plastic surgeon for a nose job, it will not surprise you. Therefore, I will give a brief information to make you come up with this idea. Please go to a medical book store, and put the thickest book of ENT and thinnest book of plastic surgery next to each other. You will see that nose job parts have more place in the plastic surgery book than the thickest ENT book. If you ask in the book store the most important books written about nose job, you will see that authors are the plastic surgeons. Is it so important? What it shows to us? This proves us esthetical perception is a training and it has a significant place in natural flow of plastic surgery. Even while removing a cancer tissue, we plastic surgeons are concerned about how would it look like after. ENT doctors are trained in the way focusing on the respiratory mechanisms of nose. After completing their training if they are interested in, they try to learn rhinoplasty surgery. Vice versa, plastic surgeons might improve their skills to correct respiration problems. Precisely, there is no doubt there are some ENT doctors with the skill of performing very good nose jobs as there are some plastic surgeons with bad results.  The most dangerous ones are the ones who say “while solving the respiration problem, let me correct some parts of your nose”.  One should be scared of a physician who oversimplifies a rhinoplasty surgery this way. Also in international community, if a surgeon operates 150-200 nose jobs annually, he gains a reputation especially for being a rhinoplasty (nose job) surgeon. Maybe this might be a criteria for you while deciding.

Should I have open rhinoplasty surgery, or closed rhinoplasty surgery? What is the difference?

Open rhinoplasty surgery starts with an incision on the middle nasal septum which is called columella and continues by separating the nasal skin from cartilage and bone. Proponents of open rhinoplasty surgery claim that operating after seeing all the composition has more successful results. Although 95% of physicians performs open rhinoplasty surgery, they cannot explain the reasons of high revision rates. Closed rhinoplasty surgeries also require incisions, but since those incisions are inside nostrils, they are not visible. Of course, it looks difficult for the one who lacks necessary training for this operation because he has to work in a confined space. However, it is not a type of surgery operated blindly and left the results to fate. Nearly all of the necessary features can be clearly seen during closed rhinoplasty as much as it is in open rhinoplasty surgery. Including nasal tip. All intervention moves in open rhinoplasty surgery can also be done in closed rhinoplasty surgery without even opening the nose. Swellings (especially the ones on nasal tip) disappear faster in closed rhinoplasty. And at the open rhinoplasty surgery even the physician himself cannot see the last version of the nose until he puts columella stiches and closes. Generally, there a lot of colleagues who perform open rhinoplasty surgery. I can understand that closed surgery might seem difficult for a surgeon who does not have expertise on this technique. Nevertheless, I can’t accept a surgeon who lacks this technique to say no for the closed rhinoplasty surgery. It is very clear due to above mentioned arguments that I am in love with the closed rhinoplasty surgery. I believe that if it can be done with less trauma and less incision, it should be done that way.

Will I have natural nose look after the nose job?

It is the biggest concern of the patients for nose job. And they are right about it. All of us see those bad examples. During 1980s there was a time that noses were carved like a slide and people liked it. But 1990s were spent to correct those noses and a lot of studying done on the seconder nose job.  Nowadays, the target with the nose job is to obtain noses which look natural and without functional loss. I want to highlight it again that recently no one wants to have big nostrils to be seen from far like headlamp of a truck and noses in slide shape. I think that the cases we run into may be due to some technical mistakes, or miscommunication between physician and patient. Simulation workshops are the best way for your physician to understand your expectations. Of course it will not be the computer operating the surgery. Yet, either on a paper, on your mask, or on a 3D visualization what you will be seeing will be the concept of beauty in your surgeon’s mind. If you like this simulation work, it means you think your surgeon has a good taste of what is esthetical. During the surgery, your nose, your physician and his blade will be alone together.  Good music, too…

Will you break my nasal bones during the rhinoplasty surgery?

This is a kind of question terrifying even me. Breaking is a rude explanation and it doesn’t match the poetic side of nose job. During the rhinoplasty surgery each move is measured by millimeters, and excessive pieces (if there is any) in bones or in cartilage are incised after carefully measuring them. The incised pieces are removed kindly. And yes, in closed rhinoplasty surgery, we do it through your small nostrils without opening or cutting it.

Will you use tampons after rhinoplasty surgery?

Depending on septum, or if the concha is not touched during the surgery, usually there is no need to use tampons after the rhinoplasty surgery. In case concha or septum were touched in the surgery, what we use is simple: thin silicon supports which are called “splints”. You can breathe easily thanks to small poles in the middle of it and it can be removed easily. It is no similar to that scary and meters long tampons. Nearly all the plastic surgeons I know of use these silicon splints recently. It means you can relax about this problem.

After rhinoplasty surgery, will my breathing problem also be solved?

Some deformity at nose shape directly affects functioning of the nose. Deriving from this, I can say that for some noses your breathing problems might be solved after its shape is corrected. We see it mostly with the deviated noses. When we correct the angle of the nose in the middle, all airway might be opened for breathing.  Besides this, all concha and septum problems can be treated at the same time during the operation. Depending on his experiences and practices before, plastic surgeon might solve breathing problem either alone or cooperating with an ENT surgeon during the surgery. You should ask your physician what is his preference. My choice? I am one of the people who think that one captain for one ship.  Thus, I prefer solving breathing problems myself during rhinoplasty surgery except sinus and extreme poliposis cases.

 After rhinoplasty surgery, will my nasal alars also get smaller?

If it is needed, yes. Nose is a three dimensional organ. If I reduce the size of other parts, reduction in the size of alars is usually needed. In my practices, I downsize nearly 95% of my patients’ alars in rhinoplasty surgeries. This operation might be applied to the patient either by only reducing the wall size of the alars or by also downsizing nostrils. Are you confused? For your information, we can downsize alars even without downsizing nostrils. It is very important that we can reduce the size of alars without creating breathing problems

For rhinoplasty, how long the surgery takes place and what is the hospitalization process?

Hospitalization should usually be started 1-2 hours before the surgery. Of course, you should stop eating and drinking water one night prior to the surgery. You shouldn’t take any blood thinner medication lately. You should be aware that some vitamins and herbal teas might also result in bleeding.  I prefer working under general anesthesia since rhinoplasty surgeries cannot be performed comfortably under local anesthesia. For a primary nose, which is not operated before, surgery takes around 1,5-2 hours. For seconder cases, length of the surgery depends on the problem as I may use cartilage from ribcage or ears. After rhinoplasty surgery I recommend you to stay in the hospital for one night. In case of inevitable situations, we are able to discharge you the same night.

After rhinoplasty surgery, what will happen following discharge? And what should I be careful about?

The most important rule: “please, don’t hit your nose!”. You can eat and drink anything you want. Slight bleeding, bruise and swelling are normal. They will disappear in one week. Sleeping your head up with two pillows and applying ice the first day will be helpful. I will probably keep splint 7-10 days depending on the possibility of oedema and thickness of nose skin.  I will remove silicon support before or together with the split. Depending on the situation of the swelling I may put thin paper flaster on your nose and ask u to keep it for one week. Following it, I will tell you how to take care of your nose by spray and various moisturizing. You will take care this way. After removing flasters, I will want to appoint you at the first, sixth, and twelfth months. In case of additional problems, I would always be glad to help. 

Could you please tell us also a bit about the worst case scenarios at nose job?

Sure. Crookedness of nose, heavy bleeding, stickiness, dislocation of graft, extreme swelling and bruises, perforation in septum, infection, suture reactions, irritation against medication, complications of anesthesia… According to the international publications, average complication level is accepted as 10%. It depends on who the physician is. My average is around 6%. Half of them are simple problems that we can solve while only chatting 5-10 minutes in my office. The ratio of resurgery of my cases is around 2-3%. There is a famous idiom among surgeons: “there is no complication risk of a physician who does not operate surgeries.”

Final Word…

There is no final word if rhinoplasty is the case. I hope this brief information was helpful for you. For more, I would like to have your opinions and suggestions. Wish you speedy recovery already J

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Op. Dr. Ozan Balık

Ozan Balık, M.D. was born in 1975. After he graduated from Adana Karşıyaka Highschool in 1992, he started Electronic Engineering major in Istanbul University. While he was having a series of operations he realized his tendency to medicine. In order to say “Don’t worry, they will be safe in here.”

Contact Op.Dr. Ozan Balık Levent Mah. Çilekli Cad. No:10 Beşiktaş İSTANBUL Tel: 0212 215 53 33 - Whatsapp: +90532 609 08 73 Mail: ozan.balik@gmail.com
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