WHAT IS NORMAL?
- From the side, the bridge is straight in the male and may be straight or have a mild sloping in the female.
- The tip comes straight out or has a slight upturn. From the side, the tip makes a 100 degree angle with the upper lip.
- The tip is no wider than the bridge.
- From the front, the bridge is well-defined.
- The nose is straight and symmetric.
- The outer skin of the nostrils is no wider than the inner corners of the eye.
- The shape of the skin that forms the nostrils has a roundness that compliments the tip.
- The tip is defined. The edges of cartilage bring it to a clear point.
COMMENT: In no other structure than the nose are the rules of beauty so variable. In general, the smaller the nose the better. Classically, the nose is meant to breath and not be seen. We adorn the eyes and the lips to increase their beauty, but the nose is not considered a center of beauty. Again, ethnic variations and different characteristics may lend unique positive qualities to different noses. Exceptions to these rules are common.
- Have a picture taken of your nose. Face only. One straight from the front and one directly from the side.
- Draw on the profile photo and erase or increase the bridge as you desire.
Does the tip come out too far from your face? Maybe the tip doesn't come out far enough. That is a problem with projection.
- Is the tip too high or too low? That is a problem with rotation.
- Check the front view. Is the crest of your nose straight? Does the tip point in one direction?
- Are the nostrils symmetric? Do they pass the corners of your eye?
- Is there definition in your nose? Is the base too broad and flat? Is the tip too round and bulbous?
HOW MUCH CAN BE IMPROVED?
- Virtually anything can be changed but sometimes at a price.
If the nose is made too small breathing problems can develop. The smaller the nose, the harder it may be to breath. This is particularly the case if the base is reduced.
Thick skin can limit the appearance of definition in the nose. Very thick skin can be thinned but mildly thick skin may not be worth the risk.
- Perfect is the enemy of good. So often patients tell me they don't need it to be perfect, then describe the perfect result that they want!
Results from revision surgery may be less beneficial than the first surgery, but not always. Sometimes at the first surgery key changes were not made at all.
Scarring can occur at the bottom of the nose if the nostrils are reduced
by external incisions. The more skin removed, the more tension on the tissue, and the worse the scarring. Otherwise, all of the surgery can be done from inside the nose.
The breathing can always be improved by increasing the size back to the original conditions. It amazes me how many patients would rather suffer with a blocked nose than have it widened again.
A perfectly straight nose can be achieved 95% of the time. Proper tip height as well. Tip definition and other features can all be improved 95% of the time as well. A lot depends on what you start with.
THE OPTIONS: NOSE
In the view of many plastic surgeons, the nose is the flagship of plastic surgery, since in many individuals it sets the tone of the face and to some extent on a structural basis, is the only aspect of the face and human body that has its own unique qualities. Whereas eyelid and facial surgery is strictly a question of removing wrinkles and folds, nose surgery involves fairly complex relationships.
In the scheme of facial beauty, the nose has a peculiar role in that it is basically meant to breath and not to be seen. When make-up is applied to the face, the eyes are adorned to make them alluring and lipstick is applied to create luscious lips but the nose is left to stand on its own.
LOOKS VERSUS BREATHING
It is important to keep in mind that the nose is a functional organ as well as a cosmetic entity and that the two are connected. There is a give and take. The nose must be big enough to breathe but small enough to look good.
Sometimes the patient is the culprit. In their zeal to obtain the smallest nose possible, they persuade the doctor to reduce the size too much, thereby eliminating some of the significant structural support. Comply with the doctor's wisdom if they suggest that some aspects of the width or the base need to remain intact.
Most curious is the fact that sometimes a large nose can breath worse than a small nose. When the nose itself is too long and thin, the inward motion of air may create a drafting effect. Then, the sidewalls may collapse and reduce the airway.
CHOICES IN THE APPEARANCE OF THE NOSE
In regards to cosmetics, let's discuss each area of the nose as a separate unit. There are three general areas of discussion from the layman's point of view.
- BRIDGE The upper portion of the nose down to the tip.
- TIP The point of the nose above the nostrils.
- BASE The width of the nostrils.
THE BRIDGE OR CREST (DORSUM)
The upper part of the nose is made of bone whereas the lower portion of the nose is made of cartilage. In a skull, you might notice that the upper portion remains and everything else that would make up the nose is gone. The missing portion was cartilage. A bump in the nose or hump is usually composed of both bone and cartilage.
BREAKING THE NOSE- YES OR NO?
If the bump is large, the nose usually needs to be broken to remove this bony component. Also, if there is any crookedness or asymmetry about the nasal bridge, this would be corrected by fracturing the nose.
Patients are always asking if their nose needs to be broken. A certain amount of work on the nose can be accomplished by rasping or filing the nose. Certainly small bumps and irregularities are well-improved by rasping. Larger deformities can be a
problem with this technique. In particular what often happens, since the nose can be conceptualized as a triangle in cross section, by rasping off the top, one is left with a base that is too wide and the height of the nose looks too plump.
In our office we notice that a good number of the revisions that are required are a result of rasping that did not do the job. Again, sometimes the patient has insisted that their nose not be broken and the doctor has complied and neither ended up truly
satisfied with the outcome.
BUILDING UP THE NOSE- CARTILAGE VERSUS PLASTIC
On the other hand, the patient with the bridge that is too low, such as an oriental or black patient, may need some form of implant to raise the height of the bridge so it comes close to matching the projection of the tip. In some cases, even when this addition is made, the basic width is too wide, and the surgeon might recommend fracturing the nasal bone to create a desirable width near the base. Occasionally the height of the nose is satisfactory and the bone of the nose simply needs to be fractured to be straightened out.
Patients often debate about the use of plastic versus natural materials to increase the height of the bridge. Although for years I scorned plastic, these days I use quite a bit. When properly managed it is safe and reliable. Cartilage or bone, either from the patient themselves or a tissue bank, may be reabsorbed with time. Also, it may be difficult to fashion a sharp tip. In these cases, you must discuss your individual desires with your doctor.
POINTS OF CONCERN- THE TIP
There are four basic features you can discuss with your surgeon:
- ROTATION Does the tip point up or down? Too high or too low.
- PROJECTION Does the nose stick out too far?
- DEFINITION Does the nose come to a sharp point?
- SIZE (BULBOUS NESS) Is the overall tip too big or small?
If you focus on these general features, then you and your surgeon will be talking the same language. Check each one yourself and develop an idea what bothers you the most. You will need your surgeon's guidance. I strongly recommend that you listen to him on these matters.
TO MAKE THE TIP SMALLER?
The concept of the tip actually is sometimes as vague in the mind of the surgeon as it is in the mind of the patient. Although the tip certainly refers to the point of the nose, it also includes some additional portion of the lower half of the nose. No one really knows where the tip ends and begins.
The main concern is that as the tip gets smaller, the shape does not become irregular and distorted. Clarify exactly what you hope to accomplish with the doctor. Let him know exactly what aspect bothers you.
If the tip changes a lot, you may lose some definition because of too much scarring, that is another consideration.
WHY DO SOME TIPS TURN OUT BETTER THAN OTHERS?
Thin skin makes the nose easier to work on. Since the skin itself will not be cut, the surgeon relies on thin skin to re-drape correctly over the newly-shaped cartilage.
As a surgeon, one thing that I generally do is look very hard at the tip to see whether it needs anything done. Sometimes by reshaping the nasal bridge and removing the bump, the tip region can take on a satisfactory appearance.
I will very strongly discourage a patient from fiddling with the tip itself if the size and definition are satisfactory. More bad results occur from misadventures of the tip than from any other single problem with nasal surgery.
There are other factors that contribute to the results of the tip, having to do with the nose you start with.
THE BASE- TO REDUCE THE BASE?
The base of the nose usually refers to the area around the nostrils, where the nose meets the face. As a general guideline, I tell patients that the nostrils, the widest portion of the nose, should not extend past the corner of the eyes. If the edges of the
nostrils pass the corners of the eyes, this would be an indication to reduce the base.
Many patients just focus on the overall diameter of the nostrils themselves, which alone is probably not a good indicator. All surgeons have to make an incision on the outside of the nose to reduce the base. This incision can be kept unnoticeable, but often leaves scars that are detectable to the knowing. Of all the surgeries to the nose, this particular area I discourage the patient from having altered unless there is a significant problem, only because it is most commonly a give away of an artificial result. The more the nostrils are reduced, the greater the scar. The more demanding the patient is about repeat surgery around the nostrils to make them smaller, the more noticeable is the scarring.
WHAT IS THE SEPTUM?
The SEPTUM is the cartilage that separates the two sides of the nose on the inside. Often problems with the septum cause breathing problems that need to be addressed.
The other portion on the inside of the nose is the turbinate tissue which are the two large radiator coils that regulate the air flow in and out of the nose. At the time of cosmetic surgery, the surgeon may consider it important to alter these two structures as well to preserve a good airway.
WHAT CHANGES DO I WANT IN MY NOSE?
The vast majority of patients want a perfectly straight and smooth bridge, with the occasional patient who wants a gentle curve in the bridge. I always find it amusing that patients will say, "I don't need a perfect nose." The doctor is well aware that if it is not perfect, the patient will want it changed. If the bridge is not straight or is indented, the patient has a right to be unhappy.
OPEN VERSUS CLOSED RHINOPLASTY
The choice of the open- or closed-rhinoplasty has its greatest relevance when dealing with the tip. The so-called Open Rhinoplasty involves a cut across the skin that connects the two nostrils and allows the surgeon to visualize the tip region directly instead of through one nostril at a time.
The more traditional or standard procedure is completely through the nostrils. Although this seems like an impossible task to the average patient, in fact, experienced surgeons get to be very comfortable with this technique. In my own case, early in my practice I performed a large number of open rhinoplasties, but at this point, I am doing it less and less. Though almost virtually everything that is done through the open rhinoplasty, can be performed equally well without the extra cut. Although the surgeons who use that technique will argue against it, I believe that the scar from that incision is findable in almost all cases.
In defense of the open rhinoplasty, which has certainly been in vogue in certain areas of the country and amongst certain very prominent plastic surgeons, the technique does allow the surgeon comfortable access to the tip and in special cases may be helpful.
WHAT IS THE PERFECT NOSE?
A lot has been written about the aesthetics of the tip of the nose and the relative proportions and proper distances. As a patient, it is probably best not to get bogged down in the discussion of these proportions with your doctor and to reach some general agreement on what your nose needs.
There are also gradations of surgical procedures that require more or less surgery to the tip. Less surgery is often better. In plastic surgery, our general rule also for patients to keep in mind, as much as they fight it, is that "perfect is the enemy of good". If the nose has small problems, little areas of crookedness or the tip is not particularly small, these defects may keep it looking natural and might be better off left alone.
Many times when a patient will come up to me thinking they have a perfect nose, I am often delighted to find that there are many imperfections that the patient does not notice.
Routinely, we wait six months to one year to make adjustments in the tip or bridge because so many problems seem to resolve with time. Problems with crookedness may be treated earlier.
Too much tissue has been removed. The tip or bridge area must be built up again. Sometimes, the inside of the nose needs just a little more work, too.
If a lot of tissue is removed from the base, noticeable scarring may develop. This may be difficult to repair.
LOSS OF IMPLANT
Tissue grafts may reabsorb and need to be replaced. Plastic implants may get infected or displaced and also need revision.
NOSE AFTER CARE
THE FIRST NIGHT
There is no packing in your nose (some doctors put it in). Change the gauze under your nose as necessary. This is usually done once per hour.
Stay on decongestant pills for three days. We recommend any twelve-hour pill, like CZ-3. Keep a nose decongestant drop handy. If the bleeding becomes significant, squirt a large blast down the bleeding side.
The bleeding is the worst about 3-10 hours after surgery. Do not worry. You won't lose a unit of blood that you would donate to the blood bank. If it does appear out of control, contact the doctor.
- CALL DR. RAKESH KALRA for any problems or emergencies.
- Mild temperature elevation the first night after surgery is insignificant.
You will have trouble breathing through the nose, especially the first night, because of swelling. You will wake up every few hours with a dry mouth. Keep water by the bedside. It will get better slowly over the first week.
Do not drink milk or dairy products after you get home. If there is blood in your stomach, dairy products will make you nauseated. Drink clear liquids on the day of surgery, like Seven-up. You may have a light meal later in the day if you feel well.
If you vomit blood on the day of surgery, don't worry. Often there is a slow drip down the back of the throat and the blood has irritated your stomach.
- Infection after rhinoplasty is rare. We do not routinely give antibiotics.
- Ice on your face may keep the swelling down, but keep the splint on your nose dry.
Take the pain pills as necessary. Most people find that they do not need many. In some individuals, narcotics can cause nausea, so use them sparingly.
STEAM. STEAM. STEAM. This is the road to your salvation. Once the bleeding stops, you need to breath some steam through the nose to clean out the mucous and old blood as soon as possible.
THIS WILL GREATLY REDUCE THE PAIN AND PRESSURE THAT YOU WILL EXPERIENCE.
Steaming the nose is very simple. This involves taking a hot face cloth and holding it close to the nostrils, breathing in the steam that is emitted from the face cloth in and out through the nose. Blow out any mucous or blood that comes out easily.
Repeat this process. You do not have to blow hard. You do not have to breath in the steam for more than a few minutes.
YOU DO NEED TO BREATH IN STEAM OFTEN- EVERY FEW HOURS TO KEEP YOUR NOSE CLEAN AND
You may clean the front of the nose with Hydrogen Peroxide on a Q-tip. Do not be afraid to clean blood from within the nose. You can't do any harm by cleaning aggressively. You may coat the inside of the nose with ointment. Vaseline and Neosporin work equally well for this purpose.
- You may take a shower or bath, but keep the nose dry while you are wearing a splint.
5. If the splint falls off, don't worry. You can tape it on again. It does not have a tremendous effect on the outcome.
Glasses may rest on the splint. After the splint is removed (4 to 7 days) you must put cotton on the bottom of your glasses to keep them from pressing on the bridge of the nose. You may put in contacts on the day after surgery, if your eyes aren't too
If you do not mind the appearance, you may return to work the next day. Most patients wait until the splint comes off, usually at 4 or 5 days. By then, most of the swelling has gone down. The black eyes go away in about 7 to 10 days.
- Bruising is variable. It has little to do with the quality of surgery.
PROTECT THE NOSE FROM DIRECT SUNLIGHT FOR THE FIRST THREE TO SIX MONTHS AFTER
SURGERY. IT WILL SUNBURN EASILY. IF IT BECOMES SUNBURNT, IT MAY TAKE MONTHS FOR THE
REDNESS TO GO AWAY.
Everyone is different and some noses are more sun sensitive than others. Make your first sun exposures short and see what happens.
- Continue the STEAM, once daily, for two or three months after surgery.
- PRESSING EXERCISES
The doctor may instruct you on a pressing exercise to help the nose settle straight and smooth. Follow this program religiously.
No heavy exercise for the first two weeks after surgery. After that you can build up according to your ability.
- Do not play with your nose. It will increase the scarring.
If your nose gets hit again, don't worry. It can be reset at any time. In most instances, the nose has about the same strength as before surgery once it has healed.