Septorhinoplasty

Background

Surgery to change the shape of the nose can be performed if the patient is not happy with the natural shape or size of their nose, following injury to the nose (sometimes as a child) or following previous surgery which has changed the shape. It may also be required when the patient complains of nasal blockage when surgery to improve the nasal airway requires a change in the shape, for example, following a fractured nose when the shape is affecting the size of the internal nasal passage. Often there are features of the nose that the patient is not happy with, typically, these include a prominent profile or the end of the nose being too prominent or bulky. There are also many more subtle features that can be addressed and these can be discussed fully in the clinic. Most patients want a nose that does not stand out and blends into the other features of their face. They usually want a natural ‘non-operated’ looking nose.
Injuries to the nose are relatively common both in children and adults. The nature of the injury will determine the effect on the structure and function of the nose.
When the nose is broken, the bone at the top of the nose becomes fractured and usually becomes deviated or depressed. The nasal septum (the partition inside the nose) which is made of cartilage and bone often also fractures which commonly leads to a blocked nose on one or both sides.

 

MUA Nose

MUA stands for manipulation under anaesthetic. When the nose has been broken, there is a window of opportunity to replace the displaced and fractured bone back to its original position before it sets. This is usually done under a brief general anaesthetic. The nose is usually swollen after a significant injury for a few days which can make the accurate assessment of the underlying injury difficult. The operation is therefore often performed between one and two and a half weeks. A broken nasal septum can be corrected at the same time.

 

Septorhinoplasty

This term refers to an operation which encompasses a range of surgical procedures that change the shape and internal structure of the nose.
The structure and function of the nose are inextricably linked together. When performing nasal surgery, It is vital that the structures that hold the nasal airway open are preserved and that the long term stability of the nose is maintained.
Good communication between the surgeon and the patient undergoing nose re-shaping is essential. It is crucial to spend time with the surgeon discussing the specific way in which you would like your nose changed. Often, a second consultation is undertaken to discuss any issues arising from the initial discussion. It is important that both the surgeon and the patient are happy with the goals and limitations of surgery before undergoing a procedure, particularly if the patient has had previous surgery. Your nose will be examined and if you are complaining of blockage, a very small scope will be used to examine the inside of the nose in order to identify the cause.

The Operation

The surgery is performed under general anaesthetic either as a day-case or with an overnight stay. The steps taken during the procedure vary and are tailor-made to the patients requirements but often involve breaking the nasal bones and changing the shape of the cartilage that makes up the framework of the nose.
There are three basic approaches that are used in septorhinoplasty surgery. The first involves making incisions inside the nose to gain access to the main part of the nose and is called the endonasal or closed approach. The second involves a small incision in the narrow area of skin between the nostrils combined with internal incisions and is known as the external or open approach. The open approach is usually used when more extensive work needs to be carried out or work to the end of the nose (nasal tip) is required. An external incision will also be required if the nostrils need to be narrowed. Generally these incisions heal up very well. The third approach is called the delivery approach and involves ‘delivering’ the cartilages that make up the nasal tip out of one nostril without making a cut in the skin. This can be used for some tip modifications.
Often it is necessary to use cartilage grafts to achieve the desired change in appearance and stabilize the nose. These are taken either from the inside of the nose, the ear or from a rib. We can also use donor pig or human dermis (the deep layer of the skin) in some circumstances. All the options are fully discussed with the patient pre-operatively

 

After the Operation

A dressing and a nasal splint (if the nasal bones have been broken during the operation) are applied to the nose for a week. If there are external incisions, the stitches are removed at 5 to 7 days.

The surgery is not particularly painful but there is some discomfort which lasts for around a week. We will give you painkillers to take home. You will be given antibiotics to take home if a cartilage graft is used in the nose, if internal packing or splints have been inserted (see below).

The nose has a very good blood supply and usually bleeds a little after the operation. A nasal pack (sponge like material placed inside the nose at the end of the operation) is sometimes required and is removed before you leave hospital (non absorbable sponge type) or is left in the nose to fragment (fragmentable type). The bleeding gradually resolves although very rarely further treatment is required to stop the bleeding.

Swelling of the nose and under the eyes is variable but the majority of this usually settles in the first 1-2 weeks after the operation and then gradually subsides. If the nasal bones have to be broken there will be bruising under the eyes and this is often gone by two weeks but there may be some traces of bruising that can take a little longer to go.

Depending on the degree of surgery performed inside the nose, your nose will be blocked for a few days after the surgery- see also septoplasty.
It is important to realize that the healing process goes on for several months and even years.
We do everything to ensure that you have an excellent result and will see you in the clinic after the surgery as required.

Post-operative advice for patients undergoing Septorhinoplasty surgery

1. You will either stay overnight or be discharged the morning after surgery depending on how well you are feeling. If you go home on the day of surgery you will require a friend or relative to pick you up from the hospital and you will need to have someone with you at home for the first night.

2. Depending on the degree of surgery on the internal nasal passages you will feel blocked for the first 1-2 weeks after the surgery and this will then gradually improve.

3. Your nose may bleed a little after the operation and this can sometimes continue for several days. We may insert nasal packs to control bleeding during the operation and these are either removed before you leave hospital (non absorbable type) or left in the nose when you go home (fragmentable type). If bleeding starts when you are at home and is profuse then you need to phone for an ambulance to take you to Casualty, remain calm! This can occasionally occur after nasal surgery. If it is relatively minor and persistent phone the office for advice. Very occasionally a patient may require further treatment to stop post-operative haemorrhage or even require to go back to the operating theatre (< 1%).

4. The surgery is not particularly painful although you may feel ‘under the weather’ due to postoperative nasal blockage and the effects of the anaesthetic.

5. You will be given pain killers and sometimes antibiotics to take home with you from the hospital.

6. Your nose will feel slightly numb after the surgery. Sensation will gradually return with time but may take months and occasionally will not return to normal.

7. You will have a nasal splint on the outside of your nose for around 7 days.

8. Occasionally during septal surgery we insert plastic splints inside the nose to prevent scar tissue formation and support the nasal septum. These are removed in the clinic one week after the surgery. You will require antibiotics to prevent infection when splints are inserted.

9. If the surgery is performed using an ‘open approach’ you will have fine stitches that will need to be removed from the skin between your nostrils between 5 and 7 days. The application of Vaseline to the incision and just inside the nostrils twice a day for the first week is helpful as it prevents crusting. The incision invariably heals well. If the surgery is performed by the ‘closed approach’ there will be no stitches to remove. All the stitches within the nose are dissolvable.

10. You should not blow your nose for the first week after your surgery. If you sneeze, try to let it out through your mouth!

11. The inside of your nose may be swollen and contain dry blood and mucus after the surgery depending on the type of surgery that you have had. This will clear between weeks 2 and 6.

12. Sometimes we will need to take cartilage from your ear. You will have a dressing on the ear after the surgery with stitches which we remove at one week. You may experience discomfort in the ear for several weeks although this is usually mild and not troublesome.

13. Occasionally we will need to take rib cartilage. There can be discomfort associated with this for several days and we will provide you with medication for pain relief.

14. Wearing contact lenses after the operation is ideal but if you need to wear glasses you will need to tape them to your forehead for at least 2 weeks. This prevents pressure being applied to the nose.

15. Avoid physical exertion for 2 weeks after surgery and then gradually increase to your normal level of exercise. Avoid contact sports for 4 weeks.

16. If you are exposed to the sun after surgery use high factor block for 3 months. The skin over the nose is sensitive to the sun after surgery.

17. The surface of the nose after surgery does not always feel smooth and may have minor irregularities. This is normal.

18. Our aim is that your expectations are realized and we will do everything that we can to achieve this. If you have any concerns after the surgery please do not hesitate to contact us. We will routinely arrange a follow-up appointment 5 to 7 days after your operation.