“Rhino” is the Greek word for nose, and “plasty” means to sculpt or shape with surgery. In other words, rhinoplasty means nose reshaping or a “nose job”. Although the majority of people have rhinoplasty for purely cosmetic reasons, other indications include functional blockage with difficulty breathing or prior injury to the nose.
During rhinoplasty, a cosmetic surgeon restructures the skin, soft tissues, cartilage, and bone to reshape the nose. Rhinoplasty is considered a common cosmetic operation and is usually a day-case procedure.
More recently, “non-surgical rhinoplasty” has been used to describe the correction of minor nasal defects with the use of s soft-tissue fillers, these will improve soft tissue defects only and are a temporary solution.
Grafts are commonly used in the nose to give the nose further definition, shape or support of the airway. The grafts are frequently made from the nasal septum which sits in the centre of the nose.
Particularly in revision cases there may be no nasal septum remaining, in which case the cartilage can be taken from elsewhere in the body including the ear cartilage or costal cartilage of a rib.
A beautiful nose is a combination of features including smooth bridge, defined tip, well proportioned and in harmony with the persons’ face and body shape.
There are a spectrum of technical skills including open (skin incision) or closed (no skin incision) techniques, use of tissue grafts for sculpting and re-shaping the nose (nasal septum cartilage or man-made materials), cartilage modifications and stitching, narrowing by breaking the bones of the nose, and finally reshaping of the nostrils.
Different techniques must be tailored to the individual, which requires both skill and experience. In addition re-shaping of the nose requires techniques to maintain functional breathing, to avoid narrowing of the airways and breathing difficulties.
There is a degree of artistry with rhinoplasty, the shape and contours of a person’s nose sit in the centre of a person’s face and draw continued attention. The Key is the nose fitting a person’s face and body shape. Dr De Silva uses skills to obtain a natural-looking nose and avoid the signs of rhinoplasty such as the scooped or ski-slope nose or scars from size reduction.
Dr De Silva values subtle changes in the nose so that people you meet and friends are not able to tell that a person has had rhinoplasty.
Dr De Silva specializes in the face and in rhinoplasty surgery, he does not operate on other parts of the body. By specializing on only on facial cosmetic surgery, he has developed specialist expertise and technical skills.
Dr De Silva tailors his surgical skills for the individual patient, uses both open (skin incision) and closed (no skin incision) techniques, where possible he prefers the closed technique, however, to give the necessary tip definition and refinement it is necessary to open the noses in two-thirds of cases.
Dr De Silva’s trained in rhinoplasty in the cosmetic surgery havens of Los Angeles and New York amongst the best Facial Plastic Surgeons in rhinoplasty in the World, completing 15-20 rhinoplasty procedures per week (over 600 per annum), there is no fellowship training in the UK that offers this experience, with an average experience of less than 15 per annum.
Dr De Silva uses a variety of sculpting and suturing techniques to preserve the function and structural integrity of the nose, which gives in the best shape. A combination of tried and tested techniques and
Dr De Silva is a keen teacher and has taught numerous instructional courses and led the development of new courses. Dr De Silva teaches rhinoplasty skills at the prestigious American Society of Oculo-Facial Plastic Surgery conference in the USA.
Dr De Silva is an artist having painted for exhibitions in London at the Royal Academy of Arts and National Portrait Gallery and a sculptor of clay. The sculpting of a nose to balance the proportions of the face and body-type require both artistic interpretation and technical knowledge.
For example, a small nose on a long face can look as out of place as a large nose. Dr De Silva prides himself on obtaining natural-looking results and does not like pinched tips or “ski-sloped” bridges that flag-up as signs of surgery.
Dr De Silva trained in microscopic surgery before cosmetic surgery. In micro-surgery millimetres makes the difference between success and failure. Using these same principles of microsurgical finesse and obsession with detail, Dr De Silva is able to give natural-looking rhinoplasty results.
Dr De Silva recognizes limitations in surgical results that may be a result of past scarring, skin thickness or trauma, and will advise you against surgery if he believes that a patient is unlikely to obtain the result they desire. Occasionally patients may have expectations that far exceed the likely results from surgery, if the likely result is below a patient’s expectations Dr De Silva will advise against surgery.
Rhinoplasty is a challenging procedure and is regarded as the most difficult cosmetic surgery. Dr De Silva advises patients seeking rhinoplasty surgery to see a surgeon who routinely performs rhinoplasty surgery in their practice.
Dr De Silva performs a highly conservative rhinoplasty that preserves the cartilage structure of the nose, by using tissue-sparing techniques, sutures and grafts, the structural integrity of the nose is preserved, this prevents the surgical signs of complicated rhinoplasty such as pinching and collapsed airway.
Ideal candidates for rhinoplasty are from any age after late teens once the nose is fully developed. Common reasons why people seek rhinoplasty include a humped or crooked bridge, wide or droopy tip, or flared nostrils.
Additionally, patients may present with difficulty breathing through the nose due to a crooked nose (nasal septal deviation), allergy and enlarged turbinates or collapsed nasal bridge.
Patients may have had a previous rhinoplasty and been left with surgical flags such as a scooped ski slope, tip pinching or collapse.
Patients may be left unhappy by a previous rhinoplasty as a result of over-removal of cartilage resulting in a scooped nasal bridge, pinching of the tip, irregularities, asymmetries or even collapse.
Revision rhinoplasty can improve a patient’s appearance by correcting these surgical hallmarks, utilizing a combination of grafts (nasal septal cartilage, ear cartilage, rib cartilage). Sometimes the person’s own graft tissue is inadequate and an implant (silicone, medpor) is required.
Revision rhinoplasty takes longer than primary rhinoplasty and may take 3 hours to complete. Revision rhinoplasty is more challenging than primary rhinoplasty as there is pre-existing scarring of the nasal tissues, cartilage tissue has been removed and there is an increased likelihood of airway collapse.
Dr De Silva utilizing super-specialized techniques can improve the appearance and function of most noses, however, patients need to have reasonable expectations for success.
Rhinoplasty is the most challenging cosmetic surgery and a good result is dependent on both technical excellence and artistry. A marker of technical skill is a cosmetic surgeon should specialize in facial plastic surgery and who performs cosmetic rhinoplasty on a daily/ weekly basis.
A plastic surgeon that specializes in the entire body is used to surgery of centimetres of the breast and body, rhinoplasty requires fine millimetre precision work for a great result. The artistic ability of the surgeon to sculpt a nose in both proportion and harmony to a persons’ face and body-type can be evaluated before and after photographs.
Dr De Silva takes great care to ensure that he is able to give his patient’s natural-looking result to meet their expectations, in rare cases that Dr De Silva believes he is unable to perform surgery that will achieve the patient’s expectations he will advise against surgery and suggest seeing one of his super-specialist colleagues.
To find the best rhinoplasty surgeon for you does require taking the time and researching your surgeon. At the end of the day this is your face and you need to put some time into this, these are a few aspects to consider:
Dr De Silva completed multiple fellowships in the UK and USA, including Facial Plastic Surgery in New York with a top Ear Nose and Throat specialist. Dr De Silva performs a comprehensive assessment for all his rhinoplasty patients including an evaluation of both the outside of the nose and an examination of the inside of the nose using a telescope.
An evaluation of the inside of the nose is important to assess septal deviation, suitability of the nasal septum for grafting techniques and an evaluation of the functional breathing of the nose. Dr De Silva advises all patients’ undergoing rhinoplasty to have a telescoping nasal evaluation before consider surgery to avoid breathing difficulties afterwards.
Dr De Silva takes clinical photographs of all his patients during the consultation, in most case he will also use computer animation to show patients’ an approximate end result.
The hallmarks of rhinoplasty surgery include pinching of the tip, over the scooped bridge of the nose and airway collapse. A natural-looking nose avoids these stigmata and is characterized by a smooth nasal bridge with tip refinement.
In women, a normal-looking bridge includes a smooth angle with a very soft and subtle bend before the tip, called the supratip break. In men, this is usually a straight bridge, although Dr De Silva will customize the bridge to the patient.
In addition, that are specific elements to a natural-looking rhinoplasty that are based on the patients face body type and ethnicity. A long face requires an appropriately long nose to be proportionate, similarly, a tall person requires a tall nose to be harmonious. Ethnicity is important as it influences rhinoplasty techniques and suitable outcome.
Afro-Caribbean and African noses often require narrowing and dorsal augmentation, and surgical technique and artistry are important to give a natural result.
After rhinoplasty, a cast is placed over the bridge of the nose. The patient goes home approximately 1-hour after surgery and should avoid strenuous activity for the next 3-weeks. The patients should place ice over the bridge of the nose 10 minutes every hour for the first two days, this reduces swelling around the nose.
Dr De Silva uses meticulous surgical technique including cartilage suturing and electrocautery to minimize post-operative swelling. In addition, Dr De Silva uses a modified deep plane incision within the nose to avoid unnecessary bleeding, a technique pioneered and only used by top facial plastic surgeons in New York.
Approximately 80-90% of the swelling will have dissipated over the first two weeks. All patients are seen at 1-week post-rhinoplasty when the cast and stitches are removed, the patient’s breath better after this visit. Dr De Silva often uses innovation anti-inflammatory medications in the recovery period to enhance and speed up the resolution of swelling.
The final result from surgery is usually apparent at 1-year, using such agents reduced tip swelling in a shorter period. Patients who undergo revision rhinoplasty surgery and of certain ethnicity may have swelling that takes a longer period to resolve, in such noses, Dr De Silva uses novel anti-inflammatory injections into the nasal tip to reduced swelling and speed up recovery.
All patients have a degree of swelling and bruising, that resolves over a period of weeks, 90% of the swelling resolves over the first week although the final result is not apparent until 6-12 months. Risks that are relatively uncommon include asymmetries, bridge scooped appearance, tip pinching, delayed healing, bleeding or a collection of blood, numbness, collapse, infection and scarring.
The majority of these risks are avoidable with technical expertise and skill, e.g. over-scooped nose, pinched tip and collapse. Revision rates for rhinoplasty are around 8%, although the risks can be resolved, revision rhinoplasty is more challenging than primary rhinoplasty as a consequence of previous surgery and scarring. Patients who smoke have delayed healing as a consequence of smoking, Dr De Silva will not perform rhinoplasty on patients who smoke, because of the risk of delayed healing, safety must come first.
A crooked nose is often caused by a deviated nasal septum (this the wall of tissue that separates the right and left nostrils and airway). The septum is a cartilage plate that lies in the very centre of the nose (see the picture below). A deviated septum often causes a crooked nose and difficulty in functional breathing. The septal deviation should be corrected during the cosmetic rhinoplasty to give a good long-lasting and effective result.
Allergic changes in the nose, for example as a result of hay fever, can result in enlargement of the nasal tissues called turbinates. These are often reduced at the same time as rhinoplasty to improve functional breathing after rhinoplasty. Systemic medications including antihistamines may be advised to treat enlarged turbinates and improve functional breathing.
The above image is taken from Dr Julian De Silva’s forthcoming book on Facial Cosmetic & Plastic Surgery, the figure shows the anatomy of the nose in cross-section. The green arrow marks the septum of the nose, if this cartilage is deviated to one side it may lead to an obstruction and reduced breathing on that side of the nose. Dr De Silva corrects septal deviation at the same time as cosmetic rhinoplasty in approximately 30% of patients.
The reason for breaking the nose during rhinoplasty is to narrow the nasal bridge, often this is done in combination in reducing boney hump or irregularity. The nose needs to be broken, termed osteotomies, in approximately two thirds of cosmetic rhinoplasty surgery. The advantage of not breaking the nasal bones, is less bruising and swelling occur and the recovery period is shorter.
The decision whether you need to have your nose broken is based on a number of feature of both the nose and the natural curvature and arcs that are present on your face. The dorsal aesthetic lines run from a patient’s brow along the side of their nose to the nasal tip. In an attractive and well-proportioned face, the lines are smooth and symmetrical.
Irregular, wide and asymmetrical dorsal aesthetic lines may require breaking the nasal bones to give the best possible result. In addition, if you have a bump on the bridge of your nose, there is a strong possibility that you will require your nose to be broken in order to give a refined and natural-looking result.
Dr De Silva uses several different types of osteotomies depending on the individual patient and nose. Internal osteotomies are usually preferred as the incisions are hidden within the nose and avoid scarring. In a small group of people, a direct osteotomy may be preferred as it offers the advantages of accuracy and predictability.
At the same time as a cosmetic rhinoplasty Dr De Silva may suggest a chin implant to give more balance to a person’s face and an even better result. A short chin is usually apparent on looking at a person’s side profile. Dr De Silva customizes silicone chin implants by sculpting the implant to fit a patient’s natural jaw line. A chin implant is a very low risk implant that can greatly improve harmony of a patients face and is completely removable.
The chin implant can be inserted into place under local anaesthesia with or without sedation with a small incision under the chin in a natural hidden crease. Patients are given a week of antibiotics as a preventative measure against infection and the implant requires no further management.
Cost is tailored to an individual patient needs based on the type of rhinoplasty whether it is combined with additional procedures such as a chin implant. Also, prices differ depending on whether it is a revision or primary rhinoplasty, as revision rhinoplasty is technically challenging. For an accurate assessment of price, a consultation is recommended. If you decide to have surgery, the consultation fee will be deducted from your surgical fee.
Shopping for price may be counter-productive, a good long lasting result that is free of problems is the preferred outcome. Although cost is an important issue, the quality of your care and outcome is most crucial and low cost surgery is ill-advised as there will be compromises in safety and the quality of the result.
Cosmetic rhinoplasty is not covered by insurance or NHS. In severe cases where the nasal irregularity is secondary to an underlying medical condition then health insurance may cover the cost of rhinoplasty in the NHS.
Ethnicity has an important role in the structure, function and suitability to specific rhinoplasty techniques. Caucasian noses often have thinner skin overlying the cartilage and boney structure, any irregularities of the cartilage are readily seen. Rhinoplasty surgery in thinner skinned individuals requires specific finesse to ensure that there are natural curves and if necessary innovative grafts are used to hide skin changes.
In contrast, some ethnicities such as Middle Eastern and Afro-Caribbean noses tend to be thicker with broader cartilages. In these patients with a thicker skin type, specific techniques are necessary to increase the definition of the cartilage underlying the nose. Usually, graft material from the patient’s nasal septum is used to aid tip support and definition, however, particularly in Asian patients with a low bridge, a customized and sculpted implant (silicone or medpor) is used to give the most natural-looking and long-lasting result.
Complications in rhinoplasty may occur because of several reasons. One of the most important factors responsible for the success of surgery is the surgeon. The surgeon needs to have complete knowledge of how the surgery has to be performed. Rhinoplasty is demanding and requires in depth knowledge of the anatomy, an artistic sense and attention to detail.
Complications can be defined as any unforeseen occurrence during or after the surgery. The complications that can occur during or after rhinoplasty and can be divided into four categories; intra-operative, immediate post-operative, early and later post-operative.
Intra-operative complications occur during the surgery. For example, these can occur due to a reaction to some medication or due to the local or general anaesthesia given and are managed by the surgical team at the time of surgery.
Immediate post-operative complications occur immediately after the surgery when the patient is in the initial recovery stage and may include bleeding or a medication. These complications need to be handled immediately by the surgeon who performed the operation.
Early postoperative complications in rhinoplasty are the ones that occur once the patient has been discharged. These appear almost immediately after the person returns to normal routine. They can include bleeding, a reaction to a medication, infection and can be corrected by contacting the doctor immediately.
Late postoperative complications associated with rhinoplasty are the ones that may occur when the patient fails to take proper care after the surgery, the surgical technique used or the patient’s healing process.
These complications include those of the nasal tip (pinching, asymmetry, inadequate projection of tip), bridge of the nose (irregularities, pollybeak fullness, saddle depression, residual nasal bump, wide-open roof), nostrils (asymmetry, flaring, collapse) size of the nose (too short, too long), breathing difficulty).
Most of these complications are minor and can be easily corrected and may occur in the best of hands as a patient’s healing process play an important role in rhinoplasty.
Open rhinoplasty refers to a small skin incision under the nose, in closed rhinoplasty, all the incisions are internal (also called endonasal rhinoplasty). Some surgeons advocate only open rhinoplasty and other surgeons advocate only closed rhinoplasty (older generation of surgeons).
Both techniques have different strengths, Dr De Silva performs both types of surgery and tailors the technique in accordance with the patients’ need. The decision should be based on clinical need and includes the nasal anatomy, whether tip surgery is required, whether the surgery is revision rhinoplasty with the use of graft material and the nature of the patient’s skin.
To give a patient a sculpted and defined tip requires precision and delicate surgery on the tip that is best performed through an open technique, which will give the best final result. A patient who has a hump on the bridge of their nose could be better suited to a closed hidden incision technique as there will be faster recovery and reduced swelling.
In conclusion, the technique requires tailoring towards the patients’ individual needs and optimised to give them the best final result.
Rhinoplasty can be performed under general anaesthesia or sedation, both are comparable and safe techniques. In the UK, rhinoplasty is more commonly performed under general anaesthesia and in the US, rhinoplasty is commonly performed under local anaesthesia with sedation, also called MAC (Monitored anaesthesia care) or “twilight anaesthesia”.
Having a large nasal tip can result in boxy or bulbous tip that is both unattractive and unbalanced in your face. The tip of the nose is made of a delicate arrangement of cartilage that give the nasal tip its shape and provide an important supporting role in breathing and maintaining smooth flow of air through the nostrils.
Dr De Silva uses a combination of sculpting the nasal tip cartilages and fine stitching of the cartilages to refine the appearance of your nose. At the same time, he uses additional techniques such as the use of graft tissue to support the architecture of the nose enabling a smooth flow of air and effective breathing.
A droopy nasal tip is an appearance of the nose that can be both unattractive and disturb facial harmony. The cause of the dropping tip may be structural based on the arrangement of the nasal tip cartilages, in addition it may be the result of collapse of the cartilages through time, ageing of the nose or traumatic injury.
Dr De Silva uses a variety of techniques to correct a droopy nose depending on an individuals characteristics. In some patients this may mean refining the nasal tip cartilages with sculpture and additional support of the nasal tip with fine sutures and grafts. Other patients may require modification of the middle and upper third of their nose to improve the facial proportions and symmetry.
All the internal sutures that Dr De Silva uses to correct the position of the nasal cartilages and lift the nasal tip are hidden from view and cannot be seen after the surgery. The benefit of correction of a droopy nose is a more attractive facial profile, and sometimes this can mean that a person’s other attractive facial features such as a patient’s eyes becoming more prominent.
The nose has an important role in both facial symmetry as well as functional breathing. Nose re-shaping, rhinoplasty that reduces the size of the nose, reduces the size of the potential airway. Dr De Silva supports the architecture of the nose with a combination of grafting and suture techniques to improve function and provide long-term support.
In the majority of his patients he uses your own septal cartilage to support the nose. However sometimes the amount or quality of the cartilage is not sufficient for providing support and giving you the best result. As a consequence, Dr De Silva may utilise cartilage from your ear and graft this to improve stability and the long-term nasal appearance. The ear has ample cartilage within is natural architecture, so the appearance of the ear remains unchanged and the incision in the back of the ear and remains hidden from view.
Dr De Silva consents all his patients for the use of ear cartilage so that he may give his patient the best possible result. It is important that rhinoplasty results in improved breathing as well as an improved cosmetic result.
The nose has important functions in both facial harmony and in breathing. A large nose can be effectively and elegantly reduced in size with rhinoplasty, with a combination of sculpting and stitching of the nasal cartilages and resetting of the nasal bones. Reducing the size of the nose and the proportions of the nasal airways has the potential to reduce airway size and affect breathing.
To maintain effective nasal breathing Dr De Silva uses septal cartilage grafts in specific locations in the nose to support the nasal airways to maintain breathing and the airway. A good result in rhinoplasty includes a well-proportioned nose that matches an individual’s face and physique, in addition has good functional breathing.
Tip refinement or nasal tip surgery refers to rhinoplasty surgery that focuses on the tip of the nose. Common tip improvements for the tip include, sculpting a bulbous or box shaped appearance, increasing the tip by projection or reducing the tip de-projection.
In most cases, when changes to the tip are requested, Dr De Silva suggests changes to the other parts of the nose are required as well to give a well-proportioned and harmonious result. This is because the nose is a three-dimensional features, and changes made to one area can change the way the other areas appear in contrast.
Tip projection refers to the distance the tip of the nose projects from the face. On some noses the tip area of the nose can appear short and round this is improved by increasing the projection of the nasal tip away from the face, to give the best result this maybe combined with tip defining techniques.
The surgical approach to rhinoplasty is dependent on the characteristics of your nose and what is required to give you the best final result. The closed rhinoplasty technique refers to hidden incisions on the inside of the nose and open rhinoplasty refers to a small incision at the base of the nose. If the principal feature is a nasal hump on your bridge then a closed approach may be the preferred option, this avoids an incision in the skin.
For some people an open approach gives a better result as this technique allows an improved view of the nasal cartilages, enabling fine sculpting of the nose to give a more refined tip. Hence some nasal characteristics are better suited to an open rhinoplasty technique, that requires a small incision that can be hidden under the base of the nose.
Dr De Silva performs both open and closed rhinoplasty dependent on the characteristics of your nose and will be able to advise you on what approach will give you the best final result.
The breaking of your nose during rhinoplasty is often necessary to give a well-proportioned and natural looking result. During rhinoplasty, sculpting and refinement of the nose is completed, this may result in the base of the nasal bones being relatively broad to the remainder of the nose, breaking the nose is required to give a well-proportioned result.
When the nasal bones need to be changed Dr De Silva uses precise bone cuts called osteotomies to control movement of the bones into their new position. After the rhinoplasty a split is placed on the surface of the nose and removed after one week at the same time as the stitches are removed.
Although at 2-months all the bruising and most of the swelling will have resolved. The tip of your nose may well be swollen for 6-12 months after nose re-shaping. Generally 6-months is the minimum before such an important event, although it does depend on your ethnicity, your nose and the surgery is required. If you have a small bump on your nose and tip surgery is not required, then the recovery will be faster.
If you have had previous rhinoplasty or certain ethnicities, there tends to be more swelling after surgery and the recovery will be longer, Dr De Silva uses anti-inflammatory medications to speed up the resolution of swelling in the tip. The timing of rhinoplasty before marriage is important to consider as it is a decision that depends both on your nose, requirements for surgery, and your expectations for your important day.
Common reasons for rhinoplasy include reducing the size of a large nose and a large bump on the bridge of your nose when this occurs the nose is referred to as having an open roof deformity. An analogy to this is considering the top of pyramid that has the top third removed the top becomes a platform which is the equivalent to an open roof deformity.
To close the open roof, the base of the bones are brought together sometimes referred to as osteotomies. Without osteotomies the hump can only be partly reduced, and the bones being brought together forms a key part of rhinoplasty.
A mild upper respiratory tract infection with no fever is generally fine to proceed with surgery. Symptoms of a bacterial infection usually associated with thick mucus discharge and fever may require treatment with antibiotics and post-poning the surgery.
Rhinoplasty is non-urgent and if there is an increased risk of infection, swelling and bleeding, the safest option maybe to delay the surgery until you are recovered.
After rhinoplasty, the upper lip can sometimes feel stiff and difficult to move as a result of swelling. Rhinoplasty always results in some degree of swelling as this normal healing, and swelling at the base of the nose can result in stiffness in the upper lip. As the swelling improves the lip movement and sensation will return to normal.
The likelihood of stiffness is dependent on the rhinoplasty surgery, revision surgery with multiple grafts are more likely to result in an increased degree of swelling and resulting stiffness. The symptoms improve in most people within a few weeks however rarely up to 6 months. After rhinoplasty there are measures that can be taken to increase the resolution of swelling and stiffness of the upper lip:
After rhinoplasty some swelling is normal as this is the way the bod naturally heals. Most of the swelling goes over the first 2-weeks however much more will go over the first 6-weeks, there can then be some fluctuation in swelling for a period of months, the final result is 12-months.
There is a degree of swelling after rhinoplasty that is dependent on your ethnicity, genetics, environmental factors, and surgical factors including if the surgery included nasal tip surgery, nasal hump reduction and revision rhinoplasty.
There are surgical techniques that Dr De Silva utilises to reduce swelling including the use of electrocautery, 3D telescopes and micro burrs. In addition there are measures that can be taken to reduce swelling after surgery including applying ice to the bridge of the nose for the 3-days, applying compression to the nasal bridge and tip after surgery.
Non-surgical nose job is a name given to the application of filler products into the nasal soft tissue to augment or change the shape of the nose (usually hyaluronic acid fillers). The fillers can be used to augment a low nasal bridge or elevate a depression along the nasal bridge and help straighten the nose. Fillers in the nose have a fairly limited nose and many nasal shapes will not be suitable for a non-surgical nose job (e.g. large nose or large nasal tip).
Fillers are mostly temporary (lasting 6-18 months), however they do have the potential of some risks including scarring, skin damage and colour changes. Any breathing of functional issues affecting the nose will not be improved with a non-surgical procedure.
A thorough assessment is required to assess both suitability for a non-surgical nose job and discuss realistic expectations from the treatment.
Although swelling is a normal part of healing after rhinoplasty, bruising is less common and more dependent on surgical technique. With surgical technique steps can be taken to reduce the risk of bruising, this includes the methods used to bring the bones inwards (osteotomies), as well as the extent of soft tissue trauma along the nasal bridge and base
In addition there are patient factors that influence bruising including increasing age, ethnicity, relative skin thickness, bleeding disorders, and medications and herbal products that thin the blood.
There are steps that I recommend taking to reduce the chance of bruising occurring with rhinoplasty surgery:
If bruising does occur, it generally takes 2-6 weeks to resolve completely, the lower eyelid skin is very thin and does not hide discolouration. The bruises can be covered with concealer cosmetics from 1-week after the rhinoplasty.
There is some evidence that if bruising does occur the use or arnica tablets speeds up the resolution of bruising.
Tip rhinoplasty describes rhinoplasty nose re-shaping that focuses on alteration of the tip of the nose. The tip of the nose can be too large, box shaped, bulbous or ill-defined, droopy or up-turning or can be twisted to one side. The tip of the nose is comprised of skin, subcutaneous tissues, and a pair of cartilages.
The tip of the nose is a highly variable part of the nose. Cartilages that makes up the tip varies in each patient in regards to their anatomical length, strength and shape, curvature, relative symmetry, depending on genetics, ethnicity, gender and environmental factors. The skin thickness differs significantly between patients and is an important factor that influences the final result.
Tip rhinoplasty usually requires shaping of the lower lateral cartilages (shape and size of the nasal tip, with shaping of the cartilages, stitches and graft tissue), the distance the tip of the nose from the face (termed projection), the rotation of the tip (down or up turning), the angle between the tip of the nose and the upper lip.
According to Dr De Silva, Rhinoplasty surgery generally requires attention to several aspects of the nose, including the tip, the bridge, the junction between the bridge and the forehead (the radix), the position of the bones and width of the nose, as well as consideration to breathing the septum and nostril positions.
Although the tip of the nose can be changed in isolation, the characteristics of a nose includes multiple aspects of the nose and altering only the tip is unlikely to result in the best possible aesthetic result.
Many patients are concerned that they will have their nasal bones fractured during rhinoplasty. The process of breaking the bones is both controlled and cautious, the bones usually need a controlled reduction to give the best aesthetic result.
Although not always required, if the nose has been reduced in size or had a large bump then it becomes essential part of the procedure.
The reason that the bones need to be brought inwards with osteotomies, is to close the “open roof” created during hump reduction, otherwise the nose will appear too wide.
There are different surgical techniques that are used to complete osteotomies, most patients have very similar recovery to that is different to if the bones are left intact. Dr De Silva uses controlled osteotomies to bring the bones inwards and to provide patients with a more attractive and refined nasal appearance that results from having a narrower nose.
Having osteotomies does not alter recovery with the exception that the bones take approximately 3-months to heal regaining their strength, during this time it is important to avoid trauma to the nose.
Bringing photos of desired noses to a rhinoplasty consultation can be useful as it conveys the aesthetic of noses that you like including the size, shape, definition and tip position. This can be useful in discussing the objectives of your surgery and expectations from surgery.
Sometimes bringing photographs can be useful in that it may be that the celebrity’s nose is just not realistic for your rhinoplasty. For example if you have thick skin it may not be realistic to expect a very fine tipped nose at the end of the surgery as this will be masked by the thickness of the skin.
Other considerations with magazine photographs or celebrity photographs are that often these photographs have been heavily edited and touched up which may result in unachievable perfect symmetry.
Celebrities, models, singers, actors and actresses all work in an industry that places much importance on the appearance of beauty and youth. Such patients undergoing surgery place a high level of importance on the results from rhinoplasty.
Dr De Silva has performed surgery on all professionals and does not perform different surgery for celebrities, he does advise patients who work with high importance on the appearance of their face to allow sufficient time for healing and swelling to resolve before their next professional shoot or public event.
Celebrities generally request complete anonymity which requires surgeons to be discrete about their consultations without other patients present as well as discrete facilities for surgery that avoid unnecessary publicity.
In terms of the best rhinoplasty surgeon, it is beneficial to spend time researching your surgeon, so that you feel comfortable that the procedure will match your expectations. A surgeon who shares your aesthetics and is open with you showing you before and after photographs as well as testimonials.
A dorsal hump is a common appearance of the nose that can be improved with rhinoplasty. The bump usually is combination of both cartilage and bones that can be shaped and modelled to give an improved nasal profile. Both open and closed techniques can be used to reduce a dorsal hump.
Other considerations are also important including the width of the nose and need to bring the bones inwards after reducing the bump (termed osteotomies). Depending on the size of the hump different procedures may be required to give the best aesthetic result. A further consideration is the need to maintain functional breathing when reducing the size of the nose (including the use of cartilage grafts and septoplasty).
Dr De Silva utilises a variety of different techniques to reduce a nasal bump depending on the individual’s unique nasal characteristics including conventional rasps to modern burrs and micro-tool devices that may offer more control and reduced swelling.
There is a degree of artistry in rhinoplasty as once the dorsal hump, the bridge of the nose can be shaped to give a different aesthetic of the nose, the shape should be tailored to the patient’s preference and aesthetic.
Having a nose that is out of proportion to your face because it is too large, bulbous, a large hump can be a difficult issue during growing up and a source of lowered esteem and confidence. Although surgery to re-shape the nose with rhinoplasty can improve the appearance of the nose it is important that other factors are considered:
The nose is one of the key characteristics in a person’s face. Teenage rhinoplasty should be performed with consideration to all of the factors above. In general at 14 years old, this is too young for surgery as a combination of physical, emotional and psychological immaturity will all be relevant at this age.
Tips to consider for undergoing Teenage Rhinoplasty
There are a number of issues teens and their parents should consider prior to undergoing rhinoplasty.
Driving after surgery, it is essential that you are alert, orientated and able to make an emergency stop should it be required. Generally speaking most people can drive 3-5 days after surgery. On the day of surgery, you are not able to drive home after surgery as you will still be effected by the general or sedative anaesthesia.
Patients should be restful and avoid flying for 1-week after surgery. Most rhinoplasty patients have a cast over the bridge of the nose with or without stitches and this is removed 1-week after surgery. The day after the cast and stitches are removed a patient can fly.
During the recovery period the bridge of the nose is more sensitive to the weight of sunglasses and can affect the healing of the nasal bridge. To ensure optimal healing, Dr De Silva advises waiting for 6-weeks before wearing glasses on the bridge of the nose.
For the first week, there is a cast that protects the bridge of your nose, after this Dr De Silva is able to give you support if you need to wear glasses from 2-6 weeks. During this time it is fine to use contact lenses.
The cartilage that is used for graft tissue, is often taken from your own nose (nasal septum) and is used to either reinforce weakened areas of the nose from previous surgery or trauma. Grafts are commonly used in revision rhinoplasty when excessive cartilage has been removed from the nose.
With revision surgery, sometimes all your natural nasal septum has been removed, in which case, other options depending on where it is required from the nose include using ear cartilage (from a hidden part of the ear), or banked cartilage.
The first option from your own cartilage septum is preferred, the other two options depend on the location and type of cartilage required.
For the curved aspect of the nose that require strengthening curved, Dr De Silva prefers ear cartilage as this creates a natural curve. For straight aspects of the nose that require straightening, Dr De Silva prefers straight septum or costal cartilage. In some patients noses, different types of grafts are required to strengthen and support different aspects of the nose.
There are synthetic graft material that is available, however, this is generally not preferred as it is unnatural and can have risks such as infection and exposure of the material.
Bringing photographs of noses that you like can be useful in a rhinoplasty discussion as it conveys the aesthetics of the nose that you like. Rhinoplasty is a procedure that is has both important technical and aesthetic elements, and key to success is an understanding of the aesthetic that you like.
At the same time, there are no two people who have identical facial features, body shape and ethnic considerations, and with rhinoplasty key is that the result suits your own personal facial characteristics for it to look balanced and natural.
A Caucasian female’s nose will not look good on a person with Asian facial characteristics and vice versa. Dr De Silva uses imaging to show you his aesthetic which is a natural looking result that keeps an individual’s character and ethnicity.
Hay fever is a common condition in which the lining at the back of your nose has a tendency to become inflamed and thickened by an allergy to pollen. Characteristically this can result in symptoms of stuffiness, sneezing and nasal discharge.
Rhinoplasty will result in swelling immediately after the surgery that can result in symptoms of congestion, rhinoplasty will not change or be affected by the hay fever. Rhinoplasty will change the shape of your nose however it will not effect the lining of the nose, and tendency for hay fever will remain after rhinoplasty and require the same treatment including antihistamines.
After rhinoplasty, Dr De Silva recommends staying out of the sun for 6-months. Although it is safe to go on holiday even 1-week after surgery, avoiding sun exposure is important to ensure optimal healing. The healing nasal skin may darken with sun exposure and relative numbness in the nose can make the nose more prone to sun burn.
To aid healing and fast recovery, Dr De Silva recommends avoiding sun exposure, using a hat that shades your nose and sun protection factor of 30 or above.
Nicotine products have a powerful effect on blood vessels in the skin by causing them to shut and close down, termed vasoconstriction. Blood vessels and circulation is important as after rhinoplasty, as your nose is healing and requires a good blood supply for it to heal quickly and naturally.
Nicotine products can cause delayed healing and avoidable risks after rhinoplasty, Dr De Silva recommends avoiding all nicotine products for a minimum of 6-weeks after surgery.
In most people discomfort and pain after rhinoplasty settles 24-48 hours after the surgery. In patients where the nasal bones have been narrowed, termed osteotomies, a minority of patients may find some sensitivity and discomfort over the bridge of the nose intermittently for several weeks.
In addition there is some swelling on the inside lining of the nose that can result in symptoms of congestion, this can result in headaches particularly in sensitive individuals if coupled with other conditions such as hay fever or sinusitis.
These patients may benefit from a course of antibiotics or anti-inflammatory medications during the recovery period. There can be a wide variation in individual patient’s threshold for pain, most patients report only mild or minimal discomfort.
After rhinoplasty there is some swelling on the inside of the nose that leads to intermittent congestion. The degree of congestion can vary from person to person and can be improved with saline spray and other conservative measures to reduce swelling, such as sleeping with your head elevated. With diving, it is essential to be able to re-equilibrate the pressure in your ears.
The second consideration is the diving mask which that is worn over the eyes and nose, early after the surgery the nose will be more sensitive to the mask. After rhinoplasty, Dr De Silva recommends waiting 6-weeks before diving.
A non-surgical rhinoplasty utilises a filler material to alter the shape and position of the nose. The principal advantage of the technique is that it avoids a surgical procedure, however by definition the treatment is not permanent.
A non-surgical nose job can be effectively used to correct these nasal appearances: a nose with a small hump, a nose that has depression along the bridge (termed saddle nose deformity), nasal collapse from previous trauma, droopy nasal tip, beak-shaped nasal bridge (termed pollybeak). A non-surgical nose job can also be used to improve certain features of a patient’s nose who is not yet ready for a surgical rhinoplasty.
The filler material is injected into specific areas in the nose with a fine needle or cannula into a specific part of the nose. Precautions are required in non-surgical rhinoplasty, as the nose is an intricate structure with important anatomy that must be preserved.
Non-surgical rhinoplasty should ideally be performed by a surgeon who is also experienced in surgical rhinoplasty. Dr De Silva only performs non-surgical rhinoplasty in a sterile environment to maximise rapid recovery and reduce the risk of infection. The most common filler used is a type of hyaluronic acid that naturally dissipates, most results typically last up for over one year.
Some patients may be concerned that rhinoplasty could lead to a change in their voice, particularly relevant to specific professions that are dependent on personal vocal character. There was a scientific research study published in the Plastic Reconstructive Surgery Journal in January 2014 that concluded that patients should be advised of a possible risk to voice changes following a nose job.
This study was conducted in Iran, with Farsi speaking patients and there was a self-assessment component to the study that may have led to inaccuracies in the data collection and potential flaws in the study. Generally speaking surgeons in the USA and Europe, believe that the risk in rhinoplasty effecting voice is very small.
There are many potential variables that can influence your voice and vocal acoustics including the anatomy of the voice box, ethnicity and language (Middle Eastern languages including Farsi can have a more nasal component relative to English or European dialects). Dr De Silva believes that in the great majority of his patients’ voice is not affected by rhinoplasty, however in certain patients with specific anatomy, ethnicity, certain lingual dialects there may be subtle changes in voice.
Often patients who have functional breathing issues with their nose benefit from rhinoplasty, as the nasal airways may be opened during the surgery and the nasal tonality reduced.
Immediately after the surgery as a consequence of swelling, there is likely to be a change in the quality of your voice as a consequence of swelling and congestion. However, with the resolution of the swelling over the first period of weeks, the natural vocal characteristics return.
A further consideration in effecting voice during surgery is the type of anaesthesia. General anaesthesia often involves the placement of a tube inside your airway that has the potential to damage the vocal cords. Dr De Silva continually uses newer techniques to reduce potential risk and improve results and avoids the potential for trauma in rhinoplasty by using twilight anaesthesia also known as sedation.
By using sedation anaesthesia, no tube is placed in the airway, and this avoids potential mechanical damage to the airway associated with general anaesthesia.
Professionals dependent on their voice for their career should consider subtle changes to their voice before undergoing rhinoplasty. Most people report an improvement in singing after rhinoplasty coupled with septoplasty with or without turbinectomy, as the airways are more open after surgery.
However, every person’s situation is unique and your concerns should be assessed and discussed with your surgeon. Although all surgery carries potential risks, the influence of rhinoplasty on altering voice is relatively small.
Dr De Silva takes care to ensure necessary precautions are taken with rhinoplasty to ensure the airway is maximized during surgery to improve breathing and reduce the risk of changes to the voice.
Dr De Silva has completed numerous rhinoplasty procedures on professionals dependent on their unique vocal characteristics including actors, actresses, vocalists, singers and celebrities taking precautions to preserve vocal character.
Celebrities, models, singers, actors and actresses all work in an industry that places much importance on the appearance of beauty and youth. Such patients undergoing surgery place a high level of importance on the results from rhinoplasty.
Dr De Silva has performed surgery on all professionals and acknowledges that his patients are looking for both natural-looking results and fast recovery, he does advise patients who work with high importance on the appearance of their face to allow sufficient time for healing and swelling to resolve before their next professional shoot or public event.
Celebrities request anonymity which requires surgeons to be discrete about their consultations without other patients present as well as discrete facilities for surgery that avoid unnecessary publicity.
The length of a rhinoplasty procedure will depend on the complexity of the surgery. On average a rhinoplasty will take from 2 to 3 hours, less than 1 and a half hours is a short length of time. There is a great deal of complexity in your nose and good surgery requires meticulous attention to detail, technical knowledge of surgical techniques and artistry.
It is important that your surgeon takes adequate time to complete the surgery cautiously and without rushing. More complex revision rhinoplasty that requires additional procures may take 4 hours, particularly if complex graft tissue is required.
Dr De Silva allows a minimum of 3-hours for most rhinoplasty procedures and allows additional time to ensure the best possible result. For more complex rhinoplasty including nostril refinement additional time up to 4-hours. Dr De Silva generally limits rhinoplasty to 4-hours as after this time there can be increased swelling that can affect the appearance of the nose.
Immediately after rhinoplasty your nose feels blocked and breathing through your nose can be difficult. Dr De Silva does not use any packs in the patient’s nose after rhinoplasty, however, the nose can feel congested because of swelling of the inner lining of the nose, this will improve at the end of the first week.
Swelling can also alter your sense of smell and this returns over the first 4-6 weeks. A permanent change in sense of smell is very rare.
In most people discomfort and pain after rhinoplasty settles 24-48 hours after the surgery. In patients where the nasal bones have been narrowed, termed osteotomies, a minority of patients may find some sensitivity and discomfort over the bridge of the nose intermittently for several weeks.
In addition, there is some swelling on the inside lining of the nose that can result in symptoms of congestion, this can result in headaches particularly in sensitive individuals if coupled with other conditions such as hay fever or sinusitis. These patients may benefit from a course of antibiotics or anti-inflammatory medications during the recovery period.
There can be a wide variation in individual patient’s threshold for pain, most patients report only mild or minimal discomfort.
With the techniques Dr De Silva uses, most patients describe surprisingly little pain, and usually for less than 24-48 hours. Oral analgesia is adequate for a couple of days after surgery, and many of my patients never take any analgesia.
How long before your smile returns to normal after rhinoplasty?
This is a common concern among recent rhinoplasty patients. Most patients have a normal smile even a few days after rhinoplasty, however, swelling is a normal part of healing by which your body attracts healing cells to the area that has undergone surgery.
Your smile can sometimes be affected by swelling of the upper lip as it lies immediately below your nose after rhinoplasty. Over the first few weeks as this swelling resolves your smile will go completely back to normal.