Written by Dr. Julian De Silva

Rhinoplasty is a facial plastic procedure that requires a comprehensive understanding of the underlying anatomy and an artistic approach to incorporate an individual’s facial characteristics to give a natural looking result. The key for a natural looking result is refinement surgery that is conservative and avoids an unnatural ski slope or pinched appearance. These principal steps in rhinoplasty surgery are as follows however the surgical technique is tailored to the individual.

In closed rhinoplasty the incisions are placed in the inside of the nose, where they are hidden. In open rhinoplasty a small incision is place under the nose near the nostrils, this becomes hidden with time. Many surgeons are able to complete only one technique, Dr De Silva completes open or closed technique depending on the patient’s individual needs for their best result. The underlying soft tissues, cartilages and bone are sculpted, shaped and stitched to create the nose’s new shape. An implant may be used to enhance the bridge of the nose, increase tip definition or prevent collapse by adding support. The skin is re-draped over the nose’s new frame and all incisions are closed with stitches. A splint or case is placed over the nasal bridge to hold support of the nose while the tissues heal and is removed after 1-week.

Rhinoplasty Technique (A.K.A. Nose job)

Reducing a Nasal Hump

A nasal hump or bump defines the size and shape of the nose and may be elevated as a hump or depressed as a consequence of collapse of the nose through trauma or over surgical resection. The nasal hump of the nose is reduced in size by reduction of both the cartilage (lower two thirds) and bones of the nose (upper one third). In addition, other measures are required to maintain the natural pyramidal shape of the nose and prevent the nose becoming too wide, this is why the bones are usually narrowed with osteotomies. For some patients the bridge is also supported with the use of cartilage grafts, as these support the nose long-term and maintain functional breathing, however care is required to avoid widening the nose. Other additional measures may also be required for patients with thin skin or thicker ethnic skin.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty animation - How can a Nasal Hump be reduced?

Large or Bulbous Tip

A more refined, elegant nasal tip is a common request from rhinoplasty. There are a few common factors that can create tip bulbosity. The shape of the nasal tip is made by the cartilage in lower third of the nose. The cause of an enlarged or bulbous tip may be a result of enlarged cartilages, wide or convex shape or asymmetry. In addition, the thickness of the patient’s skin can also determine the width of the nasal tip. Patients with ethnic skin tend to have thicker skin that enlarges the size of the nasal tip.

Dr De Silva creates a more refined nasal tip by shaping and sculpting the lower lateral cartilages that are often too wide and asymmetrical. The use of special stitches (termed dome binding sutures) will also help shape the tip further by creating additional definition. These dome binding sutures can be used to reshape and define the nasal tip. In patients with thicker skin additional techniques may also be required including thinning the skin at the nasal tip and placing a cartilage graft underneath the cartilages called a lower lateral crural strut graft.

Shaping of the Lower lateral cartilages. Key with refinement is to avoid over reduction of the lower lateral cartilages as this can sufficiently reduce the structure of the nose resulting in a pinched nasal tip or collapse on breathing. Dr De Silva takes care to measure the cartilages to ensure there is sufficient structural support of the tip to last for years to come.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Animation - How can a Large Over-Projected nose be made SMALLER?

How can a droopy nasal tip be lifted?

Rhinoplasty can be used to reposition the tip in a more natural position by lifting the nasal tip. The pair of cartilages that make up the tip of the nose are shaped and sculpted, these are termed the lower lateral cartilages that are often too wide and asymmetrical. In addition, placing special stitches (termed dome binding sutures) will shape the tip further by creating additional definition.

Care is required with this procedure as the tip should not be over lifted as this can result in a piggy shaped nose in women, and more feminine appearance in men. Artistry is required in ensuring the tip is lifted to a natural position. The natural position will depend on male or female sex, facial proportions, height of patient as well as ethnicity.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty animation - How can a Large and Wide Bulbous Tip be made smaller?

How can a large over-projected nose be corrected?

A long-over projected nose is described as a nose that comes out from the face too far, essentially is too big, this is called over-projection.
Tip projection refers to how far forward the nose travels from the face and rhinoplasty can be used to treat a long nose by repositioning or trimming the tip cartilages.

To reduce the size of an over-projected nose requires shaving down the underling bone and cartilage and reposition the nasal tip further back towards the face.

Dr De Silva feels It is important to consider the nose with the other facial characteristics, if you have a small chin it may create an illusion of a large nose when actually your chin is too small. For some patients combing rhinoplasty and a reduction in nose size with chin implant surgery will give the best possible result.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Animation How can a Droopy Nasal Tip be lifted?

How can a crooked or asymmetrical nose be straightened?

A crooked nose or an asymmetrical nose is one that turns either to the right or left sides. Broadly speaking the nose can be separated into three parts the top third, middle third and lower third. To straighten a nose requires evaluating and treating each of these three thirds to improve the appearance of the nose.

It is very difficult in rhinoplasty to completely straighten a crooked nose. The deviated cartilage and bone have a certain level of memory such that the nose wants to drift back towards its original shape, graft tissue can be used to help straighten the nose. Too much graft material in the nose can have a tendency to widen the nose so a balance is required in avoiding over widening the nose while improving its symmetry.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Animation - How can a Crooked or asymmetrical nose be straightened?

How can a wide nose be narrowed?

A narrower nose generally has a more elegant appearance in both women and men and across different ethnicities and cultures. Narrowing the nose can generally refer to three main areas: narrowing the bridge of the nose, narrowing the tip of the nose and narrowing the nostrils.

Narrowing the bridge of the nose, termed Osteotomies also known as breaking the nose. Narrowing the base of the nose, termed osteotomy, are required in most rhinoplasty surgeries to give the nose an improved shape and narrower nasal bridge. Dr De Silva utilises electrocautery to minimise bleeding and to make a pocket incision for the osteotome instrument to be used. The nasal bones that make up approximately the upper third of the nose are individually broken with special instruments that result in a controlled and planned break. The nasal bones are then brought together and pressure applied to minimise bleeding. Osteotomies can be performed through the skin or hidden within the inside of the nose; Dr De Silva prefers to use hidden incisions where possible as this avoid unnecessary scarring of the skin.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Animation - How can a Wide nose be narrowed?

How can wide nostrils be narrowed?

Narrowing of the nostrils that are indicated for some patients. This surgery requires both precision and delicacy to hide the incisions on the inside of the nostril and maintain adequate functional breathing through the nose.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Animation - How can Wide Nostrils be Narrowed?

How can breathing be improved by correcting a deviated septum?

Septal deviation refers to the central cartilage in the nose (this wall of cartilage tissue separates the right and left nostrils). A septal deviation often causes a crooked nose and may cause difficulty in breathing because of blockage of the airway. Dr De Silva corrects a septal deviation with septoplasty in 30% of rhinoplasty procedure to improve breathing.

Septoplasty is a common procedure that is combined with rhinoplasty. The septum is a cartilage plate that lies in the very centre of the nose (see the figure below), the septum is a wall of tissue that separates the right and left nostrils and airway. A deviated septum is commonly without symptoms, however if severe it may cause a crooked nose and difficulty in functional breathing, it is an important consideration in rhinoplasty to ensure that the breathing is not affected by rhinoplasty. In addition, the septal cartilage may be used for graft material which Dr De Silva uses for supporting the nose and enhancing the fine definition of the nasal tip. The septal deviation should be corrected during the cosmetic rhinoplasty to give a good long-lasting and effective result.

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Animation - How can Breathing be improved by correcting a Deviated Septum?

What does a deviated septum look like?

The CT imaging illustrates septal deviation. The green arrow shows a straight septum, this allows equal air flow in the right and left sides of the nose and normal breathing. The red arrow shows a deviated septum, this results in reduced flow to the side of the deviation by narrowing the air flow. Septal deviation can vary substantially in severity, a severe deviation can cause near complete obstruction of the airway. Dr De Silva will commonly include septoplasty with rhinoplasty surgery to give the patient the best possible cosmetic result as well as functional breathing. In some patients’ additional grafts are required to support the breathing particularly when the nose is being reduced in size.

Rhinoplasty Technique (A.K.A. Nose job)

How can a small chin make your nose look larger?

A small chin can give the illusion of a larger nose by effecting relative proportions and facial balance. In a person with good facial proportions the chin is positioned 1-2mm behind the lower lip. There are variations in facial harmony and balance based on genetics, gender and ethnicity.

The position of a recessed chin is characterised by a chin position (>5mm) behind a vertical profile line drawn through the lips. By augmenting the chin at the same time as rhinoplasty this can improve the final result. With chin augmentation the chin is moved forward and the relative distance from the lips to the chin is reduced. Dr De Silva uses reference points on the face to evaluate proportions, and the artistry of chin augmentation also includes taking into account gender, ethnicity and chin shape into account with chin shaping.

Particular importance is shaping the implant to soften the appearance of the chin and ensure a natural jaw line (shown with hatching in the figure below). Dr De Silva is known for natural looking work and customization of techniques that are in harmony with a person’s facial characteristics.

For more information on chin implants please click here.

Rhinoplasty Technique (A.K.A. Nose job)
Chin Implant Animation Video - How is a chin implant inserted?

How is rhinoplasty completed?

These are the principal steps in rhinoplasty surgery, although the surgical technique is tailored to the individual:

  • The nose is marked prior to surgery commonly on the under surface of your nose. Other marks may be made specific to individua need, including marking of the nostrils for alar reduction, and the chin area for chin augmentation
  • Anaesthesia is administered by, principally sedative anaesthesia or general anaesthesia. Local anaesthesia with adrenaline is injected into the nose, this aids the surgery by reducing bleeding
  • Incision: which maybe either through the skin (open or transcutaneous technique) or through the lining of the nose (closed or intranasal technique) is completed.
  • Tip refinement: The tip of the nose consists of two principal cartilages called the lower lateral cartilages. In a large or bulbous tip these cartilages are shaped, sculpted and re-stitched together to give the tip of the nose a more defined appearance. Often there are natural asymmetries or uneven shapes in the cartilage in the tip of the nose that can lead to a widened irregular and asymmetrical tip. With open rhinoplasty the cartilages on the right and left sides can be measured to a millimetre to make even and with specific stitches the shape made more even and refined.
  • Drooping nasal tip: the tip is elevated and rotated, depending on the amount of droop this is corrected with a combination of elevation of the tip cartilages and refinement of the lowest cartilage of the nose, termed the caudal nasal septum.
  • Upturning nose or short nose: The tip is counter-rotated downwards to lengthen the nose and reduce the upturning nose. With revision rhinoplasty additional graft tissue may be required to lower the nasal tip.
  • A nasal hump defines the size and shape of the nose and may be elevated as a hump or depressed as a consequence of collapse of the nose through trauma or over surgical resection. The nasal hump of the nose is reduced in size by reduction of both the cartilage (lower two thirds) and bones of the nose (upper one third). In addition, support of the bridge is often completed with the use of cartilage grafts these support the nose long-term and maintain functional breathing.
  • A depressed or collapse of the bridge of the nose requires augmentation of the cartilages in the bridge of the nose, often this requires graft tissue to support the nose. The graft tissue may be taken from the patients’ septal cartilage (Primary Rhinoplasty), in other cases this must be taken from elsewhere including ear cartilage or harvested costal cartilage. Dr De Silva prefers to use a patient’s own septal cartilage where possible as this is the closest to a patient’s own cartilages, however in cases where this has already been removed, other alternatives are necessary.
  • Breathing through the nose is an important function of the nose and rhinoplasty often narrows the airway passages that can reduce breathing. To improve the airways and maintain breathing, Dr De Silva frequently uses graft tissue to support the structure of the nose long-term.
  • Septoplasty is a common procedure that is combined with rhinoplasty. A deviated septum is commonly without symptoms, however if severe it may cause a crooked nose and difficulty in functional breathing. In addition, the septal cartilage is often used for graft material which Dr De Silva uses for supporting the nose and enhancing the fine definition of the nasal tip. Dr De Silva performs septoplasty in 30% of cosmetic rhinoplasties.
  • Osteotomies also known as breaking the bones, involves narrowing the base of the nose, termed osteotomy. This is required in most rhinoplasty procedures to give the best result and narrower nasal bridge. Dr De Silva utilises electrocautery to minimise bleeding and to make a pocket incision for the osteotome instrument to be used. Osteotomies can be performed through the skin or hidden within the inside of the nose; Dr De Silva prefers to use hidden incisions where possible as this avoid unnecessary scarring of the skin.
  • Further refinement of the nasal bridge is completed until it is straight and refined (masculine appearance to the nose) or has a small curve just above the nasal tip, termed the supra-tip break (feminine appearance to the nose).
  • Additional grafts may be required to increase the definition, projection of the nose, these are sculpted to an individual’s unique nasal characteristics. Dr De Silva uses different types of graft tailored to an individual’s specific needs, these include: Strut supporting grafts, Spreader grafts, alar grafts, batten grafts, cap and tip grafts, dorsum grafts and shield grafts.
  • Closure of the mucosal inner lining of the nose is completed with dissolvable stitches.
  • Stitches: Closure of the skin beneath the nose with small stitches, these are removed 1-week after surgery.
  • Alar/ Nostril Reduction: Narrowing of the nostrils is indicated for some patients. This surgery requires both precision and delicacy to hide the incisions on the inside of the nostril and maintain adequate functional breathing through the nose.
  • Use of packing within the nose, Dr De Silva rarely applies packing within the nose as the septum is individually repaired with stitches and patients often find packing of the nose uncomfortable.
  • Splint: A plaster of paris or Denver splint is applied to the bridge of the nose. The splint holds the position of the bone in place as the nose heals over the first week after surgery and reduces swelling.
  • Tape: A fine skin coloured Micropore tape is applied over the surface of the nasal splint and provides additional support to the nasal tip.
Rhinoplasty Technique (A.K.A. Nose job)

*Results May Vary

Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Technique (A.K.A. Nose job)
Rhinoplasty Technique (A.K.A. Nose job)

Revision Rhinoplasty

Over 30% of Dr De Silva’s patients have undergone previous surgery, termed revision nose reshaping or revision rhinoplasty.

More information on Rhinoplasty:

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