Rhinoplasty (Greek: Rhino = nose + Plasty = to shape), commonly known as a nose job, is a plastic surgery procedure for correcting  the form (shape), restoring the function (breathing),  and aesthetically (cosmetically) enhancing the nose by resolving nasal traumacongenital defect ( Secondary cleft  lip nose deformity, Binder’s Sundrome), or a failed primary rhinoplasty.

Primary Rhinoplasty

Surgery for reshaping of nose in a patient who has never undergone nasal surgery. It can be either a cosmetic procedure performed to improve the appearance of the nose, a medically necessary procedure to improve nasal breathing, or a combination of both. Rhinoplasty is a surgical procedure to improve the appearance or correct the function of the nose. While there is no one ideal nose that is suitable for all face types, having the rhinoplasty procedure done can deliver dramatic results for individuals who wish to improve the appearance and function of their nose. Aesthetics isn't the only reason people undergo rhinoplasty. Traumatic injuries to the nose, some types of cancer or birth defects can lead to decreased function of the nose, making breathing difficult, painful or even impossible without corrective surgery.

Secondary Rhinoplasty

Secondary rhinoplasty I sa term given to Corrective reshaping of a nose which was operated earlier by a different surgeon (a failed primary rhinoplasty). It requires exceptional analytical and surgical skill. Only surgeons with extensive training and significant rhinoplasty experience can restore breathing function and improve less-than-desirable results from previous nose surgery. A secondary rhinoplasty is corrective nasal surgery that serves to alter the form and/or function of the nose after a previous rhinoplasty. Secondary aesthetic and reconstructive nasal re-shaping is indicated for cosmetic or functional deformities not properly treated or made worse from the primary operation. Some also refer to secondary rhinoplasty as "revision rinoplasty." This broader terminology can apply to rhinoplasty required beyond a secondary operation, such as a third or fourth operation.

Patients request secondary rhinoplasty to address specific imbalances that persist, are newly created, or that have become more severe. Often the nose is imbalanced or in disharmony with the rest of the facial features due to an un-anticipated healing complication, improper, or incomplete surgical maneuvers. A secondary rhinoplasty is often much more complicated than a primary rhinopasty. The first time in rhinoplasty is always the best time to address all the cosmetic and functional nasal issues, however with appropriate application of advanced techniques by a rhinoplasty specialist, secondary procedures can be successful. The majority of surgeons who specialize in rhinoplasty also have necessary experience with more complex revisional surgeries and will be able to address patient concerns. Of course, as with primary rhinoplasty, your expectations and goals need to be appropriate and thoroughly discussed with your surgeon. It may be helpful to bring in photos of your nasal appearance prior to your previous operation. Your rhinoplasty surgeon may also request previous operative records and medical records, although this is not mandatory.

Common Indications for Secondary Rhinoplasty:

  • Nasal airway obstruction
  • Collapse of cartilage or nasal bones
  • Artificial cosmetic appearance to nose ("Overdone nose job")
  • Internal and external nasal valve collapse
  • Worsened asymmetry
  • Over reduction or inadequate reduction of dorsal height (bridge height/hump)
  • Incomplete shaping (not enough of a cosmetic change)
  • Excessive or inadequate tip projection
  •  Excessively narrowed nasal tip ("pinched tip")
  • Excessive internal and/or external scarring (thickened scar tissue)

The changes necessary in secondary rhinoplasty can be done through a "closed" or "open" approach. Typically, if there are major structural changes required, and open approach may be preferred. Minor contour corrections can be performed via a "closed" technique. Closed rhinoplasty is when only internal incisions (endonasal) are made for access to the nasal structures. Open rhinoplasty refers to the addition of an incision in the skin bridge between the two nostrils (columella) in order to lift up the nasal skin for more direct visualization of the structures to be altered. The decision to use either the closed or open approach in revision rhinoplasty is based on surgeon preference and each technique has its pros and cons.

Cartilage grafts (portions of cartilage from the septum, ear, or a rib) are often necessary to accomplish the cosmetic and functional goals in secondary rhinoplasty. It is very common for the primary procedure to have depleted much of the nasal cartilage. A lack of septal cartilage is the most common indication for needing ear or rib cartilage sources for graft material. These segments of cartilage are then shaped into structural and shaping pieces for use in the nose. As with primary rhinoplasty, there is very little room for error and it is vital that you seek a rhinoplasty expert who is skilled and has vast experience in secondary techniques. In order to reduce the rates of further revisions and ensure a successful outcome, it is best to seek a plastic surgeon or facial plastic surgeon who specializes in rhinoplasty and revision rhiinoplasty.

Revision Rhinoplasty

Further changes/augmentation or reduction by same surgeon in a previously operated nose is termed as revision rhinoplaty. Sometimes a primary rhinoplasty procedure doesn't produce the desired aesthetic or functional result or was unable to completely achieve its corrective goal. Revision rhinoplasty is the term used to describe secondary or subsequent rhinoplasty procedures. These subsequent procedures are performed to improve breathing issues and/or correct poor aesthetics - most often due to the patient not being pleased with the first results or some other adverse effect of the first procedure. Structural support of the nose with patient's own cartilage is the single most important aspect of revision rhinoplasty. Rhinoplasty has a higher revision rate than any other cosmetic procedure.

Frequently Asked Questions :

Q : What is rhinoplasty?
A : A rhinoplasty, commonly referred to as nose reshaping or a nose job, is a surgical procedure that is performed to change the shape or look of a nose or to improve its function.

Q : How much does rhinoplasty cost? 
A : The cost of rhinoplasty greatly depends on hospital and class you choose and how much alteration you want for your nose. The average cost of a rhinoplasty procedure ranges from 50,000 to 2, 50,000 INR. The average cost does not take into consideration an overnight hospital stay if required. Rhinoplasty and other cosmetic surgeries are not covered by any mediclaim or insurance.

Q : When It Is Done?
A : Rhinoplasty is most often performed for cosmetic reasons. A nose that is too large, crooked, misshapen, malformed at birth, or deformed by an injury or cancer surgery can be given a more pleasing appearance. If breathing is impaired due to the form of the nose or to an injury, it can often be improved with rhinoplasty. The majority of individuals who undergo nose reshaping surgery are dissatisfied with the appearance of their noses and wish to improve the proportions of their facial features. A smaller percentage of rhinoplasty candidates are patients who deal with discomfort or breathing difficulties due to structural abnormalities or previous nose injuries. The optimal candidates for rhinoplasty are in good general health, understand the risks associated with surgery, and have realistic expectations regarding the surgery results.


Indications of Rhinoplasty :
Rhinoplasties are done for different reasons :
1. Conginental defects like secondary cleft lip nose deformity
2. Traumatic disruption of normal structure of nose so that the nose is asymmetrical.
3. Purely cosmetic reasons like hump correction, length correction, or for decrease in height of nose etc.
4. Correction of structural as well as functional deformity (deviated nasal septum with crooked or off-center dorsum , or damaged valves)
5. Nasal tip ; drooping, rotating, boxy, bulbous or bifid.
6. Excessively flared or pinched nostrils

Q : How It Is Done ?
A : Nose surgery is done by two methods 
1. Open 
2. Closed
Advantage of open rhinoplasty is good visibility of all the defects but at the same time it is more difficult and requires training and expertise. Closed rhinoplasty is comparatively easier but field of vision is restricted and so all the deformities cannot be corrected by this. It has got limitation of vision as well as surgical outcome. Primary Rhinoplasty:
Surgery for reshaping of nose in a patient who has never undergone nasal surgery. It can be either a cosmetic procedure performed to improve the appearance of the nose, a medically necessary procedure to improve nasal breathing, or a combination of both.
Secondary Rhinoplasty: Corrective reshaping of a nose which was operated earlier by a different surgeon. It requires exceptional analytical and surgical skill. Only surgeons with extensive training and significant rhinoplasty experience can restore breathing function and improve less-than-desirable results from previous nose surgery. Revision Rhinoplasty:
Further changes/augmentation or reduction by same surgeon in a previously operated nose.

Q : Who Can Opt For Rhinoplasty ? What is the appropriate age to undergo rhinoplasty?( Rhinoplasty candidates) 
A : Any adult (>18 years of age) with perceived aesthetic issues or birth defect can opt for it. As the nasal cartilage is growing till the age of 18 years it is advisable to delay any corrective surgery of nose till this time. In extreme cases where there is severe breathing difficulty it can be performed at 14 - 16 years of age.. Regardless of the reason for surgery, we recommend that girls wait until age 14 or 15, and that boys wait a few additional years to undergo rhinoplasty. By this time, the nose should have finished growing.The best way for a patient to determine his or her candidacy for rhinoplasty is to schedule a consultation with a qualified rhinoplastic surgeon.
Technically speaking, cosmetic rhinoplasty can be performed any time after nasal growth is complete. Nasal growth is usually complete in girls by age 15 and complete in boys by age 16. However, an emotionally mature and cooperative patient is also an essential requirement for a successful rhinoplasty. In rare cases, surgery may be performed at younger ages when severe functional impairment or other medical indications dictate.
Cosmetic rhinoplasty becomes increasingly more challenging with age. All other factors being equal, the best time to perform cosmetic rhinoplasty is in mid-to-late adolescence or early adulthood. By the fourth decade of life, the cosmetic outcome is sometimes less favourable

Q : Can I get reshaping of my nose and correction of breathing problem in one sitting?
A : Certain breathing problems (such as a crooked / pinched nose /post traumatic deviation or collapse) need reshaping of nose as well as straightening of septum. This procedure is called Septorhinoplasty which can improve both appearance and function. Surgeons who are trained in both cosmetic and functional nasal surgery can do this procedure with perfection and can achieve a more attractive nose while simultaneously improving nasal function.

Q : What are the Pre-op Preparation / Pre Requisites for rhinoplasty?
A : First and foremost thing is detailed consultation to know about patient's desires and expectations to evaluate the patient's nose and to discuss the procedure, down time and expected/unexpected complications with the patient. Proper evaluation by an anaesthetist as it is done under general anaesthesia is a must. Depending on the patient's age and medical history, blood investigations, chest X-Ray is ordered and if the anaesthetist finds the patient fit for anaesthesia, operation is scheduled.
In preparing for rhinoplasty surgery few instructions are must-
Stop smoking and avoid taking aspirin, anti-inflammatory drugs, and herbal supplements atleast a week prior to date of surgery as they can increase bleeding.

About The Surgery

There is nothing like one nose fits all. So depending upon the evaluation and discussion with patient open/closed approach is chosen. If augmentation is to be done then the patient is given the option of conchal /septal /costal cartilage graft or implant. Different combinations of procedures like augmentation with ala correction and tip plasty or septal correction or only lengthening is done. Pre-op and post-op photographs are taken to compare and to audit the results.

Q : Why one needs cartilage grafts in rhinoplasty?
A : Two essential ingredients are needed to produce a successful rhinoplasty outcome: a cosmetically pleasing skeletal contour and durable skeletal support to maintain that contour over time. Both of these goals typically require the rearrangement and/or reinforcement of the existing nasal framework with cartilage grafts. For instance, a wide and droopy nasal tip must be lifted and narrowed to achieve a more attractive nasal contour. By elongating and strengthening the existing tip cartilage using additional cartilage tissue, a sturdy and elegant contour is achieved. However, seamlessly incorporating cartilage grafts into the existing nasal tip framework is an art form that takes years to master and requires an adequate supply of healthy donor cartilage. Although an improperly shaped or malpositioned graft may occasionally spoil the cosmetic outcome, cartilage grafting is an indispensable tool in cosmetic nasal surgery and nearly all accomplished nasal surgeons employ cartilage grafts on a routine basis. In fact, cartilage grafts are almost always required in revision rhinoplasty to replace damaged or lost components of the nasal skeleton.

Q : What is the relation of skin thickness to rhinoplasty results? 
A : In patients with nasal skin of average thickness, small imperfections in the underlying nasal skeleton remain hidden and are difficult to detect. However, in patients with ultra-thin nasal skin, even small skeletal imperfections can become visible and spoil the cosmetic outcome. For this reason, the thin-skinned rhinoplasty patient is regarded as among the most challenging in cosmetic nasal surgery. However, that's not to say that the thin-skinned patient can't achieve a satisfactory cosmetic result. With meticulous and precise contouring of the nasal framework, coupled with secure placement of carefully sculpted cartilage grafts, a glassy smooth and well-proportioned nasal framework can ensue. In severe cases, soft tissue overlay grafts such as fascia, perichondrium, or dermis can also be placed beneath the skin to increase thickness, improve camouflage, and enhance the cosmetic result. However, thin-skinned noses are typically not for beginners. Patients with thin nasal skin should select an accomplished rhinoplasty surgeon familiar with the nuances and pitfalls of this challenging anatomic variant.

Q : What is good, Closed or open rhinoplasty?
A : "Closed" rhinoplasty refers to a form of limited surgical access in which all of the surgical incisions are hidden within the nostril. Although some surgeons prefer the closed approach since it avoids a potentially visible scar, it also significantly limits the surgical exposure, making it difficult or even impossible to utilize many of today's most effective rhinoplasty techniques. As a result, many surgeons prefer the "open" rhinoplasty approach, which connects the nostril incisions at the columella to dramatically improve surgical exposure. Direct visualization of the nasal skeleton not only facilitates diagnostic accuracy, it also enables the surgeon to modify and strengthen the skeletal framework without interference from the overlying soft tissues. This approach is particularly useful with challenging nasal anatomy, such as a complex revision rhinoplasty where the tissues have been previously altered. Although the columellar incision is initially visible, when carefully re-approximated, it seldom results in an objectionable nasal scar and it often fades completely in the months following surgery. For the overwhelming majority of individuals, the advantages gained by the open approach are well worth the limited risk of an unsightly columellar scar. By the same token, avoidance of a potential scar is little consolation if the rhinoplasty result is compromised by poor exposure.

Q : Is general anesthesia must for rhinoplasty?
A : Minor touch-up procedures excepted, rhinoplasty is almost always performed with one of two forms of deep body-wide anesthesia: intravenous sedation or general anesthesia. Various factors, including comfort, safety, cost and technical logistics, must be considered when selecting a rhinoplasty anesthetic.

Q : How long would you keep me hospitalized ?
A : Minor corrections are done on day care basis. Patients undergoing rhinoplasty where nose packing is not needed or no rib cartilage is harvested, usually need 1-2 days of hospitalization. Patients undergoing extensive surgery and/or rib cartilage harvest Usually need 2 days till nose remains packed and donor site pain is decreased/tolerable in cases.

Q : What is the recovery time for rhinoplasty? (Rhinoplasty recovery)
A : Post procedure nasal pack is kept for 48 hours and nasal splint is placed for 2 weeks to support and protect the new structures during initial healing.
Patient is called for suture removal and if required plaster change on 7th post-op day. Cold exposure /swimming /strenuous exercise /face wash during this period is strictly not allowed for the patient. Once the wounds have healed, regular cleaning of nose is advised and patient can resume his normal activities. While initial swelling subsides within a few weeks, it may take up to a year new nasal contour to fully refine. During this time one may notice gradual changes in the appearance of the nose as it refines to a more permanent outcome. 
Swelling may come and go and worsen in the morning during the first year following your rhinoplasty surgery. Few don't's for patients are-No blowing and nose picking for 4 weeks. At the time of sneezing mouth should be kept open to avoid stress on inflamed nasal mucosa which may bleed.Patient should not use specs (eye glasses)for 4-6 weeks.


Donor site recovery
Due to donor site (chest) pain/discomfort patient needs atleast 48 hours of hospital stay and regular chest physiotherapy and breathing exercise.It also takes a bit longer to perform this type of rhinoplasty procedure, and the nose will usually be more swollen after surgery.

Q : How long should I take rest following rhinoplasty ?
A : Rest and relaxation are strongly advised during the first week after surgery to hasten recovery and minimize bruising and swelling. Although some bruising may be evident upon nasal splint removal 2 weeks after surgery, patients with sedentary jobs (desk work) may safely return to the workplace at this time. Those whose jobs require physical exertion (athletes, firefighters, etc.) may need 23 additional weeks before returning to full work activity. In every case, avoiding exercise or unnecessary exertion is recommended for at least 6 weeks after surgery to avoid prolonged swelling and infection.

Q : What are the risks of rhinoplasty?( Complications /Side effets)
A : Rhinoplasty is a generally safe surgical procedure, but as with any surgery, things can go wrong. The most common risks during a rhinoplasty procedure are excessive bleeding and infection, adverse reaction to the anesthesia. There is also the slight possibility that you will need additional surgery in the future. Another risk in regards to cosmetic rhinoplasty is that you may be unhappy with the procedure of rhinoplasty has the highest rate of revision in cosmetic surgery.
Though this surgery can be done as day care surgery, but it needs a good hospital with OT staff and anaesthesia facilities. This surgery shouldn't be tried in places with inadequate facilities as complications do occur and may require multi-specialty care.
Swelling and bruising on the nose, cheeks and eyelids are normal side effects. They usually resolve within 2 to 3 weeks after the procedure. Bleeding, asymmetry, possible recurrence of deformity and difficulty in breathing are few usual complications. A touch up procedure may require refining the results. If all pre-op, operative and post-op precautions are taken, complications are negligible.

Q : What can I expect after rhinoplasty? ?( Results)
A : Results from a rhinoplasty surgery can typically be seen once the swelling goes down and your surgeon removes the nasal splint. Nasal breathing is also difficult for about 3 weeks after the surgery due to swelling. Most of the swelling is gone in first two months after the surgery performed. As time passes nose becomes more refined and easy breathing.

Q : How long should I take rest following rhinoplasty ?
A : Rest and relaxation are strongly advised during the first week after surgery to hasten recovery and minimize bruising and swelling. Although some bruising may be evident upon nasal splint removal 2 weeks after surgery, patients with sedentary jobs (desk work) may safely return to the workplace at this time. Those whose jobs require physical exertion (athletes, firefighters, etc.) may need 2-3 additional weeks before returning to full work activity. In every case, avoiding exercise or unnecessary exertion is recommended for at least 6 weeks after surgery to avoid prolonged swelling and infection.

Q : For revision surgery how long should I wait ?
A : One must wait atleast six months to one year as healing from previous surgery is continued for long time. Edema /swelling takes long time to settle. Once swelling and toughness of tissues settle completely that is the time when one should intervene.

Q : Can I expect best of the results after failed rhinoplasty?
A : Results are permanent, but aging may affect. Nasal anatomy and proportions are quite varied and final look of any rhinoplasty operation is the result of the patient's anatomy, as well as of the surgeon's skill. A cosmetic change in the shape of the nose changes a person's appearance as well as improves the self esteem. Surgical goal is to avoid the "operated look" and produce a nose that looks natural, functions properly, and in balance and harmony with other facial features.
Secondary or revision rhinoplasty is a very challenging procedure that most surgeons take lightly.Secondary surgery of nose requires an experienced surgeon. One can expect best of the results when the deformity lies with the nasal skeleton and skin is undamaged.Whether the deformity is aesthetic(cosmetic),functional or both, can be corrected to its best by an experienced surgeon