Rhinoplasty by Dr. Haworth

RHINOPLASTY TERMINOLOGY NOTES

To perform your rhinoplasty, Dr. Haworth begins by making the necessary incisions in and around the nose. Dr. Randal Haworth, a specialist in rhinoplasty in Beverly Hills has the skills and eye for detail that can effectively enhance the appearance and/or the functionality of the nose. Usually, Dr. Haworth employs the patients’ own nasal cartilage for support to the nose that has previously been weakened by surgery and/or to enhance the aesthetic appearance and/or improve breathing. Most often cartilage is obtained from the patient’s septum because of its strength, availability and generally ample supply. When that is not available ear cartilage is a second choice but it is often not ideal for many uses in the nose because of its inherent curvature. Rib cartilage may also be used, but this too is not ideal because of the need to operate on the chest. Dr. Randal Haworth goes on to say, “Since every patient is unique, rhinoplasty has to be strategically and precisely tailored to each individual. In certain circumstances, when septal or ear cartilage are unavailable and the patient does not want to have an operation on their chest to harvest rib, I have no hesitation to use a synthetic implant with a long history of use and safety in medicine. My preferred synthetic implant is Gore-Tex® and I’ve been using it for over 15 years in rhinoplasty. When used in the appropriate circumstances, contrary to some reports, it has an excellent safety profile with a very low complication rate, including infections.”

Gore-Tex® Synthetic MaterialGore-Tex® is a synthetic material that has been used in plastic, general and cardiac surgery for many years. It now allows the rhinoplasty surgeon to reconstruct a nose without the need to harvest cartilage from the ear or rib, thereby decreasing surgical time and lessening the morbidity of the procedure. Gore-Tex® integrates with the surrounding tissue and has no potential for human rejection (not including infection). Even though harvesting ear or rib cartilage is well tolerated by patients, any opportunity to avoid creating extra incisions and performing extra dissections on the body, the patient benefits. Therefore, Gore-Tex® provides an excellent synthetic material for rhinoplasty when septal cartilage is unavailable. Fortunately, it is becoming more widely accepted as a grafting material as its safety profile is being discovered. OPEN VS. CLOSED RHINOPLASTY Dr. Haworth used to perform 80% of his rhinoplasties closed to avoid the theoretical scar across the columella (the narrow strip of tissue that separates the nostrils) as well as prolonged swelling. However, he found that these supposed advantages to the closed method were not always true. The closed method tended to result in less accurate suture placement, shifted cartilage grafts and less consistent results; therefore, Dr Haworth has shifted his approach to an open one in over 85% of rhinoplasty procedures based upon practicality, reliability, safety and ultimately, patient satisfaction. MEDICAL DEFINITIONS To achieve the ideal nose, Dr. Haworth employs many different techniques. As you browse Dr. Haworth’s image gallery of before and after results, note the different techniques applied to each individual’s rhinoplasty procedure. Any rhinoplasty procedure is uniquely composed of one or more of the following:

• Hump reduction of either cartilage and/or bone, osteotomies to reduce the size both in profile and frontal view. This image describes the region typically reduced using this technique
• Modified techniques to correct a birth defect
• Rib, ear or cranial bone grafts to reconstruct after an accident or a previous rhinoplasty
• Cartilage, bone and fascia grafts to build up a nose
• Cartilage grafts and suture techniques to modify the shape of the nasal tip (e.g., to improve a bulbous,boxy, drooping, hooked or upturned tip)
• Cartilage strut grafts and suture techniques to change the angle between the nose and upper lip
• Weir excisions to narrow the nostril span. The image to the right displays regions typically reduced or removed using this technique
• Septoplasty, turbinectomies, spreader and batten cartilage grafts to correct breathing problems

Depending on the individual’s case, Dr. Haworth may apply a few or many of these surgical concepts during the same surgery.

OPERATION AND RECOVERY LOGISTICS

Surgery duration: 1.5 – 4 hours. Rhinoplasty may take longer than anticipated due to the deformity encountered and the complexity of surgery needed to correct it. Anesthesia: Sedated. Sutures and cast removed: 5-7 days As you wake up from surgery, you will feel mild pressure in your nose similar to what you feel when you have a cold but without the total body symptoms which normally accompany it. However, prescription painkillers will easily control the discomfort. You will most likely have a cast or tape over your nose to control bruising and swelling, while stabilizing the new shape of your nose in the immediate postoperative period. By the end of the second week, you’ll look and feel much better. Most patients are back at work about one to two weeks after surgery. If you need it, special camouflage makeup can mask most bruising that remains. Gradually, you will be able to resume to your normal activities:

• 1-3 days read or watch television
• 7 days resume wearing makeup (most bruising will be gone). However, you will most likely still be swollen.
• 7-14 days be out in public, back to work and take long strolls
• 2-3 weeks begin moderate and work up to vigorous exercise.

Minimizing Scars As a top Beverly Hills rhinoplasty surgeon, Dr. Haworth keeps up to date on optimal, scar-free healing. Scars resulting from a rhinoplasty are minor and generally hidden. Where there is a trace of a hairline scar across the columella, Scar Gard, Kelocote or similar silicone gel treatments can be somewhat effective in decreasing scar visibility faster. Or, if the patient wishes about six months after nasal surgery, Dr. Haworth can use resurfacing lasers to render an already light scar virtually undetectable.

RISKS & CHALLENGES

Conditions that make nose surgery of a challenge and may require additional consent/consultation include:

• Thick, sebaceous or very thin skin
• Past nasal surgery
• Severely crooked nose
• Presence of a septal perforation
• Preexisting scars or a tendency to form excessive scars
• Active sinus infections
• Cocaine abuse
• Uncontrolled high blood pressure
• Blood clotting problems
• Smoking

No surgery is entirely risk-free. However, both our staff and facilities have the highest possible qualifications to produce a happy outcome. While complications are rare in experienced hands, be aware that those for nose surgery include:

• Missed aesthetic expectations
• Worsening of nasal breathing
• Persistent septal deviation
• Altered sense of smell (uncommon)
• Prolonged pain (very rare)
• Numbness or stiffness despite a great aesthetic outcome
• Infection (rare)

Additional treatment of either a surgical or non-surgical nature may be required to alleviate these problems and additional costs may apply.

FAQs

View frequently asked questions from patients considering Rhinosplasty & Revision Rhinoplasty facial procedures. 1. IS NOSE SURGERY PAINFUL? No. It is uncomfortable at times because you will not be able to breathe through your nose for a couple of weeks after the surgery. 2. DO YOU NEED TO BREAK MY BONES DOCTOR? Only if aesthetically advisable. Remember, “breaking the bones” doesn’t add any pain to the procedure postoperatively and only augments the result. “Breaking the bones” is, in fact, a very controlled maneuver using delicate instruments; indeed, “controlled infracture” is a more accurate term. 3. DO I NEED A CAST AND IF SO, FOR HOW LONG? Most rhinoplasty patients will require casting for up to 1 week postoperatively to allow the bones to set. After 1 week the cast is removed. 4. WHEN CAN I GO BACK TO WORK AND SEE MY FRIENDS? Most patients feel confident to see other people at 7-10 days after surgery. 80% of swelling takes 2-3 weeks to resolve while the remaining 10-20% takes 6 months to a year to go away. Bruising takes about 7-10 days to fade away. At 2 weeks postop, I administer a minute shot of cortisone that “turbo-charges” the disappearance of the swelling, so that most feel really great about their result at 3-4 weeks. It is only the very rare patient who experiences prolonged postoperative inflammatory swelling lasting many months. 5. MY NOSE FEELS HARD AND STIFF AND NUMB. IS THIS NORMAL? Yes. These sensations last about 3 months and are par for the course. 6. WHEN CAN I PLAY SPORTS? Your nose will be quite fragile for up to 8 weeks after surgery, so it is important to avoid all contact sports for this time. This also includes free bicycle riding (you can fall off), tennis water sports, etc. Murphy’s Law dictates that if something bad can happen, it will. Be forewarned. 7. MY NOSE IS STUFFY. WHEN WILL I NOTICE AN IMPROVEMENT IN BREATHING? This depends on the individual, the extent of the surgery and how bad your breathing was in the first place. It will take several weeks to notice improvement in nasal inspiration, so before that time, you will be breathing mainly through your mouth. Consequently your mouth can get very dry especially while sleeping. Therefore, it is advisable to utilize a humidifier while sleeping to help alleviate the discomfort associated with a dry mouth. Nasal stuffiness after rhinoplasty results from normal postoperative swelling and obstructing crusts. Occasionally, I will prescribe a nasally inhaled steroid to help reduce the postoperative inflammation and associated blockage. Avoid vasoconstrictors such as Afrin™ after surgery since this may have a deleterious effect upon healing and long term breathing. Nasal saline sprays, such as Ayr™ and Ocean™ are very useful to clean out the nasal passages of crusts as well as the careful use of Q-Tips soaked in hydrogen peroxide. Honey dissolved in a small amount of warm water is quite effective in dissolving crusts, by either carefully sniffing the mixture through the nose or through applying it with Q-Tips. Honey also possesses some antibacterial activity. 8. IF I NEED A MINOR REVISION, WHEN CAN I GET IT DONE? This is infrequent (under 4% with my patients), but if necessary, it is advisable to wait a minimum of 6 months after the original surgery. Very minor asymmetries can be corrected under local anesthesia (like the dentist) utilizing a permanent fat transfer technique, before 6 months. 9. WHY DO YOU PLASTIC SURGEONS RECOMMEND CHIN IMPLANTS AT THE SAME TIME AS RHINOPLASTIES? We only do if the chin is small in relation to the other facial features. Both the nose and chin are the most prominent features when the face is viewed in profile. Consequently, they should be aesthetically balanced. However, the patient will be the ultimate judge of this. 10. HOW DIFFICULT ARE CHIN IMPLANTS? WHAT IS THE RECOVERY TIME? Chin implant surgery is relatively easy surgery to perform for the surgeon and to recover from for the patient. Swelling is minimal and once the surgical tape is removed after a few days, patients feel comfortable going in public-even making television appearances! The implant will feel like your regular bony chin and should not move or shift. Infection is exceedingly rare. Liposuction under the chin and of the neck to highlight the jawline can be performed at the same time through the small small incision (about 1 cm long).