Rhinoplasty is a very unique operation in
that changes in nasal shape continue to occur over the patient's
lifetime. Most other operations heal over a finite period of
time and then stabilize. This is not the case with rhinoplasty.
Many patients whom we see for secondary surgery tell us that
soon after the cast came off, their noses looked good. Then,
over time, the swelling decreased, and the nose became narrowed
and then deformed. Patients also state that their nasal
breathing worsened over time after rhinoplasty. Some patients
describe a situation in which their noses were fine for over 15
years and then changes occurred that resulted in deformity.
does this occur with rhinoplasty?
When one undergoes rhinoplasty, there are
two primary healing processes that occur. The first healing
process is the resolution of the initial postoperative swelling.
The rate at which this swelling goes down is variable from
patient to patient and also depends on whether a patient
underwent previous surgery or if he/she has a lot of scar
tissue. In most thin skinned patients, this initial swelling
goes down in several months. In patients with thick skin,
swelling can persist for many years.
Even after the initial postoperative
swelling after rhinoplasty has resolved, the secondary healing
process continues. In this case, the layer of scar tissue that
forms over the nasal structures gradually contracts over time.
In most patients, this scar contracture occurs over their
lifetime. This is why many patients state that their nose
continued to change years after surgery. Some patients may not
realize that their nose is still changing, but, if they were to
look at a series of high quality close up photographs, they
likely would see the changes. Patients with thicker skin have
less pronounced changes than patients with medium to thin skin.
In fact, some patients with thicker skin may see that their nose
stabilized over time, with minimal changes after the initial
healing process was completed.
I have noted these changes described in
patients who have undergone rhinoplasty, and I am acutely aware
of the long term healing process after rhinoplasty. Therefore,
I have adopted a method of surgery that employs a degree of over
correction when performing rhinoplasty. In other words, the
nose is made about 10 to 15% larger than ideal during surgery
and then, as the long term scar contracture process occurs, the
patient can expect to see gradual improvement in his or her
nasal contour instead of initially looking good and worsening
over the years. This method is very difficult for the patient,
especially early on after surgery, as the patient just sees a
big nose. Fortunately, this process of scar contracture helps
to improve nasal contour over time, which helps to alleviate the
It would be much easier to perform
rhinoplasty in a way that makes the nose look good early on.
However, that approach could result in poor long-term outcomes
for many rhinoplasty patients. When I approach a rhinoplasty,
my primary concern is a good long-term result for every
patient. My intent is to perform every rhinoplasty as though it
is the patient's last nasal operation, even if it is a
Some patients are at high risk for collapse
of the middle portion (middle vault) of their nose. In these
patients, we also tend to over-correct the width of the middle
portion of the nose. As time goes by, the forces of scar
contracture lead to narrowing of the middle portion of the nose,
resulting in a more normal width. This over correction also
will help to maximize the patient's nasal breathing. This is
important, as I will never compromise nasal function for
Another reason why some patients are very
swollen and wide after rhinoplasty is that their nose may have
been made smaller. Any time that a nose is made smaller and/or
less projected, the skin envelope over the nose must shrink to
accommodate the new smaller nasal structure. Unfortunately, it
takes many months, and sometimes years, for the skin envelope to
contract. Patients with thinner skin will shrink faster than
patients with thicker skin. In fact, most patients with thicker
skin may need to keep a large nose to keep the skin expanded.
This is because, if the nose is made too small in a patient
with thick skin, the skin may never shrink and will continue to
appear very wide on frontal view. These factors I must take
into consideration when deciding how small I can make a nose on
the lateral view.
Illustrative patient case:
This patient presented requesting both
aesthetic and functional improvements with her nose. She had
nasal obstruction that compromised her ability to sleep and
exercise. She was also concerned about the size of her nose. She
stated that her nose was too long and that it “stuck out” too
On exam, it was noted that she had an
over-projected and long nose. Her skin was
thickness. In surgery, I made the nose as small as I felt
possible without compromising the ability of her skin envelope
to shrink over the smaller nasal structure.
In the series of frontal photos shown, one
can see how wide her nose looked early on in her postoperative
course. As one might imagine, this patient was concerned, but
she recalled our preoperative discussions, emphasizing how her
nose would be very wide initially and then narrow over time,
which helped to alleviate her concerns. By 7 months after
surgery, her nose has a reasonable width and looks normal. These
photos demonstrate how wide a nose can appear after rhinoplasty,
especially when the size of the nose is reduced. The photos
also demonstrate how the nose will tend to shrink over time, as