Rhinoplasty

Nose is the most protruding part of ones body and so it is easily get injured. Nasal injuries can result in damage to the skin, bone, cartilage or any combination. If the skin is cut this requires cleaning and then closing using either sutures or self adhesive strips. An injection to prevent tetanus is advisable if your vaccination is not up to date (every 10 years). Bony fractures of the nose account for nearly 50% of all facial fractures. Fractures to the nasal bones cause a lot of swelling and it may take about five days for the swelling to settle down enough for the bones to be checked.

Treatment

X-rays do not contribute to the clinical management of nasal fractures, as the majority are simple and uncomplicated. Only when more serious injuries have taken place are they important and should include the skull and face.

Most of the time when the swelling has settled down and there is either no or little change in the shape of the nose.

If the nose is deformed after the swelling has subsided (five to seven days after the injury), manipulation under anaesthesia is performed. Manipulation must take place before 14 days after the injury and the patient made aware that the deformity may not be corrected completely. Any residual deformity even after manipulation may require more surgery (Rhinoplasty)say 12 months or more after the injury.

Complications

Nosebleeds (epistaxis)

Nosebleeds are common and usually settle on their own with simple first aid by gently pinching the lower half of the nose for 15 minutes. Nasal packing or cautery in hospital is reserved for nosebleeds that do not stop of their own accord.

Septal haematoma

Blood collecting (haematoma) under the lining (mucosa) of the central partition wall of the nose (septum) is stripped off either side causing a purple swelling inside the nose. If this occurs it will give you nasal obstruction and pain and need treating by draining the blood away soon after it happened.
If the blood is left and not drained it can become infected or cause damage to the underlying support destroying cartilage and then leave a ‘saddle nose’ deformity. (explanation please) Treatment is by surgical drainage and a course of antibiotics.

Deviated Nasal Septum

Nasal blockage usually occurs after the injury due to swelling inside the nose and this may take a few days to settle. If the nose is still blocked after three weeks it may be due to the septum being deviated . Septal deviation may require surgical correction if the blockage is significant.

Rare complications

Cerebrospinal fluid leak

Severe nasal trauma can push the nasal bones into the face, giving the face a pug-like appearance. The thin cribiform plate at the roof of the nose may fracture causing the cerebrospinal fluid that bathes the brain to leak out.

Small fractures seal spontaneously with conservative management (95% within two weeks). Antibiotics are not given unless infection is proven to be present. If fluid leak continues , more treatment may be required. Loss of sense of smell The smell organ in the roof of the nose can also be damaged. Loss of sense of smell very rarely returns

The demand for aesthetic surgery continues to grow, and an objective means of assessing the patient is required. Proper patient selection and facial analysis is very important before attempting the operation of Rhinoplasty.
First and foremost the surgeon must understand the motivation of the patient. The patient may mask their true desires, applying a fake reason for surgery. Occasionally, the patient suffers from a psychiatric illness.
The goals of aesthetic surgery are a satisfied patient and surgeon. There should be a rapport between the surgeon and patient. Discuss the details and explain the chances of having improvement.

Unrealistic expectation- step ladder principle
One cannot climb more than one step at a time. One cannot make an ugly nose to a very beautiful Nose. The nose ladder is ugly, bad, normal, and pretty, very pretty. One cannot make an ugly nose to very pretty. Often patient has some cine star type nose in their mind and if they don’t achieve that they get depressed.
It is important to have several views of preoperative digital images of face and nose views. This will be useful after surgery to evaluate the result.
Preventing patient dissatisfaction depends upon proper patient selection. Any patient that makes the surgeon uncomfortable should at the minimum have surgery delayed, and perhaps referred for psychiatric evaluation. The most commonly diagnosed psychological conditions which should make the surgeon concerned include: neurotic disorders, personality disorders, psychotic disorders, and depression/mania.
Cosmetic surgery is not a game. It should be taken seriously by both patient and surgeon alike.

Postoperative Instructions after Rhinoplasty

First 12 hrs after Surgery

once fully awaken in the theatre, you will be shifted to the ward. You can expect to have cool compresses on your eyes and cheeks to reduce any swelling or bruising that may occur following surgery. Your nose will be blocked as a result of swelling from the surgery and from the thermoplast that are placed in your nose to assist in maintaining its new shape and function. For this reason, you must remember to breathe through your mouth.
The nurses will be checking your vital signs frequently- Pulse, BP Temperature etc.

Nasal Packing

There will be a nasal pack to prevent any bleeding after surgery. We use Merocel pack with or without an airway.
If the nasal septum is straightened (Septoplasty), thin silastic splint will be sewn inside the nose to assist in keeping the septum straight while it is healing. These silastic sheets are removed by in the OPD one week after surgery. Removal of the splints is usually painless.

Columellar incision

Inverted V shaped incision on the columella should be taken care of.Keep moist with applying Neosporin ointment, avoid rubbing.

Avoid sneezing

Take antihistamine(loratidine) as prescribed by the surgeon.

Swelling and Discoloration

Every operation, no matter how minor, is accompanied by swelling of the surrounding tissues. The amount varies from person to person, but it always seems more dramatic in the face. We suggest that you keep your head elevated as much as possible.
Your nose and eye area may remain swollen with varying amounts of discoloration for several days. The most important thing to remember is that these conditions always subside.

Remember

1. Stay vertical. Sit, stand and walk around as much as is comfortable beginning on your second postoperative day. Of course, you should rest when you become tired but keep your upper body as upright as possible.
2. Apply ice packs frequently for a minimum of 24 hours after your return home from surgery.
3. Avoid bending and lifting heavy things for one week. In addition to aggravating swelling, bending and lifting may elevate blood pressure and start bleeding.
4. Avoid hitting or bumping yur Nose. It is wise not to pick up small children and you should sleep alone for one week after your operation.
5. Sleep with head end up for 1-2 weeks following your surgery. To accomplish this, place two or three pillows under the head of the mattress and one or two on top of the mattress. It is recommended that you sleep on your back for 30 nights. Some patients find a reclining chair placed at a 45-degree angle to be more comfortable than a bed.
6. Avoid straining while in Toilet. If you need a laxative, take Dulcolax or Creamalax tablet one at night. Proper diet, plenty of water and walking are strongly recommended to avoid constipation.
7. Avoid direct sunlight on your face for one month.
8. Avoid heavy exercise for one week following surgery.

It is not unusual to have varying amounts of discoloration in the nose and eye area. Like the swelling, it may become more pronounced, especially in the eye area, after the first day or so. Remember this is normal and temporary. It usually lasts no more than two weeks, all the while decreasing in intensity. The measures previously described that help the swelling to subside will also help diminish discoloration; however, there is no medication that will cause it to disappear rapidly - only the natural course of time.
If you have external incisions, do no apply make-up over the incisions themselves until one day after the sutures have been removed; however, you may bring make-up to the line of the incisions.

Nasal Drainage or Bleeding

You should expect some blood-tinged drainage from your nose following any nasal surgery. The hospital nurses will place a nasal pad under your nose when you are discharged from the hospital. This pad should be changed whenever it becomes soiled. If you develop active bleeding from the nose, spray each nostril 4 to 6 times with a decongestant nose spray such as Otrivine and ice pack over the Nose .You may repeat this maneuver every 10 minutes for up to 30 minutes. If bleeding continues despite these steps, call the doctor.

Cold compress

This provide the simplest and most effective cold compresses to reduce swelling, bruising, and discomfort following surgery. During your waking hours, apply the packs to the cheek and eye area around your nose for 20-30 minutes each hour for at least 48-hours following surgery.

Pain killers

Even though you may not feel much initial discomfort following your surgery, pain medication should be taken as prescribed, every 4-8 hours for the first 24 to 36 hours after surgery. We find that many patients initially feel very well following surgery and are reluctant to take any medication for symptoms of pain. Unfortunately, the patients who “tough it out” often develop discomfort 18 to 24 hours after the procedure, which may then last for 3 to 4 days. Those patients who take their medicines faithfully, as instructed, have very little, if any, discomfort. Beginning 36 to 48 hours after surgery, Diclofenac and Paracetamol is usually adequate for any discomfort you may still experience.

Antibiotics

You will take an oral antibiotic for 7 to 10 days following your surgery. All antibiotics should be taken with food or liquids to prevent nausea and promote proper absorption of the medication (do not consume milk or dairy products when taking your antibiotic as they can inactivate many medicines). Take your antibiotic as instructed by your physician until medication is completely gone. Do not forget to take your antibiotic and do no stop taking it because you feel better.

Gastric acidity

Gastric acidity develops following many types of surgery and is not uncommon after nasal surgery. You may be given a prescription medication, Rabeperazole and Domperidone capsule to be taken once daily.

Fever

Generally, the body temperature does not rise much above 100 degrees following nasal surgery. If any high fever, call the doctor.

Feeling dizzy

It is not unusual for a patient to feel weak, have palpitations, break out in “cold sweats,” or get dizzy following any type of surgical procedure especially when anesthesia has been administered. Within a few days these feelings will generally disappear without medication. Returning to a normal diet and light activity will shorten the duration of these feelings.

Not able to sleep

If you experience excessive difficulty in sleeping during the postoperative period, take mild sedative and pain killer at night. It should be remembered that such drugs also tend to make some people feel light-headed and weak and should be taken only if absolutely needed.

Resuming Activities

1. DO NOT SMOKE & AVOID ALCOHOL CONSUMPTION for 3 weeks. Both of these activities significantly slow the healing process.
2. WEARING GLASSES AND CONTACT LENSES. Eyeglasses should not be supported by the nose for at least one month after surgery. Eyeglasses may be taped to the forehead or a device called a “cheek rest” may be purchased to clip on to your glasses. (These steps are taken to avoid any external forces being applied to the nose which may result in a change in its new shape and function). Contact lenses may be inserted the day after surgery, if no eyelid surgery was performed.
3. HOUSEHOLD ACTIVITIES. On your second postoperative day, you are encouraged to be up and around the house with your usual activities; however, no bending, no heavy lifting, and no strenuous activity for 1 week.
4. PULLOVER CLOTHING. For 1 week following surgery, you should wear clothing that fastens either in the front or at the back rather than the type that must be pulled over the head.
5. EXERCISE. No strenuous athletic activity or exercises that involve straining or heavy lifting for 1 week following surgery.
6. RETURNING TO WORK AND RESUMING SOCIAL ACTIVITIES. When you return to work depends on the amount of physical activity and public contact your job involves and also the amount of swelling and discoloration you develop; the average person is ready to return to work or go out socially 1 week after surgery.
7. DO NOT DRIVE A CAR for one week. Also, do not drive while taking any sedative or prescription pain medications.
Follow up Appointments
Your first postoperative appointment will occur 5-7 days after your surgery .Your second postoperative visit will be 2-3 weeks after your surgery