The Ultimate Guide to Looking Good with Rhinoplasty (2020)

Guides
Dr Terence Goh
5.0

"Plastic Surgeon at AZATACA Plastic Surgery"

Missed our webinar on Enhance the Shape of your Nose: Defining your Nose with Rhinoplasty? Watch out for more webinars or the highlights on Sessions and Videos!


What is Rhinoplasty and what are the key considerations you should take into account?  What are the risks? Are you a suitable candidate?

I’m Dr Terence Goh and I want to share what I know with you so that you can make an informed decision before embarking on your journey.

Using my experience with and research on this topic, I would like to share with you useful techniques and important considerations regarding rhinoplasty. 

What is Rhinoplasty?

Rhinoplasty, commonly known as a nose job is a plastic surgery procedure for altering the shape of the nose or reconstructing the nose.

There are two main reasons why people consider rhinoplasty: medical (also known as reconstructive) rhinoplasty which restores the form and function of the nose or cosmetic rhinoplasty which improves the shape and appearance of the nose.

In some cases, a person might have both cosmetic and medical indications for undergoing a rhinoplasty.

For instance, a person with a crooked nose, might want to have the deviated nose straightened for cosmetic reasons, but he may also experience breathing difficulties from the crooked septum,which is a medical indication. 

I have spent considerable hours reading on and training in Rhinoplasty as it is one of the most complex procedures in plastic surgery.

It consists of an interplay of many different manoeuvres put together to alter the framework of the nose, resulting in an improvement in the final shape and aesthetics.

These manoeuvres depend on the parts of the nose that require shaping.

During my training and practice in Seoul and Singapore respectively, I have come across countless variations of rhinoplasty requests.

For example, someone with wide nostrils (ie. widened alars) would go for an alar reduction to make the alars slimmer, and another with flat nasal tip would opt for a tip plasty [1]. 

Is Rhinoplasty covered by Medisave or Insurance?

There are medical and cosmetic reasons to do a Rhinoplasty.

Medically, you may have difficulty breathing through the nose which can lead to snoring and disturbed sleep [2].

Other reasons for medical rhinoplasty include nose injuries and fractures or correction of birth abnormalities from cleft lip and palate.

For such problems due to medical reasons, the surgery may be covered under Medisave or your insurance plans.

However, if your nose is fully functional but you still want to undergo rhinoplasty to narrow your nostrils or reshape your nose tip, then it’s considered a cosmetic procedure. 

How does Rhinoplasty work?

Let’s establish the goal of Rhinoplasty before talking about how Rhinoplasty works.

First, the overall goal of cosmetic Rhinoplasty is to change how your nose looks so it aesthetically suits your face better.

We can change many different variables, such as the height of the nose, size of the nose tip and width of the nose, to help you achieve a harmonious relationship between your nose and other facial features [3].

These are the top three enquiries I have from my rhinoplasty patients [4].

Infographic on Rhinoplasty works

What is open or closed Rhinoplasty?

Rhinoplasty can be performed using a closed technique or an open technique.

In a closed procedure, all the cuts are made inside the nose and there will be no scars visible from the outside.

Closed rhinoplasty is usually done for minor changes, such as nose implant with minor tip-work. An open rhinoplasty is similar except there is an additional small incision across the columella (the skin separating your nostrils).

This approach is used when more significant adjustments to the nose need to be made. The scar across the columella usually heals well and is not visible.

Is Rhinoplasty Painful?

During the procedure, you will be adequately anaesthetised so you will not feel any pain at all.

At my practice, the anaesthesia will be customised to your requirements and comfort levels.

Not all patients would have to be fully sedated. Local anaesthesia can be suitable for simple procedures such as implant insertion and minor tip-work and this ensures a faster recovery.

However, if you need more extensive surgery, deeper anaesthesia can be provided by a trained anaesthetist who will monitor your status closely during surgery [5].

Most of the procedures can be done as a day procedure and do not require an overnight stay.

From the experience of most of my patients, you may feel some swelling and pain during days 1 to 5 after surgery, but most of that can be easily managed with oral pain-killers and nasal decongestants.

Are there non-surgical procedures for rhinoplasty?

There are also non-surgical procedures some patients choose to opt for.

These procedures may either involve fillers or threads. Fillers are a form of injectable that is placed beneath your skin to add volume.

Threads are sutures that are placed in the nose to lift the tip or create volume.

Fillers or threads can be used to raise the nose bridge or camouflage minor humps and bumps to create that perfect line. 

However, there are limitations and those procedures are unable to change the length and width of the nose or correct a bulbous tip.

These treatments are non-permanent (lasts 6-9 months), reversible, and have been certified safe when used by trained professionals.

And whilst they are less effective and require frequent top-ups, it can be seen as a first step that allows you to try on that nose that you desire before you commit to actual surgery.

I have many patients that have decided to go for definitive surgery after fillers [6]. 

As I am a plastic surgeon with special interests in Rhinoplasty, I will focus mainly on what we can achieve with surgery for the rest of this article.

What can a Rhinoplasty do for me?

Rhinoplasty is conducted to enhance and reshape your nose. For instance, it is common for Asians to have a flat nose, which results in the persons’ facial features looking rather wide and poorly defined. 

The common reason behind a flat nose is a low nose bridge.

In such cases, a procedure called an “Augmentation Rhinoplasty” is done to increase the height of the nose bridge to make the nose look higher.

Other common complaints include low or droopy nose tips, which results in a poorly projected nose.

In such cases, a tip-plasty procedure can make the nose tip higher and sharper, resulting in a sharper and more defined look. 

What are the different manoeuvres in Rhinoplasty?

There are many different steps in a Rhinoplasty procedure.

As a firm believer in educating my patients about the surgery they are undergoing, I will go into a bit of detail of what these steps entail.

These steps are designed to correct certain features such as flat nose (low dorsum) or bulbous nose.

The important consideration is to understand how each step affects the other so that when put together, the final form of the nose is stable, aesthetic and functional. 

Different maneuvers in Rhinoplasty

  1. Flat nose or Low nasal dorsum. Augmentation of nose dorsum increases the height of the nose bridge. A graft made out of your own tissue (autologous rhinoplasty) or an implant made from an artificial material such as silicon or Gore-Tex is used to increase the height of the nose. (See below on the different materials for a rhinoplasty) Learn more about Dorsal Augmentation here.

  2. Broad, fleshy nose or bulbous nose. Nose tip plasty is a technique aimed at individuals with a round and large nose tip. A tip-plasty can remove the fat from the nose, making the nose tip slimmer, reducing it and making it appear more refined. Tip grafts taken from the ear cartilage can also help to increase the projection of the nose to make it more projecting and defined. Learn more about Tip-plasty here.

  3. Wide nose. The alars are the fleshy parts of the nose (ie. the parts where we pinch our nostrils when we sneeze). Asians tend to have large alars, which contributes to a nose that looks wide.

    In such cases, alar reduction will decrease the width of the nose. The surgeon will take into account the size, shape, and symmetry of the person's nose, in considering the specific type of
    Alar base reduction to be used.

    In some cases removal of the tissue from the edge of the nostrils, then pulling down and reattaching the nostrils would work––this technique is called a Weir Incision.

    In other situations, the surgeon would perform a technique called Joseph Incision, which removes tissue from the base of the nose (called the nasal sill), in order to reduce the width of the nostrils.
    Learn more about Alar-plasty.

    The above 3 changes to the nose are the most commonly requested for by my patients.

  4. Hooked nose or nose with a hump. Hump nose can either be genetic or a result of trauma, and can cause difficulties in breathing. Hump resection is done to make the nose bridge flatter and smooth.

    To do this, the surgeon takes into consideration ethnic and family features in order to properly carve down the nasal hump, to make the nose look smoother and straighter. 

  5. Curved or crooked nose. Individuals with a crooked nose, usually through an accident, would consider a procedure to straighten the nose.

    This is often called a
    Septo-rhinoplasty where the curved septum of the nose is removed and this may occasionally also require an osteotomy (to break the bone of the nose) to re-align it. Learn more about correction of crooked nose.

  6. Retruded columella. The columella refers to tissue under the tip of the nose, which separates the left and right nostrils.

    In some cases, a person might have a “retracted columella” which looks like the columella has been pulled into the nose, and is not visible from the front view of the person’s face.

    In other cases, a person might have a “hanging columella” which leaves the person’s nostrils quite visible from the side of his/her face. These issues can be treated by using cartilage taken from the ear or inside the nose to change the profile of the columella. 

Is nose surgery for me?

We usually wait till you are above 18 years old before performing Rhinoplasty as that is when the nose stops changing. There is no upper age limit for this treatment.

During the consultation, I will take a thorough medical history when you come in for a consultation, including known medical issues and any nose symptoms you may have.

Assuming you have no significant medical issues, we will then ask you about what you want to achieve with rhinoplasty and what kind of look you want.

There are some objective measures of what looks good, so I will measure your facial features and determine how your nose can best compliment your face [7] [8].

I have been using the Crisalix Imaging System for many years. This allows me to take a photo of your current self and analyse your nose and facial features.

Using computer analysis, we are able to show you a before-and-after simulation based on these photos.

Whilst this imaging system is unable to mirror the surgical process 100%, it allows me to translate the surgical changes that I am planning so that patients can visualise the planning process and also decide on the changes they would want to have.

This has been most useful in enabling me to discuss with my patients what to expect during the rhinoplasty without relying on complicated medical terms.

What are the common reasons patients consider Rhinoplasty  and what are the solutions?

Here are some of the common patients/requests that come by my practice. You may click here to find out more.

  1. Flat and wide bulbous nose  (Asian Rhinoplasty)
  2. Reduction Rhinoplasty (Caucasian Rhinoplasty)
  3. Male Rhinoplasty
  4. Revision Rhinoplasty

What is Asian Rhinoplasty? 

Having the opportunity to run rhinoplasty courses and do anatomical research on cadavers has helped me to adapt caucasian rhinoplasty concepts for my use in Asian Rhinoplasty.

My fellowship in Seoul has also exposed me to the complexities of advanced rhinoplasty some of which I have detailed in this article on creating a natural dorsum in Asian Rhinoplasty [9].

Asians tend to have a low nose bridge and wider nostrils, leading to their noses and overall facial structure looking less defined.

As such, it is common for Asians seeking Rhinoplasty to request that their nose bridge be augmented to look higher.

Therefore, the term “Asian Rhinoplasty” tends to include manoeuvres that augment the nose, in order to make it look higher, to contribute to a more defined nose and face.

This is in contrast to Reduction Rhinoplasties that is commonly done for the Caucasian patients.

However, the procedure for Asian Rhinoplasty is more than simply increasing the height of the nose bridge.

The nose has to be rebuilt to be stable and to fit symmetrically with the person’s facial structure.

Other factors such as a low or droopy nose tip, or wide nostrils (ie. alar), could also contribute to the nose looking less defined, in addition to the low nose bridge.

As a result, other methods such as a nose tip plasty or an alar reduction, or a combination of both, would be required for an “Asian Rhinoplasty” to be successfully carried out.

Each person’s nose and facial structure is different, and the specifics of an Asian Rhinoplasty are customized specifically to the individual. 

What is Reduction Rhinoplasty?

A reduction rhinoplasty is a procedure where we make your nose smaller.

Depending on your facial structure, you can either go for a full reduction which reduces the size of the entire nose, or a partial reduction, which only reduces certain aspects of the nose.

In some instances, nose reduction would require the upper and lower nose to be narrowed. 

First, the thickness and width of the upper nose would be reduced by osteotomies (fracture and shifting of the nasal bones).

Then, the lower nose would be narrowed while maintaining or increasing the height of the nose.

The skin of your nose won’t be trimmed off as it will shrink by itself to fit your new nose shape.

You can also alter the tip of your nose to complement your look when you undergo a reduction rhinoplasty.

What is Male Rhinoplasty?

Male rhinoplasty angles

The nose is an important feature, giving depth and angles that contribute to a masculine-looking face.

Male Rhinoplasty is a set of manoeuvres that does just that, enhancing the nose to bring out the depth and sharpness that is desired in a strong and sharp looking face.

Ideally, the angle between the nose bridge and the forehead should be at about 130°-140°, and at about 85° to 95° between the septum and lips in males.

Further, to accentuate masculinity, the volume would be given to the nose tip. And, the nose bridge would be enhanced to give it a sharper look. 

What is Hooked Nose Excision?

Hooked Nose Excision or hump reduction (see above) is a method used to smoothen out the protrusion/hump of a hooked nose.

However, it is more than just the excision of the protrusion.

Depending on other factors, additional manoeuvres may also be done to increase the height of the nose, to narrow the nose bridge and to create a nose that is not only smooth but also complements the face of the person.

What is Long Nose Correction surgery?

Long Nose surgery is done to correct a nose that is too lengthy for the face and when the nose tip hangs down.

Long nose is also called an “arrow-shaped” nose. Fixing a long nose requires a series of steps, such as increasing the projection of the nose tip and excising septal cartilage to change the angle of the nasal tip.

This will not only shorten the nose but also achieve an angle that fits the patient well. 

What is a Revision Rhinoplasty?

Some patients who have gone through a prior rhinoplasty sometimes come to me for a second rhinoplasty procedure.

This is called a revision rhinoplasty procedure.

This type of rhinoplasty always presents a challenge. The first challenge comes from the goals of the patient.

Sometimes, the initial rhinoplasty gave a good result, but over the years the patient’s body has changed such that the nose needs a touch-up.

Other times, the patient is not happy with their previous rhinoplasty procedure and wants minor or sometimes major tweaks.

In a few cases, the previous rhinoplasty led to medical issues such as difficulty breathing, so a second rhinoplasty needs to be done to correct underlying problems.

A revision rhinoplasty is often more challenging as the patient already had prior surgery and this would mean that the anatomy has been changed.

There will be more unpredictable factors such as scarring, infection or the shortage of potential graft sites.

Hence, I believe that careful planning is of utmost importance in approaching a revision case.

If what the patients want is achievable with a revision, then I will do the usual preparation and computer scanning required to project expected results and plan out the next steps.

Some of the common revision cases that come through my door include deviated nose implants, exposed nose implants and crooked nose tips. Learn more about revision rhinoplasty here.

How does the choice of Rhinoplasty materials play a role?

No article on rhinoplasty would be complete without mentioning the different types of materials or implants we can use.

As much as it is important to have detailed surgical planning for a nose that fits the face, there is also a need for harmony between the material and the existing anatomy. 

Silicone has been the most common choice of implants for decades.

Previously, silicone implants were L-shaped, which were associated with an increased risk of extrusion. I have moved away from using L-shaped implants due to this reason.

The newer versions of silicone implants are I-shaped and softer, making the risk of extrusion lower. 

Gore-Tex is a newer material and has been gaining popularity with patients.

Similar to silicone, it is a synthetic material. Gore-tex has pores that allow tissue ingrowth, which integrates better with the tissue, thus giving it a more natural look.

However, it is more difficult to remove as compared to silicone. 

The ideal material to use is your own tissue (autologous) and this can either be in the form of cartilage or skin (yes the skin and fat in your body can also be used!).

Research has shown that the use of synthetic implants is associated with a higher risk of infection and extrusion when compared to autologous implants.

Most rhinoplasties I perform today are hybrid rhinoplasty (silicone implant with ear cartilage for the nasal tip).

A total autologous rhinoplasty is one where there is no artificial material at all. This is the gold standard but may require more downtime than most patients are comfortable with.

Autologous implants do not have a risk of extrusion or infection once it has completely healed, as it is made out of your own tissue. Usually, the cartilage from the rib or the back of the ear would be used. Fascia (ie. fat tissue) from the scalp can also be harvested for an autologous implant. The advantage of using your own tissue is that it is permanent and it carries a blood supply and your body will never reject it.

What is a Total Autologous Rhinoplasty?

A total autologous Rhinoplasty, also known as no-implant rhinoplasty, is a nose job which ONLY uses your own tissue, instead of any artificial material such as silicon or Goretex.

Using your own tissue is definitely preferred over an artificial implant. Unlike the use of artificial material, the use of your own tissue removes the risk of infection once it has healed, and further eliminates the risk of triggering an immune response leading to extrusion. 

There are several options available. 

Available options for Total Autologous Rhinoplasty

First, cartilage from your nasal septum can be used, as the cartilage is firm and straight and the scars are hidden within the nose.

However, there might not be enough cartilage in the nasal septum in certain situations where more cartilage is needed, such as in Tip-plasty or Revision Rhinoplasty. 

Second, ear cartilage from the back of the ear can be used. The ear cartilage is curved and is not as strong as cartilage from the septum but it is ideal for creating the dome of the nasal tips. The scar is hidden behind the ear and well concealed.

Third, rib cartilage can also be utilized. This is considered to be the gold standard because of the large volume of cartilage available in the rib, providing lots of material for structural support and volume augmentation.

Moreover, rib cartilage is strong and straight, leading to consistent and reliable results. These are shaped into the necessary components and stitched down to maintain a stable shape.

Finally, skin and fat can also be used to form a “dermal graft” and this can be taken from the back (with a hidden scar) and used to augment the dorsum of your nose.

What are the complications and risks of a rhinoplasty?

There are risks and complications associated with every surgical procedure. You will need to sign a consent form so that we know you understand the procedure and the risks that come with it. Here are some of the potential complications that can happen after a rhinoplasty. 

  • Bleeding (hematoma)
  • Swelling
  • Wound Infection
  • Poor wound healing or scarring
  • Numbness or change in skin sensation - this is usually temporary

Occasionally  there may be other less common but more serious complications, such as:

  • Nasal Septal perforation, which is a hole in the nasal septum - the skin dividing your nose in two. This complication rarely happens but may occur if there is a hole made during harvest of the septum or an infection.
  • Nasal collapse. Overzealous harvest of the nasal septum can destabilise the nose leading to a collapse of the nose.
  • Breathing difficulties. I mentioned this under ‘Revision Rhinoplasty’, and is a complication that can be treated if you suffer from this complication.

Inforgraphic on recovery journey

What is recovery like?

Majority of the rhinoplasty procedures are done as a day surgery procedure.

You will be under hospital care for a few hours, after which you will be allowed to leave but not drive.

I recommend having a family member or friend pick you up, or taking a taxi.

A plastic splint will be put on your nose so that it can keep its new shape and over the next few days do expect some bleeding.

This will be in small amounts and the blood can be swallowed. You will also be prescribed antibiotics, antibiotic creams and painkillers for any headaches and swelling.

After a week, you will have to return to the clinic to get your splint removed and, if your stitches are not dissolvable, have your stitches removed.

You can then return to work by around the end of the first week.

How much does Rhinoplasty cost?

Procedure

Approach

Facility

Anaesthesia

Estimated Costs

Implant insertion

Closed Technique

Clinic or OT

Local Anaesthesia or IV Sedation

$3000-$5000

Hybrid Procedure

Open Technique

Clinic or OT

Local Anaesthesia or IV Sedation

$8000-15000

Total autologous  or reconstructive rhinoplasty requiring rib harvest

Open Technique

OT

General Anaesthesia

$15000-25000

 

The average cost of a Rhinoplasty in Singapore varies as it really depends on how complicated the procedure is and how long the surgery would take. The costs can be broken down into:

  1. Surgeon’s fees
  2. Anaesthetist fees and 
  3. Facility fees. 

A simple implant-only rhinoplasty to increase the height of the nose can be done as a closed procedure under local anaesthesia and it can cost between $3000-$5000.

Yet again a hybrid procedure involving implant and ear cartilage harvest may require anaesthesia and this can be done as a day surgery procedure and this may cost between $8000-$15000.

However, a total autologous rhinoplasty requiring rib harvest may take 4-5 hours and require overnight stay in a hospital ward and that may cost between $15000-$25000.

Conclusion

Rhinoplasty may be a scary sounding name, but you can reap many aesthetic benefits from it if you understand what it can do for you.

We have learnt what manoeuvres there are in a rhinoplasty, what risks there are, and how long results can last for. Come by my clinic and get a consultation so that we can discuss whether Rhinoplasty is suitable for you.

References:

1. Rhinoplasty - Mayo Clinic. Mayoclinic.org. https://www.mayoclinic.org/tests-procedures/rhinoplasty/about/pac-20384532. Published 2019. Accessed April 1, 2020.

2. Shaye DA. Thinking about rhinoplasty? - Harvard Health Blog. Harvard Health Blog. https://www.health.harvard.edu/blog/thinking-about-rhinoplasty-2019030616112. Published March 6, 2019. Accessed April 1, 2020.

This article was published on Monday, 11 May 2020. Dr Terence Goh medically reviewed the article on Monday, 11 May 2020. The last update was made on Tuesday, 11 August 2020.

Quote RequestWhatsapp