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  Ancient history
  Modern history
  Traditional operation
  Open rhinoplasty
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  Alar base reduction
  Septal surgery
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  Bone grafts

Traditional Operation

There are many ways to change a nose. For example, reducing a prominent bridge line, narrowing a broad nose tip and shortening a long nose. The Typical Rhinoplasty Patient requests reduction of a large nose to refined dimensions.

The traditional operation, rarely used by Paul O'Keeffe since 1990, has LIMITATIONS. For instance, release of skin and soft tissue from the skeleton is restricted in order to maintain muscle attachments to the nasal bones. That limits skin and soft tissue redistribution so it thickens as its area shrinks after skeletal reduction, sometimes producing a bulbous appearance. The more the skeleton is reduced the more the soft tissue thickens particularly if the skin is very glandular. Thickening is much less if skin and soft tissues start out as a very thin layer. These variables make it almost impossible to accurately predict the rhinoplasty result so detailed pre-op planning and the use of a profile template is inappropriate. Post-op result: supratip swelliing

Lifting the nose tip is carried out by trimming the edge of the septal cartilage, trimming the upper edge of the tip cartilages and removal of some lining skin or mucous membrane inside the nostrils. Unfortunately, the tip position may change in the months following the surgery, most commonly a slight drooping of the nose tip while the nostril rims stay elevated. The Miss Piggy deformity is an exaggerated form of this change. Over zealous changes to the nasal pyramid may also weaken the nose too much. Thus, it is better to aim for modest improvement rather than great changes when doing the traditional operation.

The traditional operation is usually carried out in hospital under general anaesthesia. Lines are drawn on the skin of the nose to indicate the desired reductions and incisions are made through the skin inside the nostril openings. A special instrument called a retractor is inserted into a nostril and held by an assistant surgeon or nurse. The skin and soft tissues are dissected away from the cartilaginous and anterior bony skeleton enabling reduction of these structures. Scalpels, scissors, rasps. diamond files and special dissectors are used. When the desired reduction in nasal prominence is achieved it is time to make cuts called osteotomies through the nasal bones  5  with a hammer and chisel so that the width of the nose may be narrowed. The incisions inside the nostril opening are then sutured with dissolving (cat gut) sutures.

An external splint is applied and this is usually made from six layers of Plaster-of-Paris which is fixed to the face with stretchy sticky tape. Photo of a nasal splint taped to a nose
Photo showing nasal pack placed at conclusion of a rhinoplasty A temporary pack is often placed inside the the nose and removed just before the patient leaves hospital after two days.

The patient returns to the office for splint removal one week after surgery. At that time there will usually be some bruising around the eyes and upper cheeks and this is gone after another week allowing a return to work.

The nose feels rather stiff for approximately three months and then it softens. This is when a slight drooping of the nose tip may occur. Often the nose will have been upturned a little too much at first so the droop is a welcome change!

Swellings are present and are usually soft and easily indented in the first three or four weeks becoming firmer and sometimes hard at six weeks. The commonest site for swelling is just above the nose tip in the supra tip area. It usually takes twelve months for the swellings to subside completely.

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