RHINOPLASTY GUIDE

©copywrited William Portuese MD, 2007/8

Imaging

Computer imaging is done with our patient care coordinator and Dr. Portuese at the time of your consultation in our private offices and is not done over the telephone. A side profile picture of the nose is taken with our digital camera, inserted into the software morphing system on our computer, and an artistic simulation will be performed, which represents what the approximate new nose will look like. Dr. Portuese listens to the patient’s concerns, and he will discuss options with you. The purpose of the computer imaging software simulation is to give the patient an idea of the potential visual outcome from the rhinoplasty surgery. There is no implied warranty given during the computer simulation.

Preop

Preoperative preparation for a rhinoplasty consists of making sure the patient is in good physical and emotional spirits prior to any elective cosmetic surgery. Any questions or concerns a patient may have will be answered prior to surgery either by Dr. Portuese or one of our registered nurses. At the time of the preoperative appointment, the patient’s medical history is reviewed, along with current medications. Blood work or an EKG may be necessary depending upon the patient’s age and physical status. Refraining from taking any aspirin, ibuprofen, vitamin E and herbal supplements are discussed at the time of this appointment. It is also a good idea to refrain from smoking of any cigarettes due to the healing process. Patients need to arrange to have a caretaker take them home after their rhinoplasty surgery. It is also important that patients do not eat or drink anything before midnight the night before their nasal surgery.

Anesthesia

At the Seattle Rhinoplasty Center the type of anesthesia given is a general anesthetic. The anesthesiologists are board-certified physician doctors of anesthesia who are attending physicians at Swedish Hospital. On the day of the surgery, Dr. Portuese and the patient will review the various techniques that will be performed to the nose to effect the change. There is a mini consultation done the morning of surgery with Dr. Portuese. The patients are then brought into the operating room, and an IV, an intravenous line, is started usually in the right hand. Medications are given to relax the patient and then place them asleep. A small breathing tube is inserted on top of the vocal cords, called the laryngeal mass airway. The patients are then placed asleep under a general anesthetic for approximately one to one-and-a-half hours while Dr. Portuese performs the rhinoplasty surgery. The Seattle Rhinoplasty Center is a Medicare-certified ambulatory surgery center, which is one of the highest level of certifications that exists for surgery centers. Once the surgery is completed and the cast is placed across the nose, the anesthetic is turned off by the anesthesiologist, and patients are woken up and brought to the recovery room.

Rhinoplasty Surgery

The rhinoplasty surgery, the procedure itself, Dr. Portuese performs the rhinoplasty or revision rhinoplasty through a closed technique. He does not perform the open rhinoplasty technique, which tends to have more swelling, edema, and a longer recovery. All the incisions are placed on the inside of the nose and there is no incision placed across the columella. This technique offers the exact same exposure to the nose for all the structural cartilage grafting that may need to be performed on the more complicated and revision-type rhinoplasties. During the rhinoplasty procedure itself, the specific changes are made which were agreed upon between the patient and Dr. Portuese. Irregularities of the nose such as a hump or wide nose or wide tip are all addressed at the time by narrowing the tip by removal of cartilage, or sometimes when a bulbous tip is present, the tip cartilages are sewn together. Crooked, fractured, and broken noses are all realigned by resetting the nasal bones. Asian noses are typically refined on the tip and then augmented the bridge by either cartilage grafts or synthetic Silastic implants. Large projecting noses can be de-projected for a better aesthetic, pleasing profile, and occasionally a chin implant may be placed underneath through incision in the submental area for augmentation and better facial balance and structure. The chin implant is used to deemphasize a projecting nose when there is a receding chin. Revision rhinoplasty is a much more difficult operation to perform due to previous scar tissue and the unpredictability of healing, along with further reduction and/or augmentation has to be performed at the same time. Patients typically will spend approximately an hour to an hour-and-a-half in the recovery room waking up, and once awake are discharged with their caretaker to home or a local hotel for out-of-town patients.

Postoperative Phase

The postoperative phase for a rhinoplasty lasts approximately one year. The healing from a rhinoplasty is a very long, slow process. In the immediate postoperative phase directly after the surgery there can be some mild nausea and vomiting associated with the anesthetic. A cast is usually placed across the bridge of the nose and stays on for approximately five to six days after the rhinoplasty procedure. There is no packing placed on the inside of the nose. A simple mustache dressing or drip pad is placed underneath the nose for the first 24 hours after the nasal surgery. Bruising and swelling lasts approximately two weeks after the surgery. Patients are able to get back into their social work environment after two weeks without any detectability of having had a rhinoplasty surgery. Depending upon the tip technique, most of the swelling will remain in the tip of the nose for upwards of a year. The majority of tip swelling occurs from lymphatic edema, which settles down in the tip and has to re-channelize and move out of the nasal tip. Occasionally cortisone shots in the first month or two after the surgery can be performed to the nasal tip to speed this recovery. Approximately 20% of the swelling in the nasal tip is still present two months after the surgery. The nasal bridge tends to take shape much faster than the tip, and usually by about the first month most people are really starting to see the shape of their new nose. Occasionally, minor touch-up procedures are performed on the nasal bridge if a small irregularity occurs in the six-month postoperative timeframe. With regards to a deviated septum surgery, typically patients are not able to breathe out of their nose for one week, and starting at about the second or third week the breathing becomes much easier and less congested. The deviated septum surgery can be done at the same time as a fractured broken nose or a rhinoplasty. A minimal amount of narcotic pain pills are taken in the postoperative phase, and many patients just take Extra-Strength Tylenol. Patients return to the Seattle Rhinoplasty Center to see Dr. Portuese at the first week after the surgery to remove the cast. Patients then return in approximately one, month, three months, six months, and twelve months postoperatively to check on the progress of their new nose.

Conclusion

Dr. Portuese and his staff take great pride in realizing a patient’s desire of having a new nose. We specialize in rhinoplasty at our center, and Dr. Portuese has performed thousands of nasal surgeries, which includes rhinoplasty, deviated septum, and broken nose surgeries for the last 20 years in private practice. A very large percentage of our practice involves nasal surgery of some type, and we are pleased to offer our services to our patients.

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