Nose Job

Nose Job
All babies and most children have a small, cute and pretty nose.
So why can't we apply this sentence to all adults as well? Because in adolescence, along with all the other changes, the nose also changes.
First of all - and for everyone - it simply grows (after all you wouldn't like to wander around with a body of a 20-year-old and a nose of a 2-year-old). For most people, the nose grows in a manner suiting the facial structure. However, while growing, it may also become longer, protrude some more, become less refined at the edge and even "descend" downward.
Additional facial modifications occur during the growth process: the sinuses (air cavities located within the cheekbone) develop and following them the cheeks also grow, the jaw extends (downward and forward) and subsequently the chin protrudes.
All of these changes, including the nasal change, are usually transferred genetically in a manner typical to different ethnic groups. Regarding this matter, it is worth noting that there is no such thing as a "Jewish nose". Our nose is similar the nose of all other inhabitants of the Middle East.

What is the nose made of and how is it built?
In order to understand how the nose is built try to imagine a pup tent.
The side panels of this "tent" are made of two flat bones (the nasal bones), besides them there are two triangle-shaped cartilages which are connected at the center to the cartilage partition.
The tent's extremity, the one closest to its entrance (the nostrils) – consists of two additional cartilages whose shape reminds of the letter "n" and they surround they nostrils opening.
These bones and the cartilages construct the nose's side walls – the tent. Between the walls there's a cartilage partition (the one that "separates" between the nostrils and prolongs inside throughout the whole depth of the nose).
The spot at which the walls and partition connect is called the nasal bridge.

What can be done in a rhinoplasty?
Modify the size of the nose.
Reduce a big nose or – if necessary - turn a small nose into a bigger one. Change the angle between the nose and the lip. That is, enlarge the angle (the distance) between the nose's edge and the upper lip (in cases where the edge of the nose descends downward).

Narrow the nose.
Literally: turn a wide nose into a narrow one. This can be done at the nasal bridge, the nose's extremity or the nostrils area, in each area separately and in all together. Straighten the nose, straighten the nasal bridge (remove a nasal hump). Repair a nasal septal deviation. This partition – the cartilage wall which separates between both parts of the nose – begins at the nostrils, reaches the area between the eyes and ends in the pharynx, near the uvula. An uneven partition may cause air passage problems (and this cannot be seen but felt) as well as cause a visible distortion of the nose. In this case, the operation will straighten the partition. Shape the tip of the nose. That is precisely what clowns and jesters do, only they distort and exaggerate it on purpose. During surgery, it is possible to shape the tip of the nose, refine it, and befit it to the general shape of the nose. Create a depression at the nasal root. The nasal root is the spot between the eyebrows where the nose commences. Most people have a depression in that location. The operation is intended for those people who do not have such a depression and this is what is performed in it: a depression is created. Reduce the nasal conchas. The nasal conchas are structures encountered inside the nose whose function is to humidify the incoming air and filter it. So why should they be reduced? Because sometimes they react in response to allergic processes and then swell and block the air passage.

Who is suitable for rhinoplasty?
Rhinoplasty requires a "minimum age": 14-15 for women (preferably two years after the menstrual cycle has begun) and 16 and above for men. Why? Because around these ages the nose's growth process terminates and only at the end of that process we can ensure that the result obtained remains permanent. Medically speaking, the operation can be performed earlier but then it must be taken into account that the result won't be definitive.

Where is the incision performed?
Usually inside the nose, that is, without an external scar.

What is done during surgery?
In order to understand what is done during surgery, try to imagine again the tent we previously talked about, remember that the operation is performed on the skeleton of the nose and not over its skin. That is, the operation commences by separating the nasal skin from the nasal skeleton. This is the first stage.
Afterwards, the height of the tent's side panels is reduced. Meaning, the nasal bones are filed or sawn. This is then the second stage, after which the "tent" remains with open-roofed. How do we close the roof? We break the nasal bones at their base, where they connect to the cheeks, and then we press them towards the middle of the nose until the roof is closed. At the end of this stage, a nose lower and narrower than the previous one is obtained. At the fourth stage, the nose's extremity is being taken care of. It is repaired by incising and stitching the cartilage that builds it. If adding cartilage to the extremity of the nose is required (or to other places, sunken, in the nose itself), cartilage taken from the partition of the nose is utilized, or surplus cartilage segments that were removed by the surgeon.
At the end of surgery, the surgeon inserts into the nose two tampons that must remain there for 24-48 hours. The purpose of these tampons is to help prevent the bleeding and to counteract the cast that preserves the new form from the outside.
In order to reduce the swelling that is bound to appear and to preserve the nasal bones at the desirable place, the nose is bandaged by a cast or a splint made of plastic material.

What is an open rhinoplasty (open nose surgery)?
It is the same type of surgery, with an additional incision. In a regular rhinoplasty the incision is performed inside the nose. In an open rhinoplasty, another incision is added to the first one, it is performed across the columella (the little column, the soft portion that separates both nostrils). With the assistance of this additional incision, the surgeon can lift the nasal skin and see the cartilages themselves.

And the scar? The incision performed at the columella's base heals excellently and the scar almost disappears with time.

When should the nostrils be narrowed?
The simple answer is when their width bothers you. That is, when relative to other organs in the face, the nose seems too wide to you at the nostrils. However sometimes they need to be narrowed as part of a surgery designated to handle a completely different section of the nose as well. When does this happen? For example, when the tip of the nose is extremely high, and during surgery it is lowered downward. If you can once again imagine our tent, you will "see" that lowering the tent's roof widens its entrance. Meaning, lowering the tip of the nose will cause widening of the nostrils and therefore the need to narrow them.

How are the nostrils narrowed?
By removing small skin sections from the base of the nostril. The incision, which is a very thin miniature line, is performed at the nostril's angle. In most cases this is feasible by performing little almost invisible scars, but there are cases in which it is necessary to extend the scar line around the nostril, right at the fold.

Doesn't this create "excess" skin on the nose?
The nasal skin contracts very neatly and adjusts itself to the new structure of the nose.
Sometimes, and even then only with people aged over 60, it is necessary to add a supplementary amputation of excess skin in order to avoid wrinkles.

What type of anesthesia is being used?
In rhinoplasty, just as in other plastic surgery, the decision regarding the type of anesthesia must be a joint decision made by you and the surgeon. The operation can be performed both under local anesthesia (with intravenous sedation) as well as under general anesthesia.
If you have chosen to use local anesthesia, you must know that the anesthetic is injected around the perimeter of the nose and inside it, and all of this done only after the intravenous sedation is already active. Does it hurt? Yes, for a few seconds.

How long does the surgery last?
Between one to two hours, depending on what is exactly done in the operation and on the surgeon's degree of expertise.

Is hospitalization required?
In most cases there is no real need for hospitalization following surgery.
In the USA, for instance, most of these operations are performed on an ambulatory basis. The patient arrives to the hospital, undergoes surgery and then after a few hours, is released home.
In Israel, the Ministry of Health recommends a one-night hospitalization after surgery. Why? Because in their opinion, surgery which involves the respiratory system requires hospitalization, especially in order to avoid respiratory airways complications.

What should be emphasized in the meeting with the surgeon?
In the meeting prior to rhinoplasty, as well as in any other meeting intended for plastic surgery, it is important to tell the surgeon what bothers you and listen tentatively to what he or she says. When it comes to the appearance of the nose, one important fact must be remembered: usually we look at each other straightforward. Face to face. Through this gaze which is called "en face", we cannot observe all the forms of the nose. An aquiline nose, for example, looks this way only in profile and not at a straight glance. And why should this fact be remembered when meeting with the surgeon? Because in order to create a harmonious appearance of the nose the surgeon must take into consideration the structure of the chin, the cheeks and the lips adjacent to it. In some cases, the size of the nose and the facial structure are rather harmonious, but a receding chin (which is a bit "backward") makes that nose seem much larger than it really is. There are cases where, in order to improve the profile appearance, it is necessary not only to operate the nose but also enlarge the chin. In other cases, a rhinoplasty is totally unnecessary and in order to change the profile appearance, chin surgery will suffice. Sometimes the structure of the upper lip must be taken into account since if it is very small, lifting the nose upward will create a lack of proportion and it won't look too good. Sometimes, in order to match the size of the nose to the facial structure, an enlargement or filling of the cheekbones and the zygomatic arches (which are the bones extending forward from the side of the skull, over the opening of the ear, at the upper and lateral part of the cheek) is required and not a rhinoplasty.

About surgeons and computers
Suppose you've explained the surgeon exactly, but exactly, what you want. And suppose the surgeon said that was exactly what he was intending to do. How do you know it really looks good on you?
For the purpose of illustration, most surgeons use explanations, diagrams and photographs of other operated patients. Some have adjoined computerized imaging. They will photograph your face using a digital camera, upload the picture to their computer, and using specialized software, will modify the appearance of your nose to the one you desire.
No doubt such imagery is very vivid, lovely and seductive, and yet - a word of warning: it is very easy to be tempted by the refurbished image which stares back at you from the computer. However, it is also very easy to forget that this is not a promise but only a capability demonstration. Not the surgeon's capability but the computer's.
You have to remember that the computer cannot only provide you with a wonderful nose, but also adhere it to your ear. In reality it does not work that way, and it's important to remember that not all the computer can do, the surgeon also can.
After watching the computerized result, the level of expectations increases accordingly. Indeed you "saw" how you may look, and this is exactly what you need to be careful about. Once you have fallen in love with your computerized nose, disappointment from surgery is almost guaranteed.

What else must be detailed in the conversation with the surgeon?
Everything related to your physical and mental health. And yes, tell him whether you are undergoing a psychological or a psychiatric treatment, and it is important. Why? So both of you know whether you can or cannot withstand the complications or the disappointments. It is important to tell the doctor if you are suffering from allergies, frequent colds or herpes at the mouth and nasal areas, also state all the medications you are taking and any drug sensitivity. A tendency for herpes and other allergies requires the administration of medication prior to surgery. And in any case, you must know that in situations of allergies, colds or active herpes, the operation will be postponed. Even pimples on the nose will result in a delay of the operation
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