These individuals can be considered good candidates for operation (other factors being equal) even though there may be a limited degree of physical growth still to take place. Delay under these circumstances means sacrificing the essential objective in treatment by giving lesser importance to emotional needs than to the one or two millimeters of physical change that might take place after the surgical procedure. A child of fifteen or sixteen years may, however, be at the same stage of physical development and not at all emotionally prepared for this procedure. In this case, the operation should be deferred until there is more evidence of maturity. Certainly, there will be some youngsters whose entire growth and development are late so that even at the chronological age of seventeen, surgery would best be postponed. The guidelines are rather clear and are consistent with attitudes towards cosmetic surgery in general: the objectives extend beyond purely anatomical considerations.
There are few circumstances where being in a middle to older age group disqualifies the patient as a candidate. As previously noted, modified rhinoplasty procedures have become more desirable in association with facelift surgery, to supplement overall results in achieving a more youthful appearance. Quite frequently the operation may be performed in the fifties and sixties.
Changes in the nasal contour are made by removing, shifting, or altering the underlying bone and cartilage structures. The skin over the surface can then be moulded or draped over a new foundation to achieve the desired result. This operation is performed from inside the nose, leaving no external scars except in special circumstances. One might consider this procedure similar to raising or lowering the central support of a tent, resulting in change of its outside appearance.
It should be quite easy to understand how the nature of the skin might influence the final results. Thinner skin can easily drape over the new contour; thicker skin is more difficult to control and will not adapt as easily to the new form. A change can be made in the operation to compensate for this variable, but a new set of limitations may then appear. The nasal passages cannot be narrowed beyond a certain point, since some of the underlying framework must be preserved. I attempt to achieve a delicate balance, leaving sufficient framework to permit normal breathing capacity while removing excess or distorted anatomical parts. In addition, one cannot direct attention to the nose without considering the other facial features .An experienced plastic surgeon considers all of these variables before he makes any final decision concerning the technical and aesthetic goals of the operation. Almost everyone contemplating nasal surgery has considered what type of nose he or she would like to have. All of these attitudes should be communicated, but they must be realistic and possible within the limits of the patient's normal anatomy. Functional aspects also require consideration.
Final decisions are best left to the surgeon for judgment. Drastic changes are not reasonable objectives and generally are not compatible with already existing bone and soft tissue contour. Nor are such corrections likely to harmonize with other facial features. The goal should be removal of major bone deviations or deformities and subtle refinements of cartilage and soft tissue contour. Total change which eliminates all definition of ethnic character is anatomically and aesthetically as well as psychologically undesirable.
In planning the surgical procedure, photographs are made to provide a permanent record and permit careful study. These are frequently helpful in showing the relationship of the nose to other facial features. The upper lip and chin are important contiguous structures which under some circumstances may require modification in order to achieve maximum benefit .Their relationship may become more evident in simple profile photography (see section under mentoplasty).
While nasal surgery is usually performed through the inside of the nose without external incisions or noticeable residual scars, there are a few special circumstances that require external incisions, particularly at the base of the nose near the normal fold. These incisions heal well and are difficult to detect. Discomfort is quite limited after the first twenty-four hours.
The most common postoperative complaint concerns the presence of a small amount of surgical packing placed in the nose at the end of the operation. It provides some control of postoperative bleeding, and the longer such packing remains, the easier it will be to remove without disturbing any of the freshly healing tissues.
At the end of the operation a small splint is used over the outside to maintain proper position and limit nasal swelling. This splint affords some protection from injury during the healing process. Varying degrees of swelling and discolouration around the eyes will become evident within the first twenty-four hours and will gradually decrease within the first week. Nasal swelling will persist somewhat longer, but a significant amount of it will disappear in ten to fourteen days. After that time most patients can return to their customary activities.
Some numbness and limited swelling in the nasal tip area will normally persist. It varies depending upon the exact nature of the surgical procedure. It is not conspicuous but can be detected by a feeling of tissue firmness for some time after surgery. Final settling and softening may take twelve months, during which time all of the final contour changes take place. It is a rather gradual process that cannot be hurried. While many patients want to see the final result immediately upon removal of the dressing, the presence of the early swelling can be misleading and premature judgments should not be made.
The specific risks of nasal surgery (apart from those associated with every surgical procedure) are few in number. Postoperative nasal bleeding can occur but is not ordinarily difficult to manage. Bleeding may occur approximately one week after the surgical procedure or after removal of the nasal packing. Postoperative infection is only a remote possibility.
Perhaps the greatest risk is that of a result that appears undesirable from the patient's point of view. Several conditions seem to invite this risk. One of the most significant factors is a desire on the part of both the surgeon and the patient to accomplish more than the local tissues will permit. Overly ambitious attempts to correct severe deformities are frequently destined to failure. It is much better to settle for lesser degrees of change so as to avoid totally unfavorable results. The problem is essentially one of unrealistic expectations on the part of the patient, who prevails upon the surgeon to attempt an impossible task.
Lesser degrees of temporary dissatisfaction may be encountered when minor irregularities of contour (bone or soft tissue) are noted after surgery. Some of these are difficult to control. Fortunately, a significant degree of change can be expected spontaneously during the first three to six months. Often the irregularities are noticed only by the patient and the surgeon and are not detected by others.
Some asymmetry or contour irregularity can result from imperfect surgical judgment or technical accomplishment. This must be accepted as a potential risk, regardless of the surgeon's experience. The operation requires precise judgment and execution which cannot be repeated in a machine-like fashion every single time. Some deviation, characteristic of all human effort, will occur despite every precaution. It is fortunate that these irregularities are quite limited and are ordinarily correctable.
Instructions will be provided regarding specific do's and don'ts after the operation. They will vary to some extent, but all are directed toward avoiding injury or distortion during the early postoperative period.
Finally, please remember that improvement is the goal of the operation. Larger changes are easier to accomplish; smaller corrections require the surgeon to work within narrower limits. Subtle differences - the last to become evident - are best seen after all swelling has subsided. Think positively when the operation is over and be patient while waiting for the final result.
You will be hospitalised for a period of two days and recovery will take approximately seven days.
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