Rhinoplasty in Melbourne

Cosmetic · Functional · Reconstructive Rhinoplasty

Rhinoplasty is both aesthetic and functional surgery. Changes to the appearance of the nose also alter its underlying structural framework, while changes intended to improve breathing can influence its external shape.

My approach to rhinoplasty draws on my experience in both rhinology and facial plastic surgery. I consider the appearance of the nose and its relationship with the rest of the face together with the nasal airway, septum, nasal valves and structural support.

The objective is not to create a particular type of nose, but to determine what changes are appropriate for the individual face while preserving, and where necessary improving, nasal function and structural stability.

Function · Structure · Facial harmony · Longevity

On this page

Approach · Cosmetic rhinoplasty · Structural & preservation · Functional rhinoplasty · Revision · Selected cases · Costs · Consultation · Surgery · Recovery · Risks

Rhinoplasty experience and training

Dr Philip Michael is an ENT specialist with qualifications from the Royal College of Surgeons of Edinburgh and the Royal Australasian College of Surgeons (FRCSEd (ORL-HNS), FRACS (ORL-HNS)). Following specialist training in otolaryngology, he undertook further training in rhinology and rhinoplasty in Australia and Europe, including a rhinology fellowship at the Royal Victorian Eye and Ear Hospital and travelling fellowships in Germany and Switzerland.

His practice has a particular focus on rhinology and facial plastic surgery, including cosmetic, functional, revision and reconstructive rhinoplasty and the management of nasal obstruction.

My approach to rhinoplasty

There are several principles that I discuss with patients when considering rhinoplasty.

1. Minimise the possibility of making things worse

Every alteration to the nose has consequences. Removing or repositioning cartilage can change structural support, while narrowing parts of the nose may affect airflow.

My first consideration is therefore what should be preserved.

2. Improve what can reasonably be improved

The next consideration is what can realistically be changed and whether doing so is likely to produce a worthwhile improvement.

Rhinoplasty has limitations. Understanding these is as important as understanding what surgery can achieve.

The following three considerations are equally important.

3. Function

The nose has evolved primarily as a functional organ. The nasal airway, septum, turbinates, nasal valves and structural support therefore need to be considered alongside its external appearance.

4. Facial harmony

There is no single ideal nose.

The nose needs to be considered in relation to the forehead, eyes, cheeks, lips and chin. I think of it as the central fulcrum of the face. Ideally, it should direct attention towards the other facial features rather than detract from them.

The aim is therefore not necessarily to create a conspicuously different nose, but one that sits naturally within the face.

5. Longevity

Rhinoplasty changes a living structure that continues to heal and age after surgery.

Cartilage, scar tissue and the forces acting on the nasal framework can influence the result over time. I therefore place considerable importance on preserving, and where appropriate reconstructing, structural support.

The objective is a result that works aesthetically and functionally not simply in the early postoperative period, but as the nose continues to heal and mature.

Cosmetic Rhinoplasty

Cosmetic rhinoplasty aims to change the appearance of the nose while considering its relationship with the face as a whole.

Concerns may relate to the profile or bridge of the nose, its width, projection or rotation, the shape and definition of the nasal tip, asymmetry, or a nose that appears out of proportion with other facial features.

There is no single ideal nasal shape or set of measurements that is appropriate for every face. The same nasal feature may appear quite different depending upon the forehead, eyes, cheeks, lips, chin and overall facial proportions.

My preference is therefore for changes that maintain the individual character of the face rather than creating a particular style of nose. The aim is a natural appearance in which the nose sits harmoniously with the surrounding facial features.

Depending upon the anatomy and the changes being considered, surgery may involve reshaping, repositioning, preserving or supporting different components of the nasal framework. Some patients may be suitable for a closed approach, while in others an open approach provides better access to make the required changes.

The choice of technique is determined by the individual anatomy and the objectives of surgery rather than by using one particular rhinoplasty technique for every patient.

Structural and Preservation Rhinoplasty

Structural and preservation rhinoplasty describe different principles and techniques that can be used when reshaping the nose. I do not regard them as mutually exclusive approaches. The techniques used need to be selected according to the individual anatomy and the changes being considered.

Preservation rhinoplasty

Preservation techniques aim, where appropriate, to retain existing structures of the nose rather than routinely removing and reconstructing them. This may include preservation of components of the nasal bridge and minimising disruption of supporting tissues.

Preservation techniques are not suitable for every nose, and the decision to use them depends upon the existing anatomy and the objectives of surgery.

Structural rhinoplasty

Structural techniques use repositioning, suturing and, where required, cartilage grafting to reshape or support the nasal framework.

Structural support can be particularly important when correcting significant deviation, altering tip position or support, treating nasal valve problems, or reconstructing a nose that has undergone previous surgery.

In practice, elements of preservation and structural rhinoplasty can be used together. The objective is not to follow a particular surgical philosophy, but to preserve useful anatomy where possible and provide additional support where it is required.

Ultrasonic / Piezo Rhinoplasty

Ultrasonic, or piezoelectric, instruments can be used during some rhinoplasty procedures to reshape or divide the nasal bones.

Unlike conventional instruments that act through mechanical cutting or impact, piezoelectric instruments use ultrasonic vibration to act on mineralised tissue. This can allow controlled treatment of the nasal bones while limiting the effect of the instrument on surrounding soft tissues.

Ultrasonic instrumentation is a surgical tool rather than a separate type of rhinoplasty. It may be useful for particular parts of an operation, while other techniques are still required to reshape cartilage, alter the nasal tip, support the airway or reconstruct the nasal framework.

Whether ultrasonic instrumentation is useful therefore depends upon the individual anatomy and the changes required.

Functional Rhinoplasty

Functional rhinoplasty considers the relationship between the structure of the nose and the nasal airway.

Nasal obstruction does not always arise from the septum alone. The external framework of the nose, the internal and external nasal valves, nasal sidewalls, septum and turbinates can all influence airflow. Assessment therefore needs to consider the nose as a three-dimensional functional structure rather than focusing on a single component.

The nasal septum

A deviated nasal septum can narrow one or both nasal passages. In some patients, septoplasty alone may be sufficient to address the relevant obstruction.

When septal deviation is associated with distortion of the external nasal framework, however, correcting the septum alone may not address the entire problem. Functional septorhinoplasty may then be considered to address the septum and external nasal structure together.

The nasal valves

The nasal valves are narrow regions of the nasal airway and make an important contribution to resistance to airflow.

Narrowing or weakness in these areas can contribute to nasal obstruction. In some patients, the sidewall of the nose may also move inward during inspiration.

Treatment depends upon the underlying anatomy and may involve repositioning or supporting components of the existing nasal framework.

The turbinates

The turbinates are structures within the nose that contribute to warming, humidifying and filtering inspired air. Enlargement of the turbinates can contribute to nasal obstruction independently of the septum or external nasal framework.

Where appropriate, treatment of the turbinates may therefore be considered as part of the overall management of the nasal airway and can sometimes be undertaken at the same time as rhinoplasty.

Function and appearance together

Functional and cosmetic rhinoplasty are not necessarily separate operations.

Changing the external framework of the nose may influence the airway, while changes undertaken to improve nasal function can affect external shape. For this reason, I prefer to consider nasal function, structure and appearance together when planning rhinoplasty.

Revision and Reconstructive Rhinoplasty

Revision rhinoplasty presents different challenges from surgery on a nose that has not previously been operated upon.

Previous surgery may have removed or repositioned cartilage, altered structural support and created scar tissue. The anatomy encountered during revision surgery can therefore be substantially different from the original nasal anatomy.

Assessment needs to consider the patient's cosmetic and functional concerns, what structural support remains, the condition of the skin and soft tissues, and whether further surgery is likely to produce a worthwhile improvement.

In some cases, revision surgery is primarily a process of reconstruction rather than further reduction.

Cartilage grafting may be required to restore support or reshape parts of the nasal framework. Septal cartilage can be useful when sufficient material remains. Following previous septal or rhinoplasty surgery this may be limited, and cartilage from another site, such as the ear or rib, may occasionally be required.

Revision surgery also requires particular caution. Further surgery is not necessarily the appropriate recommendation for every patient, and the potential benefits need to be considered alongside the limitations and risks of another operation.

Selected Rhinoplasty Cases

Rhinoplasty needs to be planned around the anatomy, function and facial features of the individual patient. The changes that may be appropriate for one nose may not be appropriate for another.

The cases shown here are selected to illustrate different anatomical problems, surgical considerations and approaches to rhinoplasty. They are not intended to represent a typical or expected result.

Individual anatomy, surgical requirements, healing and outcomes vary. The outcome demonstrated for one patient does not predict the outcome of surgery for another person.

Case 1 — Subtle profile change with functional reconstruction

Presentation

This patient had difficulty breathing through the nose because the outer wall of the nostril tended to collapse inwards when breathing in. There were also concerns about fullness of the nasal bridge, the nose projecting slightly too far from the face, and a nasal tip that pointed slightly downwards.

An important objective was to make subtle changes to the appearance of the nose while maintaining its function and addressing the areas contributing to nasal obstruction.

Assessment

Examination showed that part of the outer nasal wall collapsed during inspiration (dynamic alar collapse). The lower end of the nasal septum was also displaced away from the midline.

The turbinates — structures inside the nose that help warm and humidify inhaled air — were moderately enlarged in association with allergic rhinitis. There was also asymmetry between the cartilages supporting the two sides of the nasal tip and nostrils.

Surgical approach

The operation was planned to address the structure and function of the nose together.

The lower part of the septum was repositioned towards the midline. The patient's own cartilage was used to provide additional support to the nasal tip and outer walls of the nostrils, while the tip cartilages were reshaped to address their pre-existing asymmetry.

The fullness of the nasal bridge was reduced using an ultrasonic (piezoelectric) instrument to carefully sculpt the nasal bones. In this case it was not necessary to make cuts through the nasal bones to reposition them.

Three-month follow-up

These photographs were taken three months after surgery. The intended aesthetic change was deliberately subtle, particularly in the profile and tip.

Three months remains relatively early in the healing process after rhinoplasty. Some swelling is still present and the appearance and definition of the nose can continue to change as healing progresses over subsequent months.

Individual anatomy, surgical requirements, healing and outcomes vary. The result shown for this patient does not predict the outcome of surgery for another person.

What is the cost of rhinoplasty in Melbourne?

The cost of rhinoplasty varies according to the type and complexity of the procedure.

Dr Michael's professional surgical fee is generally between $6,500 and $15,000. A more accurate estimate can only be provided after consultation, when the changes being considered and the likely extent of surgery have been assessed.

There are usually additional costs associated with anaesthesia and the hospital or surgical facility. These vary according to factors including the duration of surgery and the hospital at which the procedure is undertaken. A detailed estimate of the expected costs is provided before proceeding with surgery.

Where surgery is undertaken for an eligible functional or reconstructive indication, Medicare and private health insurance may contribute towards some components of treatment. This does not mean that all costs are covered, and out-of-pocket expenses may remain.

Purely cosmetic rhinoplasty does not attract a Medicare rebate. GST may also apply to procedures undertaken for cosmetic purposes.

Cost is only one consideration when deciding whether to proceed with rhinoplasty. Consultation provides an opportunity to discuss what changes may reasonably be achievable, the limitations of surgery, recovery and the potential risks before making a decision.

What happens before rhinoplasty surgery?

The first consultation begins with a detailed discussion of the reasons you are considering rhinoplasty. This includes concerns about the appearance of the nose, nasal breathing, previous injuries or surgery, and what you would like to change.

Examination considers both the external structure of the nose and the nasal airway. Nasal endoscopy may be performed where appropriate to assess structures within the nose. Standardised photographs are also taken from a number of different views.

Additional investigations may sometimes be helpful. These can include imaging, particularly where there has been previous trauma, surgery or other nasal or sinus problems. Questionnaires may also be used to document nasal symptoms and their impact.

An important part of consultation is determining what changes may reasonably be achievable and discussing the limitations, recovery and potential risks of surgery. Photographs may be used to assist this discussion, including computer-generated image modifications where appropriate. These images are a communication and planning tool rather than a prediction or guarantee of the surgical result.

For most patients considering rhinoplasty, there is a further consultation before deciding whether to proceed. This provides time to consider the information discussed at the first appointment and to ask further questions.

If surgery is planned, the proposed procedure, consent, expected recovery, risks and costs are reviewed. Instructions are also provided regarding preparation for surgery, including smoking and any medicines or supplements that may affect surgery or bleeding. Medicines should only be stopped or altered following appropriate medical advice.

There is another opportunity to discuss questions with Dr Michael before the operation.

What does rhinoplasty surgery involve?

Rhinoplasty is usually performed under general anaesthesia.

The operation may be undertaken through incisions entirely within the nose (a closed approach) or through an open approach, which includes a small incision across the skin between the nostrils. The choice of approach depends upon the anatomy of the nose and the changes that need to be made.

Rhinoplasty is not a single manoeuvre. The nose is made up of interconnected bony, cartilaginous and soft-tissue structures, and surgery may involve a combination of techniques to reshape, reposition, preserve or support different parts of the nasal framework.

Depending upon the individual anatomy, this may involve treatment of the nasal bones, bridge or tip, correction of asymmetry or deviation, modification of cartilage, or reinforcement of areas requiring additional structural support.

Where nasal obstruction is also being addressed, surgery may include correction or reconstruction of the nasal septum, treatment of the nasal valves, or reduction of enlarged turbinates.

Cartilage grafts are sometimes required to reshape or support the nasal framework. Septal cartilage is generally useful when sufficient material is available. In some operations, particularly following previous surgery or when more cartilage is required, cartilage from the ear or rib may be considered.

The components of the operation vary considerably between individuals. The proposed approach and the procedures considered appropriate for your nose are discussed during consultation before deciding whether to proceed with surgery.

What happens after a rhinoplasty operation?

At the end of the operation, tapes and an external splint are usually placed over the bridge of the nose. Internal nasal splints may also be used depending upon the procedures performed. Nasal packing is not routinely required but may occasionally be necessary.

After recovery from the anaesthetic, most patients are able to go home on the day of surgery. Some discomfort, nasal congestion and a small amount of bleeding or blood-stained discharge can be expected during the early recovery period. Local anaesthetic is used during surgery as part of postoperative pain management, and additional pain relief is provided as required.

The first few weeks

Swelling is expected after rhinoplasty and is often most noticeable during the first few weeks. If the nasal bones have been repositioned, bruising around the eyes can also occur. The amount of swelling and bruising varies considerably between individuals and according to the procedures performed.

The nose can feel blocked during the early postoperative period because of swelling within the nasal passages. This gradually improves as healing progresses but may persist for several weeks.

Altered or reduced sensation, particularly around the nasal tip, can also occur. Sensation generally improves as the tissues heal, although this can take a number of months and occasionally some altered sensation may persist.

Most patients plan approximately two weeks away from work. Some people undertaking predominantly desk-based work may feel able to return earlier, while others require longer depending upon the extent of surgery and their recovery.

Follow-up

An early postoperative appointment is arranged to assess healing and remove external sutures or splints when appropriate. Taping may then be continued for a period depending upon the operation and the degree of swelling.

Instructions are provided regarding nasal saline irrigation, wound and skin care, medication and other aspects of postoperative care. The exact postoperative regimen can vary according to the procedures performed.

How long does a rhinoplasty take to heal?

Removing the external splint does not represent the final result of rhinoplasty.

Swelling continues to change over the following months. Different parts of the nose can settle at different rates, and the appearance may vary during the healing process. The nasal tip commonly takes longer to soften and settle than the bridge.

Although much of the early swelling resolves during the first few months, more subtle changes can continue for a year or longer. Healing may take longer following revision or reconstructive surgery and in noses with thicker skin.

For this reason, I prefer to regard rhinoplasty as a process of healing and maturation rather than attaching a precise percentage of the final result to a particular point in time.

Activity after surgery

The nasal framework needs time to heal and regain strength. Patients are given individual instructions about returning to exercise and other activities. Strenuous exercise is restricted during the early healing period, and activities in which the nose could be struck need particular caution.

Sun protection is also advisable while the nose is healing, particularly where there has been bruising or an external incision.

The timing of recovery varies between individuals and depends upon the procedures performed. More specific postoperative instructions are provided as part of the surgical planning process.

Are there any risks to having a rhinoplasty?

All surgery involves risks, and rhinoplasty is no exception. The likelihood and significance of individual risks vary according to the anatomy of the nose, the procedures being performed, previous surgery, general health and the way in which an individual heals.

Possible risks and complications include:

Bleeding

Some bleeding or blood-stained discharge is expected during the early postoperative period. More significant bleeding can occasionally occur and may require additional treatment, including nasal packing or, rarely, a further procedure.

Infection

Infection can occur following rhinoplasty and may require antibiotics or other treatment. Infection involving cartilage or graft material can have consequences for healing and nasal structure.

Swelling, bruising and prolonged healing

Swelling and bruising are expected to varying degrees after surgery. While much of the swelling settles during the earlier stages of recovery, more subtle swelling can persist for many months. Healing may be more prolonged following revision surgery or in patients with thicker skin.

Altered sensation

Temporary numbness or altered sensation can occur around the nasal tip, upper lip, upper teeth or palate. This usually improves as healing progresses, but altered sensation can occasionally persist.

Scarring

An open rhinoplasty involves a small external incision in addition to incisions within the nose. Scars generally mature and become less noticeable with time, but visible, raised or otherwise unfavourable scarring can occur.

Scar tissue also develops internally following surgery and can influence both the appearance and function of the nose.

Septal perforation

Surgery involving the nasal septum carries a risk of developing a perforation, or hole, within the septum. A septal perforation may cause symptoms including crusting, dryness, bleeding or whistling. Larger perforations or loss of septal support can also affect the structure of the nose.

Nasal breathing

Although surgery may be undertaken partly to improve nasal breathing, obstruction can persist after surgery and, in some circumstances, new or increased obstruction can occur.

Changes in the septum, nasal valves, turbinates, scar tissue and external nasal framework can all influence the airway.

Appearance, asymmetry and change over time

Rhinoplasty cannot produce perfect symmetry or guarantee a particular appearance.

Residual asymmetry, irregularity, deviation or differences from the planned appearance may remain after surgery or become apparent during healing. Cartilage, scar tissue, skin and the forces acting on the nasal framework can also influence the shape of the nose over time.

Further treatment or revision surgery

Occasionally, further treatment or revision surgery may be considered because of a functional problem, an aesthetic concern or a complication.

The decision to undertake further surgery requires the same consideration of potential benefit, limitations and risk as the original operation. Revision surgery can itself be more complex because of scar tissue and changes to the available nasal structures.

General surgical and anaesthetic risks

Rhinoplasty also carries the general risks associated with surgery and anaesthesia. These are discussed as part of the consent process and, where appropriate, with the anaesthetist.

This information is intended to provide an overview rather than an exhaustive list of every possible complication. The risks that are particularly relevant to an individual patient and the proposed operation are discussed during consultation as part of the informed consent process.