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Rhinoplasty Blog


  1. The following postoperative instructions are given to the patient on discharge from the hospital. The first ten instructions are carefully read by our staff nurse:
    1. Take your antibiotics regularly as indicated.
    2. Do not expose yourself to any visitors with common colds or infections.
    3. Stay at home for five days to avoid dust and contamination of the nose by the outdoor atmosphere.
    4. Do not swim for six weeks.
    5. Remain upright and moving around at home as much as possible.
    6. Avoid bending over, lifting heavy things and climbing up stairs in a hurry.
    7. Do not play with young children in order to avoid bumping the nose.
    8. Sleep on your back with head elevated for the next two weeks.
    9. Report frank bleeding, headache or fever to our clinic or hospital.
    10. Avoid pushing hand tissue into the nostril or rubbing the nostril.
    11. If the nose continues to drain blood, use moustache dressing with light paper adhesive tape.
    12. Avoid excessive sneezing. If sneezing is troublesome it should come out through the mouth and use decongestant and antihistamine.
    13. Avoid the type of clothing that must be pulled over the head to avoid injury to the nose.
    14. Brush the lower teeth as usual and clean the upper teeth with toothpaste on a face cloth.
    15. Do not smile excessively or pull down the upper lip.
    16. Avoid exposure to sun for one month.
    17. Avoid getting the nasal cast and tapes wet.
    18. Avoid using glasses for one month. Use contact lenses. Glasses may cause depressions or dorsum deviation.
    19. Avoid jogging and tennis for six weeks.
    20. Avoid diving and skiing for two months and avoid contact sports for four months.
    21. Body bathing allowed and the hair washed in the sink as in the salon and avoid cast and bandage becoming wet.
    22. Avoid decongestant nasal sprays.
    23. Discolouration: usually bluish below the eyes. Alleviated by the use of Reparil or Herudoid gel and may be covered by make-up. Usually disappears in two weeks.
    24. Patient should keep busy by reading and doing other activities during first few days postoperative to avoid depression which may be due to swelling, discolouration and the hangover effects of anaesthesia, analgesics and antihistamine.
    25. Mild nose swelling and oedema may last for one year. 80% of the swelling will subside during the first six weeks and remaining 15% within the next six months and the last 5% up to twelve months. The swelling and oedema may last more (up to two years) in patients with thick skin and a wide nose. These patients should be well informed and reassured.
    26. During the first three weeks the tip may appear over-rotated and turned up too much. This is due to the swelling over the tip of the nose and in the upper lip. Our patients are usually concerned about this temporary over-rotation and overprojection but we reassure them that this will go away in three weeks.
    27. The upper lip may look longer and feel stiff and interfere with smiling. This always bothers the patient and he/she usually says, “My smile has changed”. This will disappear in two months .
    28. Numbness over the tip of the nose may bother the patient. This too will eventually disappear.
    29. The nose may be blocked for the first two weeks after the operation due to blood clots and swelling. Normal saline drops and gentle sniffing are encouraged to clear the nose.
    30. A mild degree of vasomotor rhinitis may occasionally last for a few months and eventually disappears.
    31. Patients with difficult noses, complications, severely crooked noses and revision cases should be advised to keep follow-up appointments at the clinic for at least twelve months postoperative because there is always the possibility of considering a secondary procedure.
    32. For the first two weeks eat easily chewed food such as soups, hamburger, potatoes, chicken and avoid steak and chewing gum.
    33. It is not unusual for the patient to feel dizzy or to get cold sweats for a few days postoperative.
    34. Return to work after seven to ten days according to the degree of swelling and discolouration.
    35. Avoid excessive sniffing which may cause some bleeding.
    36. Avoid sitting under the beauty salon’s hair dryer for two weeks. Use a hand held hair dryer.
    37. Swelling around eyes will reach its peak on the third day and then gradually subside.
    38. Patient should report by telephone any injury to the nose, and should see the doctor if haemorrhage and swelling occur.
    39. Remember that the nose is classified into five categories:
      Beautiful nose
      Normal nose
      Abnormal nose
      Ugly nose
      Ridiculous nose

Only one procedure will improve the nose for a stage down to a stage up. We can not achieve a beautiful nose from an ugly nose. Sometimes the surgeon may be able to achieve two or three stages in one procedure (but not usually). The patient should wait at least eight months before considering a second procedure.



  1. Preoperative preparation
  2. Anaesthesia and sedation
  3. Immediate postoperative care
  1. Preoperative preparation of the patient
    • Patient is admitted to the day case surgical center or to the hospital at 7 a.m.
    • Patient receives clinical examination by the admitting doctor and nurse.
    • Patient with his preoperative investigations reviewed by the anaesthetist at 8:30 a.m.
    • Premedications are given. (p. 56)
    • Decongestant nose drops and Emla cream (Lidocain) applied to the nose one hour pre surgery.
    • Zinacef 1.5mg (Cefuroxim) IV give one hour pre surgery.
  2. Anaesthesia and sedation: It has been fully explained in the chapter on local anaesthesia.
  3. Immediate postoperative care
  • The patient is kept in a semi-sitting position, 30° with head elevated.
  • Ice pack applied to the forehead.
  • Sedation and pain killers are considered to avoid excessive movement.
  • Zinacef 1.5mg (Cefuroxim) every twelve hours.
  • Voltaren (Diclofenac) 75mg. intramuscular every twenty four hours.
  • Panadol two tablets every eight hours.
  • 5% Dextrose IV every eight hours.
  • Patient’s nasal packs are removed about 7 p.m. and then one hour later is discharged home on the following medicines:
    • Zinnat (Cefuroxim) 500mg _ one capsule every twelve hours for seven days.
    • Panadol two tablets every eight hours.
    • Normal saline drops _ four drops in each nostril every two hours during daytime.
    • Fucidine (Sodium Fusidate) ointment to be used on cotton tip applicator to paint the marginal incision and alar wedge incision.
  • The above prescription and the use of ointment and nose drops are explained fully to the patient by our staff nurse.
  • Postoperative instructions are read to the patient by our staff nurse and asked to follow strictly. A follow-up appointment is given in the clinic after seven days.



Preoperative Instruction
The following investigations are routinely performed to check the general health of the patient:

  • CBC, RBS, Creatinine, Liver function test, Hepatitis, HIV.
  • ECG and Chest x-ray.
  • CT scan of nose as sinuses: if patient is going for both functional and cosmetic surgery.


Preoperative Instruction
Referral form is given to the patient for the hospital with map direction. The following instructions written clearly in the referral form and explained to the patients:

  1. Do not drink or eat after midnight before surgery or six hours before surgery for children.
  2. Bring to the hospital all the preoperative investigations and x-rays.
  3. If diabetic, asthmatic, on hypotensive drugs, anticoagulants or any medicines, please inform the hospital nurse and the anaesthetist.
  4. To take a shower on the morning of the day of the operation.
  5. If, for any circumstances, there is a change in operation date, please inform the clinic as soon as possible.
  6. Try to be in the hospital at the exact time indicated to avoid any delay in the operation time.
  7. Do not hesitate to contact the clinic for any further questions.


  1. The first follow-up visit will be one week postoperative for cast removal. When removing the cast consider the following:
    1. Reassure the patient that there is no pain.
    2. Remove both sides of the tape at the same time and the cast from the middle. Do not remove side by side, the cast will cause pressure and bump the nose. Clean the nose with soapy wet tissue (Chubs wet pack).
    3. Remove blood clots from the nares. Trim long sutures but do not remove as the sutures will be absorbed.
    4. If pimples developed, they should be scraped and the nose cleaned with wet soap and hydrogen peroxide.
    5. Patient is allowed to use mirror to see the reshaped nose.
    6. Vasovagal attack may occur at this stage in some emotional patients, in particular when a big difference has been achieved as in preoperative crooked nose or patients with hump and long noses. Patient should lie flat with legs and feet elevated. The vagovasal attack will disappear in two minutes time.
    7. Nasal massage instructions:
      We instruct the patient to use two types of massages:

      1. Bidigital massage:
      2. By using the two index fingers to achieve gentle pressure on the sides of the dorsum of the nose to keep the nose straight and to reduce oedema. The gentle pressure is applied for ten minutes three times a day. (Fig. 2 – 6)
      3. Index-thumb massage:
        By using the thumb and index fingers of one hand for massaging the base of the bony pyramid of the nose in order to avoid nasal bone displacement and reduce oedema. The massage from down-up is repeated twenty strokes three times a day. (Fig. 2 – 7)


Fig. 2 – 6. Bidigital massage: By using the two index fingers to achieve gentle pressure on the sides of the dorsum of the nose to keep the nose straight and to reduce oedema. The gentle pressure is applied for ten minutes three times a day.


Fig. 2 – 7. Index-thumb massage: By using the thumb and index fingers of one hand for massaging the base of the bony pyramid of the nose in order to avoid nasal bone displacement and reduce oedema. The massage from down-up is repeated twenty strokes three times a day.


2. Further follow-up

  1. The next visit after cast removal will be after three weeks in order to watch for any mild deviation or any infection or intranasal adhesions or to remove obvious sutures. If mild deviation is noticed at this stage, the patient is instructed to perform unilateral index finger massage by placing the index finger along the deviated side and pushing gently to the opposite side for ten minutes / four times a day.
  2. Next follow-up will be in two months time to watch for any mild deviation, notching, pinching or any nasal asymmetry. If any of the other mentioned problems are obvious and concerning the patient, correct without any delay.
  3. The next visits will be in six months, then, one year. If any problems arise, correct without any delay and don’t leave your patient waiting even with a minor problem.


Patient Management

1. Anderson J, Johnson C: A self-administered history questionnaire for cosmetic facial surgery candidates. Arch Otolaryngol 104:89-99, 1978.
2. Bittle R: Psychiatric evaluation of patients seeking rhinoplasty. Otolaryngol Clin North Am 8:689-704, 1975.
3. Butler J: Graphics and microcomputers, present and future. Paper presented at symposium, June 26, 1987.
4. Donald P: Postoperative care of the rhinoplasty patient. Otolaryngol Clin North Am 8:797-806, 1975.
5. Echavez M, Mangat D: Effects of steroids on mood, edema, and ecchymosis in facial plastic surgery. Submitted 1993.
6. Hayden R: Postoperative care. In Krause C, Mangat D, Pastorek N (eds): Aesthetic Facial Surgery. Philadelphia, JB Lippincott, 1991, pp 113-212.
7. Huffman D: Preoperative management of the rhinoplasty patient. Otolaryngol Clin North Am 8:679-684, 1982.
8. Gorney, M: Psychiatric and medical-legal implications of rhinoplasty, mentoplasty, and otoplasty. Symposium of Aesthetic Surgery of the Nose, Ears, and Chin. Vol. 6, St. Louis: Mosby, 1973.
9. Jacobson, W.E., et al. Psychiatric evaluation of male patients seeking cosmetic surgery. Plast. Reconstr. Surg. 26:356, 1960.
10. MacGregor, F.C., and Shaffner, B. Screening patients for nasal plastic operations. Psychosom. Med. 12:277, 1950.
11. Meyer, E., et al. Motivational patterns in patients seeking elective plastic surgery (women who seek rhinoplasty). Psychosom. Med. 22:193, 1960.
12. Palmer, A., and Blanton, S. Mental factors in relation to reconstructive surgery of nose and ears. Arch. Otolaryngol. Head Neck Surg. 56:148, 1952.
13. Peterson R: Preoperative evaluation for rhinoplasty. In Millard DR (ed): Symposium on Corrective Rhinoplasty. St. Louis, MO, CV Mosby, 1976, pp 56-63.
14. Reiter D, Alford E, Jabourian Z: Alternatives to packing in septorhinoplasty. Arch Otolaryngol Head Neck Surg 115:1203-1989.
15. Shoenrock L: Five year facial plastic experience with computer imaging. Facial Plast Surg 7:18-25, 1990.
16. Shoenrock LD: Computer graphics-a new form of aesthetic editing. Paper presented to Nippon Aesthetic Surgery Society, Japan, October 26, 1986.
17. Shoenrock LD: Computer graphics _a new form of aesthetic editing, Update I. Otolaryngol Head Neck Surgery, 56-61.
18. Schwartz M, Tardy ME: Standardized photodocumentation in facial plasty surgery. Facial Plast Surg 7:1-12, 1990.
19. Stern, K., Fournier, G., and LaRiviere, A. Psychiatric aspects of cosmetic surgery of the nose. Can. Med. Assoc. J. 76: 469, 1957.
20. Thomas S, Baird I, Frazier R: Toxic shock syndrome following submucous resection and rhinoplasty. JAMA 247:2402-2403, 1982.
21. Zimmerman G: Imaging Systems. Patient’s video guide. May, 1987.



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  1. Mobilization and repositioning of the lateral nasal bones to achieve the desired satisfactory position.
  2. Prevention of open roof deformity.


  1. Medial Osteotomies.
  2. Lateral Osteotomies.

Additional Osteotomies: This may be needed in crooked noses:

  1. Intermediate osteotomies.
  2. Transverse osteotomy.

Techniques: We use the following techniques:

  1. Medial Osteotomies
    1. The instrument used is Masing’s single guarded osteotome:
      Right curved, left curved and straight. (Fig. 17 – 4)
    2. Usually performed after hump removal or even without hump removal if needed to narrow the bony pyramid. (Fig. 17 – 18)
    3. Start with left single guarded Masing’s osteotome on the left side, push the osteotome between the upper lateral cartilage and nasal septum until it reaches the osteocartilagenous junction, try to be as close to the midline as you can. Start tapping and while the osteotome is moving cephalically guard it with your index finger and direct it towards the medial canthus curving laterally. This leaves a more natural root to the nose and avoids cribriform plate injury. Then repeat the same on the right side. (Figs. 7 – 1,2)
  2. Lateral Osteotomies
    1. Cottle’s two mm osteotome is used.
    2. The osteotomy is carried out via an external stab incision (Bull’s technique).
    3. Push the osteotome into the small stab incision and create a subperiosteal tunnel. The tunnel should be as close to the face as possible starting at the inferior border of the bony pyramid one millimeter above the face and moving up cephalically along the desirable path to meet the cephalic end of the medial osteotomy which has already been performed. (Figs. 7 – 1,2)
1. Medial Osteotomy
2. Lateral Osteotomy
Fig. 7 – 1. Outlining the sites for medial and lateral osteotomies.
Fig. 7 – 2
    1. Medial osteotomy: performed by right or left Masing’s single guarded osteotome.
  1. Lateral osteotomy performed, through a “nick” on the skin by Cottle’s two mm osteotome.


Fig. 7 – 3. (A) The main indication for transverse osteotomy is when deviation starts from the root of the nose.
Main indications of intermediate osteotomy are the spindle shaped, banana shaped and wide bulky lateral bony walls.
(B) Outstanding:

  1. Transverse osteotomy
  2. Medial osteotomy
  3. Intermediate osteotomy
  4. Lateral osteotomy


  1. The two mm osteotome should not penetrate the endosteum (periosteum of the medial wall of nasal bone). The surgeon knows this when the tone of tapping changes or from your experience. Stop at this endosteum otherwise the lateral nasal wall will collapse in and become depressed. (Fig. 7 – 4)
  2. It is essential that the lateral walls are completely mobile for accurate repositioning. The lateral nasal bones are put at the end of the procedure into a satisfactory desired position by careful manipulation with the thumb and index fingers. Bilateral incomplete mobilization leads to an open roof deformity and wide bony pyramid. Unilateral incomplete mobilization leads to the appearance of a crooked nose. (Fig. 17 – 18)
  1. Transverse Osteotomy
    1. One main indication is a crooked nose with deviation that starts from the root of the nose.
    2. Performed with two mm Cottle’s osteotome.
    3. The osteotome is pushed through the small tab incision at the nasion with the osteotomy then performed between the two cephalic ends of the medial osteotomies. (Fig. 7 – 3)
    4. This transverse osteotomy should be performed after medial and lateral osteotomies, if complete mobilization of the lateral wall was incomplete.
  2. Intermediate Osteotomy
    1. Main indications :
      • Crooked nose
      • Curved convex lateral nasal wall (Spindle shaped)
      • Banana shaped nasal wall
      • Wide nasal wall
    2. With the above mentioned indications if we only do medial and lateral osteotomies, we will only be moving the nose towards the midline and preserving the abnormal shape (banana, spindle). Therefore, intermediate osteotomy is essential to break the convex and concave surfaces of the nasal bones (break the banana or spindle shape), in order to achieve full mobilization and accurate repositioning of the nasal bones. (Fig. 7 – 3)
    3. Technique: It is performed in a similar manner to the lateral osteotomy but at a level between medial and lateral osteotomies, usually parallel to the lateral osteotomy or slightly curve obliquely inferiorly towards the face according to the desired path. (Fig. 17 – 18)
Fig. 7 – 4. A broad bony dorsum: Using a bone nippler, a gap is created in the midline at the junction of the nasal bones, then lateral osteotomies are considered to close the gap and narrow the dorsum.
Board bony dorsum
A gap is created in the midline
Narrowed dorsum The gap is closed by lateral osteotomies
Fig. 7 – 5. Correction of broad bony dorsum.


Bizrah Day Surgery Medical Center
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Umm Suqeim, Dubai, UAE.
T: +971 4 344 4688
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London, UK
Tel: +44 20 7224 2242


Residence in Saudi Arabia
can contact pioneer-cosmo in
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