Augmentation rhinoplasty

The target is better balance of the nose against the rest of the facial features, on the front and on the profile. Projection and length are the primary dimensions. Width still matters. A tip that is brought forward or lengthened without a matching change in the alar base can look heavier rather than more defined. Depending on the features of the nose, a reduction in the width of the nostrils — alar base reduction — may be included in the same sitting.

Typical changes that are planned together, rather than as isolated gestures:

• Height and definition of the bridge.

• Projection, length and definition of the tip.

• The relationship of the tip to the upper lip and to the smile.

• Width of the alar base when the nostrils would stay wide relative to the new framework.

The aim is a nose that reads as the patient’s, only better supported — not a borrowed profile line sitting on someone else’s midface.

It is for people whose nose is under-projected or short because the cartilaginous support never developed to match the rest of the face, or because injury or earlier surgery took that support away. Soft tip support, a low wide bridge and thicker tip skin often travel together; they do not have to.

It is also for secondary work. When the septum has already been harvested, or when previous reduction has left a short or collapsed framework, there is usually not enough reliable cartilage left inside the nose to rebuild with. Rib cartilage then becomes the structural material rather than an optional extra.

It is not a filler treatment. Injectable volume can trial a small change in the bridge for some patients; it does not create a stable tip framework, and it does not stretch skin in a controlled way. It is also not the same operation as reduction rhinoplasty. Taking a bump down and building a low bridge up are opposite mechanical problems, even when both are called nose reshaping.

A good nasal airway still has to be maintained. Building projection does not automatically improve breathing, and a poorly designed graft can narrow the internal valves. Function is part of the plan, not an afterthought.

When the nose is lengthened or projected, the skin envelope has to travel further than it did. Skin has memory. It tends to push the new framework back toward the old shape. If the support behind that skin is too soft — septum that is short, ear cartilage that flexes, or a leftover construct from previous surgery — the framework buckles and the gain is lost.

That is why we prefer rib cartilage for constructing the bridge and the tip. It is stiff enough to resist the recoil of the skin. The same stiffness is what the patient feels afterwards in the tip. In our practice we treat that firmness as an expected property of a stable result, not as a complication to be surprised by later.

Skin thickness works in the opposite direction from reduction work. Thick tip and nostril skin can mask definition even when the framework underneath is correct. Some thinning of the skin of the tip and the nostrils can be part of an open-tip operation when that thickness is getting in the way. Thin skin, by contrast, shows every irregularity in a graft. Neither extreme is a reason to abandon the operation; both change how far definition can honestly be promised.

We use rib cartilage as the material for the bridge and the tip. Two sources are available.

The patient’s own cartilage — autologous — is harvested at the same time as the nasal work. There is normally a scar that measures approximately 2.5 cm, placed in the crease under the breast for women, or slightly lower on the front of the chest for men. The donor site adds a period of chest-wall discomfort that the nose itself does not produce. That is the cost of using living cartilage from the same person.

Preserved donor cartilage — allograft — avoids a harvest scar and the extra recovery of the chest. It is still a structural graft, not an implant in the silicone sense, and it is still used to build a framework that can resist skin recoil. The choice between the two is made in consultation, against the amount of support required, previous surgery, and the patient’s preference about a second scar.

We do not treat silicone or porous polyethylene nasal implants as the default in this practice. Rib cartilage gives more flexibility when the tip as well as the bridge has to be defined, and it avoids the particular risks of an implant sitting under thin or previously operated skin — infection that is hard to clear, and extrusion through the skin.

The operation benefits from planning with computer simulation. Most of that planning is 2D simulation from standard photographs. 3D simulation is used when it helps to design the goals, test whether the skin envelope can accept the new dimensions, and set out a treatment protocol. A cone beam CT scan examination may also help, particularly when previous surgery or trauma has left the septum, the bones or the airway difficult to read from the outside.

A simulation is a planning tool. It is not a photograph of the outcome. Surgery cannot replicate a simulation. That caveat matters here as much as it does in reduction work, for the opposite reason: the skin is being asked to stretch over a larger framework, and how far it will drape, thin or recoil is individual.

The plan also has to be read against the chin and the midface. A low nose next to a small chin can look under-projected even after a well-judged graft. Chin enhancement is a separate page and a separate decision; it is often the right companion when the profile imbalance is shared.

In our practice this is an open-tip intervention. An incision across the columella, with the rest of the access hidden just inside the nostrils, lets the new framework be built where it can be seen and measured against the plan. That correlation between preoperative planning and what is actually constructed is the reason the open approach is the default here, not a closed one.

The columellar scar is small. It is still a scar. When alar base reduction is included there are additional fine scars in the crease at the base of the nostrils.

General anaesthetic. The procedure commonly lasts two to three hours, longer when the reconstruction is more extensive or when the patient’s own rib is harvested in the same sitting.

It is most of the time a day-case intervention. It can be an overnight stay. The potential benefit of an overnight stay in some patients is to allow a course of intravenous antibiotic treatment, to reduce the risk of infection after surgery when a sizeable cartilage graft is being used.

The sequence is built around the graft. The rib cartilage — autologous or donor — is shaped for the bridge and for the tip support. The existing framework is released enough to accept that construct. Where the nasal bones also need a change of width or of the radix, that work is done as part of the same operation; ultrasonic instrumentation is available in the practice for bone contouring, but the defining step of augmentation rhinoplasty is the structural graft, not the bone cut.

Alar base reduction is added when the nostrils would remain wide relative to the new tip and bridge. It is not a routine extra.

Consultation is where the indication is decided, not confirmed. Medical history and the current list of medicines matter. Blood-thinning medication and raised blood pressure both increase bleeding risk and have to be planned for before a date is set. Previous nasal surgery, previous injury, and any history of nasal infection or septal perforation belong in the same conversation — they change both the available cartilage and the infection risk of a new graft.

Bring a clear sense of which view is the problem: a profile that disappears into the face, a tip that lacks support on three-quarter view, a nose shortened by earlier surgery, or a front view in which the bridge and tip lack definition. Fees for the operation are discussed in consultation rather than published as a single figure, because the source of the cartilage, the need for overnight antibiotics, and any companion procedure change the work.

A cast and sutures come off at one week, as they do after other forms of rhinoplasty. If the patient’s own rib has been harvested, the chest scar is managed at the same time; discomfort at the donor site is usually more noticeable than the nose in the first days.

Recovery is usually:

• 1 week for working from home.

• After cast removal and suture removal, 2 weeks for work in an office.

• 3 weeks for return to gentle exercise.

• Return to normal-intensity exercise typically at 5 to 6 weeks.

Glasses are kept off the bridge for about a month; contact lenses are safe from the start. Sleep on the back so side-lying does not put tension on a newly built framework. Early breathing through the nose is often tighter, as it is with a cold — usually swelling of the lining rather than a structural blockage. Saline rinses are part of the usual aftercare.

The tip will feel firmer than the rest of the nose. That firmness is expected to persist. Swelling of the tip and of the junction between the side walls and the cheeks takes longer to settle than the first week of social recovery implies; the main change is visible early, the last refinement is not.

Augmentation rhinoplasty carries the risks of any operation under general anaesthetic, and some that belong specifically to a grafted nose:

• Anaesthetic risk, bleeding, infection, pain and visible scars — the columellar scar of an open approach, the fine scars of an alar base reduction when that is included, and the 2.5 cm chest scar when the patient’s own rib is harvested.

• Infection around a graft. This is why some patients stay overnight for intravenous antibiotics. Infection remains possible even with that precaution, and can threaten the graft.

• Donor-site problems when autologous rib is used — pain, a visible scar, contour irregularity of the chest wall, and, uncommonly, issues related to the chest cavity itself. These do not apply when preserved donor cartilage is used.

• Persistent firmness of the nasal tip. This is an expected property of a rib-supported tip, not a short-lived stiffness of healing.

• Warping or irregularity of the graft, more visible under thin skin.

• Reduced sensation in the tip, expected for some months after an open approach, and occasionally longer in small areas.

• Airway restriction. Temporary tightness is common. A graft that narrows the internal valves, or lingering swelling, can leave a more lasting change and may need further treatment.

• Asymmetry, under-correction or over-correction. The two sides of a nose are not the same to start with, and skin recoil is not perfectly symmetrical.

• A result limited by skin thickness or by how far the skin envelope will stretch.

• The need for further surgery. Revision after rhinoplasty is a recognised possibility, for small irregularities or for a more substantial change. Secondary work is already one of the settings in which this operation is used.

• Deep vein thrombosis, uncommon in day-case facial surgery, and reduced by early mobilisation.

Blood-thinning medication and raised blood pressure both increase bleeding risk and have to be planned for before a date is set.