Dr Mohammad Hassan Ameri, otorhinolaryngologist

On a daily basis many people exercise different cosmetic surgeries to find further self-reliance and to get further pleasure from their lives. The subsequent information is presented only for your acquaintance. It is obvious that I can advise you for additional details about this surgery and also its efficacy. Amongst other cosmetic surgeries, nose plastic surgery, so called Rhinoplasty, enjoys special characteristics, so I try to discuss this surgery specifically. This operation needs something more than surgery skill and in fact it is a combination of knowledge and art. Before anything else, a Rhinoplasty surgeon is a physician who understands all the medical and psychological factors which direct a healthy individual to refer willingly to a doctor for performing an operation; meanwhile the doctor acts as a sculptor similar to Michelangelo. Michelangelo had a piece of stone in which his work was being emerged through his insight eye. He put his work into perspective through carving extra parts of the stone. Considering the appropriate form of a nose for every special face, a cosmetic surgeon puts his artistic work into perspective by removing extra parts and forming the rest parts. It is obvious that a professional plastic surgeon never considers a nose as a single entity but nose and other parts of a face are imagined collectively. In other words, it is impractical to design a beautiful nose just via taking into consideration an ideal nose but the best nose stands in a harmonic form with the other components of a face. There are many unrealistic imaginations and expectations about Rhinoplasty. Sometimes, it is not possible to change human tissues to achieve a desired figure that the patient demands for. A surgeon tries to beautify further semblance of a patient through some well-planned operations. Achievement of this result highly depends on his/her educations, experience, knowledge and skills which are all the variable factors. Cooperation of patient as well as undesired reactions play fundamental role to obtain the final result. A surgeon cannot guarantee achievement of an ideal result at the end of the operation; however, he/she can assure patients about his/her utmost efforts to achieve a better result. Every Rhinoplasty applicant must be informed about the following facts:

1. The aim of each cosmetic surgery is to improve the appearance, not to achieve an absolute and perfect concinnity.
2. Anyone who is the volunteer of such operation may not be a good candidate for cosmetic surgery due to various reasons including the type of her skin; therefore the operation is not recommended to all the volunteers. For example, the surgeon is not so much free to slim down the tip of fat noses. Fat nose is referred to the type of nose which has thick skin and weak cartilages at its tip. There are numerous sebaceous glands in fat noses and distribution of the mentioned glands amidst the skin makes it thick. Surgeon is able to change the skin type during cosmetic surgery and to focus on nose cartilage and bone. Thus, nasal tip of fat noses is not slimed down drastically after operation and the patient may be unsatisfied about the shape of his nasal tip after the surgery. While analyzing all aspects, the physician will explain about patient’s skin condition, if necessary. It is worthy to say that, most people who suffer from a large nasal tip think that their nose is categorized as a fat nose, while as it was explained earlier there are two possible cases for a big nasal tip: if big nasal tip is developed because of skin thickness of the nose, the surgeon is faced with the mentioned limitations but if it is due to large cartilages of nose tip, it is not categorized a fat nose and there is not any problem for operation; so, you can refer to my office for close examination if you are not sure about the type of your nose skin and cartilage.
3. There are certain limitations for children which prevent Rhinoplasty prior to complete puberty. Typically, girls and boys will be mature at the end of 16 and 18 years of age respectively and they can conduct Rhinoplasty. Refining nose defects in these ages enhances self-reliance of adolescents in a golden period of their lives and it should not be forgotten that an adolescent not only recognizes himself/herself in this age but he/she will establish his/her future. On the other hand, at the current time a great number of Rhinoplasty volunteers are over 40 years of age. Most of them complains about the form of their noses during their lifetime and have decided to reshape their noses by Rhinoplasty. Never is late to commence to achieve a more beautiful nose if you intend to enjoy a good body condition and health. In such a case, Rhinoplasty is performed simultaneously along with other facial cosmetic surgeries e.g. face lift etc.
4. Nasal septal deviation should be improved either during plastic surgery or before it; septum is the wall that divides your nose down the middle, into right and left sides. Its location at the middle line is ideal but actually the septum of many people is deviated to left or right side which is called deviation of nasal septum or septal deviation. Performing operation is unnecessary if this deviation is minute and has not blocked the air duct and potential disorders; however, for acute cases it should be improved through septoplasty. It should be mentioned that, the people who intend to perform Rhinoplasty and suffer from nasal septum deviation (though trivial) must refine this abnormality at first because after Rhinoplasty the nostrils will become narrower, thus slight deviation of nasal septum which might be harmless prior to Rhinoplasty can block the air duct after the surgery. Hence, in order to avoid subsequent nasal obstructions, septal deviation should be improved during Rhinoplasty through septoplasty.
5. Several causes including enlarged turbinates and/or nasal polyps may result in nasal obstruction which should be fitted during Rhinoplasty.
6. Laser plays a very important role in many surgeries but it is useless in Rhinoplasty and only may be used instead of scalpel to make initial incisions. You cannot find any preferences for laser-based incision over scalpel in terms of post-operation pains or results and/or suture marks, etc.
7. There is a mutual interaction between facial components and nasal form. Particularly, chin condition of an individual affects his nose appearance in others’ view. Naturally, when we look at a person from a profile angle his chin is seen a bit posterior than anterior side of underlip, but for some people the chin trespasses the normal limit and is seen so farther than normal form. In such cases, the patient takes bird-face form in which both nose and middle half of the face are very anterior than other components of the face. In such people, not only chin is posterior than the normal form, but their posterior chin increases the size of nose than its real size. In contrast, the chin of people with very large nose is seen posterior than the real form. Therefore, nose condition must be evaluated in companion with other components of the face. Although chin prosthesis may be used solely to bring the chin forward, mostly it is conducted simultaneously along with Rhinoplasty and it brings about a condition in which each surgery doubles the effects of other surgery.
8. Rhinoplasty neither improves nor deteriorates nasal allergic symptoms. People who suffer from nasal allergies may decide to perform surgery, but they should not use anti-allergic medicines for sometime before and after the operation.
9. Rhinoplasty does not affect the vision and eye-form; however, since wearing glasses after operation is impossible for sometime it is recommended to perform laser-assisted in situ keratomileusis (LASIK) before Rhinoplasty. Consultation with an ophthalmologist is highly recommended in such cases.
10. Orthodontic plates are not impediments for Rhinoplasty and they will be harmless.
11. Since halothane and other inhaled anesthetic gases are not used anymore in private surgery centers and new anesthetic drugs are free from (or have very slight) side effects, therefore if you are experiencing an anesthesia recently it is not necessary to wait for counteraction of the effects of your previous anesthesia.
12. Surgery commission varies from city to city and even from a district to district of the same city and from a surgeon to another surgeon. Although the cost of surgery is important factor to select a surgeon, the patients are successful whose factors to select a surgeon are based upon efficiency, experience and knowledge of the surgeon. Typically, the surgeons specify operation costs based on the shape and type of nose and the work which should be done on it, but aside from the shape and type of nose I consider an equal price for all Rhinoplasty; so you can call my office (+98-21-22583291) in order to obtain more information about the surgery and hospital costs.
13. There are two “open” and “closed” techniques for Rhinoplasty. Some surgeons prefer closed and other use open technique. However, generally open technique users are increasing. Application of open or closed technique has no privilege for the patient and even surgeon; here the only important issue is the result of surgery. There are cases in which most surgeons prefer open option including re-operation, operation of nose which has been deformed due to a trauma and Rhinoplasty along with septoplasty. The only difference between open and closed techniques is that for open technique a small incision is made on columella skin besides an incision line which is made in closed technique. The columella is the portion of your nose between your nostrils which is placed lower than nose blades. You can find the locus of the incision which is marked with a marker in the above figure. This incision enables surgeon to pick up nose skin and to examine precisely all the main structures of nose including bone section, cartilage section and soft tissue, therefore the operation is conducted under direct vision. Fused place of sutures is not apparent and you should not worry about it. The point which must be outlined here is that fusing nose blades is not related to open or closed technique but depends on the size of nostrils and blades, i.e. if nostrils are large and should be extenuated and narrower, there is no way except fusing blades even the surgery is conducted as closed technique.
    Advantages of Closed Technique:
    • Closed operation can be wrapped up almost 15 minutes sooner than open technique.
    • There is not any incision on columella skin.
    • Swelling of nose tip is smaller than that of open technique; so it will be recovered sooner.
    Advantages of Open Technique:
    • Surgery is conducted under direct vision, so the possibility of asymmetry is minimized;
    • There is more space for maneuver and working.

    

14. Various abnormalities of nose may be fitted by Rhinoplasty, for instance:
    • Big size of nose
    • Nose aquiline
    • Nasal tip drooping or short angle between nose and lip
    • Flat nose
    • Large nostrils
    • Wavy nose
    • Large distance between nose tip and face
    • Displaced nose blade and asymmetric nose
    • Two-branched nose tip
    • Saddle nose subsequent to prior traumas and/or deformation of nose blade
    • Deformities after operation
15. Your operation site will be Erfan Hospital or one of the surgery centers of Northern part of Tehran.
16. The emergence of different computer-based software has drastically changed our life. Fortunately, medical sciences have enjoyed such technologies as well. Computer design of nose, before operation, is an optimum example of these achievements. Such a design prepares an opportunity to take a realistic image of nose after operation; on the other hand, they enable surgeon to get acquaintance with expectations of the patients and inform them about feasible or unfeasible nature of the expectations. It may be a question that how far a computerized image may be close to the reality? In simple words; will operation result be similar to the designed image? Some factors must be considered to answer these questions:
    1. Before designing, your nose (particularly internal sides) should be examined by the physician.
    2. If designing is conducted by the surgeon, then more similarity will be achieved after operation because the surgeon is not only the individual who tries to generate a better image from a picture by using software, but also he/she is the specialist who will consider the limitations during designing.
    3. The more advanced software is used, the more realistic image will be gained. We expect a kind of software which is capable to present a 3D image from nose and face but the current software are applicable only on 2D photographs. Thus, if the patient is willing to observe his/her nose before the surgery, a photograph is taken by digital camera from his/her profile during preliminary consultation, and then its abnormalities are improved by the computer.
    4. Despite the abovementioned condition, it cannot be claimed that the nose will be exactly as the same as the photograph after operation, but their similarity will be considerable.

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Practical Stages to Rhinoplasty

Your nose will be examined in terms of appearance and state of the septum, nasal turbinates during the preliminary visit and I will be informed regarding your requirements and expectations so I can offer feasible operations in turn and you will be informed about your impossible expectations. If you want, a photograph will be taken from your nose with a digital camera and then you can observe your nose after operation by using computer-based design. Finally a photograph will be requested which should be taken by other photographer. Blood test may be prescribed for you, if necessary. After taking the photos, you can inform me personally or by telephone about your readiness for operation, then a time for operation will be set according to a mutual agreement. While fasting, you will attend the surgery center one hour before operation in the predetermined date. Surgery will take about 1.5 hours. 15 minutes before operation and 15 minutes after surgery you will be cared directly by my assistants and after that you will be cared for 30 minutes in recovery state. Consequently, you will enter operating theatre until returning to the general ward and it takes about 2.5 hours. In terms of anesthesia method, your opinion will be obtained as far as it is possible. General anesthesia and semi-conscious sedation have their own advantages and disadvantages. However, according to my experiences, general anesthesia is preferred to semi-conscious sedation because we can better control the blood pressure of patient, patient feels better, anesthesiologist cares the patient better and easier and secretions are not secreted into throat and lung during operation, so the surgeon can perform better his operation and finally lower coughs are seen in anesthesia cases. Of course, semi-conscious sedation is preferred to general anesthesia in some cases, for example for patients who suffer from special diseases such as cardiovascular disorders or diseases which are deteriorated by general anesthesia or people who are anxious about general anesthesia. In these cases, the anesthesiologist takes care of the patient all the time and provides a pain-free operation through giving analgesic, sedative and sleeping mediations. About six hours after returning to the general ward, you will be allowed to go. However, you can stay in the center until the day after operation if you wish so; it is free for you.”

1. You should not drink or eat anything up to 5 hours after the operation, because the movements of your intestine and stomach are very slow and if you eat anything it will result in nausea and vomit. About 5 hours after the operation, drink a bit of water and if you have not any problem continue to drink fruit juice after 15 minutes and then you can start eating soft foods and at the third day of the operation you will be allowed to eat everything.
2. Using cold compress up to 24 hours is necessary. When you stay in surgery center, our caregiver will perform this task. When you are back to your home, squash some pieces of ice and then pour them in a freezer pack then put it on your face and cheeks. It minimizes swelling and bruise on your face.
3. Excessive lying down will result in swelling of your nose, so try to lie down normally.
4. At third day, you can perform light chores of house, administrative works and work with PC etc.
5. After operation, I will not put tampon in your nose, therefore you will not feel any pain or discomfort, but if you feel pain for any reason including relevant or irrelevant pains, ordinary acetaminophen or codeine acetaminophen, as sedatives, will be prescribed. Avoid using other sedatives such as Brufen, Indomethacin, and Aspirin etc.
6. Pain, bruising and bleeding after operation depend on various post-operation factors. The patients who are operated by me will not experience bleeding after operation, they usually have no pain and if they have it is very little and it can be improved by acetaminophen. Some bruising may be seen during the first and second days but it will be improved up to sixth day, the day when plaster cast of nose will be removed.
7. Small gauze is placed beneath your nose after operation, so any serum of your nose will be absorbed by this gauze. It is better to fix this dressing and avoid any displacement.
8. Whenever your plaster cast is not removed you should wear open front dresses in order to avoid wearing clothes by your head.
9. You can wear glasses whenever your nose is protected by plaster, but after removing it using glasses is forbidden for you for 6 weeks unless its weight is not felt by your nose directly, so you may use a certain adhesive to adhere the middle of glasses to your forehead (you will be trained about this process, if necessary).
10. Six days after the operation you have to come to my office in order to take off your nose cast so called “medical plaster”. During this period, you should protect your nose dressing against moisture and water; so, during taking bath use a hand shower to wash your neck and lower limbs then lie down flat-wise to allow another person to wash your hair without letting the dressing become wet.
11. You will come to my office about every five days to replace the adhesive up to six weeks after taking off the medical plaster. However, if you don’t live in Tehran or cannot come to my office every 5 days for any reason, you will be trained to replace the adhesive.
12. Swimming or any other struggling activities are forbidden for two weeks. Sports with high possibility of crash should not be exercised for 4 months.

No 450,Between Ekhtiarie&Dibaji,Kolahdooz (Dowlat)St,Pasdaran Cross,Tehran