Rhinoplasty

Rhinoplasty has become a very powerful and detailed procedure compared to what it was 15 years ago. There is a wide array of surgical techniques available now, which can alter many unfavorable features of a nose with natural and durable results. The following is a list of problems for which patients commonly seek rhinoplasty:

Nasal deformities that can be corrected with rhinoplasty

• Bulbous tip
• Asymmetric tip
• Upturned nose
• Droopy nose
• Crooked nose
• Deviated septum
• Broken nose
• Low bridge
• High bridge
• Dorsal hump
• Narrow nose
• Wide nose
• Wide or flaring nostrils
• Hanging columella
• Nostril collapse (nasal valve problems)

During your initial consultation, Dr. Demirkan will first ask what you do not like about your nose, then add his suggestions regarding your specific facial proportions. Next, he will work with you on your simulation to understand what you desire and whether it fits your face and physical properties. There may be features that cannot be changed but still affect the outcome, such as the thickness of your skin.

As a surgeon with tremendous experience in rhinoplasty, Dr. Demirkan will understand all of your concerns, tell you about any drawbacks present, and establish a realistic surgical plan that aims to achieve your aesthetic goals while maintaining a natural appearance.

There are a few features in your nose that may not be altered with current surgical techniques. Having knowledge about these features is important in setting your goals and understanding what the possible outcome will be.

Rhinoplasty is the oldest type of aesthetic surgery, with a centuries-old history of continuous change and evolution in the surgical techniques used.

Based on the incision site

Based on the surgical philosophy

Based on the area of focus

Tip rhinoplasty focuses on enhancing the appearance of the nasal tip — a more refined, balanced tip shape without interfering with the nasal bones, dorsum, hump or septum.

Septoplasty corrects a deviated septum that can cause breathing difficulties, congestion, recurrent sinus infections and nasal blockage. The deviated portion is straightened, reshaped or removed to improve airflow, without changing the external nose.

Septorhinoplasty is needed when the septal deviation is reflected externally as a deviation in the axis of the nose, so a rhinoplasty is added to correct the deviated nasal bones and asymmetric soft tissues.

Based on the number of previous surgeries

1. 1°

   Primary Rhinoplasty

   The first-time nasal reshaping surgery on a patient with no previous nose surgery.

2. 2°

   Secondary (Revision) Rhinoplasty

   A corrective procedure after a previous rhinoplasty, working with altered anatomy and scar tissue and often requiring cartilage grafting.

3. 3°

   Tertiary Rhinoplasty

   Follows a previous revision and is much more complex, with more limited success.

Non-Surgical Rhinoplasty

Non-surgical rhinoplasty (liquid rhinoplasty) alters the shape of the nose with injectable fillers instead of incisions. It is quick and minimally invasive but useful only in a small group of selected patients with suitable anatomy, to:

• Correct small bumps or irregularities on the bridge
• Enhance the projection of the nasal tip
• Give a lifted appearance to a drooping tip
• Reduce the appearance of a prominent bridge

A filler injection always adds volume, so a successful result is an illusion rather than a real reduction. It does not correct functional problems, the hyaluronic acid eventually disappears, and the nose is one of the facial danger zones where inadvertent intra-arterial injection can cause serious complications.

Male rhinoplasty can differ from female rhinoplasty in terms of facial evaluation and planning, to protect the masculine look. For men, a more masculine appearance is typically sought, which may be obtained by:

• Maintaining a straighter nasal bridge without a prominent supra-tip break-point
• A higher-located nasofrontal angle between the brows
• A stronger nasal profile, preserving a slightly wider bridge and adequate nasal width
• A less projected or refined nasal tip
• Chin and/or mandibular angle augmentation with implants if necessary

Female rhinoplasty, on the other hand, often aims for a softer, more feminine nose, with a slightly curved or sloped bridge and a more delicate, defined tip. There is no standard nasal shape for men, and the operation may be planned just to elevate a drooping tip while maintaining the hump, or to make the nose a bit smaller without changing the shape at all.

If a smaller nose is desired, it should be balanced with the other stronger anatomical features of the male face, such as prominent cheek and jaw bones, low-set eyebrows and a prominent chin. In a face that does not have these strong features, a smaller, finely defined nose may cause feminization. While there are key differences in the desired outcomes, the overall principles and surgical techniques apply to both men and women.

Simulation plays a valuable role in rhinoplasty by providing a preoperative visualization of potential outcomes and aiding in surgical planning. Dr. Demirkan likes to communicate with you visually over your computer-generated simulation, to help you understand what can be achieved, express what you really want, and understand what to expect.

A simulation should never be seen as a guaranteed post-operative result; it is a visual draft over which the physician and patient discuss an operative plan. A well-done simulation may have an 85 to 90% resemblance to the real late result. The simulation also lets Dr. Demirkan evaluate the proposed changes in the context of your overall facial harmony — alongside your cheekbones, upper lip and chin — and discuss any additional corrections.

Rhinoplasty is an aesthetic procedure aiming to improve nasal shape. However, the nose has an important role in breathing, and conditions deteriorating that function — septal deviation, allergic polyps or sinusitis — are not rare in people seeking aesthetic improvement. Performing aesthetic surgery without attention to these functional problems may worsen your breathing.

Dr. Demirkan will take a detailed history of any breathing problems during your initial consultation, and may order tests or ask for a consultation from his ear-nose-throat surgeon partner. After identifying the exact cause(s), he creates an individual treatment plan covering both your aesthetic and functional issues — which may be a one-session surgery, or surgery preceded or followed by medical treatment.

Examples of treatment plans for breathing problems

• A septum deviation only — a septoplasty is performed during your aesthetic rhinoplasty.
• Internal or external valve insufficiency — treated with cartilage grafts during your rhinoplasty.
• Concha bullosa (a bony cystic malformation of a turbinate) — an ENT surgeon performs a turbinate reduction in the same session.
• Sinusitis — an ENT surgeon joins to perform endoscopic sinus surgery.
• Advanced allergic rhinitis with polyps — about 6 weeks of medical treatment before surgery, continued afterwards.
• Mild allergic rhinitis — surgery proceeds with anti-allergic medication continued afterwards.

Chin augmentation or reduction can be performed in conjunction with rhinoplasty to achieve facial balance and harmony. There is a close relationship between our perception of facial beauty and the chin-nose proportion. A large or protruding nose may make a moderately projecting chin appear smaller, while a small nose might make a weak chin seem even weaker.

A simple rule to understand whether your chin is in balance with your nose is to look at the relative position of the nasal tip, lips and chin. On an oblique line in front of the face, the nasal tip should touch first, then the upper lip, then the lower lip, and finally the chin. If your chin is well behind this alignment you may need augmentation; if it touches the line together with the nasal tip, it may need to be set back.

Chin Augmentation

The treatment for a weak chin is an augmentation genioplasty, usually by inserting a bone-like synthetic implant at the tip of the chin through a small incision under the lower teeth. Hyaluronic acid fillers are another option, but their effect is limited compared with a solid implant.

Chin Reduction

A prominent chin may be treated by a setback genioplasty, in which the bony chin tip is cut horizontally, set backward and fixed with a plate; smaller problems may be solved by bone shaving with piezo devices. When a chin is treated surgically, it is important to rule out any associated dental occlusion problems first.

Piezo devices have revolutionized rhinoplasty by offering precise, controlled bone sculpting. They use ultrasonic vibrations to cut bone while minimizing trauma to surrounding tissues — a huge difference from the chisel-and-hammer bone fracturing of old times.

The impact of piezo devices can be significant

• Enhanced precision in bone cutting and shaping, leading to better results with fewer complications.
• Minimal trauma to surrounding tissues during osteotomy, as the energy is selectively targeted to bone.
• Less edema and bruising after surgery due to reduced fracture trauma.
• The ability to perform moves not possible before the piezo era, such as multiple bone cuts, narrowing and polishing.

The impact ultimately depends on the surgeon's skill and ability to combine the technology with other techniques. Dr. Demirkan has used piezo successfully in all of his cases since 2016. Microsaw (oscillating saw / micro-motor) devices are another advancement with similar benefits, but slightly less precise and not bone-selective; Dr. Demirkan used them between 2010 and 2016 but now prefers piezo.

Preparing for a rhinoplasty involves several important steps to ensure a smooth and successful procedure. Here are some general guidelines:

• Arrange a live online consultation with Dr. Demirkan; beforehand, send your full medical history, goals, any breathing problems and facial photos. A simulation is prepared before your consultation.
• Depending on the consultation, some tests or radiologic examinations — and possibly an ENT consultation — may be requested.
• Quit smoking at least 15 days before surgery, as it increases the risk of complications and impairs healing.
• Stop blood-thinning medicines and supplements (aspirin and derivatives, coumadin, heparin, Vitamin E, DHA, ginseng) 1-2 weeks before, as advised.
• Use anti-allergic sprays or medications beforehand if indicated.
• Replace glasses with contact lenses — glasses are not allowed for the first 6 weeks due to the weight on the healing nasal bones.
• Arrive in Istanbul 1-2 days before surgery to acclimatize; blood tests and an anesthesiology consultation are done at the hospital.
• Plan to stay at least 6 more nights in Istanbul after surgery (1 night at the hospital). A companion is optional but supportive.

The postoperative period is a crucial time for healing and achieving the desired result. Compliance with medication, nasal cleaning, keeping the cast safe, tuning activity to your recovery pace, sun protection, the prescribed massages and protecting your nose from trauma all have significant effects on the final result.

The reaction to the operation is quite variable between patients. With piezo devices, collateral tissue damage during osteotomies is much lower, reflected in less edema and bruising. Drainage at the osteotomy sites, silicone nasal stents with airways and effective cooling devices also help reduce edema and bruising.

Immediate and early recovery period

• You are monitored in recovery until the anesthesia wears off; nasal breathing may be difficult due to internal splints, which can create a pressure sensation.
• Internal splints are usually removed on the 3rd day; the nasal cast is replaced or removed on the 7th day.
• Swelling, bruising and congestion are common in the first days — frequent cold packs to the nose and eyes are the best precaution; keep your head elevated and avoid straining.
• Pain is usually mild and mainly due to packing pressure; effective pain medication and a prophylactic antibiotic are prescribed.
• Follow the medication regimen strictly, and clean the nose with saline sprays as shown after the packing is removed.

Late recovery period

• Nasal edema reduces gradually but usually takes at least 2-3 months to reach the optimal phase; thicker skin takes longer.
• The nose is not structurally stable until 6 weeks after surgery — protect it from trauma, avoid glasses and do not sleep on your side or front during this period.
• The nose may be numb for about 6 months, which can increase the chance of accidental trauma.
• Avoid bending over, heavy lifting and strenuous exercise for the first 6 weeks.
• Use effective sunscreen from day 1 to 6 weeks to prevent post-inflammatory hyperpigmentation.
• The final shape appears around the third month, but changes continue more slowly until the end of the first year — so it is best to wait a year to judge the final result.

Rhinoplasty is generally considered a safe procedure with a low risk of complications. As with any surgery, there are potential risks, and their likelihood varies with the complexity of the surgery, the surgeon's expertise, the number of revisions and individual patient characteristics.

The informed consent form lists all possible complications, but it does not mean each will occur in your case with equal probability. When you arrive in Istanbul, Dr. Demirkan will tell you which, if any, are more likely after examining you, and explain the variables affecting your surgery so your expectations are realistic.

If you have an external nasal deviation from childhood, thick nasal skin, or this is not your first rhinoplasty, you have a higher postoperative complication risk.