What gives the nose its shape?
The shape of your nose comes from the shape of the bone and cartilage (gristle) inside, and the thickness of the skin covering them. The nasal bones make up the hard top part of the nose, which is shaped like a roof. The middle and tip of the nose are made of cartilage, which is softer.
The nasal septum is the thin piece of cartilage and bone between your two nostrils. It is usually straight, but in some patients, the nasal bones and septum may be bent or twisted. This can happen after an injury, which may have taken place in childhood. The injury may have broken the nasal bones and septum and moved them. The top, bony part of your nose may be pushed out of shape. This makes the inside of your nose narrow, and you may feel your nose is blocked.
Bent nasal septum and nasal bones, blocking the nose, mainly on the right side of the patient.
What is a septorhinoplasty?
A septorhinoplasty is an operation where the nasal septum is straightened, and the outside parts of the nose are moved to make it look more symmetrical.
Do I need a septorhinoplasty?
If you have a blocked nose because of a bend in the nasal bones and septum, an operation may help. This is called a septoplasty.
In some cases, a bent septum may be very severe or may cause a twist in the outside shape of the nose. In these cases, surgery on the nasal septum and nasal bones will straighten the inside and outside of the nose. This is a septorhinoplasty.
Are there other treatments I could have?
The only way to put the nasal bones and septum back into the right position is with an operation. But a nose which is out of shape and a bent septum will not do you any harm. You can leave it alone if you want to. It is your decision whether you want further treatment.
Nasal steroid spray or drops can help reduce swelling inside the nose, which might improve your nasal blockage symptoms. This will need to be an ongoing, long-term treatment.
You can change your mind about the operation at any time. Signing a consent form does not mean that you have to have the operation.
If you would like a second opinion about the treatment, you can ask your specialist, who will not mind arranging this for you. You may wish to ask your own GP to arrange a second opinion with another specialist.
Do I need any tests?
You do not need an x-ray before the operation. Your surgeon may prefer that you have a CT scan. A photograph of your nose will be taken before the operation. You and your specialist will discuss the shape of your nose before the operation and will agree on what the surgery can realistically achieve.
What happens in the operation?
The surgery is performed while you are asleep under a general anaesthetic. It can take between two and five hours.
This operation can be carried out through small cuts made inside the nose (closed septorhinoplasty), or through a small cut on the outside skin on the bottom part of the nose, between the nostrils (open septorhinoplasty). The surgeon will straighten the septum and move it back into the centre of the nose. Bumps and dips on the top of the nose can be smoothed out and, if the nose has been broken and is bent to one side, it can be straightened out again.
The cuts inside the nose will be closed with dissolvable stitches that do not need to be removed. You might have some non-dissolvable stitches in the skin on the bottom part of the nose that will need to be taken out after seven days in the clinic.
The surgeon may make tiny cuts between the cheek and the nose on either side and on either side at the top of the nose. These cuts are only millimetres long. Because they are so small, they do not need stitches, heal very quickly, and leave hardly any scar.
Sometimes additional cartilage from the ear or even from the rib cage may be needed to help build up your nose. This will be discussed with you in the clinic before the operation.
We may need to pack your nose with some dressing to stop any bleeding and to support the broken bone. These will block your nose, so you will have to breathe through your mouth until they are removed. This will happen a few hours after the operation, or possibly the next day. The process can be a bit uncomfortable, but it does not take long. There will be a bit of bleeding after the dressing is removed, but this usually stops very quickly. In some cases, dressings that dissolve by themselves in the nose may be used. These do not need to be removed.
We usually put a small metal or plastic splint on the outside of your nose. This stops the bones from moving out of their new position while you heal.
You may need to have a small piece of plastic (called an internal splint) put inside the nose to prevent the septum from moving out of its new position while you heal. This also stops scar tissue from forming inside the nose. An internal splint is usually taken out in the clinic a week or two after the operation. This can be a bit uncomfortable but is over very quickly.
What happens after the operation?
After the operation, you will be taken to the theatre recovery area. When your anaesthetic has worn off, you will be taken back to the day surgery unit if your surgery is planned as a day case, or to the ward if you are staying overnight.
Like any operation, you may feel a bit sick afterwards, but this tends to pass quickly. You will be given anti-sickness medication if you need it. You should eat and drink once your anaesthetic has worn off and you are no longer feeling sick.
Your nose may feel a bit uncomfortable. This should be eased by the pain medication you are given. You can ask for more pain medication if you are still in pain.
You will have bruising around the eyes or black eyes for a few days after the operation. This usually settles down after a week.
Your face and nose will be swollen after the operation. Most of the swelling stops within a few weeks, but it can take up to three months for your nose to settle down and your breathing to be clearer again. Try to stay away from dust or smoky places. There will be some dissolvable stitches inside your nose, which usually fall out by themselves.
Are there any complications to this operation?
All operations involve some risks, but most patients who have a septorhinoplasty recover well.
The complications and risks of any surgery are grouped into the following categories:
Discomfort in the nose
Your nose is expected be a little sore after the operation, but this can be helped by taking simple painkillers. You will be given regular pain relief medication. Please ask for more if you need them.
Bruising on the face
It is common to have swelling and bruising around the eyes after the operation. This will fade in a few days.
A blocked nose
Your nose will feel blocked after the operation. This is because of swelling and the dissolvable packing (if used). You will have to breathe mainly through your mouth, which will make your mouth feel dry. Drinking water will help to keep it moist.
It is normal for your nose to bleed after septorhinoplasty. Most of this will be old blood from your operation, but there may be some fresh bleeding as well. When you go home, you will be given instructions or a leaflet on what to do if you get a nosebleed.
Take it easy at home. Do not blow your nose until the splints inside and outside your nose are removed. If you sneeze, try to sneeze through your mouth. Do not do anything too energetic during the first few days in case this makes your nose bleed. In rare cases, patients have bleeding strong enough they must come back to the hospital. If this happens, we may need to pack your nose with dressings to stop the bleeding.
You might develop a collection of blood under the lining of the septum called a ‘septal haematoma’, but this is rare. If you do have a haematoma, you may have to return to the operating theatre to have it drained as soon as soon as possible. This would be done under general anaesthetic.
[illustration coming soon]
Figure 2. Septal haematoma
Infections in your nose are rare after this operation, but if your nose does become infected, it can be serious. You should see a doctor if your nose gets more and more blocked or is red and painful. It may be a sign of a septal haematoma or a ‘septal abscess’, where the blood is infected and pus collects.
An infection will need to be treated with antibiotics. If you have a septal abscess, you may need another general anaesthetic while it is drained. This should happen as soon as possible.
A hole in the septum
You may develop a hole in your septum going from one side of your nose to the other. This is rare. It may happen if you have an untreated septal haematoma or septal abscess.
A hole in the septum can cause a whistling noise when you breathe, blockage in the nose, or nose bleeds. Most of the time it causes no problems at all and needs no treatment. If needed, further surgery can be carried out to repair a hole in the septum.
[illustration coming soon]
Figure 3. Septal perforation
Need for further treatment
Sometimes the nasal septum can’t be completely straightened, or it can bend again after surgery, causing further blockage. This can happen in one out of ten cases. It can happen if you bump your nose soon after surgery, while playing a sport, for example.
Sometimes you can get scarring inside the nose, or parts of the inside of the nose sticking together, which causes more nasal blockage. In this case, you might need further treatment or surgery.
Realistic expectations will be discussed with you before the operation. It is not always possible to fully correct a nasal deformity. It is usually possible to achieve some improvement, however. Between five and ten people out of 100 need more surgery to adjust the shape of the nose.
Numbness of upper teeth and lips
You may have some numbness on the tip of your nose, your upper teeth, or your lips. This usually settles down with time.
In rare cases, permanent discolouration can occur around the eyes.
The operation is usually performed under a general anaesthetic. Complications include blood clots in the legs (deep vein thrombosis) or lungs (pulmonary embolism), heart attack, chest infection, stroke, and death. The pre-assessment team and anaesthetist will explain to you what happens during a general anaesthetic and any risks that are relevant to you. The document linked explains the common events and risks of a general anaesthetic.
When can I go home?
Some septorhinoplasty operations are carried out as a day case. This means you will be able to go home on the same day as your operation, a couple of hours after the general anaesthetic has worn off, as long as you feel well enough. In some cases, you will be required to stay in hospital for one night.
The splint on the outside of your nose should stay in place for a week or two. The doctor will remove this when you go to the clinic. If the splint falls off before your appointment you should contact the department to have it replaced.
You will be given pain medication when you leave hospital. You may also be given a course of antibiotics. Most patients who have had a septorhinoplasty will be given nasal cream to apply to both nostrils and the wound on the outside of the nose.
How long will I be off work?
You should take two weeks off work to recover from this procedure, especially if you work in a dusty environment or if your work requires physical activity such as lifting heavy boxes.
You can ask for a sick note if you need one.
Can I take a shower?
You can take a shower and wash your hair, but please be careful to use lukewarm water for the first 48 hours to reduce the risk of a nosebleed.
Avoid getting the dressing on the outside of your nose wet for the first two weeks. You can do this by wiping your face rather than washing it.
Can I exercise?
Avoid any strenuous exercise such as weight training, jogging, keep-fit classes, etc., for two weeks after the operation.
It is important to remember that after this surgery the nose will be weak for a couple of months. Any bumps to your nose could make the nose or septum move back out of place. No contact sports, such as rugby or football, should be played at this time.
Can I smoke?
Avoid smoky places. Cigarette smoke will irritate the inside of the nose and delay healing. We advise you don’t smoke before or after your surgery. For advice on how to quit smoking, please contact your GP or local pharmacist. Ideally you should have stopped smoking three months before your surgery.
Can I fly?
We recommend that you don’t fly for 14 days after your operation.
You will be followed up after this surgery. You will be seen in clinic usually a week or two later to have the splint on the outside of your nose removed. If this has fallen off before your appointment, please contact your surgeon’s secretary for advice.
Author: Mohammed Bahgat, Isma Iqbal
Disclaimer: This publication is designed for the information of patients. Whilst every effort has been made to ensure accuracy, the information contained may not be comprehensive and patients should not act upon it without seeking professional advice.