Rhinoplasty is a very unique operation in that changes in nasal shape continue to occur over the patient's lifetime. Most other operations heal over a finite period of time and then stabilize. This is not the case with rhinoplasty. Many patients whom we see for secondary surgery tell us that soon after the cast came off, their noses looked good. Then, over time, the swelling decreased, and the nose became narrowed and then deformed. Patients also state that their nasal breathing worsened over time after rhinoplasty. Some patients describe a situation in which their noses were fine for over 15 years and then changes occurred that resulted in deformity.  

Why does this occur with rhinoplasty?

When one undergoes rhinoplasty, there are two primary healing processes that occur. The first healing process is the resolution of the initial postoperative swelling. The rate at which this swelling goes down is variable from patient to patient and also depends on whether a patient underwent previous surgery or if he/she has a lot of scar tissue.  In most thin skinned patients, this initial swelling goes down in several months.  In patients with thick skin, swelling can persist for many years.

Even after the initial postoperative swelling after rhinoplasty has resolved, the secondary healing process continues.  In this case, the layer of scar tissue that forms over the nasal structures gradually contracts over time. In most patients, this scar contracture occurs over their lifetime.  This is why many patients state that their nose continued to change years after surgery. Some patients may not realize that their nose is still changing, but, if they were to look at a series of high quality close up photographs, they likely would see the changes. Patients with thicker skin have less pronounced changes than patients with medium to thin skin. In fact, some patients with thicker skin may see that their nose stabilized over time, with minimal changes after the initial healing process was completed.

I have noted these changes described in patients who have undergone rhinoplasty, and I am acutely aware of the long term healing process after rhinoplasty.  Therefore, I have adopted a method of surgery that employs a degree of over correction when performing rhinoplasty.  In other words, the nose is made about 10 to 15% larger than ideal during surgery and then, as the long term scar contracture process occurs, the patient can expect to see gradual improvement in his or her nasal contour instead of initially looking good and worsening over the years. This method is very difficult for the patient, especially early on after surgery, as the patient just sees a big nose.  Fortunately, this process of scar contracture helps to improve nasal contour over time, which helps to alleviate the patient's concerns.  

It would be much easier to perform rhinoplasty in a way that makes the nose look good early on.  However, that approach could result in poor long-term outcomes for many rhinoplasty patients.  When I approach a rhinoplasty, my primary concern is a good long-term result for every patient.  My intent is to perform every rhinoplasty as though it is the patient's last nasal operation, even if it is a primary rhinoplasty.

Some patients are at high risk for collapse of the middle portion (middle vault) of their nose.  In these patients, we also tend to over-correct the width of the middle portion of the nose. As time goes by, the forces of scar contracture lead to narrowing of the middle portion of the nose, resulting in a more normal width.  This over correction also will help to maximize the patient's nasal breathing. This is important, as I will never compromise nasal function for aesthetics.

Another reason why some patients are very swollen and wide after rhinoplasty is that their nose may have been made smaller. Any time that a nose is made smaller and/or less projected, the skin envelope over the nose must shrink to accommodate the new smaller nasal structure. Unfortunately, it takes many months, and sometimes years, for the skin envelope to contract. Patients with thinner skin will shrink faster than patients with thicker skin. In fact, most patients with thicker skin may need to keep a large nose to keep the skin expanded.   This is because, if the nose is made too small in a patient with thick skin, the skin may never shrink and will continue to appear very wide on frontal view.  These factors I must take into consideration when deciding how small I can make a nose on the lateral view.

Illustrative patient case: