Nose Surgery (Rhinoplasty)

The Main Content
Every baby and most children have a small, cute, and beautiful nose. So why can’t we say the same about all adults? Because during adolescence, along with all the other changes, the nose also undergoes transformation.
First of all – and in everyone – it simply grows, which is definitely a positive phenomenon (after all, you wouldn’t want a 20-year-old body with the nose of a 2-year-old). For most people, the nose grows in a way that fits the facial structure. But, at the same time, it can elongate, protrude, become less refined at the tip, and even droop downward.
Along with the growth, other changes occur in the face: the sinuses (air cavities located in the cheekbone) develop, and with them, the cheeks grow. The jaw expands (downward and forward), and the chin becomes more prominent.
All these changes, including the changes in the nose, are usually passed down genetically, typical of different ethnic groups. It’s important to note that there is no such thing as a “Jewish nose.” Our noses are similar to those of other people from the Middle East.

How is the Nose Built?
To understand how the nose is built, try imagining a tent.
The walls of this “tent” are made up of two flat bones (the nasal bones), alongside two cartilages shaped like triangles, which connect in the center to form the nasal septum.
The tip of the tent, closest to the opening (the nostrils), is made up of two additional cartilages that resemble the Hebrew letter “Chet” and surround the nostrils.
These bones and cartilages form the sides of the nose—the walls of the tent. Between them, there is a cartilaginous septum (the divider between the nostrils, continuing deep inside the nose).
Where the walls and septum meet is called the bridge of the nose.

What Can Be Done in a Nose Surgery?

• Change the size of the nose.
  • Reduce a large nose or, if necessary, make a small nose bigger.
• Change the angle between the nose and the upper lip.
  • Increase the angle (distance) between the nose tip and the upper lip (in cases where the nose tip droops downward).
• Narrow the nose.
  • Literally: make a wide nose narrower. This can be done on the bridge, the tip, or the nostrils, individually or together.
• Straighten the nose or bridge.
  • Reduce the hump or correct other deviations.
• Correct a deviation in the nasal septum.
  • The septum, the cartilage wall that separates the two sides of the nose, extends from the nostrils to the area between the eyes and ends at the throat, near the uvula.
    A crooked septum can cause breathing issues (which are felt but not seen) and can distort the appearance of the nose. In such cases, surgery aims to straighten the septum.
• Sculpt the tip of the nose.
  • This is what clowns and jesters do, but in a distorted and exaggerated way. In surgery, the nose tip can be reshaped, refined, and adjusted to the overall shape of the nose.
• Create a depression at the root of the nose.
  • The root of the nose is the area between the eyebrows where the nose begins. Most people have a natural depression there, but surgery can create a depression for those who don’t.
• Reduce the turbinates of the nose.
  • The turbinates are structures inside the nose that serve to humidify and filter the air entering. Sometimes, they swell due to allergic reactions, blocking airflow. In such cases, they may need to be reduced.

Who is Nose Surgery Suitable For?
Nose surgery has a “minimum age”:

• 14-15 years for women (preferably about two years after the start of menstruation)
• 16 years and older for men
  Why? Because around these ages, the nose has finished growing, and only after this can you be sure the surgical results will be permanent. Medically, surgery can be done earlier, but the results may not be final.

Where is the Incision Made?
Usually, the incision is made inside the nose, meaning no external scars.

What Happens During the Surgery?
To understand what happens during the surgery, imagine the tent we described earlier. The surgery is performed on the nasal skeleton, not the skin. The procedure starts by separating the skin of the nose from its underlying structure. This is the first step.
Next, the walls of the tent are lowered—meaning the bones of the nose are trimmed or shaved. This is the second step, and at the end of this phase, the “tent” has an open roof. How is the roof closed? The surgeon breaks the bones at their base, where they connect to the cheekbones, and pushes them toward the center of the nose until the roof closes. This results in a smaller, narrower nose.
In the fourth step, the tip of the nose is worked on, reshaping it by cutting and stitching the cartilage. If needed, cartilage is added to the tip of the nose (or other sunken areas) from the nasal septum or additional cartilage removed by the surgeon.
At the end of the surgery, two nasal tampons are inserted, which remain for 24-48 hours. These help stop bleeding and support the external cast that holds the nose in its new shape.
To reduce swelling and keep the bones in place, a cast or splint is placed on the nose.

What is Open Rhinoplasty?
Open rhinoplasty is the same surgery but with an additional incision. In regular rhinoplasty, the incision is made inside the nose. In open rhinoplasty, an additional incision is made across the columella (the soft part between the nostrils). This allows the surgeon to lift the skin and view the cartilage more clearly.
And the scar? The incision at the base of the columella heals well, and the scar almost disappears over time.

When is Open Rhinoplasty Done?
It is used when there is a deformity or asymmetry at the tip of the nose. Lifting the skin allows the surgeon to see and reshape the cartilage more accurately.

When Are the Nostrils Narrowed?
The simple answer: when their width bothers you, meaning when, relative to other facial features, the nostrils appear too wide. Sometimes, narrowing the nostrils is done as part of a procedure addressing another part of the nose. For example, if the nose tip is very high and is lowered during surgery, this will cause the nostrils to widen, necessitating their narrowing.

How Are the Nostrils Narrowed?
Small pieces of skin are removed from the base of the nostrils. The incision, a tiny line, is made along the nostril’s edge. In most cases, small, nearly invisible scars are created, but in some cases, the incision may need to extend around the nostril in the fold.

Does Excess Skin Form on the Nose?
The skin of the nose contracts nicely and adjusts to the new shape of the nose. Sometimes, especially for those over 60, additional removal of excess skin may be required to avoid wrinkles.

What Type of Anesthesia Is Used?
As with other plastic surgeries, the type of anesthesia should be decided jointly by you and the surgeon. The surgery can be performed under local anesthesia (with intravenous sedation) or general anesthesia.
If you choose local anesthesia, the anesthetic is injected around the perimeter of the nose and inside, but only after the intravenous sedation has taken effect.
Does it hurt? Yes, for a few seconds.

How Long Does the Surgery Last?
The procedure usually lasts between one to two hours, depending on what exactly is being done and the surgeon’s expertise.

Is Hospitalization Required?
In most cases, hospitalization is not necessary after the surgery. In some countries, like the United States, most of these surgeries are done on an outpatient basis: the patient arrives, the surgery is performed, and they leave a few hours later.
In Israel, the Ministry of Health recommends overnight hospitalization for observation, mainly to monitor respiratory function and avoid complications.

What Should Be Discussed with the Surgeon?
Like any initial consultation for plastic surgery, before a nose surgery, it is important to clearly express what bothers you and listen carefully to what the surgeon advises.
When it comes to the appearance of the nose, remember a basic principle: generally, we look at each other face-to-face, and in such a view (called “en face”), not all aspects of the nose are visible. For example, a hooked nose can only be seen in profile, not straight on.

In some cases, the size of the nose may actually be harmonious with the face, but it is the recessed chin that makes the nose appear larger than it is. In such cases, improving the profile might require not only nose surgery but also chin augmentation. In other cases, there might be no need for a nose surgery at all, and only chin surgery is required.
Sometimes, the upper lip needs to be considered, because if it is very small, raising the nose upward could create disproportion and look awkward.