In performing rhinoplasty, a thorough pre-operative evaluation and well thought out plan followed by precise surgical technique ensure a successful result.
First, a local anesthetic goes into the nose with epinephrine to reduce bleeding. Sometimes local anesthetic goes in or on the nasal septum if septal surgery will be necessary.
Incisions go on the outside of the nose and also on the inside of the nostrils. Then, the surgeon dissects the skin away from the underlying structures allowing excellent visualization of the deformities.
First, the prominent dorsum is cut down (sometimes excised) to the appropriate level. This includes the removal of bone and cartilage. Later the nasal bones are fractured and very carefully pressed together to narrow the nose and to eliminate the “open book” deformity. Now the tip is freed up and the lower lateral cartilages are trimmed to narrow the nasal tip. Here, the surgeon should leave an adequate amount of tip cartilage (5-6 mm) to establish a natural look. Over-resection here leads to a small, balled-up tip with a natural look.
Next, the surgeon stitches up the remaining cartilage with multiple sutures to achieve tip projection and to also narrow the tip. Under-resection of the septal tip leads to a parrot beak deformity.
Following, attention turns to the nostrils. Small amounts of skin at the base of the nostril gets removed.
Finally, the surgeon evaluates the nose for final revisions followed by suturing of all incisions. Intra-nasal packing is usually not necessary.