What procedure would make my nose larger ?

Augmentation rhinoplasty is a complex surgical procedure aimed at increasing the size, projection, or definition of the nose. Unlike reduction rhinoplasty, which is more commonly discussed, augmentation focuses on adding volume, structure, and contour, often using grafts. This procedure can address a variety of concerns, from a nose that appears too small or flat relative to other facial features, to correcting structural deficiencies resulting from trauma, previous surgery, or congenital conditions.

Understanding the Need for Augmentation Rhinoplasty

Patients seek augmentation rhinoplasty for several key reasons :

1. Cosmetic Enhancement:
   • Under-projected Nose: A nose that doesn’t extend far enough from the face, often appearing flat or « pushed in. »
   • Low Dorsum (Bridge): A bridge that lacks height, leading to a flat profile. This is common in certain ethnic groups (e.g., East Asian, African American, some Hispanic populations) where a higher, more defined bridge is desired.
   • Lack of Tip Definition/Projection: A nasal tip that is rounded, lacks projection, or appears indistinct.
   • Asymmetry: Correcting an imbalance where one side of the nose is smaller or less projected than the other.
   • Overall Small Nose: A nose that is disproportionately small compared to other facial features, creating an imbalanced appearance.
2. Reconstructive Purposes:
   • Post-Traumatic Deformity: Repairing structural damage and volume loss after an injury.
   • Congenital Deformities: Correcting conditions present from birth that result in an underdeveloped nose.
   • Revision Rhinoplasty: Augmenting a nose that has been over-resected (too much tissue removed) during a previous rhinoplasty, leading to a « scooped » bridge or pinched tip.
   • Cancer Reconstruction: Rebuilding nasal structures after tumor removal.

Key Areas for Augmentation nose

Augmentation can be performed on various parts of the nose, depending on the desired outcome:

• Dorsal Augmentation: Increasing the height of the nasal bridge. This is one of the most common forms of augmentation, creating a stronger profile.
• Tip Augmentation/Projection: Enhancing the definition and forward projection of the nasal tip.
• Columellar Augmentation: Adding support and projection to the columella (the strip of skin and cartilage between the nostrils), which can improve tip support and overall nasal length.
• Alar Base Augmentation: Less common, but can involve adding volume to the base of the nostrils if they are too narrow or retracted.

Grafting Materials : The Foundation of Augmentation

The success of augmentation rhinoplasty heavily relies on the choice and skillful placement of grafting materials. These materials add volume and structure. They can be broadly categorized into autologous, alloplastic, and allogeneic.

Autologous Grafts (Patient’s Own Tissue)

These are generally considered the « gold standard » due to their excellent biocompatibility, low risk of infection or rejection, and natural integration with surrounding tissues.

1. Septal Cartilage:
   • Source: Harvested from the nasal septum (the wall dividing the nostrils).
   • Pros: Readily available during rhinoplasty, good stiffness, minimal donor site morbidity, natural feel.
   • Cons: Limited supply (especially if previous septoplasty was done), may not be sufficient for significant augmentation, can warp over time.
   • Use: Ideal for tip grafts, columellar struts, small dorsal grafts, and spreader grafts.
2. Ear Cartilage (Conchal Cartilage):
   • Source: Harvested from the concha (bowl-shaped part) of the ear, usually behind the ear to hide the incision.
   • Pros: Plentiful supply, easily accessible, good curvature which can be useful for certain contours.
   • Cons: More flexible than septal cartilage, can be prone to warping, donor site pain/swelling.
   • Use: Excellent for tip grafts, alar rim grafts, and camouflaging minor irregularities. Less suitable for major dorsal augmentation due to its flexibility.
3. Rib Cartilage (Costal Cartilage):
   • Source: Harvested from the patient’s own rib cage (typically the 6th, 7th, or 8th rib).
   • Pros: Abundant supply, very strong and rigid, can be carved into large grafts for significant augmentation.
   • Cons: Requires a separate incision on the chest, more invasive, longer recovery at donor site, higher risk of warping (up to 10-20% if not properly prepared), potential for pneumothorax (collapsed lung) during harvest (rare).
   • Use: Indicated for major dorsal augmentation, columellar reconstruction, and revision cases where septal cartilage is depleted. Can be used as a solid block or diced cartilage wrapped in fascia (DCF).
4. Bone Grafts (e.g., Calvarial Bone, Rib Bone):
   • Source: Calvarial bone (from the skull) or rib bone.
   • Pros: Very strong, maintains shape well, good for very large augmentations.
   • Cons: More invasive harvest, higher risk of resorption (bone dissolving over time) compared to cartilage, can feel harder than natural nasal bone.
   • Use: Primarily for significant dorsal augmentation in reconstructive cases or severe deficiencies. Less common in purely cosmetic augmentation due to invasiveness and resorption risk.

Alloplastic Grafts (Synthetic Implants)

These are man-made materials. While convenient, they carry a higher risk of complications compared to autologous grafts.

1. Silicone:
   • Type: Solid silicone, often pre-formed or custom-carved.
   • Pros: Easy to insert, readily available, doesn’t resorb or warp, can be removed if necessary.
   • Cons: Higher risk of infection, extrusion (eroding through the skin), capsular contracture (scar tissue forming around it, making it visible or palpable), migration, and unnatural feel.
   • Use: Historically popular for dorsal augmentation, especially in East Asian rhinoplasty, but its use has declined due to long-term complication rates.
2. Gore-Tex (ePTFE – expanded Polytetrafluoroethylene):
   • Type: Porous, flexible material.
   • Pros: Softer and more flexible than silicone, less prone to extrusion, tissue can grow into its pores, theoretically integrating it better.
   • Cons: Still carries a risk of infection (though lower than silicone), can be difficult to remove if tissue ingrowth occurs, can compress over time leading to some loss of projection.
   • Use: Used for dorsal augmentation and camouflaging irregularities.
3. Medpor (Porous Polyethylene):
   • Type: Rigid, porous material.
   • Pros: Strong, stable, tissue ingrowth provides good fixation.
   • Cons: Very firm, can be palpable, higher risk of infection and extrusion than Gore-Tex, difficult to remove once integrated.
   • Use: For significant structural support, often in reconstructive cases, but less common for cosmetic augmentation due to its rigidity and complication profile.

Allogeneic Grafts (Donor Tissue)

1. Irradiated Cadaveric Costal Cartilage (ICCC):
   • Source: Cartilage from deceased human donors, processed to be sterile and non-immunogenic.
   • Pros: Abundant supply, avoids donor site morbidity, good for large augmentations.
   • Cons: Higher risk of resorption (can be up to 50% or more over time), small theoretical risk of disease transmission (though highly processed), can warp.
   • Use: An alternative when autologous cartilage is insufficient or patient declines rib harvest. Its unpredictable resorption rate makes it less preferred for primary augmentation.

The Surgical Procedure : A Step-by-Step Overview

Augmentation rhinoplasty is typically performed under general anesthesia, though local anesthesia with sedation can be an option for less extensive procedures. The surgery generally takes 2-4 hours, depending on complexity and graft harvesting.

1. Anesthesia: The patient is put under general anesthesia or given local anesthesia with intravenous sedation.
2. Incisions:
   • Open Rhinoplasty: This is the most common approach for augmentation. An incision is made across the columella (the strip of skin between the nostrils), connecting to incisions inside the nostrils. This allows the surgeon to lift the skin and soft tissues, providing a direct, unobstructed view of the underlying nasal structures.
   • Closed Rhinoplasty: All incisions are made inside the nostrils. This approach is less common for significant augmentation as it offers a more limited view and less precision for graft placement.
3. Dissection: The skin and soft tissues are carefully lifted from the underlying bone and cartilage framework to create a pocket for the grafts.
4. Graft Harvesting (if autologous): If autologous grafts (septal, ear, or rib cartilage) are used, they are harvested at this stage.
   • Septal Cartilage: Accessed through the same nasal incisions.
   • Ear Cartilage: A small incision is made behind the ear.
   • Rib Cartilage: A small incision (typically 2-4 cm) is made on the chest over the chosen rib.
5. Graft Shaping and Placement:
   • The harvested or chosen graft material is meticulously carved and shaped by the surgeon to achieve the desired contour and size.
   • For dorsal augmentation, the graft is carefully placed over the nasal bridge. It might be secured with sutures to prevent displacement.
   • For tip augmentation, smaller grafts are precisely placed to add projection and definition.
   • Grafts may be stacked, layered, or combined to achieve the optimal result.
6. Securing Grafts: Grafts are often secured with fine sutures to the underlying cartilage or bone to ensure stability and prevent migration.
7. Closure: Once the grafts are in place and the desired shape is achieved, the skin and soft tissues are redraped over the new framework. The incisions are closed with fine sutures.
8. Splinting and Dressing: An internal splint (soft silicone) may be placed inside the nostrils to support the septum and external nasal structures. An external splint (plastic or plaster cast) is applied to the outside of the nose to protect it, maintain its new shape, and help reduce swelling during the initial healing phase. Taping may also be used.

Pre-operative Consultation : Your Essential First Step

A thorough consultation with a board-certified plastic surgeon is paramount.

1. Medical History Review: The surgeon will review your complete medical history, including any previous nasal surgeries, breathing problems, allergies, medications, and smoking status.
2. Physical Examination: A detailed examination of your nose, face, and potential donor sites (ears, septum, ribs) will be performed. The surgeon will assess your skin quality, cartilage strength, and overall facial harmony.
3. Photographic Analysis: Standardized photographs are taken from multiple angles. These are crucial for planning the surgery and for before-and-after comparisons.
4. 3D Imaging/Computer Simulation: Many surgeons use advanced 3D imaging or computer simulation software to show you potential outcomes and discuss your aesthetic goals. This helps ensure alignment between your expectations and what is surgically achievable.
5. Discussion of Goals and Expectations: Open communication about what you hope to achieve is vital. The surgeon will explain what is realistic, the limitations of the procedure, and potential risks.
6. Graft Material Discussion: The surgeon will discuss the pros and cons of different graft materials and recommend the most suitable option based on your needs and anatomy.
7. Pre-operative Instructions: You will receive detailed instructions on how to prepare for surgery, including dietary restrictions, medication adjustments, and what to avoid (e.g., aspirin, anti-inflammatory drugs, smoking).

Post-operative Care and Recovery

Recovery from augmentation rhinoplasty requires patience and diligent adherence to post-operative instructions.

1. Immediate Post-Op (First Few Days):
   • Pain: Managed with prescribed pain medication. Discomfort is usually moderate.
   • Swelling and Bruising: Significant swelling and bruising around the eyes and nose are common. Cold compresses help minimize this.
   • Splint/Cast: The external splint/cast remains in place for about 5-7 days. Internal splints, if used, may stay longer.
   • Drainage: Some bloody discharge from the nostrils is normal. A drip pad may be used.
   • Head Elevation: Keeping the head elevated, even while sleeping, is crucial to reduce swelling.
   • Activity Restriction: Avoid strenuous activities, bending, lifting, and blowing your nose.
2. First Week:
   • The external splint/cast is typically removed around day 5-7. The nose will appear swollen, and the new shape may not be immediately apparent.
   • Bruising usually starts to fade.
   • Most patients can return to light, non-strenuous work or daily activities.
3. Weeks 2-4:
   • Significant swelling will subside, but subtle swelling will persist, especially in the nasal tip.
   • You can gradually resume more normal activities, but still avoid contact sports or anything that could impact the nose.
   • Numbness in the nasal tip or upper lip is common and usually temporary.
4. Months 1-6:
   • The majority of swelling will resolve, and the final shape of the nose will become more apparent.
   • The skin and soft tissues will continue to settle around the new framework.
   • Graft integration continues.
5. Months 6-12+:
   • The final results of augmentation rhinoplasty can take up to a year or even longer to fully manifest, as residual swelling slowly dissipates and tissues fully settle.
   • The nose will continue to refine its shape.

Potential Risks and Complications

While augmentation rhinoplasty is generally safe when performed by a qualified surgeon, all surgeries carry risks:

• General Surgical Risks: Bleeding, infection, adverse reaction to anesthesia.
• Specific Rhinoplasty Risks:
  • Asymmetry: The nose may not be perfectly symmetrical.
  • Breathing Problems: Although less common with augmentation, changes in nasal structure can sometimes affect airflow.
  • Numbness: Temporary or, rarely, permanent numbness in parts of the nose.
  • Graft-Related Complications:
    • Warping: Autologous cartilage grafts (especially rib) can warp or bend over time.
    • Resorption: Grafts (especially ICCC or bone) can partially or fully dissolve.
    • Displacement/Migration: Grafts can shift from their intended position.
    • Extrusion: Alloplastic implants can erode through the skin, requiring removal.
    • Infection: Higher risk with alloplastic implants, sometimes requiring removal.
    • Capsular Contracture: Scar tissue forming around an alloplastic implant, making it hard or visible.
  • Unsatisfactory Aesthetic Outcome: The results may not meet the patient’s expectations, potentially requiring revision surgery.
  • Scarring: While incisions are usually well-hidden, keloid or hypertrophic scarring is a rare possibility.

Expected Results and Longevity

• Realistic Expectations: It’s crucial to have realistic expectations. The goal is improvement, not perfection. The surgeon will aim for a nose that is in harmony with your other facial features.
• Final Results: The true final results may not be visible for 12-18 months after surgery, as all swelling must resolve.
• Longevity: Autologous grafts are generally considered permanent, as they integrate with your own tissues. Alloplastic implants are also intended to be permanent, but carry a higher long-term risk of complications that may necessitate removal or revision.

Cost of Augmentation Rhinoplasty

The cost varies widely based on several factors:

• Surgeon’s Fees: Based on experience, reputation, and geographic location.
• Anesthesia Fees: Based on the type of anesthesia and duration of surgery.
• Facility Fees: Cost of using the surgical center or hospital.
• Graft Material: Autologous grafts requiring harvesting (especially rib) can increase the cost due to longer surgical time and complexity.
• Pre- and Post-operative Care: Consultations, follow-up appointments.
• Geographic Location: Costs differ significantly between regions and countries.

Augmentation rhinoplasty is typically considered a cosmetic procedure, so it is generally not covered by health insurance unless it’s performed for reconstructive purposes (e.g., correcting a breathing problem or deformity from trauma).

Choosing a Qualified Surgeon

Selecting the right surgeon is the most critical decision. Look for:

• Board Certification: Ensure the surgeon is board-certified in Plastic Surgery (or Otolaryngology with a subspecialty in Facial Plastic Surgery). This indicates rigorous training and adherence to high standards.
• Experience: Choose a surgeon with extensive experience specifically in augmentation rhinoplasty and a deep understanding of nasal anatomy and facial aesthetics.
• Specialization: Some surgeons specialize in ethnic rhinoplasty, which is particularly relevant for augmentation, as it requires a nuanced understanding of diverse nasal structures.
• Before-and-After Photos: Review their portfolio of previous augmentation rhinoplasty cases.
• Patient Reviews: Read testimonials and reviews from other patients.
• Communication Style: Choose a surgeon with whom you feel comfortable communicating openly and who listens to your concerns and goals.
• Accredited Facility: Ensure the surgery will be performed in an accredited surgical facility.

In conclusion, augmentation rhinoplasty is a sophisticated procedure that can significantly improve nasal aesthetics and facial harmony by adding volume and definition. It requires careful planning, a skilled surgeon, and a clear understanding of the available grafting materials and potential outcomes. A thorough consultation is essential to determine if this procedure is right for you and to establish a personalized treatment plan.