- Rhinoplasty ranks among the most commonly performed cosmetic procedures in the United States, with over 200,000 procedures reported in 2014.
- The primary reason for surgery can be aesthetic, functional, or both, and may include adjunctive procedures on the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses.
- The average uncomplicated rhinoplasty procedure typically exceeds $4,000. However, the costs incurred due to complications, infections, or revision surgery (long-term antibiotics, hospitalization, and lost revenue from hours/days of missed work) add considerably to the total.
- The resultant psychological impact of rhinoplasty can also be significant.
Table 1. Definitions of Words Used in the Guideline
Rhinoplasty is a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway. The primary reason for surgery can be aesthetic, functional, or both, and may include adjunctive procedures on the septum, turbinates, or paranasal sinuses. (When these adjunctive procedures, however, are performed without an impact on nasal shape or appearance, they do not meet the definition of rhinoplasty used in this guideline).
Concerned with beauty or the appreciation of beauty.
Body Dysmorphic Disorder
Psychiatric disorder consisting of distressing or impairing preoccupation with nonexistent or slight defects in one's appearance.
Relating to treatment intended to restore or improve appearance.
Inflammation of the mucus membranes of the nose frequently caused by infection or allergic reaction. It typically manifests with symptoms of nasal itching, increased mucus drainage, congestion, or post nasal drainage.
Obstructive Sleep Apnea
Sleep disorder involving at least five obstructive respiratory events per hour (detected during an overnight sleep study).
The often unnoticed alternating partial congestion and decongestion of the nasal cavities in humans and other animals. It is a physiological congestion of the nasal turbinates due to selective activation of the autonomic nervous system on one side of the nose.
Examination of the anterior part of the nose, including the inferior turbinate, the septum, and the nasal valves.
Nasal packing is material, either removable or absorbable, placed inside the nose to promote hemostasis, structural support, and reduction of scar formation. Traditional nasal packs include ribbon gauze, expandable non-biodegradable pads, and non-stick dressing material. (Yan M, Zheng D, Li Y, et al. Biodegradable nasal packings for endoscopic sinonasal surgery: a systematic review and meta-analysis. PLos One. 2014; 9(12): e115458.) There are many newer types of packing that are biodegradable. Silastic stents or nasal splints, and custom cut sheeting are not considered packing.
Table 2. Nasal Anatomy Definitions
Upper Lateral Cartilage
The lateral cartilage piece of the nose, triangular in shape, meeting with the nasal bones superiorly and the lower lateral cartilages inferiorly, and fusing with the septum in the midline.
Lower Lateral Cartilage
Thin flexible plate of cartilage folded on itself and situated just below the upper lateral cartilage. It makes up the medial and lateral wall of the nostril.
Internal Nasal Valve
Refers to the area bordered by the upper lateral cartilage laterally, the septum medially, the head of the inferior turbinate, and the floor of the nose.
External Nasal Valve
Refers to the area bordered by the lateral limb of the lower lateral cartilage laterally, the medial limb of the lower lateral cartilage and the septum medially, and the floor of the nose.
Wall of cartilage and bone that runs down the middle of the nose dividing it into left and right nasal passages.
Long narrow curved shelves of bone covered in mucus membrane and protruding into the nasal passage.
Table 3. Structures to Assess in Rhinoplasty
Example of an
Anterior rhinoscopy, nasal endoscopy
Caudal septal deviation
Anterior rhinoscopy, nasal endoscopy
Inferior turbinate hypertrophy
Anterior rhinoscopy, nasal endoscopy
Cottle maneuver, modified Cottle maneuver
Nasal valve collapse
Posterior septal spur
Chronic sinusitis, polyps, pus
Table 4. Cosmetic Assessments
FACE-Q Rhinoplasty Instrument
Initially 40 questions for patients undergoing facial aesthetic surgery to assess satisfaction with facial appearance, social function, psychological well-being, and satisfaction with the nose with subsequent refinement to 25 questions for rhinoplasty surgery.
Glasgow Benefit Inventory (GBI)
18 questions measuring the general perception of well-being and psychological, social, and physical well-being. Originally developed for multiple surgeries of the head and face including rhinoplasty with subsequent validation studies on rhinoplasty alone.
Rhinoplasty Outcome Evaluation (ROE)
6 questions examining three major domains: appearance, functional outcome, and social acceptance following rhinoplasty.
Table 5. Functional Assessments
Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE)
A 5 question scale developed specifically to evaluate nasal obstruction, with frequent literature citation in septoplasty and functional rhinoplasty surgery.
Sino-Nasal Outcome Test (SNOT-22)
A 22 item questionnaire originally designed for rhinosinusitis, adapted to assess nasal patency in septoplasty, nasal valve, and functional rhinoplasty surgery.
Figure 1. Algorithm
Reassess appropriateness of surgery
Reassess appropriateness of surgery and modify planning as needed
Incorporate into surgical planning to correct obstruction
Do not routinely give antibiotics more than 24 hours after surgery
Rhinoplasty candidate â¥15 y/o
Surgeon chooses to administer perioperative antibiotics
Bleeding disorders, intranasal vasoconstrictors?
Are expectations realistic?
Option to administer perioperative steroids
Nasal airway obstruction?
Known or suspected OSA?
Document motivations and expectations
Evaluate for nasal airway obstruction
Document at 6-12 months patient satisfaction with nasal appearance and function
Preventative OSA counseling
Counseling for pain and discomfort
Do not routinely place nasal packing
Assess for body dysmorphic disorder (BDD), obstructive sleep apnea (OSA), bleeding disorders, intranasal vasoconstrictors
Suspicion of BDD?
Further assess patient to confirm or exclude OSA
Table 6. Summary of Key Action Statements (KAS)
Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback as to whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record.
Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify, or contraindicate surgery that include obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs.
|Nasal airway obstruction|
The surgeon, or the surgeonâs designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment.
The surgeon, or the surgeonâs designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery.
|Counseling for obstructive sleep apnea patients|
The clinician, or the clinicianâs designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea (OSA) about the impact of surgery on nasal airway obstruction and how OSA might affect perioperative management.
|Managing pain and discomfort|
The surgeon, or the surgeonâs designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery.
When a surgeon, or surgeonâs designee, chooses to administer perioperative antibiotics for rhinoplasty, they should not be routinely prescribed for a duration of >24 hours after surgery.
The surgeon, or the surgeonâs designee, may administer perioperative systemic steroids to the rhinoplasty patient.
Surgeons should NOT routinely place packing in the nasal cavity of rhinoplasty (with or without septoplasty) patients at the conclusion of surgery.
Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty.
Table 7. Adjunctive Measures to Pain Management in Rhinoplasty
8â12 mg decadron preoperatively with a single additional dose in the next 24 hours
Reduces swelling, nausea, and vomiting
May reduce pain;
May decrease the duration of post-operative ecchymosis
Postoperative nasal irrigation
High volume / low pressure nasal saline and fluticasone irrigation postoperatively
Reduces nasal crusting and nasal airway patency, possibly improving patient satisfaction
Will require patient instruction and education
3 times per day
May reduce the amount of early postoperative swelling, but has no influence on ecchymosis
May increase the risk of bleeding
Avoiding the placement of packing
Reduces postoperative discomfort
Not necessary in patients that are not bleeding
Should be used if there is persistent surgical bleeding
Intra-operative cold compresses
Iced saline gauze packs on the external nose during surgery
Reduces intraoperative bleeding, surgical time, and postoperative edema
May increase comfort