Post-Operative Rhinoplasty (Nasal Surgery) Instructions

Introduction

The following instructions are based on experience with thousands of nasal surgeries. They are designed to answer most questions that may arise regarding what you should and should not do after surgery. You and your family should read these several times to familiarize yourselves with them. Attempt to follow them faithfully, because those who do so generally have the smoothest post-operative course.

What to Expect Following Your Procedure:

SWELLING

Every operation, no matter how minor, is accompanied by swelling of the surrounding tissues. The amount of swelling varies from person to person. Because of the looseness of facial tissue, the swelling is more pronounced and the facial features may appear distorted. Medication will be recommended to minimize swelling. Continuous adequate hydration and elevation help.

Typically the swelling will peak the second or third day after your surgery. Generally it will be worse when you first arise in the morning; proof that it is better to remain elevated as much as possible. This is not serious and is not an indication that something is wrong. Swelling always eventually subsides and your face will return to normal. You can help the swelling to subside in several ways:

1. Keep your face elevated with your head above the heart, even while sleeping. A recliner comes in handy. Pillows will work, but your head may slip off your pillow while sleeping. This will only cause increased facial swelling and prolong your nasal stuffiness. The main point is to keep the head above the heart, as swelling, bruising and blood all follow gravity and flow downhill towards the heart
2. Avoid bending over or lifting for about two weeks. Besides aggravating swelling, these activities may raise the blood pressure and cause bleeding.
3. Avoid hitting or bumping your new nose. It is wise not to pick up small children or pets, and you may need to sleep alone for two weeks after your operation.
4. Continue to sleep with the head of the bed elevated for at least two weeks, or until your swelling and stuffiness have subsided to your satisfaction.
5. The application of cool therapy to the eyes and forehead may soothe discomfort and somewhat reduce swelling for the first couple of days. Apply gel ice compresses or baggies of frozen peas across each eye as continually as possible during the first night and next day after discharge. But be very careful that the weight of the compresses does not put pressure on the splint or cause the tape to become wet with condensation.
6. Avoid tanning the face for several months.
7. When showering, try to minimize water exposure to the nasal dressing. Wash below your neck first. Then, shampoo and wash your face and promptly exit the shower and dab the face and dressing dry. Do not soak the dressing. Water coming in contact with the face should come from the tap, not from bath water or basin.
8. Avoid constant “sniffing”; that is, constantly forcibly attempting to pull air through the nose as some people do when their nose feels blocked. This will not relieve the sensation of blockage; it will only aggravate it because the suction created on the inside will cause more swelling.
9. Do not forcibly blow your nose for several weeks after surgery or until instructed to do so. This could precipitate bleeding.
10. Beginning the morning after your surgery, attempt to flush out each nostril with Afrin exactly four times each day. This will reduce bleeding, swelling, obstruction and crusting. Failure to use the Afrin as instructed will result in complete nasal obstruction from large crusts and scabs which can be uncomfortable to remove. In theory, the Afrin should pass all the way through both nasal passages and be expelled through the mouth. For the first few days, the Afrin will not readily pass all the way through the nose. This is expected. So, in order to minimize crusting until you can sniff the Afrin all the way back, simply lie flat on your back, and apply two big raindrops of Afrin into each nostril and allow it to percolate into the nose for a few minutes. After a few days, you will succeed at sniffing the Afrin all the way back through each nostril. Typically one side will open a day or two before the other side. Avoid any forcible blowing of the nose for several weeks. And, when you eventually do sniff, DO NOT compress the opposite nostril as you might normally do to avoid tearing some delicate internal sutures. Manipulating your nasal tip might cause a twisted nasal tip.
11. The night of surgery and for the first day or two, there will be nearly constant blood tinged nasal drainage. This is entirely normal, since no nasal packing is typically used. It may be quite bloody soon after you arrive home from surgery as the vasoconstrictors used during surgery wear off. Simply remain calm, quiet and elevated, and change the drip pad as instructed as often as necessary. As long as you remain calm and quiet, within a few hours, the bleeding will slowly diminish in quantity and become more watery. Apply and change the 4X4 gauze as necessary as we will teach you in recovery. Do not use Kleenex. If you are tempted to use Kleenex, it is time to reapply the drip pad. Kleenex is paper, and paper has wood chips. Frequent dabbing with Kleenex can actually abrade the delicate nasal skin. Most people can discontinue using the drip pad after a day or two.

DISCOLORATION

It is not unusual to have varying amounts of bruising about the eyes and face. Like swelling, the discoloration may become more pronounced after you have been discharged. It usually lasts no more than a week, all the while decreasing the intensity. However, in some cases, individuals may have bruising that seems to last for a few weeks. The measures that help swelling to subside will also help discoloration. You can camouflage the discoloration to some extent by using makeup after the splint is removed.

HEMORRHAGE

If worrisome hemorrhage occurs, lie down with your head elevated on pillows or in a recliner. Try not to get excited. Be sure to take your pain medicine if needed to avoid increased blood pressure secondary to pain. If you are worried, call us.

Do not take any blood thinning medications such as aspirin or Advil until cleared by our office.

SELF-CLEANSING OF THE NOSE

Interestingly, your nose is self-cleansing. If you simply patiently follow our instructions, your nose will take care of itself. You do not have to do anything besides follow our instructions. It can be hazardous to perform any other interventions. But be patient- this process takes weeks and weeks. The first week, the only things that should enter your nose are air and Afrin. Period. After the Afrin has done its job, you will transition to Nasal Saline and perhaps Ayr Saline gel for several weeks. No fingers, Q-Tips, tweezers, Vaseline, scissors, etc. EVER! After a few weeks, you will notice some crusts, bumps and ridges or irregularities inside your nostrils. These are completely normal and will resolve slowly on their-own. It may be tempting to try to remedy these yourself, but doing so could very easily disrupt your nasal tip permanently! The sutures stabilizing your nasal tip are tiny threads sewn through delicate cartilage; about as flimsy as a contact lens made of candle wax! If you are concerned, let us look at it before attempting any form of picking or self-surgery.

PAIN

Everyone handles pain differently. There is usually only mild pain following rhinoplasty, especially with no nasal packing. You may experience a bruised sensation as a result of the post-operative swelling that occurs, this usually seems to be worse the first night.

Unfortunately, all oral narcotics can cause sensations of lightheadedness and nausea, particularly in the immediate post-operative period. At your preoperative visit we will prescribe an appropriate pain medication. This is best tolerated and less likely to cause nausea if you take it when you are home in your own bed and after adequate intake of clear liquids. Use the prescribed pain medicine, or extra strength Tylenol for discomfort. Regular doses of Tylenol according to the product label will build up in your bloodstream and after a day or two of not missing a dose, you will have substantial analgesia from Tylenol alone. DO NOT take aspirin related products, including Motrin (ibuprofen), Advil or Nuprin.

INSOMNIA

Sleeping can be difficult after surgery, due to nasal obstruction, discomfort, and elevation. This will get easier night by night. If you are still having troubles with insomnia after a night or two, you can try over the counter Benadryl 50mg, or Tylenol PM. No Advil PM. If you desire a prescription sleeping medicine after a night or two, just let us know. However, it can be hazardous to combine various sedatives such as narcotics with sleeping medicines. Decide for yourself what your chief concern is- pain, insomnia, or anxiety- and we will work with you to make you as comfortable as we safely can.

DEPRESSION

It is not unusual for an individual to go through a period of mild depression after the surgery. No matter how much they wanted the operation beforehand and how much they were told about what to expect post-operatively, they are shocked when they see their face swollen and perhaps discolored. If this is how you feel, be realistic and realize that this is a very temporary condition which will subside shortly. The best “treatment” consists of busying one’s self with the details of post-operative care and trying to divert one’s mind.

KEEP A STIFF UPPER LIP

The upper lip is a key area in rhinoplasty surgery since much of the work is done near this area. Therefore, you should not move it excessively as long as the bandage is in place so that the healing tissues are not disturbed.

• Avoid excessive grinning and smiling.
• Do not pull the upper lip down as women do when they apply lipstick.
• Apply lipstick with a brush.
• The upper teeth should be brushed with a soft toothbrush. The lower teeth may be brushed as usual.
• Avoid gums or foods that are hard to chew. Soups, mashed potatoes, stewed chicken, yogurt or any easily chewable food is permissible. French bread, etc. should not be eaten.

RESUMING ACTIVITES

You may sleep without the head of the bed elevated after about two weeks.

Until the bandage is removed, you should wear clothing that fastens either in front or the back rather than the type that must be pulled over the head.

You should walk regularly after a few days. This will help mood, appetite, sleep, constipation and swelling. Begin light exercise after about ten days. This may include a slow-paced stationary bike or an eliptiform. No impact exercises. Slowly work up to running and strenuous aerobic exercise after several weeks.

Avoid any activities which may result in an impact to the nose for at least six weeks; any sports for two months where your nose might be bumped.

If you must sneeze, let it come out like a cough—through the mouth.

Eyeglasses may be worn briefly while the splint remains on the nose. After that, they must be suspended from the forehead with tape or supported on the cheek bones for a period of about six weeks. We will show you how this accomplished if you must wear them. This is important, for the pressure of the glasses may change the new contour of the nose.

No sunglasses for six weeks!

Contact lenses may be inserted a day or two after surgery.

DRYNESS OF THE LIPS

If the lips become dry from breathing through the mouth, coat them with Vaseline or Aquaphor. But under all circumstances, avoid ALL moisturizers within an inch or so of the splint tape. This may cause premature loosening of the tape and destabilization of the rhinoplasty.

TEMPERATURE

Generally, the body temperature rises a bit after surgery, but not normally much above 100°. This rise results from becoming mildly dehydrated from not drinking enough water. Patients will often think they have an increased temperature because they feel warm. If concerned, use a thermometer. Report any persistent temperature above 100°.

WEAKNESS/LIGHTHEADENESS

It is not unusual after a person has an anesthetic or any type of operation for him or her to feel weak, have palpitations, break out in “cold sweats” or get dizzy. This gradually clears up in a few days without medication. It is best relieved by promptly lying flat on your back for several minutes. Call us if it persists or worries you.

YOUR FIRST OFFICE VISIT

You should have your first post-operative appointment approximately seven days after surgery. If you were not given an appointment card, please call the office to schedule.

Do not build up a feeling of fear or anxiety about what is going to be done to you on the occasion of your first post-operative visit to the office. You will feel much better after the dressing is removed. Any sutures requiring removal will be taken out at this time. The outer tape and the splint will be removed. A special tape-removing solution is used to insure these come off easily. Likewise, the material inside your nose will be softened so that it comes out easily. There are no stitches to remove from the inside of your nose because they are the dissolvable type.

RETURNING TO WORK OR SCHOOL

The average patient is able to return to school the day after the bandages are removed; that is, eight days following surgery. However, that is entirely up to you. If you do not mind returning with the splint on your nose, and you do not have to physically exert yourself, you may go back to work or school within three days of surgery. When you should return to work depends on the amount of physical activity and public contact your job involves in addition to the amount of swelling and discoloration you develop.

PETS

We are all fond of our pets. However, over the years we have noticed that a few patients who tend to sleep with their pets in close proximity will sometimes have some extra inflammation or perhaps even early infection. We recommend that if your pet sleeps on your bed, you take appropriate precautions until a few days after all your sutures are removed. Pets must sleep on the floor or, if necessary, in a separate room. Make sure all of your bed sheets, pillow cases, etc. are freshly laundered.

INJURY TO THE NOSE

Many individuals sustain accidental hits on the nose during the early post-operative period. One usually needs not to be too concerned unless the blow is hard enough that hemorrhage or considerable swelling ensues. Report the incident if you are concerned.

NASAL SKIN CARE AFTER RHINOPLASTY

It may take a few months for your nasal skin to completely return to normal after rhinoplasty. It is normal for it to be oily or dry, sensitive, acne prone, pink or red, etc. You may be tempted to apply various topical regimens to try to speed up the return to normal. Do not do so! This may cause trauma to the skin or underlying structures, and may do more harm than good. Do not pop pimples! Simply follow a simple cleansing and moisturizing regimen. Avoid intensive sun exposure for the first week or so after bandage removal. Then, faithfully apply daily sunscreen of SPF 15 or higher. Avoid tanning the nose for at least a couple of months.

PATIENCE AND PERFECTIONISM

Often patients are pleased and relieved to first see their nose when the splint is removed. They expect their nose to be swollen, but are relieved to see positive changes. After about a week or so, a great deal of swelling dissipates. Then, reality sets in. It takes an entire year, sometimes even longer, for the final result to be achieved. As things settle, various small lumps and bumps, uneven swelling, etc., can understandably cause concern. The most common concerns are persistent swelling, numbness, firmness, lack of definition of the tip and the area above the tip, and bumps and irregularities inside the nostrils. When this occurs, we will advise you as to certain types of massage which can be of some benefit. But realize and accept that it takes time. The nationwide average is that 10% of all rhinoplasties require some revision. Our actual rate is substantially less than 10%. But no surgeon or nature can create a perfectly proportioned or perfectly symmetrical nose. Every surgeon in the world has to revise a nose occasionally. Of course, EVERY effort and all of our training and experience will be used to the utmost to giving you the best possible result. But occasionally, some revision is required. And this must be postponed for at least one year. Some anxious patients fear that a revision may be necessary, yet the vast majority of time things settle down nicely and no additional work is necessary. The most common revisions we encounter involve merely a small rasp of a bony prominence due to warping, a small trim of some cartilage, or a small injection of cortisone or a filler such as Restylane. Occasionally, you may incur additional financial costs, such as cost of the operating room or cost of the filler. This does not indicate your rhinoplasty was not successful or was not performed properly.

FINALLY

Remember the things you were told before your operation; namely:

• When the bandage is first removed, the nose will appear fat and turned up to much. This is due to operative swelling over the nose and in the upper lip. This swelling will subside to a large extent within a week; however, it will take up to one year for all the swelling to disappear and for your nose to reach its final contour.
• The discoloration will gradually disappear over a period of seven to ten days in most cases. We have yet to encounter a case where it persisted permanently.
• The thicker and oiler the skin, the longer it takes for the swelling to subside.
• The upper lip may appear stiff for awhile and you may feel that it interferes with your smile. This will disappear within a few weeks.
• The tip of the nose sometimes feels “numb” after a rhinoplasty, but this eventually disappears.

If you have any further questions, please feel free to call us. You can reach us twenty-four hours a day, and we are here to help you. We hope this helps you and reassures you during your recovery.