If you have chosen an IV Liquid Sedative, they will insert a hypodermic into your tube that you are attached to or they attach the bag of it with a drip system to add a few drops every few seconds and when they spring open the stopper and it starts heading towards your body.  The the effects of the anesthesia are felt soon after injection or opening the stopper - a few seconds in fact.  It may feel similar to a sensation of "heat" entering your arm or hand at the catheter site.  It then feels as though it is creeping up your arm - then it "jumps" from your shoulder to a metallic-like taste under your tongue and then you are blissfully anesthetized.   The anesthesiologist or surgeon will then determine if you are sedated properly, your stats are stable and if you are ready for the surgery to begin.

You will then be marked with a magic marker type pen for the incision placement areas if your surgery will be an "open" one.  You will then be scrubbed with Betadine, the surgical marker markings will remain - although not as dark.  You will be injected with a solution of Lidocaine, epinephrine and saline, or an epinephrine/bicarbonate/lidocaine mixture. The epinephrine is a vasoconstrictor.  This will impede your skin's ability to bleed excessively.

Open Rhinoplasty
As we have explained in the "Open vs. Closed Rhinoplasty" Section - this is dependent upon your needs as a patient and your surgeon's preference as well. If you are opting for an open technique there is not much difference until we get to the columella incisions. As with the closed technique, the incisions will start within the nose along the top of the columella and the on the marginal areas of the upper alar rims. The skin is then dissected (separated) from the underlying cartilages very carefully with a pair of nasal scissors very much like the ones below:

Joseph® stainless nasal scissors

Your tissue is not cut with these scissors rather the scissors are inserted between the cartilage and overlying skin closed and then opened very gently. Care is taken to slowly separate the tissues to decrease risk of tearing or damaging either tissues. The columella and lower lateral cartilages are separated. After this is performed  you are then ready for that key external incision known as the "open" technique. The incision is made in either the form of an inverted "V" or "step" or "stair" type fashion. The columella skin is very thin so care is taken not to damage or slice into the underlying cartilage. After dissection and full incision the overlying skin is pulled back carefully from the cartilages and held in place with a retractor like below:

Converse® alar retractor

It is quite a frightful sight to the unseasoned onlooker. But the surgeon if you chose him will, will know what he is doing. Personally, my spouse saw my primary performed and will be present at my revision. He reported feeling only slightly woozy due to the smell in the room, the sights and sounds as well as his  having stayed up all night to help me prepare for surgery. Not to mention he disliked having a mask over his face and found it difficult to breathe.

I have seen the rhinoplasty procedure performed and although I do have a strong stomach it seemed very surreal to me. The sounds were the worst aspect of it, especially the rasping of the dorsum and the tapping of the stainless mallet. Still it was extremely interesting and I notice that some surgeons are very meticulous, almost anal, about the procedure. Some take a very long time for standard rhinoplasties and some breeze right through it with ease. It depends upon the surgeon and his or her surgical team but a well experienced team often produces a wonderful result with no "hitches" with of course the exclusion of the unforeseen.

Closed Rhinoplasty
There are similar cuts and dissections of the skin and cartilage as in the open but the visible external incision is not made. Reportedly this requires more skill and may not be appropriate for extreme deformities, although it can be argued that it depends upon the skill of the surgeon not the complexity of the problem. They are highly skilled surgeons who can perform a smooth surgery and obtain a wonderful result by "feel" and partial site, perhaps with small mirrors and lights. It may seem to the patient that a surgical Houdini has made a larger nose disappear or a too small one reappear. Well, rhinoplasty isn't magic and there is definite expertise behind each cut and tap.

Regardless of Incision Technique
If your surgery is for thinning the tip of the nose, sometimes called a Tiplasty, you will have cartilage removed or reworked to result in a more defined nasal tip. If you are having your nostrils narrowed you may have two incisions one on each side where the nose meets the face and forms a crease. The surgeon will normally take care to make the scars as inconspicuous as possible. Sometimes only incisions on the floor of the nose are made to bring in the nostrils but this is for very slight improvement.

If the nasal bone structure needs "thinning" or you have a hump on your bridge/dorsum you will have incisions leading up through the cartilage into the bridge of the nose so that a chisel like tool that looks more like a square flat blade of a butter knife or better yet, a flathead screwdriver, called an osteotome, or even sometimes a "V" shaped type chisel like below.

Sheehan® Osteotome	Ballenger®  4mm V shaped chisel

The osteotome is very sharp on the business end of it and can be inserted and tapped manually with a rubber or nylon tipped mallet (hammer) or more commonly, a stainless surgical mallet (which can be easily sterilized to reduce risk of infection and prolong its use. This act removes the bony hump on your bridge after the cartilage hump  is removed. 

Gerzog® stainless surgical mallet

 

Also a chisel like instrument is used for the side bones that meet the cheek to nose junction. This may take a few (usually no more than 8 sets of two, but this is highly individual) taps to "break" the facial bones precisely. This is usually called an osteotomy (where bone is divided or removed). The surgeon does not just break your nose with a hammer - it is precisely carried out. This instrument can be seen above (osteotome) If a smaller hump is present, the dorsal hump can be rasped (filed down) with an instrument called, well what else, a rasp. This instrument is almost like a nail file crossed with a stainless callous file.

typical rasp
(Joseph® brand)

After the bones are "broken", they are moved together to form a narrower nasal area as well as a little more projection, if needed. After all the reduction or infracture methods have been carried out, the nose is moved into position or the tip work, especially with need for rebuilding such as with septal cartilage or in more extensive reconstructions or revisions - rib or ear cartilage and even synthetic or biological  implants. 

After the nose is satisfactory to the surgeon and he feels that your needs and desires have been met, the incision lines are then sutured and you may then have "packing" inserted. Your nose is then taped and a cast made from plaster, metal, tape or more commonly, plastic, is applied to the nose to protect it and help it retain its "new" shape during the healing phase. The bones fuse together quite rapidly but refrain from contact sports until you receive the 'okay' from your doctor. The cartilage, unfortunately, takes quite some time to define and may appear swollen and distorted for many months.

Please Check Our Information Resources (Links) Section for links to Rhinoplasty & Revision Rhinoplasty Tutorials, Medical Journals & Abstracts with Photos & Diagrams

 

References
all surgical instrument diagrams and photos are the property of www.surgical911.com: In my opinion, the best in online surgical instrument sales
Rhinoplasty Tutorial - Dr. Steven B. Denenberg at FacialSurgery.com 
Bermant Rhinoplasty Encyclopedic Tutorial - Dr. Michael Bermant 
Dr. Paul O'Keeffe's Rhinoplasty Patient Resource 
Aesthetic Nose Surgery - T.Y. Steven Ip, M.D. 
Anatomy as Related to Rhinoplasty - Index and Description - Rod J. Rohrich, M.D., F.A.C.S. and Jack Gunter, M.D., F.A.C.S 
Functional Endoscopic Sinus Surgery - September 1, 1998 - American Academy of Family Physicians 
Open Rhinoplasty - Kyung Shik Suh, M.D
The Rhinoplasty Surgery Video - Jeffrey C. Friedman