Long-term results

What repeats

Five findings that hold across the literature.

Swelling is mostly gone at a year and completely gone at four

A surgeon reporting 9398 primary and secondary rhinoplasties over 25 years states the figure directly: resolution of swelling at one year is roughly 90 to 95 percent, and complete resolution continues to the end of the fourth year. Photographs taken at six months are not the result.

Rests on: Erol, 25 years of experience · and recovery.

The tip drops, and how far depends on what supports it

Primary open rhinoplasties by one surgeon were measured on standardised photographs at two months and at twelve months. Projection loss at one year was 4.7% where a columellar strut was used and 0.2% where a septal extension graft was used. Rotation loss averaged 4.9 degrees against 1.3 degrees. Using a strut alone carried a 5.1-fold increased risk of losing more than 4% of projection. Where the septum itself was rebuilt, three-dimensional measurement of 144 patients found no significant loss of nasal length or projection between the early and the final follow-up, and no alar or columellar retraction over time. Three-dimensional photogrammetry followed 20 patients whose tips were held by a caudal septal extension graft for a mean of 3.3 years and as long as 6.6. Rotation fell 4.3% between the first and the sixth week after surgery, then held: projection, rotation and nasal length showed no significant change from six weeks out to two years or to the final visit.

Rests on: Bellamy and Rohrich, graft comparison · Mookerjee et al., long-term tip position · Asher et al., subtotal septal reconstruction · and alar retraction.

At four years the revision rate settles near one in twenty-five

A series of 1526 patients operated by open, modified open and endonasal approaches was followed for an average of about four years. Revision was performed in 4% of patients, and reported satisfaction exceeded 90% for all three techniques. A database study of 101,562 patients required at least three years since the primary operation before counting revisions, which is the interval at which the number stops moving much. The population figure comes from 175,842 septorhinoplasty patients tracked through three state databases for at least three years: revision ran at 3.3% overall, 3.1% after a primary operation and 11.0% after a secondary one. Satisfaction after a revision holds as well. At a mean of 2.5 years after revision rhinoplasty, 88% of the 46 patients who answered reported a real improvement in how the nose performed and 79% would have the revision again, and satisfaction fell as the count of previous rhinoplasties rose.

Rests on: Spataro et al., revision rates in 175 842 patients · Ors et al., 1526 patients · Hellings and Nolst Trenite, satisfaction after revision · Garbaccio et al., predictors of revision · and revision rhinoplasty.

Grafts change over years, and the change is measurable

Pooled across 14 studies of 2380 patients, diced cartilage used to build up the dorsum produced long-term complications in 11.5% and revision in 5.3%, with visible irregularity in 5.3%, infection in 4.5%, overcorrection in 0.7% and absorption in 0.5%. Onlay grafts to the upper third of the nose were measured on photographs after years of follow-up, and at least 50 percent resorption was seen in almost every graft type studied. Rib cartilage behaves differently. Thirty-eight patients whose dorsum was built up with rib were measured a mean of 27.4 months later, and tip projection was 4.2% higher than before surgery with nasal length 1.2% higher, so the graft had held its height. Of those patients, 81% rated the size of the nose normal, 75% the symmetry good and 66% the shape good, and nine needed a second operation.

Rests on: Li et al., diced cartilage meta-analysis · Lee et al., long-term resorption · Yilmaz et al., rib graft at 27.4 months · and rib cartilage grafts.

The gains that hold longest are the breathing gains

A prospective study of 54 patients followed for a year found general health, energy, physical functioning, pain and well-being all improved, and traced the improvement to patient-reported breathing rather than to appearance. Emotional limitation and social functioning did not change. In a programme that has measured every referred patient since 2014, the mean nasal obstruction score of the operated group fell from 69.1 before surgery to 23.1 at one year. The gain lasts. Two hundred and thirty-eight patients surveyed between 2 and 11 years after septal surgery, 89% of whom had come in because breathing was hard, reported satisfaction with the result in 68% of cases, and 73% would have the operation again.

Rests on: Xavier et al., quality of life · van Dam et al., ten years of measurement · Lindemann et al., satisfaction 2 to 11 years after septal surgery · and nasal airway obstruction.

By how long since the operation

Four points at which the nose is a different nose.

One year

The point the clinical practice guideline picks. Clinicians should document the patient's satisfaction with appearance and with breathing at a minimum of twelve months, which is also when most published series close.

Rests on: the clinical practice guideline · van Dam et al..

Two years

The longest follow-up in the comparison of dorsal preservation against conventional hump reduction. Across 377 patients, preservation showed better patient-rated appearance at six months, and by twelve and twenty-four months the difference had gone. Function was the same throughout.

Rests on: Wei et al., seven-year review · and preservation rhinoplasty · and the dorsal hump.

Five years

Where the swelling story ends and the graft story begins. Complete resolution of swelling runs to the fourth year, and graft resorption and visibility are measured over the same span.

Rests on: Erol · Lee et al. · Li et al..

Ten to twenty-five years

The evidence thins to single-surgeon retrospectives. One surgeon reports results from four to twenty-five years after diced cartilage grafting and states that late visibility of the graft did not occur. Another chronicles twenty years of nasal tip grafting from 1968 to 1991, in which displacement and visibility of the graft fell as the technique moved to multiple softer grafts and ear cartilage. Over that span the nose also ages on its own, with skin change, loss of tissue elasticity and bone resorption all altering the shape the surgeon left. The longest follow-up in the graft literature is a reconstructive one: 32 patients with 38 rib grafts to the nasal dorsum, reviewed an average of 7.9 years afterwards and as far out as 15 years. Blinded observers rated the appearance improved in 66.3% of responses, unchanged in 26.5% and worse in 7.2%, and almost two-thirds of the patients had fixation screws taken out because the screws eroded or showed.

Rests on: Erol · Sheen, tip graft twenty-year retrospective · Gurley et al., rib graft up to 15 years · Toriumi and Rosenberger, the ageing nose.

What to ask about long-term results

Questions the evidence supports asking.

Can I see photographs from more than a year out

Ask for the same patient in the same views at one year and at five. Swelling is still resolving into the fourth year, so a six-month photograph flatters the result.

Rests on: Erol · the clinical practice guideline.

What is holding my tip up

A septal extension graft held projection and rotation better than a columellar strut over the first year in a direct comparison. Ask which is planned and what the surgeon expects the tip to do by a year.

Rests on: Bellamy and Rohrich · Asher et al. · and the pinched tip.

What happens to the graft material over ten years

Ask about resorption and about the graft becoming visible under thin skin. Both are measured, and both depend on the material and how it is prepared.

Rests on: Li et al. · Lee et al. · and rib cartilage grafts.

How will you record my result at a year

Ask which questionnaire is used before surgery and repeated afterwards. A practice measuring every patient can answer the long-term question with its own numbers instead of a photograph.

Rests on: van Dam et al. · the clinical practice guideline.

Will my nose keep changing as I get older

Yes. Skin damage, tissue elasticity, bone resorption and gravity change the nose whether or not it has been operated on, and surgical planning for an older nose is written around resisting those forces.

Rests on: Toriumi and Rosenberger.

The terms, defined

The words used about the nose years later.

• Tip projection: how far the tip stands out from the face, measured on the lateral view. [36728586]
• Rotation: how far the tip is turned up, measured as the angle between the columella and the upper lip. [36728586]
• Columellar strut: a bar of cartilage set between the medial crura to support the tip. [36728586]
• Septal extension graft: cartilage fixed to the septum itself so the tip is anchored to the septum rather than floating on it. [36728586]
• Resorption: the body absorbing part of a graft, so the built-up area loses height. [35077410]
• Late graft show: a graft becoming visible through the skin years after surgery. [26818276]
• Diced cartilage: cartilage cut into small pieces and wrapped or glued before being laid on the dorsum. [34357798]
• NOSE score: Nasal Obstruction Symptom Evaluation, the questionnaire used to track breathing before and after surgery. [38016662]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology guideline sets the twelve-month record as the standard for documenting the result, covering satisfaction with appearance and with breathing. The plain language summary explains the same expectation for patients.

• The guideline landing page

Rests on: the clinical practice guideline.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a chapter on what a rhinoplasty does over time and one reporting a ten-year follow-up of a named tip technique.

• Rhinoplasty Long Term Effects
• Long term evaluation of the Goldman nasal tip procedure, a ten-year follow-up

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the technique, the healing course and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information on what to expect after surgery. See associations.

The trials in progress

Long-term reporting of tip support is being registered prospectively.

• Patient-Reported Outcomes and Complications After Structural Rhinoplasty Using Septal Extension Grafts, recruiting, 50 participants.

What is not settled

• Almost every rhinoplasty series stops at one year. The guideline asks for twelve-month documentation, and what runs past it is mostly septal surgery or reconstruction rather than cosmetic rhinoplasty. [28145823] [38016662] [28699038] [11743373]
• Long-term follow-up with dorsal preservation is acknowledged by its own authors to be scarce, and the longest comparative series stops at twenty-four months. [36396283] [42053436]
• Reports running past a decade are single-surgeon retrospectives of one technique, with no independent measurement and no control group. [26818276] [8416539]
• Graft resorption is measured on photographs rather than on imaging, and the studies report proportions of projection lost rather than volume. [35077410]
• Quality-of-life gain at a year tracks breathing, not appearance. Whether the appearance gain holds at five or ten years has not been measured. [36037858]
• No study separates the change caused by the operation from the change caused by ageing over the same period. [26862965]