Rhinoplasty
Rhinoplasty is one of the most performed cosmetic surgeries worldwide. One fourth of the patients are male. It is a challenging procedure, requiring great surgical skills and experience. Statistics show that patient satisfaction increases with the increasing experience level of their surgeons. The position of the nose makes it responsible for facial attractiveness and harmony, this may cause self-esteem issues when there are things about their noses that leave the person unsatisfactory.
The reason for an unsatisfactory nose can differ; it may be a congenital deformity, can be hereditary, can be obtained later in life due to accidents. But, disliking a nose to undergo a rhinoplasty isn’t always due to aesthetical concerns. Correcting breathing issues is a health related improvement that rhinoplasty has to offer.
Aesthetical concerns:
Breathing problems:
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Nasal surgeries are usually avoided until adolescence. There is a controversy on this; some surgeons choose to avoid nasal surgery on pediatric patients, due to its potential impact on the nasal and midface growth. The others, though, say delaying may result in negative functional and aesthetic outcomes and may have an adverse effect on the child’s psychological development.
Today, nasal surgeries in younger patients are being performed safely, in selected patients. Goal of the surgery is a determinant. Aggressive surgical approaches are to be avoided in order not to deter facial development. The goals should be in line with; restoring, repositioning, preserving the structure. Congenital or developmental deformities should be addressed as early as possible. Traumatic deformities should be attended to immediately. If the nose has a deformity that is too unnatural of an appearance, it is also to be improved.
On the other hand, the reason of an aesthetic concern should be delayed at least until adolescence.
The open rhinoplasty technique is widely used. The advantages are the direct visualization and access to the nasal structures, which makes it easier to operate on the nose. It also allows for the precise identification and correction of the deformity. Relative ease of suturing grafts is another advantage. The disadvantages include prolonged swelling, possible visibility of the columellar scar, possibility of vascular compromises, possible unnecessary dissection and the longer (than the closed approach) operation time.
In the open approach, the nose is opened from an incision made under the columella that is just under the column that separates the nostrils, under general anesthesia to ensure the comfort of the patient and the protection of the airway. From this incision, the skin of the nose is separated and lifted up to allow the surgeon to see and work on the interior of the nose.
Depending on the reason and the goal of the surgery, after the incision is made, one or multiple of the following procedures can be done
These structures are located bilaterally deep in the nose and help cleanse and humidify the air that is inhaled through the nose into the lungs. They can get enlarged, which can obscure the air passage to the lungs.
It allows a graduated approach to correct the nasal dorsum (bone & cartilage structure of the nose) by keeping the upper lateral cartilages intact.
Septoplasty is done to straighten the bone and cartilage dividing the two nostrils. If needed, during rhinoplasty a small piece of septal cartilage can be harvested to use in another part of the nose for reshaping.
Performed to narrow wide bony vault at the base or at the dorsum, but can also be performed to close an open roof, or to straighten the deviated nasal bones.
Repositioning the nasal bones following osteotomies, to correct any residual asymmetries.
Employed to increase projection of the columella, or to strengthen and straighten it.
The shape of the nose tip is addressed. Different sutures (Interdomal Suture, Transdomal Suture, Middle Crura Suture) are used to address individual problems.
The rotation of the nose tip is one of the most frequent factors for patients deciding to have rhinoplasty. It can be done by several techniques depending on the anatomical features of the patient; Cephalic Trim, Caudal Septal Trim, Lateral Crural Shortening, Tip Rotation Suture.
Done to correct or prevent retraction or collapsing of the alar rim (nostril). To keep an appropriate opening in the nostril is very important for easy breathing, but can also be an aesthetical concern.
It is performed to address alar flaring, large nostrils, wide alar base, or nostril asymmetries.
Grafting is widely performed in rhinoplasty surgeries, for either functional or aesthetic purposes. It is an essential part of primary and revision rhinoplasties. The reinforcement provided by the grafts enable for the results of the rhinoplasty to last longer without falling prey to the effects of gravity and aging. Depending on the area, grafting techniques will differ. The material for the graft is mostly determined by the specific needs, availability of the graft material, and the surgeon’s preference. Areas that grafts are used include: Nasal Tip, Nasal Dorsum & Septum, Alar Region.
Autogenous cartilage is the most safe and preferred material for grafting.
If it is available, septal cartilage (cartilage part of the septum) is the preferred donor material because of the ease of access and availability. If it’s not available for harvest or it’s insufficient, rib or concha (ear) cartilages can be used in place.
When septal cartilage is not available or enough, cartilage of the ear can be used as the graft.
Cartilage from the ribs is another possible graft donor as they are very sturdy. When a total reconstruction is underway ribs are chosen the most as the graft material because of its volume, which is more than 4 times larger than the ear cartilage.
Nonautogenous materials that are not the patient’s own cartilage are used when the patient’s own cartilages are unavailable, insufficient or inoperable.
Harvested from prescreened donor cadavers and either subjected to 60k Gy of radiation or fresh frozen non-irradiated costal cartilage that is decontaminated using light surfactant and antibiotic solution for sterilization, these irradiated or non-irradiated homograft costal cartilages provide an option without requirement of a donor site.
Synthetic materials that are biocompatible, inert and can be integrated well provide many advantages; lack of additional donor site, abundant supply, ability to retain shape, and the ability to be patient specific. Most commonly used alloplastic materials include: Silicone, Medpor (Porous High-Density Polyethylene), Gore-Tex (Expanded Polytetrafluoroethylene).
All synthetic grafts are prone to migration and extrusion, but the risk for both is higher for silicone grafts than the other two. Medpor and Gore-Tex allow tissue growth in their porous structures which lowers the risk of extrusion or migration.
Piezoelectric instrument assisted rhinoplasty can be used with both open and closed approaches. The device is used for osteotomy procedure, and reshaping the nasal pyramid. Open approach is the generally used approach for osteotomies, but with the help of Piezoelectric instruments closed approach can also be chosen. Piezoelectric instrument is an ultrasonic tool that has a variety of tips such as saws, rasps, and scrapers; allows for precise management of bony structures, while minimizing the soft tissue damage. This makes the reshaping, cutting and rasping of the nasal bones a lot faster and easier, while reducing the risks of complications.
People who are dissatisfied with their primary rhinoplasty results often seek a revision rhinoplasty. Revision rhinoplasties make up from 5.0% to 15.5% of all rhinoplasties. Since the nose has already been worked on, and there are unwanted effects, producing the desired effects that will be satisfactory even in the years to come, this is a highly challenging surgery.
Most common deformities that lead to a revision rhinoplasty:
Pollybeak Deformity
Nose tip related:
Tip asymmetry,
Tip over-rotation or depression
Columella (column of tissue that links the nasal tip to the nasal base and separates the nostrils) related:
Retracted or hanging columella,
wide columella
Dorsum (bone & cartilage bridge that connects the nose to the face) related:
Dorsal Saddle,
over-resected dorsum
Alar (the tissue that connects the nasal tip to the cheeks, making up most of the nostrils) related:
Alar retraction,
Alar distortion
Crooked nose, mid-nasal asymmetry
Residual hump, dorsal irregularity
Airway obstruction
The complications can vary depending on the approach and methods as well as the patient’s anatomy. Although rhinoplasty has a low complication rate, with increased experience of the surgeon the risk of a complication is further minimized.
In reduction rhinoplasties, the collapsing of the nasal structures may block the air passage and result in difficulty breathing.
Either due to scars or loss of sensation, patients may feel like their nose is blocked while there is no obstruction.
Some swelling and hematomas after rhinoplasties are normal and not significant risk or complication.
Tissue loss, sensation loss (numbness), fibrosis, cysts can be seen. Edema and hematomas can also occur, but usually resolve with time.
With any surgery, there is a risk of infection of the operated site. If not addressed immediately, the infections can lead to necrosis.
The result may not be as ideal as desired, and the nose may look deformed. In such cases, patients usually resort to a secondary revision rhinoplasty.