| Rhinoplasty | |
|---|---|
| Intervention | |
Rhinoplasty: The lower lateral cartilage (greater alar cartilage) exposed for plastic modification via the left nostril. |
|
| ICD-9-CM | 21.87 |
| MeSH | D012225 |
Rhinoplasty (Greek: ῥίς rhis, nose + πλάσσειν plassein, to shape), also nose job, is a plastic surgery procedure for correcting and reconstructing the form, restoring the functions, and aesthetically enhancing the nose, by resolving nasal trauma (blunt, penetrating, blast), congenital defect, respiratory impediment, and a failed primary rhinoplasty. In the surgeries — closed rhinoplasty and open rhinoplasty — an otolaryngologist (ear, nose, and throat specialist), a maxillofacial surgeon (jaw, face, and neck specialist), or a plastic surgeon, creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the soft tissues from the osseo-cartilaginous nasal framework, correcting them as required for form and function, suturing the incisions, and applying a stent to immobilize the corrected (new) nose to ensure the proper healing of the surgical cuts.[1]
Contents |
Rhinoplasty (reconstructive nose surgery) was first developed in ancient India, by the ayurvedic physician Sushruta (ca. 800 BC), who described reconstruction of the nose in the Sushruta samhita (ca. 500 BC), his medico–surgical compendium. The physician Sushruta and his medical students developed and applied plastic surgical techniques for reconstructing noses, genitalia, earlobes, et cetera, that were amputated as religious, criminal, or military punishment. Sushruta also developed the otoplastic technique for reconstructing an earlobe with skin from the cheek, and the forehead flap rhinoplasty procedure that remains contemporary plastic surgical practice. In the Sushruta samhita compendium, the physician Sushruta describes the (modern) free-graft Indian rhinoplasty as the Nasikasandhana, wherein:
The portion of the nose to be covered should be first measured with a leaf. Then, a piece of skin of the required size should be dissected from the living skin of the cheek, and turned back to cover the nose, keeping a small pedicle attached to the cheek. The part of the nose to which the skin is to be attached should be made raw, by cutting the nasal stump with a knife. The physician then should place the skin on the nose and stitch the two parts swiftly, keeping the skin properly elevated, by inserting two tubes of eranda (the castor-oil plant) in the position of the nostrils, so that the new nose has proper shape. The skin thus properly adjusted, it should then be sprinkled with a powder of liquorice, red sandal-wood, and barberry plant. Finally, it should be covered with cotton, and clean sesame oil should be continually applied. When the skin has united and granulated, if the nose is too short or too long, the middle of the flap should be divided, and an endeavour made to enlarge or shorten it. (Sushruta samhita 1.16)[2]
During the Roman Empire (27 BC – AD 476) the encyclopaedist Aulus Cornelius Celsus (ca. 25 BC – AD 50) published the 8-tome De Medicina (On Medicine, ca. AD 14), which described plastic surgery techniques and procedures for the correction and the reconstruction of the lips, the ears, the nose, et cetera, and for the amputation of diseased and damaged parts of the human body.[3]
At the Byzantine Roman court of the Emperor Julian the Apostate (AD 331–363), the royal physician Oribasius (ca. AD 320–400) published the 70-volume Synagogue Medicae (Medical Compilations, AD 4th c.), which described facial-defect reconstructions that featured loose sutures that permitted a surgical wound to heal without distorting the facial flesh; how to clean the bone exposed in a wound; debridement, how to remove damaged tissue to forestall infection and so accelerate healing of the wound; and how to use autologous skin flaps to repair damaged cheeks, eyebrows, lips, and nose, to restore the patient’s normal visage.
Nonetheless, during the centuries of the European Dark Ages (AD 5th – 15th centuries) that followed the Imperial Roman collapse (AD 476), the fifth-century BC Asian plastic surgery knowledge of the Sushruta samhita went unknown to the West until the tenth century AD, with the publication, in Old English, of the Anglo-Saxon physician’s manual Bald's Leechbook (ca. AD 920) describing the plastic repair of a cleft lip; as a medical compendium, the Leechbook is notable for categorizing ailments and treatments as internal medicine and as external medicine, for providing herbal medical remedies, and for providing supernatural incantations (prayers), when required.
In the eleventh century, at Damascus, the Arab physician Ibn Abi Usaibia (1203–1270) translated the Sushruta samhita from Sanskrit to Arabic. In due course, Sushruta’s medical compendium travelled from Arabia to Persia to Egypt, and, by the fifteenth century, Western European medicine had encountered it as the medical atlas Cerrahiyet-ul Haniye (Imperial Surgery, 15th c.), by Şerafeddin Sabuncuoğlu (1385–1468); among its surgical techniques featured a breast reduction procedure.[4][5]
In Italy, Gasparo Tagliacozzi (1546–1599), professor of surgery and anatomy at the University of Bologna, published Curtorum Chirurgia Per Insitionem (The Surgery of Defects by Implantations, 1597), a technico–procedural manual for the surgical repair and reconstruction of facial wounds in soldiers. The illustrations featured a re-attachment rhinoplasty using a biceps muscle pedicle flap; the graft attached at 3-weeks post-procedure; which, at 2-weeks post-attachment, the surgeon then shaped into a nose.[6]
In time, the fifth-century BC Indian rhinoplasty technique — featuring a free-flap graft — was (re) discovered by Western medicine in the eighteenth century, during the Third Anglo–Mysore War (1789–1792) of colonial annexation, by the British against Tipu Sultan, when the East India Company surgeons Thomas Cruso and James Findlay witnessed Indian rhinoplasty procedures at the British Residency in Poona. In the English-language Madras Gazette, the surgeons published photographs of the rhinoplasty procedure and its nasal reconstruction outcomes; later, in the October 1794 issue of the Gentleman's Magazine of London, the doctors Cruso and Findlay published an illustrated report describing a forehead pedicle-flap rhinoplasty that was a technical variant of the free-flap graft technique that Sushruta had described some twenty-three centuries earlier:
A thin plate of wax is fitted to the stump of the nose, so as to make a nose of good appearance; it is then flattened and laid on the forehead. A line is drawn around the wax, which is then of no further use, and the operator then dissects off as much skin [the flap] as [the wax plate] had covered, leaving undivided a small slip [the flap-pedicle] between the eyes. This slip preserves the blood circulation till a union has taken place between the new and the old parts. The cicatrix of the stump of the nose is next pared off, and, immediately behind the new part, an incision is made through the skin, which passes around both alae, and goes along the upper lip. The skin, now brought down from the forehead, and being twisted half-around, is inserted into this incision, so that a nose is formed with a double hold above, and with its alae and septum below, fixed in the incision. A little Terra Japonica (pale-catechu) is softened with water, and after being spread on slips of cloth, five or six of these are placed over each other to secure the joining. No other dressing, but this cement, is used for four days. It is then removed, and cloths dipped in ghee are applied. The connecting slip of skin is divided at about the twentieth day, when a little more dissection is necessary to improve the appearance of the new nose. For five or six days after the operation, the patient is made to lie on his back, and on the tenth day, bits of soft cloth are put into the nostrils to keep them sufficiently open. This operation is always successful. The artificial nose is secured and looks nearly as well as the natural nose, nor is the scar on the forehead very observable after a length of time. (Gentleman’s Magazine of London, October 1794)[7]
Pre-dating the Indian Sushruta samhita medical compendium is the Ebers Papyrus (ca. 1550 BC), an Ancient Egyptian medical papyrus that describes rhinoplasty as the plastic surgical operation for reconstructing a nose destroyed by rhinectomy, such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time and culture.[8] In the event, the Indian rhinoplasty technique perdured in nineteenth-century Western European medicine; in Great Britain, Joseph Constantine Carpue (1764–1846) published the Account of Two Successful Operations for Restoring a Lost Nose (1815), which described two rhinoplasties: the reconstruction of a battle-wounded nose, and the repair of an arsenic-damaged nose. (cf. Carpue’s operation)[2][9]
In Germany, rhinoplastic technique was refined by surgeons such as the Berlin University professor of surgery Karl Ferdinand von Gräfe (1787–1840), who published Rhinoplastik (Rebuilding the Nose, 1818) wherein he described fifty-five (55) historical plastic surgery procedures (Indian rhinoplasty, Italian rhinoplasty, etc.), and his technically innovative free-graft nasal reconstruction (with a tissue-flap harvested from the patient’s arm), and surgical approaches to eyelid, cleft lip, and cleft palate corrections. Dr. von Gräfe’s protégé, the medical and surgical polymath Johann Friedrich Dieffenbach (1794–1847), who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published Die Operative Chirurgie (Operative Surgery, 1845), which became a foundational medical and plastic surgical text. (see strabismus, torticollis) Moreover, the Prussian Jacques Joseph (1865–1934) published Nasenplastik und sonstige Gesichtsplastik (Rhinoplasty and other Facial Plastic Surgeries, 1928), which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions.[10]
In the United States, in 1887, the otolaryngologist John Orlando Roe (1848–1915) performed the first, modern endonasal rhinoplasty (closed rhinoplasty), about which he reported in the article The Deformity Termed “Pug Nose” and its Correction, by a Simple Operation (1887), and about his management of saddle nose deformities.[11][12]
In the early twentieth century, Freer, in 1902, and Killian, in 1904, respectively pioneered the submucous resection septoplasty (SMR) procedure for correcting a deviated septum; they raised mucoperichondrial tissue flaps, and resected the cartilaginous and bony septum (including the vomer bone and the perpendicular plate of the ethmoid bone), maintaining septal support with a 1.0-cm margin at the dorsum and a 1.0-cm margin at the caudad, for which innovations the technique became the foundational, standard septoplastic procedure. In 1921, A. Rethi introduced the open rhinoplasty approach featuring an incision to the columella to facilitate modifying the tip of the nose.[13] In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1947, Maurice H. Cottle (1898–1981) endonasally resolved a septal deviation with a minimalist hemitransfixion incision, which conserved the septum; thus, he advocated for the practical primacy of the closed rhinoplasty approach.[8] In 1957, A. Sercer advocated the “decortication of the nose” (Dekortication des Nase) technique which featured a columellar-incision open rhinoplasty that allowed greater access to the nasal cavity and to the nasal septum.
Nonetheless, at mid–twentieth century, despite such refinement of the open rhinoplasty approach, the endonasal rhinoplasty was the usual approach to nose surgery — until the 1970s, when Padovan presented his technical refinements, advocating the open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the later 1970s, and by Jack P. Gunter in the 1990s.[14][15] Goodman impelled technical and procedural progress with the article External Approach to Rhinoplasty (1973), which reported his technical refinements and popularized the open rhinoplasty approach.[16] In 1982, Jack Anderson reported his refinements of nose surgery technique in the article Open Rhinoplasty: An Assessment (1982).[17] During the 1970s, the principal application of open rhinoplasty was to the first-time rhinoplasty patient (i.e. a primary rhinoplasty), not as a revision surgery (i.e. a secondary rhinoplasty) to correct a failed nose surgery. In 1987, in the article External Approach for Secondary Rhinoplasty (1987), Jack P. Gunter reported the technical effectiveness of the open rhinoplasty approach for performing a secondary rhinoplasty; his improved techniques advanced the management of a failed nose surgery.[18]
Hence does contemporary rhinoplastic praxis derive from the primeval (ca. 600 BC) Indian rhinoplasty (nasal reconstruction via an autologous forehead-skin flap) and its technical variants: Carpue’s operation, the Italian rhinoplasty (pedicle-flap reconstruction, aka the Tagliocotian rhinoplasty); and the closed-approach endonasal rhinoplasty, featuring exclusively internal incisions that allow the plastic surgeon to palpate (feel) the corrections being effected to the nose.[19]
Non-surgical rhinoplasty originated at the turn of the nineteenth century, when the New York City neurologist James Leonard Corning (1855–1923) and the Viennese physician Robert Gersuny (1844–1924) pioneered the technique of using liquid paraffin to elevate the collapsed nasal dorsum that characterizes the saddle nose deformity. Yet, despite its corrective efficacy, liquid paraffin proved biologically harmful, and its medical use as a nasal soft-tissue filler, was abandoned because it caused paraffinoma (wax cancer), a serious medical complication.
During the 1960s, soft-tissue fillers of medical-grade silicone gel were introduced to the rhinoplastic armamentarium, however, like liquid paraffin, silicone gels also proved biologically harmful, because they caused medical complications such as the corrective soft-tissue filler migrating from the nasal tissues to elsewhere in the patient’s face and body, and the development of ulcers and granulomas.[20] To minimize the risk of these medical complications for the patient, practitioners such as D.S. Orentreich advocated effecting the non-surgical correction by “microdroplet technique”, minute doses of silicone injected in the course of multiple correction sessions.[21]
Contemporary non-surgical rhinoplasty was established with the Australian study Rhinoplasty Using Injectable Polyacrylamide Gel — A Patient Study (2005), wherein Dr. Andrew Tuan-anh Le reported successful corrective outcomes using the soft-tissue filler polyacrylamide gel (PAAG), a hydrophilic colloid injected to the tissues of the nasal defect or deformity in order to (re)create a functional and aesthetically proportionate nose for the patient.[22][23] Among the subcutaneous soft-tissue filler agents employed to achieve non-surgical rhinoplasty are: injectable silicone, calcium hydroxyapatite, hyaluronic acid, collagen (human, bovine, and porcine), and polymethylmethacrylate. Possible complications include infection, hematoma, discomfort, anatomic asymmetry, foreign body reaction (rejection) or granuloma, or both, over-correction, under-correction, intravascular injection (with potential for thromboembolism), adverse medication reaction (anaphylaxis), allergic reaction, the need for additional “touch up” injections of the tissue filler, palpability, visibility, distortion with muscular contraction, the need for secondary revisions, and the physician’s inability to guarantee a specific cosmetic result to the patient.
At four (4) weeks of gestational development, the neural crest cells (the precursors of the nose) begin their caudad migration (from the posterior) towards the midface. Two symmetrical nasal placodes (the future olfactory epithelium) develop inferiorly, which the nasal pits then divide into the medial and the lateral nasal processes (the future upper lip and nose). The medial processes then form the septum, the philtrum, and the premaxilla of the nose; the lateral processes form the sides of the nose; and the mouth forms from the stomodeum (the anterior ectodermal portion of the alimentary tract), which is inferior to the nasal complex.
A nasobuccal membrane separates the mouth from the nose; respectively, the inferior oral cavity (the mouth) and the superior nasal cavity (the nose). As the olfactory pits deepen, said development forms the choanae, the two openings that connect the nasal cavity and the nasopharynx (upper part of the pharynx that is continuous with the nasal passages). Initially, primitive-form choanae develop, which then further develop into the secondary, permanent choanae.
At ten (10) weeks of gestation, the cells differentiate into muscle, cartilage, and bone. If this important, early facial embryogenesis fails, it might result in anomalies such as choanal atresia (absent or closed passage), medial nasal clefts (fissures), or lateral nasal clefts, nasal aplasia (faulty or incomplete development), and polyrrhinia (double nose).[24]
This normal, human embryologic development is exceptionally important — because the newborn infant breathes through his or her nose during the first 6 weeks of life — thus, when a child is afflicted with bilateral choanal atresia, the blockage of the posterior nasal passage, either by abnormal bony tissue or by abnormal soft tissue, emergency remedial action is required to ensure that the child can breathe.[25]
For plastic surgical correction, the structural anatomy of the nose comprehends: A. the nasal soft tissues; B. the aesthetic subunits and segments; C. the blood supply arteries and veins; D. the nasal lymphatic system; E. the facial and nasal nerves; F. the nasal bones; and G. the nasal cartilages.
To plan, map, and execute the surgical correction of a nasal defect or deformity, the structure of the external nose is divided into nine (9) aesthetic nasal subunits, and six (6) aesthetic nasal segments, which provide the plastic surgeon with the measures for determining the size, extent, and topographic locale of the nasal defect or deformity.
In turn, the nine (9) aesthetic nasal subunits are configured as six (6) aesthetic nasal segments; each segment comprehends a nasal area greater than that comprehended by a nasal subunit.
Using the co-ordinates of the subunits and segments to determine the topographic location of the defect on the nose, the plastic surgeon plans, maps, and executes a rhinoplasty procedure. The unitary division of the nasal topography permits minimal, but precise, cutting, and maximal corrective-tissue coverage, to produce a functional nose of proportionate size, contour, and appearance for the patient. Hence, if more than 50 per cent of an aesthetic subunit is lost (damaged, defective, destroyed) the surgeon replaces the entire aesthetic segment, usually with a regional tissue graft, harvested from either the face or the head, or with a tissue graft harvested from elsewhere on the patient’s body.[26]
Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant blood. The principal arterial blood-vessel supply to the nose is two-fold: (i) branches from the internal carotid artery, the branch of the anterior ethmoid artery, the branch of the posterior ethmoid artery, which derive from the ophthalmic artery; (ii) branches from the external carotid artery, the sphenopalatine artery, the greater palatine artery, the superior labial artery, and the angular artery.
The external nose is supplied with blood by the facial artery, which becomes the angular artery that courses over the superomedial aspect of the nose. The sellar region (sella turcica, “Turkish chair”) and the dorsal region of the nose are supplied with blood by branches of the internal maxillary artery (infraorbital) and the ophthalmic arteries that derive from the internal common carotid artery system.
Internally, the lateral nasal wall is supplied with blood by the sphenopalatine artery (from behind and below) and by the anterior ethmoid artery and the posterior ethmoid artery (from above and behind). The nasal septum also is supplied with blood by the sphenopalatine artery, and by the anterior and posterior ethmoid arteries, with the additional circulatory contributions of the superior labial artery and of the greater palatine artery. These three (3) vascular supplies to the internal nose converge in the Kiesselbach plexus (the Little area), which is a region in the anteroinferior-third of the nasal septum, (in front and below). Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the sinus caverns, which makes possible the potential intracranial spreading of a bacterial infection of the nose. Hence, because of such an abundant nasal blood supply, tobacco smoking does therapeutically compromise post-operative healing.
The pertinent nasal lymphatic system arises from the superficial mucosa, and drains posteriorly to the retropharyngeal nodes (in back), and anteriorly (in front), either to the upper deep cervical nodes (in the neck), or to the submandibular glands (in the lower jaw), or into both the nodes and the glands of the neck and the jaw.
The sensations registered by the human nose derive from the first two (2) branches of cranial nerve V, the trigeminal nerve (nervus trigeminis). The nerve listings indicate the respective innervation (sensory distribution) of the trigeminal nerve branches within the nose, the face, and the upper jaw (maxilla).
The maxillary division innervation
The supply of parasympathetic nerves to the face and the upper jaw (maxilla) derives from the greater superficial petrosal (GSP) branch of cranial nerve VII, the facial nerve. The GSP nerve joins the deep petrosal nerve (of the sympathetic nervous system), derived from the carotid plexus, to form the vidian nerve (in the vidian canal) that traverses the pterygopalatine ganglion (an autonomic ganglion of the maxillary nerve), wherein only the parasympathetic nerves form synapses, which serve the lacrimal gland and the glands of the nose and of the palate, via the (upper jaw) maxillary division of cranial nerve V, the trigeminal nerve.
In the upper portion of the nose, the paired nasal bones attach to the frontal bone. Above and to the side (superolaterally), the paired nasal bones connect to the lacrimal bones, and below and to the side (inferolaterally), they attach to the ascending processes of the maxilla (upper jaw). Above and to the back (posterosuperiorly), the bony nasal septum is composed of the perpendicular plate of the ethmoid bone. The vomer bone lies below and to the back (posteroinferiorly), and partially forms the choanal opening into the nasopharynx, (the upper portion of the pharynx that is continuous with the nasal passages). The floor of the nose comprises the premaxilla bone and the palatine bone, the roof of the mouth.
The nasal septum is composed of the quadrangular cartilage, the vomer bone (the perpendicular plate of the ethmoid bone), aspects of the premaxilla, and the palatine bones. Each lateral nasal wall contains three pairs of turbinates (nasal conchae), which are small, thin, shell-form bones: (i) the superior concha, (ii) the middle concha, and (iii) the inferior concha, which are the bony framework of the turbinates. Lateral to the turbinates is the medial wall of the maxillary sinus. Inferior to the nasal conchae (turbinates) is the meatus space, with names that correspond to the turbinates, e.g. superior turbinate, superior meatus, et alii. The internal roof of the nose is composed by the horizontal, perforated cribriform plate (of the ethmoid bone) through which pass sensory filaments of the olfactory nerve (Cranial nerve I); finally, below and behind (posteroinferior) the cribriform plate, sloping down at an angle, is the bony face of the sphenoid sinus.
The cartilaginous septum (septum nasi) extends from the nasal bones in the midline (above) to the bony septum in the midline (posteriorly), then down along the bony floor. The septum is quadrangular; the upper-half is flanked by two (2) triangular-to-trapezoidal cartilages: the upper lateral-cartilages, which are fused to the dorsal septum in the midline, and laterally attached, with loose ligaments, to the bony margin of the pyriform (pear-shaped) aperture, while the inferior ends of the upper lateral-cartilages are free (unattached). The internal area (angle), formed by the septum and upper lateral-cartilage, constitutes the internal valve of the nose; the sesamoid cartilages are adjacent to the upper lateral-cartilages in the fibroareolar connective tissue.
Beneath the upper lateral-cartilages lay the lower lateral-cartilages; the paired lower lateral-cartilages swing outwards, from medial attachments, to the caudal septum in the midline (the medial crura) to an intermediate crus (shank) area. Finally, the lower lateral-cartilages flare outwards, above and to the side (superolaterally), as the lateral crura; these cartilages are mobile, unlike the upper lateral cartilages. Furthermore, some persons present anatomical evidence of nasal scrolling — i.e. an outward curving of the lower borders of the upper lateral-cartilages, and an inward curving of the cephalic borders of the alar cartilages.
The form of the nasal subunits — the dorsum, the sidewalls, the lobule, the soft triangles, the alae, and the columella — are configured differently, according to the race and the ethnic group of the patient, thus the nasal physiognomies denominated as: African, platyrrhine (flat, wide nose); Asiatic, subplatyrrhine (low, wide nose); Caucasian, leptorrhine (narrow nose); and Hispanic, paraleptorrhine (narrow-sided nose). The respective external valve of each nose is variably dependent upon the size, shape, and strength of the lower lateral cartilage.[27]
In the midline of the nose, the septum is a composite (osseo-cartilaginous) structure that divides the nose into two (2) similar halves. The lateral nasal wall and the paranasal sinuses, the superior concha, the middle concha, and the inferior concha, form the corresponding passages, the superior meatus, the middle meatus, and the inferior meatus, on the lateral nasal wall. The superior meatus is the drainage area for the posterior ethmoid bone cells and the sphenoid sinus; the middle meatus provides drainage for the anterior ethmoid sinuses and for the maxillary and frontal sinuses; and the inferior meatus provides drainage for the nasolacrimal duct.
The internal nasal valve comprises the area bounded by the upper lateral-cartilage, the septum, the nasal floor, and the anterior head of the inferior turbinate. In the narrow (leptorrhine) nose, this is the narrowest portion of the nasal airway. Generally, this area requires an angle greater than 15 degrees for unobstructed breathing; for the correction of such narrowness, the width of the nasal valve can be increased with spreader grafts and flaring sutures.
The surgical management of nasal defects and deformities divides the nose into six (6) anatomic subunits: (i) the dorsum, (ii) the sidewalls (paired), (iii) the hemilobules (paired), (iv) the soft triangles (paired), (v) the alae (paired), and (vi) the columella. Surgical correction and reconstruction comprehend the entire anatomic subunit affected by the defect (wound) or deformity, thus, the entire subunit is corrected, especially when the resection (cutting) of the defect encompasses more than 50 per cent of the subunit. Aesthetically, the nose — from the nasion (the mid-point of the nasofrontal junction) to the columella-labial junction — ideally occupies one-third of the vertical dimension of the person’s face; and, from ala to ala, it ideally should occupy one-fifth of the horizontal dimension of the person’s face.[28]
The nasofrontal angle, between the frontal bone and the nasion usually is 120 degrees; the nasofrontal angle is more acute in the male face than in the female face. The nasofacial angle, the slope of the nose relative to the plane of the face, is approximately 30–40 degrees. The nasolabial angle, the slope between the columella and the philtrum, is approximately 90–95 degrees in the male face, and approximately 100–105 degrees in the female face. Therefore, when observing the nose in profile, the normal show of the columella (the height of the visible nasal aperture) is 2–mm; and the dorsum should be rectilinear (straight). When observed from below (worm’s-eye view), the alar base configures an isosceles triangle, with its apex at the infra-tip lobule, immediately beneath the tip of the nose. The facially proportionate projection of the nasal tip (the distance of the nose’s tip from the face) is determined with the Goode Method, wherein the projection of the nasal tip should be 55-60 per cent of the distance between the nasion (nasofrontal junction) and the tip-defining point. A columellar double break might be present, marking the transition between the intermediate crus of the lower-lateral cartilage and the medial crus.
The Goode Method determines the extension of the nose from the facial surface by comprehending the distance from the alar groove to the tip of the nose, and then relating that measurement (of nasal-tip projection) to the length of the nasal dorsum. The nasal projection measurement is obtained by delineating a right triangle with lines parting from the nasion (nasofrontal juncture) to the alar–facial–groove. Then, a second, perpendicular delineation, that traverses the tip-defining point, establishes the ratio of projection of the nasal tip; hence, the range of 0.55:1 to 0.60:1, is the ideal nasal-tip-to-nasal-length projection.[29]
To determine the patient’s suitability for undergoing a rhinoplasty procedure, the surgeon clinically evaluates him or her with a complete medical history (anamnesis) to determine his or her physical and psychological health. The prospective patient must explain to the physician–surgeon the functional and aesthetic nasal problems that he or she suffers. The surgeon asks about the ailments’ symptoms and their duration, past surgical interventions, allergies, drugs use and drugs abuse (prescription and commercial medications), and a general medical history. Furthermore, additional to physical suitability is psychological suitability — the patient’s psychological motive for undergoing nose surgery is critical to the surgeon’s pre-operative evaluation of the patient. In the case of men, the surgeon must identify prospective patients presenting the mental traits denoted by the psychiatric acronym SIMON (single, immature, male, over-expectant, and narcissistic), which might indicate a man over-valuing the outcome of a rhinoplasty.[8]
The complete physical examination of the rhinoplasty patient determines if he or she is physically fit to undergo and tolerate the physiologic stresses of nose surgery. The examination comprehends every existing physical problem, and a consultation with an anaesthesiologist, if warranted by the patient’s medical data. Specific facial and nasal evaluations record the patient’s skin-type, existing surgical scars, and the symmetry and asymmetry of the aesthetic nasal subunits. The external and internal nasal examination concentrates upon the anatomic thirds of the nose — upper section, middle section, lower section — specifically noting their structures; the measures of the nasal angles (at which the external nose projects from the face); and the physical characteristics of the naso-facial bony and soft tissues. The internal examination evaluates the condition of the nasal septum, the internal and external nasal valves, the turbinates, and the nasal lining, paying especial attention to the structure and the form of the nasal dorsum and the tip of the nose.[8]
Furthermore, when warranted, specific tests — the mirror test, vasoconstriction examinations, and the Cottle maneuver — are included to the pre-operative evaluation of the prospective rhinoplasty patient. Established by Maurice H. Cottle (1898–1981), the Cottle maneuver is a principal diagnostic technique for detecting an internal nasal-valve disorder; whilst the patient gently inspires, the surgeon laterally pulls the patient’s cheek, thereby simulating the widening of the cross-sectional area of the corresponding internal nasal valve. If the maneuver notably facilitates the patient’s inspiration, that result is a positive Cottle sign — which generally indicates an airflow-correction to be surgically effected with an installed spreader-graft. Said correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. Nonetheless, the Cottle maneuver occasionally yields a false-positive Cottle sign, usually observed in the patient afflicted with alar collapse, and in the patient with a scarred nasal-valve region.[30]
The plastic surgical correction of congenital and acquired abnormalities of the nose restores functional and aesthetic properties by the surgeon’s manipulations of the nasal skin, the subcutaneous (underlying) cartilage-and-bone support framework, and the mucous membrane lining. Technically, the plastic surgeon’s incisional approach classifies the nasal surgery either as an open rhinoplasty or as a closed rhinoplasty procedure. In open rhinoplasty, the surgeon makes a small, irregular incision to the columella, the fleshy, exterior-end of the nasal septum; this columellar incision is additional to the usual set of incisions for a nasal correction. In closed rhinoplasty, the surgeon performs every procedural incision endonasally (exclusively within the nose), and does not cut the columella.[8]
The open rhinoplasty approach affords the plastic surgeon the advantages of ease in securing the grafts (skin, cartilage, bone) and, most important, in seeing the nasal cartilages proper, and so make the appropriate diagnosis. This procedural aspect can be especially difficult in revision surgery, and in rhinoplastic corrections of the thick-skinned “ethnic nose” of the colored man or woman. The study, Ethnic Rhinoplasty: a Universal Preoperative Classification System for the Nasal Tip (2009), reports that a nasal-tip classification system, based upon skin thickness, has been proposed to aid the surgeon in determining if an open rhinoplasty or a closed rhinoplasty shall best correct the defect or deformity afflicting the patient’s nose.[32]
Etiologically, the open and closed approaches to rhinoplastic correction resolve: (i) nasal pathologies (diseases intrinsic and diseases extrinsic to the nose); (ii) an unsatisfactory aesthetic appearance (disproportion); (iii) a failed primary rhinoplasty; (iv) an obstructed airway; and (v) congenital nose defects and deformities.
Acquired abnormalities such as:
A rhinoplastic correction can be performed on a patient who is under sedation, under general anaesthesia, or under local anaesthesia; initially, a local anaesthetic mixture of lidocaine and epinephrine is injected to numb the area, and temporarily reduce vascularity, thereby limiting any bleeding. Generally, the plastic surgeon first separates the nasal skin and the soft tissues from the osseo-cartilagenous nasal framework, and then corrects (reshapes) them as required, afterwards, sutures the incisions, and then applies either an external or an internal stent, and tape, to immobilize the newly reconstructed nose, and so facilitate the healing of the surgical cuts.[1] Occasionally, the surgeon uses either an autologous cartilage graft or a bone graft, or both, in order to strengthen or to alter the nasal contour(s). The autologous grafts usually are harvested from the nasal septum, but, if it has insufficient cartilage (as can occur in a revision rhinoplasty), then either a costal cartilage graft (from the rib cage) or an auricular cartilage graft (concha from the ear) is harvested from the patient’s body. When the rhinoplasty requires a bone graft, it is harvested from either the cranium, the hips, or the rib cage; moreover, when neither type of autologous graft is available, a synthetic graft (nasal implant) is used to augment the nasal bridge.
For the benefit of patient and the physician–surgeon, a photographic history of the entire rhinoplastic procedure is established; beginning at the pre-operative consultation, continuing during the surgical operation procedures, and concluding with the post-operative outcome. To record the “before-and-after” physiognomies of the nose and the face of the patient, the specific visual perspectives required are photographs of the nose viewed from the anteroposterior (front-to-back) perspective; the lateral view (profiles), the worm’s-eye view (from below), the bird’s-eye view (overhead), and three-quarter-profile views.[8]
In plastic surgical praxis, the term primary rhinoplasty denotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The term secondary rhinoplasty denotes the revision of a failed rhinoplasty, an occurrence in 5–20 per cent of rhinoplasty operations, hence a revision rhinoplasty. The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of an unaddressed nasal fracture; a defective tip of the nose, i.e. pinched (too narrow), hooked (parrot beak), or flattened (pug nose); and the restoration of clear airways. Although most revision rhinoplasty procedures are “open approach”, such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from the ear (auricular cartilage graft) or from the rib cage (costal cartilage graft).
In reconstructive rhinoplasty, the defects and deformities that the plastic surgeon encounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose; congenital defect, trauma (blunt, penetrating, blast), autoimmune disorder, cancer, intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). When cartilage is disrupted, suturing for re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial) prostheses, because of the reduced incidence of histologic rejection and medical complications.[33]
The human nose is a sensory organ that is structurally composed of three types of tissue: (i) an osseo-cartilaginous support framework (nasal skeleton), (ii) a mucous membrane lining, and (iii) an external skin. The anatomic topography of the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose into nasal subunits: (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures.[34][35]
Therefore, the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three (3) anatomic layers:
The technical principles for the surgical reconstruction of a nose derive from the essential operative principles of plastic surgery: that the applied procedure and technique(s) yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of the mucosa; cartilage battens to brace against tissue contraction and depression (topographic collapse); axial skin flaps designed from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting of bone, cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the reconstructed nasal subunit is not a nose proper, but a collagen-glued collage — of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments of ear cartilage — which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose.[37]
In nasal reconstruction, the plastic surgeon’s ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patient’s “normal nose”, as perceived at conversational distance (ca. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach, which requires that the surgeon balance the patient’s required rhinoplasty, with the patient’s aesthetic ideal (body image). In the context of surgically reconstructing the patient’s physiognomy, the “normal nose” is the three-dimensional (3-D) template for replacing the missing part(s) of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials — such as bone, cartilage, and flaps of skin and of tissue. In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the “normal nose” and from photographs of the patient before he or she suffered the nasal damage.
The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining with mucosa, cartilage with cartilage, bone with bone, and skin with skin that best match the native skin color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notable scarring propensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude.
The most effective nasal reconstruction for repairing a defect (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in the topographic transition zone(s) between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose with skin flaps. Nonetheless, in the final stage of nasal reconstruction — replicating the “normal nose” anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars, and render them (more) inconspicuous.[38]
The effectiveness of a rhinoplastic reconstruction of the external nose derives from the contents of the surgeon’s armamentarium of skin-flap techniques applicable to correcting defects of the nasal skin and of the mucosal lining; some management techniques are the Bilobed flap, the Nasolabial flap, the Paramedian forehead flap, and the Septal mucosal flap.
The design of the bilobed flap derives from the creation of two (2) adjacent random transposition flaps (lobes). In its original design, the leading flap is applied to cover the defect, and the second flap, is emplaced where the skin flexes more, and fills the donor-site wound (from where the first flap was harvested), which then is closed primarily, with sutures. The first flap is oriented geometrically, at 90 degrees from the long axis of the wound (defect), and the second flap is oriented 180 degrees from the axis of the wound. Although effective, the bilobed flap technique did create troublesome “dog ears” of excess flesh that required trimming and it also produced a broad skin-donor area that was difficult to confine to the nose. In 1989, J. A. Zitelli modified the bilobed flap technique by: (a) orienting the leading flap at 45 degrees from the long axis of the wound; and (b) orienting the second flap at 90 degrees from the axis of the wound. Said orientations and emplacements eliminated the excess-flesh “dog ears”, and thus required a smaller area of donor skin; resultantly, the broad-based, bilobed flap is less prone to the “trap door” and the “pin cushion” deformities common to skin-flap transposition procedure.[41]
The design of the bilobed flap co-ordinates its lobes with the long axis of the nasal defect (wound); each lobe of the flap is emplaced at a 45-degree angle to the axis. The two lobes of the bilobed flap rotate along an arc, of which all points are equidistant from the apex of the nasal defect.
In the nineteenth century, the surgical techniques of J.F. Dieffenbach (1792–1847) popularized the nasolabial flap for nasal reconstruction, for which it remains a foundational nose surgery procedure. The nasolabial flap can be either superiorly based or inferiorly based; of which the superiorly based flap is the more practical rhinoplastic application, because it has a more versatile arc of rotation, and the donor-site scar is inconspicuous. Depending upon the how the defect lay upon the nose, the flap pedicle-base can be incorporated either solely to the nasal reconstruction, or it can be divided into a second stage procedure. The blood supply for the flap pedicle are the transverse branches of the contralateral angular artery (the facial artery terminus parallel to the nose), and by a confluence of blood vessels from the angular artery and from the supraorbital artery in the medial canthus, (the angles formed by the meeting of the upper and lower eyelids). Therefore, the incisions for harvesting the nasolabial flap do not continue superiorly beyond the medial canthal tendon. The nasolabial flap is a random flap that is emplaced with the proximal (near) portion resting upon the lateral wall of the nose, and the distal (far) portion resting upon the cheek, which contains the main angular artery, and so is perfused with retrograde arterial flow.[42]
The pedicle of the nasolabial flap rests upon the lateral nasal wall, and is transposed a maximum of 60 degrees, in order to avoid the “bridge effect” of a flap emplaced across the nasofacial angle.
The paramedian forehead flap is the premier autologous skin graft for the reconstruction of a nose, by replacing any of the aesthetic nasal subunits, especially regarding the problems of different tissue thickness and skin color. The forehead flap is an axial skin flap based upon the supraorbital artery (an ophthalmic artery branch) and the supratrochlear artery (an ophthalmic artery terminus), which can be thinned to the subdermal plexus in order to enhance the functional and aesthetic outcome of the nose. Restricted length is a practical application limit of the paramedian forehead flap, especially when the patient has a low frontal hairline. In such a patient, a small portion of scalp skin can be included to the flap, but it does have a different skin texture and does continue growing hair; such mismatching is avoided with the transverse emplacement of the flap along the hairline; yet that portion of the skin flap is random, and so risks a greater incidence of necrosis.
The paramedian forehead flap has two disadvantages, one operational and one aesthetic: Operationally, the reconstruction of a nose with a paramedian forehead flap is a two-stage surgical procedure, which might a problem for the patient whose health (surgical suitability) includes significant, secondary medical risks. Nonetheless, the second stage of the nasal reconstruction can be performed with the patient under local anaesthesia. Aesthetically, although the flap donor-site scar heals well, it is noticeable, and thus difficult to conceal, especially in men.[36]
The surgeon designs the paramedian forehead flap from a custom-fabricated three-dimensional metal foil template derived from the measures of the nasal defect to be corrected. Using an ultrasonic scanner, the flap-pedicle is centre-aligned upon the Doppler signal of the supraorbital artery. Afterwards, the distal one-half of the flap is dissected and thinned to the subdermal plexus.
The septal mucosal tissue flap is the indicated technique for correcting defects of the distal half of the nose, and for correcting almost every type of large defect of the mucosal lining of the nose. The septal mucosal tissue flap, which is an anteriorly based pedicle-graft supplied with blood by the septal branch of the superior labial artery. To perform such a nasal correction, the entire septal mucoperichondrium can be harvested.[43][44]
The surgeon cuts the anteriorly based septal mucosal tissue-flap as widely as possible, and then releases it with a low, posterior back-cut; but only as required to allow the rotation of the tissue-flap into the nasal wound.
A technical variant of the septal mucosal flap technique is the Trap-door flap, which is used to reconstruct one side of the upper half of the nasal lining. It is emplaced in the contralateral nasal cavity, as a superiorly based septal mucosal flap of rectangular shape, like that of a “trap-door”. This septomucosal flap variant is a random flap with its pedicle based at the junction of the septum and the lateral nasal skeleton. The surgeon elevates the flap of septal mucosa to the roof of the nasal septum, and then traverses it into the contralateral (opposite) nasal cavity through a slit made by removing a small, narrow portion of the dorsal roof of the septum. Afterwards, the septomucosal flap is stretched across the wound in the mucosal lining of the lateral nose.[38]
The following rhinoplastic techniques are applied to the surgical management of: (i) partial-thickness defects; (ii) full-thickness defects; (iii) heminasal reconstruction; and (iv) total nasal reconstruction.
A partial-thickness defect is a wound with adequate soft-tissue coverage of the underlying nasal skeleton, yet is too large for primary intention closure, with sutures. Based upon the locale of the wound, the surgeon has two (2) options for correcting such a wound: (i) healing the wound by secondary intention (re-epithelialisation); and (ii) healing the wound with a full-thickness skin graft. Moreover, because it avoids the patched appearance of a skin-graft surgical correction, healing by secondary intention can successfully repair nasal wounds up to 10-mm in diameter; and, if the resultant scar proves aesthetically unacceptable, it can be revised later, after the wound has healed.
In the event, larger nasal wounds (defects) do successfully heal by secondary intention, but do present two disadvantages. First, the resultant scar often is a wide patch of tissue that is aesthetically inferior to the scars produced with other nasal-defect correction techniques; however, the skin of the medial canthus is an exception to such scarring. The second disadvantage to healing by secondary intention is that the contracture of the wound might distort the normal nasal anatomy, which can lead to a pronounced deformity of the alar rim area. For this reason, healing by secondary intention generally is not recommended for defects of the distal third of the nose; nonetheless, the exception is a small wound directly upon the nasal tip.
Full-thickness skin grafts are the effective wound-management technique for defects with a well-vascularized, soft-tissue bed covering the nasal skeleton. The patient’s ear is the preferred skin-graft donor site from which to harvests grafts of pre-auricular skin and grafts of post-auricular skin, usually with an additional, small amount of adipose tissue to fill the wound cavity. Yet, nasal correction with a skin graft harvested from the patient’s neck is not recommended, because that skin is low-density pilosebaceous tissue with very few follicles and sebaceous glands, thus is unlike the oily skin of the nose.
The technical advantages of nasal-defect correction with a skin graft are a brief surgery time, a simple rhinoplastic technique, and a low incidence of tissue morbidity. The most effective corrections are with a shallow wound with sufficient, supporting soft-tissue that will prevent the occurrence of a conspicuous depression. Nonetheless, two disadvantages of skin-graft correction are mismatched skin color and skin texture, which might result in a correction with a patch-work appearance; a third disadvantage is the natural histologic tendency for such skin grafts to contract, which might distort the shape of the corrected nose.
Full-thickness nasal defects are in three types: (i) wounds to the skin and to the soft tissues, featuring either exposed bone or exposed cartilage, or both; (ii) wounds extending through the nasal skeleton; and (iii) wounds traversing all three nasal layers: skin, muscle, and the osseo-cartilaginous framework. Based upon the dimensions (length, width, depth) and topographic locale of the wound and the number of missing nasal-tissue layers, the surgeon determines the rhinoplastic technique for correcting a full-thickness defect; each of the aesthetic nasal subunits is considered separately and in combination.
The skin between the nasal dorsum and the medial canthal tendon is uniquely suited to healing by secondary intention; the outcomes often are superior to what is achieved with either skin grafts or skin-flaps and tissue-flaps. Because the medial canthal tendon is affixed to the facial bone, it readily resists the forces of wound contracture; moreover, the animation (movement) of the medial brow also lends resistance to the forces of wound contracture. Furthermore, the medial canthal region is aesthetically hidden by the shadows of the nasal dorsum and of the supraorbital rim, thereby obscuring any differences in the quality of the color and of the texture of the replacement skin (epithelium).
Healing by secondary intention (re-epithelialisation) occurs even when the wound extends to the nasal bone. Although the rate of healing depends upon the patient’s wound-healing capacity, nasal wounds measuring up to 10 mm in diameter usually heal in at 4-weeks post-operative. Nonetheless, one potential, but rare, complication of this nasal correction approach is the formation of a medial canthal web, which can be corrected with two (2) opposing Z-plasties, technique which relieves the disfiguring tensions exerted by the scar tissue’s contracture, its shape, and location on the nose.
The size of the nasal defect (wound) occurred, in either the dorsum or the lateral wall, or both, determines the reconstructive skin-flap technique applicable to the corresponding aesthetic nasal subunits.
The width of the human nasal-tip ranges 20–30 mm; the average width of the nasal tip, measured between the two alar lobules, is approximately 25 mm.
The appropriate surgical management of an alar lobule defect depends upon the dimensions (length, width, depth) of the wound. Anatomically, the nasal skin and the underlying soft tissues of the alar lobule form a semi-rigid aesthetic subunit that forms the graceful curve of the alar rim, and provides unobstructed airflow through the nostrils, the anterior nares.
The reconstruction rhinoplasty of an extensive heminasal defect or of a total nasal defect is an extension of the plastic surgical principles applied to resolving the loss of a regional aesthetic subunit. The skin layers are replaced with a paramedian forehead flap, but, if forehead skin is unavailable, the alternative corrections include the Washio retroauricular-temporal flap and the Tagliacozzi flap. The nasal skeleton is replaced with a rib-graft nasal dorsum and lateral nasal wall; septal cartilage grafts and conchal cartilage grafts are applied to correct defects of the nasal tip and of the alar lobules.[46][47]
The nasal lining of the distal two-thirds of the nose can be covered with anteriorly based septal mucosal flaps; however, if bilateral septal-flaps are used, the septal cartilage does become devascularized, possibly from iatrogenic septal perforation. Furthermore, if the nasal defect is beyond the wound-correction scope of a septal mucosal flap, the alternative techniques are either an inferiorly based pericranial-flap (harvested from the frontal bone) or a free flap of temporoparietal fascia (harvested from the head), either of which can be lined with free grafts of mucosa to achieve the nasal reconstruction.
Illustration 1: The surgeon cuts the excessively wide bones of the upper nasal dorsum (violet) with an osteotome (bone chisel), then detaches, corrects, and relocates them inwards, to a position, between the ocular orbits (red), that narrows the width of the nasal dorsum.
Illustration 2: The surgeon chisels two cuts (incisions) to the nasal bones, each incision begins at the nasal cavity. The first incision begins at the yellow dot and extends upwards, along the green arrow, until meeting the zig-zag line (red). The second incision begins at the blue dot and extends upwards, along the black arrow, until meeting the zig-zag line (red). Once cut and loosened from the face, the nasal bone pieces are corrected, then pushed inwards and re-set, thus narrowing the nose.
The rhinoplasty patient returns home after surgery, to rest, and allow the nasal cartilage and bone tissues to heal the effects of having been forcefully cut. Assisted with prescribed medications — antibiotics, analgesics, steroids — to alleviate pain and aid wound healing, the patient convalesces for about 1-week, and can go outdoors. Post-operatively, external sutures are removed at 4–5 days; the external cast is removed at 1-week; the stents are removed within 4–14 days; and the “panda eyes” periorbital bruising heal at 2-weeks. Throughout the first year post-operative, in the course of the rhinoplastic wounds healing, the tissues will shift moderately as they settle into being a new nose.[52]
Rhinoplasty is safe, yet complications can arise; post-operative bleeding is uncommon, but usually resolves without treatment. Infection is rare, but, when it does occur, it might progress to become an abscess requiring the surgical drainage of the pus, whilst the patient is under general anaesthesia. Adhesions, scars that obstruct the airways can form a bridge across the nasal cavity, from the septum to the turbinates, and require surgical removal. If too much of the osseo-cartilaginous framework is removed, the consequent weakening can cause the external nasal skin to become shapeless, resulting in a “polly beak” deformity, resembling the beak of a parrot. Likewise, if the septum is unsupported, the bridge of the nose can sink, resulting in a “saddle nose” deformity. The tip of the nose can be over-rotated, causing the nostrils to be too visible, resulting in a porcine nose. If the cartilages of the nose tip are over-resected, it can cause a pinched-tip nose. If the columella is incorrectly cut, variable-degree numbness might result, which requires a months-long resolution. Furthermore, in the course of the rhinoplasty, the surgeon might accidentally perforate the septum (septal perforation), which later can cause chronic nose bleeding, crusting of nasal fluids, difficult breathing, and whistling breathing.
Because it is the anchor-feature at the center of the face, an aesthetically proportionate nose balances the physiognomic features of a person to produce a handsome face in a man, and a beautiful face in a woman. Therefore, the rhinoplastic correction (surgical or non-surgical) of any defect or deformity (functional and aesthetic) is important, lest an aesthetically disproportionate nose distract the beholder’s attention from the other features of the face, such as the eyes, the lips, the cheekbones, and the jaw line.
A non-surgical rhinoplastic correction is performed upon a patient under local anaesthesia; the plastic surgeon uses a syringe and a hypodermic needle (e.g. 27-G, 25-mm) to inject and emplace the soft-tissue filler under the nasal skin, most commonly in the deep subcutaneous tissues, and, occasionally, immediately above the (periosteum), in order to correct the nasal defect or deformity, or to achieve the desired modification. Filler-injection technique makes feasible corrections such as the augmentation of a flat nasal bridge (depressed dorsum); the added projection of the nasal tip; the camouflage diminution of a nasal hump; the filling of a nasal sidewall depression; the enhancement of a retracted anterior nasal spine; the enhancement of a retracted maxilla lateral to the pyriform (pear-shaped) aperture, to displace the anterior plane; the elevation of a saddle nose deformity caused by a failed primary rhinoplasty; and traumatic injury. The technical procedures for injecting and emplacing the soft-tissue filler require approximately 1-hour to perform in the surgeon’s consultation room; thus, upon completion of the filler-injection operation, the patient convalesces at home, and resumes his or her normal life activities.
Non-surgical correction is indicated for the rhinoplasty patient who presents an innate, treatment-suitable aesthetic defect, or one occurred after a surgical rhinoplasty (either primary or secondary). Nonetheless, the functional and corrective limitations of the soft-tissue-filler medium indicate a surgical correction for the patient whose nasal defect requires extensive anatomic correction that exceeds the (aesthetic) technical scope of filler-injection procedure — which does not increase, nor does it decrease the size of the nose, and does not correct functional defects.
The corrective and technical efficacy of non-surgical rhinoplasty — achieved with syringe-and-hypodermic-needle injections of fillers to the soft tissues of the nose — was confirmed with the Australian study Rhinoplasty Using Injectable Polyacrylamide Gel — A Patient Study (2005), by Dr. Andrew Tuan-anh Le, which reported the pilot study assessment of injection techniques for emplacing a non-biodegradable colloid-filler to the soft tissues of the nose for the correction of a nasal dorsum defect; and ascertained the medical suitability of non-surgical rhinoplasty as a treatment alternative to surgical rhinoplasty.[22][23]
An aesthetically proportionate and functional nose for the patient was the satisfactory corrective outcome required of the assessed filler-injection techniques. In the 12-month pilot study, the nasal dorsum defects of 89 patients (84 women, 5 men, 32 yrs. avg. age) were non-surgically corrected with filler-injection treatments of polyacrylamide gel (PAAG), a non-biodegradable, hydrophilic filler for soft tissues (commercially: Aquamid). As a soft-tissue filler, PAAG is a chemically dynamic, hydrophilic colloid that continually exchanges water molecules with the surrounding nasal tissues, thus minimizing the risk of histologic rejection.
|
|||||||||||||||||||||||||||||||||||