The cosmetic surgery of the nose is one of the most commonly performed surgeries in the aesthetic surgery. In the United States about 100 000 aesthetic corrections of the nose is performed annually. The nose is placed in the central and the most protruding part of the face, and because of that it is most exposed to trauma. The trauma of the nose is the most common cause of the deformities in the external nose and nasal septum. The aesthetic correction of the nose is considered to be the most demanding operation in the aesthetic surgery. The spectrum of deformities of the external nose is very diverse, so the approach and planning of the operating procedures must be strictly individual. The nasal deformities can be acquired and congenital. Congenital can be hereditary and unhereditary. The acquired deformities are mostly the result of the external nose injuries. Deformities can be located in the upper third of the nose (the bony bridge of the nose), in the middle or lower third of the nose (the cartilaginuos bridge and nasal tip). The most common deformities are:
- humpy nose (rhinokyphosis)
- crooked nose (rhinoskoliosis)
- overprojecting nose (macrorhinia)
- wide nose (pachirhinia)
- saddle nose deformity (rhinolordosis
Humpy nose
The humpy nose is the most common deformation of the external nose, most often characterized by normal nasal breathing. The nasal “hump” consists of the bone and cartilage components. The isolated bone or cartilage hump is rarely diagnosed, and occurs as the result of previous unsuccessful nasal corrections.
Crooked nose
The crooked nose is always the result of a trauma. The slightly curved nose usually does not cause breathing problems, but more severe cases of the crooked nose always cause nasal obstruction. The correction of the crooked nose is the most demanding type of rhinoplasty. The nose may be crooked in all thirds of the nose or only in the upper two, or the lower two thirds. The successful correction of the crooked external nose almost always requires surgery of the nasal septum by which the permanent normalization of nasal breathing is achieved. So, it is at the same time aesthetic and functional correction in one stage surgery (rhinoseptoplasty).
Overprojecting nose
The overprojecting nose or machrorhinia is caused by the hypertrophy of the nasal bones, then the hypertrophy of the dorsal edge of the septal cartilage and/or hypertrophy of the nasal tip cartilage (the lower lateral cartilage). Such nose usually does not cause nasal obstruction. The correction of the overprojecting nose must include lowering of the nasal bridge height and reducing the height of the nasal pyramid (the height of the nasal pyramid is called the nasal tip projection, and that is the distance from the joint of the nose with the filtrum of the upper lip to the most protruding point of the nasal tip. In the “Polyclinic Ostojić,” we use a special modification of reducing the nasal tip projection which so far has not been described in the scientific medical literature and, unlike the other methods, preserves the integrity of the nasal tip cartilage, and consequently and permanently retains stability of the nasal tip.
Wide nose
The wide nose or pachirhinia can be manifested in all parts of the external nose or only in the bony or cartilaginous part of the external nose. The wide nose occurs as the result of a trauma or hereditary factors. The wide nose is usually located in the central or middle line of the face and is not accompanied by nasal breathing disorders.
Saddle nose deformity
“Saddle nose deformity” or rhinolordosis occurs as the result of the external nose trauma, heritage, and very rarely chronic inflammatory nasal diseases such as tuberculosis or syphilis. The moderate stage of the saddle nose deformity does not obstruct nasal breathing, while more expressed rhinolordosis significantly compromits the normal nasal breathing. Nasal breathing is the only normal breathing while mouth breathing is pathological. When breathing through the nose, the inspirium is deeper, more air enters the lungs, ie more oxygen enters the bloodstream (better tissue oxygenation). The reasons for heavier nasal breathing are multiplex: the curvature or deformity of the nasal septum, nasal polyps, allergic inflammation of the mucous membrane of the nose and sinuses, chronic hypertrophy of the inferior nasal turbinates (the anatomical structures on the lateral walls of the nasal cavities), tumours. The most common reason for the nasal obstruction is the chronic hypertrophy of the inferior nasal turbinates, with or without the nasal septum deformity. In the “Polyclinic Ostojić,” we very often combine the aesthetic surgery of the external nose or reconstruction of the nasal septum (septoplasty) with the procedure of the permanent reduction of the nasal turbinates (bipolar electroturbinectomy), because in the medical practice it is often forgotten that the correction of the septum may not be sufficient for normalization of the nasal breathing; the additional surgery results in the permanent reduction of the volume of the lower nasal turbinates. Normal nasal breathing allows the normal ventilation of the paranasal sinuses, and that is the main prerequisite of the healthy sinuses.
Operative techniques
The aesthetic rhinoplasty can be done by the so-called “closed” and “open” technique or decortication. In the “Polyclinic Ostojić” most nasal corrections are performed by the “closed” technique (about 95%) because we think that the biggest part of the aesthetic problems can be resolved this way. When using the “closed” technique, all surgical incisions are located within the vestibule of the nose and the upper vestibule of the mouth, with no external scars. A surgical manual skill of orientation in the crowded and poorly visible operative field as well as the experience in a large number of operations is required (in the “Polyclinic Ostojić” we have done about 1 400 different nasal operations) to achieve the excellent aesthetic result. The “open” technique is indicated particularly at severe nasal tip deformities or multiple previously operated or traumatized noses, which can not be done successfully with the “closed” approach. The open technique leaves a small scar in the form of the letter V on the part of the nose that separates the nostrils (columella), just at the point where the columella meets the skin portion of the upper lip. Swelling of the nasal tip skin lasts longer than with the closed technique, and that mostly depends on the type of the nasal tip skin. We are convinced, based on the long experience, that the thickness of the nasal tip skin is the most important prognostic factor for the successful outcome of the aesthetic nasal correction. The thick skin nasal tip (the so-called sebaceous type of skin) is swollen for a long time, and sometimes it can be permanently thickened after the nasal correction, and may compromise a meticulous work on the bones and cartilage of the nose. The ideal type is thin and dry nasal tip skin, where the aesthetic result is significantly better, recovery faster, and the aesthetic result is entirely in the hands of a surgeon. Therefore, we apply the injection of diluted corticosteroids in the area of the nasal tip, if it is the case of thick and greasy skin, to reduce swelling of such skin in the postoperative period, and significantly improve the aesthetic appearance of the nose with the sebaceous type of skin. During the performance of the aesthetic nasal correction we use very fine and expensive surgical instruments which minimally traumatize the tissue, and allow us a maximum of comfort while performing these demanding techniques. We constantly try and succeed in the mission that every patient gets a new nose adjusted to her/his own face, and we strictly avoid creating uniform noses, because every nose does not fit every face. Second, and not less important, rule is to always protect normal breathing function of the nose. Never must normal breathing be sacrificed to the account of the aesthetic look of the nose. We succeed maximally to harmonize the aesthetic and functional requirements for the benefit of our patients.
Nasal septum reconstruction or septoplasty
Septoplasty can be done as an isolated surgical procedure or as a part of the external nose correction in one stage surgery, so called rhinoseptoplasty, which is a very challenging operation. The basic principle of such a combined, aesthetic-functional, procedure is the fulfillment of two criteria: the achievement of good-looking external nose and permanent normalization of nasal breathing. Thereby the static of the external nose, which mostly depends on the front parts of the nasal septum, must be maximally preserved so such a nose could be steady and stable in the postoperative period. If this basic surgical principle is not respected, the external nose can be very unstable and sensitive to the least trauma, which can easily cause the septum deformity recurrence with the consequential opstruction of nasal breathing. Septoplasty is very often combined with a permanent reduction of the volume of the lower nasal turbinates, because it achieves the optimal nasal breathing, and the whole body gets much more oxygen in the bloodstream.
Procedure
The first step is preoperative examination of a patient during which the type of the external nose and/or nasal septum deformity must be accurately ascertained. The approach to each patient is strictly individual. A thorough family and personal history has to be taken. Wishes and expectations of the patient are carefully observed. After the consultation follows the examination (palpation, inspection, rhinoscopy and postrhinoscopy). If it is the humpy nose, the location of the nasal hump must be accurately established. In addition, the measure of the septolabial angle should be taken (the angle between the nose and the upper lip) and ascertained whether there is a drop of the nasal tip downwards in the face animation. The type of the nasal tip skin is one of the most important prognostic factors to achieve the optimal aesthetic results. The best type is thin and dry nasal tip skin. The nasal cavity can be shown by the rhinoscopic and postrhinoscopic examination and thus determine the deformities of the nasal septum, the internal nasal valve, nasal turbinates and possible formations in the nasal cavity. The important part of the examination is a psychological evaluation of each patient. Any possible asymmetries in the area of the nasal tip, nasal wings and nostrils should be noted and submitted to the patient.
Surgical procedure or rhinoplasty
In the “Polyclinic Ostojić” 95% of the aesthetic corrections of the external nose are being performed by the so-called “closed” technique, and only 5% by the “open” or decortication technique. Performing the closed technique requires precise surgical work on a small and poorly available space and requires the enviable surgical skill. The demonstration of the closed aesthetic rhinoplasty follows.
The preoperative “marking”.
The chief surgeon, Dr Duje Ostojić, places the head of the patient on the operating table in the appropriate position in order to be able to access the nose and perform the surgery more easily.
The first step in a surgical procedure is the application of the local anesthetic directly into the external nose, the surrounding areas of the face and the nasal cavity. The left nostril is filled with the patches of gauze that were previously impregnated with a spray of the local anesthetic and ephedrine nasal drops. Thus is achieved painlessness of the local anesthetic application and the excellent view into the nasal cavity for the diagnosis of the possible deep nasal septum deformities.
The beginning of the aesthetic correction of the nose is the so-called V-Y procedure: cutting of the phrenulum of the upper lip and the muscle fibers that lower the nasal tip in the face animation (laughter, speaking). The aim of this surgical maneuver is the achievement of the nasal tip stability after the surgery, or preventing the nasal tip to drop down in the face animation.
Removing the pieces of the hypertrophic bone (the nasal spine) will further relieve the anatomical relation between the nose and the upper lip.
Sewing the initial V-incision to form the final incision in the form of the letter Y with the resorptive sutures.
V– surgical maneuver raises the nasal tip for about 1-2 mm.
The initial incision in the right vestibule of the nose. The operation is almost bloodless because of the precise application of the local anesthetic with epinephrine.
The removed piece of the nasal tip cartilage with the aim of nasal tip narrowing. A very precise and delicate surgical work on the soft and gentle cartilages is necessary.
Completing the incisions in the vestibules of the nose in order to enable access to the caudal septal margin and the nasal bridge.
A part of the caudal septal margin cartilage is removed together with the surrounding mucosa to obtain further raising of the nasal tip.
The special surgical scissors are used to separate the external nose skin from the underlying nasal bones and cartilages.
With the precise and careful surgical work a part of the nasal bones which had formed the so-called “humpy” nose (rhinokyphosis) is removed.
The careful estimation of the nasal bridge line from the profile view and satisfaction with the results achieved.
Sewing of the incisions in the vestibule of the nose with 4-0 resorptive thread.
Setting of the sponge nasal tampon into the nasal cavities in order to achieve the internal immobilization. In our polyclinic we use the sterile nasal tampons from the sponges that have the great power of absorption of the mucus in the nasal cavities. Such tampons can not fall behind into the larynx because they are made in one piece, they can be easily and painlessly extracted out and they achieve a great immobilization without expanding operationally narrowed nasal bones.
The condition after the narrowing of both nostrils is shown. The incisions are precisely located on the joint of the nasal wings with the face, and they will be almost invisible after two to three months.
In the picture the most modern material (turbocast) is shown, which is used as the external nasal splint after the appropriate modeling. The material is perforated, which allows better “skin breathing” under the splint. The specified material can be excellently molded into the desired form of the external nose and is of much better quality and is more efficient, but also more expensive than the other materials used for the nasal splint.
Putting the special U.S. steri strip plasters for reducing the swelling of the external nose.
Setting the splint on the external nose and the final modeling of the nose.
Setting the steri strip plasters to achieve a more natural curvature of the lower surface of the nasal tip.
The condition after the completion of the procedure of placing the splint and plasters is shown. In the aesthetic rhinoplasty, the nasal tampons are removed after 24 hours, and the external splint is removed after 7 days. Most sutures (the vestibule of the oral cavity and the nose) are resorptive so they do not have to be removed. If the permanent sutures are set when narrowing the nostrils, then they are removed the seventh postoperative day.
Postoperative period
Given that most aesthetic corrections of the nose in the “Polyclinic Ostojić” are performed under reinforced local anesthesia with intravenous sedation, the patient is retained for a few hours under the supervision of the doctors. The patient does not suffer from any postoperative pain because of receiving the intramuscular injections of analgetics. The mild bloody secretion from the nose lasts for several days. The nasal tampons are removed from the nose the next day (aesthetic rhinoplasty), or after 3-5 days (rhinoseptoplasty and septoplasty). Bruises and swelling of the eyelids and face may be most visible 2-4 days after the surgery, and usually they last for 10-14 days. The patient should sleep in a supine position with a high pillow for at least 4 weeks. The local application of the nasal sprays can speed up the cleaning of the nasal cavities from the crusts, clots and resorptive sutures, which allows normal nasal breathing. During the next month a patient must strictly avoid trauma and/or physical manipulation of the nose. Physical activity such as sports with a ball also must be avoided for at least 4 weeks. Numbness or hypoesthesia of the nasal tip usually persists for 2-4 months after the procedure. The patients should not wear heavy glasses for at least 4 weeks. Meals should be strained or mushy for a few days with the regular hygiene of the oral cavity after each meal.
Complications
The complications of the nasal correction are very rare. Possible complications include:
- infection (in the “Polyclinic Ostojić” we did not have any case of postoperative nasal infection in more than 1400 operations)
- bleeding (very rarely, mostly occurs with people who had suffered preoperatively from often nasal bleeding)
- hypertrophic scars or keloids (we did not have a single case in our practice)
What are the most common nasal deformities?
Deformities of the nose are diverse and vast in number. They can be acquired and congenital. The congnital ones can be hereditary and non-hereditary. Acquired deformations are most often a consequence of an injury to the external part of the nose, because the nose occupies the central and most peripheral part of the face, therefore it is most exposed to trauma. The most common deformations of the nose are the humpy nose, the crooked nose, the too long nose, the broad nose and the concaved or saddle nose.
What is rhinocifosis?
Humpy nose or rhinocifosis is the most common form of the external nose deformity. The nasal “hump” consists of a bone and cartilage component and you can generally normally breathe on the nose. Isolated bone (cartilage) hump is rarely diagnosed and is usually the result of previously unsuccessful nasal corrections.
What causes a “crooked” nose?
Crooked nose or rhinocytosis occurs almost always because of the trauma of the nose. If this is not a pronounced form, the curved nose (hence the mild form) does not cause nasal discomfort. As the nose can be crooked in all thirds, the correction of the crooked nose is one of the most demanding surgeries in rhinoplasty, and it always requires straightening of the nasal septum, thus achieving a permanent normalization of breathing on the nose.
Does a too long or wide nose impact on the breathing?
Macrorinia or having a nose that is too long causes nasal bone hypertrophy, hypertrophy of the frontal cartilaginous nasal septum, and hypertrophy of the cartilage of the nasal tip. Usually, it does not cause difficulty in breathing. A wide nose or pahirini may occur in all parts of the outer nose or only in the bone / cartilaginous part of the external nose. It may arise as a result of hereditary factors or trauma. Usually it does not cause disturbance while breathing.
What causes rhinorrhoeosis?
Rhinorrhoeous or a concave nose is most often caused by the trauma of the external nose or is hereditary. Very rarely the cause may be a chronic inflammatory nose disease.
What techniques of rhinoplasty are used in the “Ostojić Practice”?
In general, aesthetic rhinoplasty can be performed in the so-called “closed” and “open” technique. In “Ostojić Practice” about 95% of nose corrections are carried out by the so-called “closed” technique. We consider that most aesthetic problems can be solved by this technique that gives excellent aesthetic result. As with this technique all surgical cuts are located inside the nasal lobes and the upper lobe of the mouth and there are no external scars, it requires a high degree of surgical experience and manual handling in a cramped and poorly visible operational field. Dr. Ostojić and his expert team have done over 1400 successful nasal surgeries.
The “open” technique is used in correction of severe deformation of the nasal tip, multiple traumas to the nose (or previously operated) or when it is simply not possible to successfully implement the “closed” technique. It should be noted that an open technique leaves a small scar in the form of a letter V at the attachment of a part of the nose that divides the nostrils into the skin part of the upper lip.
When is septoplasty applied?
Septoplasty can be performed as an isolated surgical procedure or in combination with the correction of the outer part of the nose in one operative act, then it is called rinoseptoplasty. With this combined procedure, the two criterias are met – achievement of a nice appearance of the external nose and permanent normalization of nasal breathing. In such a case, the static of the outer nose must be maximally preserved so that the nose is firm and stable after the postoperative period. Otherwise, the outer nose will be unstable and sensitive to trauma (even the least bit), which often results in the return of septum deformation and nasal obstruction. Septoplasty is often combined with a permanent reduction in the volume of the lower nose bones, as this results in optimal breathing through the nose, and the whole organism receives significantly more oxygen into the bloodstream.
What do you need to do when preparing for rhinoplasty?
Preoparative examination begins by taking a thorough personal and family anamnesis and talking with the patient where the wishes and expectations of the procedure are carefully being listened to. After the interview, an examination is performed – palpation, inspection, rhinosopia and postrinoscopy. If it is a humpy nose, the location of the nasal hump is accurately detected. The septolabial angle, or the angle between the nose and the upper lip, should also be measured, and determine whether there is a drop of the nasal tip downward in the facial animation. The nasal cavities can be excellently shown by rhinoscopic and postrinoscopic examination and determine deformities of the nasal septum, internal nasal valves, and possibly nasal cavities. In addition, it is necessary to note and present to the patient any possible asymmetry in the area of the nasal tip, nasal wings and nostrils. A very important part of the preoperative examination is the psychological evaluation of each patient.
What are the possible complications of nasal correction?
Complications are very rare, and infections along with bleeding and hypertrophic scars or keloids can occur. In the “Ostojić Practice” in more than 1400 operations we did not have any case of postoperative infection, bleeding was extremely rare (most of it occurred in people who suffered from often bleeding from the nose – before surgery), and we have not recorded any case of keloids (hypertrophic scars).
How does the postoperative period of rhinoplasty look like?
Patients stay for a few hours under the supervision of the doctor. A discharge from the nose lasts for several days and because of it, tampons are used. They are taken out immediately after the next day (aesthetic rhinoplasty) or after three to five days (septoplasty and rinoseptoplasty). Bruising and swelling of the eyelids usually last ten to fourteen days, and are most pronounced two to four days after surgery. At least for four weeks a patient should sleep on the back with a slightly raised head. In the month after surgery, the patient must avoid any physical trauma or manipulation of the nose. The numbness of the nasal tip is usually felt two to four months after the procedure. The patient must avoid wearing heavy glasses at least four weeks. It is recommended that the diet be poached or mushy for the next few days, and after each meal, regular oral hygiene is required.
In this text, we want to inform you about the types of nasal correction surgery, so called septoplasty and rhinoplasty, how to perform nasal septum surgery and nose deviation, when a closed and open technique is performed and which criteria have to be met. The aesthetic correction of the nose can be done in 2 ways, using a closed or open technique. In closed technique there are no external cuts, and therefore no visible scars after surgery. All cuts are made inside the nasal lobes and lips. This technique requires the manual craftsmanship of the aesthetic surgeon and excellent handling in a poorly visible operational area, but the aesthetic results are top-notch. In “Ostojić Practice” the pleasure of patients is in the first place, and we have a great experience with this technique (over 1400 performed surgeries on the nose), whenever possible, we decide on a closed nasal correction technique.
In some cases, on a severely deformed nasal tip or on a previously multiply operated or traumatized nose, external technique cannot be performed. Then, an internal technique is applied which leaves a small scar between the upper lip and nostrils. The swelling of the nasal tip depends heavily on the skin type at the nasal tip part, but regularly lasts longer than the closed technique.
The duration of postoperative swelling and the general aesthetic result of the correction of the nose depends mostly on the thickness of the nasal tip. From our experience, thin and dry skin give the best aesthetic results and the fastest recovery from surgery. The sebaceous skin type (greasy and thick skin) of the nasal tip is usually long swollen after surgery, and sometimes a permanent thickening occurs. All of the above may have a negative impact on the work of the bones and the cartilage of the nose. With this type of skin in the nasal tip of the nose, diluted corticosteroid injections are used to reduce swelling at the tip of the nose and generally improve aesthetic results.
Septoplasty can be performed separately in combination with rhinoplasty (aesthetic correction of the outer nose) and this surgical procedure is called rinoseptoplasty. In the “Ostojić Practice”, we often combine the aesthetic procedure of the external nose with the procedure of permanent reduction of nasal bivalve shells (bipolar electrourbinectomy). Rinoseptoplasty also satisfies aesthetics in functional results (normalized nasal breathing). It is observed that the static of the external nose is maximally preserved, which results in the firmness and stability of the nose after surgery. The most common reason for nasal obstruction is a chronic increase in the lower nasal shell, with or without deformity of the septum nose, so often septoplasty is combined with a permanent reduction in the volume of the lower nasal shells, thus achieving optimal nasal breathing.
Due to all of this, we work uncompromisingly to achieve the ideal aesthetic and functional form so that patients are absolutely satisfied with the procedure. The corrected nose is therefore always adapted to the face, while preserving the normal respiratory function. Multiannual experience with the corrective actions of the nose, maximum attention and expertise, individual approach to each patient and high quality surgical instruments ensure excellent results and satisfaction of our clients.
