Rhinoplasty

 

Rhinoplasty describes a procedure which reshapes the external appearance of the nose.  It is considered one of the most difficult operations in plastic surgery due to the complex anatomy of the nose and how millimeter changes can result in the difference between success and failure.

 

 

Sushruta Ayurveda described the first rhinoplasty 600 BC in ancient India. During this period, the punishment for adultery was nasal amputation.The “Indian Rhinoplasty” was primarily a recreation of patient’s amputated noses with a local pedicled flap of tissue.   The first modern day rhinoplasty was performed by John Orland Roe in 1887. However, Jacques Joseph is often credited with being the father of modern day rhinoplasty with the definitive textbook of techniques to transform the nose in 1898.  With respect specifically to modern open rhinoplasty, Rethi first introduced the columellar incision for open rhinoplasty for tip modification in 1921.

 

 

Rhinoplasty is classified into two types of operations:  closed (endonasal) or open (external) rhinoplasty.  In endonasal rhinoplasty, the entire operation is performed from within the nostril, without an external incision.  In external rhinoplasty, a small incision is made at the columella (soft tissue between the nostrils) in order to better visualize the nose.  Endonasal rhinoplasty has the advantage of less swelling along the nasal tip, shorter operation, and avoidance of an external scar.  External rhinoplasty has the advantage of the ability to visualize and manipulate the nose more accurately and thereby create more profound changes to the nose.

 

 

The nasal bones of the nose are located at the upper one third of the nose.   Bissecting the nose in half is the nasal septum, which is comprised of both bone and cartilage.  Deviation of the septum may obstruct the nasal airway resulting in nasal obstruction.  Along the middle one third of the nose lie the upper lateral cartilages, which lend support to the nasal airway.  The lower lateral cartilages are responsible for formation of the shape and character of the nasal tip.

 

Projection is the term for how far the nose sticks out from the face.  Rotation is the term for how much the nasal tip hangs low or is up in the air.  A dorsal hump is a bump along the bridge of the nose.

 

 

The procedure is typically performed with either IV sedation or general anesthesia.  Prior to the procedure, local anesthesia is used to shrink the nasal mucosa and minimize bleeding of the soft tissues during the case.  Some surgeons place topical anesthesia in the nose, including Afrin (phenylephrine), Cocaine, or Oxymetazoline.

 

The bridge of the nose can be manipulated by various rasps and bony chisels, termed osteotomes.  Often times bumps are smoothed are removed with these instruments in an effort to create an improved profile.  If the nasal bones are crooked or too wide, ostetomes will break the bones and push them in to create a narrower look to the nose.

 

The nasal tip can be addressed by a variety of techniques.  With a closed technique the surgeon can remove extra cartilage along the nasal tip in an effort to refine the nose.  Sutures can be placed to reshape the lower lateral cartilages and create narrowing of the nose.  If more dramatic changes are needed, an open approach is often utilized.  Here a variety of cartilage grafts can be placed in an effort to recreate nasal anatomy.

 

Grafts used in rhinoplasty can be harvested from the nasal septum, parts of the ear (concha cymba and cavum of the auricle), and the cartilage portion of the rib cage (costal cartilage).  When removing cartilage from the nasal septum, the surgeon will ensure that the support of the nose is adequate.  The cartilage from the nasal septum is generally thought to be the most desirable material for grafting.  Ear cartilage is softer and can be used as well.  In cases requiring larger amounts of material, costal cartilage can be used to recreate nasal anatomy.

 

At the conclusion of the procedure, a nasal cast is placed on the nose to help it heal in the proper orientation.  Furthermore, the nasal cast lessens the amount of swelling (edema) to the nose during the postoperative period.