Rhinoplasty

Understanding Rhinoplasty: More Than Just Aesthetics

Rhinoplasty, commonly known as "nose surgery" or a "nose job," is a plastic surgery procedure designed to reshape the nose, restoring or creating a harmonious relationship between its anatomical structures. While often pursued for aesthetic reasons, rhinoplasty frequently addresses functional issues as well, particularly those related to nasal breathing.

 

Anatomy and Multifunctionality of the Nose

The nose serves as the initial segment of the upper respiratory tract. It is a complex three-dimensional structure composed of bony and cartilaginous sections that, when connected, form an irregular triangular pyramid covered with skin. The internal nasal septum, a wall of cartilage and bone, divides the nasal cavity into two passages and plays a crucial role in supporting the external nose and regulating airflow.

Beyond its external appearance, which makes it a prominent anatomical feature of the face and a common focus of aesthetic surgery, the nose and nasal septum perform numerous vital physiological functions:

• Air Conduction: Directing airflow into the respiratory system.
• Air Conditioning: Purifying, warming, and humidifying inhaled air before it reaches the lungs.
• Olfaction (Sense of Smell): Housing the olfactory receptors, which provide the body's connection to environmental odors.
• Resonance: Contributing to voice quality.
• Respiratory Resistance: The inspiratory resistance provided by the nasal cavity is essential for creating negative intrathoracic pressure during inhalation. This, in turn, enhances pulmonary ventilation and venous return to the lungs and heart.

A correct anatomical relationship and balance of these structures are essential not only for a positive facial perception but also for optimal nasal function.

 

The Interplay of Form and Function

Impaired nasal breathing resulting from deformation of the external nose and/or the nasal septum can lead to significant health issues beyond local discomfort. These include chronic hypoxia (reduced oxygen levels), and can contribute to or exacerbate diseases of the lungs, upper respiratory tract, and even the cardiovascular system. Therefore, restoring the physiological function of the nose, often through procedures like septoplasty (nasal septum plastic surgery), is just as important as, and frequently integral to, aesthetic rhinoplasty.

In rhinology, the principle that **function is almost always dependent on form** is paramount. Deformities of the nasal skeleton, whether congenital developmental anomalies or acquired through trauma, often present with pronounced signs of asymmetry and primarily concern patients due to their aesthetic impact. However, the restoration of an aesthetic nasal shape must often occur simultaneously with the restoration of its physiological functions, particularly those related to the nasal septum and airflow.

 

Indications for Rhinoplasty: Aesthetic and Functional Concerns

Patients seek rhinoplasty for a variety of reasons, which can be broadly categorized as aesthetic or functional, though often these are intertwined:

• Aesthetic Concerns:
  • Dissatisfaction with the size or shape of the nose (e.g., too large, too small, too wide, too narrow).
  • Presence of a dorsal hump or depression (saddle nose).
  • Asymmetry of the nasal tip, bridge, or nostrils.
  • Undesirable angle between the nose and upper lip.
  • Post-traumatic deformities affecting appearance.
• Functional Concerns:
  • Nasal airway obstruction due to a deviated nasal septum.
  • Breathing difficulties related to narrowed nasal valves (internal or external).
  • Hypertrophied turbinates contributing to congestion.
  • Correction of congenital deformities affecting breathing (e.g., cleft lip nasal deformity).
  • Repair of post-traumatic structural damage impairing airflow.

Often, a patient presenting with a cosmetic concern (e.g., a crooked nose after trauma) will also have functional issues like a deviated septum that needs to be addressed simultaneously in a procedure known as septorhinoplasty.

 

The Otorhinolaryngologist's Role in Rhinoplasty

Performing aesthetic rhinoplasty requires an otolaryngologist (ENT surgeon) to possess a thorough knowledge of complex surgical techniques and a deep understanding of the delicate anatomical and topographic relationships of the structures that constitute the nose. A deformed nose can leave an unattractive impression even if the rest of the face is aesthetically pleasing.

The participation of an otorhinolaryngologist surgeon, who is intimately familiar with the methods of intranasal surgery developed over many years, is often considered a priority, especially when functional issues are present. The ENT surgeon faces two interrelated tasks:

1. Restoration of the functions of the nasal septum and the nasal valve mechanism, which regulates nasal breathing.
2. Surgical correction of any cosmetic defect to improve the aesthetic perception of the face and nose as a whole.

It is generally inappropriate and often detrimental to consider these two aspects separately. Aesthetic rhinoplasty, when performed with consideration for underlying functional issues, not only improves appearance but also restores physiological functions, enhances the patient's quality of life, and creates psychological comfort.

 

Challenges and Considerations in Rhinoplasty

The field of rhinoplasty is of great interest to specialists in various medical fields, but otorhinolaryngologists typically perform the widest range of surgical interventions, especially when nasal deformity is combined with deformities of the nasal septum and other internal nasal structures.

 

Complexity of Nasal Deformities

Nasal deformities can be complex, involving various combinations of issues:

• Deviation of the nasal pyramid from the midline.
• Retraction or depression of the nasal dorsum (saddle nose).
• Prominent dorsal hump.
• Excessively wide or narrow nasal dorsum.
• Deformities of the nasal tip (e.g., bulbous, ptotic, over-projected, under-projected).
• Asymmetries of the nostrils or alar base.

Many works in both domestic and foreign literature are devoted to the correction of nose deformities, and a large number of surgical intervention methods have been proposed. Despite this, various authors report a notable percentage of unsatisfactory results when correcting the nose, whether for aesthetic or functional reasons.

 

Importance of Surgical Tactics

Unsatisfactory outcomes are often associated with errors in choosing the appropriate surgical tactics for the specific deformity. Given the constant rise in injuries and an increasing number of patients with post-traumatic nasal deformities—which are frequently accompanied by nasal breathing disorders and can lead to secondary diseases of various organs and systems—there is a persistent need for effective endonasal and external surgical interventions.

The choice of surgical treatment tactics depends on many factors, including the degree of complexity of the deformity, the extent of deviation from the midline, the presence and size of a dorsal hump or retraction, and the width of the nasal dorsum or tip. Thus, the ongoing challenge in rhinoplasty is the continual search for and refinement of surgical intervention methods aimed at improving the results of surgical treatment, encompassing both endonasal surgery to restore nasal breathing and external approaches to correct cosmetic alterations of the nose.

 

Modern Approaches and Goals of Rhinoplasty

Modern rhinoplasty emphasizes achieving natural-looking results while preserving or improving nasal function. This often involves a nuanced approach to reshaping cartilage and bone, using grafts where necessary, and paying close attention to the airway.

• Open vs. Closed Rhinoplasty:
  • Closed Rhinoplasty: All incisions are made inside the nostrils, leaving no visible external scars.
  • Open Rhinoplasty: Involves a small incision across the columella (the strip of tissue between the nostrils) in addition to internal incisions. This approach provides wider exposure and direct visualization of the nasal framework, often preferred for more complex deformities or revision cases.
• Structural Rhinoplasty: Focuses on reinforcing or reconstructing the underlying nasal framework to ensure long-term stability and support, rather than just reductive techniques.
• Preservation Rhinoplasty: A newer philosophy aiming to preserve as much of the patient's native bone and cartilage as possible, reshaping rather than aggressively resecting, to achieve more natural and predictable long-term results.

 

Endonasal Techniques and Minimally Invasive Surgery

When functional issues like septal deviation or turbinate hypertrophy are the primary concern, or when they accompany external deformities, endonasal (intranasal) surgical techniques are employed. These are often minimally invasive and aim to:

• Straighten the nasal septum (septoplasty).
• Reduce the size of hypertrophied turbinates (turbinoplasty).
• Address nasal valve collapse.
• Remove nasal polyps or other obstructions.

These procedures can be performed alone or in conjunction with external rhinoplasty techniques to achieve both functional and aesthetic goals.

 

Benefits of Rhinoplasty: Improved Quality of Life

Successful rhinoplasty, whether primarily aesthetic, functional, or combined, can offer significant benefits:

• Improved facial harmony and aesthetic appearance of the nose.
• Enhanced self-esteem and psychological comfort.
• Improved nasal breathing and airflow.
• Alleviation of symptoms related to nasal obstruction, such as snoring, dry mouth, or recurrent sinus issues (if related to anatomical blockage).
• Correction of deformities resulting from trauma or congenital conditions.

 

Preoperative Evaluation and Consultation

A thorough preoperative evaluation is essential for successful rhinoplasty. This includes:

1. Detailed Discussion of Goals: Understanding the patient's aesthetic desires and functional complaints.
2. Medical History: Including previous nasal trauma, surgeries, allergies, medications, and general health status.
3. Physical Examination: External and internal nasal examination (often including nasal endoscopy) to assess the skin, bony and cartilaginous framework, septal position, turbinate size, and airway patency.
4. Photographic Documentation: Standardized photographs are taken for analysis and surgical planning.
5. Computer Imaging/Simulation (Optional): May be used to help the patient visualize potential surgical outcomes, facilitating communication between patient and surgeon.
6. Discussion of Surgical Plan, Risks, and Recovery.

 

Postoperative Care and Recovery

Postoperative care is crucial for optimal healing and results. It typically involves:

• External nasal splint or cast for about one week.
• Internal nasal packing or splints (if septoplasty was performed), usually removed within a few days to a week.
• Pain medication to manage discomfort.
• Nasal saline rinses to keep passages clean and moist.
• Avoiding strenuous activity, nose blowing, and wearing glasses directly on the nasal bridge for a specified period.
• Swelling and bruising around the eyes and nose are common and gradually subside over weeks.
• Final results may take 6-12 months or longer to fully manifest as subtle swelling resolves and tissues settle.

 

Potential Risks and Complications

Like any surgical procedure, rhinoplasty carries potential risks, including but not limited to:

• Bleeding (epistaxis)
• Infection
• Adverse reaction to anesthesia
• Numbness or altered sensation in the nose or upper lip
• Persistent pain
• Difficulty breathing through the nose (if not fully corrected or due to scarring)
• Nasal septal perforation
• Unsatisfactory aesthetic outcome requiring revision surgery
• Skin problems or discoloration
• Scarring (especially with open approach, though usually minimal)

Choosing a qualified and experienced surgeon specializing in rhinoplasty is critical to minimize risks and achieve desired outcomes.