RHINOPLASTY

Nose is the most conspicuous part of the facial beauty due to its up front and center position on the face. lt is the part of our face that people we interact with one-on-one notice the first in our daily lives and in social settings.  Therefore, the aesthetics of our nose, its harmony with our face or its figure abnormalities and its general disharmony with the general structure of our face are the first things people notice on your face. People’s first impression of us is an important part of our image. Naturally, the shape of our nose doesn’t determine our status and respectability in society. Our character, experience and knowledge, and communication skills are far more important, however, it is hard to ignore the emphasis placed on the decisiveness of visual perception and the priority of physical appearance especially in this day and age.  Noticeable deformities may cause the person to develop a lack of self-confidence.  The person may ignore the rest of his or her face and specifically focus on the nose, shy away from the mirrors due to a deformity, assume that everyone stares at his or her nose, and be reluctant to have pictures taken.  At this point the need to correct the shape of the nose and achieve harmony with the rest of the face arises. Rhinoplasty is a plastic surgery for correcting the shape of the nose and changing it permanently. The size, shape and the proportions of your nose can be improved via rhinoplasty. The cartilage and the bone structures forming the nose structure are reshaped. Nasal humps can be corrected, the nose can be taken back to center if it has deviated left or right, the tip can be raised, lowered, enlarged or shrank, symmetry can be restored, the nose can be heightened or shortened, nostrils can be shrank, flattened radiks can be filled in, collapsed nasal valves can be structurally supported and stabilized, and droopy base can be corrected.   One of the most important points to remember here is that the main function of our nose is to breathe. It is often observed that nose deformities are  accompanied by a stuffy nose complaint. Especially in crooked noses, it is either very difficult or, in most cases, impossible to correct just the anterior of the nose without interfering with the interior.   As the renown nose surgeon AUFRICHT says “Where the septum goes, there goes nose” In fact, just the opposite is also true. Thus, the interior and the exterior of the nose should be considered and evaluated as one for a successful aesthetic and functional result in rhinoplasty. Still, there are limits to what we can accomplish with rhinoplasty.  Excessive removal of cartilage and bone or unsuitable bone interventions may impair breathing function, which is otherwise normal. It is absolutely necessary to maintain the breathing function intact, and furthermore, to fix any existing nasal obstruction while changing the shape of the nose during rhinoplasty.  Suitable candidates for rhinoplasty include female patients over the age of 16 and male patients over 17 who are unhappy with the shape of their nose, are sure of what they want and don't want regarding their nose, can openly share their wishes with their doctors, understand the operation process and results, aware of the possible changes and constants with their new nose in their post-operative lives, and are knowledgeable about the benefits, risks, and results of the operation. Communication with your doctor and your motivation in the preoperative consultation, evaluation, and decision-making stages are crucial. It is important to talk about preoperative aesthetic and functional evaluation, picture analysis and the determination of problems, operation plan, need for and use of grafts, postoperative process, and possible complications openly and in-depth.   Candidates should keep in mind that the success of the operation doesn’t only rely on the experience, knowledge, and the skills of the surgeon, but also on their desire, motivation, and patience. I go through the operation a few times in my head beforehand, plan out the possible challenges and how to overcome them during the operation. Rhinoplasty is one of the most difficult operations in facial plastic surgery. There is no standard rhinoplasty. Every patient, face, and nose carries different anatomical features and has its own unique structure when considered as a whole in and of itself. Therefore, it requires a special surgical planning for each patient including a complete assessment of aesthetic and functional deformities, a good design and surgical plan, and most importantly, the experience and the ability to materialize the plan. A nose that looks appeasing from each angle and is in harmony with the rest of the facial features is targeted. The surgeon's artistic ability, experience, education, and training in rhinoplasty, and the desire to develop himself are the vital factors for a successful result. In addition, the balance between aesthetics and functionality should be very well preserved. Personally, I avoid excessive resections in rhinoplasty operations, strive to protect the natural support, and achieve a natural look for my patients that will last them a lifetime.   Preoperative Evaluation Aesthetic Evaluation First comes observation. Nasal ala and nasal valve are checked to determine if a collapse is present. Next nose skin thickness is evaluated. Then, cartilage and bone structure are examined and evaluated starting from the radiks of the nose all the way down to the lips. Nasal bones (check for short nasal bones, thickness, hardness, nose bridge, crookedness, asymmetry, and irregularity,) Cartilage (shape, position, size, thickness, flexibility, asymmetry, excess, shortage, nose tip support, droopy or raised tip, width, crookedness, and fullness), nasal base and nostrils (width, narrowness, asymmetry, retraction at the sides) are evaluated.  Nose-forehead and nose-lip angles, the proportion of the nose to the face and those of its own are evaluated. Tension and contractions in nasal muscles and the upper lip and nose relationship when smiling and talking are carefully assessed. Lower jaw and tip are evaluated. Shape deformities and details desired to be corrected regarding the shape of the nose are discussed starting from the forehead down to the lips.   Functional Evaluation It is found out if stuffy nose exists and, if so, on which side it is dominant, if it is constant or inconstant, if it exists during regular breathing or deep breathing and during physical activity.  Next comes the examination of the nose interior. The existence of the following are evaluated; Nasal septum (crookedness, deviation, cartilage thickness and amount) turbinates (size and anatomical variations)’ nasal valve, polyps, and sinuses. 40% of the problems in the posterior of the nose are overlooked during a standard  examination of the nose interior. Therefore, the posterior of the nose and the nasopharyngeal definitely need to be checked out via an endoscopic examination.  Nose and sinuses tomography are done if necessary.       Photography Shoot and Computer Analysis In a standard photo shoot, the nose is shut from six different angles including the front, the base, right side (profile), right oblique (45°), left side (profile), and left oblique (45°). Besides the standard photo shoot, I also shoot the nose when smiling and from the top. While the photos shut smiling show the nose to lip relationship, the deviations from the center in the nose are best seen in the photos taken from the top. Next, the photos are uploaded to the computer, and the best nose shape is designed with the help of a specific software. This design is significantly helpful in planning for the operation. However, it should be noted that the operation result may not meet expectations from the computerized appearance 100% although a very close look is possible to attain. You must definitely inform your doctor of all your regular medication for chronic diseases (hypertension, diabetes etc.), previous surgeries, allergies, and any bleeding issues prior to the operation. It is recommended to stop taking aspirin and the likes (naproksen, ibuprofen) blood thinner pain relievers, vitamin A, and Ginkgo Biloba (they may increase bruises and swelling) 10 days prior to the operation and to stop drinking alcohol 5 days before the operation (it may increase edema), giving up smoking (it prolongs the healing of woods, increases lung related post anesthesia problems and the risk of infection).   How is the Rhinoplasty Operation Done?  The approach to and understanding of Rhinoplasty have changed with the developments in science and art in the last century. In the past, Rhinoplasty operation was performed as a nose reduction procedure (reductive Rhinoplasty ). In reductive Rhinoplasty, excessive cartilage and bones were removed and a small nose was achieved, leading to a weak nose skeleton. Although this look was satisfactory for patients in early times, the artificial and imbalanced appearance developed in the nose through the years made patients unhappy. In addition, many problems with breathing developed due to the weakening of many of the nose’s support structures. In today’s understanding of Rhinoplasty, the principle of reshaping over reduction is accepted. Therefore, excision (removal of cartilage and bones), suture (sewing) and graft techniques are applied only as needed. My philosophy and goal in Rhinoplasty is to achieve a nose that is aesthetically beautiful and attractive, proportional to the whole face, structurally strong and lasting, and that functionally breathes comfortably.    What are the Closed and Open Approaches? Whether Rhinoplasty should be performed closed or open has been the topic of discussion for almost 50 years. It is important to be aware right from the beginning that closed or open approaches are not operation techniques but rather methods to access the cartilage and bone structure of the nose. The cartilage and bone structure of the nose are accessed through an inverted V or W shaped small incision in the columellate (the structure separating the nostrils) and elevating the skin in the external approach, also known as, the open approach. The incision in the skin is sutured and closed in the last stage of the operation. This incision scar is almost invisible after recovery. In the closed approach, all incisions are made inside nose. There is no such rule as one approach is better than the other. I perform both of these approaches depending on the requirements of the nose. For example, for a nose with a hump in the middle, I prefer the closed approach if the nose tip is symmetric and smooth. Some of the advantages of the closed approach are that it protects the nose tip support structure, causes less trauma, enables faster postoperative healing period and reduction of swelling, and prevents loss of sense in the nose tip. I prefer the open approach in crooked noses, ones that require major revision or with a significant asymmetry in the tip and in cleft lip Rhinoplasty.  The advantage of the open approach is that it allows for complete access to  the whole cartilage and bone structure of the nose and enables all kinds of graft and suture technique applications. The operation takes 1-4 hrs depending on the nose shape and the approach. What matters to me is the result of the operation rather than the duration!    What is the Postoperative Process Like? You may experience an increase in swelling around the eyes and on the face in general. The patient should sleep in an upright position supported by two pillows (at a 40-45 degree angle), and should apply cold compress with ice or frozen peas for 10-15 minutes ever hour in order to reduce swelling and bruising. Swelling decreases after the third day, it slowly goes down to the cheeks and then completely disappears after 5-7 days. Bruising, on the other hand, is observed in different proportions depending on the patient’s skin, thickness of bones, duration of operation, and the tools used. If bruising develops, it fades in 10-14 days and then completely disappears. Using an ointment to recuse bruising is recommended in order accelerate this process. How the nose bones are treated and the tools used play an important role in the development of bruising. I prefer cutting the bones to breaking them in Rhinoplasty, and I use 1-3mm sharp osteotomes (bone cutters) for that. I encounter bruising in only 20% of my patients. Nose bleeding like spotting may happen in the first 2-3 days followed by a flow mixed with mucus after the third day. The external splits (thermal splint) on the nose exterior are removed a week after the operation. After the checks and dressing are completed sticky tapes in the skin color are placed on the nose. These tapes remain on the nose for a week. Taping provides both for reducing the swelling and protecting the nose. Flexible and soft packs made of silicon (doyle splints) are placed inside the nose at the end of the operation. These packs have an open lumen design which allows for easy breathing unless is blocked with dried mucus or blood clotting. Tampons are removed in 3-5 days depending on the scope of the operation (Septoplasty along with Rhinoplasty, nasal turbinate reduction etc.). The removal procedure lasts only 10-15 seconds and it is pain-free. Some patients may be eligible for an operation without the need for tampons where the mucus and septum are sewn to each other with self dissolving stitches. However, silicon tampons are preferred because they reduce both the bleeding and the risk for postoperative nose adhesions. Crusting in the nose happens a few weeks after the tampons are removed. Crusting may last longer in patients who have had their nasal turbinate reduced along with Rhinoplasty. This crusting can be softened by applying a serum or salty water and rinsing inside the nose. Afterwards, it can be cleared by deep inhales or blowing the nose lightly. Crusting in the nostrils can be softened and cleared with oxygen water or antibiotic ointments. Patients may experience  mild-to-moderate pain after the operation which can easily be taken care of with a pain reliever. Patients may go back to their normal life, school or work, a week to 10 days after the operation with minimum effort. Patients may start to exercise with the exception of physically demanding activities a month after the operation.  It is crucial to avoid traumas during exercise. It is recommended to use sun protection at least for two months (use sun protection with high SPF), and avoid wearing glasses (even sun glasses). Direct exposure to the sun may lead to both a delay in the reduction of swelling and to permanent skin spots. Glasses may cause disorientation or collapse due to constant pressure on the nasal bones .    What are Possible Complications? Some complications may arise during and after the operation. Functional and/or aesthetic complications may be encountered. Minor resection’ excessive resection and/or problems with symmetry may frequently happen. Sometimes, unusual scarring (needle) may occur.   Possible Complications during the Operation ● Anesthesia related complications  ● Bleeding; Regular blood pressure checks, getting off blood thinners, maintaining a low blood pressure during the operation, protecting the tissue plans and treating the tissues gently reduces this possibility.     Possible Postoperative Complications  ● Bleeding; Bleeding that requires  postoperative medical intervention is observed in less than 1% of patients.  ● Infection ● Septal hematoma or abscess apse; it is the accumulation of blood between the cartilage in the nasal septum and the layer called mukoperikondrium on top of it. As the accumulated blood remains it becomes infected and access may develop. It is vital to draw the accumulated blood or the infection out because the septum feeds off of this layer.    ● Septum perforation; Septum perforation happens when a hole develops in the nasal septum seperating the two cavities of the nose. The most common cause for it is complications with nose operations (septum surgeries).  While some patients may experience crusting, bleeding, a whistle sound during breathing through the nose, stuffy nose, pain, nose and post nasal drip, others may have none of these complaints.   ● Nose Adhesions (Synechias); It most frequently happens between the septum and the nasal turbinate. It may lead to a stuffy nose.  ● Suture and Incision Issues; While it is seldom observed, suture may break off or dissolve in the early stage and the body may refuse the suture or try to dispose of it in the later stage. Another seldomly observed complication is the development of visible scars in the areas of incision and the development of scars (nedbe) during the healing of the incision areas inside the nose.    Complications with Breathing and other Functional Complications  Nasal valve narrowing and problems with breathing may be observed in approximately 15-25 % of primer Rhinoplasty patients. While patients satisfied with the aesthetic results don’t dwell on this problem at first, they start to feel the decline in the quality of their lives once they get used to their new nose. In order to avoid this complication, the valve area must definitely be supported with a graft during the operation for patients with nasal valve narrowing.     Aesthetic Complications and Undesirable Results ● The persistence of Crooked Nose: It may happen even with the best of surgeons in primer and secondary Rhinoplasty   ● Droopy Nasal Tip: This is not an occurrence in operations where nasal tip support is provided. ● Pig Snout: In instances of excessive resection  and when the nasal tip is raised too much the nostrils become too prominent and a pig snout appearance happens.   ● Alar Retraction-Collapse, Valve Insufficiency; The nose becomes too narrow if the lower lateral cartilage is resected too much,  lateral nasal walls collapse during breathing and the nose looks like it is pinched.  ● Pollybeak Deformity; Underresection of the nose bridge cartilage may lead to the persistence of the problem or a Pollybeak deformity.   ● Open Roof Deformity; An incomplete osteotomy leads to a condition where the nasal dorsum remains open or a hole forms.     ● Saddle Nose; It happens when the nasal dorsum collapses due to the loss of septum support. It It occurs in the case of excessive septum resection, and a 1.5-cm, L-shaped cartilage support should be left inside in order to prevent it.   ● Inverted V Deformity and Middle Vault Collapse; It is an inverted V-shaped appearance at the  joint of nasal bone and cartilage and leads to difficulty in breathing. For prevention, it is important to pay attention especially in patients with short nasal bones and to support the middle vault with grafts.     In fact, the aesthetic complications and undesirable results in primer Rhinoplasty account for revision Rhinoplasty.    What are the Success Criteria and Rates? Rhinoplasty may deliver three different results  1. Happy patient-happy Surgeon (ideal outcome), 2. Happy patient-unhappy Surgeon  (surgeon thinks he could have done better)  3. Unhappy patient-Unhappy Surgeon (Unsuccessful Outcome).   Aesthetic and functional success rate in Rhinoplasty is above  85-90%. There may be a need for a revision in 7-15% of patients preRhinoplasty depending on the nose deformities, experience and the abilities of the surgeon. See our article on Revision Rhinoplasty for a comprehensive explanation.    A Rhinoplasty patient should have an in-depth  understanding of the changes to follow after the operation and set realistic expectations with regard to the postoperative changes regarding their nose and their life. Patients should not rule out the possibility that there are no guarantees even with the most capable and experienced surgeons.    Frequently Asked Questions  What should the Ideal Nose Look Like? In fact, a standard understanding of an ideal nose doesn’t exist. The concept of ideal may differ depending on the sociocultural and ethic makeup of societies as well as age and gender.  Furthermore, the concept of  a beautiful nose has changed throughout history.  Regardless of a lack of an ideal standard of beauty, appearances that come close to the “golden standard” of (1,618) ratio in most living beings in nature and human body are considered aesthetic and beautiful. Most the of idea body and face ratios have fit in with the golden standard since Leonardo Da Vinci (1452-1519). There is a golden standard for our face and nose as well. For example, in an ideal face, the ratio of mouth width to nasal width, and nasal length to nasal projections correspond to the golden standard. An ideal face is divided into 3 equal parts on the horizontal facial plane and 5 equal parts on the vertical plane. The nose has ideal ratios to the other facial features and within itself. These ratios are carefully considered during the operation. The angles and ratios of the nose to other facial features vary from men to women. For example, Nazo-frontal (nose-forehead) angle is 115–130º, and Nazo-labial (nose-lips) is 90-120º. This angle  is ideally wider in women and narrower in men. As a result, the ideal nose is one that is aesthetically in harmony with with the other facial features and that can functionally breath comfortably.     Can I See my Postoperative Nose Before the Operation? The best shape for your face is designed using an imaging software based on the pictures taken before the operation. This design in significantly helpful in planning for the operation. It should be noted that the post operative nose shape and the imaging appearance may not be one-to-one yet in great proximity.    What is the İdeal Age and Season for Rhinoplasty? Minimum age is 16 in women and 17 in men, however mental age is equally important in Rhinoplasty. The prospect should be psychologically mature enough to make a decision with permanent changes to the nose and the face such as Rhinoplasty and hold the responsibility. There is no age limit in adults as long as the patient’s general health allows for the operation and  anesthesia. Every season is suitable for Rhinoplasty. Patients should pay attention to sun protection and wearing sunglasses for two months if they have Rhinoplasty in the summer.    Choice of Anesthesia  Rhinoplasty; general anesthesia, local anesthesia or  intravenous sedation, without completely being under.  Operations under 1-1.5 hrs can utilize local or intravenous sedation. I prefer general anesthesia both for the patient’s comfort and my ease of work. General anesthesia has become considerably safe with the increase in anesthesia specialists and the advances in devices and medicine.   What are the Open and Close Techniques? How Do I Decide on the Technique I use? Will my nose scar? First of all, I would like to clarify that the terms of open and close techniques aren’t operation techniques but methods to access cartilage and bone structures of the nose.    The cartilage and bone structure of the nose are accessed through an inverted V or W shaped small incision in the columellate (the structure separating the nostrils) and elevating the skin in the external approach, also known as, the open approach.  The incision in the skin is sutured and closed in the last stage of the operation. This incision scar is almost invisible after recovery. In the closed approach, all incisions are made inside nose. There is no such rule as one approach is better than the other. I perform both of these approaches depending on the requirements of the nose. For example, for a nose with a hump in the middle, I prefer the closed approach if the nose tip is symmetric and smooth. Some of the advantages of the closed approach are that it protects the nose tip support structure, causes less trauma, enables faster postoperative healing period and reduction of swelling, and prevents loss of sense in the nose tip. I prefer the open approach in crooked noses, ones that require major revision or with a significant asymmetry in the tip and in cleft lip Rhinoplasty.  The advantage of the open approach is that it allows for complete access to the whole cartilage and bone structure of the nose and enables all kinds of graft and suture technique applications. As an ear, throat and nose specialist, I perform more than half of the operations using the open approach due to complications and problems with breathing in both the primer and revision Rhinoplasty patients.     Is it a Painful Process? Patients may experience  mild-to-moderate pain after the operation which can easily be taken care of with a pain reliever.   How Long is the Operation?  The operation takes 1-4 hrs depending on the nose shape and the approach. The duration may be prolonged if there is a need for rib or ear cartilage graft. What matters to me is the result of the operation rather than the duration!    Are Packs Necessary to Use in the Postoperative Stage? Can the Patient do without Packs? Are Packs Painful?  There is no need for packs if the patient has only had Rhinoplasty without any interference with the septum, however, packs are required if there has been interference in the septum or the turbinates. In this day and age, flexible packs made of soft silicon are used.  These packs have an open lumen design which allows for easy breathing unless is blocked with dried mucus or blood clotting. Packs are removed in 3-5 days depending on the scope of the operation. The removal procedure lasts only 10-15 seconds and it is pain-free.  Some patients may be eligible for an operation without the need for packs where the mucus and septum are sewn to each other with self dissolving stitches. However, silicon packs are preferred because they both reduce the risk of bleeding and adhesion inside the nose after the operation.     Dressing Materials? At the completion of the operation, dressing material is placed on the outside of the nose to fixate the new nose shape, to prevent blood accumulation, reduce swelling and edema, and to protect the nose from possible traumas. While this dressing used to be prepared with plaster in the past, nowadaysreadily available thermal splints and aluminum splints are increasingly preferred.    Bruising, on the other hand, is observed If bruising develops, it fades in 10-14 days and then completely disappears. Using an ointment to recuse bruising is recommended in order accelerate this process. How the nose bones are treated and the tools used play an important role in the development of bruising. I prefer cutting the bones to breaking them in Rhinoplasty, and I use 1-3mm sharp osteotomes (bone cutters) for that. I encounter bruising in only 20% of my patients. Nose bleeding like spotting may happen in the first 2-3 days followed by a flow mixed with mucus after the third day.    Does every Patient Experience Ecchymosis(Bruising)? How long does it take to Heal in case of Occurrence? Ecchymosis doesn’t occur in every patient and not every patient who experiences it does so to the same extent. The amount of Ecchymosis varies from patient to patient depending on the patient’s skin, thickness of bones, duration of operation, the tools used, and most importantly, operating on the right anatomic plane. The patient should sleep in an upright position supported by two pillows (at a 30-45 degree angle), and should apply cold compress with ice or frozen peas for 10-15 minutes ever hour in order to reduce swelling and bruising. If bruising develops, it fades in 10-14 days and then completely disappears. Using an ointment to reduce bruising is recommended. I prefer cutting the bones to breaking them in Rhinoplasty, and I use 1-3mm sharp osteotomes (bone cutters) for that. I encounter bruising in only 20% of my patients. Patients may go back to their normal life, school or work, a week to 10 days after the operation with minimum effort. Patients may start to exercise with the exception of physically demanding activities a month after the operation.  It is crucial to avoid traumas during exercise. It is recommended to use sun protection at least for two months (use sun protection with high SPF), and avoid wearing glasses (even sun glasses). When can I go back to Work and my Social Life? You can resume work that doesn’t require much effort after the 10th day of the operation if you don’t mind the external tapes. You can go back to school. You can start to do light exercises after the 1st month and you can swim. It is recommended to avoid direct sun exposure and wearing glasses, even sunglasses. You can have physical intimacy after 20 days. However, you should be careful to protect you nose in the first month after the operation. When can I Breath Normally? You can breath normally after the first 15-20 days it takes for the edema and the crusting inside the nose to disappear.  I have Allergic Rhinitis. Will Rhinoplasty Cause a Challenge? Allergic Rhinitis is not an obstacle to Rhinoplasty. If necessary, allergic complaints can be contained with medication after the operation.  Should I massage my Nose after the Surgery? Will it help? Massaging is usually not necessary, however it may be helpful in situations where there is excessive edema in the skin or the subcutaneous. A structural deformity arising from the operation can not be reversed with massaging.   Is Droopiness Observed after the Operation?  Droopiness is not observed in operations where the nose tip is supported. However, in the early postoperative stages, the tip may look overprojected due to the tapes and swelling. It goes back to normal after a few weeks.  What Other Operations Possible along with Rhinoplasty? (sinus, polip, turbinate, deviation) How does it impact Recover? Any operation targeted at problems in the nose is possible along with Rhinoplasty. In fact, the ease, nose, throat doctor can neither sacrifice on aesthetics nor functionality. Septoplasty, turbinate surgery, endoscopic sinus surgery (in the presence of sinusitis and polyps), nasal septum perforation repair can be carried out along with Rhinoplasty. The additional procedures prolongs the duration of the operation.     Why is the Skin Important in Rhinoplasty? What are the Advantages and Disadvantages of Thin or Thick Skin?  Skin and the subcutaneous soft tissue is an important structure that covers the cartilage and the bone structure. While the small irregularities on the nasal dorsum or the cartilage structure on the nasal tip are easily visible in especially patients with thin skin, they are unrecognizable in patients with normal skin thickness. In order to avoid this issue, I use crushed cartilage graft, temporal fascia or alloderm, when needed, in patients with thin skin. Strong cartilage is needed in patients with thick skin to provide for a stable nasal tip and to carry the weight of the skin. Swelling takes longer to go down in patients with thick skin (lymphatic drainage takes longer to go back to normal), it may sometimes take up to 2 years.  What is a Difficult Nose? There is no such thing as an easy Rhinoplasty. However, crooked nose, revision rhinoplasty, and cleft lip rhinoplasty require special experience.    What are Tip Problems? What is Tip Surgery or Tip Plasty?  Sometimes, there may be a shape deformity only in the nasal tip rather than in the whole nose.  There may be asymmetry, excess wideness, narrowness, visible protrusions, droopiness, overprotection etc. in the nasal tip cartilage. If the remainder of the nose is in normal condition, the correction of the shape deformities only in the nasal tip is called “Tip Plasty.” Is it Possible to Perform Rhinoplasty without Osteotomy? Rhinoplasty may be performed on patients with a slight nasal hump or a narrow nose without osteotomy. In these cases, the hump may be rasped, the perception of hump in the nasal dorsum may be reduced with the insertion of grafts in the nasal radix.  When does the Nose Reach its Final Shape? The nose reaches its shape 70% in the first month, and 90% at the end of the first year.  What are the Check and Followup Procedure after the Operation? After we are done with the dressings, I would like to see my patients in the 1st, 3rd, and 6th months and the year anniversary of the operation.  What does Nose Aesthetics without an Operation Mean? It means covering up the minor nose defects with fillers. It lasts 3-9 months depending on the fillers used. It can be repeated when the fillers are absorbed.  

Rhinoplasty

REVISION RHINOPLASTY

Revision Rhinoplasty (Corrective Nasal Aesthetics Surgery) Revision rhinoplasty or corrective nasal surgery is performed to remedy the undesired results of a previous rhinoplasty operation. Some disputes regarding the terminology exist. According to some, the subsequent operation(s) performed by the same surgeon to correct the unfavorable results arising from the first operation is called revision rhinoplasty while secondary rhinoplasty is the name given to corrective operation(s) performed by other surgeons. However, Secondary Rhinoplasty is widely referred to as the corrective nasal aesthetics surgery performed for the second or more times regardless of the performing surgeon in the first operation.  Unfortunately not every rhinoplasty operation can produce desirable results. A broad, bulbous or pinched tip, asymmetry, droopiness, and extremely short or raised (pig nose) nose may be the case. Nostrils may be asymmetric or wide. There may be a collapse of the nasal sidewalls (alar collapse) and difficulty breathing. There may still be a hump or collapse of the nasal bridge. The nose may resemble a parrot’s beak (Polly-beak) due to insufficient removal of cartilage or there may be a collapse in the nasal bridge (saddle nose) due to excessive removal of cartilage. An inverted V look in the middle of the nose, twisted nose, continued deviation, irregularities on the nasal bridge, excessive scar tissue development inside and outside the nose, skin and soft tissue problems may exist. Actually, the aesthetic and functional complications in the primary rhinoplasty account for the possible indications that may arise in the revision rhinoplasty. Unfortunately, 7-15% of primary rhinoplasty operations require secondary (revision) rhinoplasty. Some of these operations call for minor revisions while some involve major corrections. In a minor revision surgery, the results of the first operation are acceptable and only small touchups are necessary. The patient may be happy with the look and feel of the current nose in general, but ask for small revisions. However, if the previous rhinoplasty surgery has caused obvious shape deformities, a major corrective revision surgery is required. An unsuccessful rhinoplasty surgery may lower a patient’s self-confidence and cause the patient to shy away from social activities. Generally, such patients are both unhappy with their noses and scared of a revision surgery. (What if it fails again? Could it get worse? Could I trust my doctor? etc.) Common Reasons why a Rhinoplasty (nasal aesthetic surgery) may fail.  1. The surgeon may have inadequate experience. 2. The patient may have unrealistic expectations. 3. The surgeon’s goals may be excessive. 4. Functional problems may occur due to poor healing and tissue scarring. 5. A postoperative nasal trauma may have occurred.   How can Failure be Avoided or Minimized?   1. Examination The surgeon must do a full preoperative examination of the patient, plan a good course of action, and perform patiently and meticulously during the operation. Incorrect incisions, the excessive or inadequate removal of cartilage or bones, the inability to repair nasal support mechanisms are the most commonly observed reasons for undesirable consequences. The surgeon mustn’t rush through the operation. In cases where the surgeon isn’t fully satisfied with the results, it is critical to start over and make the necessary revisions. The result of the operation is of the essence, not the duration.   2. Experience Rhinoplasty requires an experience of at least 5-7 years. It is often mentioned both by ear, nose and throat specialists and plastic surgeons that Rhinoplasty is one of the most challenging and demanding surgeries among aesthetic operations. Being a good surgeon alone doesn’t cut it. It also demands a surgeon with a strong artistic eye who works with patience and rigor and treats tissue with sensitivity and respect. It is vital to consider the many structures that make up the nose and their three dimensional relation to each other to operate and fix for desired results. In addition, it is necessary to anticipate what forces, and at what capacity, will have an impact on the nose postoperative and how to stabilize the nose in the long run. All of this demands experience. Revision rhinoplasty requires extra experience compared with regular rhinoplasty.   3. Focus It should be kept in mind that the main function of a nose is to breathe healthily and visual appearance should not be the sole area of focus. The emphasis should be on fixing the nose without neither sacrificing the appearance nor healthy breathing. It is advised to wait for at least a year after the first operation to undergo revision rhinoplasty.    Preoperative Evaluation Although the preoperative evaluation is the same as of the primary rhinoplasty, it requires a more in-depth look and care. Moreover, the surgeon should determine any need for grafts and their possible resources, and secure patient approval.   Aesthetic Evaluation A detailed analysis of the nose is a must for a successful surgery. First, the skin is examined. The thickness, quality, fullness, and integrity of the skin and subcutaneous tissue and its relation with the nasal structures underneath are assessed. In the meantime, resections of any kind, insufficient, excessive, or asymmetrical are established. The surgeon tries to identify the untouched areas in the nose in the previous operation. Next, the surgeon looks into the possible graft areas. The osteotomies and their positions on the nasal dorsum are evaluated. They may be very high, normal or very low. Are they straight, crooked, wide or narrow? Will there be a need for revision osteotomies? Is there an Open Roof Deformity or Rocker Deformity in hand? In addition, the surgeon should evaluate whether an excessive or inadequate removal of the nasal hump or the nasal bone is in question. Also, the nasal dorsum should be examined in terms of irregularity. In the evaluation of the middle vault, the surgeon should look for any inverse V deformities and narrowness. It should be assessed whether grafts are needed or not. The cartilage is examined to figure out if there are any insufficient or excessive resections, irregularities, or crookedness. Anterior septal angle is studied to assess its role in the Polly-beak deformity. In the evaluation of the nasal tip, symmetry, projection, rotation, alar-columella relationship, and the state of the lower lateral cartilage are assessed. Tip support and the tip of the septum cartilage are examined. All the incisions inside and outside the nose are checked out. Any possible presence of grafts is analyzed.   Functional Evaluation Static or dynamic valve collapse (shrinkage or collapse in the nasal valve) is widely observed among revision rhinoplasty patients. Narrowness in the nasal lateral wall and collapse in the nasal ala when breathing are significant signs of valve narrowing. An immediate diagnosis is possible through the observation of the patient during regular and deep breathing. The modified Cottler’s maneuver (the visible improvement in the patient’s breathing when the nasal lateral wall is supported by a plug curette) supports the diagnosis. Anterior rhinoscopy can help determine septum deviation, inferior turbinate hypertrophy (enlargement of the inferior turbinates), synechia (adhesion), scar, septum perforation, and other anomalies. However, in 40% of patients, some anomalies (such as adenoid hypertrophy, middle turbinate hypertrophy, concha bullosa, choanal stenoz, nasal polyposis, chronic sinusitis…) may not be detected in this type of examination . Therefore, an endoscopic examination is required and a sinus tomography must be taken if necessary.   Photo Shoot and Computer Analysis Photo shoot for a revision rhinoplasty is the same as for a rhinoplasty. In a standard photo shoot, the nose is shot from six different angles including the front, the bottom, the right side (profile) the right oblique (45°), the left side (profile), and the left oblique (45°). I take photos of the patient smiling and from the top in addition to these standard shots. While pictures of smiles show lip to nose correlation, deviations from the center are best seen in pictures taken from atop. Next, the pictures are transferred to the computer and the most suitable nose shape for the face is designed with the help of proprietary software. The target nose design has to be realistic and achievable. Otherwise, it may lead to disappointment. The computer-assisted design imaging process is instrumental in planning the operation. However, it should be kept in mind that a significantly close visual appearance is to be achieved rather than a one-to-one, identical appearance to the computer simulation. It is essential to be in honest and open communication with the patient and inform them of any possible favorable and adverse outcomes. It goes without saying that it is every revision surgeon’s goal to achieve successful and pleasing results. However, if there are serious reservations surrounding any restrictions to achieve better results, surgical boundaries are better kept unchallenged, and this case should be shared with the patient. “Primum Nihil Nocere” (first, do no harm!) is the founding principle of medicine. Patients must inform their surgeon of any regularly taken medication, chronic diseases (hypertension, diabetes, etc.) any previous operations, allergies, and bleeding related issues. It is advised that patients stop taking aspirin and similar blood thinner painkillers (naprosyn®, ibuprofen), vitamin A, Ginkgo Biloba (they may cause increased bruises and swelling) 10 days, and cut out alcohol consumption (it may cause increased edema) 5 days before the operation as well as giving up smoking (delays healing of wounds, increases lung problems and risk of infection post anesthesia).   Revision Rhinoplasty Procedure Revisions rhinoplasty can be performed both open and closed as in primary rhinoplasty. It should be known here that open or closed approaches are not surgery techniques but rather methods applied to reach the cartilage and bone structures of the nose. In the open, also known as, the External approach, the skin is lifted to reach the cartilage and bone structures via a small inverted V or W shaped incision applied to the columella (the structure separating the nostrils). The incision is sewn closed in the last stage of the operation. This incision is usually unobservable postoperative unless looked at closely and carefully. In the closed approach, all the incisions are made inside the nose. There is no clearly stated rule here that one of the approaches, open or closed, is better than the other. The determining factors here are the required interventions on the nose and which approach can manage their complete delivery. No interference with the nose tip support mechanisms, decreased trauma, faster healing and disappearance of postoperative edema, and no postoperative numbness on the nasal tip can be counted as some of the advantages of the closed approach. I prefer the open approach on noses that are crooked, require major revisions, and with distinct asymmetry on the tip as well as in half lip rhinoplasty. The advantage of open rhinoplasty is the ability to be in command of the whole nose cartilage and the bone structures and its allowance for the application of any kind of graft and suture techniques.   Revision surgery involves differences from primary surgery. Some tissues have often narrowed, valuable cartilage and bone tissues have been excessively or asymmetrically removed and the weak or weakened cartilages have been twisted. This situation requires more delicate and meticulous work during the operation. Skin and soft tissues are essential in a revision rhinoplasty. Most of the time, skin has scarred tissue. There is more intensive tissue inflammation in revision rhinoplasty compared with primary rhinoplasty. All the protruding structures in patients with thin skin must be filed, the grafts must be thinned correctly, and if necessary, must be wrapped in fascia and used.  In patients with thick skin, strong cartilage is needed to stabilize the nasal tip and to bear the weight of the nose skin. It takes longer for the swelling to go down in patients with thick skin. It may take up to two years. The duration of the operation varies between 30 minutes to 4 hours depending on the shape of the nose and the approach applied.  While minor touches can be carried out in 30 minutes, major revisions may require 3-4 hours. Most of the time, revision rhinoplasty demands the use of grafts. Nasal septum cartilage is frequently overused or insufficient due to the previous operation. In such cases, cartilage from the ears or the rib (costal) cartilage may be used depending on the need, and the operation takes longer. However, it should be kept in mind that the priority is the result of the operation and not the duration. The success of the revision rhinoplasty depends on a well-developed judgment, competence, knowledge, and above all, experience. It is vital that the surgeon has significant knowledge of anatomy and is on top of surgical approaches in this process. In addition, the surgeon must be equipped to handle undesired results and challenges. Postoperative patient follow up should be in place for a long time. My philosophy in rhinoplasty is to be the first and the last surgeon performing the operation. And, my philosophy in revision rhinoplasty is to make the patient happy and be the last surgeon performing the operation. The postoperative process is the same as in primary rhinoplasty.   Frequently Asked Questions When can Revision Rhinoplasty be done at the Earliest? There is a waiting period of at least one year for the primary rhinoplasty results to settle and for the surgeon to correctly determine the required interventions in the revision rhinoplasty. Where do you procure the Cartilage from when needed in a Revision Rhinoplasty? Grafts are the structural components we use in shaping the nose from time to time. If need be, I primarily use cartilage from the septum provided that it doesn’t disturb nose support. If not, from the ear, and if that’s not sufficient either or if there are major revisions requiring structural support, I use the rib cartilage I obtain from the patient. While we can almost always fulfill the entire need for graft with cartilage from the septum in primary rhinoplasty, ear or rib cartilage are needed most of the time in a revision rhinoplasty depending on the scope of the deformities. Cartilage can be removed from the nose septum provided that a 1,5cm L shaped support is left behind in place. Cartilage from the septum is my first preference both because it exists in the operative field, and therefore, doesn’t require extra incisions and also because it is easily shaped, can create structural support, and maintain its shape. However, the remaining cartilage is often inadequate for revision rhinoplasty due to the frequent use of cartilage from the septum in the previous surgeries. There may be incisions to the front or back of the ear when taking cartilage from the ear. The incisions are unobservable after healing since the incisions are made to correspond to the ear folds. No changes occur in the shape of the ear since cartilage from only the pit is removed. There is no interference with hearing. Grafts may be obtained from both ears depending on need. Ribcage cartilage is removed from the cartilage where the 7th rib unites with the chest bone. The rib cartilage is accessed via a 2-3cm incision and the required size of cartilage is removed. Choice of Anesthesia General or local anesthesia or intravenous sedation (no loss of consciousness) is applied in a revision rhinoplasty. Surgeries performed under 1-1.5 hrs. utilize local anesthesia or intravenous sedation. My preference is general anesthesia both in terms of the patient’s comfort and my ease of work.  Plus, general anesthesia has become much safer with the increase of experienced anesthesia specialists and the advancements in anesthesia equipment. Is it a painful process? There may be mild to moderate pain postoperative revision rhinoplasty. These pains can easily go away with painkillers. How long does a revision rhinoplasty operation take? The operation takes between 1-4 hrs. depending on the shape of the nose, the actions required, and the approach utilized. This period may be delayed if grafts are to be obtained from the ear or the rib. Minor revisions usually take 30-60 minutes. What are the risks in a revision rhinoplasty? Revision rhinoplasty is riskier than a primary rhinoplasty. Occurrence of scar tissue, dislocation of grafts, insufficiency, delayed swelling are more frequent.

Revision Rhinoplasty

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