. Posted in SURGERY

Rhinoplasty corrects the overall structure of the nose. It can be performed for cosmetic as well as functional reasons. This surgery can be performed under local anesthesia with sedation or it can be performed under general anesthesia.

Techniques vary from surgeon to surgeon. Rhinoplasty can be performed by making cuts inside of the nose and then tunneling underneath and performing the surgery through these incision sites. Or the procedure can be performed through an external approach (known as external rhinoplasty) through an incision at the tip of the nose, by which the surgeon lifts the soft tissue off of the framework of the nose, giving him or her a direct view of the bone and the cartilaginous framework. I perform rhinoplasties both ways as both techniques have their advantages and disadvantages. I usually decide which way to perform
the rhinoplasty based on what needs to be done to achieve the desired functional and aesthetic result. Typically, the soft tissues of the upper and lower lateral cartilages are sculpted with scalpels or scissors, and I like to be very conservative in this area.

During the surgery, nasal bones are usually broken, shaped to the right size, and placed in the right position. However, in doing revision rhinoplasty (after a previous rhinoplasty) rebuilding a collapsed nose after trauma or as a result of an autoimmune disease (Wegener’s granulomatosis), bone and/or cartilage grafting may be necessary to build up the bridge of the nose. During functional rhinoplasty, septal surgery is usually performed at the same time for patients whose septum is deviated. Very often the septal deviation lends to the nose being crooked.

Functional rhinoplasty is usually performed when someone suffers a trauma to the nose, which causes a deviation of the nose and leaves it crooked. Trauma to the nose often leads to an obstruction of the nasal airway. This trauma can occur at any time, even as early as coming out of the birth canal. The nose will then continue to grow crooked throughout a person’s life. Or trauma can occur as a result of a fall in the crib or a fall when you were young, riding your bicycle, playing a sport, or roughhousing with siblings. You might not remember the incident. Maybe you had a slight nosebleed, a little swelling and the rest went unnoticed. The injuries that you had as a child may not be as apparent as those that occur later in life such as an accident (sports injury or car crash), fall, or assault. Patients usually remember injuries that occur later in life more clearly because they are older and the trauma causes a more acute problem.

There are patients that request a pure cosmetic rhinoplasty. It is important for the surgeon who performs the operation to be cognizant of the fact that changing the outside of the nose can cause nasal obstruction when the surgery is done. Cosmetic rhinoplasty styles change with the times. You can see this by skimming through the fashion magazines. Back in the 1960s many women wanted to have a little, tiny nose. Their plastic surgeon would tell them, “I am going to give you a cute, little
nose but I want you to know that your nasal breathing might not be so great thereafter.” And the women would say: “No problem, I don’t care about breathing through my nose. I just want to look good.” Now these women are older and they want to breathe through their nose. In addition, as the years went on, the styles of nasal work changed and the aesthetics of the nose have progressed to a more natural-appearing nose. Now these patients are coming back for their nose to be redone for both functional and cosmetic reasons.

I love doing this surgery and have had excellent results. I enjoy the challenge, and most patients are very appreciative when you can return their nose back to near normal, both functionally and aesthetically. However, some surgeons do not like to do revision rhinoplasty for many reasons, including these:

■ It is very challenging and often difficult, even in the best of hands, to get a perfect result.

■ It often requires more work and skill than a primary rhinoplasty.

■ It often involves an unhappy patient who has had a bad experience with another surgeon.

■ The surgery may require significant grafting.

■ The surgery may need to occur in stages.

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