Rhinoplasty is a surgical procedure to correct mainly aesthetical problems of the nose such as bone humps, e.g. having a prominent dorsal bone of the nose similarly to a hump, any right or left deviations of the whole nose and any congenital malformations including cleft lip and palate, and other genetic factors, and those acquired in life due to traumas and diseases.
When in search for a solution to the obstructed nose as a result of excessive strain, deviated septum or nasal septum solely, we are referring to septoplasty. There are other structures inside the nose, turbinates and nasal valves, swollen mucosa, among others, the congenital or acquired alterations of which may contribute or be the cause of obstruction. Despite the fact that the latter is a different procedure, both surgeries -rhinoplasty as well as septoplasty- may be performed at the same time in most of the cases.
The surgery including both procedures is called Septorhinoplasty or functional rhinoplasty.
Currently, rhinoplasty is intended to return the facial balance of the patient. In other words, an ideal result which generally makes the nose follow the structural traits of the face. One of the main goals of the surgeon is to produce noses looking as “non-operated”.
The nose surgery or rhinoplasty is a day procedure performed with general anesthesia. This surgery has aesthetical and functional applications, most frequently performed in patients seeking to reduce or increase their size, change the shape or the outline, and the change in the angle between the nose and the upper lip. In turn, in functional procedures patients choose the surgery in order to improve impaired breathing and correct injuries in the organ structure.
There are two types of procedures to perform rhinoplasty:
Closed rhinoplasty: it is often the technique mostly used by surgeons and it offers a great advantage: there is no visible scar. Cartilages, septum or the area on which some sort of action is to be performed are accessed through the nostrils so that the operation is conducted with no exterior incisions, and this results much more comfortable in the long run for the patient, since he does not see any mark of the operation.
The surgeon has access to most of the problematic zones, thus, he may work on the section until achieving the desired shape of the nose.
Open rhinoplasty: it is a more arduous procedure than the closed one in which the surgeon makes an incision in the middle zone of the nose, with an aim to make the bones and cartilages more accessible. As a general rule, it is recommended for cases of more complicated patients or second procedures.
The nose anatomy is rather complex. The patient only locates it as the pyramid of the face center, the visible part of the nose. Nevertheless, it is such a deep and wide cavity just like the mouth with interconnections with other systems. However, for practical purposes, the external nose may be considered as a pyramid-like shape three-dimensional structure, essentially made up of an osseous and cartilaginous skeleton. The osseous skeleton or bony vault mainly comprises the nose bones in the upper part, which are articulated with the upper frontal bone and in the lower part with the ascending apophysis of the upper jawbone.
The cartilaginous skeleton comprises the nasal lateral cartilages, two lower cartilages (also known as alar cartilages) and two upper cartilages. Another core structure in the maintenance of the shape and nasal function is the nasal septum, which is made up of a posterior osseous part and an upper osseous part (comprising the vomer and etmoides bones), and another anterior and inferior cartilaginous part.
Based on the above concepts, the nasal pyramid may be divided into three thirds for aesthetical purposes and five zones from a broader functional point of view.
The concepts of face balance help us easily identify which the characteristics and dimensions of an aesthetic nose should be and harmonically acceptable for a particular face. For the nose analysis we mainly consider its three basic views or projections: front, profile and nasal base.
This view essentially allows us to evaluate three aspects: the nose size, the dorsum shape and the rotation as well as the projection of the nasal tip. The ideal size of the nose according to some anatomists should be equal to the ear length; another useful measure is to divide the face into three thirds (approximately equal): a superior third which goes from the hair insertion line up to the most prominent point of the nasal-frontal junction (glabella), a middle third going from the glabella up to the subnasal point (where the nasal columella emerges) and a lower third from the subnasal point up to the lowest point of the chin.
The shape of the nasal dorsum may be evaluated by drawing a line from the nasal root or radix (the most depressed point of the nasal-frontal junction up to the nasal tip. This measurement may identify abnormalities of the dorsum such as humps or very low dorsum. The nasal rotation refers to the position of the nasal tip with respect to the nasal dorsum and may be essentially evaluated with the nasolabial angle which should be between 90° and 95° in men, whereas in women it should be between 100° and 110°.
The nasal projection refers to how much the nose stands out or projects from the face. The ideal measure of the nasal projection at the tip equals to 0.67 times the nasal length.
The baseline view allows us to evaluate the shape of the nasal tip, the symmetry of the nostrils or blowholes.
Ideally, the projection of the nasal base lines should form an equilateral triangle, where one third of the nasal base length equals to the nasal lobule of the tip and the other two thirds to the columella length.
First of all, the face should be considered as a whole containing two halves nearly equal; the line which divides the face into two halves should cross the middle nasal root, continue along the nasal dorsum and divide the nasal tip exactly into two equal parts; this first consideration is useful when evaluating deviations from the nasal pyramid. Likewise, this view allows us to determine the ideal nasal width, which should be exactly equal to the distance between the ocular angles or the innermost lachrymal points (interocular distance). The last measure should, in turn, match with the size of the eyes.
In one or more visits, the surgeon will listen to the patient’s desires and expectations with respect to his nose. He will investigate the nasal sinus pathology or any other by questioning, the physical examination and a CAT scan of the nose and paranasal sinuses, essential in most of the cases. The surgeon will analyze the photos and suggest to the patient a surgical plan, without creating any false expectations. Also, the surgeon will refer the patient to an anesthesiologist for the pertinent evaluation. It is of vital importance the careful evaluation of the patient not only from the aesthetic point of view, since, ideally, both the aesthetic and the functional aspects should be solved in the same surgical time. This will avoid future reinterventions.
The plastic surgeon may rely on the otorhinolaryngologist’s experience and vice versa or the experience of a similar specialist. It is also at this stage where medical fees and other expenses resulting from the surgery are agreed (fees for use of the surgery room, anesthesiologist’s fees, etc.)
On the day of the surgery, the patient is required to appear with at least eight-hour fasting, wearing comfortable clothes, no jewelry or makeup and they should avoid consuming medicines or any other substance which may alter the scaring or generate more bleeding than usual (painkillers, aspirin, ging seng, ginkgo biloba, vitamins, among others).
It may be local for some minor procedures, or general.
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