Art and Science of Rhinoplasty:Insights from ENT and Plastic Surgery

Rhinoplasty (Rie-no-plas-tee) is surgery that changes the shape of the nose. The reason for rhinoplasty may be to change the appearance of the nose, improve breathing or both. 

 Rhinoplasty is one of the most popular surgeries worldwide. This surgical procedure is considered one of the most complex in plastic surgery. The procedure has significantly changed over the years since the first aesthetic procedure described by John Roe in 1887. In pursuance of batter and more consistent results, the reduction concept in nasal surgery has now changed to a more proportional approach, using a combination of careful reduction and grafting. Such advancements were possible mainly due to a better understanding of the anatomical structures and by the works of great surgeons like Joseph and Sheen. 

 Rhinoplasty is not exclusively a cosmetic procedure. The Surgery aims to maintain nasal function or improve it if the patient has reduced airflow due to an obstructed process. This adds to the complexity of the operation as internal nasal structures have to be modified in order to correct functional issues. This aspect of functional correction (nasal obstruction) requires a through training in deptt. of E.N.T (ear, nose, throat), for a period of not less than 2-3 years, with further training with expert E.N.T surgeons. 

 Patients often report to E.N.T. Surgeons, after having been operated by plastic surgeons, with failure of relief of symptoms of nasal obstruction. This is purely because, plastic surgeons, who have no training in E.N.T don’t address the issue of nasal obstruction adequately. 

 In simple terms, nasal obstruction is mainly because of two categories – one is obstructive pathology which involves two main structures in the nose – one is nasal septum and the other is turbinate hypertrophy, which itself could be an after effect of septal deviation to other side (commonly referred to as compensatory hypertrophy of turbinates). 

 A deep understanding of nasal anatomy is the corner stone of a good rhinoplasty. A through pre operative clinical evaluation is of paramount importance before taking the patient for surgery. I must emphasize here, I have taken, not days, but weeks to learn from seniors, how to hold the mirror in the month to perform rhinoscopy. (Examination of posterior part of nose). 

Although imaging like CT Scan and nasndoscopy have made it easy to evaluate the pathology but clinical examination, like in other branches of medicine, can’t be bypassed. This clinical evaluation by rhinoscopy and nasendoscopy is not possible by a plastic surgeon, who had no training in E.N.T. Therefore it is imperative for a Rhinoplasty to have double qualifications, both in E.N.T and plastic surgery. The training has to be for a period of 2-3 years structured training and not just limited to courses or workshops. 

Coming to the techniques of Rhinoplasty, I have noticed the turbinate hypertrophy which in many patients is the main case of obstruction, is not addressed by plastic surgeons, obviously because of lack of training in the surgery of turbinate hypertrophy (turbinectomy) or because of the fear of Post-operative bleeding. An E.N.T surgeon is never fearful about post op bleeding, because he/she has spent years in E.N.T casualty room, treating epistaxis. He / She is well trained in anterior nasal packing, posterior nasal packing or ligation of a vessel in an occasional case. This is beyond the domain of a plastic surgeon, who had no formal training in E.N.T. This again shows, how important is it to have a well-trained, doubly qualified surgeon available in the post-operative period to take care of bleeding, which could be fatal.  One more disorder, namely body dysmorphic disorder is characterized by excessive preoccupation with a time gained noticeable defect in appearance. It is very important for surgeons to recognize this type of patients in an early manner because symptoms may worse postoperatively if not diagnosed and the patients will not be satisfied with the results.  Obstructive sleep Apnea is characterized by repeated episode of airway obstruction during sleep. Patients with this condition have a high risk of perioperative complications. 

Although this condition is not an absolute contra indication, patients with this disease should be advised of the risks, and preoperative measures like the use of a continuous positive airway pressure device (CPAP) could be implemented in order to reduce complication rates. 

 Bleeding disorders should be ruled out before undertaking Septo / Septorhinoplasty procedure to avoid post-operative complications. Patients should be asked about history of excessive bruising or bleeding, consumption of drugs, supplements, or vitamins that alter coagulation cascade. 

 Nasal hump is a common issue in Kashmiri population. Some amount of lump is our racial character, which most of the patients accept. So, we need to be careful which reducing the lump in our population. If a dorsal lump exists, an objective evaluation should be made in order to differentiate whether it is a cartilaginous lump, bony lump or both. Reduction of the bony lump should be performed by using a rasp, osteotomy, or an ultrasonic device. Sometimes we may need to augment the dorsum. 

 Lateral osteotomies are an important part of Rhinoplasty to straighten the dorsum. 

 Septoplasty most of the time involves excision of the central part of septal cartilage, with preservation of dorsal and cephalic part (L-Strut). 

 Tip plasty is an extremely important part of cosmetic Rhinoplasty. Various manures are described to correct tip projection, tip rotation, bulbous tip etc. 

 When it comes to open Rhinoplasty, an experienced plastic surgeon can well manage the problem of skin and soft tissue components in addition to various mannevers in cartilages and nasal bones. The dorsal skin flap needs utmost care in handling, as is true for other flaps in plastic surgery. Too little thinning of flap in a bulbous nose may not show the results of cartilage suturing, and too much thinning may result in distal necrosis of flap near columella, resulting in a disastrous scar. So proper handling, proper size sutures, early removed of sutures are extremely important in producing a good result. These mannevers have a slow learning care during plastic surgery training. 

 Complications of Rhinoplasty are bleeding (Epistaxis) Septal hematoma, Infectious complications, traumatic complications, intracranial injury, and injury to lacrimal ducts. 

 Late complication are in the form of Septal Perforation, Nasal Adhesions, Rhinitis etc. 

 Aesthetic Complications usually appear late in the form of asymmateric tip, residual hump, middle vault collapse etc.

Author is a Consultant Plastic Surgeon in Super Specialty Hospital, GMC, Srinagar