Rhinoplasty

Rhinoplasty

In rhinoplasty, it is necessary to plan a special surgery for each nose and obtain a nose shape suitable for the person's face and, more importantly, a "breathing nose" that is expected to accompany it.

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The nose is one of the most important sensory organs with its breathing and smell functions. Smell, which also greatly affects the taste function, must be in harmony with the breathing function. Apart from this, our nose, which is one of the most important determinants of facial expression, is expected to comply with aesthetic criteria. Within the basic aesthetic proportions, when viewed from top to bottom, the nose is located in the middle 1/3 of the face, while on the horizontal axis it should not extend beyond the colored layer of the eye called the iris. It should be in harmony with the lower and upper jaw when viewed from the side.

Image Note: Aesthetic proportions of the nose in front and side view

Not everyone may be a candidate for nose surgery (rhinoplasty).

Our patients who do not have any significant problems in terms of aesthetics and function in the nose also apply for minor changes. In patients who persistently request very minor changes, patient satisfaction may remain below expectations, no matter how well the surgery is performed. At this point, revealing that the problem may actually be in the patient's subconscious through long patient-physician interviews may mean saving from an unnecessary surgery. Apart from this, patients who have diseases or a history of diseases related to other organ systems should give detailed information to their physicians on this subject. If approval is not given by the physicians who will anesthetize the patient, the surgery may not be performed.

Breathing problems are often encountered in the nose, which has a problematic aesthetic appearance.

We often encounter breathing and smell problems during the examination of our patients who have problems with rhinoplasty. These can range from the nose wings sticking together during deep breathing, blocking the airway [video link], to not being able to breathe normally at all. These should be examined in detail by the surgeon and should not be ignored in the surgery planning. Remember that noses that do not function well but appear aesthetically beautiful will definitely need function-oriented restorative surgeries in the future. In addition, the aesthetic results are generally below expectations in patients whose breathing does not improve after 6 months to 1 year, when swelling and edema disappear in the postoperative period.

Image Note: In the computerized tomography image of a patient, the "turbinate" gland in the nose, shaped like a balloon, is seen. (Pink dotted formation)

Nose problems can lead to serious health problems.

While it can cause problems such as not being able to breathe through the nose, sleeping with your mouth open at night, bad breath, and dry mouth, it has also been blamed for serious health problems such as acute coronary syndrome and hypertension in the pulmonary vessels in the long run (1) . Therefore, I recommend that our patients who have serious problems breathing through the nose undergo a detailed examination.

Only surgical solutions are not used to correct the shape of the nose.

In patients whose nose deformities can be corrected with minor interventions, especially if they do not want to undergo surgery, it is possible to correct the deformities with temporarily effective hyaluronic acid-based fillers. However, as we said, the intervention is temporary and must be repeated at certain intervals. I would like to remind you that interventions with fillers will be insufficient in our patients with obvious deformations in the axes of the nose and insufficient cartilage.

Plastic surgery of the nose is one of the rare surgeries that are described as "painless".

Our patients have prejudices about the pain that may be felt after aesthetic nose surgeries. However, in extremely deformed noses, pain in the nose area is a finding that we do not encounter frequently, except for a few days of pain in the rib cage due to the cartilage patch taken from the rib. In my own patients, with the application of ice from the beginning to the end of the surgery, bleeding is reduced throughout the surgery and bruising and edema are rarely observed.

It may not be necessary to create bone fractures in every nose surgery.

In nose surgery, shaping and breaking procedures in the bone may be necessary in patients with severe deviations in the top-to-bottom axis of the nose and/or in patients with a bump on the back of the nose that affects the shape. Edema, bruising and swelling are less common in patients who do not undergo these abrasion and crushing procedures. In my surgeries, I perform bone shaping with the piezzo system, which is an ultrasonic sculptor that has become current in recent years. In this way, swelling and bruising in my patients are minimized. However, these maneuvers must be implemented when necessary . Apart from the fracture formation process, it may also be possible to support the area with artificial or self-taken tissues called "grafts" in order to eliminate the problems I mentioned.

Most of our patients do not require nasal packing.

Another nightmare for nose surgery candidates is the various materials called nasal tampons used to stop bleeding. Patients who have received a tampon often wonder whether there will be pain when removing the tampon. The area that is generally the focus of bleeding in the nose is the middle compartment of the nose called the "septum", and at the end of the surgery, stitches are placed in this compartment at many points to reduce the possibility of bleeding. However, at the end of surgical interventions on the intranasal glands called "turbinate", a certain amount of bleeding may occur in the form of leakage. In this case, silicone tampons can be used to keep the respiratory tract open through the channel inside. These tampons are also removed the next day, and their removal is a seconds-long process and is mostly painless. Very rarely, the amount of bleeding may increase in patients due to sudden blood pressure changes that occur in situations such as sneezing or straining. In this case, slightly larger tampons can be used. If necessary, the bleeding focus can be detected and burned with local anesthesia and camera guidance. Our patients should be aware that they are undergoing surgery and should not forget that, as with any surgery, there may be a possibility of bleeding. This possibility is especially higher in the first 15 days, and therefore heavy activities that will increase the blood pressure in the head should be avoided.

It is necessary to make a special surgery plan for each nose to obtain a nose shape suitable for the person's face and, more importantly, a "breathing nose" that is expected to accompany it.

Facial proportions of each person vary significantly from each other. Because it is visible, the nose has a key role in creating this structure that is unique to the person, like fingerprints. When I make changes to my patients' photographs together with them, they see that small changes in the shape of the nose seriously affect their facial expression. Therefore, during the decision-making phase, patient expectations must be appropriate to their face and to an extent that does not affect their breathing function. For example, in patients with a wide chin angle, making the nose too small may lead to a visually unattractive facial expression. As I tell all my patients, photo changes are only intended to give a preliminary idea and to help my patient tell me about their expectations, and they may not reflect the result of the surgery exactly. Because every change made in the photo must have a surgical equivalent.

The formation of an incision scar in surgery is related to the size of the anatomical problem.

My patients naturally ask whether there will be any scars after the surgery. Plastic surgeries of the nose are basically divided into three main types. The first is a method we call "open technique rhinoplasty", which requires an incision in the transition area called columella, which connects the tip of the nose and the lip, and incisions on the inner surface of the nose wings. Although the scar on the columella is a visible scar, it becomes indistinct within a few months. No visible scars are expected from the outside in the incisions on the inside of the nose wing. Open technique is the technique in which anatomical structures can be observed best and intervened most easily. Although there are publications reporting that postoperative edema and bruising are higher than in the closed technique because an incision is made in the columella, I have not observed a significant difference in my personal experience. It is the technique that provides the most comfortable approach to severe deformities of the nose. In the method known as the delivery method or semi-closed technique, intraoperative skeletal arrangements are made by delivering the nasal structures outside through internal incisions without making an incision in the columella. It is a slightly more limited technique than the open technique in terms of seeing the back of the nose. But it is especially useful for shaping the tip of the nose. In the closed technique , surgery is performed through incisions made in the nose wings and the middle section of the nose. Thus, there is no visible scar from the outside. It is the technique that allows the most limited observation of the internal anatomical structure. Sometimes it is possible to see in more detail with cameras called endoscopes. The use of cameras may be necessary, especially in ultrasound-mediated (piezzo) surgeries.

Image Note: Various incisions used in nose surgery. In the open technique, various opening incisions that leave a scar on the outside, often in the shape of the letter "V", are used in the part of the nose called the columella.

Since some of our patients have very wide nasal wings, external incisions are applied to narrow the nasal wings, and these may leave scars in the shape of a crescent.

Comments such as "In a few days, all the swelling and bruises of the nose surgery will disappear and you can return to your normal life" are erroneous and should not be relied upon.

It takes between 6 months and 1 year for the changes that occur after nose surgery to return to patients. Although patient-satisfying results can generally be achieved in the first 3 months, making a comment before the first 6 months can generally be considered premature. Our patients generally get opinions from many physicians. It is a very assertive promise that there will be no swelling on your face. In fact, it is not expected that these swellings and bruises will completely disappear in a few days. In particular, bruises can rarely last longer than 3 weeks. During this process, I recommend to my patients the application of ice for no more than 15 minutes per hour for the first days and various gels with proven edema-relieving effects for the cheeks and lips.

Informing my patients in detail about what they may encounter after surgery also reduces their pre-operative tension.

As is true for everyone, human beings experience less tension when engaging in actions whose consequences they can predict or learn. Therefore, when they are aware of the postoperative process and the "complications" that we can describe as possible risks and negative consequences, they are more in harmony with their physicians regarding the management of these problems. Some problems may be encountered after every surgery, and the important thing and where surgery comes to the fore is the management of these problems. The main problems that may arise in aesthetic nose surgery include a result below the patient's expectation, nose bleeding, wound line infection, recurrence of axis shift in patients with severe axis shift, collapse of the nasal skeleton, breathing problems due to lack of function in the nasal wings, re-swelling of the glands inside. Problems such as this may be encountered. I always give my patients detailed information about these. In addition to these, intraoperative problems that cannot be predicted in all types of surgery may be encountered. For example, drug allergy and general risks related to the anesthesia procedure are in this group. Again, at this point, the patient is in complete safety due to being in the operating room, and such problems can usually be eliminated without serious consequences.

Second or third nose surgeries will be more comprehensive in terms of getting better results than the first nose surgery.

Some of my patients who applied due to problems with rhinoplasty have had nose surgery before. These patients are disturbed by the inadequacy in shape or function. For example, a re-swollen turbinate gland in the nose is a problem that we do not see very rarely and negatively affects breathing. In this case, correction using radiofrequency, laser or surgical methods may be required. In case of problems with nose shape and skeleton, rhinoplasty surgery from scratch may be necessary. In this case, any surgery may cause thinning of the nasal skin, and the repair in the skeleton may need to be supported by patches taken from the ribs or ear cartilages. In order to prevent thinning of the nasal skin, the membrane layer (fascia) of the surrounding muscles can be removed from the area where the patch was removed during correction surgeries and the cartilages can be covered. In this case, a scar may remain on the patched area, which may become obscured over time if it is not properly maintained. In women, this scar can usually be hidden in the fold under the breast.

A reference publication for our curious patients:

(1) Mladina R, Skitarelić N, Carić T, Raguž M. Type 5 and 6 nasal septal deformities: Could we predict and prevent acute coronary syndrome attacks in the future? Med Hypotheses. 2015 Nov;85(5):640-4.