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General Information About Rhinoplasty (Nose Reshaping) Fayetteville

The nose is a central anatomic feature of a person’s identity and self-image. The nasal appearance can also positively or negatively affect self-confidence. When communicating face to face, the nose is central to the field of vision and will always be seen during the subconscious facial scan that occurs at that time. Self-awareness of the appearance of nasal aesthetics has existed for many centuries, but until modern times, little was possible to predictably and accurately change the appearance of the nose. There was no safe and adequate manner in which to provide anesthesia for the rhinoplasty procedure. Materials engineering and machining had not advanced enough to allow construction of delicate and precise surgical instruments required to perform the procedure with accuracy. Advancements in all these areas combined with an enormous amount of Plastic surgery research made possible the modern day rhinoplasty, which is very predictable and safe. A multitude of surgical techniques and surgical planning techniques exist now that were yet to be described just a few years ago. The combination of all these factors has made the modern rhinoplasty a highly sought Plastic surgery procedure.

There is a very long and rich history regarding the nose and rhinoplasty. The nose has been the focus of writers, philosophers, and physicians for many centuries. Gasparo Tagliacozzi (1545-1599) developed the “Italian method” of nasal reconstruction, and his description of this method is thought to be the first practical treatise in the specialty of Plastic surgery. The well known play, Cyrano De Bergerac, written by Edmund Rostand in 1897, describes a man with self doubt due to his very large nose. The Adventures of Pinnochio, written by Carlo Lorenzini in 1880, is a novel about a marionette whose nose grew longer when he told lies. So ingrained into modern culture is this novel, that pundits assign a “Pinocchio count” (four Pinocchios being the worst) for perceived dishonesty in the media. These are just a few of the many well known examples of the nose being the center of literature and medicine in years past.

The rhinoplasty procedure has evolved into a very complex operation with a multitude of maneuvers to change the nasal skeleton, which in turn changes the size and shape of the nose. Specific surgical maneuvers will cause a specific and predicatable change in the nasal size and shape. In some cases, the nasal supportive structures (nasal tissues) of the nose are simply reshaped to achieve the desired aesthetic result. In some cases, the nose is simply reshaped by partial removal of the nasal supportive structures (nasal tissues) to achieve the desired aesthetic result. In other cases, nasal supportive structures (cartilage and bone) are added to the nose to achieve the desired aesthetic result. In other cases, nasal supportive structures (cartilage and bone) is removed and added during the rhinoplasty procedure. In some cases, nasal supportive structures (cartilage and bone) are reshaped, and partially removed, and added to achieve the desired aesthetic result. A very large body of research is available on the subject of rhinoplasty, and the final aesthetic results are now very predictable.

Rhinoplasty has become one of the most popular procedures in aesthetic Plastic surgery. Modern day rhinoplasty can be partly credited to Dr. Jacques Joseph (1865-1934), and while these techniques are considered crude by today’s standards, his work brought attention to this very specialized area of Plastic surgery, which led to focused research on the topic. The Joseph procedure was described over a century ago and was arguably the beginning of the modern era of rhinoplasty. While Dr. John Roe (1848-1915) was thought to be the first to perform the intranasal rhinoplasty, more credit is given to Joseph because he popularized the rhinoplasty procedure. Dr. Roe’s scientific paper on rhinoplasty was published in 1887. As a result of Plastic surgery research and improvements in instrumentation, the basic rhinoplasty has improved dramatically in the last thirty years. The most significant change in the technical aspect of cosmetic rhinoplasty is the concept and principle of conservatism. Conservatism in this context means limited change with the rhinoplasty procedure. Early cosmetic rhinoplasty procedures, and even rhinoplasty procedures for functional problems, were characterized by unnecessary excessive removal of nasal tissues (cartilage and bone). This procedure is now referred to with negative connotations as a “reduction rhinoplasty”. In modern cosmetic rhinoplasty, what the Plastic surgeon leaves in the nose is just as important as what the surgeon removes from the nose, and is arguably more important. Stevie Ray Vaughn, the legendary electric blues guitarist, underwent a reduction rhinoplasty at age six around 1960. This has been written about extensively in his biographies, and those books implicate that he was left with very little cartilaginous nasal septum following this surgery. Images of him later in life reveal a depressed nasal dorsum, sometimes referred to as a “saddle nose”. While the reduction rhinoplasty may have been the standard of care in 1960, it is not the standard today.

Stevie Ray Vaughn

The nose can be thought of as having the same “design principles” as a camping tent. A camping tent is supported by a frame (“internal skeleton”) constructed of wood, plastic, or metal, and the frame is what gives the tent its shape. Once the tent frame is assembled, a covering is draped over the frame, and the covering takes the shape of the frame. The frame is what determines the tents shape and size. If the shape of the frame is changed, then the shape of the tent covering changes. The anatomy of the nose works in a similar manner. The frame (“internal skeleton”) consists of cartilage and bone. The cartilage and bone provide the internal support for the nose. The cartilage and bone would be analogous to the wood, plastic, or metal frame of the tent. The skin of the nose would be analogous to the tent covering. The skin of the nose drapes over the cartilage and bone just as the tent covering drapes over the frame of the tent. In order to change the size and shape of the nose, the internal skeleton (cartilage and bone) is changed. As the internal skeleton of the nose changes, the skin re-drapes over the new supportive shape. Because the nasal skin is elastic, it naturally re-drapes over the newly shaped internal nasal skeleton after rhinoplasty. As a result, there is no need to remove “extra skin” during the rhinoplasty procedure.

If the correct anatomical support of the nose (cartilage and bone) is not preserved during the rhinoplasty procedure, the nose becomes an amorphous blob without defined shape. If the correct anatomical support of the nose (cartilage and bone) is not preserved then a less than optimal aesthetic issues can result. The nose can lose tip projection so that the nose appears too small. One can lose dorsal support as in the case of Stevie Ray Vaughn, which can result in a “saddle nose”. This can be particularly pronounced when scar contracture pulls the nasal skin during healing and there are no supporting structures (cartilage and bone) to resist that force. From a functional standpoint, loss of support can also result in airway obstruction. When these situations occur, the repair procedure then falls into the reconstructive realm. This procedure is called a secondary (second) rhinoplasty, and this procedure is typically much more challenging than a primary (first) rhinoplasty. Preservation of adequate nasal skeletal support during rhinoplasty is critical, which has lead to the accepted concept of conservatism. The conservative rhinoplasty is in stark contrast to the reduction rhinoplasty, where no thought or effort was made to preserve critical anatomic nasal skeletal structures, thereby preserving shape and function. It is the concept of conservatism that has ushered in the modern rhinoplasty.

As an example of how the current “standards” of Plastic surgery have changed one can consider the evolution of the surgical maneuvers used to re-size and re-shape the alar (lower lateral) cartilage. The previously noted Joseph procedure frequently transected (divided) the alar (lower lateral) cartilages in attempting to improve the nasal tip. This maneuver (reportedly) frequently resulted in kinking of the nasal tip, asymmetry, and an overall unfavorable outcome. The records (images) of the results of the Joseph rhinoplasty are less than detailed because the science of photography was in its infancy at the time. Because nasal aesthetics are a direct reflection of the nasal skeleton, any irregularities or asymmetries in the nasal skeleton are observable after surgery. This is particularly true in patients with thin nasal skin. As a result of the less than optimal results with the Joseph procedure, years later Plastic surgeons were taught to never transect (divide) the alar (lower lateral cartilage). For a period of time, transecting the alar (lower lateral cartilage) was considered taboo by many Plastic surgeons. Other surgical maneuvers were adopted in lieu of alar (lower lateral cartilage) transection in an attempt to attain the desired shape of the nasal tip such as cartilage “scoring”. This technique takes advantage of the natural tendency of cartilage to curve when “scored”, but this procedure has somewhat unpredictable results. The result of the “scoring technique” in some patients was a somewhat bulbous amorphous nasal tip, which was not ideal, but was certainly superior to the Joseph procedure. The unpredictable results with the “scoring technique” led some Plastic surgeons to re-examine the alar (lower lateral) cartilage transection technique. The new interest in the “open rhinoplasty technique” led to the “rediscovery” of the alar cartilage transection technique. After the “rediscovery” of the alar cartilage transection technique, surgeons realized that with meticulous surgical technique, and a more thorough understanding of the nasal anatomy, the alar (lower lateral) cartilage could be transected safely and effectively to achieve the anatomically ideal nasal tip anatomy. The alar cartilage transection maneuver, when properly performed, has resulted in a predictable, well-defined, anatomically ideal nasal tip. Further, the nasal tip can be “customized” to match a patient’s facial shape as well as other individual factors. Transection of the alar cartilages is now commonly performed during rhinoplasty with excellent aesthetic and physiological results. With the latest techniques, the problems with the Joseph procedure were completely eliminated. In summary, the surgical maneuvers to improve the aesthetics of the alar cartilage during rhinoplasty went full circle in about one hundred years.

Another example of the evolution of “standards” of Plastic surgery is the approach to rhinoplasty. In Dr. Joseph’s original technique, he used an “open rhinoplasty technique”. This technique used external incisions (as opposed to incisions made inside the nose), which allowed direct vision of the nasal anatomy. This is a great technical advantage for the surgeon. The “open rhinoplasty technique” allows precise surgical alterations of the nasal anatomy to achieve a very predictable aesthetic result. This technique is also very safe. The ostensible disadvantage of the “open rhinoplasty technique” is the visible scars that result. The “open rhinoplasty technique” for aesthetic rhinoplasty fell into disfavor for a long period of time, during which time the “closed rhinoplasty technique” (which use incisions inside the nose) was used. Also called the “endonasal approach”, the “closed rhinoplasty technique” did not have external scars but did have the significant disadvantage of not directly visualizing the nasal structures during the procedure. In other words, the procedure was performed “blind”, meaning by “feel”, and not under direct vision. As a result, the “closed rhinoplasty technique” is less accurate and less predictable in some circumstances, and especially in the more complicated rhinoplasty procedures. Further, there are many maneuvers that can be utilized during the “open rhinoplasty procedure” that are difficult or impossible with the “closed rhinoplasty technique”. As a result, aesthetic result with the “closed rhinoplasty technique” was inferior to the “open rhinoplasty technique” in some patients. The minimal external scars which were previously a concern with the “open rhinoplasty technique” are now considered (and are) inconsequential. The minimal external scar from the “open rhinoplasty technique”, which is measured in millimeters and is in an inconspicuous area of the nose, virtually disappear with time. About 100 years after Dr. Joseph described his rhinoplasty technique, the “open rhinoplasty technique” has regained great popularity and is now widely used.

Modern rhinoplasty techniques are very safe and very predictable. In a properly screened patient population, the satisfaction rate is very high. Most patients that undergo a cosmetic rhinoplasty state that they would make the same decision again to get the surgery if privileged with that opportunity.