Rhinoplasty surgery-an overview

Reasons for Rhinoplasty in Mediterranean individuals

In septorhinoplasty the surgeon corrects the external appearance of the nose and also corrects internal deviations of the nasal septum to help breathing.

Why do patients have septorhinoplasty surgery?

The author carried out a recent audit on his septorhinoplasty patients and the results were presented at the Mediterranean Rhinoplasty course in January 2010. The great majority of these patients were from the central Mediterranean although some were North African and Northern European countries.

57% were women and 43% men, aged predominantly between 20 and 40 years of age. 64% of all individuals wished to have a rhinoplasty to improve their cosmetic appearance-two thirds of these were women. 36% of patients had septorhinoplasty primarily to improve their breathing and at the same time, their appearance-these were mostly men. Occasionally septorhinoplasty is done purely for functional reasons. 20% of patients had nasal trauma in the past which directly contributed to the nasal deformity. As expected, the great majority (two thirds) of patients with significant previous trauma were men.

Occasionally young women consult the ENT surgeon under the guise of sinus or allergy complaints, with the real reason for the visit being cosmetic improvement.

Patients with nasal obstruction following cosmetic rhinoplasty who want revision surgery, are much more prepared to compromise on the cosmetic result because they are so fed up with their breathing problems.

©Mr. Adrian M Agius

The Mediterranean Nose

The ‘Mediterranean’ nose collects a number of features typical of people living around the Mediterranean basin. This wide term includes Roman, French, Greek and North African types of nose.

All of these types of nose are seen in the central Mediterranean and are characterized by large, curved nasal bones, large nasal tip cartilages and thick skin.

All of these features render the Mediterranean nose rather difficult to work with, from the cosmetic surgeon’s point of view. Refinement of the nasal dorsum and tip in order to reach a nose whose proportions are harmonious to each other is rather demanding, especially if there is an associated sideways bend.

In such cases the nose may have to be practically ‘rebuilt’ starting from straightening of the internal nasal septum, refining the profile, hump removal and narrowing of the nasal bones and tip refinement. Having a thick skin means that many of the refinements carried out on the nasal skeleton are not so easily appreciated in the final result. This is like operating under a quilt instead of a sheet-the sheet is much thinner and underlying changes easier to detect externally. An advantage of thick cartilages and bones, however is that good quality grafting material is provided by the nose itself. Grafts are often used in the tip area to help provide support and projection. Removal of too much cartilage, especially in the tip area may lead to collapse of the ala, or sides of the nose, during breathing.

All of these points mentioned above are considerations that the nasal surgeon has to bear in mind, and there has to be a ‘trade-off’ between the cosmetic expectations of the patient and good function of the nose in terms of breathing.

Publications, Presentations and Audit Studies

Cosmetic Surgery

ENT surgeons (or Otolaryngologists) have long been involved in facial cosmetic surgery. The nose is a central feature of the face and its modification is known as rhinoplasty. 

Pinnaplasty or correction of prominent ears has also featured high on the ENT surgeon’s list of cosmetic procedures. Blepharoplasty, or the correction of drooping or excessive skin above the eyes or removal of the bags beneath lower eyelids to remove that ‘tired’ look also forms part of facial rejuvenation as do the injection of fillers or botox to smooth out facial wrinkes.

Patients usually come for advice about facial cosmetic surgery after several years of soul searching. They just do not like the person in the mirror. Many would have kept their feelings hidden from their family members and often feel self conscious and over-sensitive about comments directed at their appearance. They often feel guilty because they cannot be happy with themselves and at the same time feel that others consider their desire for cosmetic change as frivolous and low down in the priorities of family life. Indeed, other family members who take for granted the patient’s appearance often show surprise or lack of understanding to this individual since they have accepted that person as he/she was and expect him/her to continue being exactly the same person.

The consultation

A frank discussion with the surgeon should take place where there is good communication and where the patient is as clear as possible on what is bothering him/her. Most individuals would be happy with removing or improving most of the features that are bothering them but surgeons are very wary of those with excessive demands who can never be satisfied. A ‘natural’ look is very important in Southern Europe and people do now want to look ‘operated’.

©Mr. Adrian M Agius 

Septorhinoplasty for Twisted or bent noses

Patients wanting a nose job often have had some sort of injury to their nose that has caused some twisting or bending. External deviations of this type are usually accompanied by corresponding bends in the nasal septum inside the nose.Such individuals complain of a blocked nose and headaches and may snore at night.

Cosmetic surgery for this type of patient is technically very demanding. The internal septum has to be straightened first. Sections of nasal cartilage are often harvested during this process to be reused later on in the operation as splint material to enable straightening of the nasal bridge. The external part of the nose is then corrected and the nasal bones reset or reshaped if this is necessary. Cartilage is a living material and has a ‘memory’ so it may tend to bend slightly even after repositioning. This fact has got to be borne in mind when carrying out this surgery.

Often past nasal injury has caused death or necrosis of the nasal cartilage. Previous operations may have diminished the quantity of cartilage available. In these cases sections of ear cartilage may have to be taken to be used as structural grafts. Very occasionally cartilage may be harvested from ribs.

Septorhinoplasty in my practice is carried out on a day case basis and patients do not have any nasal packing. There is minimal discomfort and an external splint is applied for one week.

©Mr. Adrian M Agius