Patient I fig 1    Patient II fig 2 Nasal Surgery (Cosmetic Rhinoplasty) We seldom see ourselves as others see! We look at a photograph and are surprised by our appearance. Frequently, we can hardly believe our eyes! Nowhere else is this more true than in nasal surgery. We hardly ever view ourselves except from the direct frontal direction. Yet others see us from all angles. If the nose is broad and out of proportion as illustrated in (Patient I, figure 1,) then we may readily recognize a need for cosmetic alteration. Patient II fig 3    Patient II fig 4   Patient II fig 1   Patient II fig 2 If, however, the nose is relatively normal from the frontal view, (patient II, figure 1) then one may not recognize a desire for cosmetic alteration until seeing a photograph taken from the lateral (patient II, figure 3). In each instance, rhinoplasty resulted in dramatic change of the appearance, but the change is much more dramatic from the frontal view in patient one and more dramatic from the lateral in patient two. Patient II fig 3   Patient II fig 4 Actual performance of the cosmetic rhinoplasty may be under either local anesthesia with sedation or under general anesthesia. Technical details vary markedly depending upon the goal to be accomplished. In some instances, simple rasping of a prominent hump may achieve the desired results. In this case, small incision are made inside the rim of the nose and a dissection is carried up past the tip cartilages and a narrow tungsten carbide rasp utilized to rasp down the prominent hump which may be either predominantly bony or predominantly cartilaginous in nature (Patient III, 1 and 2). On the other hand, multiple features of the nose may be altered in dramatic ways which requires an incision which allows rolling the skin back off the tip and cartilaginous portions of the nose to allow direct visualization of the skeletal components. In this way very precise alterations in the width, height, and rotation of the tip may be accomplished. At the same time, direct excision of the hump and osteotomies of the nasal bones may be performed to not only reduce the hump but narrow the entire nasal skeleton. Severe deformities such as caused by trauma, prior operation, or major developmental defects call for complex surgical restorations. In the most complex operation, the skeleton of the nose is exposed by open technique, cartilaginous graft material is obtained from the nasal septum or the ear, the lower lateral tip cartilages are exposed and remolded, a "strut" graft is inserted in the area between the nostrils to lift and rotate the tip cartilages, a shield graft is fashioned to add definition to the tip, the bony and cartilaginous hump is reshaped or rebuilt, sidewalls of the nose are brought in to narrow the nasal vault and the tip skin is de-fatted to allow the maximum redraping of the skin. If the "blind" approach is utilized, no stitches will be apparent. If the more precise "open" technic is utilized small stitches are present between the nostrils which will be removed in a week. If a graft has been obtained or if any work has been done on the nasal septum to relieve obstructive symptoms then internal splints will be inserted which are removed in several days. In all cases an external plastic splint is applied to stabilize and maintain the new shape of the nose until tissue solidification has occurred. This splint is usually removed a week following the surgery but in some instances may be required to stay in place for up to 10 days. The following pre-operative/post-operative photos illustrate instances of minor change, ie: simple rasping of the nasal hump through an internal rim incision and major changes effected through rhinoplasty with strut and tip graft, hump reduction, osteotomies, and major alterations in the tip cartilages (Patient III, I and 2, and Patient IV, I and 2, below). Patient III fig 1   Patient III fig 1  Patient IV fig 1    Patient IV fig 1  In instances where the base of the nose is quite wide or flared nostrils are apparent incisions may be made in the alar base to narrow the nose in the basal portion. In these instances incisions are made which require stitches to be removed approximately five to seven days after surgery. The following pre-operative / post-operative photos show examples of alar base resection which illustrate this point (Patient V, 1 and 2).   Patient IV fig 1   Patient IV fig 1 Nasal Surgery (Functional Rhinoplasty) Obstruction to the breathing passages occurs due to deformities of the nasal septum or enlargement of the nasal turbinates. The nasal septum is the portion of the nose separating the two breathing passages and the nasal turbinates are projections from the lateral walls of the nasal chambers which are very vascular and which function to heat and moisturize and filter the air on it way through the lungs. The nasal septum has no function except as support to the external portion of the nose. Major deformities of the nasal septum may occur as the result of development, after injury suffered in childhood or directly subsequent to trauma suffered as an adult. Even without fracture to the bony portion of the nose, injuries to the cartilages or hematoma may lead to deformities resulting in protrusions which obstruct the breathing passages. It is not uncommon to find major internal deformities of the nasal septum in patients who have absolutely no recollection of any injury either in childhood or as an adult. Presumably many deformities are simply congenital in nature and have no known cause. Deformities of the nasal turbinates are usually related to chronic recurring allergic conditions and not only cause obstruction to the passage of air but may predispose to chronic recurring sinus problems. The treatment for both deformities of the nasal septum and deformities of the nasal turbinates is surgical removal of the obstructing portion. This is accomplished by direct excision of a part of one or more turbinates and submucous resection of parts of the cartilaginous and bony septum. This is usually done under general anesthesia, requires packing in the nose post-operatively and several weeks are required for resolution Of post-operative swelling before final results are obtained. Functional rhinoplasty can be done at the same time as cosmetic rhinoplasty and usually is covered by insurance where as cosmetic rhinoplasty is seldom covered by insurance. At times a portion of the sinuses are removed at the same time during functional rhinoplasty to allow better drainage of these organs.

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