Rhinoplasty

Definition

The term rhinoplasty means "nose molding" or "nose forming." It refers to a procedure in plastic surgery in which the structure of the nose is changed. The change can be made by adding or removing bone or cartilage, grafting tissue from another part of the body, or implanting synthetic material to alter the shape of the nose.

Rhinoplasty is the most frequently performed cosmetic surgical procedure in the United States as of the early 2000s. According to the American Society of Plastic Surgeons (ASPS), 356,554 rhinoplasties were performed in the United States in 2003, compared to 254,140 breast augmentations and 128,667 facelifts.

Purpose

Rhinoplasty is most often performed for cosmetic reasons. A nose that is too large, crooked, misshapen, malformed at birth, or deformed by an injury or cancer surgery can be given a more pleasing appearance. If breathing is impaired due to the form of the nose or to an injury, it can often be improved with rhinoplasty.

Precautions

The best candidates for rhinoplasty are those with relatively minor deformities. Nasal anatomy and proportions are quite varied and the final look of any rhinoplasty operation is the result of the patient's anatomy, as well as of the surgeon's skill.

The quality of the skin plays a major role in the outcome of rhinoplasty. Patients with extremely thick skin may not see a definite change in the underlying bone structure after surgery. On the other hand, thin skin provides almost no cushion to hide the most minor of bone irregularities or imperfections.

A cosmetic change in the shape of the nose will change a person's appearance, but it will not change self-image. A person who expects a different lifestyle after rhinoplasty is likely to be disappointed.

Rhinoplasty should not be performed until the pubertal growth spurt is complete, between ages 14-15 for girls and older for boys.

The cost of rhinoplasty depends on the difficulty of the work required and on the specialist chosen. Prices run from about $3,000 to over $6,000. If the problem was caused by an injury, insurance will usually cover the cost. A rhinoplasty done only to change a person's appearance is not usually covered by insurance.

Description

The external nose is composed of a series of interrelated parts which include the skin, the bony pyramid, cartilage, and the tip of the nose, which is both cartilage and skin. The strip of skin separating the nostrils is called the columella.

Surgical approaches to nasal reconstruction are varied. Internal rhinoplasty involves making all incisions inside the nasal cavity. The external or "open" technique involves a skin incision across the base of the nasal columella. An external incision allows the surgeon to expose the bone and cartilage more fully and is most often used for complicated procedures. During surgery, the surgeon will separate the skin from the bone and cartilage support. The framework of the nose is then reshaped in the desired form. Shape can be altered by removing bone, cartilage, or skin. The remaining skin is then replaced over the new framework. If the procedure requires adding to the structure of the nose, the donated bone, cartilage, or skin can come from the patient or from a synthetic source.

When the operation is over, the surgeon will apply a splint to help the bones maintain their new shape. The nose may also be packed, or stuffed with a dressing, to help stabilize the septum.

When a local anesthetic is used, light sedation is usually given first, after which the operative area is numbed. It will remain insensitive to pain for the length of the surgery. A general anesthetic is used for lengthy or complex procedures or if the doctor and patient agree that it is the best option.

Simple rhinoplasty is usually performed in an outpatient surgery center or in the surgeon's office. Most procedures take only an hour or two, and patients may return home right away. Complex procedures may be done in the hospital and require a short stay.

Preparation

During the initial consultation, the patient and surgeon will determine what changes can be made in the shape of the nose. Most doctors take photographs at the same time. The surgeon will also explain the techniques and anesthesia options available to the patient.

For legal reasons, many plastic surgeons now screen patients for psychological stability as well as general physical fitness for surgery. When a person consults a plastic surgeon about a rhinoplasty, the doctor will spend some time talking with the patient about his or her motives for facial surgery. The following are considered psychological warning signs:

• The patient is considering surgery to please someone else, most often a spouse or partner.
• The patient expects facial surgery to guarantee career advancement.
• The patient has a history of multiple cosmetic procedures and/or complaints about previous surgeons.
• The patient thinks that the surgery will solve all his or her life problems.
• The patient has an unrealistic notion of what he or she will look like after surgery.
• The patient seems otherwise emotionally unstable.

The patient and surgeon should also discuss guidelines for eating, drinking, smoking, taking or avoiding certain medications, and washing of the face.

Aftercare

Patients usually feel fine immediately after surgery; however, most surgery centers do not allow patients to drive themselves home after an operation.

The first day after surgery there will be some swelling of the face. Patients should stay in bed with their heads elevated for at least a day. The nose may hurt and a headache is not uncommon. The surgeon will prescribe medication to relieve these conditions. Swelling and bruising around the eyes will increase for a few days, but will begin to diminish after about the third day. Slight bleeding and stuffiness are normal, and vary according to the extensiveness of the surgery performed. Most people are up in two days, and back to school or work in a week. No strenuous activities are allowed for two to three weeks.

Patients are given a list of postoperative instructions, which include requirements for hygiene, exercise, eating, and follow-up visits to the doctor. Patients should not blow their noses for the first week to avoid disruption of healing. It is extremely important to keep the surgical dressing dry. Dressings, splints, and stitches are removed in one to two weeks. Patients should avoid sunburn.

Patients should remember that it may take as long as a year for the nose to assume its final shape; the tip of the nose in particular may be mildly swollen for several months.

Risks

Any type of surgery carries a degree of risk. There is always the possibility of unexpected events, such as an infection or a reaction to the anesthesia. Some patients may have a so-called foreign body reaction to a nasal implant made from synthetic materials. In these cases the surgeon can replace the implant with a piece of cartilage from the patient's own body.

Some risks of rhinoplasty are social or psychological. The ASPS patient brochure about rhinoplasty mentions the possibility of criticism or rejection by friends or family if they feel threatened by the patient's new look. This type of reaction sometimes occurs with rhinoplasty if the friends or relatives consider the shape of the nose an important family or ethnic trait.

When the nose is reshaped or repaired from inside, the scars are not visible, but if the surgeon needs to make the incision on the outside of the nose, there will be some slight scarring. In addition, tiny blood vessels may burst, leaving small red spots on the skin. These spots are barely visible but may be permanent.

About 10% of patients require a second procedure; however, the corrections required are usually minor.

Resources

PERIODICALS

Chou, T. D., W. T. Lee, S. L. Chen, et al. "Split Calvarial Bone Graft for Chemical Burn-Associated Nasal Augmentation." Burns 30 (June 2004): 380-385.

Daniel, R. K., and J. W. Calvert. "Diced Cartilage Grafts in Rhinoplasty Surgery." Plastic and Reconstructive Surgery 113 (June 2004): 2156-2171.

Honigman, R. J., K. A. Phillips, and D. J. Castle. "A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery." Plastic and Reconstructive Surgery 113 (April 1, 2004): 1229-1237.

Raghavan, U., N. S. Jones, and T. Romo, 3rd. "Immediate Autogenous Cartilage Grafts in Rhinoplasty after Alloplastic Implant Rejection." Archives of Facial and Plastic Surgery 6 (May-June 2004): 192-196.

ORGANIZATIONS

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). 310 South Henry Street, Alexandria, VA 22314. (703) 299-9291. 〈http://www.facemd.org〉.

American Society of Plastic Surgeons (ASPS). 444 East Algonquin Road, Arlington Heights, IL 60005. (847) 228-9900. 〈http://www.plasticsurgery.org〉.

OTHER

American Society of Plastic Surgeons. Procedures: Rhinoplasty. 〈http://www.plasticsurgery.org/public_education/procedures/Rhinoplasty.cfm〉.

KEY TERMS

Cartilage— Firm supporting tissue that does not contain blood vessels.

Columella— The strip of skin running from the tip of the nose to the upper lip, which separates the nostrils.

Septum— The dividing wall in the nose.

Rhinoplasty

Definition

The term rhinoplasty means "nose molding" or "nose forming." It refers to a procedure in plastic surgery in which the structure of the nose is changed. The change can be made by adding or removing bone or cartilage, grafting tissue from another part of the body, or implanting synthetic material to alter the shape of the nose.

Purpose

Rhinoplasty is most often performed for cosmetic reasons. A nose that is too large, crooked, misshapen, malformed at birth, or deformed by an injury can be given a more pleasing appearance. If breathing is impaired due to the form of the nose or to an injury, it can often be improved with rhinoplasty.

Demographics

Rhinoplasty is the third most common cosmetic procedure among both men and women. Total number of rhinoplasty procedures in the United States in 1999 was 133,058. More than 13,100 of those procedures were performed on men.

Description

The external nose is composed of a series of interrelated parts that include the skin, the bony pyramid, cartilage, and the tip of the nose, which is composed of cartilage and skin. The strip of skin separating the nostrils is called the columella.

Surgical approaches to nasal reconstruction are varied. Internal rhinoplasty involves making all incisions from inside the nasal cavity. The external, or "open," technique involves a skin incision across the base of the nasal columella. An external incision allows the surgeon to expose the bone and cartilage more fully and is most often used for complicated procedures. During surgery, the surgeon will separate the skin from the bone and cartilage support. The framework of the nose is then reshaped in the desired form. Shape can be altered by removing or adding bone, cartilage, or skin. The remaining skin is then replaced over the new framework. If the procedure requires adding to the structure of the nose, the donated bone, cartilage, or skin can come from another location on the patient's body or from a synthetic source.

When the operation is completed, the surgeon will apply a splint to help the bones maintain their new shape. The nose may also be packed, or stuffed with a dressing, to help stabilize the septum.

When a local anesthetic is used, light sedation is usually given first, after which the operative area is numbed. It will remain insensitive to pain for the length of the surgery. A general anesthetic is used for lengthy or complex procedures, or if the doctor and patient agree that it is the best option.

Diagnosis/Preparation

The quality of the skin plays a major role in the outcome of rhinoplasty. Persons with extremely thick skin may not see a significant change in the underlying bone structure after surgery. On the other hand, thin skin provides almost no cushion to hide many minor bone irregularities or imperfections.

Rhinoplasty should not be performed until the pubertal growth spurt is complete, ages 14–15 for girls and older for boys.

During the initial consultation, the candidate and surgeon will determine what changes can be made in the shape of the nose. Most doctors take photographs during that consult. The surgeon will also explain the techniques and anesthesia options available to the candidate.

The candidate and surgeon should also discuss guidelines for eating, drinking, smoking, taking or avoiding certain medications, and washing the face for the weeks immediately following surgery.

Aftercare

Patients usually feel fine immediately after surgery. As a precaution, most surgery centers do not allow patients to drive themselves home after an operation.

The first day after surgery, there will be some swelling of the face. Persons should stay in bed with their heads elevated for at least a day. The nose may hurt and a headache is common. The surgeon will prescribe medication to relieve these conditions. Swelling and bruising around the eyes will increase for a few days, but will begin to diminish after about the third day. Slight bleeding and stuffiness are normal, and vary according to the extent of the surgery performed. Most people are walking in two days, and back to work or school in a week. No strenuous activities are allowed for two to three weeks.

Patients are given a list of postoperative instructions, which include requirements for hygiene, exercise , eating, and follow-up visits to the doctor. Patients should not blow their noses for the first week to avoid disruption of healing. It is extremely important to keep the surgical dressing dry. Dressings, splints, and stitches are removed in one to two weeks. Patients should avoid excessive sun or sunburn.

Risks

Any type of surgery carries a degree of risk. There is always the possibility of unexpected events such as an infection or a reaction to the anesthesia.

When the nose is reshaped or repaired from inside, the scars are not visible. If the surgeon needs to make the incision on the outside of the nose, there will be some slight scarring. In addition, tiny blood vessels may burst, leaving small red spots on the skin. These spots are barely visible, but may be permanent.

Normal results

The best candidates for rhinoplasty are those persons with relatively minor deformities. Nasal anatomy and proportions are quite varied and the final look of any rhinoplasty operation depends on a person's anatomy, as well as the surgeon's skill.

A cosmetic change of the nose will change a person's appearance, but it will not change self-image. A person who expects a different lifestyle after rhinoplasty is likely to be disappointed.

The cost of rhinoplasty depends on the difficulty of the work required and on the specialist chosen. If the problem was caused by an injury, insurance will usually cover the cost. A rhinoplasty done only to change a person's appearance is not usually covered by insurance.

Morbidity and mortality rates

Death from a rhinoplasty procedure is exceedingly rare. When it occurs, the cause is often due to an adverse reaction to anesthesia or postoperative medications or to an infection. About 10% of persons receiving rhinoplasty require a second procedure.

Alternatives

The alternative to cosmetic rhinoplasty is to accept oneself, literally, at face value. Persons contemplating rhinoplasty may want to question some of the conventional standards of beauty and work on their body image issues to improve their self-confidence.

See also Blepharoplasty; Forehead lift.

Resources

books

Engler, Alan M. BodySculpture: Plastic Surgery of the Body for Men and Women, 2nd Edition. Poughkeepsie, NY: Hudson Pub, 2000.

Irwin, Brandith, and Mark McPherson. Your Best Face: Looking Your Best without Plastic Surgery. Carlsbad, CA: Hay House, Inc, 2002.

Man, Daniel, and L. C. Faye. New Art of Man: Faces of Plastic Surgery: Your Guide to the Latest Cosmetic Surgery Procedures, 3rd Edition. New York: BeautyArt Press, 2003.

Papel, I. D., and S. S. Park. Facial Plastic and Reconstructive Surgery, 2nd Edition. New York: Thieme Medical Publishers, 2000.

periodicals

Ahn, M. S., C. S. Maas, and N. Monhian. "A Novel, Conformable, Rapidly Setting Nasal Splint Material: Results of a Prospective Study." Archives of Facial Plastic Surgery 5, no.2 (2003): 189–192.

Bagal, A. A., and P. A. Adamson. "Revision Rhinoplasty." Facial Plastic Surgery 18, no.4 (2002): 233–244.

Lascaratos, J. G., J. V. Segas, C. C. Trompoukis, and D. A. Assimakopoulos. "From the Roots of Rhinology: The Reconstruction of Nasal Injuries by Hippocrates." Annals of Otolology Rhinology and Laryngology 112, no.2 (2003): 159–162.

Rohrich, R. J., and A. R. Muzaffar. "Rhinoplasty in the African-American Patient." Plastic and Reconstructive Surgery 111, no.3 (2003): 1322–1339.

Russell, P., and C. Nduka. "Digital Photography for Rhinoplasty." Plastic and Reconstructive Surgery 111, no.3 (2003): 1266–1267.

organizations

American Board of Plastic Surgery. Seven Penn Center, Suite 400, 1635 Market Street, Philadelphia, PA 19103-2204. (215) 587-9322. <http://www.abplsurg.org/>.

American College of Plastic and Reconstructive Surgery. <http://www.breast-implant.org>.

American College of Surgeons. 633 North Saint Claire Street, Chicago, IL 60611. (312) 202-5000. <http://www.facs.org/>.

American Society for Aesthetic Plastic Surgery. 11081 Winners Circle, Los Alamitos, CA 90720. (800) 364-2147 or (562) 799-2356. <http://www.surgery.org/>.

American Society for Dermatologic Surgery. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-9830. <http://www.asds-net.org>.

American Society of Plastic and Reconstructive Surgeons. 44 E. Algonquin Rd., Arlington Heights, IL 60005. (847) 228-9900. <http://www.plasticsurgery.org>.

American Society of Plastic Surgeons. 444 E. Algonquin Rd., Arlington Heights, IL 60005. (888) 475-2784. <http://www.plasticsurgery.org/>.

other

American Academy of Facial and Reconstructive Plastic Surgery. [cited April 9, 2003]. <http://www.facial-plasticsurgery.org/patient/procedures/rhinoplasty.html>.

National Library of Medicine. [cited April 9, 2003]. <http://www.nlm.nih.gov/medlineplus/plasticcosmeticsurgery.html>.

Restoration of Appearance Trust. [cited April 9, 2003]. <http://www.raft.ac.uk/plastics/rhinoplasty.html>.

Revision Rhinoplasty. [cited April 9, 2003]. <http://www.revisionrhinoplasty.net/>.

L. Fleming Fallon, Jr. MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Simple rhinoplasty is usually performed in an outpatient surgery center or in the surgeon's office. Most procedures take only an hour or two, and patients go home right away. Complex procedures may be performed in a hospital and require a short stay.

Rhinoplasty is usually performed by a surgeon with advanced training in plastic and reconstructive surgery.

QUESTIONS TO ASK THE DOCTOR

• What will be the resulting appearance? (Often, computer programs are available to assist in visualizing the final result.)
• Is the surgeon board certified in plastic and reconstructive surgery?
• How many rhinoplasty procedures has the surgeon performed?
• What is the surgeon's complication rate?
• Will this surgery really make a huge difference to my life or am I trying to live up to an impossible media stereotype of beauty?

Rhinoplasty

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

The term rhinoplasty means “nose molding” or “nose forming.” It refers to a procedure in plastic surgery in which the structure of the nose is changed. The change can be made by adding or removing bone or cartilage, grafting tissue from another part of the body, or implanting synthetic material to alter the shape of the nose.

Purpose

Rhinoplasty is most often performed for cosmetic reasons. A nose that is too large, crooked, misshapen, malformed at birth, or deformed by an injury can be given a more pleasing appearance. If breathing is impaired due to the form of the nose or to an injury, it can often be improved with rhinoplasty.

Demographics

Rhinoplasty is the third most common cosmetic procedure among both men and women. Total number of rhinoplasty procedures in the United States in 1999 was 133,058. More than 13,100 of those procedures were performed on men.

Description

The external nose is composed of a series of interrelated parts that include the skin, the bony pyramid, cartilage, and the tip of the nose, which is composed of cartilage and skin. The strip of skin separating the nostrils is called the columella.

KEY TERMS

Cartilage— Firm supporting tissue that does not contain blood vessels.

Columella— The strip of skin running from the tip of the nose to the upper lip, which separates the nostrils.

Septum— The dividing barrier in the center of the nose.

Surgical approaches to nasal reconstruction are varied. Internal rhinoplasty involves making all incisions from inside the nasal cavity. The external, or “open,” technique involves a skin incision across the base of the nasal columella. An external incision allows the surgeon to expose the bone and cartilage more fully and is most often used for complicated procedures. During surgery, the surgeon will separate the skin from the bone and cartilage support. The framework of the nose is then reshaped in the desired form. Shape can be altered by removing or adding bone, cartilage, or skin. The remaining skin is then replaced over the new framework. If the procedure requires adding to the structure of the nose, the donated bone, cartilage, or skin can come from another location on the patient’s body or from a synthetic source.

When the operation is completed, the surgeon will apply a splint to help the bones maintain their new shape. The nose may also be packed, or stuffed with a dressing, to help stabilize the septum.

When a local anesthetic is used, light sedation is usually given first, after which the operative area is numbed. It will remain insensitive to pain for the length of the surgery. A general anesthetic is used for lengthy or complex procedures, or if the doctor and patient agree that it is the best option.

Diagnosis/Preparation

The quality of the skin plays a major role in the outcome of rhinoplasty. Persons with extremely thick skin may not see a significant change in the underlying bone structure after surgery. On the other hand, thin skin provides almost no cushion to hide many minor bone irregularities or imperfections.

Rhinoplasty should not be performed until the pubertal growth spurt is complete, age 14-15 for girls and older for boys.

During the initial consultation, the candidate and surgeon will determine what changes can be made in

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Simple rhinoplasty is usually performed in an outpatient surgery center or in the surgeon’s office. Most procedures take only an hour or two, and patients go home right away. Complex procedures may be performed in a hospital and require a short stay.

Rhinoplasty is usually performed by a surgeon with advanced training in plastic and reconstructive surgery.

the shape of the nose. Most doctors take photographs during that consult. The surgeon will also explain the techniques and anesthesia options available to the candidate.

The candidate and surgeon should also discuss guidelines for eating, drinking, smoking, taking or avoiding certain medications, and washing the face for the weeks immediately following surgery.

Aftercare

Patients usually feel fine immediately after surgery. As a precaution, most surgery centers do not allow patients to drive themselves home after an operation.

The first day after surgery, there will be some swelling of the face. Persons should stay in bed with their heads elevated for at least a day. The nose may hurt and a headache is common. The surgeon will prescribe medication to relieve these conditions. Swelling and bruising around the eyes will increase for a few days, but will begin to diminish after about the third day. Slight bleeding and stuffiness are normal, and vary according to the extent of the surgery performed. Most people are walking in two days, and back to work or school in a week. No strenuous activities are allowed for two to three weeks.

Patients are given a list of postoperative instructions, which include requirements for hygiene, exercise, eating, and follow-up visits to the doctor. Patients should not blow their noses for the first week to avoid disruption of healing. It is extremely important to keep the surgical dressing dry. Dressings, splints, and stitches are removed in one to two weeks. Patients should avoid excessive sun or sunburn.

QUESTIONS TO ASK THE DOCTOR

Candidates for a rhinoplasty procedure should consider asking the following questions:

• What will be the resulting appearance? (Often, computer programs are available to assist in visualizing the final result.)
• Is the surgeon board certified in plastic and reconstructive surgery?
• How many rhinoplasty procedures has the surgeon performed?
• What is the surgeon’s complication rate?
• Will this surgery really make a huge difference to my life or am I trying to live up to an impossible media stereotype of beauty?

Risks

Any type of surgery carries a degree of risk. There is always the possibility of unexpected events such as an infection or a reaction to the anesthesia.

When the nose is reshaped or repaired from inside, the scars are not visible. If the surgeon needs to make the incision on the outside of the nose, there will be some slight scarring. In addition, tiny blood vessels may burst, leaving small red spots on the skin. These spots are barely visible, but may be permanent.

Normal results

The best candidates for rhinoplasty are those persons with relatively minor deformities. Nasal anatomy and proportions are quite varied and the final look of any rhinoplasty operation depends on a person’s anatomy, as well as the surgeon’s skill.

A cosmetic change of the nose will change a person’s appearance, but it will not change self-image. A person who expects a different lifestyle after rhinoplasty is likely to be disappointed.

The cost of rhinoplasty depends on the difficulty of the work required and on the specialist chosen. If the problem was caused by an injury, insurance will usually cover the cost. A rhinoplasty done only to change a person’s appearance is not usually covered by insurance.

Morbidity and mortality rates

Death from a rhinoplasty procedure is exceedingly rare. When it occurs, the cause is often due to an adverse reaction to anesthesia or postoperative medications or to an infection. About 10% of persons receiving rhinoplasty require a second procedure.

Alternatives

The alternative to cosmetic rhinoplasty is to accept oneself, literally, at face value. Persons contemplating rhinoplasty may want to question some of the conventional standards of beauty and work on their body image issues to improve their self-confidence.

Resources

BOOKS

Cummings, CW, et al. Otolayrngology: Head and Neck Surgery. 4th ed. St. Louis: Mosby, 2005.

PERIODICALS

Becker DG. “Reducing complications in rhinoplasty.” Otolaryngology Clinics of North America 39, no.3 (2006): 475–492.

Citardi MJ. “Advanced Techniques in Rhinology.” Otolaryngology Clinics of North America 39, no.3 (2006): xiii–xiv.

Romo T. “Reduction Structured Rhinoplasty.” Dermatology Clinics 23, no.3 (2005): 529–540.

Rohrich, R. J., and A. R. Muzaffar. “Rhinoplasty in the African-American Patient.” Plastic and Reconstructive Surgery 111, no.3 (2003): 1322–1339.

Russell, P., and C. Nduka. “Digital Photography for Rhinoplasty.” Plastic and Reconstructive Surgery 111, no.3 (2003): 1266–1267.

ORGANIZATIONS

American Board of Plastic Surgery. Seven Penn Center, Suite 400, 1635 Market Street, Philadelphia, PA 19103-2204. (215) 587-9322. http://www.abplsurg.org/.

American College of Plastic and Reconstructive Surgery. http://www.breast-implant.org.

American College of Surgeons. 633 North Saint Claire Street, Chicago, IL 60611. (312) 202-5000. http://www.facs.org/.

American Society for Aesthetic Plastic Surgery. 11081 Winners Circle, Los Alamitos, CA 90720. (800) 364-2147 or (562) 799-2356. http://www.surgery.org/.

American Society for Dermatologic Surgery. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-9830. http://www.asds-net.org.

American Society of Plastic Surgeons. 444 E. Algonquin Rd., Arlington Heights, IL 60005. (847) 228-9900. http://www.plasticsurgery.org/.

OTHER

American Academy of Facial and Reconstructive Plastic Surgery. [cited April 9, 2003] http://www.facialplasticsurgery.org/patient/procedures/rhinoplasty.html.

National Library of Medicine. [cited April 9, 2003] http://www.nlm.nih.gov/medlineplus/plasticcosmeticsurgery.html.

Restoration of Appearance Trust. [cited April 9, 2003] http://www.raft.ac.uk/plastics/rhinoplasty.html.

Revision Rhinoplasty. [cited April 9, 2003] http://www.revisionrhinoplasty.net/.

L. Fleming Fallon, Jr., MD, DrPH

Septoplasty

Definition

Septoplasty is a surgical procedure to correct the shape of the septum of the nose. The goal of this procedure is to correct defects or deformities of the septum. The nasal septum is the separation between the two nostrils. In adults, the septum is composed partly of cartilage and partly of bone. Septal deviations are either congenital (present from birth) or develop as a result of an injury. Most people with deviated septa do not develop symptoms. It is typically only the most severely deformed septa that produce significant symptoms and require surgical intervention. However, many septoplasties are performed during rhinoplasty procedures, which are most often performed for cosmetic purposes.

Purpose

Septoplasty is performed to correct a crooked (deviated) or dislocated septum, often as part of plastic surgery of the nose (rhinoplasty). The nasal septum has three functions: to support the nose, to regulate air flow, and to support the mucous membranes (mucosa) of the nose. Septoplasty is done to correct the shape of the nose caused by a deformed septum or correct deregulated airflow caused by a deviated septum. Septoplasty is often needed when the patient is having an operation to reduce the size of the nose (reductive rhinoplasty), because this operation usually reduces the amount of breathing space in the nose.

During surgery, the patient's own cartilage that has been removed can be reused to provide support for the nose if needed. External septum supports are not usually needed. Splints may be needed occasionally to support cartilage when extensive cutting has been done. External splints can be used to support the cartilage for the first few days of healing. Tefla gauze is inserted in the nostril to support the flaps and cartilage and to absorb any bleeding or mucus.

Demographics

About one-third of the population may have some degree of nasal obstruction. Among those with nasal obstruction, about one-fourth have deviated septa.

Diagnosis/Preparation

The primary conditions that may suggest a need for septoplasty include:

• nasal air passage obstruction
• nasal septal deformity
• headaches caused by septal spurs
• chronic and uncontrolled nosebleeds
• chronic sinusitis associated with a deviated septum
• obstructive sleep apnea
• polypectomy (polyp removal)
• tumor excision
• turbinate surgery
• ethmoidectomy (removal of all or part of a small bone on the upper part of the nasal cavity)

Septal deformities can cause nasal airway obstruction. Such airway obstruction can lead to mouth breathing, chronic nasal infections, or obstructive sleep apnea. Septal spurs can produce headaches when these growths lead to increased pressure on the nasal septum. Polypectomy, ethmoidectomy, tumor removal , and turbinate surgical procedures often include septoplasty. Individuals who have used significant quantities of cocaine over a long period of time often require septoplasty because of alterations in the nasal passage structures.

Septal deviation is usually diagnosed by direct observation of the nasal passages. In addition, a computed tomography (CT) scan of the entire nasal passage is often performed. This scan allows the physician to fully assess the structures and functioning of the area. Additional tests that evaluate the movement of air through the nasal passages may also be performed.

Before performing a septoplasty, the surgeon will evaluate the difference in airflow between the two nostrils. In children, this assessment can be done very simply by asking the child to breathe out slowly on a small mirror held in front of the nose.

As with any other operation under general anesthesia, patients are evaluated for any physical conditions that might complicate surgery and for any medications that might affect blood clotting time. If a general anesthetic is used, then the patient is advised not to drink or eat after midnight the night before the surgery. In many cases, septoplasty can be performed on an outpatient basis using local anesthesia. Conditions that might preclude a patient from receiving a septoplasty include excessive cocaine abuse, Wegener's granulomatosis, malignant lymphomas, and an excessively large septal perforation.

Aftercare

Patients who receive septoplasty are usually sent home from the hospital later the same day or in the morning after the surgery. All dressings inside the nose are usually removed before the patient leaves. Aftercare includes a list of detailed instructions for the patient that focus on preventing trauma to the nose.

The head needs to be elevated while resting during the first 24-48 hours after surgery. Patients will have to breathe through the mouth while the nasal packing is still in place. A small amount of bloody discharge is normal but excessive bleeding should be reported to the physician immediately. Antibiotics are usually not prescribed unless the packing is left in place more than 24 hours. Most patients do not suffer significant amounts of pain, but those who do have severe pain are sometimes given narcotic pain relievers. Patients are often advised to place an ice pack on the nose to enhance comfort during the recovery period. Patients who have splint placement usually return seven to 10 days after the surgery for examination and splint removal.

Risks

The risks from septoplasty are similar to those from other operations on the face: postoperative pain with some bleeding, swelling, bruising, or discoloration. A few patients may have allergic reactions to the anesthetics. The operation in itself, however, is relatively low-risk in that it does not involve major blood vessels or vital organs. Infection is unlikely if proper surgical technique is observed. One of the extremely rare but serious complications of septoplasty is cerebrospinal fluid leak. This complication can be treated with proper nasal packing, bed rest, and antibiotic use. Follow-up surgery may be necessary if the nasal obstruction relapses.

Normal results

Normal results include improved breathing and airflow through the nostrils, and an acceptable outward shape of the nose. Most patients have significant improvements in symptoms following surgery.

Morbidity and mortality rates

Significant morbidity associated with septoplasty is rare and is outlined in the Risks section above. Mortality is extremely rare and associated with the risks involving anesthesia. This procedure can be performed using local anesthesia on an outpatient basis or under general anesthesia during a short hospital stay. General anesthesia is associated with a greater mortality rate, but this risk is minimal.

Alternatives

In cases of sinusitis or allergic rhinitis, nasal airway breathing can be improved by using such nasal sprays, as phenylephrine (Neo-Synephrine). Patients with a history of chronic uncontrolled nasal bleeding should receive conservative therapy that includes nasal packing to identify the source of the bleeding before surgery is contemplated. Those who have been diagnosed with obstructive sleep apnea have a variety of conservative alternatives before surgery is seriously considered. These alternatives include weight loss, changes in sleep posture, and the use of appliances during sleep that enlarge the upper airway.

Resources

books

Muth, Annemarie S., and Karen Bellenir, eds. Surgery Source-book. New York: Omnigraphics, 2002.

Schwartz, Seymour I., ed. Principles of Surgery. New York: McGraw-Hill, 1999.

"Septal deviation and perforation." In The Merck Manual, edited by Keryn A. G. Lane. West Point, PA: Merck & Co., 1999.

other

"Septoplasty." MEDLINEplus Medical Encyclopedia [cited July 7, 2003]. <http://www.nlm.nih.gov>.

Mark Mitchell

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Septoplasty is performed by a medical doctor (M.D.) who has received additional training in surgery. Typically, septoplasty is performed by a board-certified plastic surgeon, a specialist called an otolaryngologist, or a head and neck surgeon. The procedure can be performed in a hospital or in a specialized surgical clinic.

QUESTIONS TO ASK THE DOCTOR

• What are my alternatives?
• Is surgery the answer for me?
• Can you recommend a surgeon who performs septoplasty?
• If surgery is appropriate for me, what are the next steps?

QUESTIONS TO ASK THE SURGEON

• How many times have you performed septoplasty?
• Are you a board-certified surgeon?
• What type of outcomes have you had?
• What are the most common side effects or complications?
• What should I do to prepare for surgery?
• What should I expect following the surgery?
• Can you refer me to one of your patients who has had this procedure?
• What type of diagnostic procedures are performed to determine if patients require surgery?
• Will I need to see another specialist for the diagnostic procedures?

Septoplasty

Definition

Septoplasty is a surgical procedure to correct the shape of the septum of the nose. The nasal septum is the separation between the two nostrils. In adults, the septum is composed partly of cartilage and partly of bone.

Purpose

Septoplasty is performed to correct a crooked (deviated) or dislocated septum, often as part of plastic surgery of the nose (rhinoplasty ). The nasal septum has three functions: to support the nose, regulate air flow, and support the mucous membranes (mucosa) of the nose. Septoplasty is done to correct the shape of the nose caused by a deformed septum or correct deregulated air flow caused by a deviated septum. Septoplasty is often needed when the patient is having an operation to reduce the size of the nose (reductive rhinoplasty), because this operation usually reduces the amount of breathing space in the nose.

Septoplasty may also be done as a follow-up procedure following facial trauma, as the nose is frequently broken or dislocated by blows to the face resulting from automobile accidents, criminal assaults, or sports injuries.

Precautions

Septoplasty is ordinarily not performed within six months of a traumatic injury to the nose.

Description

Septoplasties are performed in the hospital with a combination of local and intravenous anesthesia. In some cases, hypnosis has been successfully used as anesthesia. After the patient is anesthetized, the surgeon makes a cut (incision) in the mucous tissue that covers the part of the septum that is made of cartilage. The tissue is lifted, exposing the cartilage and bony part of the septum. Usually, one side of the mucous tissue is left intact to provide support during healing. Cartilage is cut away as needed.

As the surgeon cuts away the cartilage, deformities tend to straighten themselves out, reducing the amount of cartilage that must be cut. Once the cartilage is cut, bony deformities can be corrected. For most patients, this is the extent of the surgery required to improve breathing through the nose and correct deformities. Some patients have bony obstructions at the base of the nasal chamber and require further surgery. These obstructions include bony spurs and ridges that contribute to drying, ulceration, or bleeding of the mucous tissue that covers the inside of the nasal passages. In these cases, the extent of the surgery depends on the nature of the deformities that need correcting.

During surgery, the patient's own cartilage that has been removed can be reused to provide support for the nose if needed. External septum supports are not usually needed. Splints may be needed occasionally to support cartilage when extensive cutting has been done. External splints can be used to support the cartilage for the first few days of healing. Tefla gauze is inserted in the nostril to support the flaps and cartilage and to absorb any bleeding or mucus.

A newer option for closing perforations in the septum is a button made of Silastic, a compound of silicone and rubber.

Preparation

Before performing a septoplasty, the surgeon will evaluate the difference in airflow between the two nostrils. In children, this assessment can be done very simply by asking the child to breathe out slowly on a small mirror held in front of the nose.

As with any other operation under general anesthesia, patients are evaluated for any physical conditions that might complicate surgery and for any medications that might affect blood clotting time.

Aftercare

Patients with septoplasties are usually sent home from the hospital later the same day or the morning after the surgery. All dressings inside the nose are removed before the patient leaves. Aftercare includes a list of detailed instructions for the patient that focus on preventing trauma to the nose.

KEY TERMS

Cartilage— A tough, elastic connective tissue found in the joints, outer ear, nose, larynx, and other parts of the body.

Rhinoplasty— Plastic surgery of the nose.

Septum (plural, septa)— The dividing partition in the nose that separates the two nostrils. It is composed of bone and cartilage.

Splint— A thin piece of rigid material that is sometimes used during nasal surgery to hold certain structures in place until healing is underway.

Risks

The risks from a septoplasty are similar to those from other operations on the face: postoperative pain with some bleeding, swelling, bruising, or discoloration. A few patients may have allergic reactions to the anesthetics. The operation in itself, however, is relatively low-risk in that it does not involve major blood vessels or vital organs. Infection is unlikely if proper surgical technique is observed.

Normal results

Normal results include improved breathing and airflow through the nostrils, and an acceptable outward shape of the nose.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Septal Deviation and Perforation." Section 7, Chapter 86 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

PERIODICALS

Piatti, G., A. Scotti, and U. Ambrosetti. "Nasal Ciliary Beat after Insertion of Septo-Valvular Splints." Otolaryngology and Head and Neck Surgery 130 (May 2004): 558-562.

Wain, H. J. "Reflections on Hypnotizability and Its Impact on Successful Surgical Hypnosis: A Sole Anesthetic for Septoplasty." American Journal of Clinical Hypnosis 46 (April 2004): 313-321.

ORGANIZATIONS

American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). 310 South Henry Street, Alexandria, VA 22314. (703) 299-9291. 〈http://www.facemd.org〉.

American Society of Plastic Surgeons (ASPS). 444 East Algonquin Road, Arlington Heights, IL 60005. (847) 228-9900. 〈http://www.plasticsurgery.org〉.