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Archive for the 'rhinoplasty' Category
1. How will my nose look after a rhinoplasty?
One of the most important considerations about having a rhinoplasty is to end up with a ‘new’ nose that makes you happy. While no surgery can absolutely be guaranteed as to how it will look, there should be a good understanding between the you and your plastic surgeon as to what your goals are. This is why computer imaging is so important before surgery. It serves as a method of communication so that what you would like and what is possible can be meshed into an image of a likely outcome.
As a plastic surgeon, we can reasonably predict what each patient will say bothers them about their nose. Whether it is a nasal hump, a wide tip, a downturned nose or a nose that is off center, we can quickly see what makes one’s nose out of proportion. The pupose of computer imaging is to make sure what we see is the same as you see. And it also allows us to know how to modify the changes we might do (e.g., more hump reduction, too much tip narrowing, tip up too high or still too low) so that it meets your needs better.
2. Does rhinoplasty leave scars?
Rhinoplasty can be done two ways, open and closed. While there may be some debate and advocates for either approach, most rhinoplasties today are done through an open approach. This does leave a small horizontal scar on the strip of skin between the nostrils. (columella) The remainder of the incisions are hidden inside the nose just like a traditional closed technique.
While the open approach does result in a scar, it almost always heals so well that it is virtually impossible to find when the scar matures. In some patients, you can only see that scar if you are within 10 cms or less. And it requires one to be looking from below the tip of the nose…a very unnatural viewpoint.
3. Will rhinoplasty improve the breathing through my nose?
Nose surgery can be done to change the external appearance of the nose (aesthetic rhinoplasty) or to improve obstructed breathing through the nose. (functional rhinoplasty or septorhinoplasty) Often both are done together.
Functional nasal surgery, however, is done completely inside the nose and works on those structures that contribute to air flow. This includes the septum (straightening a deviation), turbinates (reduction or partial resection) and manipulation of the internal nasal valve. (cartilage grafting for expansion)
It is important to realize that doing the two together has many benefits. Straightening a deviated septum can help straighten a crooked nose and is a good source for cartilage grafts. Turbinate reductions help open up an airway that may be adverseloy affected by some of the external changes. Expanding the middle vault with grafts can make a pinched-looking nose wider and make the dorsal lines more symmetric.
4. Will insurance pay for my rhinoplasty?
While we all would like health insurance to cover all of our medical needs, rhinoplasty is not usually one of them. Expenses related to improve breathing are almost always covered within the limits of your policy, any external changes to the appearance of the nose however are not. There are certain exceptions to that exclusion if there is a documented medical reason for how the nose is deformed. Birth defects (e.g., cleft lip and palate) and traumatic injuries (e.g., fractures)are the two main examples. I emphasize the word ‘documented’ as just saying that it occurred is not sufficient.
5. What can be done if I am unhappy with how my nose looks after surgery?
For most rhinoplasties, the biggest risk or complication is that of an undesired appearance outcome. This is usually not a large cosmetic problem but more like an irregularity, a dip or deviation, or some location of asymmetry of the bridge, tip, or mostrils. As a plastic surgeon, we are very sensitive to how even a minor ‘problem’ is of a big concern to a patient, particularly when it is on their nose.
When one sees something on their nose after surgery that displeases them, one should first be patient. The nose is unique in that the skin continues to change on the nose for months after surgery, sometimes even up to a year. What may be there to day, could be gone or even more apparent months from now. Secondary or revisional surgery is not usually done for at least six months from the initial surgery. The primary reason is that we want to operate on a ‘stable target’, not a nasal feature that is in a state of evolution. Also, it is important that the stiffness of the nose tissues has had time to settle down and become softer again. Revisional surgery done too early is highly prone to fail.
The risk of the need for revisional rhinoplasty surgery is not rare. Because of the many different types of nose problems and types of surgery needed, no one can give a reliable estimate that applies to any specific patient. In my Indianapolis plastic surgery practice, I use the estimate of a 10% risk…a not insignificant number.
6. What type of anesthesia is used for rhinoplasty surgery?
Surgery of the nose has a history of being done under local or IV sedation in many practices. While some plastic surgeons still do so, one should never compromise the ‘fear’ of anesthesia vs a good outcome. Comfort of the patient and the ability to manage any bleeding that may occur during surgery is best done under general anesthesia. Many older patients can recall having their nose done when they could hear or feel their ‘bones being broken.’
Today’s anesthesia techniques and drugs are so good, I see no reason to use anything less than a general anesthetic for almost all cases.
7. I have heard that rhinoplasty is a difficult surgery to do, why is that so?
While the nose is a small structure in comparison to the rest of the face, there is a lot of complex anatomy packed in there. Contrast the nose to the chin, for example, which is much larger. The chin has only two pieces of important anatomy (solid piece of bone and soft tissues) while the nose has three bone and six pieces of cartilage covered by a very thin layer of skin. The interrelationship of how this anatomy comes together, what changes occur by altering parts of it, and how it responds to healing and scar contracture make rhinoplasty less predictable than almost any other facial surgery that we do.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
As the U.S. population continues to become increasingly multicultural, one of the increasing ethnic groups is that from the Middle Eastern region. This is a geographic term that does not have a true precise meaning as it can vary based on which countries one chooses to include in the region. Most commonly, many would include the countries that surround the Gulf Sea as well as that of Northern Africa.
While the Middle Eastern region is a blend of many cultures, there are certain nasal characteristics that are commonly seen. The overlying skin is almost always thick and heavy, a large dorsal hump is present, the nasal tip is ill-defined and bulbous, and the columella is frequently short. These characteristics give the appearance of a long and plunging nose with an acute nasolabial angle.
The Middle Eastern nose, like all ethnic rhinoplasties, poses challenges based its thick skin and cartilaginous make-up. But beyond the anatomy of the nose, it is important to have clear communication with the patient about their nasal goals. When the plastic surgeon and the patient have different ethnic and cultural backgrounds, it is easy to have objectives that are unintentionally different. Computer imaging and multiple consults can help to prevent this communication gap.
The open approach should almost always be used. To rework the cartilage framework in a way that will make a significant change in nasal appearance requires optimal visualization. Some plastic surgeons may be able to achieve a great rhinoplasty result in the Middle Eastern patient through a closed approach, but that has not been my experience in my Indianapolis plastic surgery practice. While there is always a concern about the columellar scar in patients with increased skin pigmentation, that has not been a problem. That is not a surprise given the known experience with other ethnicities.
Structural support to the tip and the middle vault is essential. The thick skin of the nasal tip can make it challenging to achieve definition and a more upright position with an increased nasolabial angle. Septal grafts to the columella are always needed to support the large and heavy skin sleeve. Tip grafts are usually beneficial to create more definition through tip skin which has been slightly defatted. The septum can provide more than enough graft material and almost always needs work anyway as it is frequently deviated and off midline.
The dorsal hump must be looked at and analyzed carefully during surgery. While it can appear to be high, it may not need to be as significantly reduced as one initially thinks. In some cases, this is an illusion due to the downturned tip and decreased nasolabial angle. Rasping and radix grafts may be all that is needed. In other cases, however, a large bony hump does exist and full osteotomies are needed to bring down the dorsal line.
Alar and nostril narrowing by excising skin at the sill or base is often needed. One should not hesitate to do so when indicated as adverse scarring is rarely seen.
Rhinoplasty in the Middle Eastern patient is challenging but successful results and a happy patient can usually be achieved. The use of well known structural support principles through an open approach are important intraoperative maneuvers. Preoperative planning with an understanding of the patients aesthetic objectives is just as important in any form of ethnic rhinoplasty.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Building up the nasal bridge, known as dorsal augmentation, is needed for certain types of rhinoplasty surgeries. These include secondary correction of traumatic nasal injuries and saddle nose deformities as well as in some primary ethnic rhinoplasties. Often a rebuilt or elevated dorsal line is one of the most important objectives to achieve in these rhinoplasty endeavors.
While there are numerous methods available for dorsal augmentation, the use of a graft material is needed for all of them. Cartilage is the best nasal graft material. While it takes greater effort to harvest and shape the dorsal graft using cartilage, the long-term benefits of doing so are always worth it. At the least, there is no risk of foreign body reaction and very little absorption of the graft. Because of the size and length of the nasal dorsum, rib cartilage can always supply an adequate graft amount. (this doesn’t mean that rib is the only donor site)
When solid rib grafts are used for dorsal augmentation, they are prone to warping, deviation, and being able to feel the graft move around across the nasal bridge. As a result, using cartilage in a less structured form has become popular. Initially known as the ‘Turkish graft’ and studied and popularized here in the U.S. by Daniel, diced cartilage has become a good method of dorsal augmentation. When cartilage is cut into small segments approximately 1 mm in size and then placed in some form of a containment wrap, a moldable dorsal implant can be easily made. There is some debate as to the merits of a fascial vs. absorbable collagen wrap. Successful clinical outcomes have been obtained with either method.
Besides being easy to make out of cartilage scraps or imperfect graft pieces, a diced cartilage graft can be molded like clay. Once placed on the dorsum, it can be shaped and held in place for one week after surgery with an external splint. The graft is still slightly malleable in the first couple of weeks after surgery. Therefore, if some irregularities are seen early in the first few weeks after surgery, the dorsal graft can be pressed and molded to improve its shape.
Diced cartilage grafts have been shown to be heal together into a solid piece of cartilage without loss of volume. It is able to be revised, reshaped, and easily identified during further surgeries if necessary. In my Indianapolis plastic surgery practice, I have used this technique for over five years and find that the results are similar to pioneers of this technique sat that it is. It has been a revolutionary approach for me in dorsal augmentation, which can be a difficult rhinoplasty manuever because of graft requirements.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Rhinoplasty is one the most challenging and unforgiving operations of all facial plastic surgery operations. Due to the complexity of nasal anatomy and how its multiple parts interrelate, many different surgical maneuvers and changes are possible. Some of these changes are more significant while others are more subtle. But they all can make a difference in the final result, whether it be how the nose looks or how well it breathes.
Because of the importance of the nose to one’s facial appearance and the many different maneuvers that can be done in rhinoplasty, communication between patient and plastic surgeon is absolutely critical. In my Indianapolis plastic surgery practice, I use paper diagrams of the anatomy of the nose during a rhinoplasty consultation and computer imaging forwarded to the patient after the appointment. Both visual methods are essential in having the patient understand what the problems are and what is surgically possible.
In the course of this communication, some appreciation by the patient of the anatomy of the nose and the terms we use in rhinoplasty surgery are necessary to make sure we are really communicating.
Most people underestimate the complexity of the nose because they are thinking only about its visible external appearance. But beneath the skin lies an intricate arrangement of cartilaginous- and bone-based structures that give the nose both its form and function.
The surface of the nose features a number of distinct regions and structures.
· The root or radix of the nose is the area between and just below the eyebrows. It is the uppermost part of the bridge.
· The bridge lies below the root and forms the upper one-third of the nose.
· The middle vault lies between the bridge and the tip of the nose.
· The dorsum (roofline) is the shape and height of the nose as it runs between the root and the tip of the nose.
· The tip of the nose is where the dorsal line of the nose meets the columella.
· The columella is the strip of skin between the nostrils which extends down from the tip to the upper lip.
· The ala are the sidewalls of the nose forming the roof of the nostrils
· The nasal base extends from one side of the nostril to the other along where the nose meets the upper lip.
Beneath this surface topography lies the bone and cartilage structures which give it both shape and support. Some of these important structures are:
· The paired nasal bones (root and bridge)
· Two upper lateral cartilages (middle vault)
· The septum which runs between the upper lateral cartilages
· Two lower lateral cartilages (tip and nostrils)
· The medial crural footplates (columella)
Contemporary rhinoplasty is focused on conservative and subtle anatomical changes accomplished by preservation, reconstruction and modification of the osseo-cartilaginous framework of the nose. There are two surgical approaches to these structures – the open and the closed approach.
The open approach is performed by making a trans-columellar skin incision combined with internal incisions, followed by skin envelope dissection and elevation. The open approach offers full exposure to the nasal framework, allowing for accurate diagnosis and precise manipulation of its external structures. If extensive changes are needed in a first rhinoplasty or if a secondary rhinoplasty is needed, the open approach is usually better.
The closed approach does not require any skin incision and does not leave external scar since all the incisions are made inside the nose. The lower lateral cartilages can be dissected and freed from the surrounding tissues and “delivered” outside. This approach is best suited for isolated hump deformities or minimal tip changes.
Armed with this basic nose anatomy and surgical terminology, may your rhinoplasty consultation and discussion make you a better educated patient!
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
‘For the most part I like my nose, but I have a slightly rounded, bulbous tip. I don’t really want to change my nose… just tweak it a little bit and give the tip of my nose slightly more definition.’
‘I have a decent nose. However, as I’ve gotten a little older, I noticed the tip of my nose has became more rounded and less defined. I wanted a “tweak” to refine the nose.’
These are common statements that I have heard in my Indianapolis plastic surgery practice from patients seeking nose changing surgery. Often in rhinoplasty, patients are concerned about one specific feature of their nose that they don’t like. As a plastic surgeon, I am trained and experienced to see the entire nose and how it relates to the rest of their face. This perspective allows me to offer suggestions about other changes to the nose that may also be beneficial. However, it is important to respect a patient’s concerns, particularly if they are concrete about one specific change. After all, patient’s know their own nose the best and they have to live with the result.
The tip may be the smallest third of the external nose by surface area but it is the complex. Its shape and angulation has a profound impact on nasal and facial appearance. It is the one feature of the nose that is the most unique between every person.
A tip rhinoplasty is a variety of operative manuevers that seeks to change the volume, angle, or height of the nasal tip. Alterations can range from simple to complex, depending on the degree and scope of an individual patient’s problem. Many different outcomes are possible, depending on both the patient’s desires and the plastic surgeon’s aesthetic sense.
Anatomically, a tip rhinoplasty involves changing the relationship of the lower lateral (alar cartilages) with the upper lateral cartilages and the caudal (end) of the septum. It can be as ‘simple’ as a cephalic trim, a reduction of the upper part of the bulbous tip cartilage, or more involved with adjustment of the septum at its base and grafts placed between the nasal ala to enhance and rotate the tip. Various types of techniques, including suture modification, cartilage excision, or structural grafting may be used to achieve the desired aesthetic outcome.
Most commonly when a patient refers to tweaking the nose, they usually mean making it a little narrower (more refined) or lifting it just a bit… or both narrowing and a little lift combined. Such changes can be done through either an open or closed approach. When the changes are small, I prefer a closed or endonasal approach to lessen the duration of time that the patient has to endure the surgical swelling.
When modifying the tip of the nose, it is critical to not ‘over tweak’ it. This means to not make the tip into a single point (too narrow) or lift it too high or short. When this happens one will have an operated look which is synonymous with having had one’s nose done…exactly what patients are trying to avoid.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
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Rhinoplasty is a complex array of cartilage rearrangement and bone manipulation that takes place underneath or behind the skin that covers the nose. Getting to the structures of the nose can be done be either working underneath the skin or seeing the structures directly by lifting off the skin. These two approaches are done by using incisions placed inside the nose (endonasal approaches) or via incisions placed inside the nose combined with incisions placed outside the nostrils (external approach), on the columella. (strip of skin between the nostrils) In the past two decades, the external (open) rhinoplasty approach has become popular and by far is how most noses are done today. Prior to this, however, the terms rhinoplasty and endonasal rhinoplasty were almost synonymous as this was how noses were done from the inception of the operation over 100 years ago.
In theory, an experienced rhinoplasty surgeon can use either an endonasal or an external rhinoplasty approach, based on what is best for the patient’s nasal anatomy. In reality, the difficulty of rhinoplasty surgery and the high level of patient scrutiny make the open approach a more comfortable one to get the most assured result. But the open approach is not perfect with more extensive scarring and sometimes unpredicted distortions of the nose with scar contracture in some cases. By like all things in life, the endonasal approach is beginning to undergo a resurgence and what’s old is likely to become new again. With the trend towards less invasive approaches and quicker recoveries, endonasal rhinoplasty will definitely become more popular in the next decade. The trend towards more closed rhinoplasties, however, will incorporate what has been learned from open procedures…..that of support and increasing structural integrity. Endonasal rhinoplasty has long been considered a reductive operation in which nose structures were removed. This left many noses over reduced and in need of difficult secondary revisions. Thus was born the open rhinoplasty, where the use of cartilage grafting for support became necessary. When such principles are applied to this new generation of endonasal rhinoplasty, more predictable and better long-term results will be obtained.
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Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Rhinoplasty remains one of the more challenging of all plastic surgery procedures. Because of the intricacy and interconnections of the bone and cartilages of the nose, surgical outcomes are far from guaranteed. Given that the nose is the most central and forward projecting part of the face, it undergoes considerable patient scrutiny, particularly after surgery. The recipe of its anatomic complexity and the high visibility of the results makes the need for secondary rhinoplasty surgery not rare.
Fortunately, most secondary nose surgeries are relatively minor and improvement easy to get. Whether it is a small residual bump or irregularity at the nasal bridge or some tip or nostril asymmetry, a few minor adjustments can make the results better. Correction of more significant problems, such as persistent deviation, middle vault collapse, and nasal bone asymmetry for example, however, require more than just a few tweaks or minor adjustments.
In certain cases of secondary and tertiary rhinoplasty, the need for structural takedown and reconstruction with support is the key to an improved result. The need for support requires either cartilage grafts harvested from the patient or the use of synthetic materials which are off-the-shelf prefabricated materials. These two nose graft choices have their advocates and opponents. In the right scenario both may be effective and each has its own advantages and disadvantages which must be considered on an individual case basis.
In my Indianapolis plastic surgery practice, however, I have developed my own philosophy about these graft choices. In primary rhinoplasty where the soft tissues are unscarred and in the best condition, synthetic implants are the most likely to have long-term success without infection or extrusion…provided they are not placed under significant tension. The most classic example is for dorso-columellar augmentation in the ethnic nose with a preformed implant. In most other cases of primary rhinoplasty, grafts are either not needed or the septum is capable of fulfilling available graft needs. (e.g. columellar strut or spreader grafts)
Secondary rhinoplasty or the multiply operated nose oftens presents with different problems. The tissues are scarred and the septum is usually depleted. Graft choices become harder and donor sites outside of the nose must be considered. It is at this point that synthetic grafts have their greatest appeal as they offer very useable forms which are easily modified. But their use in secondary or tertiary rhinoplasty puts them at greatest risk, implanting them in scarred and thinned tissues whose vascularity is less than ideal. Which makes their risk of postoperative much higher.
For these reasons, I prefer to avoid synthetic materials in any type of secondary or complicated rhinoplasty. Harvesting ears and rib cartilage does not require some finesse and expertise but you never run into wound or extrusion problems with them. In redo rhinoplasty, you often have to consider where you want to ‘pay your price’. Using synthetic materials makes the operation technically easier with a shorter recovery but you will likely live to see the synthetic material pose a problem later. Or invest your effort into cartilage harvesting and grafting up front with a longer and more technically difficult operation but a likely much lower risk of graft complications later.
Barry L. Eppley, M.D., D.M.D.
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Getting a change in your nose without surgery seems impossible. But yet there are some nose imperfections that can be corrected without resorting to surgery. Some have referred to these as a Non-Surgical Rhinoplasty or a Surgery Free Nose Job. Personally I don’t like these terms as they imply one can have a major changes in their nose without surgical intervention…which is not true. But when the right kind of small nasal problem, such changes may be possible.
While it is true that volume is being added to the nose, this will not necessarily make it bigger. In most cases, the nose may look smaller or at the least better balanced as it will fit more proportionately on the patients face. With a change in some of the angles of the nose, it may even make it appear smaller.
The good question is who is a good candidate for a non surgical rhinoplasty? For those patients looking for major reshaping or size reduction, this is not the procedure. If you need a major change then you need to undergo a more traditional surgical rhinoplasty. However, if you only need a small adjustment and want immediate results with no recovery, thern this non surgical procedure could be a good choice for you. Injectable rhinoplasty is best for correcting small nasal bumps, low-sitting bridges of the nose, and certain types of middle vault or tip asymmetries.
Since the injections are done just under the skin, the treatment will not interfere with your breathing. And it can be used to make some very precise and subtle adjustments. However, its biggest disadvantage is that it is not a permanenet procedure so that it will fade and you’ll need to have touch-ups every few years to keep the result.
While any of the injectable filler materials will work, I prefer to use in my Indianapolis plastic surgery practice Radiesse due to its long-lasting behavior.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
Rhinoplasty continues to be a popular facial procedure and is one operation that is almost synonymous with plastic surgery. The central position of the nose on the face makes the need for any rhinoplasty surgery to be very precise. Good results in rhinoplasty are largely dependent upon a detailed understanding of the anatomy of the nose. Whether it is a small area of nasal change or an entire nose restructuring, how the anatomical framework is altered will eventually be revealed through the overlying skin.
What makes your nose look like it does? Think of the shape of your nose like a single level house. The roof covering is the overlying skin, the framework of the roof is the nasal bones and upper and lower alar cartilages, the central support beam is the septum, and the walls are the nasal lining. The look of one’s nose, like the shape of the roof on the house, is directly influenced by how the framework of the roof is shaped. A hump or bump on the nose occurs, for example, because the central beam is arched (too long), raising up a normally smooth roof line. The tip of the nose is too long, for example, because the legs of the tripod support on the roof edges is too long. Deviated noses occur because the central support beam is deviated or the tripod edge supports are longer or shorter on one side.
As an Indianapolis plastic surgeon, I think of changing the nose in terms of four areas, three outer framework and one inner framework support. The upper outer one-third is the nasal bones, the middle third (also known as the middle vault) is the upper cartilages, and the lower one-third is known as the lower cartilages or the tip of the nose. The septum is the central internal support. One important nose area is the thickness of the outer skin which, although we can not change, definitely influences how the changed framework will eventually be seen.
Rhinoplasty surgery is about changing the way these framework parts are joined and in how they are shaped and inter-relate. Taking down a hump on the nose, for example, is a matter of lowering the roof line by reducing the nasal bones and septum heights and usually allowing the roof sides to fall back in together once shortened. Reshaping the tip of the nose is by changing how the sides of the lower cartilages come together in the middle and changing their unified angulation to the underlying septum. Building up the nose is by adding some form of graft to the top of the roofline along its entire length.
Due to the complexity of how all of these framework structures come together, many rhinoplasties today are done through an open approach to best view how the parts come together. For minor changes, however, a closed or endonasal approach still works well and is associated with a quicker recovery time and less nasal tip swelling after.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis
The nostril , although often overlooked, plays very important aesthetic and functional roles in the nose. Beside being the obvious and only inlet for airway passage through the nose, its shape and opening help form the tip of the nose in both height and width. While nostril morphologies are as variable as the rest of the nose, significant changes in their shape affect the nose adversely.
Nostril stenosis, or collapse of the side of the nostril, is a well known nasal problem. It can be caused by differing reasons (e.g, lacerations, burns, birth defects) but they all create the same fundamental problem…loss of nostril tissue and contracture. This creates the pinched nostril look with its shape being a more narrower vertical slit. Such a change limits the amount of airflow due to both internal and external valve collapse. The nasal tip also becomes narrower and in some cases may deviate away or toward the collapsed nostril side.
Correction of nostril stenosis is a difficult problem. In the early phase after the injury, many different types of stents have been described and their use is needed for up to a year after placement. The use of stents in established stenosis is not a primary treatment but a potential postoperative management strategy.
Surgical correction of nostril stenosis involves the addition of tissue. Tissue is usually lacking in both cartilage support and in lining inside the nose. The concept is to build up or support the hypotenuse of a triangle. Cartilage batten grafts, usually harvested from the ear, can be used on top of or underneath the overlying lower alar cartilage. Alar expansion grafts can also be placed between the upper and lower alar cartilages. Nasal lining can be replaced by chondrocutaneous grafts from the ear. It is important to have some cartilage in these skin grafts otherwise their small size will shrink almost to nothing. Their use is of particular value at the inside of the nostril base. They can help open up the nostril base-sill angle which is the opposite mate to the external and internal nasal valve angles.
In my Indianapolis plastic surgery experience, I have found it takes a multitude of rhinoplasty techniques to help re-expand the stenotic nostril. No single one of the above techniques will be sufficient. Nostril stenosis is a difficult problem and should not be confused with its more common nasal valve collapse cousin. Nostril stenosis always has valve collapse but that is a secondary effect from constriction of the alar sidewall.
Postoperative stenting of the surgically expanded nostril is certainly helpful and does no harm. Whether the patient can tolerate wearing a stent for an extended period of time is often another story. I plan the way the nasal reconstruction is done not counting on a stent for success.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis