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The nose it’s a very important central feature of your face, defines in part the character and beauty of your face, participates in the symmetry and proportions of your face and thus, in the interaction with the surrounding persons. As part of these relationships you should feel yourself comfortable with it. A rhinoplasty is the surgical procedure with many variants and technical details adjusted to your needs that can help you achieve balance and beauty in your face.

 

Rhinoplasty is a cosmetic and sometimes reconstructive surgical procedure in order to improve or modify the shape of the nose or correct its function. There are many factors involved in the esthetic aspect of the nose, such as anterior projection, width, height, shape of the tip, nostrils, columella, base and its harmony with the rest of the facial features.

There are not specific measures, shapes or angles for a beautiful nose, but facial lines and proportions are taken in account, as well as genre, age, skin characteristics and patient’s wishes.

The unattractive esthetic appearance of the nose can be caused by hereditary factors, diseases or injuries in the past.  A excessively  big or small a nose, a dorsal hump, the curvature of the nose and the nasal partition , a dropping tip of the nose, asymmetry of nasal cartilages, too wide nostrils and an uneven angle between the nose and the upper lip indicate at the need for nose reshaping.


Functional disorders can be resolved in a single cosmetic and reconstructive nose surgery, like deviations of the septal cartilage, birth defects, alterations in the nasal valves and breathing and bone malposition after nose trauma.


Rhinoplasty can be combined with other surgical procedures such as chin augmentation to enhance the aesthetic results and other cosmetic surgeries like blepharoplasty, ear surgery, and lip augmentation for example.
The cosmetic rhinoplasty procedure is very technical and requires a long period of clinical practice and training so it is very important to choose experienced plastic surgeons like Dr. Bojan Ignatovski, a member of the Croatian Society of Plastic, Reconstructive and Aesthetic Surgery.


External nasal anatomy
Externally, the nose can be divided in subunits that include the dorsum, the sidewalls (paired), the hemilobules (paired), the alae (paired), the soft triangles (paired) and the columella for the purpose of analysis and surgical planning.
Ethnic influences can result in different appearances of the nose: Caucasian, African, Hispanic, and Asian as the main groups, presenting more or less common features like projection, wideness and bulbar volume.

Internal nasal anatomy
The septum is a midline bony and cartilaginous structure that divides the nose into 2 similar halves.
Regarding the lateral nasal wall and paranasal sinuses, the superior, middle, and inferior concha form corresponding superior, middle, and inferior meatus on the lateral nasal wall. The superior meatus is the drainage area for the posterior ethmoid cells and the sphenoid sinus. The middle meatus provides drainage of anterior ethmoid and the maxillary and frontal sinuses. The inferior meatus provides drainage of the nasolacrimal duct.
The internal nasal valve involves the area bounded by upper lateral cartilage, septum, nasal floor, and anterior head of the inferior turbinate. This comprises the narrowest portion of the nasal airway in the Caucasian nose. Generally, an angle wider than 15° is needed in this area. The width of the nasal valve can be increased with spreader grafts and flaring sutures.

Nasal Analysis
Viewing the external nasal anatomy by its subunits is important because defects that span an entire subunit are usually repaired with reconstruction of that subunit.  Aesthetically, the nose—from the nasion (nasofrontal junction) to the columella-labial junction—ideally occupies one third of the face in the vertical dimension. From ala to ala, it should ideally occupy one fifth of the horizontal dimension of the face.
The nasofrontal angle between the frontal bone and nasion is usually 120° and slightly more acute in males than in females. The nasofacial angle, or the slope of the nose compared with the plane of the face, is approximately 30-40°. The nasolabial angle between the columella and philtrum is about 90-95° in males and 100-105° in females.
On profile view, normal columella show, i.e., the height of the nasal aperture visible is 2-4 mm. The dorsum should be straight. Appropriate projection of the nasal tip, or the distance of the tip from the face, is judged by using the Goode rule. Tip projection should be 55-60% of the distance between the nasion and tip-defining point.
During the nasal analysis, the following features must be taken in account:

Frontal view

  • General aspect and congruence with other facial features and discussion of the primary reason for the patient's consultation, palpation of the nose and examination of the interior chamber through nasoscopy.
  • Skin quality: Thin, medium or thick.
  • Following of the brow to nose tip lines: Narrow, wide, normal, wide-narrow-wide, deviated.
  • Tip: Deviated, bulbous, asymmetric, amorphous, and other.
  • Base view:


Base View

  • Triagularity: Good versus trapezoidal shape
  • Tip: Deviated, wide, bulbous, bifid, asymmetric
  • Base: Wide, narrow, normal and inspection of lower septum
  • Columella: Columella-Lobule ratio (Normal is 2:1 ratio)


Lateral View

  • Nasofrontal angle: Shallow or deep.
  • Nasal starting point: High or low
  • Dorsum: Straight, concavity, convexity, bony-cartilaginous component.
  • Nasal length: Normal, short or long.
  • Tip projection: Normal, decreased or increased.
  • Alae-columella relationship (collumelar show): Normal or abnormal, 2-4 mm of collumelar show is normal.
  • Naso-labial angle: Obtuse or acute (90 to 120 degrees, within this range, more obtuse angle more favorable in female, and more acute in male patients)


Oblique View

  • Similarity to the other views (frontal, lateral, basal)External nasal anatomy

Surgical approach: Open vs. closed

Rhinoplasty can be performed under a general anesthetic, sedation, or with local anesthetic. Initially, local anesthesia, which is a mixture of lidocaine and epinephrine, is injected to numb the area and temporarily reduce vascularity.
There are two possible approaches to the nose: closed approach and open approach.
In closed rhinoplasty, incisions are made inside the nostrils and all the surgery is made through these incisions. Most of the surgeries are done with the closed technique, especially when removing a dorsal hump with or without reducing the nose width.
In open rhinoplasty, an additional inconspicuous incision is made across the columella (the bit of skin that separates the nostrils). Open rhinoplasty is indicated when important corrections of the tip of the nose must be done or when doing a secondary rhinoplasty. The surgeon first separates the skin and soft tissues of the nose from the underlying structures. The cartilage and bone is reshaped, and the incisions are sutured.
At the end of the surgery we place inside the nostrils vaselinated gauze that minimizes the bleeding after the surgery, tape over the nose and a stent or cast covering the nose for few days.
Depending on the case, we may shape a small piece of the patient's own cartilage or bone, as a graft, to strengthen or change the shape of the nose. Usually the cartilage is harvested from the septum. If there is not enough septum cartilage, which can occur in revision rhinoplasty, cartilage can be harvested from the concha of the ear or the ribs. In the rare case where bone is required, it is harvested from the cranium, the hip, or the ribs.


Revision rhinoplasty, also known as secondary rhinoplasty, is a nose operation performed to correct or revise an unsatisfactory outcome from a previous rhinoplasty. There are two main reasons for performing secondary rhinoplasty.
Patients often seek secondary rhinoplasty to correct a cosmetic deformity of the nose. A nasal fracture may not have been reduced enough, or too much. A prominent or bulbous nasal tip may have not been addressed appropriately, or over-aggressively. The nose may look pinched; it may look like a parrot’s beak, or like a boxer’s nose.
There are many ways in which previous nose surgery may have left a nose aesthetically unappealing to a patient. The second reason is functional. The original nasal surgery may have been carried out to help with difficulties in breathing, and the outcome may have been unsatisfactory. Alternatively, the original surgery may have been performed for cosmetic reasons, but also may have disrupted a normal physiologic mechanism involving the inspiration or expiration of air, making it difficult to breathe.
Secondary rhinoplasty is technically challenging and many of the surgeries must be done with the open technique. This allows the surgeon to directly visualize the deformity. Advances in rhinoplasty techniques, such as stabilization of rib cartilage grafts and utilization of the open approach, allow now satisfactory results in secondary rhinoplasty that were not possible in the past.


Reconstructive rhinoplasty refers to restoring the normal shape and function of the nose following damage from a traumatic accident, autoimmune disorder, intra-nasal drug abuse, previous injudicious cosmetic surgery, cancer involvement, or congenital abnormality. Rhinoplasty can restore skin coverage, recreate normal contours, and re-establish nasal airflow. To improve nasal breathing function, a septoplasty may also be performed.

Rhinoplasty may be sought in the aftermath of traumatic deformity. Traumatic accidents are the most common cause of nasal deformity. Typically, the nasal bones are broken and displaced. Occasionally, the nasal cartilages are disrupted or displaced, and in the worst cases, the nasal dorsum is collapsed. Rhinoplasty allows shaving of the displaced bony humps, and re-alignment of the nasal bones after they are cut. When cartilage is disrupted, stitching of the cartilage for re-suspension, or use of cartilage grafts to camouflage depressions allows re-establishment of normal nasal contour. When the dorsum is collapsed, grafts of rib cartilage, ear cartilage, or cranial bone can be used to restore continuity to the dorsum. Although synthetic implants are also available for augmenting the nasal dorsum, cartilage or bone graft from the patient’s own body poses fewer risks of infection or rejection.

Rhinoplasty to correct nasal obstruction following injudicious cosmetic surgery is common. After a normal period of wait from 6 to 9 months, the patient notices that the airflow still is difficult in one or both sides. Reconstructive rhinoplasty after aggressive cosmetic surgery allows the restoration of normal breathing. When nasal cartilages are over-aggressively trimmed during rhinoplasty, the nose can appear pinched and nasal patency compromised. Patients complain of nasal blockage that is worsened by attempts at deep inspiration. Internal cartilage grafts to support the nasal tip (batton grafts) or widen the middle vault of the nose (spreader grafts) can be quite effective in restoring normal breathing. These grafting techniques will increase the size of the nasal tip and widen the dorsum.


Patients of African descent commonly seek narrowing of wide nostrils in a procedure known as alar base reduction. This procedure may include removing sections of the base of the nostrils or sections of the nose where it meets the face. Risk of keloid scar formation is very low if the patient has not had keloids in the past. The tip of the nose can be restructured by removing tiny sections of cartilage to give the nose more definition, or adding cartilage grafts to provide additional structure to the nasal tip.


Patients considering a procedure of rhinoplasty and/or septoplasty can be evaluated in Poliklinika Arcadia or in the consultation offices. In this moment, with the careful esthetic, anatomic and functional evaluation, the aims of the surgery are thoroughly discussed the patient’s desires, goals and expectations in mind. Not all expectations can be accomplished with surgery and it is important that these issues be carefully discussed before surgery.
The surgical plan then emerges from:

  1. Your honest assessment of your desired aesthetic goals and motivations,
  2. Your anatomical and surgical constraints,
  3. Our honest assessment of ability to achieve these goals based on our extensive knowledge, surgical ability, and aesthetic appreciation for your unique features.

Photographs can be helpful in this regard to analyze all areas in question and facilitate to the patient the analysis and understanding of the procedure, as well as to compare the results after the surgery.   Computer animation is available to patients to see the expected results, though they must know that results can vary slightly from the pre operative animation.


According to the patient age and medical antecedents, different tests can be taken in our clinic such as hemogram (blood analysis), coagulation tests, metabolic and urine tests, electrocardiogram, and Internal medicine evaluation when needed. If you are a young patient without clinical history of diseases, only the basic tests are taken with minimal discomfort for you.
Medication such as aspirin and analgesics must be avoided 2 weeks prior the surgery and smoking suspended 3 weeks before, as both conditions can interfere with coagulation and oxygen delivery to the manipulated tissues. If you are taking any medication or you are allergic to any medication, material or food please notice it to the surgeon and staff people when arriving to our clinic.
The admittance to Arcadia Clinic for Plastic and Aesthetic Surgery should be arranged in advance by telephone or email. The patient can arrive early the same day or the previous day of the surgery. After accommodating in the room, vital signs, tests and medical history and examination is taken, as well as anatomic measurements to confirm the choice of breast implant, and record photographs are taken if not available from before.    Every patient of Poliklinika Arcadia must sign an Informed Consent Agreement before the surgery, which authorizes the surgeons and clinic’s staff to perform the discussed procedures and belongs to the usual requirements in any hospital and clinic around the world.


A rhinoplasty can be performed under local or general anesthesia and this depends on the comfort of the patient and the extension of the surgery, which is discussed together with the anesthesiologist and the best option for the patient taken.  In both cases a mild sedative is given before the surgery so you will avoid any anxiety in the previous moment.


Patients can mobilize very fast after the cosmetic and reconstructive procedure on the nose, in general few hours after the surgery. The most unpleasant sensation after the cosmetic surgery on the nose includes dry mouth because the patients have tampons in the nose and breathe through the mouth. After the cosmetic correction of the nose the tampons are taken out after 24-72 hours depending on the technique used. The splint remains on the nose from 5 to 14 days, though patients to go back to their normal life using it. Some subtle swelling of the nose may be present for up to 3 months after surgery.
In case of reducing the width of the nose through lateral osteotomies we advice patients not to carry glasses over the nose in the next 3-4 weeks, you can fix them with a small tape to the forehead to avoid compression over the bones that are healing.
Antibiotics and analgesics are prescribed for few days to avoid any risk of infection and minimize local swelling.
Controls are programmed 3 days after the surgery to remove the tampons, a week after to check for early postoperative evolution and 3-6 months after the surgery to check later postoperative evolution. Additional controls can be programmed as needed.


Preoperative imagePostoperative control

 

 

 

 

 

Preoperative imagePostoperative control

 

 

 

 

 

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Pre-op picture14 days post-op control

 

 

 

 

 

 


The final shape of the nose may become apparent 3 months after the procedure. As soon as the splint is removed changes on the nose can be observed. You might experience some unexpected reactions from family and friends, particularly if you have changed something they consider a family or ethnic trait, but most of patients rapidly get used to their new look and feel comfortable with themselves.


Early complications

  1. Bleeding after the tampons are removed: This is the most common complication observed, usually the bleeding is mild and stops in few minutes. In some cases a new tampon is placed again until the next day.
  2. Infection: This is uncommon, the nose has a very good blood supply that provides a strong immune defense against pathogens and also strict measures of sterilization and instrument handling are used in our clinic.


Late complications

  1. Unsatisfactory esthetic effect: Sometimes the result of the surgery is different from what the patient expected, and this usually happens when the new image does not fit the result obtained. To prevent this we discuss before the procedure the real results expected and also after the surgery we compare the changes before and after the surgery, so the patients can see the improvement of their appearance, leaving most of patients satisfied.
  2. Additional touch-up surgery
  3. Communication between the nostrils: This is a rare complication of surgery involving the perforation of the septum of the nose, inside it, requiring a corrective surgery to cover the small defect.

 


The best candidates are those looking for improvement, not perfection, in the way they look. Rhinoplasty can enhance your appearance and self-image, but it will not make you look like a movie star. Those that are physically healthy, psychologically stable, and have realistic expectations make the best candidates. Age can also be a consideration. Most doctors prefer not to operate on teenagers until after they have completed their growth spurt. It is also important to consider the teen's emotional state and if surgery is what they, and not their parents, truly want.

Clinic:  Strma Ulica 16, HR - 43500 Daruvar, Hrvatska
Tel: 043 675 200     Fax: 043 675 214
Skype: poliklinika.arcadia
E-mail: poliklinika@poliklinika-arcadia.hr
Offices: Daruvar - Zagreb - Varaždin
  

 

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