Rhinoplasty


Rhinoplasty is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.
In closed rhinoplasty and open rhinoplasty surgeries – a plastic surgeon, an otolaryngologist, or an oral and maxillofacial surgeon, creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the soft tissues from the nasal framework, altering them as required for form and function, suturing the incisions, using tissue glue and applying either a package or a stent, or both, to immobilize the altered nose to ensure the proper healing of the surgical incision.

History

Treatments for the plastic repair of a broken nose are first mentioned in the Edwin Smith Papyrus, a transcription of text dated to the Old Kingdom from 3000 to 2500 BCE.
The Ebers Papyrus, an Ancient Egyptian medical papyrus, describes rhinoplasty as the plastic surgical operation for reconstructing a nose destroyed by rhinectomy. Such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time and culture.
Rhinoplasty techniques are described in the ancient Indian text Sushruta samhita by Sushruta, where a nose is reconstructed by using a flap of skin from the cheek.
During the Roman Empire the encyclopaedist Aulus Cornelius Celsus published the 8-tome De Medicina, which described plastic surgery techniques and procedures for the correction and the reconstruction of the nose and other body parts.
At the Byzantine Roman court of the Emperor Julian the Apostate, the royal physician Oribasius published the 70-volume Synagogue Medicae, which described facial-defect reconstructions that featured loose sutures that permitted a surgical wound to heal without distorting the facial flesh; how to clean the bone exposed in a wound; debridement, how to remove damaged tissue to forestall infection and so accelerate healing of the wound; and how to use autologous skin flaps to repair damaged cheeks, eyebrows, lips, and nose, to restore the patient's normal visage.
In Italy, Gasparo Tagliacozzi, professor of surgery and anatomy at the University of Bologna, published Curtorum Chirurgia Per Insitionem, a technico–procedural manual for the surgical repair and reconstruction of facial wounds in soldiers. The illustrations featured a re-attachment rhinoplasty using a biceps muscle pedicle flap; the graft attached at 3-weeks post-procedure; which, at 2-weeks post-attachment, the surgeon then shaped into a nose.
In Great Britain, Joseph Constantine Carpue published the descriptions of two rhinoplasties: the reconstruction of a battle-wounded nose, and the repair of an arsenic-damaged nose..
In Germany, rhinoplastic technique was refined by surgeons such as the Berlin University professor of surgery Karl Ferdinand von Gräfe, who published Rhinoplastik wherein he described 55 historical plastic surgery procedures, and his technically innovative free-graft nasal reconstruction, and surgical approaches to eyelid, cleft lip, and cleft palate corrections. Dr. von Gräfe's protégé, the medical and surgical polymath Johann Friedrich Dieffenbach, who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published Die Operative Chirurgie, which became a foundational medical and plastic surgical text. Moreover, the Prussian Jacques Joseph published Nasenplastik und sonstige Gesichtsplastik, which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions.
In the United States, in 1887, the otolaryngologist John Orlando Roe performed the first modern endonasal rhinoplasty in order to treat saddle nose deformities.
In the early 20th century, Freer, in 1902, and Killian, in 1904, pioneered the submucous resection septoplasty procedure for correcting a deviated septum; they raised mucoperichondrial tissue flaps, and resected the cartilaginous and bony septum, maintaining septal support with a 1.0-cm margin at the dorsum and a 1.0-cm margin at the caudad, for which innovations the technique became the foundational, standard septoplastic procedure. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1934, Aurel Rethi introduced the open rhinoplasty approach featuring an incision to the nasal septum to facilitate modifying the tip of the nose. In 1947, Maurice H. Cottle endonasally resolved a septal deviation with a minimalist hemitransfixion incision, which conserved the septum; thus, he advocated for the practical primacy of the closed rhinoplasty approach. In 1957, A. Sercer advocated the "decortication of the nose" technique which featured a columellar-incision open rhinoplasty that allowed greater access to the nasal cavity and to the nasal septum.
The endonasal rhinoplasty was the usual approach to nose surgery until the 1970s, when Padovan presented his technical refinements, advocating the open rhinoplasty approach; he was seconded by Wilfred S. Goodman in the later 1970s, and by Jack P. Gunter in the 1990s. Goodman impelled technical and procedural progress and popularized the open rhinoplasty approach. In 1987, Gunter reported the technical effectiveness of the open rhinoplasty approach for performing a secondary rhinoplasty; his improved techniques advanced the management of a failed nose surgery.
In early 2021, it was reported that a trend that involved getting a rhinoplasty had emerged on the social media platform TikTok. The trend became known as the #NoseJobCheck trend and involved users of the platform posting videos that showed how their noses looked before and after their rhinoplasty surgeries, with a specific audio soundtracking the video. From October 2020 to January 2021, the #NoseJobCheck audio had been used in over 120,000 videos and videos with the #NoseJobCheck hashtag had accumulated over one billion views.

Anatomy of the human nose

The structures of the nose

For plastic surgical correction, the structural anatomy of the nose comprises: A. the nasal soft tissues; B. the aesthetic subunits and segments; C. the blood supply arteries and veins; D. the nasal lymphatic system; E. the facial and nasal nerves; F. the nasal bone; and G. the nasal cartilages.

A. The nasal soft tissues

  • Nasal skin – Like the underlying bone-and-cartilage support framework of the nose, the external skin is divided into vertical thirds ; from the glabella, to the bridge, to the tip, for corrective plastic surgery, the nasal skin is anatomically considered, as the:
  1. Upper third section – the skin of the upper nose is thin, subcutaneous fat layer is thicker and relatively distensible, but then tapers, adhering tightly to the osseo-cartilaginous framework, and becomes the thinner skin of the dorsal section, the bridge of the nose.
  2. Middle third section – the skin overlying the bridge of the nose is the thinnest, least distensible, nasal skin, because it most adheres to the support framework.
  3. Lower third section – the skin of the lower nose is as thicker and less mobile, because it has more sebaceous glands, especially at the nasal tip. Subcutaneous fat layer is very thin.
  • Nasal lining – At the vestibule, the human nose is lined with a mucous membrane of squamous epithelium, which tissue then transitions to become columnar respiratory epithelium, a pseudo-stratified, ciliated tissue with abundant seromucous glands, which maintains the nasal moisture and protects the respiratory tract from bacteriologic infection and foreign objects.
  • Nasal muscles – The movements of the human nose are controlled by groups of facial and neck muscles that are set deep to the skin; they are in four functional groups that are interconnected by the nasal superficial aponeurosis—the superficial musculoaponeurotic system —which is a sheet of dense, fibrous, collagenous connective tissue that covers, invests, and forms the terminations of the muscles.
    The movements of the nose are affected by
  1. the elevator muscle group – which includes the procerus muscle and the levator labii superioris alaeque nasi muscle.
  2. the depressor muscle group – which includes the alar nasalis muscle and the depressor septi nasi muscle.
  3. the compressor muscle group – which includes the transverse nasalis muscle.
  4. the dilator muscle group – which includes the dilator naris muscle that expands the nostrils; it is in two parts: the dilator nasi anterior muscle, and the dilator nasi posterior muscle.

    B. Aesthetics of the nose – nasal subunits and nasal segments

To plan, map, and execute the surgical correction of a nasal defect or deformity, the structure of the external nose is divided into nine aesthetic nasal subunits, and six aesthetic nasal segments, which provide the plastic surgeon with the measures for determining the size, extent, and topographic locale of the nasal defect or deformity.
The surgical nose as nine ''aesthetic nasal subunits''
  1. tip subunit
  2. columellar subunit
  3. right alar base subunit
  4. right alar wall subunit
  5. left alar wall subunit
  6. left alar base subunit
  7. dorsal subunit
  8. right dorsal wall subunit
  9. left dorsal wall subunit
In turn, the nine aesthetic nasal subunits are configured as six aesthetic nasal segments; each segment comprehends a nasal area greater than that comprehended by a nasal subunit.