Rhinoplasty (Cosmetic Nose Surgery) and related Cosmetic Surgery Topics

Newer is Better When it Comes to Cosmetic Surgery??

Certain new techniques have come into plastic surgery and cosmetic surgery over the years.  Many of them have proved to be unsuccessful and not worthy of further study.  Many lasers have come and gone, many new techniques for liposuction have come and gone, and yet the newer machines and the more expensive machines keep coming and coming and coming.  Occasionally, there is a new laser technique or machine that will work, such as laser hair removals and certain types of new lasers that can help rejuvenate the skin; however, we must not forget there are many much simpler methods to help rejuvenate the skin and give a better texture to the skin that avoid expensive lasers.  Simple things like trichloroacetic acid peels, or TCA peels, at a fraction of the cost of lasers can get a fine result for increasing texture on the facial skin and ridding it of very fine lines.  When it comes to certain types of surgical procedures, such as cosmetic nose surgery (Rhinoplasty), cosmetic eyelid surgery (blepharoplasty), and even face lift surgery, some of the newer techniques are worse rather than better.  The open nasal revisional surgery which has come to vogue and is extremely popular, in my opinion, is going backwards.  It is opening up the nose and causing tremendous trauma when all you have to do is make small incisions inside the nose, and you can get excellent results as long as you have a well-trained surgeon who is very familiar with this type of closed rhinoplasty/nose technique.  The same is true of face lifts.  Newer techniques for face lifts have been developed that, in my opinion, distort the face and cause a cat eye appearance, high cheek bones, pulled looks, and looks artificial.  The same for eyebrow lifts.  The same for certain types of blepharoplasty procedures.  The true art of plastic surgery is for one to look natural without pulled or artificial looks.  Some of the newer techniques, in fact, give artificial, pulled looks, which are far from improved.  Some of the older, more restrained techniques that are more conservative yet get great results are better than some of the newer techniques.  Reason -- they give more natural-appearing faces and looks without the pulled earlobe, retracted corners of the eye, or a variety of looks that look typically operated on.

Anesthesia Fear - Reason to Avoid Cosmetic Surgery?

One of the biggest fears that patients have to undergo any elective surgery, and particularly cosmetic surgery, is the fear of anesthesia and “going under.”  This fear, in modern day anesthesia, should be completely eliminated from the patient’s mindset.  The patient should be more concerned with the surgeon he or she goes to and the cleanliness of the facility and the surgicenter or hospital he or she actually attends rather than the anesthesia.  In competent hands, anesthesia is exceptionally safe.  It is a rare event when you hear about an anesthetic death following any type of surgery.  When this occurs, the vast majority of the time it is actually due to negligence and has nothing to do with some unusual drug reaction or something that just happens because of an unusual type of allergic reaction to a drug or a patient’s heart not working during the anesthesia.

New drugs and new ways of administering anesthesia are exceptionally safe.  I commonly tell patients that the risk of them driving to the office for a consultation is about 100 times or 10,000 times higher risk factor-wise than having anesthesia in a controlled environment.  Also, the new drugs and medication allow a patient to go under appropriate sedation so they are comfortable yet breathing on their own and in total control of all of their respiratory functions and yet have no pain or discomfort because of the use of local and regional anesthesia in conjunction with a qualified anesthesiologist and a qualified plastic surgeon, who work together as a team.  In fact, there are ways of doing anesthesia without the patient even requiring intubation, that is, tubes put down the patient’s throat to allow for proper airway.  Some procedures can quite safely be done without using intubation, or tubes down the throat, combined with a very qualified anesthesiologist, qualified plastic surgeon, and the proper use of certain medication.  Nausea postoperatively is a rare event and, in today’s modern anesthesia world, nausea postoperatively is exceptionally rare and, when it occurs, is usually avoidable had the anesthesiologist used a different drug or different medication.

Therefore, in summary, to avoid cosmetic surgery or any elective surgery for that matter because of the fear of anesthesia is a misguided thought.  There are a lot of reasons to avoid surgery, but certainly the risk of anesthesia is not one of them.

Revision Nose Surgery Using the Closed Technique - Can It Be Done?

Yes, in the general plastic surgical arena, many patients are told that revision surgery on the nose can only be done using an open technique in order to get ideal results. This is not true because in the hands of very fine surgeons that have used the closed technique for many years, they often have and can get very successful results using the closed rhinoplasty technique.

What are the advantages of closed versus open technique? The advantages are that the patient goes through much less trauma, much less scar tissue formation, no external scars, and a much faster recovery. It also allows for  further possible revision surgeries without the surgeon having to work through extensive scar tissue, which is produced by open techniques. In fact, many doctors who do open technique only cause tremendous trauma to the nose, which decreases the circulation and, in fact, makes revision nose  surgeries sometimes impossible. A closed technique is a harder technique to learn and, therefore, it is not as widely used because of the extensive learning curve required by the surgeon; however, after having performed hundreds of closed rhinoplasties, a competent surgeon can easily do revision surgeries closed, limiting the downtime, discomfort, and chronic edema and swelling that lasts for months following all open procedures. In addition, a major advantage is avoiding external scars. It is a fact that most plastic surgeons will mention to a patient that an open rhinoplasty technique is the only way to get a good result in a difficult nose. When the plastic surgeon has had extensive experience doing closed rhinoplasty, the end result can be exceptionally pleasing to the patient resulting in little discomfort and a faster recovery period. Testimonials to this fact abound on the Internet when patients realize the extreme benefits to closed procedures versus open rhinoplasty.

Open Versus Closed Rhinoplasty Technique

Rhinoplasty, or cosmetic nose surgery is well known to be the most difficult cosmetic surgery performed by plastic surgeons. In order for the physician to perform rhinoplasty, or cosmetic nose surgery, a high degree of skill is required along with judgment and artistic ability. Young plastic surgeons finishing their training usually have difficulty in getting enough experience to perform cosmetic nose surgery in their training, and this is one of the main reasons that the open rhinoplasty technique have become popular. The open rhinoplasty technique, which involves making an incision along the base of the nose and lifting the skin off the bony and cartilaginous structures of the nose, allow better visualization of the structures of the nose and allow for better teaching of young residents in training to perform cosmetic nose surgery. There are drawbacks to the open rhinoplasty procedure, in that it does produce more scarring and requires extra cartilage support in order to reverse some of the disruption of the normal delicate attachments of the skin to the subcutaneous structures of the nose.

Plastic surgeons who ultimately become familiar and comfortable with doing closed rhinoplasty, that being making small incisions in the nose and performing reshaping of the nose through these small incisions, have found this to be a much more desirable procedure. The patients heal much faster, there is significantly less swelling, and the end result can often be more predictable. In order to do rhinoplasty surgery, which, as mentioned above, is already a difficult and a very skillful procedure; it takes years and years of experience and training. When performed properly, rhinoplasty can be very fulfilling and can help change a person’s life by reshaping an undesirable nose that often takes away from certain beautiful facial features that many people have, such as their eyes or lips. Cosmetic nose surgery, when performed properly and with the proper aesthetic balance and natural appearance, can very much enhance a person’s total facial aesthetics.

In Summary, closed rhinoplasty procedures are desirable, in that faster healing with less disruption of the delicate nasal structures occurs. Open rhinoplasty can be performed by many plastic surgeons with success but do cause more inherent trauma to the nose. Open rhinoplasty operations are able to be learned more readily by young plastic surgeons and, therefore, that procedure has increased in popularity. The closed rhinoplasty technique are often a much better choice, especially for people having their noses done cosmetically for the first time; however, it is difficult to find a skilled plastic surgeon with enough experience to perform this procedure adequately.

Using Facial Fillers on Revision Nose Surgery

With the recent advent of a variety of fillers for the face, including Restylane, Juvederm, and fat transfer, defects found in revision noses can be easily corrected without any surgical intervention whatsoever. Sometimes the injectables, or fillers, are used during revision rhinoplasty procedures. Other times, fillers for the face, are used by themselves to correct deformities either temporarily or   permanently and can lead to a very natural-looking nose without any surgical intervention. Such facial fillers used about the nose should only be done by an established rhinoplasty surgeon who performs an extensive number of revision rhinoplasties. A normal physician who injects fillers throughout the face would not have the skill required in order to exactly correct nasal deformities that are often seen following one, two, or three previous nasal surgeries.

Patients whom are not good surgical candidates for a variety of reasons, many of them having had five or six surgical operations can achieve an excellent result using Restylane or Juvederm. These patients, often walk out of the office with a normal or close to normal-looking nose that can last up to six months before repeat fillers are required. One can also substitute fat grafting into the nose, which may require one to three sessions or more, and this can lead ultimately to a permanent improvement and, therefore, no further fillers are necessary. Fat transfer can be highly successful, but two to three sittings or more are necessary in order to get the final result, and then no more fillers are required.

Fillers for the face, including Restylane, Juvederm, and fat, into nasal deformities or revision nose deformities are highly successful in qualified surgeons’ hands and should be considered by all patients who are not surgical candidates or who wish to have their nasal deformity corrected without surgical intervention.

Anesthesia For Rhinoplasty - Cosmetic Nose Surgery

Rhinoplasty can be done without intubation. The surgeon and the Anesthesiologist work as a team to provide the best possible patient experience.

Anesthesia for Rhinoplasty is a combination of intravenous propofol given by the Anesthesiologist together with local anesthesia injected in and around the nose by the surgeon. The intravenous use of propofol for anesthesia is sometimes called total intravenous anesthesia or TIVA.

Propofol is a gentle, safe, non-opiate medication with rapid smooth action, and quick offset. It is exceedingly unlikely to cause any allergic reaction, and does not cause nausea. In the proper hands, it is easily controlled, and can be used for mild sedation to general anesthesia. It can be used for very short operations, lasting a few minutes, to long procedures lasting many hours.

For cosmetic nose surgery without intubation, the patient is fully monitored for respiratory, heart and cognitive function. The TIVA with propofol is continuously adjusted with the aid of a computerized pump. Initially, enough medication is given to eliminate the discomfort of the local anesthesia injections. The local anesthetic also includes a vasooconstrictor,epinephrine, to eliminate bleeding during the operation. The local anesthetic used is long acting, and the pain relief lasts long after the rhinoplasty is completed. As soon as the nose is numb, the propofol dose is decreased to the minimum required to keep the patient asleep. Since the nose is completely numb, the dose of propofol is usually quite small at this point. The patient continues to breathe naturally, remaining asleep and unaware until the end of the Rhinoplasty procedure. Patients wake up shortly after the TIVA is stopped, and are fully alert, ready to eat drink and ambulate minutes after nose surgery is done. A combination of oral and intravenous anti-inflammatory medications are given before, during and after surgery resulting in minimal swelling and pain after surgery.

General anesthesia with intubation typically involves the use of propofol together with paralyzing drugs and inhaled anesthetic gases. A tube is placed through the mouth into the windpipe. In medical terms, this is called oral endotracheal intubation. The patient depends on the anesthesiologist to help with breathing using a manual and/or powered ventilator for most if not all of the duration of the surgery. Since the patient doesn't move (paralyzing medications are used), the nose does not have to be as thoroughly numbed as in the TIVA technique. There is more likely to be bleeding, and gauze packing is frequently used in the nose and throat. When blood is swallowed patients are also more likely to wake up nauseated. Before patients wake up, they are often given medications to reverse the paralyzing drugs. These medications and intravenous opioid narcotics, and inhaled gases and contribute to a significant incidence of post operative nausea and vomiting. Even in experienced and gentle hands, many patients complain of sore throat, and less frequently, hoarseness and vocal irritation.

TIVA and local anesthesia for rhinoplasty require the Anesthesiologist and the surgeon to work together as a team. The Anesthesiologist needs to monitor the patient closely, both visually and electronically. The surgeon needs to thoroughly and carefully numb the nose with the appropriate propofol dose adjusted constantly by the Anesthesiologist. Once the nose is completely numbed, a few minutes are required for the anesthetic and vasoconstrictor (epinephrine) effect to fully work. At this point the rhinoplasty can proceed with total sedation and minimal medication until the surgery is completed.

The Art of Revision Rhinoplasty using the Closed Technique

The art of revision rhinoplasty has been revised over 35 years of performing this type of surgery using the closed technique.  The open technique limited the surgeon in many aspects of revision surgery.  The open technique does not allow certain degrees of finesse in placing cartilage grafts in exacting locations in order to correct deformities that are found in revisional rhinoplasties.  In my experience, using small incisions and taking cartilage from the septum or the ear, you can accurately place small millimeter-type grafts into various locations throughout the tip, the dorsum, and sides of the nose and spare the patient extensive surgical intervention, which is the case when open technique is used.  The open technique distorts the normal anatomical attachments of the skin to the nasal bones and nasal cartilages, further complicating the surgeon’s ability to perform a natural revision rhinoplasty.

            After harvesting cartilage from the nasal septum or the ear, and occasionally the rib, small incisions are made inside the nose in order to accomplish the reconstructive aspects of this rhinoplasty procedure. Anesthetic used is local in the nose plus intravenous sedation.  Intubation and deep general anesthesia is avoided and, therefore, much less nose bleeding is encountered during the procedure, allowing for even further improvement in technique because of the limited amount of blood loss.  The small cartilage grafts are placed where the surgeon marks the external aspect of the nose with ink in order to allow for exacting placement of the reconstructive cartilage grafts.  The patient is seen in the treatment room preoperatively and in the upright position.  The surgeon has direct communication with the patient prior to surgery, and exact locations for cartilage grafts are discussed and agreed upon by both the patient and the surgeon.  Once the various ink marks are made on the external part of the nose, the patient is then taken to the operating room and given intravenous sedation, avoiding all narcotics and anesthesia gases, which help very significantly in reducing postoperative nausea.  There is very little discomfort to the patient postoperatively, since packing is never used, and nausea after surgery is a rare event.  Discomfort and pain are absolutely minimal because the open technique has been avoided, which prevents unnecessary incisions and unnecessary dissection throughout the nose area.  The exact appearance of the nose is noted right after surgery, and minimal swelling takes place postoperatively.  This avoids the long two to three-month delay in seeing the final result when the open technique is used.

            In conclusion, excellent results are obtained with minimal patient discomfort and quick recovery using the above-described technique.