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A special report for physicians
regarding nasal reconstruction
Case #1
A minister in his early 40s, Mr. M.P. injured his nose in a sporting
accident in 1970s. He had undergone reconstructive surgery that left him
with severe nasal valve collapse. His disfigurement was significant but
was not the primary concern; he could not breathe through his nose and
could not use the C-PAP system prescribed for his sleep apnea (see photo
A1).
On examination of the patient, we found that the probable cause of the
collapse was that too much cartilage had been removed, leaving very
little support; in fact, his septum would have to be completely rebuilt.
Even Breathe-Right nasal strips would not open the valves enough to allow
influx of air.
We performed a nasal reconstruction and septoplasty to replace some of
the cartilage and to straighten the patient’s nose in 1997. We made three
small incisions-one below the columella and one on each side of the nose,
behind the alar rim. We then dissected the skin of the nose up toward the
forehead, to provide a clear view of the skeleton, cartilage and nasal
cavity, as well as easy access for placing and suturing grafts.
We elected to use cadaveric cartilage to provide support for the
patient’s nose. The dorsum, septum and tip were completely rebuilt, and
the cartilage was carefully sculpted to provide the aesthetic and
functional results the patient needed and desired. The four-hour
operation was a success (see photo A2) and was fully covered by
insurance.
Two years later, the patient called in a state of alarm saying he had
injured his nose in a fall and feared that he would need additional
surgery. Though his nose had taken the brunt of the impact, there was no
damage to the skeleton or cartilage. We treated his external abrasions
with antibiotic ointment; no further treatment was necessary. The patient
is doing well and is still able to use his CPAP.
Case #2
Mr. CV was distraught when he sought my help. A previous rhinoplasty,
performed for both functional and cosmetic reasons, had failed to correct
his breathing problems. The patient was even more disturbed by the
cosmetic and functional results (see photo B1).
We photographed his nose from all angles and manipulated the digital
images to show the patient what we would try to achieve, as is our
standard procedure in rhinoplasties, to prevent unrealistic expectations.
Once we determined that the patient would be satisfied with the probable
outcome of the operation, we scheduled surgery.
We made a small incision at the base of the columella and one on each
side of the nose behind the alar rim. The skin of the nose was then
dissected exposing the skeleton and cartilage. The cartilage was trimmed
and reshaped in proportion to his face, and full function was restored
(see photo set B2). The patient was very satisfied with the result and is
doing well. The reconstruction was completely covered by insurance.
While septorhinoplasty is often performed for cosmetic reasons, in
many cases it is medically necessary to restore proper breathing. Nasal
trauma can block the airway-as can an improperly performed operation.
Preserving or restoring proper function is a top priority in any nasal
surgery. It is also important that the patient have realistic
expectations regarding any cosmetic improvements. In today’s cosmetic
surgery center, computer imaging can help a patient see the possibilities
and adjust their expectations accordingly. Generally, the more
natural-looking the results, the better for the patient’s long-term
satisfaction.
When a patient has suffered serious nasal trauma, it is important that
they see a facial plastic surgeon or otolaryngologist with extensive
nasal reconstructive training within the right time frame. This is
especially important if the case is a revision case. The day after the
incident may be too soon, as the nose may still be too swollen for
effective examination. However, within five days following nasal trauma,
the swelling typically decreases and the nose is still mobile enough to
attempt a closed reduction. A small percentage of patients will need no
further repair.
If open surgery is required, precision is critical. The surgeon can
work under actual visualization by making three small incisions and peel
the skin of the nose up toward the forehead, as in the two cases
described.
Several options are available if additional cartilage is needed. In
some cases, the patient’s own cartilage from the septum or ear may be
used. Cadavaric cartilage is another safe source. Many synthetic products
such as Medpor or Gortex are available, and rejection of such materials
is rare.
A conservative approach to nasal repair is usually preferable; for
instance, the “sinuses” are often blamed for breathing difficulties when
the problem is actually the structure of the nose itself. If taken in
stages, surgical repair may not need to be extensive. If the patient does
well after reconstruction of the nose itself, usually patients will find
most “sinus” problems resolved.
Suzanne Yee, M.D., FACS is director of the UAMS Laser and Cosmetic
Surgery Center and assistant professor in the Department of
Otolaryngology-Head and Neck Surgery for the University of Arkansas for
Medical Sciences.
DEGREE:
University of Arkansas for Medical Sciences, Little Rock
INTERNSHIP:
University of Arkansas for Medical Sciences, Little Rock
RESIDENCY:
Otolaryngology-Head and Neck Surgery, University of Arkansas for
Medical Sciences, Little Rock
FELLOWSHIP:
American Academy of Facial Plastics & Reconstructive Surgery under Dr.
Russell Kridel - University of Texas Health Science Center, Houston,
Texas
BOARD CERTIFICATION:
Facial Plastic and Reconstructive Surgery, Otolaryngology
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