Rhinoplasty. Plastic surgery of the columella of the nose, nostrils, tip, open and closed. Nose plastic surgery (rhinoplasty) Columella pain

Rhinoplasty is by far the most popular plastic surgery, despite the complexity of its implementation. Correction of the shape and size of the nose (rhinoplasty) requires an integrated approach to improve the proportions of the face and the function of nasal breathing.

Who needs rhinoplasty?
As a rule, the main indication for the correction of the shape of the nose is the desire of the patient. However, there are absolute indications for nose plastic surgery, namely congenital (cleft lip, cleft palate) and acquired deformities and defects (as a result of injuries and accidents).

Before deciding on rhinoplasty, you should carefully consider, since the operation is quite complicated and has a lot of contraindications. These include diabetes mellitus, mental illness of any form, bronchial asthma, allergies to medicines, diseases of internal organs, blood clotting disorders, and cancer.

The most suitable age period for rhinoplasty is between 18 and 40 years of age. Surgeons can perform rhinoplasty on patients up to the age of eighteen, but in this case, the patient must be physically fully formed so that the operation does not provoke any major changes. After 40 years, it is undesirable to do nose plastic surgery, because at this age metabolic processes are often disturbed, the skin withers and loses its elasticity. The operation will contribute to the appearance of new wrinkles. In addition, the skin after rhinoplasty will look unnatural, and the rehabilitation period will be much more difficult. In addition, a highly qualified surgeon, a master of his craft, will never agree to perform nose plastic surgery on a patient over 40 years old.

Preparation for the operation.
Any plastic surgery is preceded by a consultation at which the patient is informed about the features of the operation and the postoperative period. The surgeon examines the respiratory function of the nose and its internal structures, reveals the level of health of the patient, the presence of allergies, a tendency to keloid scars. Computed tomography or X-ray examination helps to study in more detail the anatomical structure and functional features. Based on the results of the analyzes, the presence of possible risks associated with rhinoplasty is revealed, and the necessary procedures after the plastic surgery are discussed.

A week before the upcoming plastic surgery, the patient should stop drinking alcohol, smoking, taking anticoagulants (for example, aspirin). Rhinoplasty is not performed during exacerbation of chronic diseases, during menstruation in women, in the presence of acute respiratory infections, as well as inflammatory processes at the site of the operation.

As a rule, before the operation, patients should wash their hair, since it is desirable not to wet the postoperative bandage. On the day of the operation, the patient should not eat or drink anything. After filling in the necessary documents, the patient is taken to the ward and prepared for the operation, taking pictures of the nose.

Columella plastic.
The columella is a septum of skin between the nostrils. It is its size and position that affect the shape of the nose. The view when the columella is located below the wings of the nose is considered beautiful. A columella plasty is aimed at correcting a curvature that is too small or too large. The increase in columella is carried out by transplantation, and its reduction - through partial excision of the tissues that make up its structure. As a rule, these are the inner legs of the large cartilages of the wings of the nose. Correction of the shape of the columella is carried out using various methods, the most common of which is to change the entire shape of the tip of the nose.

Columella plasty lasts for 30-40 minutes and is performed under general anesthesia.

Nostril plastic.
Today, an anomaly of the wings of the human nostrils is not uncommon. Long wings of the nose or too wide nostrils require surgical intervention. Surgery to reduce the nostril alae aims to remove part of the wing on the outside when the wing is too long, and at the level of the nostril passage when that passage is too wide. Often a combination of the two is needed. When the wings of the nose are retracted, after an injury or excessive removal of the alar cartilages, it is necessary to restore the support of the wings of the nose, which is carried out by cartilage transplantation from the nasal septum or from the auricle of the patient. Correction of the wings of the nose is also possible during the main operation.

Open rhinoplasty.
Open rhinoplasty is performed using incisions along the skin bridge between the nostrils from the outside. This method of plastic surgery is used for very complex deformities of the nose, allows the surgeon to see the ongoing changes during the operation, provides better access. All manipulations in open rhinoplasty are carried out directly on the bone and cartilage section of the nose. The scar after this method of rhinoplasty is in the form of a small thin line, which will disappear over time.

Closed rhinoplasty.
This method of plastic surgery is the most aesthetic and often used than the open one, it does not leave scars on the columella at all. The operation is performed by incision in the nasal cavity, while all manipulations are done by touch, blindly. Closed rhinoplasty is considered less traumatic for the tissues, in addition, they heal faster than with open rhinoplasty.

Rhinoplasty with fillers.
If the patient needs to correct minor flaws, for example, correct the tip of the nose, correct symmetry, smooth out sharp corners, while there is no need to change the shape of the nose, rhinoplasty with fillers will help. The recovery period after this method of rhinoplasty is easier and much faster, moreover, the cost of the operation is lower.

A commonly used filler is hyaluronic acid, which is injected intradermally after applying an anesthetic cream. Another substance used is the patient's own fat, which is taken from the abdomen, inner thighs or knees under general anesthesia. Fat must be cleaned and centrifuged, and only after that an injection is made. Since fat is absorbed quickly enough, every second procedure requires repetition.

Secondary rhinoplasty.
Secondary rhinoplasty is necessary when the result of the first rhinoplasty did not give the expected result. The duration of the operation is about two hours. It is most often performed under general anesthesia. You should know that between rhinoplasty operations, at least six months, and preferably a year, should pass. Predicting the healing process after rhinoplasty is very difficult, no one will immediately tell you whether another operation is required or one is enough. If the first rhinoplasty was performed by an inexperienced or incompetent surgeon and performed poorly, then the second rhinoplasty can be much more difficult, so this issue should be approached more seriously, as well as the choice of a surgeon. In case of poor-quality first rhinoplasty, its reconstruction is often required, and, consequently, tissue transplantation. Most often, this tissue is taken from the inside of the nasal septum or cartilage from the ear, and for reconstruction of the bridge of the nose, the tissue is taken from the scalp, and the cartilage from the rib.

The doctor decides on the method of performing the operation, taking into account the needs and wishes of the patient. The cost of nose plastic surgery depends on the complexity, the degree of involvement of the cartilaginous and bone parts of the nose (for example, to remove the hump).

Recovery period.
After conducting a postoperative examination of the patient, the surgeon determines how long he will stay in the blade. The recovery period after rhinoplasty is accompanied by a lot of unpleasant sensations that are associated with inconveniences and limitations: sleeping only on the back, breathing through the mouth (since the nose is filled with tampons that maintain the shape and absorb postoperative secretions), do not smoke, do not wet the bandage, etc. .

After the operation to change the shape or size of the nose, the patient should be in absolute rest for two weeks. At this time, fever and weakness may appear, which, as a rule, disappear after 3-4 days. It is very important in the first week to limit yourself from any physical activity, try not to be nervous, which will avoid nosebleeds. If the plastic surgery is successful, you will feel great quickly enough, but bruises under the eyes, which occur by themselves and are a natural reaction of the body, will be present on the face for at least another two weeks. For the first ten days after rhinoplasty, it is recommended to sleep on a high pillow for faster elimination of edema.

It should be noted that after removing the nasal tampons, it will take some time to fully restore nasal breathing, since internal swelling often occurs after surgery, which can persist for several months. In addition, during the first week, the patient must wear a special butterfly cast on the nose, designed to protect against impact and secure the new shape. This plaster bandage is periodically removed to care for the skin of the nose. As a rule, after 7-10 days postoperative swelling subsides. After 5-14 days, the bandage is removed, and the rehabilitation period ends.

Edema of the soft tissues of the nose disappears in about two months after rhinoplasty, after the same time, the final result of the plastic surgery can be assessed. In rare cases, this period can be extended up to a year.

To speed up the healing process after rhinoplasty, special rehabilitation courses are recommended in every plastic surgery clinic. These activities include magnetic nuclear resonance, rubbing medicinal substances from the outside and from the inside. All this contributes to a faster removal of edema and fixing the shape of the nose.

Complications of plastic surgery of the nose.
Early complications after rhinoplasty can be:

• lacrimation;
• excessive swelling;
• bleeding;
• inflammation;
• hematoma;
• blockage of the sebaceous glands.

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General information

Kinds

All ways to correct the shape and size of the nose are divided into two types:

• open,
• Closed.

private method
In this method, tissues are cut inside the nasal cavity. Therefore, all manipulations are carried out by touch.

Both methods have the right to life and it is impossible to single out any of them as more effective or safer. But after closed operations, the tissues heal faster, their swelling is less.

The complexity of an operation of any kind is determined by which tissues are involved in the procedure: someone needs to change the shape of the back of the nose - this is work with bone, and someone just needs to change the shape of the tip or nostrils - this is work with cartilage tissue.
In any case, nose correction surgery is a rather complicated intervention.

Indications, contraindications and at what age is it better to do it?

Contraindications for rhinoplasty

• Inflammatory processes of the skin of the face and nose,
• Inflammatory diseases of the sinuses,
• Infections dangerous to other people ( hepatitis C, HIV),
• Severe liver disease
• Severe heart disease
• Mental disorders.

Examination before surgery

Preparing for the operation

Rhinoplasty of the nostrils

To reduce the volume or length of the wings of the nose, excess tissue is removed from the outside with a very long wing. If it is necessary to reduce the width of the wings, the tissue in the nasal passage area is removed. Sometimes the fabric is removed from both areas at once.
After removing excess tissue, the doctor tightens the wounds with a special suture material of increased fineness. The suture material is removed five days after the operation. But in order to completely pass the traces of the seams, you need at least 6 weeks. During this period, you should protect the body from stress, and the nose from ultraviolet radiation.

Sometimes it is necessary to add cartilage tissue to the wings of the nose. This happens after injury or unsuccessful plastic surgery. To do this, pieces of cartilage are taken from the patient's ears or nasal septum.

Alignment of the septum (septorhinoplasty)

• physiological,
• traumatic,
• Compensatory.

traumatic violation develops against the background of bruises and fractures. Even a newborn baby can have such a form of curvature obtained during childbirth. In the future, the development of the partition will go the wrong way.

compensatory a curvature of the septum develops if the shape of the turbinates is broken and in order for the nose to perform its function, the septum begins to bulge.
In some cases, the curvature interferes with normal breathing, and sometimes it does not interfere. It can be detected only when examining the patient with special devices.

Cases in which it is necessary to check the condition of the partition:

• Snoring in sleep
• Difficulty breathing through the nose
• Dryness of the nasal mucosa,
• allergic manifestations,
• Inflammatory processes of the paranasal sinuses in a chronic form,
• Obvious deformity of the nose.

Removal of the nasal mucosa (conchotomy)

• Violation of nasal breathing with hypertrophy of the nasal mucosa.

Removal of the nasal mucosa with a cutting nasal loop is a rather traumatic procedure, during which profuse bleeding is likely. In this regard, the patient recovers after it for quite a long time. It is mandatory to prescribe antibiotics to prevent infection of the wound surface. After the operation, adhesions and scars are often formed. Such a procedure today is done only by special prescription of a doctor.

Laser conchotomy - this procedure is humane in relation to the patient's body. Anesthesia is local. The patient does not need to stay in the hospital after it. Since there is no open wound surface after the laser procedure, the recovery of the mucosa is quite fast, and severe inflammation is also rare.

Electrocoagulation - This is an effect on the nasal mucosa with an electric current. This method is used in cases where hypertrophy of mucosal tissues is not strong. The course of the operation is similar to laser coagulation. The operation is performed under general anesthesia, but its duration is not great. Recovery takes place in a short time.

columella correction

Correction of the shape of the nose

Rhinoplasty

Non-surgical rhinoplasty

This is a very convenient method to correct some inaccuracies after surgery. But in some cases, after the operation, it is forbidden to use the injection method.

Non-surgical technology allows:

• Fill in the holes
• Slightly change the shape of the tip of the nose,
• Eliminate the hump on the bridge of the nose and smooth out sharp corners,
• Make the nose symmetrical.

• The duration of this procedure is not more than half an hour,
• No pain
• No bruising or swelling
• The result will be visible in 2-3 days.

• The effect lasts from 6 months to 3 years depending on the drug used,
• There is a possibility of "migration" of the gel. This happens if the procedure was performed by a not too professional doctor.

Injection rhinoplasty (using fillers)

As fillers use:

• temporary substances,
• intermediate substances.

The intermediate substances include the fat of the patient himself. It is taken from the knees, abdomen or thighs. The removal is carried out under general anesthesia. Before introducing fat into the nose, it is filtered and passed through a centrifuge. This procedure has disadvantages - since fat can be absorbed into the tissues, in five cases out of ten it is necessary to do repeated procedures.

Contour plastic

Laser rhinoplasty

The laser dissects tissue, seals blood vessels and eliminates pathogens. Under the influence of the laser, the recovery processes in the tissues are accelerated. With the help of a special laser device, you can correct the nasal septum.

There are techniques that make it possible to simultaneously eliminate aesthetic defects and improve the function of the nose.
The course of operations using a laser is usually the same as in classical surgery. The operation can also be closed or open. Incisions are usually made along the bridge of the nose and at the bottom of the nostrils.

Very often, during the operation, a laser is combined with a conventional surgical scalpel. Such interventions are most preferable, since not in all cases it is possible to do fine work with a laser that is subject to old proven methods. But, if the skin is dissected by a laser, it heals without scars and scars. The incision is very thin, the blood does not flow, and the cells are already ready for recovery.

Thus, laser technologies are successfully used in plastic surgery, including nose correction operations in combination with conventional surgical methods.

Reconstructive rhinoplasty

Often, during reconstructive operations, cartilage from the ribs, ears, or nasal septum is used to restore the framework. Tissue sections are removed from the patient's body, while tissue sampling does not harm the general condition and appearance.
Reconstructive surgery is necessary to restore normal appearance in case of cleft palate or lip. Sometimes a number of surgeries are needed.
Reconstructive surgeries are also performed after injuries that have led to damage to the bone or cartilage. In severe cases, patients who have completely lost their noses end up on the table of surgeons.

During operations, microsurgical technology is used, which makes it possible to give the patient's face a healthy look.
One of the most common nose deformities that a reconstructive surgeon has to deal with is the saddle or boxer nose. Both a severe bruise along the bridge of the nose and an infectious disease of the nasal cavity can lead to such a lesion. With this type of deformation, the cartilage that forms the septum can be completely destroyed, and the doctor completely restores the cartilaginous septum and the framework of the nose.

The duration of such an operation can be up to six hours. The patient receives general anesthesia. Outside, the skin is dissected only in the region of the columella, the remaining incisions are made inside the nasal cavity. Therefore, postoperative scars are almost invisible. The operation affects all types of nasal tissues: soft, bone and cartilage.
After the operation, to fix the new shape of the nose, tampons are inserted into the nostrils, which are kept for three to six days. The plaster bandage is removed after five to twelve days, depending on the complexity of the operation. But a day after the intervention, the patient is allowed to go home. And in a week he will come to remove the stitches.
Patients are not recommended to wear glasses for 8 weeks, and exercise for 2 weeks. After three weeks, the shape of the nose approaches the final version and further changes are visually almost invisible. However, the traces of the operation completely heal only after six to twelve months.

The patient should be observed by a doctor for a sufficiently long period.

Rehabilitation in the postoperative period

The most important tips to help prevent swelling:

• In the first few days after the operation, refrain from tilting your head down,
• Don't sleep on your stomach
• Eat soft food, not hot
• For the fastest elimination of bruises and edema, lotions should be made with an aqueous solution of furacilin,
• Rinse the nasal cavity with any special solutions ( sold in a pharmacy), injecting into each nostril 2 injections seven times a day, then gently blow out the nose,
• Antibiotic to prevent wound infection Zinnat 250 mg twice a day for five days,
• To prevent the development of a fungal infection Fluconazole 150 mg take one capsule orally on the 3rd day of treatment Zinnat,
• Entrances to the nostrils should be cleaned daily with a cotton swab and hydrogen peroxide 3%,
• Two days after the intervention, you are allowed to take a shower,
• When swimming, keep the nose area from getting wet,
• It is allowed to apply cosmetics 14 days after the intervention.

• 7 days after the intervention, exercise, carry children in your arms and lift other heavy objects,
• 14 days after the intervention visit the pool and sauna,
• Wear glasses and sunbathe for 30 days after the intervention.

• Edema is reduced by about two-thirds after 4 weeks,
• After 12 months, swelling subsides completely,
• In some patients, edema subsides asymmetrically,
• After 14 days, bruises completely disappear,
• 7 days after the intervention, nasal breathing may worsen, as caked crusts of blood appear in the nose.

Edema, callus and other complications

Complications can be of two types:

• functional,
• Aesthetic.

Functional complications: septal perforation, ethmoid avulsion, and cerebrospinal fluid leakage ( older people are more disposed), abscess, toxic shock, hematoma, respiratory impairment, tissue inflammation.
Ideally, after surgery, respiratory function should remain at the same level or even improve. If breathing worsens, the doctor must find the cause and eliminate it.
Too much exposure to the nasal mucosa can provoke the development of atrophic rhinitis.
Too much narrowing of the bony structure of the nose can lead to poor nasal valve function and nasal obstruction.
Too much trimming of the lateral legs sometimes impairs the operation of the nasal valve.

Bone callus after plastic surgery appears infrequently. However, it nullifies the entire result of the operation. A corn appears if the body is very actively taken to restore pieces of tissue removed during the intervention. In this case, the restored tissue is often larger in volume than the removed one. Most often, callus develops when the hump on the bridge of the nose is removed and in those who have completely changed the shape of the nose.

Causes of callus appearance:
1. individual response of the body. This is one of the main reasons. In some people, the body has a high degree of self-healing.
2. Physician experience. This is a big part of the operation's success. A doctor with extensive experience has enough secrets and practices to prevent the growth of calluses. If the operation was performed by a doctor with experience in plastic surgery, swelling and bruising are common complications and nothing more.

Scars after rhinoplasty

Revision rhinoplasty

According to medical statistics, most unplanned reoperations occur due to insufficient professionalism of doctors. If the second operation is done by a good doctor, then he will be able to completely correct all the mistakes of a colleague. However, in particularly difficult cases, you have to do several operations. In such a case, a specialist with extensive experience and well-conducted tissue grafting is needed.
Sometimes the first operation was done correctly, but the results did not satisfy the patient. In this case, the repeated operation is easier to do, its duration is shorter.

Issue price

The most expensive operations are those that cover not only the soft tissues of the nose, but also the bone structures. Such operations can cost 90,000 rubles or more. A full rhinoplasty today costs from 120,000 rubles. Although, you can find clinics where promotions are held, and a complete alteration of the nose will cost 100,000 rubles.

For computer modeling of the nose, they take about 2,000 rubles.
A day in the hospital will cost approximately 3,500 rubles. Moreover, in some clinics, the cost of dressings is not included in the total cost of the service.
For each dressing you will have to pay a couple of hundred rubles.
You should be especially careful if a good clinic offers services cheaper than its colleagues. Most often, a lot of necessary and rather expensive services will be added to the initial price, for example, they can charge a separate fee for anesthesia during surgery.

Free rhinoplasty

A certain number of applicants are selected and invited to the clinic for casting. And here the doctor chooses the one most needy candidate.
As incentive prizes, another two or three participants may be offered an operation for half the cost.
Very often, such promotions are held in the summer, as the influx of clients to aesthetic surgery clinics subsides at this time.

This chapter explains the first stage of rhinoplasty surgery. At this stage, the necessary incisions of the nose are made, allowing you to see its base - bones and cartilage.

Look at the images above. An external incision is made along the dotted line in the form of an inverted V, other incisions are made in the nasal cavity on the mucous membrane. The operation, during which the skin is cut, is called open rhinoplasty. If access is made only from the side of the nasal mucosa - closed rhinoplasty.

The part of the nose where the incision is made is called the columella or column. In the figure, the columella is colored blue. The incision is made in its narrowest part (indicated by red arrows). It is called a "trans-collumer" incision. The columella has the greatest width above and below this place.

The incision is made in the narrowest part of the columella so that the scar remaining after the operation is minimal. Although after complete healing of the wound, it becomes almost invisible.

As a rule, the operation does not begin with an external incision, but with one of the internal ones. With the left hand (the operation in the photographs is performed by a right-handed surgeon), the tip of the nose is turned to the left, thereby fixing the position of the nose itself. It also opens access to the site of the future incision. The images above show the described process. The left figure shows its beginning, the right one shows a ready-made incision, which is called the medial-marginal incision. During this part of the operation, a conventional medical scalpel is used.

Next, the lateral part is performed ("lateral" - remote from the middle, i.e. in this case it is the lateral part) of the marginal incision. The incision is called a marginal incision because it is made along the edge of the nasal cartilage (shown in blue in the top image) that gives the nose tip its shape. After the incision is made, the cartilage can be seen in its entirety.

In the upper left image, a small red line indicates the lateral portion of the incision. A small red strip next to the columella is the medial part of the incision (the incision running along the columella). Next, both parts of the cut are connected.

Pay attention to the work of the surgeon's hands. The left hand fixes the nose in the required position, pulls the cartilage aside, which is necessary for making accurate cuts, and also performs many other functions. In this case, the left hand holds a retractor that opens access to the right nostril. The finger of the hand presses on the nose, opening up a place for the incision and giving direction to the scalpel, which is held, respectively, by the right hand.

We return to the outer cut (indicated by the red line).

The next stage of the operation is to separate the skin of the tip of the nose from the cartilage located under it. Scissors (necessarily with blunt ends) are wound from the inside of the columella (figure above). Then they are gently opened, and the skin is separated from the cartilage. This action must be carried out with the utmost care so as not to damage the tightly connected skin and cartilage.

Pay attention to the image. Do not forget that the part of the nose painted in blue is called the columella, in green - the tip of the nose, and the base is circled with a red triangle.

After we have separated the skin from the cartilage at the tip of the nose, we must do the same on the colummel. To do this, the scissors are inserted into the medial-marginal incision, and gently advanced further until they appear on the other side (see image below).

The main advantage of external rhinoplasty over internal rhinoplasty is that the surgeon gets a better view of the nasal cartilage, which in turn allows the operation to be performed under full visual control.

Also, the use of external rhinoplasty is justified in the case of a repeated operation. As a rule, such a need arises after an unsuccessful previous one.

And so we proceed to the dissection of the columella. It is necessary to start the incision at the top of the inverted V. At the same time, the left hand pulls up the tip of the nose, and the little finger of the right hand shifts the columella down, stretching the skin, which in turn facilitates the incision. From the top, the incision is made to the base sequentially in both directions.

In order to ensure the successful completion of the stage of the operation, it is necessary to slightly push the skin along the edges of the wound. If the columella opens slightly, then the incision was made correctly.

The thickness of the skin of the columella is minimal, so the incision must be made with extreme care so as not to damage the cartilage that lies directly under the skin.

Although an external incision results in a scar, in many cases its use is necessary. At the same time, it should be noted that if the operation is performed by a qualified surgeon, then the scar is almost impossible to see. Especially after it has healed (look at the images above, the red line indicates the location of the scar).

Here it is worth touching a little on the topic of unqualified doctors. Although this requires a separate discussion, and not within the scope of this article.

Consider an example. The surgeon who performed the operation (see image) made many incorrect incisions at the base of the nose. In this case, he made the following mistakes: he incorrectly made a trans-columnar incision (indicated in green), which, if done correctly, leaves no traces at all. The next mistake is the wrong incisions made by him to reduce the size and thickness of the skin of the nostrils (indicated in red and blue, respectively).

Therefore, carefully approach the issue of choosing a plastic surgeon. After all, postoperative errors can not always be corrected.

Let's get back to the operation. After dissection of the columella with a scalpel, the skin is cut with scissors to the full thickness. This will expose the tip of the nose and get to the right cartilage.

The skin above the incision site is lifted up with a two-pronged retractor. And the lower part remains in place (in the right figure, the red line indicates the place of the incision).

With the tip of scissors, the soft tissues of the columella are separated from the cartilage. The cartilages located at the tip of the nose are called the inferior lateral cartilages (the right cartilage is colored blue in the figure).

The pink color in the upper figure indicates the surface of the skin adjacent to the cartilages of the tip of the nose.

Thus, access to the lower lateral cartilages was obtained. Further, with the help of scissors, the soft tissues of the tip of the nose are completely separated from them.

We all know that the traditional use of scissors is to place an object between the blades and cut it. Most of the time, the rhinoplasty surgeon uses this instrument in a slightly different way. Most often, he performs sliding movements, rather than cutting. To expose the lower lateral cartilage, the surgeon closes the scissors, places the ends of the scissors on the surface of the cartilage, and then opens the scissors, spreading the tissue with the scissor blades.

Now the cartilages of the tip of the nose are completely open and you can see the cartilage forming the back of the nose (in the figure it is highlighted in pink, the right lower cartilage is in blue).

In order for the skin separated from the cartilage not to interfere with the further operation, a retractor is used to hold it.

Now the lower and upper cartilages have become available (in the photo, the upper cartilage is indicated in green, and the lower ones are blue and red, respectively).

It should be noted that there is almost no bleeding in the shown pictures. This is explained as follows. The nose, like any other part of the body, has places both with abundant blood supply and areas in which the number of blood vessels is minimal. A qualified surgeon leaves intact places with a large number of blood vessels, which avoids large bleeding and does not interfere with the operation.

Let's clarify some points on anatomy and terminology (see photo above).

The tip of the nose is the part marked in pink in the right photo and circled in red in the left photo.

The bridge of the nose is the part between the tip of the nose and its upper point, located between the eyes. In the image, the bridge of the nose is marked in blue.

Hump ​​- part of the nose, located, as a rule, in the middle of the back of the nose. Often in this place the nose has a bend (in the figure, the hump is indicated by a green arrow).

The upper part of the nose, located closer to the eyes, is formed by the nasal bones, and the lower part is formed by cartilage. In the image, the border of the separation of bones and cartilage is shown as a black wavy line.

The nasal bones are firmly attached to the bones of the skull. The lower part of the nose, formed by cartilage, is much more mobile (therefore, for example, in boxers, the nose is always broken in the lower part).

The border separating the nasal bones and cartilage is located at the very top of the hump of the nose (unless, of course, it is noticeable, otherwise this place can be determined by touch).

The photo does not show the bony part of the bridge of the nose, despite the fact that the skin is pulled up with a retractor (the cartilage that forms the bridge of the nose is colored green).

The right lower lateral cartilage is shown in two colors in the photograph. The lower part of the cartilage, which forms the columella, is indicated in red, and the upper part, which is located above the nostrils, is indicated in yellow. At the junction of these areas (indicated by the blue arrow), the most protruding part of the tip of the nose is formed.

In the photo above, it's easy to tell the two areas apart. At the junction, the cartilage forms a slight bend, which is indicated by a white line.

Also, a blue arrow points to the place of transition of the collumellar part of the cartilage to the lateral part. It is this area that we perceive as the tip of the nose. This transition is called the dome of the lower lateral cartilage. In the figure, the dome is marked in green.

The upper image shows normally located, previously unoperated cartilages. The right nasal cartilage is colored blue. The skin above it is pulled upward by the retractor so that a small part of the cartilage of the back of the nose, colored green, is visible.

The photo above shows both cartilages from the same patient. This is a rare case when the cartilages are completely symmetrical. They usually vary slightly in size and shape, making it difficult to perform a rhinoplasty operation.

When the cartilages of the tip of the nose are strong enough, and the skin covering them is thin, a small visible groove forms between the cartilages (shown in blue in the photo).

It can be easily detected by pressing a fingernail against the tip of the nose (dome).

If the groove between the cartilages is clearly visible, then the tip of the nose is called split.

The picture above shows a typical view of the tip of the nose after it has been opened. The lower right cartilage is bent down with a special metal hook, which allows a good view of the cartilage separation area (the left cartilage is highlighted in blue, the cartilage of the back of the nose is highlighted in green).

It is necessary to pay attention once again to the fact that the shape and size of the cartilages are clearly visible only when they are carefully cleaned of soft tissues.

Look at the top photos. On the left is a previously unoperated patient with normal lower cartilage. On the right is the result of a poorly performed rhinoplasty. In this case, the cartilage is covered with a thick layer of connective tissue, so it is quite difficult to see them. A second operation, which must be performed due to the unsatisfactory results of the previous intervention, will be somewhat difficult because. isolating cartilage without damaging it is not easy in this case.

Here is another patient's nose after a failed rhinoplasty.

Instead of normal cartilage, which we would like to see, in this case there are large growths of scar tissue.

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Dropped tip

The most important principle in preventing unwanted changes in the nasolabial angle is to assess the anatomy and support mechanisms of the nasal tip and then maintain or increase the support of the tip, which will restore a more natural appearance of the nose. As noted above, activities that result in loss of nasal tip support can create the appearance of a dropped tip (tip ptosis and too acute nasolabial angle). The normal nasolabial angle (the angle determined by the intersection of the lines drawn from the upper point of the columella to the subnasal and from the subnasal to the border of the red border of the upper lip) is 90-120 °. Within these limits, a more obtuse angle is desirable for women, and a sharper one for men. Loss of support for the tip of the nose can lead to ptosis and decreased prominence.

Treatment of complications associated with a drooping nose is based on restoring support and prominence to the nose. In the event of such a complication as the drooping of the tip of the nose, future correction depends on the correct diagnosis. There are many ways to increase the support of the tip of the nose, restore its prominence and rotation (Table 1).

Table 1

Operational actions

Excessively upturned (rotated) nose

On the contrary, one may encounter an excessively rotated nose, with a too obtuse angle. Excessive resection of the caudal septum is a common cause of excessive rotation of the nasal tip. This rotation creates an unsightly appearance.

Careful preoperative evaluation may identify those patients in whom surgical rotation should be avoided. Treatment of complications associated with a short, upturned nose is based on lengthening the nose and rotating it in the opposite direction. There are special rhinoplasty manipulations that lengthen and rotate the nose (Table 1).

Bulges

A bulge is a fracture of the lower lateral cartilage at the tip of the nose due to the force of the scar contracture on the weakened cartilages. Patients with thin skin, strong cartilage, and a bifid nasal tip are at especially high risk. Excessive resection of the lateral crura and failure to repair the divergence of the arches may play some role in the formation of the bulge. It is believed that the bulges are the result of cicatricial contracture of an overly narrowed marginal strip, leading to the formation of a rounded protrusion during postoperative healing. Several researchers have described a link between cartilage splitting techniques and bulge formation. However, others believe that the methods of vertical division of the vaults are reliable when performed correctly and do not create such problems.

As an isolated deformity, bulges are usually corrected through a small marginal incision with minimal undercutting over the affected side, followed by clipping or excision of the portion of cartilage causing the deformity. In some cases, the area is covered with a thin layer of cartilage, fascia, or other material to smooth and hide the area.

Pull back wings

To improve the appearance of the nasal tip, a cephalic resection of the lateral crura of the inferior lateral cartilages is often undertaken. If excess cartilage is left, the diminishing forces of healing will eventually cause the wings to be retracted posteriorly (Fig. 1).

Rice. 1. Patient many years after rhinoplasty with disproportion between the wings and columella due to the posterior retraction of the wings of the nose

This is a frequently seen consequence of overresection of the lateral pedicles. The surgeon's heuristic rule is to protect the entire strip at least 6-9 mm wide. However, anatomical study of the base of the wings shows that in the normal population, a thin edge of the nasal wing is present in 20% of patients. This anatomical variant must be recognized in order to prevent the danger of the wings being retracted and/or the external nasal valve collapsing. Such patients may require an even more conservative approach. It is necessary to preserve the mucous membrane of the vestibule, since its excision contributes to cicatricial contracture with retraction of the wings.

Retraction of the wings of the nose in simple cases (1-2 mm) can be corrected with cartilage grafts. The area of ​​retraction is marked before anesthetic is injected, and a small marginal incision allows the creation of a precise pocket. An excised cartilage graft (usually from ear or septal cartilage) can be inserted into this precise pocket; it should extend down to the sesamoid cartilages and be wide enough to mimic the normal shape of the lateral crus and fornix.

In more severe cases, compound ear grafts are often used. The best contour is provided by the bowl of the conch of the opposite ear (for example, left wing - right ear). After an incision a few millimeters from the edge of the nostril, a careful dissection is made with the separation of the adhesions, the creation of a pocket and the displacement of the wing rim downwards. The suitably excised composite graft is carefully sutured into place.

Disproportions of wings and columella

Disproportions of the wings and columella can be a cause of considerable concern to the patient. The degree of normal protrusion of the columella down from under the wings is usually 2-4 mm. The complexity of the relationship between the wings and the columella was summarized by Gunter et al., who described the position of the wings and the columella in relation to a line drawn through the long axis of the nostril. All patients are divided into those with lowered, normal or retracted wings, as well as sagging, normal or retracted columella. That is, there are nine possible anatomical combinations, relationships between the wings and the columella (Fig. 2).

Rice. 2. The relationship of the wings and columella can be described by nine possible anatomical combinations (from Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Philadelphia: Lippincott Williams & Wilkins; 1999. With permission).

The disproportion of the wings and columella can be observed in the unoperated nose; it can also be caused by surgical failure (Figure 1). A protruding or sagging columella may be due to remaining uncorrected deformity, such as too wide medial crura or too long caudal septum. The deformity may be excessive protrusion of the columella downward from under the wings secondary to retraction of the wing margins rather than true protrusion of the columella. Insufficient or retracted columella may be a manifestation of pre-existing uncorrected deformity, it may also be caused by excessive resection of soft tissue, cartilage, or nasal spine. The surgeon should avoid excessive resection of the caudal septum, as well as resection of the nasal spine.

Correction of a protruding or sagging columella may consist of a full-thickness resection of the tissue of the membranous part of the columella, including skin, subcutaneous tissue, and possibly part of the caudal end of the septum itself. If the medial crus is too wide, correction may include sparing excision of the caudal margin of the medial crura.

Retraction of the columella can be corrected with rounding grafts inserted at the base of the columella to change the acute nasolabial angle; for small deformations, supports for the columella may also help. A cartilage graft can be used to lengthen a short nose. The use of composite grafts has been described.

Coracoid deformity

Coracoid deformity is defined as varying degrees of fullness above the tip of the nose, combined with an unnatural ratio of the tip to the area above the tip (Fig. 3). There may be several reasons for this, including failure to maintain adequate tip support (postoperative reduction in prominence), inadequate removal of the cartilaginous hump (anterior septal angle), and/or dead space/scarring above the nasal tip.

Rice. 3. A patient with an excessively resected bony dorsum and insufficiently resected cartilaginous dorsum. Her coracoid deformity was associated with a long cartilaginous dorsum and was therefore corrected by additional excision of the cartilaginous dorsum. To create a more balanced profile, the unnecessarily reduced upper third of the nose has been enlarged. (A) Side view before surgery. (B) Side view after surgery.

Correction of a coracoid deformity depends on the anatomical cause. If the cartilaginous hump was not sufficiently resected, the surgeon must additionally remove part of the nasal septum. Adequate tip support must be maintained; therefore, manipulations such as placing a support for the columella can be useful. If the bony hump is excessively resected, a graft may be required to increase the bony dorsum. If the formation of a coracoid deformity is associated with severe scarring, then Kenalog injections or splinting of the nose with plaster in the early postoperative period should be used before considering surgical revision.

Section of a columella

External approach for rhinoplasty includes a columella incision. Great care must be taken when making the incision to make it not oblique, but perpendicular to the skin, thereby avoiding the complication of manhole cover deformity. Also, great attention should be paid to the process of suturing the incision to prevent folded edges or other deformations (Fig. 4).

Rice. 4. When performing external rhinoplasty, special attention should be paid to the incision of the columella and its suturing. To prevent visible deformity, great care must be taken to perform these manipulations correctly (see text) (from Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Philadelphia: Lippincott Williams & Wilkins; 1999. With permission).

A single subcutaneous polydioxanone (PDS) suture may be placed to improve skin eversion and relieve tension from the suture line. This seam should provide equalization of the edges of the skin and easy eversion. Excessive eversion will create a deformity that may take many months to resolve. With this seam, the skin sections must be exactly aligned; otherwise, an unattractive scar may form. If there is no tension on the skin, a subcutaneous suture may not be required.

Five vertical mattress sutures made of 7-0 nylon are used to close the skin. The first seam equalizes the top of the inverted "V". To properly align the incision, the next two sutures are bent at an angle from the medal part of the lower flap to the lateral part of the upper flap. To equalize the skin of the vestibule in the corner of the columellar flap, a 6-0 chrome-plated catgut suture is used. This corner suture is important as improper healing in this corner can lead to visible retraction.

Daniel G Becker

Complications of rhinoplasty

Rhinoplasty is a concept that includes many different techniques to change the shape of the nose. Some patients need to work with the bone part of the back, others - with the cartilage part, and the third - with the soft tissues of the tip of the nose. Often there is a need for correction of columella. And what it is, how this part of the nose is corrected and what effect can be achieved with the help of surgical intervention, you can find out by comprehensively considering this issue.

Columella - what is it?

The nasal columella is the part of the skin located between the nostrils. Anatomically, the columella includes the medial crura of the alar cartilages, but they are not visible visually. Sometimes it is called a column or column of the nose.

This small fragment of the nose performs a number of important functional tasks in the normalization of the breathing process. Supporting the tip of the nose and maintaining the optimal lumen of the nostrils, it allows you to freely inhale and exhale air. So, to provide the body with oxygen, which is involved in all biochemical processes.

What should a columella look like?

A small area of ​​skin called the columella of the nose plays a huge role in the perception of the nose as a harmonious part of the human face. A beautiful columella should have the following qualities:

• its width should not exceed 5-7 mm;
• the angle between the nose and lip should be about 100 degrees for women, 95 degrees for men;
• the column should not sag;
• when looking at the face from the front, the columella should be located lower than the wings of the nose;
• nostrils should be symmetrical.

If these rules are ignored, any rhinoplasty will not be successful. The nose will look disharmonious, and the person may go for a second plastic surgery. While in other cases, a simple correction operation can give a more pronounced result.

Problems with columella

What problems can be with columella to require nose plastic surgery - rhinoplasty?

Based on how the ideal size and shape of a columella should look like, we can identify the problems that potential patients of a plastic surgeon most often face:

• the nasal column sags;
• columella is too high;
• the angle between the nose and the lip is too large, or vice versa, small.

A person may regard his nose as too wide, with a curved tip, snub-nosed. But in order to correct the appearance, it is not necessary to do complex and traumatic operations to change the shape of the back or its tip. It is enough just to change the column of the nose.

Non-surgical correction

In the event that the column of the nose is small, that is, the angle between the nose and the lip is increased, and there the nose looks snub-nosed, or the leg of the columella and the wings of the nose are located on the same level, you can use

Its meaning lies in the introduction of a special preparation under the skin - a filler, which increases the volume of tissues. As a result of this, the columella of the nose becomes larger, and the nose itself looks harmonious. During the procedure, the doctor injects the filler into the columella in the required volume through the needle. The intervention causes a minimum of pain, but if desired, you can use an anesthetic injection.

The advantages of the method are:

• minimum rehabilitation period;
• short duration of the procedure;
• no need to do tests and functional studies before the procedure.

The main disadvantage of the method is its fragility. The duration of the effect depends on the drug that was injected into the soft tissues of the columella: a more viscous gel will be retained in the tissues longer. But it is necessary to take into account the individual characteristics of a person.

The safety of the method is great, but relative: the introduction of any substance into the body can become a catalyst for pathological processes, for example, exacerbation of chronic diseases, the development of autoimmune diseases. In order to avoid such consequences, you need to undergo a medical examination and consult with your doctor.

Surgical correction of columella

If the columella is large or sagging, the only method of correction is surgery.

But the methods used by the surgeon when performing the operation may be different. Correction of the columella of the nose should be discussed by the doctor and the patient before the operation, so that the operated person is as satisfied as possible with the result.

The easiest way to reduce the columella is to excise the soft tissue and, if necessary, the adjacent cartilage. Understanding how the nasal septum is connected with the columella, we can conclude that in some cases it will be necessary to reduce the length of the septum itself, and only then tighten the columella.

During the preparation period, the doctor decides which operation technique will be more justified in a particular case: raising the nasal column, or deepening it to create a harmonious angle between the nose and the upper lip.

For patients who are not satisfied with the temporary solution of the problem in the form of a biogel injection in the cosmetologist's office, there is a way to permanently maintain the result with the help of surgical intervention. In this case, we are talking about lowering the columella or filling the columnar labial angle.

For this, cartilage implants can be used, which are installed in the columella region in order to lengthen the nasal septum. The implant is fixed with suture material.

Change of columella during rhinoplasty

The goal of a plastic surgeon is not only to correct a specific defect, but also to maintain the overall harmony of the nose and face, and also to make it as simple as possible. Sometimes the columella of the nose has an irregular shape, but working with it will not make the face beautiful, but, on the contrary, will make other features more obvious.

Therefore, sometimes, in order to correct the nasal column, the doctor can make a volumetric correction, based on the structure of the nose of a person who has come to the plastic surgery clinic. The doctor can change the tip of it higher, thereby pulling up the columella. Sometimes rhinoplasty is effective, when the surgeon moves them higher, so the column, remaining in the same place, becomes visually lower.

Therefore, preparation for surgery is a productive collaboration between the patient, who must explain what result of the surgical intervention he wants to see, and the doctor, who knows the structure of the nose and the person and understands what results and what methods can be achieved.

Is anesthesia necessary?

The need for anesthesia during surgery is determined by the amount of work that will be carried out by the surgeon. If the doctor plans to simply excise excess tissue, thereby raising the nasal column to the required height, local anesthesia can be used. For large-scale surgery, it is better to use general anesthesia.

The advantages of anesthesia in rhinoplasty can be identified by at least two arguments:

• the patient, being in a medical sleep, does not experience excitement, is not able to make involuntary movements, in other words, to prevent the surgeon from performing “jewelry” work on his face;
• with general anesthesia, the need for the use of local anesthetics is reduced, so the doctor gets the opportunity to work with “living” tissues, and not with various drugs that have been injected.

To find out if anesthesia is needed in a particular case, it is better to consult a doctor. Assessing the scale and duration of the proposed work, as well as the degree of pain of manipulation, he should recommend to the patient the most suitable option for a particular operation.

Preparing for the operation

Rhinoplasty in Moscow, St. Petersburg and other cities of Russia requires a mandatory medical examination of the state of health before the intervention. For this, there is a list of laboratory tests and functional studies.

In addition, opinions from the attending physician and, in the presence of chronic diseases, a specialist physician may be required.

Rehabilitation

How long it will last depends on many factors: the experience of the doctor, the extent of interventions, the state of health of the patient, the thoroughness of fulfilling all the surgeon's instructions.

On average, the tissue healing time for nose surgery is two weeks. But if the doctor corrected only columella, a person can return to normal life after 2 days.

It is quite possible to reduce the risk of unsuccessful intervention if you remember a brief reminder for a plastic surgeon's patient.

1. Choosing a doctor is half the battle. It is important to choose a specialist who will have experience in correcting noses with such aesthetic defects. Of course, finding such a doctor for rhinoplasty in Moscow or another big city is much easier.
2. Before the operation, colds, emotional and physical stress should not be allowed.
3. After the operation, you need to give the body time to heal the tissues, carefully following all the recommendations of the surgeon.

Rhinoplasty is the most common plastic surgery in the world, which is performed by people of any age and gender. And there is a reason for this: it is the nose that is called the part of the face, which to a greater extent affects the beauty of a person. Therefore, even slightly changing the structure of the human nose, you can achieve a beautiful result.