Rhinoplasty Greek: Rhinos, “Nose” + Plassein, “to shape” , a nose job, is a plastic surgery procedure for correcting and reconstructing the form, restoring the functions, and aesthetically enhancing the nose, by resolving nasal trauma (blunt, penetrating, blast), congenital defect, respiratory impediment, and a failed primary rhinoplasty. In the surgeries — closed rhinoplasty and open rhinoplasty — an otolaryngologist (ear, nose, and throat specialist), a maxillofacial surgeon (jaw, face, and neck specialist), or a plastic surgeon, creates a functional, aesthetic, and facially proportionate nose by separating the nasal skin and the soft tissues from the osseo-cartilaginous nasal framework, correcting them as required for form and function, suturing the incisions, and applying either a package or a stent, or both, to immobilize the corrected nose to ensure the proper healing of the surgical incision.
Non-surgical rhinoplasty is a method involving filler injections to alter the shape of the nose, without invasive surgery.
History of Rhinoplasty
Rhinoplasty (reconstructive nose surgery) was first developed in ancient India, by the ayurvedic physician Sushruta (ca. 800 BC), who described reconstruction of the nose in the Sushruta samhita (ca. 500 BC), his medico–surgical compendium. The physician Sushruta and his medical students developed and applied plastic surgical techniques for reconstructing noses, genitalia, earlobes, et cetera, that were amputated as religious, criminal, or military punishment. Sushruta also developed the forehead flap rhinoplasty procedure that remains contemporary plastic surgical practice. In the Sushruta samhita compendium, the physician Sushruta describes the (modern) free-graft Indian rhinoplasty as the Nasikasandhana.
During the Roman Empire (27 BC – AD 476) the encyclopaedist Aulus Cornelius Celsus (ca. 25 BC – AD 50) published the 8-tome De Medicina (On Medicine, ca. AD 14), 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 (AD 331–363), the royal physician Oribasius (ca. AD 320–400) published the 70-volume Synagogue Medicae (Medical Compilations, AD 4th c.), 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.
Nonetheless, during the centuries of the European Middle Ages (AD 5th – 15th centuries) that followed the Imperial Roman collapse (AD 476), the fifth-century BC Asian plastic surgery knowledge of the Sushruta samhita went unknown to the West until the tenth century AD, with the publication, in Old English, of the Anglo-Saxon physician’s manual Bald’s Leechbook (ca. AD 920) describing the plastic repair of a cleft lip; as a medical compendium, the Leechbook is notable for categorizing ailments and treatments as internal medicine and as external medicine, for providing herbal medical remedies, and for providing supernatural incantations (prayers), when required.
The Ottoman rhinoplast physician Şerafeddin Sabuncuoğlu (1385–1468).In the eleventh century, at Damascus, the Arab physician Ibn Abi Usaibia (1203–1270) translated the Sushruta samhita from Sanskrit to Arabic. In due course, Sushruta’s medical compendium travelled from Arabia to Persia to Egypt, and, by the fifteenth century, Western European medicine had encountered it as the medical atlas Cerrahiyet-ul Haniye (Imperial Surgery, 15th c.), by Şerafeddin Sabuncuoğlu (1385–1468); among its surgical techniques featured a breast reduction procedure.
In Italy, Gasparo Tagliacozzi (1546–1599), professor of surgery and anatomy at the University of Bologna, published Curtorum Chirurgia Per Insitionem (The Surgery of Defects by Implantations, 1597), 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 time, the fifth-century BC Indian rhinoplasty technique — featuring a free-flap graft — was (re) discovered by Western medicine in the eighteenth century, during the Third Anglo–Mysore War (1789–1792) of colonial annexation, by the British against Tipu Sultan, when the East India Company surgeons Thomas Cruso and James Findlay witnessed Indian rhinoplasty procedures at the British Residency in Poona. In the English-language Madras Gazette, the surgeons published photographs of the rhinoplasty procedure and its nasal reconstruction outcomes; later, in the October 1794 issue of the Gentleman’s Magazine of London, the doctors Cruso and Findlay published an illustrated report describing a forehead pedicle-flap rhinoplasty that was a technical variant of the free-flap graft technique that Sushruta had described some twenty-three centuries earlier.
Pre-dating the Indian Sushruta samhita medical compendium is the Ebers Papyrus (ca. 1550 BC), an Ancient Egyptian medical papyrus that 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.
In the event, the Indian rhinoplasty technique perdured in nineteenth-century Western European medicine; in Great Britain, Joseph Constantine Carpue (1764–1846) published the Account of Two Successful Operations for Restoring a Lost Nose (1815), which described 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 (1787–1840), who published Rhinoplastik (Rebuilding the Nose, 1818) wherein he described fifty-five (55) historical plastic surgery procedures (Indian rhinoplasty, Italian rhinoplasty, etc.), and his technically innovative free-graft nasal reconstruction (with a tissue-flap harvested from the patient’s arm), and surgical approaches to eyelid, cleft lip, and cleft palate corrections. Dr. von Gräfe’s protégé, the medical and surgical polymath Johann Friedrich Dieffenbach (1794–1847), who was among the first surgeons to anaesthetize the patient before performing the nose surgery, published Die Operative Chirurgie (Operative Surgery, 1845), which became a foundational medical and plastic surgical text. (see strabismus, torticollis) Moreover, the Prussian Jacques Joseph (1865–1934) published Nasenplastik und sonstige Gesichtsplastik (Rhinoplasty and other Facial Plastic Surgeries, 1928), which described refined surgical techniques for performing nose-reduction rhinoplasty via internal incisions.
In the United States, in 1887, the otolaryngologist John Orlando Roe (1848–1915) performed the first, modern endonasal rhinoplasty (closed rhinoplasty), about which he reported in the article The Deformity Termed “Pug Nose” and its Correction, by a Simple Operation (1887), and about his management of saddle nose deformities.
In the early twentieth century, Freer, in 1902, and Killian, in 1904, respectively pioneered the submucous resection septoplasty (SMR) procedure for correcting a deviated septum; they raised mucoperichondrial tissue flaps, and resected the cartilaginous and bony septum (including the vomer bone and the perpendicular plate of the ethmoid bone), 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 1921, A. Rethi introduced the open rhinoplasty approach featuring an incision to the columella to facilitate modifying the tip of the nose. In 1929, Peer and Metzenbaum performed the first manipulation of the caudal septum, where it originates and projects from the forehead. In 1947, Maurice H. Cottle (1898–1981) 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” (Dekortication des Nase) technique which featured a columellar-incision open rhinoplasty that allowed greater access to the nasal cavity and to the nasal septum.
Nonetheless, at mid–twentieth century, despite such refinement of the open rhinoplasty approach, 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 with the article External Approach to Rhinoplasty (1973), which reported his technical refinements and popularized the open rhinoplasty approach. In 1982, Jack Anderson reported his refinements of nose surgery technique in the article Open Rhinoplasty: An Assessment (1982). During the 1970s, the principal application of open rhinoplasty was to the first-time rhinoplasty patient (i.e. a primary rhinoplasty), not as a revision surgery (i.e. a secondary rhinoplasty) to correct a failed nose surgery. In 1987, in the article External Approach for Secondary Rhinoplasty (1987), Jack P. 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.
Hence does contemporary rhinoplastic praxis derive from the primeval (ca. 600 BC) Indian rhinoplasty (nasal reconstruction via an autologous forehead-skin flap) and its technical variants: Carpue’s operation, the Italian rhinoplasty (pedicle-flap reconstruction, aka the Tagliocotian rhinoplasty); and the closed-approach endonasal rhinoplasty, featuring exclusively internal incisions that allow the plastic surgeon to palpate (feel) the corrections being effected to the nose
To determine the patient’s suitability for undergoing a rhinoplasty procedure, the surgeon clinically evaluates him or her with a complete medical history (anamnesis) to determine his or her physical and psychological health. The prospective patient must explain to the physician–surgeon the functional and aesthetic nasal problems that he or she suffers. The surgeon asks about the ailments’ symptoms and their duration, past surgical interventions, allergies, drugs use and drugs abuse (prescription and commercial medications), and a general medical history. Furthermore, additional to physical suitability is psychological suitability — the patient’s psychological motive for undergoing nose surgery is critical to the surgeon’s pre-operative evaluation of the patient. The complete physical examination of the rhinoplasty patient determines if he or she is physically fit to undergo and tolerate the physiologic stresses of nose surgery. The examination comprehends every existing physical problem, and a consultation with an anaesthesiologist, if warranted by the patient’s medical data. Specific facial and nasal evaluations record the patient’s skin-type, existing surgical scars, and the symmetry and asymmetry of the aesthetic nasal subunits. The external and internal nasal examination concentrates upon the anatomic thirds of the nose — upper section, middle section, lower section — specifically noting their structures; the measures of the nasal angles (at which the external nose projects from the face); and the physical characteristics of the naso-facial bony and soft tissues. The internal examination evaluates the condition of the nasal septum, the internal and external nasal valves, the turbinates, and the nasal lining, paying especial attention to the structure and the form of the nasal dorsum and the tip of the nose.
Furthermore, when warranted, specific tests — the mirror test, vasoconstriction examinations, and the Cottle maneuver — are included to the pre-operative evaluation of the prospective rhinoplasty patient. Established by Maurice H. Cottle (1898–1981), the Cottle maneuver is a principal diagnostic technique for detecting an internal nasal-valve disorder; whilst the patient gently inspires, the surgeon laterally pulls the patient’s cheek, thereby simulating the widening of the cross-sectional area of the corresponding internal nasal valve. If the maneuver notably facilitates the patient’s inspiration, that result is a positive Cottle sign — which generally indicates an airflow-correction to be surgically effected with an installed spreader-graft. Said correction will improve the internal angle of the nasal valve and thus allow unobstructed breathing. Nonetheless, the Cottle maneuver occasionally yields a false-positive Cottle sign, usually observed in the patient afflicted with alar collapse, and in the patient with a scarred nasal-valve region