NYC Rhinoplasty Allenhurst NJ 07711
In plastic surgical praxis, the term primary rhinoplasty denotes an initial (first-time) reconstructive, functional, or aesthetic corrective procedure. The term secondary rhinoplasty denotes the revision of a failed rhinoplasty, an occurrence in 5–20 per cent of rhinoplasty operations, hence a revision rhinoplasty. The corrections usual to secondary rhinoplasty include the cosmetic reshaping of the nose because of an unaddressed nasal fracture; a defective tip of the nose, i.e. pinched (too narrow), hooked (parrot beak), or flattened (pug nose); and the restoration of clear airways. Although most revision rhinoplasty procedures are “open approach”, such a correction is more technically complicated, usually because the nasal support structures either were deformed or destroyed in the primary rhinoplasty; thus the surgeon must re-create the nasal support with cartilage grafts harvested either from the ear (auricular cartilage graft) or from the rib cage (costal cartilage graft). NYC rhinoplasty Allenhurst NJ 07711.
In reconstructive rhinoplasty, the defects and deformities that the plastic surgeon encounters, and must restore to normal function, form, and appearance include broken and displaced nasal bones; disrupted and displaced nasal cartilages; a collapsed bridge of the nose; congenital defect, trauma (blunt, penetrating, blast), autoimmune disorder, cancer, intranasal drug-abuse damages, and failed primary rhinoplasty outcomes. Rhinoplasty reduces bony humps, and re-aligns the nasal bones after they are cut (dissected, resected). When cartilage is disrupted, suturing for re-suspension (structural support), or the use of cartilage grafts to camouflage a depression allow the re-establishment of the normal nasal contour of the nose for the patient. When the bridge of the nose is collapsed, rib-cartilage, ear-cartilage, or cranial-bone grafts can be used to restore its anatomic integrity, and thus the aesthetic continuity of the nose. For augmenting the nasal dorsum, autologous cartilage and bone grafts are preferred to (artificial) prostheses, because of the reduced incidence of histologic rejection and medical complications. NYC rhinoplasty Allenhurst NJ 07711.
Surgical anatomy for nasal reconstruction
The human nose is a sensory organ that is structurally composed of three types of tissue: (i) an osseo-cartilaginous support framework (nasal skeleton), (ii) a mucous membrane lining, and (iii) an external skin. The anatomic topography of the human nose is a graceful blend of convexities, curves, and depressions, the contours of which show the underlying shape of the nasal skeleton. Hence, these anatomic characteristics permit dividing the nose into nasal subunits: (i) the midline (ii) the nose-tip, (iii) the dorsum, (iv) the soft triangles, (v) the alar lobules, and (vi) the lateral walls. Surgically, the borders of the nasal subunits are ideal locations for the scars, whereby is produced a superior aesthetic outcome, a corrected nose with corresponding skin colors and skin textures. NYC rhinoplasty Allenhurst NJ 07711.
- Nasal skeleton
Therefore, the successful rhinoplastic outcome depends entirely upon the respective maintenance or restoration of the anatomic integrity of the nasal skeleton, which comprises (a) the nasal bones and the ascending processes of the maxilla in the upper third; (b) the paired upper-lateral cartilages in the middle third; and (c) the lower-lateral, alar cartilages in the lower third. Hence, managing the surgical reconstruction of a damaged, defective, or deformed nose, requires that the plastic surgeon manipulate three (3) anatomic layers:
- the osseo-cartilagenous framework — The upper lateral cartilages that are tightly attached to the (rear) caudal edge of thenasal bones and the nasal septum; said attachment suspends them above the nasal cavity. The paired alar cartilages configure a tripod-shaped union that supports the lower third of the nose. The paired medial crura conform the central-leg of the tripod, which is attached to the anterior nasal spine and septum, in the midline. The lateral crura compose the second-leg and the third-leg of the tripod, and are attached to the (pear-shaped) pyriform aperture, the nasal-cavity opening at the front of the skull. The dome of the nostrils defines the apex of the alar cartilage, which supports the nasal tip, and is responsible for the light reflex of the tip. NYC rhinoplasty Allenhurst NJ 07711.
- the nasal lining — A thin layer of vascular mucosa that adheres tightly to the deep surface of the bones and the cartilages of the nose. Said dense adherence to the nasal interior limits the mobility of the mucosa, consequently, only the smallest of mucosal defects (< 5 mm) can be sutured primarily.
- the nasal skin — A tight envelope that proceeds inferiorly from the glabella (the smooth prominence between the eyebrows), which then becomes thinner and progressively inelastic (less distensible). The skin of the mid-third of the nose covers the cartilaginous dorsum and the upper lateral cartilages and is relatively elastic, but, at the (far) distal-third of the nose, the skin adheres tightly to the alar cartilages, and is little distensible. The skin and the underlying soft tissues of the alar lobule form a semi-rigid anatomic unit that maintains the graceful curve of the alar rim, and the patency (openness) of the nostrils (anterior nares). To preserve this nasal shape and patency, the replacement of the alar lobule must include a supporting cartilage graft — despite the alar lobule not originally containing cartilage; because of its many sebaceous glands, the nasal skin usually is of a smooth (oiled) texture. Moreover, regarding scarrification, when compared to the skin of other facial areas, the skin of the nose generates fine-line scars that usually are inconspicuous, which allows the surgeon to strategically hide the surgical scars. NYC rhinoplasty Allenhurst NJ 07711.
The technical principles for the surgical reconstruction of a nose derive from the essential operative principles of plastic surgery: that the applied procedure and technique(s) yield the most satisfactory functional and aesthetic outcome. Hence, the rhinoplastic reconstruction of a new nasal subunit, of virtually normal appearance, can be done in a few procedural stages, using intranasal tissues to correct defects of the mucosa; cartilage battens to brace against tissue contraction and depression (topographic collapse); axial skin flaps designed from three-dimensional (3-D) templates derived from the topographic subunits of the nose; and the refinement of the resultant correction with the subcutaneous sculpting of bone, cartilage, and flesh. Nonetheless, the physician-surgeon and the rhinoplasty patient must abide the fact that the reconstructed nasal subunit is not a nose proper, but a collagen-glued collage — of forehead skin, cheek skin, mucosa, vestibular lining, nasal septum, and fragments of ear cartilage — which is perceived as a nose only because its contour, skin color, and skin texture are true to the original nose.
In nasal reconstruction, the plastic surgeon’s ultimate goal is recreating the shadows, the contours, the skin color, and the skin texture that define the patient’s “normal nose”, as perceived at conversational distance (c. 1.0 metre). Yet, such an aesthetic outcome suggests the application of a more complex surgical approach, which requires that the surgeon balance the patient’s required rhinoplasty, with the patient’s aesthetic ideal (body image). In the context of surgically reconstructing the patient’s physiognomy, the “normal nose” is the three-dimensional (3-D) template for replacing the missing part(s) of a nose (aesthetic nasal subunit, aesthetic nasal segment), which the plastic surgeon re-creates using firm, malleable, modelling materials — such as bone, cartilage, and flaps of skin and of tissue. In repairing a partial nasal defect (wound), such as that of the alar lobule (the dome above the nostrils), the surgeon uses the undamaged, opposite (contralateral) side of the nose as the 3-D model to fabricate the anatomic template for recreating the deformed nasal subunit, by molding the malleable template material directly upon the normal, undamaged nasal anatomy. To effect a total nasal reconstruction, the template might derive from quotidian observations of the “normal nose” and from photographs of the patient before he or she suffered the nasal damage.
The surgeon replaces missing parts with tissue of like quality and quantity; nasal lining with mucosa, cartilage with cartilage, bone with bone, and skin with skin that best match the native skin color and skin texture of the damaged nasal subunit. For such surgical repairs, skin flaps are preferable to skin grafts, because skin flaps generally are the superior remedy for matching the color and the texture of nasal skin, better resist tissue contracture, and provide better vascularisation of the nasal skeleton; thus, when there is sufficient skin to allow tissue harvesting, nasal skin is the best source of nasal skin. Furthermore, despite its notable scarring propensity, the nasal skin flap is the prime consideration for nasal reconstruction, because of its greater verisimilitude.
The most effective nasal reconstruction for repairing a defect (wound) of the nasal skin, is to re-create the entire nasal subunit; thus, the wound is enlarged to comprehend the entire nasal subunit. Technically, this surgical principle permits laying the scars in the topographic transition zone(s) between and among adjacent aesthetic subunits, which avoids juxtaposing two different types of skin in the same aesthetic subunit, where the differences of color and texture might prove too noticeable, even when reconstructing a nose with skin flaps. Nonetheless, in the final stage of nasal reconstruction — replicating the “normal nose” anatomy by subcutaneous sculpting, the surgeon does have technical allowance to revise the scars, and render them (more) inconspicuous.