Surgical techniques for nose correction

In aesthetic and functional nose surgery for example, techniques for nasal surgery which invole modelling and reconstructing are becoming more and more popular compared to resecting (cutting away) and destructive (removing) procedures.

Access

A rhinoplasty can be performed using the so-called open or closed approaches. For a closed rhinoplasty, all incisions are inside the nose whereas for an open rhinoplasty, an additional small incision is made on the columella of the nose.

Open rhinoplasty is often chosen for aesthetic procedures due to the better overview during surgery.

Open access in conjunction with today's optical instruments allows us to work with a high level of accuracy.

Optical aids

Nose surgery is precision surgery nowadays. We always work with optical instruments such as magnifying glasses and special optics. Details that would escape even a nose surgeon with excellent vision can then be seen clearly and precisely.

Component technique for nose correction

The component technique is the systematic further development of existing nose surgery methods to make aesthetic and functional surgery of the nose safer and more reliable.

For example, a nasal hump consists of different types of tissue including various cartilage and bone parts. Removing a nose hump as a whole (en bloc resection) is therefore very challenging. Even experienced nose surgeons may accidentally remove too much or too little tissue, so that during the operation this has to be corrected. Applying component technology, the individual parts of a nasal hump can be worked on separately and each part modelled with a tool specifically designed for this part. Bumps, excessive or under corrections during your nose surgery are consequently far easier to avoid. The ideal complement of component technology is its combination with powered, specialist tools (powered instrumentation), which increase precision, especially for modelling the bony bridge of the nose.

Spreader flaps

The form and function of the nose are inextricably linked. Nose hump removal used to be performed as an en bloc resection. That is, the cartilage and bone nasal hump was removed in one piece. To stabilize the inner nose particularly the so-called internal nasal valves while at the same time preventing an inverted-V deformity, stabilising cartilage grafts, spreader grafts, were often fixed to the nasal septum.

So-called ‘spreader flaps’ are an alternative. No en bloc resection of the nasal hump is required for the spreader flap technique. There is no partial removal of the cartilaginous walls. Instead, they are mobilised and modeled so that they physiologically reconstruct the cartilaginous nasal bridge and keep the inner nose open. The benefit of this technique is that no additional cartilage material is harvested from elsewhere, as is required for spreader grafts. In addition, the vault of the nose can be modeled to a natural and agreeable shape, while simultaneously stabilising the internal nasal valve.

Lateral crura turn-in flaps for correcting the tip of the nose

There are many surgical techniques described in the literature for correction of the nasal tip. Many traditional methods are resectioning procedures in which tissue is removed. Resectioning procedures can lead to a weakening of tissue, which in the long term is detrimental to the patient’s outward appearance and the function of the nose. Unstable tissue can lead to a narrowing of the inner nose (nasal stenosis) and difficulty in breathing through the nose. When lateral crural turn-in flaps are used, the lateral alar cartilage is doubled. In this method, the upper portion of nose wing cartilage is folded under the lower portion and fixed. The approach has two advantages: firstly it allows for optimal definition and appearance of the nasal tip, secondly the nasal valve is stabilised.

Saddle-nose correction and/or nose post-correction using Kassel L-Beam

The central support of the nose is the cartilaginous and bony nasal septum. Trauma and/or previous surgery may produce a significant loss of the cartilaginous support. In some cases the result may be severe deformation of the inner and outer nose, such as a saddle nose. The shape and stability of the nose can often only be recovered through elaborate surgery. Reconstruction frequently relies on costal cartilage to offset a significant loss of substance. Cartilage is harvested from you at the appropriate place and after careful re-working and modeling transplanted to the nose. Costal cartilage grafting is not as trivial as you might imagine.

Typical undesirable side-effects of the traditional costal cartilage techniques are slippage of the implanted costal cartilage (dislocation), warping, absorption or unevenness.

We developed the Kassel L-beam to offer patients who require a costal cartilage graft the prospect of an attractive and aesthetically pleasing outcome to their rhinoplasty or saddle nose correction.

A nasal septum reconstructed from costal cartilage has a fine, stable form, which is not only the basis to improve your nasal breathing, but also the foundation for the aesthetic correction of your choice. Using this technique, results which are accepted by patients are possible, even in seemingly hopeless situations.

Extracorporeal L-beam

Development of the L-beam was inspired partly by our colleagues the Swiss nasal surgeons Simmen and Briner who straighten bent ear cartilage by double-layering the cartilage and then reconstructing the nasal septum using this graft. The complementary ear cartilage graft was named the I-beam by the surgeons, because a beam shape provides stable support for a reconstructed nose and the graft has the shape of an I.

The other inspiration for the L-beam was Wolfgang Gubisch's technique of extracorporeal septoplasty. The bent nasal septum is removed completely, straightened on the operating table, reimplanted and fixed in place with sutures. Since this graft has the form of an L, we called it by analogy with the I-beam, the L-beam.

In the early years, all nasal reconstructions were performed extracorporeally using an L-beam. The remnants of the existing nasal septum are harvested, straightened by fashioning with doubled-layered costal cartilage and then grafted back into the nose. To ensure a delicate and natural appearance of the nose, the cartilage is machined with specialised milling tools, allowing the procedure to be non-traumatic and the modeling accurate. It has since been shown that for some patients L-beams can also be implanted intracorporeally.

Intracorporeal L-beam

In a proportion of patients it is possible to implant an L beam intracorporeally despite several previous surgeries and severe deformity, such as saddle nose. This means that the remnants of the existing nasal septum are left in situ (in the nose) and the L beam is constructed intracorporeally (in the nose). This is made possible by the sophisticated preparation of costal cartilage grafts applying a special milling technique.

Nose correction and sealing septum perforation

Holes in the septum may have many causes. Not infrequently they appear as a result of previous functional nasal surgery or aesthetic rhinoplasty. In recent years operation methods to close holes in the septum permanently have been developed for these difficult initial situations. Patients with a hole in the nasal septum often suffer not only from functional impairment, but also from an aesthetic deficit. A hole in the spetum can be closed using so-called extensions, and if required the 6-extension technique can also be applied during surgery while simultaneously correcting the external nose.

Powered instrumentation

As well as precision instruments and optical aids, we also use special machine-powered cutters, which make it possible to handle tissues very carefully and in particular to model the nose bone precisely and with less trauma.

Nasal packing and supports for the septum and / or bridge of the nose following nose correction

The decision on whether nasal packing is really required is decided on a patient-to-patient basis. If, simultaneously to the aesthetic rhinoplasty, function improving nasal surgery is also going to be performed, nasal packing may well be helpful. We will advise you on this matter as needed.

The internal nasal splint, called the Doyle splint, is made of soft silicone and as such can easily be positioned in the nose. Subsequent removal is also straightforward. It prevents dangerous bleeding into the nasal septum after surgery and protects the mucous membrane of the nasal septum. In addition, it helps prevent adhesion of the lateral nasal wall to the nasal septum.

Instead of a nose plaster, at the end of the operation we apply an aluminum splint (Denver splint) specially developed for this purpose. The nose bridge splint provides protection and encourages the nose to grow into the correct position; it also helps to reduce swelling.