Presented by: Sam Most, MD, FACS
Director, Division of Facial Plastic Surgery
Stanford University Medical Center
November 5, 2009
- Breathing problems can be caused by fixed or variable structures in the anatomy of the nose.
- Rhinoplasty reshapes the internal and external components of the nose.
- Functional rhinoplasty can improve breathing function and sometimes enhance facial harmony.
- There is no ideal profile, and each patient needs to be evaluated individually, assessing breathing, overall health, expectations, and prior surgeries
Our noses look the way they do for a reason. Not only are they an essential component of the movement of air during respiration, they also filter particles, provide the sense of smell, help in vocal communication, and regulate humidification.
The nose is made up of a fleshy casing over cartilage, somewhat like the set-up of a tent. And like a tent, changes to the support system can change the appearance of the covering. Understanding normal nasal airflow is a complex formula based on the laws of fluid dynamics in which changes in radius affect flow rate.
Breathing problems can be caused by variable obstacles, such as when the lining of the nose thickens from allergies or sinusitis, or with fixed obstacles, which include the septum; internal structures called turbinates; and the internal nasal valve, the narrowest section of the airway.
“The anatomy of the nose dictates that any changes done to the outside will affect the inside as well,” said Sam Most, MD, director of Stanford’s Division of Facial Plastic and Reconstructive Surgery, who spoke at a presentation sponsored by Stanford Hospital Health Library. “You’re not just changing the shape of the nose. The most important aspect to consider is how to improve or maintain nasal airway function.”
For many people, rhinoplasty, or a nose-job, is traditionally thought of as an operation to change the shape of the nose. However, in any rhinoplasty, function must be considered along with aesthetics-a mistake too often made by inexperienced rhinoplasty surgeons. Functional rhinoplasty is surgery that exclusively addresses fixed obstacles-the structures within the nose, though it can be combined with aesthetic (traditional) rhinoplasty.
Fixed obstacles include the septum, which is rarely perfectly straight and can sometimes block the nasal passage. A septoplasty can be performed to manipulate and straighten the septum, with almost no changes to the appearance. When swollen, an abnormal turbinate can also block the passage by changing the vascular lining. Dr. Most said the first line of defense in this case should be medical therapy, such as antihistamines or nasal steroids. If those don’t help, surgical options include radiofrequency ablation, microdebridement to remove the soft tissue, or a mucosal-sparing resection.
One of the most common causes of nasal obstruction is internal valve collapse, which may be caused by trauma or prior surgery. The degree of collapse is determined by the angle of the valve to the septum and wall. Surgery to address this problem can affect the appearance even though the primary goal is to improve breathing by widening the airway, said Dr. Most, so it is often combined with other procedures.
There are two adjacent zones involved in lateral wall support problems. For Zone 1, external nasal valve dilator strips often provide temporary relief by increasing the size of the nasal valve area. “First we try to treat this problem medically,” said Dr. Most. “But when there is a structural problem, then you need to restore the nasal structural support.”
In Zone 2, closer to the nostrils, the valve has no resistance to negative pressure and needs to be repaired. Adding cartilage (alar batten grafts) has not been proven to be effective in the long term said Dr. Most; another, more promising technique involves using a suture to stiffen the area to counteract the force when breathing.
Aesthetic rhinoplasty is about both form and function. Although ideal standards have been analyzed using tip rotation, chin position, and other factors, there really is no ideal nasal form, said Dr. Most. “There’s no cookie-cutter rhinoplasty, where one size fits all,” he emphasized. “Each person needs to be evaluated individually, assessing breathing, overall health, expectations, and prior surgeries.”
Computer imaging has drastically changed the practice of cosmetic surgery, providing an educational opportunity for both the surgeon and the patient in terms of outcome and possibilities. Procedures are done on an outpatient basis and usually take between 1-1/2 to 3 hours or more. Most people will experience post-surgery bruising, and final results can take as long as one year as the soft tissue and skeleton settle and adjust.
Dr. Most showed several before-and-after shots of patients, showing some of the more common rhinoplasty procedures, ranging from rotation of the nasal tip (the direction of the tip of the nose) by adjusting the tip’s cartilage to straightening a crooked nose by manipulating the supporting structures. He suggested that people of Asian or African descent retain an ethnically appropriate appearance by augmenting the nasal bridge without choosing an overly Westernized profile.
About 30 to 40 percent of his referral practice involves revisions to earlier rhinoplasties, he said. “Revisions are complex because of scarring so they really need to be done by experts who know the options for repair.”
About the Speaker
Sam Most, MD, FACS, is director of Stanford’s Division of Facial Plastic Surgery and an associate professor of Otolaryngology-Head and Neck Surgery. His research and clinical priorities involve assessments of new and existing plastic surgery techniques to enhance results and quality of life for patients. He received his MD from Stanford, did his internship at Yale-New Haven Hospital, and completed his residency and fellowship at University of Washington Medical Center, where he was chief of the Division of Facial Plastic Surgery. Dr. Most has been on the Stanford faculty since 2006.
For More Information:
About Dr. Most
Stanford Plastic Surgery
Stanford Department of Otolaryngology
San Francisco Rhinoplasty