You may have a beautiful and attractive nose and even breathe better with rhinoplasty.

Specialized in aesthetic and functional rhinoplasty

Londrina plastic surgeon Dr. Walter Zamarian Jr., specialized in the United States, under the guidance of the best nose surgeons in the world, in aesthetic and functional rhinoplasty. Not only does he have a keen aesthetic sense to allow for a beautiful and natural result, but he also has the skill and knowledge necessary to provide the maximum possible improvement in nose breathing. That's because it addresses the four pillars of nasal breathing during rhinoplasty: septum, turbinates, internal nasal valve and external nasal valve.

The functions of the nose

The nose has the following functions: breathing, humidifying and filtering the air, as a temperature regulator and protection, in addition to enabling the sense of smell. All these important functions of the nose must be taken into account by the plastic surgeon when performing an aesthetic rhinoplasty, so that this surgery does not interfere with any of the elements responsible for these functions. These elements are: the septum, turbinates and internal and external nasal valves, fundamental structures that directly influence the flow of air in the nose.

Nasal septum

The nasal septum is a perpendicular structure, like a wall, which is composed of a cartilaginous part, called triangular cartilage, and a bony part, formed by the vomer and ethmoid bones, dividing the nose in half, in two nasal cavities, right and left. The air passes in a laminar fashion on each side of the septum. When it is desired to improve the function of the nose during aesthetic rhinoplasty, the septum must be evaluated in its entirety, as any deformity, deviating the septum, can alter the laminar flow of air and lead to a secondary increase in the turbinates. The surgery indicated in this case is septoplasty, which corrects the deviated septum. The good news is that plastic nose surgery can be combined with septoplasty to correct both aesthetic problems and functional problems of a nose, which we call rhinoseptoplasty. Dr. Walter Zamarian Jr. performs the aesthetic part of the rhinoseptoplasty, after his colleague Otorrino has improved the septum deviation and eventual hypertrophy (enlargement) of the turbinates.

Nasal turbinates

The nasal turbinates are curved bone plates, as a lateral elevation of each wall of the nasal cavity, covered with mucosa, which stand out from the inner face of the ethmoid and protrude from the outside of the nasal cavities. They play an important role in the respiratory system, the immune system and the sense of smell in humans. There are two types of turbinates: the constant turbinates which comprise the lower, middle and upper turbinates and the inconstant turbinates which comprise Santorini's turbinate and Zuckerkandl's turbinate.

The lower turbinate is the largest turbinate among the three, being responsible for humidification, temperature and filtering of the air that enters through our nose. In addition, the lower turbinate has the greatest impact of resistance to the inflow of air into the nose, and can account for up to two-thirds of that resistance. The middle turbinate is the middle one, which protects the sinuses from coming into direct contact with the air stream. Finally, the superior turbinate is a smaller structure, which is connected to the middle turbinate by a nerve ending and is responsible for protecting the olfactory bulbs.

The mucous membranes, which cover the bony part of the turbinates, undergo a cycle of expansion and contraction mediated by the autonomic nervous system. Problems related to the turbinates are treatable during rhinoplasty, when it is also desired to improve respiratory function. Changes in the size of the nasal turbinates are known as turbinate hypertrophy and are very common in cases of bullous turbinate (swelling of the turbinate that can obstruct the sinuses), allergic rhinitis, and vasomotor (non-allergic) rhinitis. They can be treated in conjunction with rhinoplasty, by cauterizing the turbinates or removing them through turbinectomy surgery, also called turbinoplasty.

Internal and external nasal valves

The nasal valve is an important regulator of airflow dynamics, and is divided into the internal nasal valve and the external nasal valve.

The internal nasal valve is the angle formed between the septum and the anterior border of the triangular cartilage. Its preservation, during nose surgery, is essential to avoid a sequel of collapse of the nose wings during inspiration. If the patient seeks a plastic surgeon with this complaint, the treatment performed may require a cartilage graft called "spreader graft".

The external nasal valve is located anterior to the internal nasal valve and is the vestibule that enters the nose. It may be obstructed by extrinsic factors (foreign bodies) or intrinsic factors (weakened alar cartilages due or not to previous plastic surgery of the nose, loss of vestibular skin or scar narrowing). There are several possible treatments for external nasal valve, which will depend on the case at hand.

Characteristics of structured rhinoplasty performed by Dr. Zamarian

• it is performed from the age of 15;
• it is indicated for nose correction with congenital aesthetic defects or due to trauma, as well as functional problems;
• can be performed at any time of the year;
• fully functional and individualized, according to the patient's ethnicity and anatomy;
• when necessary, osteotomies are performed to correct the nasal dorsum , narrowing it;
• when necessary, grafts are used, harvested from the septum, ears or cartilages of the ribs;
• does not require much rest time after surgery. surgery;
• primary rhinoplasty or even secondary rhinoplasty can be associated with other surgeries, such as mentoplasty (chin plastic surgery), improving the facial profile;
• the results are long-lasting, satisfying and natural.

Closed or open? Dr. Zamarian does both

Whatever technique Dr. Zamarian for his rhinoplasty, he will perform according to the most modern tactics, learned by him in Brazil, with professor Ivo Pitanguy, and in the United States, with the biggest names in rhinoplasty in the world. Not only does he care about improving the aesthetics of your nose, he also takes care of every detail that can be addressed so that your breathing is the best it can be. He learned from Dr. Dean Toriumi of Chicago, the most renowned otolaryngologist who performs rhinoplasty, treats the turbinates, the inner nasal valve and the nostrils, in such a way that patients with difficult breathing can have the double benefit: of a beautiful result and of a function nose properly. Likewise, Dr. Ali Sajjadian from California relayed to Dr. Zamarian the modern techniques of nasal structuring in closed rhinoplasty, making its results evolve in a high degree. "I was already passionate about the results of closed rhinoplasty, according to Professor Pitanguy's principles. Now, with the structuring of the nose, both in closed and open rhinoplasty, in addition to obtaining aesthetically natural noses, the improvement in breathing greatly increases satisfaction of patients with the result."

What's different about structured rhinoplasty?

Dr. Zamarian explains that structured rhinoplasty focuses not only on the aesthetic result, but also on improving breathing. In this way, in addition to lowering the back, narrowing the nose and raising and tuning the tip, other details are also performed, such as:

Spreader graft

The internal nasal valve is an important part of the inside of the nose that helps regulate the passage of air. For this reason, the nose plastic surgery performed by Dr. Zamarian aims to reinforce the structure of the internal nasal valve with grafts called spreader graft. They consist of a strip of cartilage placed on each side along the bridge of the nose, running from the nasal bone to the tip. These grafts, in addition to serving to keep the nose aligned in the midline, serve to keep the internal nasal valve opening, improving breathing, especially in patients with weak lateral cartilages. Grafts can be taken from the septum, costal cartilages or, less frequently, from the ears. Dr. Zamarian has been dedicated to the functional part of the nose, and performs spreader graft in both closed and open rhinoplasty. The correct technique for placing a spreader graft by closed rhinoplasty is not so widespread in Brazil, and Dr. Zamarian went to acquire this knowledge in the United States, with Dr. Ali Sajjadian. This was a landmark given to her closed rhinoplasty results. Since then, the association of spreader graft with the treatment of the turbinates, when there is hypertrophy, has given nose plastic surgery patients a greater respiratory capacity. Many notice this improvement from the first week, even with the nose swollen inside.

Septal extension graft

Many patients looking for a rhinoplasty complain of a drooping tip and present columelolabial retraction. This means that support for the tip of the nose is lacking, and it is common in patients with weak or soft cartilage in the nose. To provide cutting-edge support and open the columelolabral angle, Dr. Walter Zamarian Jr. performs one of two procedures: septal extension graft in open rhinoplasty, or stake graft in the columella, in closed or open rhinoplasty. When the tissues of the nose are heavy and the need for support is great, Dr. Walter is for open rhinoplasty with septal extension graft. This graft consists of a segment of cartilage that is placed vertically, resting on the anterior nasal spine and slightly higher than the dorsum. It is attached inferiorly to the anterior nasal spine and superiorly between the two spreader graft cartilages. This graft can be wider at the base and narrower at the apex, performing an upward and backward rotation of the tip, helping to lift the tip when necessary. It can only be performed in an open rhinoplasty.

Stake graft in the columella

This graft is also used to help support the tip of the nose, and can be performed in both closed and open rhinoplasty. When the need to extend the septum does not exist, and the support of the tip can be performed in a less robust way, the stake graft in the columella, also called strut, can be performed. . During a closed rhinoplasty, Dr. Zamarian places the graft between the two alar cartilages, in the columella, through a vertical incision, in the columella, which practically does not leave very visible scars in the postoperative period. The graft is fixed in place using absorbable threads of PDS. In open rhinoplasty, this graft is placed under direct vision, also between the two alar cartilages and also helps to reinforce the structure of the tip, allowing for greater support and projection.

Other grafts

Cartilage graft in radix

Radix is the nasal root, it is the part next to the glabella, the region that is between the eyebrows. Often, the nose bone in this part can be too low. This is very common in patients with an Indian nose, for example. That way, if the nose surgery were performed from that point on, the entire nose would be very low. To prevent this from happening, Dr. Zamarian performs a radix cartilage graft. With this, it raises the height of the nose at its root and the entire rhinoplasty can be performed from a higher point, when necessary. This graft is specially made with cut cartilage and very small pieces, which are placed inside a syringe. These little bits are then injected into the radix and modeled in place. It's like a filler with hyaluronic acid, but made with cartilage. After the healing process, this graft consolidates and becomes even harder than the cartilage, giving a very long-lasting result.

Graft to elevate the entire back

The graft mentioned above, for radix, can be performed along the entire dorsum of the nose. There are other ways to increase the height of the back, such as a rib cartilage graft or a cigar made with temporal fascia and chopped grafts, but these two have the drawback of eventually being able to move out of place or become a little palpable or apparent. For these reasons, Dr. Zamarian chose the radix minced cartilage graft, without temporal fascia, as the technique of choice to elevate the nasal dorsum.

Alar cartilage graft at the tip

During the decrease in the width of the tip, the upper (cephalic) segments of the two alar cartilages, which form the tip of the nose, are removed. This maneuver relaxes the tip and thins it out a bit. To thin it out a little more, stitches are given between the two cartilages, joining them and providing a more projected and thinner tip, with only the thickness of the skin being a limiting factor. To promote better definition of the tip of the nose. Dr. Zamarian uses one of these two cartilage segments, which were taken from the wings, and places it on the tip of the nose, horizontally. This brings the benefit of extra projection at the tip, in addition to smoothing any alar cartilage asymmetries that the person may have. In addition, you can control where the tip of the nose will have its greatest projection, making the tip as attractive as possible.

Factors for a successful rhinoplasty

There are some basic factors that must be taken into account in order to obtain the best possible result in a nose job.

Nasofacial analysis

It is of paramount importance that the plastic surgeon performs a meticulous prior assessment of the patient's nose and face before surgery. The plastic surgeon needs to understand how the structure that will work, sculpt and model is found to improve its appearance and the patient's self-esteem. Dr. Zamarian, when analyzing the patient's nose and face, is basically based, in addition to aesthetics, on mathematical proportions such as the thirds of the face and angles formed by the facial anatomy, which will allow for more accurate results of the proportions of the nose in relation to the face of a patient. each patient. Guided by his keen aesthetic sense, Dr. Zamarian begins to trace the route of the operative plan of his rhinoplasty.

Operating plan

As there are different approaches to a nose job, during the consultation, Dr. Zamarian explains what are the most viable possibilities for fixing the defects in question and what tactics can be used. In addition, after discussing the case with the patient, it outlines the operative plan that best provides the results for the specific case. It is important that the plastic surgeon correctly follows the previously stipulated operative plan so that the results are satisfactory for both him and the patient. The only exception to this is due to the occurrence of supervening causes that make it difficult for the plastic surgeon to follow the original surgical plan. Dr. Zamarian, always striving for the best results, takes the patient's entire operative plan with him to the operating room, along with standardized photos and the patient's file to resolve any possible doubts during the operative act.

Favourable anatomy

During the nasofacial evaluation, carried out in the first consultation, the plastic surgeon will understand, from the patient's nasal anatomy, which maneuvers will be necessary and what results will be possible. Unfortunately, if the anatomy is not favorable to the result dreamed of by the patient, the plastic surgeon cannot do anything in this case, as there are limits to making changes to the nose. Patients who arrive with a proposal far beyond what their structure allows should reflect on aesthetics confronting their own health and understand that not all nasal anatomy is favorable to the desired result. Therefore, it is the plastic surgeon who must show the limits, suggesting the maximum possibilities of modifications, being able to present alternatives to the very exaggerated results dreamed by patients. If this doesn't happen, the plastic surgeon can harm himself as well as put the patient's health at risk, causing the facial balance to be lost with the performance of a surgery without proper preparation.

Critical Analysis

During a rhinoplasty, it is not only the aesthetic factors that must be taken into account, as mentioned earlier. It is one of the most challenging plastic surgeries for the surgeon. A critical analysis must be done by the plastic surgeon so that he can tell the patient what will be the consequences of the modification he will make in the structure of his nose. That is, in addition to sticking to the aesthetic result of the nose, he should also be concerned with nasal functionality and health. It's like the cause and effect relationship: any change made during nose surgery will generate effects, which can be positive or negative. The positive effects involve the previous analysis, the operative plan and the favorable anatomy that, together, provide the good results.

Experience and skill of the plastic surgeon

One of the most important factors for the success of a surgery is due to the surgeon's experience and skill. Accordingly, Dr. Zamarian, cherishing for his good years in the field of aesthetic plastic surgery, is always updating himself, attending national and international congresses, as well as reading books and magazines about nose plastic surgery and other aesthetic and reparative surgeries. He accompanied the illustrious Professor Ivo Pitanguy in many of his surgeries during his three-year residency in Rio de Janeiro. He studied anatomy in depth and became an expert in facial analysis. All this made Dr. Walter Zamarian Jr. become one of the great names in nose plastic surgery in Brazil. Patients from all over the world come to learn a little more about his skills in sculpting and reshaping a nose. Schedule an appointment at the Zamarian Plastic Surgery Clinic and learn all the details of the aesthetic plastic surgery of the nose performed in Londrina, Paraná, Brazil.

Complete approach to the nose, both aesthetic and functional

In the past, you could only think of a cosmetic nose surgery. The function of the nose used to be, and is still today, the responsibility of an ORL specialist. Medicine is evolving, and both some ORLs are starting to perform cosmetic nose surgery, and plastic surgeons are treating the functional part. This has reinforced that the vision of nasal surgery should be as comprehensive as possible. No patient would certainly like to have a beautiful, functionless nose. For many years, Dr. Zamarian performed aesthetic rhinoplasty together with ORLs, which performed the functional part. However, due to the need to optimize the nasal cartilages to perform the necessary grafts, he underwent training in the United States to be able to offer his patients the same quality of functional result that he had been having with the aesthetic part. In this way, a single person makes the complete surgical plan, both aesthetic and functional, so that the approach to one aspect does not interfere with the other.

Preoperative

Nose Assessment

Patients who wish to undergo a rhinoplasty plastic surgery in Londrina undergo a thorough evaluation with Dr. Walter Zamarian Jr, who will explain the procedure, study the patient's facial structure based on mathematical formulas, thus being able to determine which areas of the nose will undergo greater changes in order to have the expected rhinoplasty result and if there will be any segment of the nose with expectations limited by several factors, such as, for example, the thickness of the nasal skin, the fragility of the bones of the nose, among others.

Aesthetic parameters of the nose

Briefly, we can mention here some parameters that the plastic surgeon takes as a basis to determine the points to be improved. They are mathematical parameters and proportions, so they help to measure what is visibly altered. It should be remembered that these parameters serve only as a guideline, and each nose has its particularities and measurements outside these parameters are totally acceptable, considering that there is harmony with the face, always reminding us of the ethnic differences that must also be taken into account.

The thirds of the face

In order to obtain predictable and more concrete results, the plastic surgeon divides the face in three, using four horizontal lines:

• a tangent to the hairline (variable and less important line);
• a line at the eyebrow level;
• another at the nasal base and
• the last tangent to the chin (chin).

Divergences in these proportions may indicate maxillofacial alterations, such as vertical maxillary excess, known as "bird face" or maxillary hypoplasia. As it is the foundation of the nose, that is, where it is located, important changes in the maxilla must be treated before rhinoplasty.

Nose Length

In order to have a certain idea of what to do when the discomfort starts from the length of the nose, one must analyze whether the length of the nose is equivalent to the vertical distance between the oral commissures (angles of the mouth) and the lowest point of the chin, in a frontal view. In this way, Dr. Zamarian can confirm whether the length of the nose is proportionately unsightly or not for the surgery.

Deviated nose

A straight vertical line is drawn that goes from the middle of the glabella (region between the eyebrows) to the chin, dividing the nasal dorsum, upper lip (with its Cupid's Bow) and incisors in the middle (so that it is parameter, the patient has a normal bite). Any nasal deviation from this line, called laterorhinia or "crooked nose", is likely to require an osteotomy (fracture of the nasal bone) and septoplasty.

Base of the nostrils

The normal distance between the nasal wings is equivalent to the distance between the medial corners of the eyes (intercantal distance), or the width of the opening of an eye. If the distance between the nostrils is greater than the intercantal distance, the cause should be studied first. If the cause is a narrow intercantal distance, it is better to leave the wings of the nose slightly open, proportionately, than to surgically correct the distance between the eyes. If the nostrils are truly wide, closing the nostrils may be indicated.

Stylus shape

The nasal tip is evaluated by drawing two triangles with their opposite bases, guided by the "supratip break" and by the columelolabial angle (formed between the lip and the outer septum, the columella). If these triangles are asymmetrical, it may be necessary to perform maneuvers to modify the tip of the nose.

In addition to modifying asymmetrical tips, it may be necessary to thin the nasal tip, especially in patients with a bulbous nasal tip, the famous potato nose.

Baseline view of the nose

In the basal view of the nose, the nostrils and the base of the nose are evaluated, which must describe an equilateral triangle, with a ratio between the lobe and the nostril of 1:2. The nostril should be in a teardrop shape, with its major axis oriented slightly medial (from base to top).

Frontonasal angle

This angle connects the glabella (space between the eyebrows) to the root of the nose, in a smooth curve, whose angle should be between 128 and 140 degrees, more specifically 134 degrees in women and 130 degrees in men.

Projection of the tip

In the side view of the nose, the tip projection should be equal to the width of the nostrils in a frontal view and 67% of the length of the nose (from root to tip). Another way to evaluate the projection of the nasal tip is to know how much it is projected anteriorly to a perpendicular line to the most anterior point of the upper lip. This previous projection is normally equal to 50 to 60% of the total tip projection.

Nasal dorsum

The analysis of the dorsum starts by drawing a line parallel to it, which goes from the root of the nose to the tip. In women, the ideal position of the back is about 2 mm below this line and almost parallel to it. In men, the dorsum should be very close to this line, to avoid feminization of the nose.

Usually, the tip is slightly more projected than the dorsum of the nose and the plastic surgeon can lower the dorsum, raise the tip, or perform these two techniques during surgery, in order to obtain the best result for each case.

Columelolabial angle

It is the angle formed between the columella and a plumb line perpendicular to the natural horizontal plane of the face. This angle should be between 95 and 100 degrees for women and between 90 and 95 degrees for men.

Columella

Also known as sub-septum or mobile septum, the columella, the column of skin between the nostrils, can also be corrected. Basically, there are two unsightly defects of the nose that can involve the columella: the retracted columella and the hanging columella .

A retracted columella is one that is “hidden” due to lack of skin or cartilage in that region. The columella hanging, in turn, stands out for having excess skin and cartilage in that region, causing it to be protruding, that is, pedant, between the nostrils and both cases can be improved. How to know if the columella is pending? It is not always that the formulas go according to the patient. There are cases that only by visual evaluation, the plastic surgeon can detect the problem. Dr. Walter Zamarian Jr, in addition to performing a visual assessment, basically uses mathematical calculations to solve this rhinoplasty problem: according to the image, when A – B is greater than 4 mm, it means that the columella is altered.

Fortunately, both columella defects can be resolved. Dr. Walter Zamarian Jr uses cartilage removal or grafts to correct such problems.

Assessment of the thickness of the skin of the nose

The nasal dorsum is formed by the osteo-cartilaginous structure and the thickness of the skin that covers it. The skin that covers the entire nasal structure is not uniform in thickness, being thinner in its upper two thirds (root) and thicker at the tip. In addition, the upper part of the skin is more mobile and has fewer sebaceous glands than the part that covers the tip of the nose.

The skin of the nose covers everything that is performed below it during rhinoplasty, which is why Dr. Zamarian draws attention to this important detail: the thick-skinned nose shows less of the refinements made, and the thin fur shows the smallest details. Just as a thick blanket has a hard time showing what's underneath, a person with thick skin might have a hard time getting a very thin nasal tip.

Overall, patients with predominantly thinner nose skin will achieve the desired results faster and more pronounced when compared to patients who have predominantly thicker skin. These will have to wait a little longer for the results to reach complete healing.

Assessment of anterior septal angle: is there support at the tip?

In order for the plastic surgeon to know if there is support on the nasal tip, there is a simple test that allows you to see it immediately, which is done by simply squeezing the tip of the nose with your finger. If the nose sinks, it means it has little support, so it can be corrected. In these cases, Dr. Zamarian can conclude whether there is a need to lower the tip or not. If it remains in the same place, sinking a little, it is a sign that the tip of the nose is well supported, so there is no need to make changes to this element.

Medications that should be discontinued before surgery

Dr. Zamarian contraindicates the use of certain medications before the surgery, as there are some medications that interfere with blood clotting, sedatives, anesthesia and adrenaline, which must be suspended for a period of fifteen days before and after this cosmetic surgery. . Among them are:

• Acetylsalicylic acid, known as AAS, which is marketed under the name Aspirin, Alka seltzer, Bufferin, etc.;
• Ginko biloba;
• Arnica, by directly interfering with blood clotting;
• Tricyclic antidepressants (amitriptyline, clomipramine, nortriptyline, etc.);
• Oral anticoagulants (marcumar, marevan, etc.);
• Appetite suppressants and weight loss medications (amphetamines, sibutramine, etc.).

Always tell your plastic surgeon about all medications you take, including natural ones.

Required exams

Before performing nose plastic surgery, it is necessary to carry out some tests, so that Dr. Zamarian can assess the patient's health, including providing greater safety to the procedure. Tests that are usually ordered before rhinoplasty are performed include:

• Complete blood count;
• TAP with INR + KPTT;
• Urea and creatinine;
• Fasting blood glucose;
• Total proteins and fractions;
• Urine I;
• Electrocardiogram;
• Surgical risk (assessment with a cardiologist);
• Radiography: profile of the bones of the nose and mentalis plate (sinuses).

To perform rhinoplasty, whether primary or secondary, it is important for the plastic surgeon to know about the nasal breathing capacity of each patient before performing the nasal plastic surgery, as well as a history of trauma in the past, previous surgeries, rhinitis or sinusitis. Deviated septum and the nose as a whole are evaluated. Dr. Zamarian usually performs an examination of the inside of the nose, looking for synechiae, deviated septum or turbinate hypertrophy for a complete evaluation.

Anesthesia

For a complete plastic surgery of the nose, which involves nasal osteotomy (bone fracture), grafts up to the tip treatment, general anesthesia is indicated, because in these cases, only local anesthesia is not satisfactory and safe for the patient. patient. As for the cases where Dr. Zamarian indicates only the tip treatment, the procedure can be done with local anesthesia and venous sedation only.

We use the term “general anesthesia” to refer to the anesthetic technique that promotes total unconsciousness (hypnosis) of the patient, pain relief (analgesia) and muscle relaxation. General anesthesia makes it possible to perform any necessary maneuver during nose surgery. Local anesthesia leaves the plastic surgeon a little limited, and this type of anesthesia is not indicated when the patient must undergo an osteotomy, for example.

After anesthetic induction, which is the period of transition from consciousness to the patient's unconscious state, the preparation of the nasal vestibules is necessary, at which time the plastic surgeon must trim the nasal vibrissae (nasal hairs) and perform the antisepsis on the inside and outside of the nose.

After preparing the vestibules for nose plastic surgery, approximately 20 ml of a solution with 1% lidocaine and 1:80,000 adrenaline is injected to minimize bleeding during rhinoplasty, thus also preventing ecchymoses (purple ) and postoperative pain.

The areas of the nose where this solution is applied before rhinoplasty are: nasal dorsum, tip, anterior nasal spine, fracture line, alar mucosa and septum. Dr. Zamarian waits approximately 12 minutes for the full vasoconstrictor effect of adrenaline before starting the procedure.

To provide greater patient safety, our specialized anesthesiologist monitors the entire surgery, from beginning to end, together with Dr. Zamarian. The presence of the anesthesiologist during the surgery is essential to monitor the patient's pressure, pulse, temperature, breathing, degree of sedation, diuresis and hydration throughout the procedure.

Rhinoseptoplasty and turbinoplasty (or turbinectomy): functional treatment of the nose

During the preoperative patient assessment by Dr. Zamarian, there are cases in which deviated septum and turbinate hypertrophy are detected. Deviated septum can occur, basically, for two reasons: congenital (present at birth) and acquired (generally after trauma). If the patient needs functional improvement with a nose job, in addition to the aesthetic improvement it provides, Dr. Zamarian performs rhinoseptoplasty, with treatment of the turbinates when necessary, where he himself performs the aesthetic and respiratory function. Therefore, rhinoplasty is not only performed for aesthetic but also functional improvement. There are several ways to correct a deviated septum, among them the simple removal of the deviated part of the septum, whether cartilaginous or bony, or also the removal of this segment, correction of its deviation with incisions and cartilage maceration and reinsertion into the nose. When the deviated segment is low and contains a spike, it is called a spur, and it can also be corrected during septoplasty. The turbinates can be treated with turbinoplasty, where the position of the turbinates is changed, or with turbinectomy, where they are removed.

Turbinectomy or turbinoplasty: correction of turbinate hypertrophy

Often, deviated septum is not the only villain that hinders respiratory function in patients who are candidates for nasal plastic surgery. The nose is made up of some turbinates, also known as turbines or shells, which are inserted into the side walls of the nose, which may be enlarged, making breathing difficult. During rhinoplasty, or rhinoseptoplasty, the combination of turbinoplasty or turbinectomy surgery may be necessary. Turbinoplasty modifies the position of the turbinates, increasing the passage of air. If the increase is very large, turbinectomy may be necessary, which consists of removing, in whole or in part, one or more turbinates. Most of the time, the turbinate that interferes with breathing is the lowest, lowest, which is also the largest.

The nasal splint and the synechiae

During rhinoplasty with septoplasty and/or turbinectomy, it is usually necessary to place, in addition to the tampon, a nasal splint, which would be a small plastic or silicone plate , in each nostril. In addition to helping to support and fix the septum in the postoperative period, it prevents contact between bloody areas of the septum and the lateral wall of the nose, also preventing a condition called synechia. The synechia in the nose is a scar that forms a bridge between the septum and the lateral wall of the nose, after a surgery that involves septoplasty or turbinectomy where there was a bloody area (without epithelium) at the same height of the septum and the lateral wall of the nose. The synechia may have nasal obstruction or wheezing (whistling during nasal breathing) as symptoms. Its treatment can involve from a cross opening or total removal, then protecting with a nasal splint.

Secondary Rhinoplasty

Secondary is the plastic surgery of the nose in those who have already had a first rhinoplasty (which is called primary). Often, it is necessary to complete an incomplete fracture, lower the dorsum, increase the dorsum with cartilage grafts, correct an inverted "V" with "spreader graft", correct supratip, improve projection or tip definition with cartilage grafts or cartilage remodeling, correct superficial irregularities, improve scars from open rhinoplasty or nostril rotation, correct deviations, among others.

Changes in surgical planning

When performing secondary rhinoplasty, Dr. Zamarian will not use the same techniques as a primary rhinoplasty, or conventional rhinoplasty, as there will be the presence of fibrous scar tissue, changes that have arisen as a result of previous rhinoplasty (primary rhinoplasty) and, mainly, it must be taken into account that the nasal structure is already more fragile after having undergone possible osteotomies, grafts, scrapings, etc. performed in the first plastic nose surgery.

In order for the plastic surgeon to consider the possibility of revision of a rhinoplasty, the ideal is that the patient has waited a period of one year, counting from the date of the primary nose plastic surgery (first rhinoplasty), because this is the time required for full recovery from a rhinoplasty, so that the entire nasal structure is completely healed, recovered and with swelling at the end. Technically, secondary rhinoplasty is more complex as the plastic plastic surgeon will be dealing with distorted or even absent anatomy. Mainly due to swelling, it is not good for the plastic surgeon to perform secondary rhinoplasty within a year of primary rhinoplasty, as swelling is still present. The swelling between the nasal skeleton and the skin that covers it can cause the surgeon to lose the parameters of the original structure of the nose, being a high risk for the results, which can be in disagreement with what the patient wants. Therefore, Dr. Zamarian recommends waiting a year from the primary period before performing secondary rhinoplasty.

Candidates for secondary rhinoplasty

Dr. Zamarian explains that, in general, there are some prerequisites for the patient to undergo secondary plastic nose surgery, which are:

• patients over 15 years of age who have undergone primary rhinoplasty, not obtaining the desired results or who have experienced complications that prevented the desired result from being achieved;
• dissatisfied patients with some visibly unsightly and/or perceptibly functional defect;
• emotionally stable patients, that is, who are in good emotional and mental condition;
• patients in good health and not have any type of contraindication to undergo secondary rhinoplasty;
• patients who are aware and willing to undergo cartilage graft if necessary;
• patients who are prepared, having an optimistic view and realistic of the secondary rhinoplasty itself, always remembering the limitation that this procedure involves.

These are just some of the general prerequisites, that even if the patient is in compatible conditions according to the requirements, he must go through a previous consultation with the plastic surgeon, at which time he will evaluate the possible aesthetic defects and /or functional to diagnose which were the reasons for failure of the previous surgery. Dr. Zamarian makes a meticulous evaluation of all the problems and points of dissatisfaction that bother the patient, so that he can outline the surgical plan that, this time, will be much more complex than that of a primary nose job.

Cartilage graft

Considering that most cases of secondary rhinoplasty treatment that reach Dr. Zamarian involve patients with a lack of cartilage to produce a satisfactory nasal reconstruction, at the Zamarian Clinic, this procedure has as its basic repair technique the use of grafts. When dealing with primary rhinoplasty, cartilage collection is not usually a problem, since this material is found in large quantities in the cartilaginous septum and in both ears. “The preference is that septum cartilage is used, to make nose plastic surgery as less invasive as possible, however, septum cartilage collection is not always possible, as the patient may have operated on a deviated septum in the first surgery” , ponders Dr. Zamarian.

Furthermore, nothing prevents the plastic surgeon, in secondary rhinoplasty, from using the cartilage of the septum and ears when they are available and they will not weaken the nasal skeleton. “The cases of grafts vary a lot when we are dealing with rhinoplasty, especially secondary ones”, says Dr. Zamarian. Despite being quite complex, it is also very important that the plastic surgeon always aims at individuality, naturalness and compatibility with the patient's ethnicity when performing secondary rhinoplasty, as well as primary rhinoplasty.