The Complete Surgeon’s Guide to Septorhinoplasty: Indications, Techniques, and Complications

Septorhinoplasty, commonly referred to as "nose job," is a complex surgical procedure that combines septoplasty (correction of a deviated septum) and rhinoplasty (reshaping of the nose). It is performed for both functional and aesthetic purposes, addressing issues related to breathing, nasal obstruction, and nasal deformities. This article will delve into all aspects of septorhinoplasty, including indications, preoperative evaluation, contraindications, surgical techniques and steps, postoperative care, possible complications, different techniques, prognosis and outcomes, alternative options, average cost, recent advances, and more.

Indications for Septorhinoplasty

Septorhinoplasty is indicated for a variety of reasons, which can be broadly categorized into functional and cosmetic purposes.

Functional Indications:

1. Nasal Obstruction: Patients with a deviated septum often experience nasal obstruction, leading to difficulty in breathing, chronic nasal congestion, and sleep disturbances. Septorhinoplasty can correct the septal deviation, improving airway patency.
2. Chronic Sinusitis: A deviated septum can contribute to sinus blockages, recurrent infections, and chronic sinusitis. Correcting the septal deformity can alleviate these symptoms.
3. Trauma: Nasal fractures or injuries resulting in deformities or breathing difficulties are common indications for septorhinoplasty.
4. Sleep Apnea: Obstructive sleep apnea may be exacerbated by nasal obstructions that can be corrected through septorhinoplasty.
5. Congenital Deformities: Conditions such as cleft lip and palate or other congenital nasal deformities may require septorhinoplasty for functional and aesthetic correction.

Cosmetic Indications:

1. Nasal Deformities: Patients seeking to improve the appearance of their nose due to congenital or acquired deformities, such as a hump, wide nasal tip, or crooked nose, often opt for septorhinoplasty.
2. Facial Harmony: Septorhinoplasty can enhance facial balance by reshaping the nose to better fit the overall facial structure.
3. Post-Traumatic Deformities: Traumatic injuries can lead to nasal deformities that affect both function and appearance, making septorhinoplasty a dual-purpose procedure.

Preoperative Evaluation

A thorough preoperative evaluation is critical to the success of septorhinoplasty. This process involves several key steps:

1. Patient History:
   • Detailed medical history, including previous nasal surgeries, trauma, allergies, and breathing issues.
   • Assessment of any pre-existing conditions that could affect surgery, such as bleeding disorders, diabetes, or hypertension.
   • Understanding the patient’s goals, whether functional, cosmetic, or both.
2. Physical Examination:
   • External nasal examination to assess the shape, symmetry, and any visible deformities.
   • Internal nasal examination using a nasal speculum to evaluate the septum, turbinates, and any signs of obstruction.
   • Endoscopic examination may be necessary for a detailed view of the nasal cavity, including the septum, turbinates, and sinuses.
3. Photographic Documentation:
   • Standardized preoperative photographs are taken from multiple angles to document the nasal structure and aid in surgical planning.
   • These images also serve as a reference for postoperative comparison.
4. Imaging:
   • CT scans may be indicated in cases of significant nasal obstruction, chronic sinusitis, or trauma to assess the underlying bony and cartilaginous structures.
5. Functional Assessment:
   • Rhinomanometry or acoustic rhinometry can be used to objectively measure nasal airflow and resistance.
6. Patient Counseling:
   • Discuss realistic expectations, potential risks, and the expected outcomes of the surgery.
   • Review the surgical plan, including the steps involved, anesthesia, and recovery process.
   • Obtain informed consent after a thorough explanation of the procedure.

Contraindications

Septorhinoplasty is generally safe, but there are contraindications that must be considered:

1. Active Nasal Infection: Surgery should be postponed if the patient has an active infection, as it increases the risk of postoperative complications.
2. Uncontrolled Medical Conditions: Patients with uncontrolled diabetes, hypertension, or bleeding disorders should stabilize their conditions before surgery.
3. Psychological Instability: Patients with unrealistic expectations or body dysmorphic disorder may not be suitable candidates for septorhinoplasty.
4. Smoking: Smoking impairs wound healing and increases the risk of complications; patients should be advised to quit smoking well before surgery.
5. Pregnancy: Elective surgeries like septorhinoplasty should be avoided during pregnancy due to the risks associated with anesthesia and stress on the body.

Surgical Techniques and Steps

Septorhinoplasty involves various techniques depending on the patient’s needs and the surgeon’s expertise. The surgery can be performed under general or local anesthesia with sedation.

1. Approach:

• Closed Technique: Incisions are made inside the nostrils, leaving no visible scars. This approach is preferred for minor adjustments.
• Open Technique: An additional incision is made across the columella (the tissue between the nostrils), allowing for better visualization and access to the nasal structures. This approach is used for more complex cases.

2. Septoplasty:

• Septal Incision: The mucoperichondrium (the lining over the cartilage) is elevated to expose the septal cartilage.
• Cartilage Removal or Repositioning: The deviated portions of the septum are removed or repositioned to straighten the nasal passage.
• Suturing: The septum is sutured to maintain its new position, and the mucoperichondrium is repositioned.

3. Rhinoplasty:

• Cartilage Sculpting: The nasal tip, dorsum (bridge), and other cartilaginous structures are sculpted to achieve the desired shape. Cartilage grafts may be harvested from the septum, ear, or rib.
• Osteotomies: Controlled fractures of the nasal bones (osteotomies) may be necessary to narrow or straighten the nasal bridge.
• Soft Tissue Adjustment: The skin and soft tissues are redraped over the new nasal framework.

4. Closure:

• The incisions are closed with fine sutures, and internal splints may be placed to support the septum during healing.
• External splints or tapes are applied to maintain the new shape of the nose.

Postoperative Care

Postoperative care is crucial for optimal recovery and outcomes:

1. Immediate Postoperative Care:
   • The patient is monitored in the recovery room until the effects of anesthesia wear off.
   • Pain management with analgesics, and antibiotics may be prescribed to prevent infection.
2. Nasal Packing and Splints:
   • Nasal packing or internal splints may be placed to support the septum and reduce bleeding. These are usually removed after 24-48 hours.
   • External splints or tapes are typically worn for 1-2 weeks to stabilize the nasal structure.
3. Instructions for Patients:
   • Avoid strenuous activities, bending, or lifting for several weeks to prevent bleeding.
   • Elevate the head while sleeping to reduce swelling.
   • Avoid blowing the nose for at least two weeks to prevent disrupting the healing septum.
   • Use saline nasal sprays to keep the nasal passages moist.
4. Follow-Up Appointments:
   • Regular follow-up appointments are necessary to monitor healing, remove sutures, and address any concerns.
   • Any residual swelling, bruising, or discomfort should be assessed and managed.

Possible Complications

Like any surgical procedure, septorhinoplasty carries risks, although serious complications are rare:

1. Bleeding: Postoperative bleeding is common but usually minimal. In rare cases, significant bleeding may require intervention.
2. Infection: Although rare, infections can occur, particularly if the nasal packing is in place for an extended period.
3. Septal Perforation: A hole in the septum can occur, leading to symptoms such as nasal crusting, whistling, or bleeding.
4. Asymmetry: Despite meticulous planning, asymmetry in the nasal shape or function may occur, sometimes necessitating revision surgery.
5. Poor Wound Healing: Scarring or poor wound healing, particularly in smokers, can affect the final outcome.
6. Numbness: Temporary or permanent numbness in the nasal tip or upper lip may occur due to nerve damage.
7. Anosmia: Loss of smell is rare but can occur if there is significant disruption to the olfactory nerves.
8. Adhesions: Scar tissue can form inside the nasal cavity, leading to nasal obstruction, requiring further surgical correction.

Different Techniques

Several techniques can be used in septorhinoplasty, depending on the specific requirements of the case:

1. Cartilage Grafting:
   • Grafts from the septum, ear, or rib may be used to support the nasal structure, particularly in cases of significant deformity or previous surgery.
2. Dorsal Hump Reduction:
   • The dorsal hump (bump on the nose) can be reduced using a chisel, rasp, or power tool to achieve a smoother nasal profile.
3. Tip Plasty:
   • Techniques such as cephalic trim, suturing, or grafting can refine the nasal tip's shape, projection, and rotation.
4. Spreader Grafts:
   • These are used to widen the middle third of the nose, particularly in cases of internal nasal valve collapse, improving both aesthetics and function.
5. Nostril Reduction:
   • Alar base reduction may be performed to narrow wide nostrils, enhancing the overall symmetry of the nose.

Prognosis and Outcome

The prognosis for septorhinoplasty is generally excellent, with most patients achieving significant improvements in both nasal function and appearance. The final outcome may take several months to a year to fully manifest as swelling subsides and the nasal tissues settle into their new positions.

Factors Influencing Outcomes:

• Surgeon Expertise: The skill and experience of the surgeon play a crucial role in achieving optimal results.
• Patient Compliance: Adherence to postoperative care instructions is essential for a smooth recovery and satisfactory outcomes.
• Complexity of the Case: More complex deformities or revisions may carry a higher risk of complications or suboptimal outcomes.

Alternative Options

For patients who are not suitable candidates for septorhinoplasty or prefer non-surgical options, alternatives include:

1. Nasal Strips: Over-the-counter nasal strips can temporarily improve breathing by widening the nasal passages.
2. Injectable Fillers: For minor cosmetic adjustments, injectable fillers can be used to reshape the nose without surgery.
3. Laser-Assisted Turbinate Reduction: Laser treatment can reduce the size of the turbinates, improving airflow without surgery.

Average Cost

The cost of septorhinoplasty can vary widely depending on factors such as the surgeon’s expertise, geographic location, and the complexity of the case. In the United States, the average cost ranges from $5,000 to $15,000. This includes surgeon fees, anesthesia, facility fees, and postoperative care. Insurance may cover part of the cost if the surgery is performed for functional reasons, such as correcting a deviated septum.

Recent Advances

Recent advances in septorhinoplasty include:

1. Piezoelectric Instruments: These devices use ultrasonic energy to precisely cut and reshape bone, reducing trauma and improving outcomes.
2. 3D Imaging and Simulation: Advanced imaging techniques allow for detailed surgical planning and patient visualization of potential outcomes.
3. Minimally Invasive Techniques: Innovations in surgical techniques aim to reduce scarring, recovery time, and the risk of complications.