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Recent Developments in Rhinoplasty

As with any body of science, the science of rhinoplasty has been constantly evolving. This evolution did not happen in a course of weeks or months, but if we look at the last decade we will see significant changes in rhinoplasty concepts from years prior.

In the past, so called “reduction rhinoplasty” had been almost a universal approach. For example, patients with bulbous tips had their tip cartilages reduced in size quite aggressively without paying much attention to cartilage strength, anatomy, overlying skin and many other important factors. This aggressive reduction quite frequently led to significant decrease in cartilaginous support of the nose. Consequently, many patients ended up with tip bossa, alar retractions, tip asymmetries and problems breathing due to external nasal valve weakness. You may ask why cartilage excision in cases of excessively wide cartilages would not always work? It may seem natural to cut the excess of the cartilage if we want to make the tip smaller, right? The answer is- not always right. Think what would have happened to a bow if you split the body thickness in half while keeping the same string tension? As you weaken the bow support, same amount of tension would likely make the remainder of the bow to bend even more with time. This is exactly what is happening with weak over-reduced nasal tip cartilages- instead of making the tip nice and small by cartilage resection, the cartilages would become weaker and more bowed, causing more tip bulbosity, various tip asymmetries and valve problems. In the same manner, aggressive dorsal reduction without restoring cartilaginous support led to inverted V deformities, overly narrowed noses and breathing problems due to internal nasal valve weakness.

It took quite a few years for rhinoplasty surgeons to fully appreciate the scope of the problem and to change their approach from resection to more of a suture modifications of the cartilages and various cartilage grafting to maintain the support of the nose. This was the time when numerous new nasal grafts have come to life. Whereas columellar strut graft was pretty much the only graft before, now we had a full plethora of new grafts developed: spreader grafts, alar batten grafts, lateral crural strut grafts, rim grafts, shield grafts, cap grafts, and septal extension grafts, to name a few. What was the outcome? The nasal support was preserved and quite frequently increased, however in many cases it did not make patients (and thus surgeons) much more satisfied. Patients started complaining of overly rigid immobile noses that would feel “foreign” to them. In addition, it would frequently take months and sometimes years for the postoperative swelling to subside. Also, excess cartilage due to numerous grafts would not infrequently cause too much “mass effect” on the airways leading to breathing problems.

So what is the solution? In the first scenario of reduction rhinoplasty, short term results might have been good, but long term results would suffer because of inadequate nasal support. In the latter scenario, the long term outcomes might have been improved, but short term results would still make many patients dissatisfied with surgery. Is there way to make both short and long term results equally optimized with one technique? Is there a “holy grail” approach to rhinoplasty?

Rhinoplasty surgeons are in the constant quest for this rhinoplasty “holy grail” technique. Last 5 years have been notable for more judicious use of cartilage grafts, conservative reduction rhinoplasty techniques, suture restructuring rhinoplasty whenever possible and paying more attention to nasal anatomy, skin quality, and airway preservation. But one thing is for certain- same as with an experienced mountain climber it takes years of practice to select the best path on the slope leading to summit, it takes years of experience for a rhinoplasty surgeon to select the correct surgical path leading to the best result!

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