There are so many conventional approaches in Medicine. As doctors, we are generally rewarded for following these conventions. Unless they are incorrect, or partially correct, then we have a conflict! How do we find new paradigms if no one is able to look for them? The answer is we never will! So, lets start the Rhinoplasty Revolution…now!
A little history:
Rhinoplasty started as a reduction procedure for oversized noses, and early rhinoplasty doctors removed lots of cartilage from the tip cartilages and septum. The unfortunate result was smaller noses, but collapsed nostrils, and unnatural pinched, and ski-slopy noses. These are not acceptable outcomes! So, in the early 90’s, doctors started reconstructing these destroyed noses by taking septal cartilage and rebuilding the tip and bridge with “grafts” from the excess cartilaginous septum. The results were…better breathing and appearance! So, logically, they took this graft approach to “virgin” noses as well, developed the open rhinoplasty technique (incision at the base of the nose), and thus the paradigm switched direction completely from a destructive procedure to a building-up procedure with grafts and great exposure! Sounds great, right? This is what you will hear in many doctors offices. Some go so far to use patient’s rib cartilage in unoperated noses!
The problem is, while the pendulum swung from the destructive rhinoplasty to the overly reconstructive rhinoplasty, we as a specialty failed to notice the middle ground. What if the over-sized noses from the “original problem” actually were oversized, and don’t need extra cartilage added or aggressive grafting approaches? Well, our most recent research shows that over-sized noses are a problem, and may be the cause of septal or nasal deviation, and aesthetic deformities like dorsal hump, or droopy tip. How? The structural support of the nose, or the septum grows from the forehead region, toward the maxilla bone (which holds the upper teeth). So, if the maxilla bone (receiving end) is too small, the springy cartilaginous septum will EXTRUDE externally into the lip and bridge regions, and buckle and bend internally (septal deviation). The result is the “tension nose” deformity, a big nose with a dorsal hump, sometimes with downward or forward pointing tip, with short upper lip and poor nasal breathing. This deformity causes mouth breathing in many, which at night causes sleep apnea, where the tongue can fall back into the throat and temporarily stop one’s breathing. It can then cause dry mouth, and headaches from poor rest. Further, this poor airflow can cause fluid to appear in the sinuses, and can cause growth of tonsillar tissue. For these visualized reasons, most ENT doctors will drain the sinuses via FESS (functional endoscopic sinus surgery), remove the tonsils and adenoids, or perform a basic septoplasty (removal of cartilage and bone from the back of the nose). However, these treatments, like open rhinoplasty with extensive grafts are mostly misguided and only address the visual manifestations of the disorder, and not the actual problem (the actual problem being chronic mouth breathing due to nasal and maxillary restriction).
So, if these conventional answers don’t work, what does? Well, its simple. Any strategy that keeps the nose and nostrils open, and keeps the lip and mouth closed at night! If you have a severe, tension nose, this requires surgery. Not graft surgery, and not simple septoplasty or sinus surgery. They won’t work? Septal reduction surgery, that reduces the external super-structure of the nose (surgeons call this the L-strut – most are taught to leave this alone at any cost). It is reduced at the lip and bridge until it is the appropriate size for the maxilla. Our article should be out in a few months in the journal PRS. An article from 2015 in PRS shows how this technique improves sleep related breathing. No grafts are required to reduce the dimensions of the nose, and relaxing the mismatch in size after tension removal also straightens the cartilaginous portions. The article has an associated video which we will link when out. The tension nose exists as a spectrum, so other options are available for minor versions. So, join the Rhinoplasty Revolution of 2017, and avoid the conventional procedures that everyone has, but rarely work. We will send more info as soon as it is out…