The history of the plastic surgery of the nose leads us to the year 2000 A.C, when were found the first repair references of this important organ. Perhaps this whole importance is due to the fact that the nose represents personality aspects and beauty.
As punishment, in the antiquity, the war enemies' nose was amputated and also in the cases of matrimonial infidelity.
Tagliacozzi who lived between 1545 and 1599 was an anatomist and Italian surgeon who described a scientific way of nasal reconstruction for the first time. However, in 1600 there was a great setback in the medicine and the anatomist's family was disturbed when an inquisition tribunal insinuated that Tagliacozzi would be an cheat; they profaned his memory, burned his books and exhumed his body of the sacred lands, taking like this to the obscurantism an incipient plastic surgery.
The medicine during the period of Renaissance (century XVI) passed from the empiricism to the medical science. All the fields of the art, music and medicine bloomed with significant contributions for the humanity.
Only two centuries later, in 1892, the American Robert Weir published about nose with fallen tip. But it was Jacques Joseph, a surgeon from Berlin, six years later in 1898 who led off the inner nose surgery, treating the external scarless nose structures.
Joseph described the following years the whole modern technique of the aesthetic rinoplastia whose evolution was improving until the current days. After this period many surgeons contributed to the evolution of the rinoplastia, as Talks, Meyer and Pitanguy and others who established the parameters of this intervention.
THE NOSE Surgeon and patient should discuss how the procedure and the correction possibilities will be in agreement with each case. There are more difficult noses, with thick skin or very fine skin, important deviations, huge and fine form, enlarged nose wings and with enlarged base and low back. Functional pathologies like allergic rinites, hipertrophy of the cornets can also be corrected. All these possibilities should be explained to the patient for to give a surgical program which is capable of being executed.
The nose aesthetic surgery is one of the surgeries that requests a great surgical experience, because a functional, artistic and anatomic knowledge (Fig. 1, 2 and 3) is necessary. Here the art and the technique walk side by side and the surgeon can place all his experience in the analysis of the facial proportions, to analyze the facial group, forehead, malar, chin and a relationship tip-back to adapt for each patient that undergoes this surgery type.
The surgical possibilities should be cleared up to the patient in the interviews that precede the procedure, showing him the best way and the real possibilities of getting a good result, acting isolated or simultaneously in other segments of the face. The patient's false expectations cannot be stimulated, because we only have to adapt the result to his face leaving the nose in harmony with full breathing function.
It is necessary that the surgeon has the sensibility so that he can contraindicate the surgery if it evidences that the patient's expectation is going far from the possibilities that the procedure can offer, or if a better result is siutable to solve situations in which other techniques would be more suitable.
EVALUATION
The whole patient should be evaluated in clinic and laboratory conditions so that the operative act can be accomplished with every safety.
Preoperative instructions about the risk of the tobacco and of certain medicines (as acetilsalic acid) should be part of the routine in that intervention type.
Explanations like the existence of nose tamponing and the immobilization period in the postoperative and also the necessary period for a definitive result should be treated previously, so that the patient is confident when he is still observing an edemic nose in the first month and understands that this is part of the cicatrization process and the normal evolution of the procedure.
The patient's photo in the preoperative (conventional and digital) in the frontal, side and profile position (static and dynamic) will allow a better surgical planning and it is also important for the medical file.
In the postoperative there are surgeons who recommend photos after the third, sixth month and later, after one year or in longer dates.
The nose which is detaching in the face plays a fundamental part and of great importance in the facial balance, besides revealing ethnic lines and the personality. For your importance it is necessary for the surgeon that practices this surgery type a solid knowledge of the anatomy of the organ before he begins any procedures on the nose. A static and, as well, dynamic examination, like the nose pit, a lot of times associated to a radiologic study, should be part of the surgical planning.
ANESTHESY
The rinoplastia is usually accomplished under local anesthesy with sedative. There are, however, patients and surgeons that give preference to the general anesthesy. The local anesthetics that we use now promote a long time of anesthesy and, with the knowledge of the reaction of face and nose we reach a longer time of the local anesthetic's duration, which, along with the combination of the sedative, give a pleasant sensation to the patient in the course of the surgery and in the postoperative. The time of permanence in the clinic or hospital should be a period in that the patient comes fully awake and in conditions of moving usually.
We should find out for the patient that in the trans-operative and in the postoperative the nostrils are tamponated, emphasizing that with this detail of the nasal obstruction the surgery is calmer.
SURGICAL TECHNIQUE
NASAL TIP
This can be approached in several ways to treat, for instance, bulbous tip (thick tip, tip that falls when laughing and to speak), high tip, fall, bifid (separate cartilages) which suffers alteration for the action of the nasal musculature; for each alteration a technique exists to be used. These approaches are always accomplished with internal accesses, not appearing apparent scars.
TREATMENT OF THE BACK
In a high nose with bony or cartilaginous hump we need to treat the excess of height of the nose that can be removed without difficulties. It is used it cold light sculpting the back with sheets and special diamantaded sandpaper to reduce the bony portion and the cartilage. The objective of the treatment of the back is to correct the structures in excess respecting the valve and the integrity of the mucous coating of the nose back.
LOW BACK
This can be treated on a nose with little projection and, sometimes on a traumatism provoking like this a so called “stamp” nose. In this case we need to increase substances for its increase.
We give preference for the removed material from the nasal septo or cartilage ear which are similar to the structures of the nose.
CORRECTION OF THE SEPTO
In the surgical planning during the plastic surgery of the nose establishes the surgeon we need to correct a septo deviation. The patient usually complains that he breathes badly. We must establishe the deviation level through complemental radiologic, tomografic and endoscopic exams for the surgical planning. There are septo deviations that don't give symptoms, but generally they should be corrected, therefore we reduce the nose and reach better proportions. Also a small deviation in the postoperative could present functional problems if the septo was not corrected. When the deviation is very important the tamponing can stay for more than 24 hours. In some cases the placement of a sheet of silicon for the septo is necessary to stay posicioned. This sheet will well be able to stay for up to 72 hours.
NASAL OSTEOTOMIA
In the interview the patient normally investigate: will it be necessary to break the nose?
The surgeon usually knows the answer because a nose with base releases a lot of times needs to approach the nasal bones to the medium line to give a better harmony to the face. Also he can tell the difficulty using glasses. But there are cases in wich an osteotomia is indicated and in others in which it is contraindicated; so we have to do a correct diagnosis and to discuss with the patient the best form of leading the procedure.
The fracture of the nasal bones promotes a larger edema in the postoperative and in some cases it forces to change the plate or plaster that immobilizes the nose in the third or fourth day, because the same becomes slack because of the decrease of the edema. The access for the osteotomia is in the inner part of the nose pits, apparently scarless.
NASAL WINGS
A great variety of alterations exists in this area of the nose. The details of this procedure should be discussed with the patient because it is the only place in which is an apparent scar. Happily the patients' great majority presents good cicatrization in this area. It is usually the last procedure of the rinoplastia. We have, at this time, the nose totally corrected and this detail at the end of the intervention will give the finish in the noses that need correction in this area.
REFINEMENT OF THE TIP OF THE NOSE
The tip of the nose is a segment that needs a perfected approach for us to obtain an appropriate result. There are cases in that the nose is bulbous, with thick skin, presenting glands in excess. In this case we should remove the excessed texture to adapt the tip of the new created nose. In other cases the cartilages come separate and we should unite them to obtain a tip with good projection. There is a great number of cases which we need to place a cartilage graft in the tip to obtain an appropriate and amusing nasal angle.
In the facial dynamics we should also evaluate the muscle which depresses the tip, called “depressor of the tip” and also “ligament of Pitanguy”.
This area of the nose shows all the complexity which is the nasal aesthetic surgery.
MAKE A SHORTER NOSE
At the end of the intervention it is analyzed the mucous membrane excesses and the length of the nose.
The shortning is gotten with the performance at the mucous membrane excesses apon the action of the muscles and the nasal septo. This maneuver allows a better positioning of the tip in relation to the back with an appropriate nasolabial angle.
In the rinoplastia of the senile nose the most surgeon’s act returns to the patient a better breathing function and a jounger facial profile in harmony with his face.
CURATIVE AND IMMOBILIZATION
The nasal tamponing stays for some hours in the aesthetic rinoplastia. During 1 to 3 days when the nasal septo was also corrected. Initially the skin of the nose is modeled with microporose ribbon and further it is placed a molling plate or plaster which stays for one week. We usually modeled the nose with a microporose ribbon for one more week.
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