There are more and more studies that demonstrate how important nasal respiration is for health, therefore, it is very important that before carrying out any intervention, properly explore the nostrils through an endoscopic study that allows us to assess whether there is a septal deviation, a hypertrophy of the lower turbinates, nasal polyposis, or chronic sinusitis. The importance of the previous exploration of the nostrils lies in the fact that the techniques used by most plastic surgeons tend to collapse the area of the nasal valve and if in a patient who previously already had a deviation at this level, although preoperatively, he was asymptomatic and does not report any respiratory difficulties, it will probably worsen after rhinoplasty. Good nasal breathing is essential for health. Normal human breathing is through the nose, mouth breathing is either an aid or an alternative but it is not how efficient nasal breathing is. When the air passes adequately through the nose it is conditioned to adequately reach the pulmonary alveoli in the adequate humidity and temperature conditions. When we breathe without difficulty through the nose, the air correctly reaches the lungs even though we are at 30º or 30º below zero, because by rubbing against the nasal mucosa especially at the level of the lower turbinates and also the middle turbinates, it is heated or cooled as necessary. The cilia of the nasal mucosa also help to clean the air breathed of the pollution, impurities or allergens that it can transport so that if we breathe well we may have rhinitis but we will probably avoid bronchitis that is much more serious. We must consider that the nasal mucosa and the mucosa of the lower airways are very similar from the pathological point of view.
Nasal breathing allows the inspired air to reach the pulmonary alveoli in the right conditions, however, when we breathe through the mouth, most of the air is blocked in what is called the “dead space” between the trachea and the bronchi but without reaching to the distal alveoli, which does not produce an adequate gas exchange with the blood. Nasal respiration creates the resistance necessary for the diaphragm to work properly so that it descends, increases the ventilatory capacity of the lung, and at the same time facilitates and increases the air reaching the distal alveoli. A person with good nasal breathing can reach 70% of their maximum aerobic capacity, that is, when we make an aerobic effort such as running, a person with good nasal breathing can reach 70% of their maximum effort using only this route. In other words, athletic and / or sports capacity is greatly increased. In rhinoplasties, in addition to improving aesthetics, we must be very careful to improve nasal breathing and always use surgical techniques for resection of wing cartilages and osteotomies that prevent the collapse of the airway. In my experience there are also certain disorders such as anxiety and even certain slight depressions that improve considerably when we improve nasal breathing after rhinoplasty, which is logical because most methods of meditation and / or relaxation are based on nasal repiration. Some of my patients after years of mild anxiety and depression have improved considerably by being able to breathe normally through the nose because it has a very beneficial relaxing effect. Nasal breathing is essential for health because it facilitates the physical and emotional wellbeing that is so necessary in the times that we have had to live, that’s why at Rinopastia Barcelona we not only value aesthetic improvement but we also consider it as very necessary to improve nasal breathing to contribute to the quality of life of the patient.
Extracorporeal septoplasty is a technique in which the entire nasal sepum is removed, trying to straighten it as far as possible and repositioning it.
The main problem that this technique has has nothing to do with its difficulty or the indications that it may have, but in the confusion that this denomination creates. very complex or advanced surgical procedures and nothing further from reality. Whenever we perform a nasal graft placement, it has a time that is extracorporeal.
In patients with a sinking of the nasal dorsum in Barcelona rhinoplasty, which was achieved in obtaining cartilage from the atrial pablellon that remodeled and subsequently sutured the nasal dorsum, in this case, although obviously there is also an extracorporeal time, we cannot say that it is an extracorporeal rhinoplasty.
This is the option that is most suitable and which is the one that I perform in patients who have undergone a septorhinoplasty in Barcelona.
Septoplasty is usually a simple surgical technique, but this does not mean that it cannot have its difficulties, as in the case of a patient with a large anterior deviation in which it is difficult to ensure adequate nasal support to prevent the nasal tip from falling. and what is called a “boxer’s nose” occurs in which there is a sinking of the nasal tip.
Extracorporeal septoplasty was initially described in 1952 by King and Ashley, and only a few authors have subsequently performed it.
When we perform a septoplasty, different authors reposition a small part of the septal cartilage that we have corrected, that is, in a way it is a limited extracorporeal septoplasty, but I insist that the medical term used is inappropriate because it leads to confusion.
According to my experience in integrated functional and aesthetic surgery, that is, in septorhinoplasty, there are several factors that are really important when we carry out this type of intervention, the first is that we must maintain at least 1 cm of support in the most anterior part of the nasal septum, that is to say, in the outermost part and that the area of the nasal valve is perfectly corrected.
Extracorporeal septoplasty is a technique that almost no surgeon uses as a surgeon, it could only be indicated in some cases and is highly debatable.
We must think that removing practically all the nasal septum bone and cartilage at once is a very difficult thing to do and that it also does not have any logic because we create a great destructuring of the entire nose, that is, we completely weaken the entire internal structure and that any The otorhinolaryngologist knows it perfectly, which I have never done in patients with septorhinoplasty in Barcelona.
Correction of the nasal septum should always take place progressively, first correcting the deviation of the anterior nasal septum (septum), that is, external and as we progress we proceed to correct the more posterior or internal bone septum.
When a technique is not popularized it is for some reason, in the case of extracorporeal setoplasty there are several. The first is the great difficulty of removing the entire nasal septum en bloc and the risk that this involves of destabilization and collapse of the nose.
The main problem however resides in the repositioning of a nasal septum that we have removed en bloc, then we try to straighten it but we can only really do it partially and finally the most difficult thing is to put this corrected nasal septum back into the nose and make sure keep it in the desired position.
Repositioning and maintaining the nasal septum in the proper position is very difficult if done as a block because we must fix it using sutures that generate symmetrical tension on both sides of the nostrils so that they do not subsequently generate a deviation of the nasal septum towards one of the graves.
Extracorporeal septoplasty generates a lot of controversy and not only because of the terminology used which is confusing but also because from the point of view of functionality it does not have much logic.
In cases where there is a large deviation of the septum in which it is not possible to ensure the adequate support of the nasal tip, it is more appropriate to place a columellar graft and if this is not enough, also add a cartilage graft obtained from the septal cartilage from the area K to the cartilaginous domus that in the sequence that I follow in these frequent cases of septorhinoplasty in Barcelona.
Extracorporeal septoplasty also presents another risk that the authors often seem to underestimate and it is the possibility of significant hemorrhage because it is one thing to correct an anterior devaccination of the caritlinal septum, and quite another to proceed to block resection the entire posterior bone septum with the Perperndicular lamina of the ethmoid and the foot of the vomer because it is precisely here where we can have significant bleeding that requires a nasal tamponade that makes it very difficult to reposition the nasal septum.
Rhinoplasty is considered one of the most difficult interventions. It has been traditionally accepted that between 3 and 5% of patients undergoing this type of surgery should be reviewed.
We in Barcelona rhinoplasty according to the last revision carried out, we remain in these figures
During the last years, however, this figure has varied considerably so that it has been discussed in the last congresses in which I have attended and where it has been considered that currently the revision figures in rhinoplasty are between 20 and 30%
The causes of this increase in reviews are due to the fact that there are currently a greater number of surgeons who perform this type of intervention and also to the higher expectations of patients.
In Barcelona, following the majority criteria, we recommend waiting at least 1 year to perform a revision of a rhinoplasty.
The great majority of patients in whom secondary rhinoplasty must be performed present problems at the level of the lower third, the most frequent being a deviation of the nasal septum, a fallen nasal tip and a deviation of the carilaginous back and to a lesser extent also of the bony back.
The best way to avoid secondary rhinoplasty is to perform a conservative intervention that avoids difficult problems to solve.
When we face the correction of a secondary rhinoplasty we must assess what is most uncomfortable for the patient if it is basically a functional problem due to deviation of the septum or nasal septum, it is aesthetic or both at the same time.
When we plan a secondary rhinoplasty, we must understand what the patient dislikes or is most uncomfortable with and explain which is the most appropriate solution. In some cases, we should explain that it may be possible to improve but not completely correct the deformity.
At Barcelona Rhinoplasty we consider that in order to achieve a functional and aesthetically correct nose in the case of secondary rhinoplasty, we must proceed to restructure the lower third of the nose so that we have to get the appropriate support to respect aesthetics and functionality.
If a nasal skeleton does not have sufficient supporting integrity, it is distorted or collapses due to scarring forces.
Reorientation and repositioning of the tip cartilage produces a more favorable and predictable appearance.
The maneuvers that we perform in Barcelona rhinoplasty to stabilize the nasal base are columellar grafts, expansion grafts and also reinforcing grafts of the wing cartilages in the event that they are greatly weakened by excessive resection.
In the case of cartilaginous back deformities, they may correspond to a “supratip” or “parrot beak” deformation above the nasal tip in which a resection of the anterior part of the septum will correct this intermediate deformity. Deformities of the cartilaginous middle third are usually due to a unilateral or bilateral collapse at this level. the solution we usually use is the uni or bilateral placement of sutured spedader graft between the triangular cartilage and the nasal septum.
If the deformity of the nasal dorsum is in a “saddle” in Barcelona rhinoplasty, we perform its correction by obtaining an atrial cartilage graft that is fixed by suturing to the nasal dorsum.
In the case of the upper bony third of the nose, the deformity may be a minimal irregularity of the nasal dorsum that a scraping will be able to solve, or a deviation (laterorrinia) due to the inadequate or insufficient performance of laterobasal osteotomies, in which case we must assess whether we perform new osteotomies, we proceed to a scraping or we must place a graft that in this case is really difficult to maintain in the proper position due to the surgical difficulty of access.
We must consider that no matter how much experience the surgeon presents, he will always have a secondary rhinoplasty rate.
Another factor to keep in mind when performing this type of intervention is if the previous rhinoplasty was performed by another surgeon, with which we cannot know for sure what was performed or what type of complications occurred.