*Based on the lecture held at the 20th anniversary of the Austrian Academy of Cosmetic Surgery and Aesthetic Medicine on 19 October 2019 in Vienna.

Preoperative computer image simulation

While the baby doll snub nose was in demand in the USA in the 20th century, today the aim is usually to achieve a natural shape that matches the individual face. Of course the ideal of beauty is also influenced by fashion and media, but it has also changed due to the improvement of the social position of women. She usually knows what she wants and often already has exact ideas about how she wants to look.

Fig. 1a – c: Original, image simulation and result after 2 months with conchacartilage augmentation of the nasal root and removal of scars and excess cartilage above the tip of the nose in case of stp. multiple nasal operations due to split nose.

The possibility of visualizing the desired nose shape in advance by means of easy-to-use computer programs in mutual consultation makes it easier for patients to imagine what they would look like after the procedure and thus to specify their wishes. The surgeon can be sure that misunderstandings are avoided and that a document is also available for the operation, showing how, where and how much the nose should be changed.

Fig. 2: Endoscopy of the spreader flaps in endonasal technique in front of the suture with the patient below (Fig. 3a + b).

Of course, it is part of the clarification to have the patient sign that the simulation is only the goal that one is trying to achieve, but that there may be deviations.

Further development of surgical techniques

Surgical techniques have evolved. From a “secret science” accessible to only a few, rhinoplasty has become an operation that can be taught and learnt, and the effect of individual measures on the complex structure of the nose has been better and better understood. The improved availability of audio-visual transmission of operations as part of the numerous operation courses has also greatly improved the teachability and comparability of the various techniques. A few – unfortunately still relatively few – quantitative evaluations of certain surgical methods have brought significant scientific findings.

The surgical instruments have also been further developed. In general, they have become softer, smaller and more gentle. For example, the use of diamond files reduces tissue trauma.  This reduces bleeding and swelling. One development in recent years is electric oscillating saws and chisels based on ultrasound. However, they also have the disadvantage that a larger area of the nasal bone must be exposed.

Fig. 3a: Tension and skew nose to the left. Fig 3b: Endonasal compo- nent cusp ablation and spreader flaps – 3 months postoperative.

The scientific dispute that has been discussed for decades as to which surgical approach would be the better one – the endonasal or the open approach, which the Americans very much favoured, has already settled in terms of individual adaptation of the approach to the structures to be changed, although personal preferences as to which technique the surgeon is more experienced in still play a role.

Fig. 4a: Long nose through hyper¬trophic tip cartilage. Fig. 4b: Exclusively tip lifting and refinement.

Hump removal

In the case of hump removal, especially in the large tension noses with a lot of cartilage in the hump, cartilage-sparing component removal is becoming more and more common, in which only the bony part is removed, while the upper lateral cartilage (lateral cartilage) is first removed under the nasal bone and the protruding part is turned in by approx. 160° and sutured to the lowered dorsal septum edge (spreader flaps). This prevents the “open roof” and maintains an outwardly directed cartilage tension, which prevents the collapse of the inner nasal valve with inverted V formation of the nasal bridge due to collapse of the lateral corpuscle, which was feared during the earlier en bloc ablation. The width of the middle third of the nose can be precisely determined by suturing and, if necessary, cutting the fold of the flap in the area of the desired eyebrow-noseline. It is therefore not necessary to remove extra cartilage from the nasal septum to insert the otherwise necessary “spreader grafts” to prevent the inverted V at the bridge of the nose.

The “Preservation Rhinoplasty” practiced in France by some specialists (e.g. Y. Saban), in which the bridge of the nose remains intact during the reduction or humiliation of the nose, is currently experiencing a renaissance.  In the “let down” or “push down” technique, a strip of septal cartilage below the bridge of the nose is resected and a ceiform excision is made in the area of the lateral osteotomy of the nasal bones, allowing the entire nasal pyramid to be lowered without destroying the continuity of the bridge of the nose. This means that no reconstruction of the bridge of the nose is necessary, and edge formation or open roof formation is avoided.

Fig. 5: Introduction of Diced Cartilage into a fascial sheath for nasal bridge augmentation.

Tip of the nose

Surgery of the tip of the nose has become much more conservative. Overresections of the wing cartilages are avoided in order to maintain sufficient stability for breathing and also to avoid possible retractions of the nostrils. The tip is usually formed by suture techniques. If necessary, cartilage stiffeners are inserted into the nostril margin to prevent or eliminate retractions of the soft triangle.

During the up-rotation of the pendulous tip of the nose, in addition to the lateral alar gliding technique, the simpler displacement and/or rotation of the lateral wing cartilage is carried out in prepared pockets, which is particularly easy in the endonasal technique.

Fig. 6a + b: Saddle nose structure with Diced Cartilage from both conchae in fascia and septal cartilage to the tip structure. Right after 8 months.

Augmentation and support

If augmentation or support is necessary, the body’s own material is preferred, whenever available. Mostly cartilage is used, if available from central septum parts, otherwise from the depth of the auricle or rib. Only if this is no longer present or if it is rejected, alloplastic material such as porous polyethylene (Medpor®) is used. However, these materials have a higher rejection and infection rate than the body’s own tissue. This is contrasted by a certain resorption rate of autologous transplants. There are also company-prepared preparations of homologous or heterologous donor fasciae or ribs. Here the patient must be informed and agree to receive foreign tissue.

New techniques have been developed for the use of cartilage material for tissue augmentation, especially of the bridge of the nose. Away from monobloc grafts in saddle nose reconstruction to millimetre small cartilage pieces wrapped in fascia (diced cartilage), which can be shaped like Plastelin® and remain surprisingly stable. If there are small uneven areas on the bridge of the nose, they can be inserted like pasta to form a camouflage.

Improvement of nasal breathing

Since the nose is a hollow organ, which primarily serves for breathing, but also for filtering and heating the air as well as for smelling, the effects of the individual maneuvers of rhinoplasty on nasal breathing have been increasingly investigated in recent decades – in part with flow models.

This has resulted in increased attention being paid to maintaining or improving the width of the inner nasal valve in particular, in which, as mentioned above, the front edge of the lateral cartilage is also involved, but also the outer nasal valve and the angle of incidence of the nasal entrance as well as the correction of curvatures of the nasal septum. Progress has also been made in septoplasty, especially in achieving stable long-term results, even when three-dimensional cartilage distortions are involved.

In the correction of the lower nasal conchae, which are often hypertrophic on the concave side of the septum, the surgeon has also become much more conservative because the humidification and filter function must not be destroyed. Therefore, submucosal radiofrequency ablation, possibly in connection with the lateroposition of the inferior turbinates, is preferred to previous mucotomies or partial resections.