Primary rhinoplasty: the importance of the conservative approach

What is a primary rhinoplasty? The definition indicates someone’s first nose surgery. If the patient is not completely satisfied with the result, he or she may decide to undergo a second or third, and so on operation. This procedure has a name of a secondary rhinoplasty or revision. But keep in mind that revision rhinoplasty is almost always more complex than the primary, as the surgeon has to operate on structures already altered comparing to the original anatomy.

The more conservative, mini-invasive and delicate is the surgeons’ approach during the primary rhinoseptoplasty, the easier it is to work in a possible revision. Whether performed by closed or open approach, the primary rhinoplasty should always incline towards minimally invasive techniques with limited cartilage removal for structural grafts. The maneuvers and techniques applied in the primary surgery will define the long-term outcome, both in case of a complete rhinoseptoplasty or a “simple” primary rhinoplasty with the nasal tip reshaping. Needless to say, that an experienced revision rhinoplasty surgeon knows well that possibilities and limits of the secondary/revision rhinoplasty depend on a large scale on what was done in primary rhinoplasty.

In this regard, it should be emphasized that grafts are superfluous in most primary nose-jobs and, even complicative in excessive use for the possible future revisions. The prudent and experienced surgeon must always consider the eventuality of a revision. Septal cartilage is the ideal material for the most grafting procedures – hence it needs to be preserved as much as possible in the first nose job. Opting for a conservative, minimally invasive rhinoplasty not only favors the better healing, rehabilitation and shorter downtime, but also reduces the possibility of going back to the operating room for further reconstructions and corrections.

Primary rhinoplasty before and after

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Primary and secondary rhinoplasty: definition and differences

Nasal surgery is an extremely vast and complex universe, full of definitions and technicalities so often misunderstood by non-specialists. Addressing such a complex topic here, we obviously need to make some simplifications. Let’s start with some definitions to distinguish the primary nose surgery from the secondary or revision for a better understanding of what a rhinoseptoplasty is.

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What is primary rhinoplasty?

Primary rhinoseptoplasty refers to the first surgical correction of the nasal structures considered in chronological order. The surgical procedure can address many different issues at the same time. Defects can be aesthetic and/or functional (among the most frequent: nasal obstruction, shortness of breath at night and sleep apnea, ear problems such as muffled hearing, alteration of the timbre of the voice, etc.), and have a congenital or traumatic cause. Nowadays, the surgical standard is aimed to manage and to improve both the appearance and function of the internal and external nose. From this point of view we are speaking about the complex operations that require extraordinarily specific and sophisticated surgical skills as well as the ability to select the most suitable technique to restore the proportion of the nose and harmony of the facial features. In the following paragraphs we will briefly talk about the open, closed and hybrid approaches in rhinoplasty. Just to summarize, primary rhinoseptoplasty can address and modify:

a) nasal bony pyramid,

b) cartilaginous dorsum,

c) cartilages, ligaments and muscles of the nasal tip.

Defining secondary rhinoplasty.

Secondary rhinoseptoplasty aims to correct the appearance and function of the nose after a previously done surgery. The reasons to go back to the surgeon for a second nose job can be linked to three fundamental causes:

  • The result of the first operation was below the patients’ expectations or even caused cosmetic or respiratory defects;
  • Previous surgery did not resolve completely the nasal problems;
  • The patient suffered a post-surgery trauma.

Reshape the nasal structures: open, closed or hybrid technique?

In a simple way, we can divide the surgical techniques in rhinoplasty in two main types of procedures: the external or open technique (primary open rhinoplasty) and the closed or endonasal technique (primary closed rhinoplasty).

In the last decades, the studies and researches of Dr Pietro Palma gave birth to a new philosophy and concept in rhinoplasty – hybrid rhinoplasty, which benefits from the advantages of both approaches. Hybrid rhinoplasty, described by Dr Palma in the literature for the first time in 2010, allows to combine the precision of the open technique with the mini-invasiveness of the surgical maneuvers of the closed approach (endonasal technique).

1. Open rhinoseptoplasty: pros and cons

In open rhinoplasty, the surgeon does a cut on the columella and then lifts the skin-soft tissue flap to reach the nasal structures. The open technique offers a complete view of the osteocartilaginous vault. Relatively easy access to the modifying area under full vision control often makes less experienced surgeons feel more comfortable in this approach, so they tend to follow it.

Summing up, the advantages of an open primary nose job are:

  • better view and operative space in complex remodeling and cartilage suturing, especially in tip rhinoplasty for the major asymmetries, bulbous tip, pinched nose, bifid tip, deviated, poorly projected, etc.

On the other hand, the disadvantages of the open technique comprise:

  • generally longer operating and healing times;
  • absence of the tactile feeling, as well as the immediate perception of the surgical result of the corrected anatomical area;
  • the greater destabilization of the nasal supporting framework requires the use of cartilaginous grafts also from the extranasal sites (ear, ribs), which in turn increases the risk of complications also in these donor areas;
  • more evident stiffness and swelling of the external nose which can persist for months;
  • formation of the excess fibrous scar tissue, especially within the tip area, which can result in less defined or squat tip shape;
  • less natural result and permanent columellar scar (however this risk is minimal, if the technique is performed correctly);
  • greater technical complexity in case of possible revision surgery.

2. Closed nose job: pros and cons

In a closed rhinoplasty, the surgeon makes the initial incisions inside the nose and then exposes the anatomical structures to correct from inside without “opening” the nose. It was considered that endonasal technique is very appropriate for correcting small defects, especially in the tip and it is less ideal in managing of the bigger osteocartilaginous vault defects. However, in skilled hands excellent results can be achieve in correcting complex deformities even with the closed technique.

Advantages of a closed primary rhinoplasty are following:

  • a generally more conservative and delicate approach, which can usually give a more natural and less “surgical” look;
  • average shorter operating and healing times;
  • no risk of visible external scar as all the incisions are internal.

The disadvantages of the closed technique are:

  • less visibility of anatomical structures which could lead potentially to the less precision of maneuvers (especially by not experienced surgeon);
  • less effectiveness in complex and extreme surgical cases which usually require advanced reconstructive procedures.

3. Hybrid technique: the evolution of nasal surgery

We can consider the closed and open techniques as two conventional procedures for a primary rhinoplasty. For more than ten years now, we have had a third option that summarizes the advantages of both. Hybrid rhinoplasty allows the surgeon to identify the critical areas to manage and, thus, apply a tailor-made set of endonasal incisions to correct these precise areas. No external columellar incision. No massive dissection. No degloving of the osteocartilaginous pyramid. Only tailor-made endonasal incisions and precise tunneling. This highly versatile approach can be tailored to the patient’s specific anatomy.

The key advantages of the hybrid rhinoplasty are:

  • visibility of the surgical field and technical precision substantially comparable to the open technique;
  • less invasiveness and faster healing thanks to:
    1. the absence of external scars;
    2. minor impact on the lymphatic drainage especially of the nasal tip;
    3. less dissection of the external nose, limited only to the areas to be corrected without disturbing the others.
  • greater accuracy and precision in the execution of surgical maneuvers: the tailor-made cuts allow the surgeon to act exactly where needed;
  • lower incidence of the adverse effects and complications, therefore better satisfaction rate and lower incidence of revision.

Best surgeon for a primary rhinoplasty in Milan

Patients wishing to improve the appearance of their noses are increasingly curious about surgical procedures. Some even choose the surgeon based on the technique described or most valued on the web pages – not the best decision-making process! However, we must point out that there is no technique absolutely superior to the others or capable of guaranteeing a 100% success.

The countless individual variables of every anatomical structure together with the pitfalls and difficulties of each surgery require customization in design and versatility in execution. This is what we call a tailor-made nasal plastic surgery. Think carefully and have a wise approach making a decision of having nose job done and try to choose the best rhinoplasty surgeon. But how can you choose the best surgeon for your nose? You should take into account these two main aspects:

  1. the ability of a surgeon to select the operative technique most appropriate for your case;
  2. the surgeon’s technical skills and capacity to adapt the whole operating plan to the targeted defect(s), anatomy and wishes of the patient.

Don’t expect less than a thorough pre-operative visit before the surgeon can determine which surgical technique and procedure could be applied in a better way to reach all the aesthetic and functional goals of your primary rhinoplasty.

Both primary and secondary rhinoplasties require vast and extensive skills, long and in-depth experience, extreme specialization and continuous professional self-mastery. If you want to change the look of your nose or to correct respiratory defects, contact the best primary rhino-septoplasty surgeon in Milan. In almost 30 years of specialized surgical practice, Dr Pietro Palma and his team helped many patient looking for male and female rhinoplasty, adolescent rhinoplasty, and revision rhinoplasty of different complexity (including cases of extreme rhinoplasties) to “come back to themselves”.

Be yourself. Be true. YOU.

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FAQ

HOW THE FIRST CONSULTATION IS CARRIED OUT?

The aim of the first consultation is to make a correct diagnosis of your external and internal nose as well as to evaluate your past medical history. Specific nose-related symptoms will be evaluated by taking a thorough history, a nasendoscopy, and performing morphological analysis of the external nose. Finally, I will take professional quality photographs of your face and nose for detailed analysis.

IS THE FIRST CONSULTATION FREE OF CHARGE?

The first consultation is not aimed to sell a product. It cannot be free of charge as it is a very specialized consultation lasting 30’-45’ by an international rhinoplasty expert using high tech-tools in a modern, comfortable and well equipped medical office.

HOW MUCH DOES RHINOPLASTY COST?

As each case is different, a standard cost cannot apply. Costs are related to the extent of surgery and the duration of the operation. Within the first 48-72 hours of the first consultation, a detailed quotation will be emailed to you.

WHICH TECHNIQUE DO YOU USE?

As your surgeon, I will adapt my technique to match your specific anatomical findings and with respect to your wish list of desirable changes. Due to my decades of dedicated rhinoplasty surgery, I can call upon a vast array of techniques in order to safely cope with the myriad variants of nasal anatomy.

I prefer closed (endonasal) rhinoplasty for most of my patients in order to be respectful of nasal anatomy and avoid unnecessary surgical aggressiveness. In more complex cases, I use an “hybrid” closed approach that allows me to utilize techniques commonly used in the open approach (sutures, grafts) but without opening the nose. I opt for the open approach in severe malformations or in specific revision cases.

IS IT POSSIBLE TO OPERATE SEPTUM AND TURBINATES AT THE SAME TIME OF RHINOPLASTY?

The nose is a complex structure in which form and function are intimately connected. Almost always, rhinoplasty is a septo-rhinoplasty because the septum not only plays a functional role, but also contributes to common problems of the external nose. Examples include: crooked nose, hump, drooping tip, excessive nasal length, over-projection of the nasal tip, just to name a few of the common deformities seen in my practice.

Inferior turbinates are probably the commonest cause of nasal obstruction, and their treatment is commonly associated with septo-rhinoplasty or rhinoplasty. Modern, minimally invasive endoscopic techniques allow the surgeon to manage these important structures precisely and conservatively.
Therefore, it is absolutely indispensable that your rhinoplasty surgeon possesses specialist training and substantial experience in treating problems of the internal nose.

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