(A) Aesthetic standards of the nose
The nose is the roof of the face, its height and shape are extremely important to a person’s image. The human nose is located in the center of the face, not only has an important physiological function, but also an important factor affecting the beauty of the facial contour, and show a person’s personality. That is why rhinoplasty was introduced in ancient India thousands of years ago. In terms of shape, the nose is a three-pronged cone, located in the middle of the midface. Whether viewed from the front or the side, the nose should have a sense of three-dimensional curves, so the height and size of the nose and whether it is in harmony with other organs of the face play a pivotal role in the handsome appearance of a person.
The Caucasian nose is high and straight, the black nose is flat and wide, and the yellow nose is in the middle. Easterners often have a wider face, two cheekbones that flare out and a lower nasal bridge, so their faces appear less three-dimensional; Westerners have high brow bones, a high nasal bridge and deep eyes, so their silhouettes are very three-dimensional.
In other words, there are more saddle noses and skyward noses; in the West, there are more straight and projecting noses, which means more hump noses and hawk noses.
The lowest point of the nose is located at the midpoint of the line connecting the two eyes and should be the same height as the double eyelid crease.
The bridge of the nose is straight and the tip of the nose is slightly curved by 2mm.
The angle of tangency between the nasal column and nasal wing is 2.1 degrees, and the shape of the nasal tip and wing looks like the shape of a seagull spreading its wings and flying.
The angle between the bridge of the nose and the vertical line of the forehead (nasofacial angle) is 25 to 30 degrees, and the bridge of the nose and the nasal small column is 85 to 90 degrees. The frontal angle of the nose for men is 115 to 120 degrees, while the nasolabial angle is 90 to 95 degrees. In women, the frontal nasal angle is 120 to 130 degrees, and the nasolabial angle is 95 to 105 degrees.
The edge of the lower lip is located on the line between the tip of the nose and the lower jaw.
The bridge of the nose is high and the nose must not be wide.
The nose and nostrils are elegant.
According to the aesthetic “five points method”, the nose is located at the center of the nasal root with the distance from the nasal root to the outer canthus as the radius to draw a circle, the base of the nasal small column and the nasal wing edge should be just on this arc; beautiful nose, its length should account for 1/3 of the entire length of the face; and from the side, the height of the nasal tip should also be 1/3 of the length of the nose; the width of the nose is slightly greater than the inner canthus spacing. Its maximum distance is equivalent to 70% of the length of the nose, and the width of the nasal root is about 10mm The width of the bottom of the nose and the cleft of the mouth are in line with the golden ratio, which is 1/4 of the width of the face; the height of the nasal root is about 12mm for men: about 11mm for women; the height of the nasal tip is about 26mm for women and about 23mm for women; the intersection of the midline of the nasal root and the line connecting the upper edge of the two eyelids is a depression point, which is called the golden point and is the starting point of the nasal root during rhinoplasty, and only Only from this point onwards can the standard of nasal aesthetics be met.
(B) Commonly used materials for rhinoplasty
The commonly used implant materials for rhinoplasty can be divided into autologous tissues and artificial synthetics. Autologous tissues include auricular cartilage, ribs, iliac bone, tibia, skull, etc., but the method is too complicated and the tissue is more traumatic, which is difficult to be accepted by the patient.
The most commonly used synthetic material is medical solid silicone nose material, nasal membrane. The popular injection rhinoplasty method in the past two years uses materials such as hyaluronic acid or artificial dermis for injection. Hydroxyapatite particulate artificial bone can only be shaped intraoperatively and requires experience.
Other materials rhinoplasty: such as expanded polytetrafluoroethylene, imported materials (Medepor) and so on. Most domestic experts advocate silicone block as the material of choice for rhinoplasty.
(III) Indications
Adults with saddle nose caused by various reasons, partial depression of the nasal bridge or low collapse of the nasal tip, short nasal column, skyward nose, etc.
(D) Contraindications
Children; systemic or local infection lesions; chronic rhinitis, sinusitis, nasal polyps and other nasal diseases; nasal sebaceous glands, rosacea, unstable mental state, or doubts about filling materials.
Some seekers only require elevated nasal bridge without regard to the tip of the nose, nasal wing shape and facial plastic structure, if done in full accordance with their wishes, obviously can not achieve the purpose of cosmetic, therefore, also not suitable for rhinoplasty.
(E) surgical methods
1.Scribe line
To both sides of the nasolabial folds and the two eyes for reference to draw the nasal median line, in the two eyes and the intersection of the two eyebrow line is the starting point.
2.Choose the incision
(1) Inner nostril incision: make the incision between the cartilage of the nose and the lateral nasal cartilage, make the same incision on the opposite side, and then combine the two incisions into one;
(2) Nasal vestibular incision: make an incision slightly inside the upper third of the nasal column to the highest point of the nostril margin on one side;
(3) Butterfly incision: the highest point of the anterior nasal margin on one side passes through the nasal columella to the highest incision of the anterior nasal margin on the opposite side.
(4) joint nasal vestibule and nasal columella incision: the highest point of the nostril is cut at the boundary between the skin and mucous membrane along one side of the nostril, cut along the nasal columella and nasal septum junction to the bottom, cross the nasal columella and upper lip junction line, then return to the highest point of the nostril on the opposite side, and then cut through both sides of the nasal columella, of course, in the rhinoplasty we should try to choose the incision with small damage and good concealment.
3.Pre-operative preparation
Nasal hair should be cut, iodine should be used to fix the starting point of the median line, disinfect the dorsal face of the nose, both sides of the nasal cavity, and fill the nasal cavity with cotton balls.
4.Anesthesia
Use 2% procaine or lidocaine, from the tip of the nose to the nostril of the nostril incision line, the height of the line from the tip of the nose to the root of the nose, push the anesthetic while entering the needle, then retreat the needle from the tip of the nasal depression to the nasal column, push the anesthetic while entering the needle, the tip of the needle against the alveolar bone, and then retreat to the tip of the nose to the side of the nasal wing while pushing.
5.Incision
Cut the skin or mucosa to the subcutaneous tissue according to the selected incision design line, use ophthalmic scissors to evenly cut the tissue on the head of the nose, turn to align with the midline of the nasal bridge, advance while separating to the junction of nasal cartilage and nasal bone, raise the tail of the scissors to cut the deep fascia of the nasal dorsum transversely, then advance the scissors to the golden point on the l two, fix both sides of the nasal dorsum with the left hand to separate the range, separate the tip of the scissors, and retreat to the tip of the nose while dividing, force when separating When separating, the force should be even, and the width of the tunnel should be moderate. If you need to implant “L” shaped prosthesis, after the tip of the nose, the scissors turn to the nasal small column and separate vertically to the upper alveolar bone.
6.Implantation of prosthesis
Use a 2mm wide, 1mm thick stainless steel piece as a guide to ring the separated tunnel, so that a tunnel is formed between the guide and the nasal bone, use hemostatic forceps to hold the sculpted prosthesis, implant it along the guide, exit the nasal guide, then use hemostatic forceps to send the nasal prosthesis to the appropriate position, hold the nasal model nasal column part to insert the stripped nasal column tunnel.
7.Shape observation and compression incision treatment
Because the tissue at the root of the nose is loose, almost all swelling after rhinoplasty affects the observation of the effect after rhinoplasty, so generally use both hands to hold the gauze to compress for 3-5 minutes, you can compress to stop the bleeding, also can compress the swelling, after the shape is satisfactory, you can use 5/0 or 6/0 cosmetic suture to close the wound, use saline cotton ball to remove the blood in the nasal cavity and then observe whether there is penetration in the nasal cavity, and then use a little bit of gentamycin eye ointment to apply to the incision. The nasal prosthesis is implanted under the deep fascia of the nasal dorsum and usually will not shake, so it can be fixed without impression splint or adhesive tape.
8.Nasal Column Lengthening
Some patients, because of the short nasal column, the tip of the nose after rhinoplasty can not be elevated, but caused the tip of the nose downward to form a steep slope, so you need to make a nasal column lengthening surgery, along both sides of the nasal column incision and then in the upper lip and nasal column skin for a “v” shaped incision, the formation of a “V CY “suture, that can lengthen the nasal column, so that the tip of the nose elevated.
9.Post-operative treatment
Apply ice compress for 24-48 hours after surgery, apply antibiotics for 3 days to prevent infection, keep the nasal cavity dry and clean, remove the stitches in 7-8 days, prohibit pinching nostrils and collision within 1 month, and review regularly after surgery.
(F) Complications of rhinoplasty and treatment
At present, rhinoplasty generally adopts solid silicone rhinoplasty, using medical silicone blocks of suitable size and good quality for rhinoplasty, which usually have good results and no serious complications. However, the following complications may sometimes occur.
1.Local edema
including the nose and both eyes, mild local edema will occur in every patient after surgery, which usually starts to subside after 2 to 3 days and can disappear completely after two weeks.
2.Prosthesis-related
(1) The prosthesis is easy to shake: the prosthesis is implanted under the skin, the outline of the implant is vaguely visible, and when touching the nose with the hand, the implanted silicone rubber nasal prosthesis is felt to shake under the skin; the prosthesis is skewed and the nasal root is stepped deformed. The stripping cavity should be located at a deeper level, (under the periosteum) so as to prevent postoperative prosthesis instability.
(2) Prosthesis translucency: postoperative nasal back reflection is enhanced, so that one can feel the presence of subcutaneous prosthesis, in addition to small depressed pits on the nasal back. The choice of brown prosthesis can reduce the postoperative nasal back reflection too strong.
(3) Exposed prosthesis: The following factors lead to the exposed prosthesis: ① The tip of the nose is overfilled, the blood vessels around the nose are dilated and congested, and the skin becomes thin. (2) The silicone rubber nasal mold is too long, the stripping of the nasal root is not sufficient, the upper end of the model is placed in the subcutaneous cavity, the surrounding fixation is not firm, the nasal mold falls to the nasal end under the action of gravity, the skin at the nasal tip column rises, becomes white and hyperplastic for a long time, and the silicone rubber is exposed when the skin is pierced. (3) In addition, the silicone rubber mold of the nasal column is too thick, the edge is not smoothly trimmed and the edge is sharp. If the distal end of the column is not implanted at the anterior nasal spine, bending and curling when implanted between the two nasal cartilages; or if the stripping here is not sufficient and the column is implanted in a deviated position, then it often happens that the silicone mold penetrates the nasal mucosa or penetrates the skin at the nasal vestibule, so that the silicone is exposed.
(4) Foreign body reaction: If the local edema does not subside after three weeks and there is yellow liquid flowing out from the incision, it may be that the body has a rejection reaction to the implant and should be removed. Three months after removal, you can consider using your own bone or cartilage as implant and perform rhinoplasty again.
3.Infection
Wound infection is not common. When it happens occasionally, it is mostly caused by poor disinfection during surgery or the patient wiping the wound with hydrogen peroxide swab after surgery. In mild cases, antibacterial agents can be used to treat the wound. In cases of septicemia, the implant should be removed and the incision should be opened for drainage.
4.Skin stasis
Skin stasis, mostly seen on the back of the nose, is caused by soft tissue trauma caused by repeated insertion of oversized implants in the subcutaneous tunnel during surgery. Usually there are no serious consequences and it is absorbed in 3 to 4 weeks.
5.Skin necrosis and exposed prosthesis
Skin necrosis mostly occurs at the tip of the nose, which is caused by the implant being too high, too sharp or the skin being too little and too tight. During surgery, after the implantation of silicone gel, if the skin color of the tip of the nose is pale, indicating ischemia, the implant should be removed and the tip of the nose should be repaired and reimplanted in order to reduce the tension of the skin. If the implant is not removed and modified during surgery, so that the skin at the tip of the nose turns from white to red and from ischemia to bruising after surgery, the overly high or overly pointed implant should be removed as soon as possible and no longer implanted to avoid final skin necrosis; if the tip of the nose is white or too tense after implantation, it must be removed and repaired before implantation, and should not be taken lightly.
6.Cracked incision
The skin incision at the edge of the nostril should not be under tension when it is sutured. If the tension is too great, the incision will have difficulty in healing and after the sutures are removed, the incision will easily split open, resulting in the exposure of the implant. If the exposed implant is autologous cartilage, the exposed part of the cartilage can be removed and the incision can be re-sutured; the re-sutured incision can also heal smoothly. Operate gently to avoid unnecessary injury, avoid hematoma, and suture delicately.
7.Healing disorder
One week before and after surgery, smoking and alcohol consumption should be strictly prohibited to ensure good wound healing.
8, unsatisfactory shape
The shape after rhinoplasty is unnatural, without normal nasal frontal angle, nasal facial angle, nasolabial angle, without ideal aesthetic curve, without natural and facial coordinated curvature. Reasonable design before surgery must be different from person to person according to the patient’s gender, face shape and the original condition of the nasal bridge; generally the aesthetic parameters of the nose should be referred to, mainly the nasal facial angle should be 25-30°, the nasal frontal angle should be about 120°, and the nasal lip angle should be about 90°. The size, length and width, thickness, curvature and arc of the silicone nose model, and the depth of the groove between the bottom surface and the occlusal surface of the nasal bone should be adjusted and sculpted according to the patient’s specific conditions.
Cautions
①As a plastic surgeon, good aesthetic training is essential. Each person’s facial features are different, and have different aesthetic views, occupation, I life features, preoperative detailed understanding of the patient’s subjective wishes, well according to the facial features of the design, the postoperative changes clearly tell the patient to get the patient’s approval is a key step in plastic surgery, many plastic surgery patient dissatisfaction is caused by insufficient communication.
② There should be a comprehensive understanding of the anatomical form of the bone, cartilage and skin of the nose, paying attention to the tension and mobility of the skin and soft tissues of each part and other characteristics. In this way, we can have a good estimation of the postoperative effect and feasibility, and clarify the dynamic changes brought about by local changes For example, for candidates with short nose and skyward nostrils, only minor changes can be made simply by rhinoplasty, otherwise the skin tension is too great and perforation, redness and swelling are likely to occur in front of the nasal tip. In addition, the skin tension at the root of the nose is high, the skin soft tissue is thin, and the prosthesis is too high or too narrow, then it is easy to occur the shadow of the contour of the prosthesis.
The sculpting of the prosthesis is a key step to the success of the surgery. Except for those with a low nasal root, the “L” type prosthesis is generally used. According to the shape of each person’s nasal bone and cartilage, carve the bone and cartilage surface of the prosthesis, and strive to match the skin surface of the prosthesis to be natural and smooth, without prominent angles, and the tip of the nose should not be too prominent, otherwise the tension will be too great.
④ After sculpting the prosthesis, it is necessary to mark the stripping range on the nasal surface, although it has not been reported in the literature, but it is helpful for the bit of prosthesis placement and stability. Local inadequacy of the stripping space can often lead to malposition and distortion of the postoperative prosthesis; too large can easily lead to unstable placement of the prosthesis. The sculpted prosthesis is placed at the site to be placed, and a line is drawn along the edge of the prosthesis on the nasal surface 2 to 3 cm outside this line and then a line is drawn, which is not easy to observe because of the swelling of local anesthetic drugs during surgery, marking the highest point of the nasal tip and the golden point of the nasal root. After the placement of the prosthesis, touch and slightly move the prosthesis by hand, carefully check whether the location of the tip and the root of the nose are centered, confirm the correct position of the prosthesis without distortion and check its stability and skin tension in all areas. No active bleeding before suturing.
⑤ Pay attention to gentle movements when separating during surgery to reduce trauma and bleeding, and separate the cavity symmetrically and at the same level. The nasal root surface should be separated under the dorsal fascia of the nose and separated to the golden point, otherwise, although the periosteum is seen on the surface of the skin to the golden point, the actual cavity under the skin is slightly smaller, which will easily lead to excessive tension in the tip of the nose, or distortion and skewing of the prosthesis. The cavity separation must be blunt, not sharp. Use mosquito clamp operation, incision after the mosquito clamp concave and downward, the end of the clamp against the nasal cartilage separated to the lower end of the nasal bone, poke the periosteum with the tip of the clamp, the tip of the clamp close to the nasal bone from the bottom upward separation, if the size of the separated cavity is appropriate, the implantation of the prosthesis is very stable. Blunt separation causes less damage, less bleeding, less postoperative swelling, and faster swelling.