Rhinoplasty is a procedure to improve the appearance of the nose by filling the nose with various autologous or allogeneic tissues or tissue substitutes to elevate the external nose.
The nose is located in the middle of the face, high and prominent, and its beauty is related to the whole face, which is most noticed. Since ancient times, people have been very picky about the appearance of the nose. In ancient Persia, a crown prince with an ugly nose could not inherit the throne. Therefore, in order to have a well-proportioned and beautiful nose, the crown prince who could be expected to succeed the throne used to ask eunuchs to shape their noses from their childhood. With the development of the times, the progress of society and the deepening of human civilization, modern people pay more attention to the appearance of the nose, and the admiration for a proportionate, handsome, natural and beautiful nose has become the general pursuit of beauty and the consensus of society on beauty. However, the sky often does not make beauty, the ideal nose is after all only the patent of a few people, the national nose shape does not meet the aesthetic standards of many people. Since the nose is the most prominent part of the face, any small defect and disproportion or irregular shape will affect the correctness of the face and bring adverse psychological and spiritual effects to the patient. Therefore, rhinoplasty, a “living sculpture” surgery to improve or beautify the appearance of the nose by correcting the poor shape of the nose, came into being and became a popular surgery in plastic and cosmetic surgery.
The name and characteristics of each part of the nose
The external nose is divided into three parts: the root of the nose, the bridge of the nose and the tip of the nose. The nasal root is the bony part, which is composed of two nasal bones and the nasal prominence of the maxilla. The bridge of the nose is between the root and tip of the nose and consists of two pieces of lateral nasal cartilage on the left and right. The tip of the nose is the terminal part of the nose and consists mainly of two nasal cartilages. Each nasal cartilage has a medial foot and a lateral foot. The two medial feet form the nasal column and the tip part of the nasal scaffold below the tip of the nose, and the two lateral feet separate to the left and right of the tip of the nose to form the two nasal wings.
The external structure of the nose, from the nasal root to the nasal columella, forms a prominent trigeminal cone. The skin covering the upper two thirds of the nose is loose and elastic, so it is easy to stretch and expand the skin; while the skin covering the lower third of the nose is tightly attached to the subcutaneous tissue below, so it is not so easy to stretch and expand the skin.
Factors that determine the shape of the nose
The shape of the nose differs significantly depending on the race, and the different shapes of the nose are the result of man’s struggle with nature. In terms of biological evolution, the warmer the climate, the wider the nostrils and the shorter the nose. Such as black Africa’s nose is both wide and flat, is to suck in a lot of warm and humid tropical air. And the colder the climate, the narrower the nostrils, the higher the bridge of the nose pointed. As in Northern Europeans, the nose is both thin and high, is to breathe in cold air, so that the cold air has more time to be heated to adapt to the survival environment. The difference of nose shape among the races is shown as ① the width of the nose root, from wide to narrow in the order of: black, yellow, white. ②The height of the nasal bridge: white people are the highest, yellow people are in the middle, and black people are the lowest. ③The size and roundness of the tip of the nose: the largest is black, yellow is in the middle, white is the smallest. ④Width of the nose: the largest for blacks, followed by yellow and white. ⑤ nasolabial angle, i.e., the angle between the nose and the upper lip; white people are the smallest, followed by yellow people and black people. It can be seen that the shape of the nose varies greatly by race. Anthropologists use this as the basis for racial classification, and the individual differences and group differences in the same race are also very large. For example, among the Han Chinese race in China, the noses of southerners and northerners are very different. Although the nose shape varies greatly from person to person, but in general, Caucasians are fine and high nose, black people are broad and flat nose, yellow people in the middle. This nasal shape determines that oriental rhinoplasty is generally done to raise the nose, while westerners have rhinoplasty done to lower the nose.
Aesthetic standards of the nose
Which nose shape actually looks good? Can we give a standard for the beauty of the nose? This is influenced by culture, customs, habits and aesthetic concepts. The ideal nose shape is not consistent from country to country, from nation to nation and from person to person. As far as our Han nation is concerned, the normal and beautiful nose is a bottom-facing trigon, located in the middle 1/3 of the face; the ideal length of the external nose is 1/3 of the length of the face; the ideal width of the external nose is the width of a glance, which is what our ancient painters called “horizontal three”, “vertical five “The ideal nasal shape is narrow at the top and wide at the bottom in an oblique shape, with its oblique surface intersecting with the face at 25-30 degrees; the ideal height of the tip of the nose is 1/3 of the length of the nose, the tip of the nose is pointed and round, the nostrils are flat and round, and the nasal small column is 90 degrees from the upper lip.
Which nose is suitable for rhinoplasty
1.Low nose: from the root of the nose to the tip of the nose, the entire nasal bridge is relatively low. Strictly speaking, each nationality has an average nasal bridge height, if it is lower than the value, it is called low nose. Some people take the height of the nose of western people as the standard, and consider their nose bridge low, which is obviously inappropriate. In addition, to determine the height of the bridge of the nose, but also with the face shape and other features to consider.
2, saddle nose: is a common nasal deformity in China. Like low nose, its nasal bridge height is lower than the normal value, the bone and cartilage part of the nasal bridge is mostly concave, but the tip of the nose is upward, the shape is like a saddle.
3.Straight nose: The nasal bridge is still high, but the shape is straight and lacks the cone feeling. The highest point is not located at the tip of the nose.
4.Nose tip low hanging nose: the tip of the nose is low hanging, the highest point of the nose is located in the back of the nose.
5.Nasal root low flat nose: nasal root low flat, nasal tip, nasal back shape is still possible, eye distance is wide, the nose body is short, seems to be out of proportion.
6, wave nose: two depressions in the nasal back axis, so that the nasal axis is not complete and smooth.
7.Nostril horizontal lying nose: due to the nasal end dysplasia, resulting in the nostril is not erected “eight”, the nasal wing is wide and flat, common in the secondary nasal deformity after cleft lip surgery.
Selection of implant materials
Whether the nose is flat and concave due to congenital, disease or trauma, people are always looking for the right material to elevate it. There are two main methods of nose augmentation, namely the transplantation method and the implantation method.
Transplantation method: Also known as tissue transplantation, bone and cartilage tissues are mainly used to fill the nose. There are three types of bone and cartilage transplantation: ① Allogeneic bone and cartilage transplantation, that is, the use of animal bone and cartilage tissue transplanted into the human nose. Animal bone and cartilage tissues are abundant and have been used for a long time. However, due to the antigenic nature of allogeneic bone and cartilage, its rejection reaction and late resorption limit its use. ② Allogeneic bone and cartilage tissue transplantation is to use someone else’s bone and cartilage tissue as filling material. Although this method can obtain better results, it is difficult to source, its application is limited, and there are also problems of rejection reactions and late resorption. ③Autologous bone and cartilage transplantation is to use the patient’s own bone and cartilage tissues as the filling material. Autologous cartilage is easy to sculpt and shape, while autologous bone is more difficult to sculpt and shape. The advantage of this method is that there is no rejection reaction and it can be permanent. The disadvantages are that bone and cartilage have to be taken from the patient, which is more painful; it cannot be shaped in advance, which prolongs the operation time; and slight absorption deformation can occur after being buried for a long time.
Implantation method: It is to implant various artificial implant materials into the nose. Up to now, people have used platinum, gold, silver, petroleum jelly paraffin oil, ivory, plexiglass, liquid silicone rubber, etc. Due to their inevitable complications, these materials have now been abandoned. At present, the more clinically used nasal filling material is medical solid silicone rubber. Medical solid silicone rubber has the advantages of stable performance, low irritation, moderate texture, can be pre-shaped, can be kept in the body for a long time without deformation, easy to deal with postoperative complications and unsatisfactory appearance, no adverse reactions when used correctly, etc. It is the longest, most abundant and most widely used material for rhinoplasty in clinical practice. With the development of science and technology, some new nasal filling materials such as polytetrafluoroethylene, medical porous materials, hydroxyapatite, methacrylic acid methacrylate, etc. have appeared in recent years. These materials have the advantages of convenient source, non-absorption in the body, no damage to the patient’s donor area, pre-shapeable, and shorten the operation time. As foreign bodies, they are easier to expel than autologous tissues, although they are less likely to cause rejection in the body. A common concern is whether these materials can cause cancer when implanted in the human body, a question that is still inconclusive. According to the medical solid silicone rubber, which has been used clinically and for a long time, it has not been found to have significant carcinogenic properties so far. As for which material is good to use, it is difficult to make a definite decision, which depends on the patient’s nasal conditions, the source of the implant material, the patient’s requirements and the surgeon’s surgical preference. Due to the short time of clinical application of the new material, whether it can safely and permanently stay in the body as a filler requires a long period of clinical case follow-up before a final judgment can be made on it.
Whether the nose can be raised by injection
Injectable fillers are always attractive because they do not involve the pain of cutting into the flesh. The mention of surgery, on the other hand, is always a source of fear. Therefore, cosmetic surgeons are always looking for cosmetic surgery with simple methods, good results and minimal pain. On the other hand, people who ask for rhinoplasty are always eager for doctors to make the surgery as small as possible, so that no one can see it, and injectable fillers become the most attractive cosmetic surgery. For example, many people ask for high nose by injection after seeing reports in newspapers and magazines that certain filler materials can be injected into the human body. Can we rely on injections to do rhinoplasty or not? And what are the results? Please see the following historical review.
As early as 1899, Gerzuni reported the use of liquid paraffin injections to raise the bridge of the nose, but its adverse effects soon became apparent. First, paraffin wax injected into the nose under the skin, cushioning capacity is limited; second, after cushioning the nose if close to the heat source, paraffin wax will dissolve and penetrate into the adjacent tissue interstices; third, the injection accumulates under the skin, will get paraffin tumor, must be surgically removed; fourth, over time, the injection will stimulate the subcutaneous tissue, causing injection site skin redness, swelling, ulceration, and finally had to be removed with the nose skin, and then another skin implant or The nose will be rebuilt. In the 1930s, people began to widely use petroleum jelly for soft tissue filling in different parts of the body, but later found that there was tumor-like growth 6-8 years after injection, so it was also abandoned. 1955, the Japanese Nishihata first reported the use of liquid silicone rubber injection for rhinoplasty. Since then, Japan, Europe and the United States and our country is very popular, think it is low toxicity, irritation is small, can be prepared according to the needs of different hardness of the colloid, injected into the nose under the skin, you can use your fingers like pinching rubber dough to press the nose under the skin of silicone, arbitrarily shape the ideal form. However, after this method became popular, it was found that it could infiltrate into the adjacent tissue gap and cause silicone granuloma, and cause skin redness, swelling and ulceration at the injection site, and it was extremely difficult to remove it, and complete removal was even more of a luxury. In 1994, polyacrylamide gel, which can be used as an injectable soft tissue filling material, was introduced for the first time in Ukraine, called “Ingelfahrer” in Ukraine and “Fulmacril” in Russia. In Ukraine, it is called “Ingelfal”, and in Russia, it is called “Fulmacril”. At present, it has been used for injectable breast augmentation and rhinoplasty in China. Since it has the advantages of simple method and more obvious short-term effect, there are still many people who like to accept and use it. However, from the reports of clinical application, it can also cause a variety of complications including non-inflammatory complications and inflammatory complications, the latter of which are septic and non-septic. Since it has the same disadvantages of difficulty in removal and extravagant hope of complete removal after adverse reaction, and there is a lack of long-term effect evaluation, more extensive and in-depth research and data collection are needed before a final conclusion can be drawn on its clinical application.
With the booming development of plastic and cosmetic surgery, various new filler materials are increasing day by day, and it is generally believed that filler materials should meet the following characteristics: 1, good biocompatibility, no absorption in vivo, no deformation, no anti-cancer and allergic reactivity; 2, will not promote the growth of various microorganisms, can be easily shaped, 3, filler materials in vivo have permeability to X-rays, low thermal and electrical conductivity; 4, for in vivo implant material, the most important point is that it can be easily removed in case of problems.
Pre-operative design
Rhinoplasty is a creative surgical modeling art, and it is never easy to shape a well-proportioned and beautiful nose. In addition to the surgeon’s clinical experience, technique and aesthetic perception, the design and production of the preoperative model is the key. Whether the nose is viewed from the front or side, it has a three-dimensional relationship with the eyebrows, eyes, mouth, lips and chin. In the preoperative design, the nose should be linked with the whole face, and the nose should be sculpted according to the patient’s face shape and ethnic characteristics to match his appearance, so that the nose created by the surgery can be coordinated with other organs of the face. The implant can be sculpted according to the patient’s nose or chosen from a pre-made “commercial nose”. It is generally believed that the nose should not be too high for a round face; a higher nose is better for a slender face; a wider nose for a square face; a higher nose for a high forehead, cheekbones and chin; a tall nose is not suitable for a small face; a flat forehead will look even flatter if the nose is higher. The nose should be straight in men and slightly concave in women. The angle of the nose and lips should be moderate, too small is like a hook nose, too big is a skyward nose. When designing the nose, it is important not to use one model for all the patients, so that all of them have the same external nose. In order to avoid the inconsistency between the shape the patient wants to have and the shape the surgeon wants to produce, the surgeon must find out what shape the patient wants and agree with his or her vision to determine the best shape of the nose after surgery. It is unrealistic to take a picture of a celebrity and ask to make a certain celebrity’s nose. A truly ideal rhinoplasty should use the art of body contouring to preserve the original lines and contours of the patient, with some artificial embellishments, so that the surgery has a beautiful and truly harmonious effect.
Pre-operative preparation
Rhinoplasty is a purely cosmetic surgery, and the patient often expects to improve his or her temperament, poise, self-confidence and other mental states after improving the appearance of the nose. Therefore, in addition to some conventional preoperative preparations, the examination and preparation of the patient’s mental state is particularly important.
1. Patients generally need to be over 18 years old, after the nasal bones and nasal cartilage have developed and matured, and those who are not satisfied with the shape of the nose can undergo surgery. Adolescents are developing physically and their psychological condition is not stable, so surgery is not suitable at this time.
2.Patients with natural expression, stable emotion, reasonable, full trust in the doctor, no doubts and hesitation; have urgent requirements to improve the appearance of the nose, but not unrealistic and excessive requirements, not to mention the requirement to change the whole face or even the whole life through surgery.
3. Surgery is not recommended when there is inflammation or allergy in the nose.
4.Patients with menstruation, blood clotting disorders and those who have recently taken drugs that may affect the coagulation function should not have surgery or be cautious about surgery.
5.Patients with systemic diseases should not undergo surgery or be cautious about surgery.
6.Patients with suspected mental or psychological disorders should not be operated or operated with caution.
7.Medical photography should be performed before the surgery and the patient should sign the consent form for the surgery, nasal hair should be cut, face and nasal cavity should be cleaned before the surgery, cosmetics should not be applied on the day of the surgery, and patients who are too nervous can be given appropriate sedatives.
How to do rhinoplasty
With the preoperative design and preparation, the surgery is relatively simple. Generally, under local anesthesia, a skin incision is made in one side of the nostril (usually the right side) along the anterior edge of the medial and lateral pedicles of the nasal cartilage, and the nasal model is implanted through subtle separation under the dorsal nasal fascia with instruments to form the corresponding tunnel. The distal end of the implant should preferably reach the midpoint of the line between the eyebrow and the medial canthus, the “golden point. If the length and height of the implant are appropriate, and the curve of the nose is harmonious and natural, the skin incision can be closed, and a beautiful nose is born. This immediate cosmetic surgery gives the patient a new look.
Post-operative care
After surgery, antibiotic ointment is applied to the wound, the exterior of the nose is fixed with cotton pads and impression adhesive or not, oral antibiotics are taken for 3-5 days to prevent infection, facial edema and even “nasal swelling” are the normal post-operative reaction process in 2-3 days after surgery, which usually starts to subside on the 4th day after surgery, and sutures are removed on 6-7 days after surgery.
Normal recovery
Due to the implantation of prosthetic material in the nose, the patient will experience discomfort after surgery and it will take a few weeks or a month to return to the pre-surgical condition. Some people can return to normal work in 1 week after surgery, while others take 2-3 weeks to return to normal work.
A new and perfect nose shape
Rhinoplasty is performed to give the nose a better shape, and if the surgery is done by a regular, well-trained cosmetic surgeon, the results are usually quite satisfactory. Generally speaking, after 1-3 months of recovery after surgery, a new and perfect nose shape will be revealed to the public.