Nasal Surgery: How to guarantee the results?

Very often, patients with indications for nasal surgery come to my office, with series of constant doubts. Will it be fine? Will I stop suffering from sinusitis? Will I stop snoring?

All these concerns are completely normal, by virtue of being unknown experiences (for the vast majority of them). However, others have had to do it on more than one occasion. This publication aims to elucidate the factors that can affect these results and answer those questions.

_{Source: Unpublished image, captured with a Samsung device and edited with the Microsoft Power Point program}
In the first instance it´s necessary to be clear, that these results will depend on three main factors:

1.- Inherent factors for the patient.
2.- Purposes of surgery.
3.- Surgical technique.

Inherent factors for the patient

Patient symptoms: constant nasal obstruction, facial pain, anosmia or hyposmia (not perceive or perceive little odors), dysphonia, headache, visual disturbances, otitis media of effusion, hearing loss, among others.
• Clinical signs: Rhinodeformity, septal deviation (deviated septum), hypertrophy of lower or middle turbinates, polyps, other nasal lesions.
• Responses to medical treatment: lack of response to medical treatment; frequent infectious episodes of more than 3 months evolution, orbital complications.
• Findings in endoscopic and tomographic studies: spurs, ridges, fracture areas; sinuses occupied by cysts, polyps, nasal mucus, other injuries.
• Clinical pictures: patient with facial asymmetries or aesthetic dissatisfaction.

Purposes of surgery

_{Source: Image captured with Samsung device}

Nasal surgery is done with three main purposes:
• To improve the aesthetic appearance.
• To improve the functioning of the nose.
• When both are desired.

Surgical technique to be developed

It’s very important to know the reasons why the patient is going to be operated. This will define the surgical management and the surgical technique, the type of surgical instruments and other medical materials. In this way, the possible eventualities that may arise, both at the time of the surgery and after it, will be reduced to the maximum.

Nasal Functional Surgery

Nasal functional surgery can be performed conventionally and using endoscopic techniques.
When the patient presents nasal septodessy, with or without the presence of spurs, ridges and hypertrophy of inferior turbinates, a conventional nasal or endoscopic functional surgery can be performed if the specialist prefers it.

Source: Unpublished image, captured with a Samsung device and edited with the Microsoft Power Point program
Nasal endoscopy in the diagnosis of various nasal pathologies, as well as in the resolution of them, has been a great ally to solve the chronic inflammatory (rhinosinusitis) and anatomical alterations that can be found in the nasal and paranasal cavity.

Nowadays, it is not justified to perform nasal and paranasal sinuses surgeries without the help of fiber optic equipment. These together with special instruments, allow you to access to the base of the skull and clean the cavities that are being affected by the presence of mucus, polyps, cysts or tumors; cases in which using conventional techniques will not guarantee surgical success.

Source: Unpublished image, captured with a Samsung device and edited with the Microsoft Power Point program

_{Source: Unpublished image, captured with a Samsung device and edited with the Microsoft Power Point program}
The previous images correspond to tomographies of sinuses, where there is evidence of retention cysts, polyps, septal deviation, bullous mid-turbinates, hypertrophy of inferior turbinates, thickening of the septal mucosa; that reflect a chronic rhinosinusitis.

In these cases, where there is evidence of chronic sinus occupation, with constant, thick rhinorrhea and polyps; a functional endoscopic surgery should be performed, with tissue sampling (biopsy) to determine the nature of the lesion and thus plan some other subsequent treatment, since we can take unpleasant surprises.

Nasal Aesthetic Surgery. Rhinoplasty-Rhinoseptoplasty

The patient may want only a modification of the aesthetic appearance of their nose, that is, they don’t like the width, the height, the projection or rotation of the nasal tip, or his nasal wings are very wide, in short they are not happy with the shape of their nose. In that case, a rhinoplasty would be performed and if there is also some deviation of the nasal septum, it would be called rhinoseptoplasty.
To perform this type of surgery, the ideal is that the patient has reached physical maturity, has passed puberty. However, if the patient is smaller and the surgeon decides, he can do the surgery weighing the risk benefit.
There are two main techniques, Open Approach, in which a small incision is made in the columella, practically imperceptible, and Closed Approach, which does not leave any type of scar, because the incisions go inside the nose. The use of one or another technique will depend on the taste, the experience of the surgeon and the changes required in the nasal structure.

_{Source: Image captured with Samsung device}

In the previous images we observed two patients. The first had a globular tip, broad, ill-defined and without projection, she wanted to improve the nose but with subtle changes.
The second had a nose tension, the product of a nasal trauma in childhood; where there was bone and cartilaginous growth, not accompanied by stretching of the skin, so it developed a high and wide nasal dorsum, with a dorsal hump; she of course wanted to totally change that form.
If we look at the "after" of each one, you can notice that in the first one we made subtle changes and in the second radical changes, in fact the number two patient seems different.
It is very important to know what bothers or what the patient doesn’t like about their nose. To know the expectations of the patient is vital for the specialists who performs these surgeries, as well as establish in advance the possible results, in order to avoid uncomfortable moments.

Will I have to use nasal packing?

Currently, nasal splints are used, however, in some cases in which any tumor lesions or polyps have been removed; a nasal tamponade will be required for two or three days.

The nasal splints, will allow the patient to breathe during the immediate postoperative period. Through these, the patient will perform nasal washes with physiological solution to prevent them from becoming clogged.
These devices will be left for at least a week, everything will depend on the surgical findings.

Is it a painful surgery? Am I going to swell? Am I going to get bruises?

It is not a painful surgery; the patient will only have mild discomfort after nasal surgery, which usually yields with common analgesics.
In the case of aesthetic surgeries, due to the need to fracture nasal bones, there will be bruises around the eyes, which will disappear in the first weeks and are not warning signs.
There are no scars when a closed approach is made and in the open approaches, the scar is imperceptible after a few weeks.
All the above reflects that to guarantee the results of a nasal surgery it is necessary to be clear about these factors:

Own Diagram

In any case, it is essential that the patient has clarified the doubts with their treating doctor and taken into account each of the details of their surgery and subsequent management, that is, everything concerning medical treatment, diet, physical rest, avoid Sun exposure and the use of nasal cover with adhesives.
The patient must commit to participate actively in the post-operative care, to attend the consultations, to carry out the cures and to notify their doctor of any eventuality.
No less important are the patient's expectations in terms of aesthetic results, since this will avoid inconvenience. Empathy is essential, as well as the confidence to handle possible final details that require refining.

I'm Eadams @elvigia, otolaryngologist.

References

• Behrbohm, H; Tardy, E. (2004). Essentials of Septorhinoplasty. Philosophy-Approaches-Techniques. Stuttgart,
• Marks, S. (2001). Nasal and Sinus Surgery. W.B Saunders Company. Philadelphia. Pennsylvania.

Note: All of the clinical images and clinical cases belong to the author
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