What did the leading plastic surgeons at the ISAPS conference not know about rhinoplasty?

An incredible event took place in Kyiv, which brought together all the leading plastic surgeons of Ukraine.  ISAPS - the international community of plastic surgeons, within which the scientific and practical program VPP ll was carried out. The invited guest at this event was Oscar Ramirez, a world-famous surgeon, the inventor of the endoscopic plastic surgery technique.

Part of the conference was devoted to rhinoplasty. The organizers conducted a live broadcast from the operating rooms and showed a significant difference in the methods of closed and open rhinoplasty.  Surgical intervention with closed access was performed by Oleg Anatolyevich Kompaniets, rhinoplasty with open access was performed by Oscar Ramirez. During the operation and at the end of the broadcast, the surgeons had the opportunity to ask questions to the operating doctors. Estet-portal has prepared an overview of the most interesting of them.

• You broke the sink on the right side, then put it back in its original position. Do you always act like this with closed rhinoplasty?

Answer: Otolaryngologists know very well that if the nasal septum is turned to one of the sides (shifted to the side) for a long time, then the shells hypertrophy compensatory, especially the lower one. Why is it provided by nature – in order to still create conditions for turbulent rather than laminar air flow. If we return the nasal septum to its ideal position and are distracted by our interpreted nasal concha, then we get improved breathing. That is, we must necessarily influence and return the nasal concha to its previous position and original volume. I love what is called mechanical disintegration from the lateroposition of the inferior turbinate. I broke it, lifted it up, then with a raspator, which is used for double septomoderation, I destroyed the body of the turbinate, that is, spent about a minute on the cavernous body with a raspator to cause scarring of the nasal concha. And in order to avoid bleeding, we also closed the place where I entered with a bipolar electrode, since we all know how cavernous bodies bleed in the postoperative period. And then I brought it back laterally, that's what concerns the turbinate. Well, that's usually enough for my patients.

• Resection of the distal septum, which is used to shorten the tip of the nose or, for example, suturing any graft to the nasal septum - Is this action legally a septoplasty?

Answer: What difference does it make what it's called? If we have restored the distal cartilage and nasal septum, then this is very important for this category of patients, because their nose shape is precisely associated with atrophy of the lower lateral, upper lateral sections, and, first of all, with the condition of the septal cartilage. You can call it plastic..

• I will now explain why this question has arisen. I had a patient who underwent aesthetic rhinoplasty, but in the operating log and on the card it was written that rhinoseptoplasty was performed. This was done because the nose was quite long, and we had to perform an operation to shorten the end section of the nose. Therefore, resection of the distal nasal septum was performed. This operation was called rhinoseptoplasty. With an absolutely ideal external result and with an absolutely mentally unhealthy status of the patient, she makes claims to us that she did not undergo septoplasty. I say that this is still septoplasty, and you say that septoplasty – this is when we undercut a piece of cartilage. Can I call these actions septoplasty?<
Answer: We do not react to mentally abnormal people and do not take offense. If you have interfered with the septum of the nose, no matter if you made a notch, cut off a piece, took it for a biopsy, you can call it a septoplasty, that's absolutely right!

• Your first postulate is that rhinoplasty is a process in which two subjects take part: a doctor and a patient. As far as I know, while communicating with you, I would like to clarify this for the public, that quite often, and even during today's operation, you also involve a third subject, that is, a witness or guarantor of the patient himself. If possible, your comment on this matter.
Answer: I actually practice this method of working with a patient. A satisfied patient is a patient who, in principle, underwent an operation not according to direct indications.  This operation did not have to be performed in terms of normal anatomy, it is an operation that is performed for the internal satisfaction of the patient. The new nose shape may not be any better than the previous one. In such a situation, two points are very important: the first – so that the patient can accurately determine the desired result, the second – make the changes as accurately as we were asked. And this is the reinforcement, when the patient's representative confirms that everything is really done as it should be and that the result that was ordered is achieved, the patient calms down, and the rehabilitation period goes much easier.

• What is the guarantee that what is done on the operating table will last long into the future?
Answer: First, if the surgeon completed the operation with the shape of the nose that he was ordered, then the patient has a great chance to keep this shape for the rest of his life. If the surgeon completed the operation with a different shape that was ordered to him, then under no circumstances will the patient receive the desired shape, therefore the operation must be completed with the shape of the nose that was ordered. Second – we have ample opportunities for rehabilitation, and if this is given due importance and how the patient should be managed, then this significantly reduces the chances of deformation of the created form. But, of course, there are a number of medical reasons why the form may change.

• During the comments from the operating room, when there was a question about the symmetry of the nostrils, you said a phrase that surprised me a little: closed access does not allow you to achieve absolute symmetry of the nostrils during the operation, and if such asymmetry persists, it will will excite the patient in the postoperative period, then this is a direct indication for secondary correction under local anesthesia. Did I understand you correctly?
Answer: You understood me correctly. I meant that very often patients come to us whose nostrils before our intervention are a priori not the same either in area or in size. If they are not the same, then from the access that I have made, it is almost impossible for me to correct them. I change the shape, change their location, but I immediately warn patients: I do not guarantee that the nostrils after rhinoplasty will be exactly the same, since I am limited in my abilities. And after the operation, there are devices that completely correct such asymmetry within 3-5 minutes. If the patient agrees and knows what the – no problem.

• Dr. Ramirez spent a lot of time removing the cartilage graft from the patient's rib, and you said in your comment during the operation that you don't use cartilage grafts to stabilize the columella. You think that it is quite sufficient to use a stabilizing seam for this. So these are two fundamentally different approaches?
Answer: You are absolutely right, this is the difference between open and closed approaches. With closed rhinoplasty, there is no such need to renew the cartilaginous framework. Therefore, this operation is more gentle. I have nothing against graft placement and I use this technology for open rhinoplasty, but with closed access, such a procedure is simply not necessary.