16Jun/20

Fibrosis After Rhinoplasty And Other Healing Problems

As occurs after any surgical operation, after a Rhinoplasty, there are a series of healing phenomena that can last more than a year. The basic healing phenomena are common to all of us, but their development can be very different from one area to another in our body and from one individual to another. In this post, we will review the main healing problems, what is fibrosis after rhinoplasty, and how all this can influence the results.

The Healing Process After Rhinoplasty

  • – Immediate phase. It is the most immediate postoperative period, which usually lasts around a month and is characterized by the presence of inflammation. Think of inflammation as a sponge that has been soaked in water. The sponge is our tissue, and the water inside is the inflammation that will make our sponge “swell.”
  • – Intermediate phase. The medium-term postoperative period usually lasts about six months, during which the greatest inflammation (60-80%) occurs.
  • – Late phase. Between 6 and 18 months, the nose is finally deflated, especially the most superficial layers of the skin. The scars will gradually end their maturation and lose volume.

What Is Fibrosis?

We must consider scars as normal structures as a consequence of tissue repair when they are attacked. Normally we see the external scars from the surgeries, but we don’t see all the scarring processes under the skin. In liposuction, for example, the area of internal healing is huge if we compare it with cutaneous scars that can hardly be 1/2 centimeter. When the healing process involves “special effort” for damaged tissue and deposits larger or poorer amounts of scar, we usually call it fibrosis.

Other Healing Problems After Rhinoplasty

Although fibrosis is perhaps the main scarring problem that we can find after rhinoplasty, there are other less frequent problems, but they also need to be recognized.

The Abnormal Bone Drop.

Just as skin can heal abnormally, bones can, too. Unlike the skin, the bones heal in a somewhat different way, which is called the bone key. A bone loss is a normal consequence of bone healing either because it has fractured or because it has been cut (Osteotomies). But just as it can happen to the skin, the bone cay can end its healing process in an abnormal way or with greater volume than desired, sometimes causing alterations in the contours of the nose.

External Scars.

It is extremely rare that skin scars after rhinoplasty is abnormal. Patients with thick skin, sebaceous skin of smokers are at greater risk of developing hypertrophic scars.

Internal Scars.

Even more infrequently, the internal scars on the nose are abnormal. In these locations, these scars can most often “contract” or “retract” excessively, generating asymmetries or defects in the contour of the wings or the tip when improperly pulling or betraying the tissues around them.

Ultrasonic rhinoplasty. Why, how and when

Since its inception, Rhinoplasties have been based on the use of mechanical instruments, such as chisels, rasps, or gouges, to model the bony part of the nose. Apart from the improvement of the materials with which this instrument has been manufactured (high-quality steels, titanium, carbon edges, etc.), there has been no overwhelming invasion of surgical equipment. For a few years now, piezo-electric devices have been incorporated into Rhinoplasties, promising a series of benefits for both the surgeon and patients. In this article, we will review what is known as Ultrasonic Rhinoplasty, why it is used, how it works, and when it is truly useful.

What Does The Piezo-Electric Technology Used During An Ultrasonic Rhinoplasty Consist Of?

The term piezo-electric derives from the Greek « piezin, «which means to press or squeeze. The piezo-electric effect was first described by Marie and Jean Curie in 1880, and its operation is based on the behavior of certain crystals when they are subjected to an electric charge or pressure. Using this technology, an ultrasonic oscillation frequency can be obtained that has proven to be very useful for making precise cuts in hard materials, such as bone. In this sense, frequencies between 26-29 Khz are especially useful because the device will be able to cut bone without affecting soft tissue.

What Practical Uses Does Ultrasonic Rhinoplasty Have?

We must be clear:

  • – Ultrasonic rhinoplasty is not a different way of «doing rhinoplasties,» just a way of treating the bony part of the nose.
  • – Don’t be confused; With piezo-electric instruments, only the bony part of the nose can be treated (approximately 1/3 of the nose). The other 2/3 of the nasal architecture are treated “without ultrasound.”

The use of ultrasound (piezo-electric instruments) in rhinoplasty is useful for:

  • – Accurate, targeted, and relatively less traumatic bone cuts than with traditional instruments.
  • – Customized osteoplasties. It is also possible to scrape or model the bone in a more progressive, delicate, and controlled way.
  • – In segments of hard cartilage (such as the rib), it is useful to obtain grafts with precision and less risk.
  • – It is helpful in certain septoplasties (nasal septum operations) where conventional instruments can be too aggressive or dangerous.

Ultrasonic rhinoplasty can be used with closed rhinoplasty techniques for very specific and limited steps such as osteotomies. But where the full potential of Ultrasonic Rhinoplasty is truly exploited is during open rhinoplasties. It must be borne in mind that one of the most interesting facets of the piezo-electric instruments is the irrigation of the tissues with pressure serum. This benefit cannot be obtained if the instruments are used during a closed rhinoplasty.…

07Jun/20

When Are Rib Grafts Used During A Secondary Rhinoplasty?

The nose has an extremely effective, precise, and delicate anatomy that is ultimately responsible for its shape, its proportions, and its position. To reconstruct this anatomy freely and precisely, in special cases, it may be necessary to resort to cartilage grafts obtained from a rib. In this article, we will see why the rib is chosen as a source of grafts, what advantages it has, how it is used, and what complications can arise.

Why we choose the rib in some secondary rhinoplasties

As we saw in another post related to the use of grafts in rhinoplasty, these are frequently necessary for patients with a history of rhinoplasty or previous trauma. This need is given by the fact that we will need to redo, supplementary, or replace the anatomical structures of the nose that have been damaged and cannot be reconstructed. The problem is that to carry out these works; we will need a quantity of cartilage large enough to cover our needs.

Under normal conditions, the nasal septum or atrial cartilage shell offers sufficient quantity and quality of cartilage to meet the needs of uncomplicated secondary rhinoplasty. Both structures can offer us between 2 and 4 cm2 of useful surface that is usually enough to make partial corrections at the tip and / or the back.

But we can meet special patients in whom:

  • We appreciate especially serious anatomical and / or scarring alterations.
  • We cannot resort to the nasal septum or the ear shells because they are already operated or damaged (by a perforation, for example).
  • The ears are intact, and the septum is not operated, but we need enough straight and flat segments of cartilage, or we need surfaces larger than 4 cm2.
  • In addition to a broad and straight cartilage surface, we need soft tissue segments such as the fascia or perichondrium of the cartilage.
  • We need to make a cartilage “paste” that allows us to model complicated areas of the nose without distortion and whose manufacture consumes a lot of cartilage.

What are the advantages of using rib in secondary rhinoplasties?

The fundamental benefits of using the rib as a source of cartilage grafts are several:

  • Have a generous source of strong, easily carvable cartilage.
  • To be able to obtain grafts of the desired shape: Laminar, curved, thin, or thick. A cartilage “paste” can also be obtained with which to model and refine complicated areas.
  • Being able to obtain generous segments of the perichondrium (the envelope of all the cartilage in the body) or fascia without having to resort to additional sources (such as the fascia of the temple area).

Thanks to this versatility we can do some things like:

  • Reconstruct the wing cartilage in its entirety, generating a totally new tip in shape and position.
  • Reconstruct the external and internal valves to improve nasal obstructions.
  • Reconstruct the dorsal lines of the nose or elevate the dorsum in cases of V deformity, open roof, or over-resections of the dorsum.
  • Reconstruct an absent or perforated septal septum.
  • Check the position of the tip to de-rotate and hold it.

It should be borne in mind that a large part of these benefits depend on the experience and ability of the surgeon to carve the rib accurately and correctly (in the same way that a sculptor has to know the structure of a specific wood in order to obtain the desired shape without spoiling it).