Edmund S. Liu, M.D. - Facial Plastic Surgery

Edmund S. Liu, M.D.

Otolaryngology
Facial Plastic & Reconstructive Surgery

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(973) 571-1933

207 Pompton Avenue
Verona, NJ 07044

Other Nasal Procedures

ANATHOMY OF THE NOSE  RHINOPLASTY (NASAL SURGERY) 

SEPTOPLASTY

Not every crooked septum requires repair. Some people have only a mild deviation but complain of a large degree of nasal obstruction. Others may have a significant deviation but have no problems. Interestingly, the direction and amount of deviation do not always correlate with the subjective complaint of nasal obstruction. For example, let us take ten patients with a septum that is really pushed over to the right side. Most people will complain of trouble with right nasal breathing. However, some may have no complaints. Others yet may complain of difficulty breathing through both sides of the nose, and a few might even complain of more trouble breathing through the left side even though there is more space. From this example it is apparent there are no steadfast rules.

A septoplasty or sometimes referred to as a "submucosal resection" or "SMR" refers to straightening out the septum. This requires lifting the lining of the nose off the septum and removing or carving the underlying cartilage and/or bone. A light nasal dressing is placed in the nostrils and is removed the following day. Sometimes, a septoplasty may be performed to obtain cartilage for grafts if a rhinoplasty is performed. If only a septoplasty is performed,there is no external evidence that surgery has been done. There is no external bruising or swelling. All incisions are inside the nose, and dissolvable sutures are used so none have to be removed. There is typically very little pain involved. There is more discomfort for the first week since there is swelling inside the nose. Sometimes one may experience temporary numbness of the upper teeth.

TURBINECTOMY

The turbinates are finger like structures that line the sides of the nose. There are three on each side – the inferior (largest), middle and superior. These structures warm and humidify the air we breathe in. The inferior turbinate (sometimes referred to as "concha") may be enlarged and cause breathing problems by narrowing the nasal passageway. The middle turbinate is sometimes enlarged and can block the sinuses on that side of the nose. Most sinuses drain into the nose underneath the middle turbinate. The turbinates can be reduced in size by numerous surgical methods. They should not be removed entirely since they serve important functions mentioned above. Turbinectomy is commonly performed as a combined procedure with a septoplasty or with sinus surgery.

There are numerous ways to reduce the size of the turbinates. Dr. Liu has been using recent technology involving radiofrequency to shrink them – this results in less pain, less crusting in the nose, and faster recovery.

SEPTAL PERFORATION REPAIR

A septal perforation refers to a hole that occurs in the septum, thus causing an abnormal communication between the left and right sides of the nose. These holes may be small or large, in the front or in the back of the nose. There are numerous causes including previous nasal surgery, nasal trauma, nasal infection, chronic use of certain over the counter nasal medications, use of cocaine, certain systemic diseases, and others. Only those perforations that cause symptoms require repair. Symptoms include nasal obstruction, whistling noises when one breathes in, dryness, frequent nasal crusting, nosebleeds,and recurrent infections.          
                     
For additional information go to:
http://www.emedicine.com/ent/topic196.htm
for an online article on septal perforation
authored by Dr. Liu,
 
Repair can range from placement of a prosthesis in the nose to close the hole to complicated surgery requiring placements of grafts. A detailed examination will
determine which procedure is best for you.
 

NASAL FRACTURES

Nasal fractures are one of the most common injuries of facial trauma. This section will only discuss isolated fractures of the nose. More complicated fractures involving other facial structures such as the orbit, cheek, jaw bone, and others require other special needs. For the most part, nasal fractures only need to be repaired if there is an obvious cosmetic deformity or worsening nasal breathing.

Evaluation is primarily made by physical examination. X rays may show a nasal bone fracture, but often this does not change the management. Most fractures that are not "displaced" (pushed from the normal position) do not require any special treatment. Immediately, ice should always be placed to reduce swelling. Bleeding often occurs but resolves on its own within a short time.

There are two time points that surgery, if needed, can be considered. The first is within roughly 10 days after the injury. The bones have not yet healed in the "wrong" place and can be reset during this time. A "closed reduction" can be performed which involves manipulation of the bones under light anesthesia followed by a nasal splint or cast for one week. A light intranasal packing is placed for 1-2 days. An initial closed reduction can only be performed if there is minimal swelling so that the surgeon can adequately assess if the fracture has been returned to its normal position.

If there is a significant amount of swelling initially, then surgery often must be delayed because it is difficult to judge exactly how the nose really looks. Also, if there is a significant deformity inside the nose (such as a severely twisted septum) often it is best to wait for a more formal surgery. The second time point would be to wait at least 3 months to completely allow for all swelling to resolve and allow any fractures to heal.

An "open reduction" can then be performed. This is a more involved surgery which requires more manipulation of the nasal bones. Postoperatively, swelling and bruising can be expected for about 1 week. Again, a cast or splint is worn for 1 week. Any internal deformities can be addressed at the same time and often a septoplasty will be performed at the same time. Deeper anesthesia is often required. Success is overall higher with open reductions but then again the procedure is more involved.

There is a complex relationship between the nasal bones and nasal cartilages. Often simply repairing the bones is not enough, and an open reduction becomes essentially a formal rhinoplasty.

ENDOSCOPIC SINUS SURGERY

The basic premise of sinus surgery is to open the drainage pathways of the sinuses since they all empty into the nose. It is not to go into every little sinus air cell. Again, the sinuses function properly when air is able to constantly circulate in and out. Technology is at a point today where the entire procedure can be performed through special telescopes and instruments entirely through the nostrils (endoscopic approach). There are no external incisions, and there is no change in appearance to the nose. There is no external bruising or swelling. All incisions are inside the nose, and dissolvable sutures if necessary are used so none have to be removed.

The procedure is typically performed under general anesthesia. A Cat Scan (CT) of the sinuses is essential before surgery to determine the extent of the disease and the exact layout of your individual sinus anatomy. There is typically very little pain involved. There is more discomfort for the first few weeks since there is swelling inside the nose. After the surgery, you will be advised to keep the inside of the nose moist with salt water nose sprays and ointment. You will be seen as often as necessary to clean out the nose in the office – maybe even once a week for the first few weeks. The post-operative care is equally as important as the surgery in obtaining a good result

COMPUTER AIDED OR IMAGE GUIDED SURGERY

Over the past few years a new technology has emerged that is predominately being used by otolaryngologists (Ear, Nose, and Throats), orthopedic surgeons, and neurosurgeons. By using a highly sophisticated computer with a specially performed CAT scan before surgery, the surgeon is able to obtain a three dimensional perspective of the sinuses during the surgery. A special computer and instruments are used for the procedure and do not add much additional time to surgery. While not necessary in every case, it certainly is helpful in revision surgery cases, surgery of the frontal sinuses, and cases that involve polyps. Use of this new technology helps provide the safest surgical setting.
 

SPECIAL CONSIDERATIONS

Age. Children – There is no one specific cutoff age to perform nasal surgery. The reason why most surgeons wait until at least the mid to later teenage years is because the middle of the face and nose is a center of growth for the entire face. Therefore, manipulation of this area should only be performed after one has finished most of his or her growing. As a general rule, if the person has not had any changes in height or shoe size over 2 years, then surgery may be undertaken. Often nasal obstruction in children occurs secondary to increased adenoid tissue. The adenoids are tissue located in the most posterior potion of the nose. It is similar to the tonsils but instead of in the back of the mouth, it is located in the back of the nose. If enlarged, the adenoids may block nasal breathing. Usually the adenoids shrink by age 10 in most but not all children.

Ethnicity. It is important to consider one’s heritage when analyzing the nose. Facial features in general vary depending upon gender and race. Again, the primary goal is to achieve harmony and symmetry with the other facial features.