Are you unhappy with your nose?

Are you thinking of having a nose operation?

Well, we are in luck!

A new form of Rhinoplasty has arrived which is less aggressive, safer and much more predictable over the long term.

The nose is a complete unit; form and function go together.

We cannot manipulate the nasal structures independently because what we do in one area influences all the others in both the exterior appearance and in the way in which that nose functions.

The nose is like a building, if we knock down a load-bearing wall, if we modify any part of the main structure, unevenness, or even collapses may occur.

The lovers of rhinoplasty are living through a moment of spectacular change in the paradigms of the surgical techniques of rhinoplasty which, for decades, have been passed on to many generations of plastic surgeons, maxillofacial surgeons and ENT specialists. We are witnessing the birth of a new school named “Preservation Rhinoplasty” (or Conservative Rhinoplasty).

 

What does Preservation Rhinoplasty consist of and how is it different from the traditional Rhinoplasty that has been done until now?

Preservation rhinoplasty consists of a set of surgical techniques performed on the cartilages, muscles, ligaments and bones of the nose which are modelled preserving their structural and functional integrity, that is to say, being as non-aggressive as possible, carrying out ultraconservative, ultra-controlled, objective corrective rhinoplasty surgery following the predictions and instructions produced by a software package.

This software package plans from the "before"; how to undertake the least aggressive "during"; the "immediate after" or result of that nose and, most importantly, its appearance over time. The latter is extremely important as aggressive rhinoplasties may lead to unpleasant surprises in the long term: collapsed noses, fallen tips, irregularities…

For example: in traditional rhinoplasty, as carried out by 95% of the surgeons, when they operate on the ridge of the nose, this is done by cutting the bone of the "roof" of the nasal pyramid. This destroys the anatomy of that area (form) which is crucial for correct respiration (function). In addition, it is not infrequent when cutting with less precision, working blind and by touch only with a chisel (which is how it is traditionally done), that over time certain imperfections may appear which are often visible and stigmatic.  Not to mention the postoperative.



However, in Preservation Rhinoplasty, using specifically designed manual micro-saws or ultrasound saws (ultrasonic rhinoplasty), the legs of the pyramid are cut with great precision so that the entire nasal pyramid is lowered (as if precision cuts were made to the foundations of a building to make it lower).

The whole block of the nose is lowered until the nose ridge is at the desired height, conserving ALL the anatomy of the roof without altering the main structure. This surgical technique has been named «Push Down»



Making a pyramid smaller conserving its cupula, by just shortening its base and not destroying-reconstructing its roof, seems logical doesn’t it? Well, sometimes the most logical is not the most frequent.

We have had to wait until 2018 for this logic to spread and begin to become more common, and here we must recognize the work of another member of the “Preservation Rhinoplasty” school, Ybes Sabán, a senior French surgeon working in Nice who has spent his whole professional life carrying out and defending the «Push Down» technique.

 

And the tip? How is the tip modeled in Preservation Rhinoplasty?

At the tip, all the surgical technique is the work of a genius. That genius is a young Turkish surgeon called Dr Barış Çakır, who is revolutionizing the world of rhinoplasty.

Traditionally the cartilages of the tip of the nose have been remodeled by means of resections, grafts and rather unsystematized coarse sutures, which gives rise to noses that are often beautiful but that have certain characteristics in common and hence «an operated appearance», all the tips look the same.

The school of the Istanbul group champions a rhinoplasty which is conceptually simple but technically very complicated, very technical and delicate, in which different polygons are sculpted in the cartilages of the nose (as if it were a diamond). It is these polyhedral shapes that will define a nasal tip which is natural, personalized and without stigmas.



 

Of course, preservation rhinoplasty is a closed rhinoplasty, (without the typical incision in the nasal columella the scar of which is often not seen, but at other times is visible) so that the inseparable group: skin-muscles-ligaments of the nose are preserved in their entirety.

The approach (the incision through which the surgeons accede to the surgical field) is unique, marginal and subperichondrial (respecting the perichondrium, the microscopic layer of tissue that protects the cartilages), «skinning» the nasal skeleton literally perfectly, without bleeding, and respecting the anatomy totally. It is an incredible sculptural technique that leaves us surgeons open-mouthed.

The cartilages are modeled using ultrafine sutures which, when combined, tauten the threads here and there (like the guy ropes of a tent), to change the three dimensional layout of the cartilages little by little, defining the polygons without needing to cut and paste (traditional techniques) but «transporting» the cartilage and preserving it, changing its rotation to raise the tip of the nose more or less to give it a natural appearance.

All this is done understanding the nasal anatomy not just to the millimeter, but I would say to the micra, to perfection. Of course, these techniques are studied and practiced beforehand on cadavers. You cannot begin to imagine the works that the Istanbul group, led by Dr. Peter Palhazi have published on the anatomy of the nose to the micra. Each, mini muscle, each mini ligament, each minimal angle, fold, nook, valve, union… everything is perfectly defined. For this reason, once you understand this type of rhinoplasty, you are hooked!

The last and, perhaps, most important thing about preservation rhinoplasty or conservative rhinoplasty is that once we have lowered (pushed down) the bone pyramid (all the skeletal structure of the nose in a body) without cutting the roof (without destroying anything) and moving the nasal cartilages three dimensionally instead of cutting and re-grafting them, it turns out that we also have the covering of all this practically intact. That is to say, the dress is perfect!

This virtually intact structure is repositioned using ultrafine sutures that fix each detail in place to reproduce a beautiful, natural anatomy which is unique to each nose. You can never tell that it’s an operated nose. Not even many surgeons could tell.

 

I admit it’s impressive. It’s simply brilliant!

As you will understand, to carry all this out you have to be a bit mad, obsessed and passionate about rhinoplasty.

In November 2018 the “First International Meeting on Preservation Rhinoplasty”  took place in Istanbul and attracted the interest of the majority of the rhinoplasty surgeons in the world. This first major event will probably signal a new era in the practice of rhinoplasty.

I have had the pleasure and good fortune of being able to attend this event, together with my great colleague and friend Dr. Ismael García-Roig. They were 3 very intensive days (10-hour days) attended by the best-known rhinoplasty surgeons in the world. A 10-meter panoramic screen, dissection of a cadaver, live surgery…. Amazing!

Are you thinking about having your nose operated?

Don’t hesitate. Come and find out how all these incredible techniques can improve your life.

Dr. José Manuel Batllés