Dr Torres-Holmes - Nasal reconstruction

As a patient it can be difficult to know who to see when one has nasal problems. One might think that if the problem is entirely cosmetic, a plastic surgeon may be the right person. If one can’t smell normally, breathe through the nose properly, or get sinus infections often with abnormal mucus, then an ENT sounds like the correct doctor. 

We know how difficult and frustrating this can be. The reality is that both surgeons may be important in order to get the best outcomes. I personally have worked with three different plastic surgeons for over ten years and have seen the benefit in good teamwork.

The inside anatomy of the nose (primarily the nasal septum) effects the outside anatomy and vice versa. The profession of medicine unwisely divided up the nose in the past, with the plastic surgeons not getting training on the inside and ENTs not getting training on the outside. We know this is important now because many a nose problem has been only partially corrected by only one surgeon, often requiring repeat surgery. One can imagine how frustrating and costly this can be. 

Ideally, experienced ENTs and plastic surgeons working together from the beginning to comprehensively assess all the problems with the nose, will likely result in the best outcome, decreasing the chance of revision surgery. 

The external nose is a pyramid which requires proper alignment of forces to be central and stable. Any number of reasons could make this pyramid unstable. Most common is trauma. Trauma can occur as early as in the womb, as a baby or toddler, or in adulthood due to any number of reasons. Sometimes the injury doesn’t have to be memorable to be significant. Cartilage can crack with minor injury and cause buckling due to changes in forces over time. Other reasons for internal or external nasal asymmetry are oral or mouth causes. Thumb sucking as a baby or toddler and the prolonged use of pacifiers push the hard palate upwards preventing the nose from growing properly. Another reason is teeth crowding and abnormal maxillary development sometimes requiring braces or maxillofacial surgery. 

Assessment of nasal problems involves photographic documentation, nasal endoscopy and often cone beam CT scan imaging. As an ENT, the primary focus is identifying the causes of the symptoms which broadly can either be structural, inflammatory or both. Structural abnormalities of the nasal septum and turbinates can result in turbulent airflow, often presenting as nasal congestion or rhinorrhoea (posterior nasal drip if it goes backwards). The septum may be deviated for the reasons already described, but the turbinates can be abnormally enlarged to compensate for this deviation or in response to the air we breath. 

The nose responds to five major factors in the air. Atmospheric pressure, humidity, temperature, allergens and pollution or irritants. Inflammation of the turbinates and sinuses can be significant as a result of sensitivity to the above factors but can also originate from an abnormal immune response to them. Primary sinus disease can be both structural and inflammatory. Secondary sinus disease means the sinus problem begins elsewhere such as in the teeth. 

Whether the symptoms a patient experiences are due to purely inflammation or from a structural problem like the septum can be difficult to determine. A trial of a nasal steroid or decongestant  spray or drop to treat inflammation is often indicated, but structural problems are not cured with medicines. 

Surgery is often indicated when medical options have been exhausted, or when we know medicines will not deal with a significant structural problem. If both the external and internal nasal anatomy is abnormal, then a combined approach with both the ear nose and throat surgeon and the plastic surgeon is indicated. After review of all the information, surgery is planned and the role of each surgeon is defined.

In principle, the ENT surgeon's goal is to align the forces on the inside so that the septum is both straight and central to allow for the best cosmetic and functional outcome. Turbinate surgery involves reducing the size of the inferior turbinates either by moving them out of the way, shrinking them with an electrical device or partial removal of them. Anatomical variations causing an enlarged middle turbinate sometimes also need to be dealt with surgically. The combination of a straight septum and decreased size of the turbinates result in laminar air flow which improves symptoms. 

Another valuable part of what an ENT does during nasal reconstruction is safely harvesting of nasal septal cartilage to be used for the external nose and septum reconstruction. Cartilage grafts are precisely placed and sutured in place to ensue the greatest stability for the longest possible time.

Sinus surgery is sometimes required at the time of nasal surgery if there is a significant history of associated chronic sinusitis.  This surgery, called endoscopic sinus surgery, involves using small cameras and instruments through the nostrils in order to remove bone at the natural openings of the sinuses to allow for better air ventilation and mucus drainage. 

No one wants to regret going ahead with surgery without thinking it through very carefully and being aware of all the implications, but the converse is also true. If one cannot breath, sleep or excise properly all because of nasal problems, this can have a significant negative impact on ones health as one gets older. This person will likely regret not having surgery.

Please feel free to contact the rooms to make an appointment for an opinion in order to gain clarity. 

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