A surgeon can sometimes be faced with cases that present a series of defects so great as to make correction appear truly impossible. These often involve severe nasal deformities caused by trauma, malformation or earlier and incorrectly executed operations, and are nearly always combined with functional problems of impaired nasal respiration. In addition to all this, there are frequently psychological problems of depression and conviction that no satisfactory solution is possible either because other surgeons have refused to operate or have operate unsuccessfully. The interview with the patient is very important in order to gain his or her trust and to clarify just what can be obtained through an operation, which usually results in a great improvement of the situation but not of course in the attainment of perfection. It proves very useful in this connection to generate digital simulations of possible results on photos of the patient to show what can effectively be obtained by operation and ascertain whether this will be satisfactory. Importance also attaches in preoperative strategy to identifying which of the various defects present is the most serious in the patient’s opinion so that much of the attention and energy can be focused on its correction during the operation. The desire to succeed in a difficult operation where other surgeons have failed or refused the challenge, to correct an unacceptable deformity, and to make a demoralized patient smile once more provides the right stimuli to undertake an “impossible” rhinoplasty and make it possible.
COMPLETE COLLAPSE OF THE NOSE
This patient presented complete collapse of the nasal pyramid and had already undergone an operation of rhinoplasty elsewhere with harvesting of cartilage from the auricular concha for grafts. He was in a state of great psychological stress and had little hope that a further operation would result in acceptable correction of the nasal pyramid. He also reported almost complete obstruction of nasal respiration.
Clinical analysis revealed deformity caused by total collapse of the lower two-thirds of the nasal pyramid. The nasal tip was devoid of any support whatsoever and the columella completely nonexistent with a severe cicatricial retraction. Evident asymmetry of the nasal walls was combined with retraction of the left nasal wing and stenosis of the left nostril. Aesthetic-reconstructive rhinoplasty was performed by means of the open approach and rib cartilage was harvested for grafts on the nasal dorsum, columella and left wing. Reconstruction of the columella was affected by means of cutaneous plastic surgery with two strips carved out of the nasal vestibule. The operation secured valid structural support of the nasal pyramid with a satisfactory aesthetic result and a marked improvement in nasal functionality.
REVISION RHINOPLASTY TO ADDRESS SERIOUS STRUCTURAL DEFICIENCIES
This patient had undergone two previous rhinoplasties elsewhere, one to address a hump on the nasal dorsum and the other to correct its results. In addition to major respiratory difficulties, she reported great anxiety, lack of confidence, and concern over the possibility of further failure.
The clinical analysis revealed collapse of the osseous upper third of the nasal pyramid with an inverted V-shaped deformity and humped projection of the nasal septum with respect to the line of the profile. The lateral walls of the nose were devoid of support and had collapsed due to severe absence of cartilage. Functional-reconstructive rhinoplasty was performed by means of open access with the use of several grafts of cartilage harvested from the auricular concha and suitably shaped to replace the missing structures.
“After undergoing two unsuccessful operations of rhinoseptoplasty in a clinic in my town, I decided to contact Prof. Armando Boccieri on the advice of a plastic surgeon. Needless to say, I was extremely worried and anxious about the third operation, but the desire to look in the mirror once again without dismay and the need to breathe properly helped me to have new confidence in doctors. It is now about three months since the operation and I can say that I am extremely satisfied with the aesthetic and functional results. Prof. Boccieri and his team did an excellent job. Writing this testimonial to their work and above all their courage to shoulder the responsibility of a third operation is the least I can do to thank them."
WHEN THERE IS NO MATERIAL AT ALL
This patient presented severe deformity due to the trauma of an accidental electrical shock to the left wing of the nose in early childhood. This was accompanied by equally severe functional deficiencies and almost complete respiratory obstruction. He had already undergone a number of surgical operations over the years in an attempt to improve this difficult situation but with largely unsatisfactory results.
Clinical examination of the patient revealed severe deviation of the nasal septum and pyramid as a result of distorted growth caused by cicatricial retraction of the left side that was present since his childhood. The left nostril was completely amputated at the base and totally stenotic, and the nasal dorsum collapsed and sunken. Reconstructive rhinoplasty was performed with the crossbar graft technique to correct the severe deviation of the nasal pyramid. A composite graft of skin and cartilage from the auricular pavilion was used to replace the missing part of the left nostril together with grafts of cartilage from the auricular concha to correct the depression of the dorsum and harmonize the profile.
SEVERE NASAL DEFORMITY DUE TO CLEFT LIP AND PALATE
This very young patient presented severe nasal deformity resulting from a condition of cleft lip and palate operated on during early childhood. The aesthetic problems were accompanied by functional ones and her nasal respiration was severely impaired. Other operations had already been performed but the results obtained were still unacceptable and the patient was in a psychological state of great stress and anxiety.
Clinical analysis revealed severe deviation of the nasal septum and pyramid to the left with consequent respiratory stenosis, marked asymmetry of the nasal tip, and high tissue deficiency of the particularly narrow and malformed left nostril. In purely aesthetic terms, the patient presented a particularly bulbous tip and an osteocartilaginous hump on the nasal dorsum. Reconstructive rhinoplasty was performed with use of the crossbar graft technique to correct the deviation of the nasal pyramid and a composite graft of skin and cartilage from the ear to replace the missing tissue of the left nostril. The aesthetic improvement was completed with sutures to the cartilages of the tip and removal of the hump.