The human nose is essential for respiration and is one of the main visual focus points during human interaction. Innovations in rhinoplasty – the surgical reconstruction of the nose – have enabled individuals to achieve a much higher quality of air flow as well as improved cosmetic appearance.
In this episode of Kentucky Health, host Dr. Wayne Tuckson welcomes a Louisville facial reconstructive surgeon to discuss how rhinoplasty helps patients and review several successful case studies.
Dr. Ziad Katrib is an assistant professor for facial plastic reconstructive surgery in the department of head and neck surgery at the University of Louisville and is a member of U of L Physicians Group.
Katrib, who specializes in rhinoplasty, says that some of his patients need surgery to correct injuries, and some to remove skin cancer, but the main portion of his practice uses surgery to correct breathing deficiencies in patients who may also want to make cosmetic changes. Problems on the outside of the nose often indicate problems inside the air passageways too, Katrib notes.
“As ENTs (ear, nose, and throat doctors), we have a deeper understanding potentially of the functional consequences of those surgeries,” he says, “so for us, anyone having any nose surgery should breathe better – that’s the number one goal. Even if I see somebody with purely cosmetic desires, I ultimately can do some things in surgery to help them breathe better.”
Surgical Techniques for Rhinoplasty and Reconstructive Surgery
Many surgeries Katrib performs correct breathing difficulties caused by an issue with the septum. The septum is the wall between the two nostrils, made of bone and cartilage. In some patients, the septum is deviated or crooked and may have been that way since birth, or caused by injury. Other patients may have a hole in their septum causing air to pass between both passages inside the nose, often caused by intranasal drug use. Issues with the septum can affect the rest of the nose as well, even causing it to slide down out of position and closer to the mouth.
If Katrib needs to find tissue to replace part of the septum, he looks to the rib, to the ear, and to the scalp. He can insert this tissue where needed and eventually it will integrate with the rest of the nose. For patients with a broken nose where the septum has been pushed sideways, Katrib will place small casts (that are actually hoses) in the nasal passages once he has moved the septum back into place to hold it steady. No screws or wires are used, and the patient usually improves quickly after having the hoses inserted for a week and then removed.
An ancient surgical procedure is still widely used and effective for more complex surgeries that are reconstructive in nature, rather than repairing an intact nose. The “forehead flap” technique dates back almost 3,000 years and requires grafting skin from a person’s forehead down to the nose and then letting it gradually fill in the contour of the nose and replace the missing tissue.
“There’s a large amount of blood supply going to the forehead in a vertical fashion,” Katrib says, “so you can take a piece of tissue and rotate it down and make it the right shape, the right size, and the right thickness, and use that to replace the nose. It’s a multiple stage procedure.”
The tissue is left connected for four weeks. “During that time, it’s living off of an artery and vein that we find in the eyebrow with an ultrasound, so it has an umbilical cord, if you will, while it’s learning to live off of the nose,” Katrib explains. “During that time, there’s blood vessels growing into that flap, and then four weeks later, you can safely divide that umbilical cord and the flap will survive from the tissue in the nose.”
Katrib says that patients often ask him if their sense of smell will be affected by surgery. He says that most of the time their sense of smell will be more acute, and that can also make food taste better. Nasal surgery does not improve sleep apnea, a disorder where throat muscles relax and block regular respiration while a person slumbers, but it does enable patients with sleep apnea to use their CPAP machines (Continuous Positive Airway Pressure) more effectively and comfortably to keep breathing passageways open.
“I tell patients that the surgery, as far as the functional part, is for daily breathing – when you’re awake, walking around, living your life, or exercising, you’ll breathe better and you’ll smell better,” Katrib says.
Successful Case Studies: “The Nose Is the Priority”
Several slides from Dr. Katrib’s practice show the different types of rhinoplasty surgeries he performs, with often striking results:
- A patient presented with significant closure of her left nasal passage due to a deviated septum, leaving a small slit to breathe through. Katrib was able to open up the nostril and align the septum properly, resulting in much improved breathing as well as symmetry for both nostrils.
- Another patient required what is called a revision rhinoplasty. Her initial surgery to improve breathing and reduce a hump in her nose did not achieve desired results, and her nose was sliding down and causing her upper lip to turn inward. Katrib used rib cartilage and part of the patient’s scalp to re-adjust the nose and lift up the patient’s upper lip, as well as excising the hump and adding tissue to her nose tip.
- An elderly patient presented with most of his left nostril, including the tip, missing. A farmer who spent a lot of time outdoors, he was diagnosed with basal cell carcinoma, the most common type of skin cancer. His cancerous tissue had been removed by a dermatologist using the Mohs technique, where the skin cancer is excised in layers and each layer is immediately examined using a microscope (often in the room where surgery is performed) until all cancer cells are completely gone. Katrib used a forehead flap to replace the missing tissue, as well as some cartilage from the man’s ear.
“You can replace 100 percent of the nose with the forehead,” Katrib says. “Now, you create problems in the forehead, but the interesting thing about the forehead is that its ability to heal is incredible, so we don’t skin graft the forehead. We leave the patients with a hole in their forehead. And we have them put ointment on it. By three months, most people have a pretty good-looking forehead… It seems counter-intuitive at times to make one hole to fix another, but our saying is, ‘the nose is the priority.’”
According to Katrib, the best recommendation for patients who want to prevent damage to their nose is obvious: wear sunscreen. But the doctor doesn’t stop with that simple tip. “Less obvious is using sunscreen when someone’s younger,” he says. “I don’t think that’s emphasized as much as maybe it should be. Many of these skin cancers take decades to form.
“Probably the most important thing is counseling parents to protect their kids from the sun – that’ll do a large part,” he adds. “I think that my generation, my children will have a much lower rate of skin cancer because of public awareness nowadays.”
