Rhinoplasty: Experience in Combined Military Hospital, Dhaka

Background: Rhinoplasty, perhaps is the most complex and challenging cosmetic surgical procedure performed today. Hence, a thorough preoperative evaluation and the surgical skill in performing the operation is most important for final desired outcome. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. Objective: To assess post-operative functional and aesthetic outcome and patient’s satisfaction of all rhinoplasty operations. Methods: Retrospective study carried out in combined military hospital, Dhaka. 50 patients with external nasal deformity who were operated for functional, aesthetic or for both reason were included. Patients’ satisfaction levels from the procedures were routinely documented in the post op visits as completely satisfied, partialy satisfied and not satisfied at all. Results: A total of 50 cases underwent rhinoplasty and septorhinoplasty operations. The most common reason of disfigurement was traumatic injury during games (40%). Different surgical procedures were done without any major complications. Except few most of the patients were fully satisfied. Conclusion: For better satisfaction of patients, adequate preoperative counseling and realistic expectations are warranted. Skillful surgical techniques reduce the chances of complications. 2


Introduction:
Nose is the central and most prominent feature of the face. It is also the most vital part of facial contour and beauty. The term rhinoplasty has derived from Greek word "Rhinos" which means Nose and "Plassein" means to shape. Commonly known as Nose job, Rhinoplasty or Nose plastic surgery which enhances facial appearance by correcting nasal deformities and improving aesthetic appearances of the nose.It was described in ancient Egypt in 2500-3000 BC. In ancient India it was first described by the ayurvedic physician Sushruta in his book "Sushrutasamhita (c.500 BC)".Sushruta is considered as the father of rhinoplasty surgery in the world. 1 The first documented evidence of the available records regarding rhinoplasty comes from Edwin smith papyrus. 2 In 1887-John Orlando Roe first performed "Intra nasal Rhinoplasty".In India Rhinoplasty started to reconstruct nose for 1. Classified specialist in ENT and Head neck surgery, Combined military hospital, Dhaka those whose nose was destroyed by rhinectomy. Such a mutilation was inflicted as a criminal, religious, political, and military punishment in that time.
Rhinoplasty is the 2 nd most common surgeries performed by facial plastic surgeons worldwide. Patient satisfaction is the principal outcome measure of success in facial cosmetic surgeries. Patient's satisfaction may be influenced by social environment, education, life experience and level of expectations, which may or may not be realistic. Complete photographic documentation is fundamental to both physician and patients for surgical planning and assessment of post-operative results. Photograph including right and left lateral and oblique views along with anterior, inferior (basal) and superior views for analyzing the target, outcomes and for discussing the surgical and aesthetic issues with the patient should be taken. 3,4 After detailed anatomical and anthropometric analysis individualized surgical planning including precise need and amount of cartilage resection, suturing, osteotomies 5 and dynamics of nasal airway should be considered. 6,7 Open rhinoplasty has certain advantages such as detailed and wide exposure of nasal shape defining structures, easy suturing and avoidance of distortion of anatomy for planning the reconstruction. There are certain definite disadvantages like trans-columellar scar, increased chances of post op edema in the tip and dorsum and need of fixation for graft placement which could be done without fixation in the closed technique. 8

Methods:
Retrospective study carried out in Dhaka combined military hospital, from 1st March 2017 to 31st Dec 2018. 50 patients with external nasal deformity who were operated for functional, aesthetic or for both reason were included. We evaluated the high resolution CT images of the nose and PNS with 3D reconstruction of face in posttraumatic cases along with analysis of photographs of all the patients in all 6 views were made.
All such patients under went detailed facial photography in frontal or anterior profile view, basal or inferior view, superior view, right and left oblique view and right and left lateral views as per protocol. All patients had undergone detailed facial analysis including objective measurement of facial angles, target oriented realistic psychological assessment and counseling prior to pre anesthetic checkup and surgical planning. Type of deformity, etiology, surgical procedures performed, grafts and splints used were analyzed and studied.Patients' satisfaction levels from the procedures were routinely documented in the post op visits as completely satisfied, partialy satisfied and not satisfied at all.
Follow up was done initially at 2 weeks then1 month, 3 months, 6 months, 12 months and 18 months period.

Limitations of the study
A. This study may not reflect the real situation in our country as the study was carried out in military population who are more active in physical activities than general population.
B. Duration of follow up is short. Not yet completed the time for 02 years for follow up.

Results:
Total 50 cases were operated in CMH Dhaka from 1st March 2017 to 31st Dec 2018. There were 38 males and 12 females; among the patients with a male to female ratio of 3.16:1 (Chart 1).
Number of male patients were higher than female because of injury during boxing, playing football, volleyball, hokey etc, as these are regular activities of military service. The age range was between 21 and 50 years among those who presented to us for rhinoplasty (Chart 2).
History and cause for which they underwent rhinoplasties were noted in patients. The most common reasons for which our patients attended the ENT OPD for rhinoplasty were results of sports injury 14 out of 50 (28%) and 13 out of 50 (26%) developmental deformity. Rest 9/50(18%) cases had post septoplasty and 6/50(12%) cases) had history of road traffic accident (Table 1).  Commercial external nasal splints were used in 37 patients and POP cast splints in 13 patients. There were no difference in the post-operative outcome between the patients in terms of types of splints were used, however patients' satisfaction concerned with splints and immediate postoperative aesthetic appearance as per patients comfort were poor with POP cast splints. There were some intraoperative and post-operative complications noticed among our cases that includes haemorrhage, Periorbitalechymosis and oedema. However, short term anesthesia over nose was seen in 3 patients which resolved by 3-4 weeks in the post-operative period.
2 patients did present to us with persistent swelling and edema over nasal dorsum which persisted more than 12 weeks and took longer to resolve. All these patients got resolution of their persistent edema in due course of time. Patients' satisfaction levels from the procedures were routinely documented in the post op visits as completely satisfied, partialy satisfied and not satisfied at all. 42 patients were satisfied with the results, 6 patients being partially satisfied and 2 were not satisfied at all. Patients who had shown no satisfaction with the results were advised for revision surgeries however none of those patients had consented for a revision surgery. Donor site morbidity was not reported among the cases.
Comparative study before and after rhinoplasty shows significant improvement and patients satisfaction in both external deformity with deviated nasal septum and external nasal deformity without deviated nasal septum.

Discussion:
Trauma accounted for most causes of nasal deformity 9 , with other causes being congenital, developmental, prior nasal surgery, infective etc. In our series the majority was traumatic patients including road traffic accident and sports injury (12%+28%= 40%). Due to military service pattern sports injury is more common than road traffic accident. Crooked nose and saddle nose deformity being found the commonest deformity. Crooked nose deformity was associated with developmental and sports injury also. Besides the obvious cosmetic defect, patients with crooked nose frequently have troublesome nasal obstruction due to the narrowed airway Open rhinoplasty gives the possibility to assess anatomical deformities, asymmetries and structural alterations by direct inspection of the nasal framework.The structures of the nose can be manipulated in a more precise manner and sutures and grafts can be placed and fixed adequately.
Open surgical technique does produce increased supra tip edema than closed rhinoplasty 10 but use of both hands for leads make the work easy and provides better results in the surgical process. 11 The scar of the skin incision is invisible in the majority of cases if the precise technique is performed. 12 In the view of this we followed open rhinoplasty rather than closed one in 78% cases without any major post-operative complications. Medial osteotomy combined with lateral osteotomy facilitates medialization of the lateral nasal wall, thus achieving open roof closure, as well as effective narrowing of the wide nasal base, even in the absence of a hump. 5,16 To improve and maintain the nasal airway we used spreader graft in all open technique because it helps to prevent narrowing of internal nasal valve, preserve the dorsal aesthetic lines, and stabilize the septum. 13,14 Foda 15 documented his complication rates as follows: septal flap tear 2.8%, alar cartilage injury 1.8%, post-operative nasal trauma 1%, epistaxis 2%, infection 2.4%, prolonged edema 17%, nasal obstruction 0.8%, and unsightly transcolumellar scar 0.8%. We had Epistaxis 4(8%), periorbital oedema 10(20%), ecchymoses of eye 5(10%), Crusting 1(2%) and Synechiae 3(6%). No major life threatening complication was seen.
Foda 15 documented patient's satisfaction 95.6% and in our series 84% were completely satisfied and 12% were partially satisfied which similar to Foda. Satisfaction is variable from person to person and depends on primary deformity, primary or revision surgery, mental state and realistic expectation. Next photographs shows few of our pre-operative and post-operative outcome.

Conclusion:
Rhinoplasty being a cosmetic surgery is of utmost importance, it has become an attractive and fascinating surgery for the otolaryngologists and plastic surgeons. It's a highly individualised problem specific operation that combines augmentation with reduction. The proportion of the so called ideal nasal shape and the operation to achieve this have been the subject of extensive training and surgical skill. Results differ with the each individual with their configuration, their healing properties and, psychological uptake. Preoperative counselling with the patient and close relatives or friends is most important to overcome the unrealistic expectations.