Crushed vs Diced Cartilage: Similarities and Differences

Looking at some forums I noticed some people are using the words crushed and diced cartilage interchangeably as if they are same thing. Another important  issue i would like to address here is correlation between  the degree of crushed cartilage and how it effects the long term outcome (re absorption rate) of the surgery.

Crushing cartilage is procedure that takes pieces of cartilage and crushes it in a device called Cottle cartilage crusher and/or using a mallet. They can be crushed to varying degree's from slightly crushed to severely crushed. They are then inserted in the desired area of the nose using a medical tweezer.

Dicing cartilage is procedure where the cartilage is sliced using a straight edge razor blade into small fine pieces.  The cartilage is normally diced into <0.5mm squares, using two #11 blades avoiding, not being morselized or crushed. . Then it is placed in a syringe to be later injected in the desired area and molded/shaped accordingly. Usually diced cartilage  is wrapped in soft material preferably deep temporal fascia.

Both crushed and diced cartilage is used to smoothen out or camouflage nasal surface area's where cartilage is placed in the nose , like the dorsum, to conceal any irregularities. Both can be wrapped or combined with different material as well.

Crushed cartilage grafts can be used for the following purposes: (1) to cover the sharp edges of an irregular nasal framework after hump resection    (2) to serve as an underlying padding material to prevent skin adhesion   (3) to fill pit holes and, thus, mask irregularities   (4) as a filler to mask asymmetries and depressions on the side walls  (5) for tip grafting   (6) to camouflage the edges of solid onlay grafts  , (7) to supply minor dorsal augmentation for the correction of an overresected dorsum, and (8) to increase the thickness and natural color of the overlying skin where skin atrophy had occurred. I believe diced cartilage can be used in most of the above situations as well.

Crushed Cartilage Grafts for Concealing Irregularities in Rhinoplasty

1. Ozcan Cakmak, MD;
2. Fuat Buyuklu, MD

Our current clinical series confirmed our previous animal⁹ and human cell culture¹³ studies that the degree of crushing applied is important to the long-term clinical outcome of crushed cartilage grafts used in rhinoplasty.

The results showed a correlation between the degree of crushing applied and the resorption rate of the crushed graft, especially in grafts applied at the dorsum. The resorption rate was zero in slightly crushed grafts, 2.1% in moderately crushed grafts, and 13.1% in significantly crushed grafts. Our results show that slight or moderate crushing of the autogenous cartilage produces an outstanding graft material that is effective in concealing irregularities, filling defects, and creating a smoother surface, with excellent long-term clinical outcome and predictable esthetic result. We suggest that intact cartilage should be used to correct major deformities and that moderately crushed grafts should be used for smaller depressions to minimize resorption. The severely crushed form of cartilage should not be used as filler except to correct negligible depressions in atrophic skin.

The edges of solid onlay grafts might be softened by placing small pieces of moderately crushed grafts on or around the solid graft. The tiny pieces of moderately or significantly crushed grafts might be successfully used in final contouring at the conclusion of surgery. In patients with thin skin or in whom revision is required, a thin layer of moderately or significantly crushed cartilage would be the proper option as a padding material to prevent the adhesion of skin and to camouflage the sharp edges of the nasal skeleton that might be visible after edema has subsided.

From the above study,  one would presume that  thinner and smaller diced cartilage would also have higher resorption rates then thicker larger pieces, but I haven't seen any clinical studies to support or contradict that conclusion. 

http://archfaci.ama-assn.org/content/9/5/352.full

The Role of Diced Cartilage Grafts in Rhinoplasty

The fundamental technique for the use of diced cartilage in rhinoplasty has been known for over 50 years. One of the most impressive uses of diced cartilage is in cranioplasty, which demonstrates that the individual pieces coalesce into a semirigid graft over time. The term diced cartilage graft may refer to several different types of cartilage, methods of preparation, and methods of containment. In the present report, only autogenous cartilage derived from excised material, septum, or distant grafts is used. Containment refers to placement of the diced cartilage directly into a tight pocket for contour, layering of the cartilage on either side of rigid dorsal graft for blending, or placement of the cartilage in peripyriform pockets to advance the midface. The technique and benefits of diced cartilage grafts in rhinoplasty were reviewed.

A prospective study of more than 150 patients in 3 years found no evidence of absorption and no warping. Any problems thus far with the diced cartilage graft have been technical problems rather than problems with the graft material itself. One problem has been the visibility of radix grafts, particularly in patients with very active eyebrows. This problem is easily corrected by reduction with a pituitary rongeur or replacement with fascia alone. Dorsal grafts may have “edge show” cephalically, and caudally there may be inadequate grafting of the supratip region. This problem is easily corrected with the patient under local anesthesia by use of a pituitary rongeur. A minor depression may develop in the supratip area because the surgeon has initially undercorrected in pursuit of an immediate supratip break. This problem is corrected by keeping the graft truly full length rather than shortening it to get tip set off.

Conclusions: 

In using diced cartilage grafts in rhinoplasty, diced cartilage wrapped in fascia is simpler to use, quicker, and aesthetically superior to solid cartilage grafts, without risks of warping, malalignment, and K-wire extrusion.

 http://www.eclips.consult.com/eclips/article/Plastic-and-Aesthetic-Surgery/S1535-1513%2808%2970596-4

For the author,Rollin K. Daniel, MD; diced cartilage grafts have revolutionized dorsal grafts in rhinoplasty, replacing layered septal grafts, stacked conchal grafts, and carved costal cartilage grafts. He asserts that diced cartilage wrapped in fascia is simpler to use, quicker, and aesthetically superior to solid cartilage grafts, without risks of warping, malalignment and K-wire extrusion.

Diced cartilage grafts in rhinoplasty surgery: current techniques and applications. 

Dr.Rollin K. Daniel has used diced cartilage grafts in nasal surgery for more than 30 years. However, the number of cases and the variety of techniques have increased dramatically over the past 6 years.  

http://www.ncbi.nlm.nih.gov/pubmed/19050542

Autogenous Dorsal Reconstruction: Maximizing the Utility of Diced Cartilage and Fascia

Jay Calvert, M.D., F.A.C.S.^1,2 and Kevin Brenner, M.D.²

 The problem of reconstructing the dorsum of the nose is complex and a source of frustration for both patients and surgeons. Dorsal deficiencies due to various etiologies and the need for dorsal contouring cause the plastic surgeon to look to time-honored techniques such as osseocartilaginous rib grafts while also searching for other options that may be less technically challenging and have the benefit of temporal success. Diced cartilage wrapped with deep temporal fascia is just such a method to achieve reliable dorsal reconstructions. The various ways to use diced cartilage and deep temporal fascia are discussed

The complications of using this technique are predictable and correctable. Because the cartilage is mobile for 10 to 14 days after placement, there can be defects that arise from poor management of the graft postoperatively. Edges are usually not visible, but they can be in a particularly thin-skinned patient. Overcorrection and undercorrection are probably the most common complications seen with this technique and must be managed accordingly. Malposition of the graft and mobility of the graft may also be seen in a rare number of cases. Absorption of the graft has not been seen in the longest of follow-ups (6 years).

In conclusion, the technique of diced cartilage with fascia (DC-F ) has been a useful method of dorsal reconstruction as a stand alone technique and in concert with other methods of building the dorsum. There are many permutations and surgical variations of the technique. The authors believe that proper preoperative analysis will help the surgeon to derive clear indications so that the correct graft variation is used with a clear purpose. There is no substitute for preoperative diagnosis and planning when using the DC-F graft. The technique is safe, easy to perform, has minimal morbidity, and is our favored method for addressing difficult problems in dorsal reconstruction.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884865/

Perichondrium vs Deep Temporal Fascia

When performing Augmentation or Revision nose surgery, soft tissue is needed. For instance it is used to cover cartilage used to build up area along the dorsum or tip or simply for augmenting an area, say's Dr. Paul Nassif. If doing Rib Harvesting, you can then use the Perichondrium which is soft tissue that lays on top of the rib instead of using temporal fascia. According to Dr. Nassif, it's a little more thicker, heavier, and firmer then Temporal fascia. He feels it's an excellent source of soft tissue. He also has a you tube video on how deep temporal fascia is harvested, but warning it is not for weak at heart. I assume he use's deep temporal fascia as a choice when not performing rib cartilage graft, to build up the radix or dorsum area's. This video  on harvesting Perichondrium.is less graphic, but still takes place in Operating Room.

Nomenclature of nose: This could be especially helpful to prospective patients who want to be more specific in communicating to their surgeon what they would like modified on their nose, for those concerned about their cosmetic outlook. You may want to make sure the pre-op report mentions the specific area of concern you addressed in your consult .

Key surface landmarks are shown from the frontal and profile perspective. Most are soft tissue landmarks critical to nasal analysis and surgical modification.

Allografts and the risks of infection and disease transmission

Here is some valuable information on the risks associated with implantation of allografts [i.e. cadaver grafts in nose surgery]

 AAOS 2004: All About Allografts -- Select Highlights of the 71st Annual Meeting of the American Academy of Orthopaedic Surgeons

 Controlling Infection is Crucial

In limiting infection during allograft procedures, it is important to determine whether the tissue bank that you or your hospital is using is a member of the American Association of Tissue Banks (AATB). This organization requires that its members perform full screening that meets US Food and Drug Administration requirements; however, secondary sterilization of the grafts is still optional. Not all tissue banks are members of AATB, and not all tissue banks are inspected. The review by Vangsness and colleagues^[2] describes the process of procurement, processing, and storage, and should be required reading for anyone who is using allograft tissue. Be sure that you know your tissue bank and its procedures.
Infection of tissue can be controlled by screening the tissue donor and through secondary sterilization of the tissue. At this time, we can screen for both hepatitis B and C, which should prevent infection by these entities. There have only been 2 cases of HIV infection through allograft tissue, and both of these incidents occurred in the 1980s. These reported infections occurred with frozen bone as the vector, but none of the freeze dried grafts from the same donor transmitted the disease. The AATB has formulated guidelines for their members; these guidelines recommend donor screening.

There are a number of methods and federal guidelines for storing tissue after procurement. The methods of storing the tissue are: fresh frozen, deep frozen, freeze dried, demineralized, and proprietary treatments, such as CryoLife (CryoLife Inc., Kennesaw, Georgia

Factoring Relative Risk
The risk of hepatitis B after blood transfusion is 1/63,000. The risk of hepatitis C is 1/100,000, and the risk of HIV is 1/1,000,000. The risk of HIV after bone transplantation is 1/1,500,000. The risk of HIV after soft tissue transplantation is 1/1,600,000 with secondary sterilization.
To put this in the proper perspective, one should remember that the risk of death due to pregnancy is 1/10,000, the risk of death from administration of penicillin is 1/30,000, and the risk of death with oral contraceptives is 1/50,000. In fact, it may be more dangerous driving to the hospital than receiving a bone graft at the hospital.
In summary, allografts are a valuable treatment option for today's orthopaedic practice. The academy believes allografts to be safe if used within the guidelines, when they are supplied by an accredited tissue bank, and if the appropriate surgical techniques are employed.

How safe are soft-tissue allografts?

By C. Thomas Vangsness Jr., MD

 Although several cases of viral infection—specifically human immunodeficiency virus (HIV), viral hepatitis, and human T-lymphotropic virus (HTLV)—have been reported, these transmissions occurred before the guidelines for donor screening for viruses and bacteria were implemented and before the availability of currently validated serologic tests.

Sterility is expressed as a mathematic probability of relative risk. According to the FDA, a sterility assurance level (SAL) of 10-3 means there is a 1 in 1,000 chance that a nonviral viable microbe exists in or on the implanted material. The Association for the Advancement of Medical Instrumentation (AAMI) states that an SAL of 10-6 (one in a million chance) in organisms is more desirable. The American Association of Tissue Banks (AATB) requires an SAL of 10-6 for tissue bank allografts.

Contamination of the graft can also occur during the final handling and packaging of tissue. Gamma irradiation is commonly used to terminally sterilize allograft tissue with lower doses of radiation.

Freeze drying (lyophilization) is a preservation process that allows tissues to be stored at room temperature. Lyophilization freezes the tissue and reduces the water content to less than 6 percent of initial weight through a primary drying process (sublimation) and a secondary drying process (desorption). Although freeze-dried allografts (lyophilized grafts) are not commonly used for sports medicine applications in the United States, this process is commonly used with soft-tissue patches.

With improved donor screening techniques, such as nucleic acid testing (NAT), the current risk of transplanting tissue from an HIV-infected donor is reported to be between 1 in 1 million and 4 in 1 million.

According to a recent AATB survey covering data from 2003 to 2004, the current risk of an allograft infection to the average patient appears to be much less than the risk of infections surrounding the surgery itself. According to the report, there were 192 reports of suspected allograft-related infections in 2003-2004; 42 percent involved soft-tissue grafts and 37 percent involved bone grafts, with an overall incidence of 0.014 percent. Currently, better reporting of infections is actively under investigation to improve the accuracy of these numbers.

Do not do routine culturing of allograft tissue in the operating room immediately prior to implantation. These cultures are documented to be inaccurate and may reflect the native airborne or backtable contamination.

Musculoskeletal tissue regeneration: biological materials and methods  By William S. Pietrzak, Charles A. Vacanti

Although the risk is low, bacteria, hepatitis, HIV, and syphilis can be transmitted from donor to recipient. There is also the theoretical possibility of transmitting slow viruses (prions) with allograft use.
Irradiation of the soft tissue allografts with high dose (>3Mrad) radiation can sterilize allograft tissue, destroying bacteria and viruses including HIV and hepatitis. Bone plug allografts may still be capable of transmitting hepatitis despite treatment with 3 Mrad irradiation. Although, allograft irradiation will reduce the risk of disease transmission, it does so at the expense of diminishing the biomechanical properties of the tissue. Newer screening tests such as polymerase chain reaction (PCR) and nucleic acid testing (NAT) improve the detection of viral and bacterial DNA and RNA, and many increase the accuracy of identifying infected donor tissue and minimizing false-negatives. By improving the sensitivity and specificity of infected donor  tissue identification, the risk of bacterial and viral disease transmission should be less, thereby increasing the safety of allograft use. These newer techniques could potentially decrease the need for graft irradiation and other sterilization techniques that many affect allograft properties.

Surgeons can minimize complications associated with infected allograft tissue by only using tissue processed from a tissue bank accredited by the American Association of Tissue Banks (AATB). It is imperative that surgeons know the source of their allograft tissue, particularly if they rely on the hospital or a surgery center to obtain the allograft tissue for their patients.

http://www.aaos.org/news/bulletin/aug07/clinical1.asp

http://www.medscape.com/viewarticle/491618

http://books.google.ca/books?id=2qq56LYomagC&pg=PA397&lpg=PA397&dq=RISK+OF+TRANSMITTED+DISEASE+WITH+ALLOGRAFTS&source=bl&ots=cU9MnbRoBB&sig=KSY91n5fKiD2lVksKSU6A8vG204&hl=en&ei=iqHuTMmwAcnFnAf0u5jwCg&sa=X&oi=book_result&ct=result&resnum=10&ved=0CFIQ6AEwCTge#v=onepage&q=RISK%20OF%20TRANSMITTED%20DISEASE%20WITH%20ALLOGRAFTS&f=false

Using freeze dried bone grafts for Nasal Dorsal Augmentation

Recently in a PRSjournal a study was conducted and reported by Dr.Richard Clark called Nasal Dorsal Augmentation with Freeze dried allograft bone. Non irradiated freeze dried bone typically comes from tibia and femur shafts (more specifically cortical shafts).

Here's some general background information on bone grafts.

Type of Grafts:

Per definition there are four types of grafts, i.e. autografts, allografts, alloplasts and xenografts:

Autografts refers to tissue transplanted from one site to another
within the same individual.
Allografts are obtained from cadavers or living individuals from the same species. In human medicine they can be obtained from tissue banks (KÜBLER 1997).
Alloplasts are synthetic materials consisting of biological inert substances.
Xenografts are composed of tissue taken from another species (i.e. from an animal source, usually bovine). In case the organic material is removed from xenogenic bone, it may be considered as an alloplast (GARG 1999).
The term 'composite grafts' refers to grafts that are composed of materials from different origins, usually autogenous bone mixed with other materials (HABAL1991).

Depending on where the bone graft is needed, a different doctor may be requested to do the surgery. Doctors that do bone graft procedures are commonly orthopedic surgeons, otolaryngology head and neck surgeons, neurosurgeons, craniofacial surgeons, oral and maxillofacial surgeons, and periodontists.^[9]
There are three types of bone allograft available:

1. Fresh or fresh-frozen bone
2. Freeze-dried bone allograft (FDBA)
3. Demineralized freeze-dried bone allograft (DFDBA)

Freeze dried bone describes the method used to process the bone, not the source, and there is freeze dried bone available that comes from cadavers.

The most commonly used allograft is demineralized and freeze-dried bone.
The latter is used for minimising the antigenicity (BLOCK and POSER 1995), resulting in a demineralized bone matrix (DFDBA).

Freeze-drying and gamma irradiation are the techniques widely use in tissue banking for preservation and sterilization of tissue grafts respectively.
Frozen allografts are stored at temperatures below −60°C,
which decreases enzyme degradation and host immune response.
Freeze-drying involves removal of water from the tissue
with subsequent vacuum packing and storage at room temperature.

Some medical terminology:
➤Osteoinduction is a process that supports the mitogenesis of undifferentiated mesenchymal cells, leading to the formation of osteoprogenitor cells that form new bone.
➤ The human skeleton has the ability to regenerate itself as part of the repair process.
➤ Recombinant bone morphogenetic protein has osteoinductive properties, the effectiveness of which is supported by Level-I evidence from current literature sources.
➤ Osteoconduction is a property of a matrix that supports the attachment of bone-forming cells for subsequent bone formation.
➤ Osteogenic property is a relatively new term that can be defined as the generation of bone from boneforming cells.

For more info on bone grafts:
http://www.master-biomed.ethz.ch/education/bio_courses/Mechanobiology/DeLong_et_al_2007.pdf

http://dare.ubn.kun.nl/bitstream/2066/18869/1/18869_autoboanb.pdf

Related articles: 

Does Type of Bone Graft Used in Spinal Fusion Increase Risk of Infection?
http://activemotionphysio.ca/Injuries-Conditions/Lower-Back/Research-Articles/Does-Type-of-Bone-Graft-Used-in-Spinal-Fusion-Increase-Risk-of-Infection/a~2442/article.html 

Effect of freeze-drying and gamma irradiation on the mechanical properties of human cancellous bone 
http://www.ncbi.nlm.nih.gov/pubmed/10937629 

Bone graft substitutes
http://books.google.ca/books?id=QnCbGDbl-UwC&pg=PA46&lpg=PA46&dq=freeze+dried+bone+non+irradiated&source=bl&ots=nwVtoPS1vS&sig=DyEXoQ0s_QHAzC042e3ltfQMdyo&hl=en&ei=R6TtTLa3MIvDnAeAoZyRAg&sa=X&oi=book_result&ct=result&resnum=8&ved=0CFYQ6AEwBw#v=onepage&q=freeze%20dried%20bone%20non%20irradiated&f=false

According to Dr.Clarks site; 

Dr. Clark has currently published pilot study using freeze dried and frozen bone to augment and straighten the nasal dorsum (bridge). Dr. Clark uses American Bone Bank approved treated bone which has an excellent history of use in orthopedic surgery for over 10 years without transmission of any disease or rejection of implants. (For details of the extensive evaluation of bone donors and cleansing of the bone, please contact Dr. Clark.) The first patient receiving a dorsal implant with a frozen bone was in June, 2004. That patient's bone graft remains in perfect position and has maintained it's size and remains thus far to be a success. This bone graft has revascularized and become live healthy bone. We are following over 10 patients with excellent results, and time will tell as to whether this will be an answer to the quandary of dorsal augmentation, and we remain very hopeful.

 http://www.ncbi.nlm.nih.gov/pubmed/19935318

Techniques used to lessen the degree of rib (costal) graft warping in nose surgery

Rib carving is a tedious procedure, says Dr. Paul Nassif in this video. He soaks the rib graft in normal saline solution to soften it up and gives you the curve of where the cartilage is going to go.  The inner cortex of rib has less chance of warping, so its left intact. For rim grafts you need to carve the cartilage which is very delicate process, since you have to make sure the graft doesn't end up splintering.


Symmetric carving of the costal cartilage graft will minimize the chance of the graft warping over time.

Here's an interesting study on comparison of  warping after using different techniques of carving.  Concentric grafts warped less than Eccentric grafts.

David W. Kim, MD; Anil R. Shah, MD; Dean M. Toriumi, MD

  http://www.shahfacialplastics.com/carvedcostal.html

Dr.Jack Gunter, has devised a technique in which the larger grafts, the dorsal onlay graft and the columellar strut, are reinforced with a centrally placed Kirschner (K)- wire to decrease warping and provide a more stable and predictable result.
"Graft warping can occur in autogenous rib cartilage and lead to long-term postoperative distortions of nasal shape. The use of stabilizing K-wires placed through the center of these grafts has been a successful technique to counterbalance the tendency of the grafts to warp. To avoid warping of smaller grafts, we follow the principle of carving balanced cross-sections originally described by Gibson and later substantiated by Kim et al"
 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884866/

 http://journals.lww.com/plasreconsurg/Abstract/1997/07000/Internal_Stabilization_of_Autogenous_Rib_Cartilage.26.aspx

Control of grafted rib cartilage warping using K wire by Dr. A. Nakamura
http://www.springerlink.com/content/t33w777gk6668438/

More info regarding techniques to avoid warping of costal grafts:

Controversies in Otolaryngology: By Myles L Pensak
http://books.google.ca/books?id=xJNDV-KxYjcC&pg=PA176&lpg=PA176&dq=how+to+avoid+rib+warping+k+wire&source=bl&ots=yqnbTNt4GH&sig=M50C2vLAynJ_zlsAvkUBkhIlY90&hl=en&ei=_Z_TTLW5KIzCnAfTwLyOBg&sa=X&oi=book_result&ct=result&resnum=3&ved=0CCIQ6AEwAg#v=onepage&q=how%20to%20avoid%20rib%20warping%20k%20wire&f=false

Revision Rhinoplasty: By Daniel G. Becker, Stephen S. Park
http://books.google.ca/books?id=vwHmwB8qSeAC&pg=PA112&lpg=PA112&dq=how+to+avoid+rib+warping+k+wire&source=bl&ots=wJ4csX9UTT&sig=AY6roDDVffKe5bniZhAz3neSmAM&hl=en&ei=_Z_TTLW5KIzCnAfTwLyOBg&sa=X&oi=book_result&ct=result&resnum=6&ved=0CC4Q6AEwBQ#v=onepage&q=how%20to%20avoid%20rib%20warping%20k%20wire&f=false

Non surgical, non-medical treatment for collapsed nostrils (nasal valve collapse)

Image via Wikipedia

One, if not the most difficult thing to do is find a non medical device that will help you breath, especially when you have a nostril that is collapsed or weakened (nasal valve collapse-internal or external), or septum which deviates to one of the sides. It for me, especially has become a challenge when i become congested on my worse side which is often, and probably a secondary condition to my nasal collapse. My collapsed side is very narrow more so in middle section with a septum that already deviates towards it, which then doesn't allow enough space to breath properly especially when the turbinates start to swell creating blocked up congestion leading to post nasal drip. One factor that I realize that aggravates this problem is salt. After eating a meal high in salt, my collapsed side gets worse. Another factor is humidity. I've noticed after a shower, i can become congested as well, but not as bad now since my turbinates were partially removed. Cold weather can be another factor. Over the nearly 30 years of suffering with my nose, i have tried different treatments and have had surgery's along the way, which changes the way your nose will respond to treatments as well. Other factors could be allergic reaction to dust, strong scents, a pet, etc etc... I have been on non steroidal sprays which don't work for me as effectively as it once did since my last surgery but still works at times. I also use to take anti inflammatory medication which seemed to give a little relief. When all else fails i would take my over the counter (otc) decongestant nose spray. Problem with that spray however is after taking it for few days straight it causes rebound congestion, making my problem much worse for days. I also use a ocean spray nasal mist every day to hydrate my nose, which is important if you've had nose surgery and experience some degree of dryness. Problem again is all these liquid sprays can and for me does cause post nasal drip. Occasionally instead of the otc decongestant spray i will take otc decongestant pill in its place. This can be better option at times, however the pill form can still cause rebound congestion if taken too often and has other side effects which affect your blood pressure, and even you heart rate.

The options for non medicated relief is limiting for those suffering with collapse&/or blocked nostril(s). Some find salt water or baking soda mixes or drops of solutions in water using a neti pot helpful for sinus issue's. Some will do steam treatments by draping a towel over their heads above a hot steaming bowl of water or mix. You may even try menthol or other topical ointment products. However if you have a collapsed nostril or over enlarged turbinate issues then those treatments won't be of much use. The only other non medicated treatment that may be of help are the nasal breath strips you place over the middle area of your outer nose, like a bandaid. For me this may work well for the first hour, but after that my nose becomes itchy from the adhesive and the strip starts to weaken over a few hours as well. It also may not open the area as much as you need or would like. So whats left??? Well there is one other option i discovered after seeing a well known nose surgeon named Dr.Dean Toriumi in Chicago a year ago. After one of my visits with him, he mentioned that i could try a plastic nose splint (plastic internal dilator) which he helped design. They go inside the nostrils and are much stronger then the otc nasal strips. Because only one side of my nose is very  hard to breath with i only use one splint . It takes time to notice its effect, but after a couple hours i find that it does help my congestion problem which then helps me breath better. I usually will try to sleep with it over night. It's not a cure, but it's the best non medicated treatment i have available, which  helps reduce the use of otc medications and therefore I strongly recommend it.

For more information contact Dr. Dean Toriumi's office.

***Update:  Dec.27 , 2010***

Here are some more new non-medicated options for nasal valve collapse utilizing internal nasal dilators such as: unseen nasal dilator, breathe with eez, nozovent & sinus cones. I will be doing another post soon on  minor surgical techniques for correcting nasal valve collapsing. But in the meantime do yourself a favor and check out the links down below. They discuss all kinds of breathing issue's with the nose and the many different options available to improve it.

http://www.feelbetterri.com/index.php?section=9&pid=90

http://www.selfgrowth.com/articles/what-you-can-do-about-your-stuffy-nose

Unusual but somewhat effective treatment for Nasal Valve Collapse
Muscle-building therapy in treatment of nasal valve collapse.
M Vaiman, E Eviatar, S Segal
 The present study was performed to investigate the best way to combine transcutaneous and intranasal surface electromyography (sEMG) biofeedback training of muscles involved in nasal valve function with a home exercise program and electric stimulation of nasal muscles. 

CONCLUSION: Relieve of nasal valve stenosis and collapse can be achieved with a complex muscle-building therapy as described. It helps a significant cohort of patients with symptoms of obstructed nasal breathing to avoid surgical intervention. Electric stimulation of the muscles does not contribute significantly in achieving of good results. http://www.camresearch.net/showabstract.php?pmid=15521668

The mystery of all the different types of nose grafts

Do you get confused by all the different types of  nose grafts that are mentioned? Wonder where do they go, and how do they work? I'm not referring to where the source of origin for harvesting  are, like ear, septal, costal, calvarial, in cases of autologous grafts,  but referring to the actual names of the grafts relative to its location in the nose. For example: Columellar strut is a hidden graft that strengthens and supports the nasal tip. Spreader graft is another hidden graft, which supports the middle part of the nose. A graft is simply a piece of cartilage or bone that is used for some purpose in rhinoplasty. Each graft has a specific purpose. There are also tip grafts, batten grafts, strut grafts, dorsal augmentation grafts, rim grafts, lateral crural grafts, plumping grafts, caudal extension grafts, radix grafts, onlay grafts, shield grafts, etc.  Enough to get anyone confused and left scratching their head. Well here are some links that will help unravel this mystery. Grafts go by many names relating to their shape, size &/or locality in the nose.  A shield graft relates to the shape of the graft in the nasal tip lobule.. An "alar" batten graft relates more specifically to locality, but batten grafts can be placed in different area's. The website links are from  Dr. Anil R. Shah , Dr. Daniel Becker (See Chapters 8-12) , Dr. Naderi and Dr. William Portuese.  Kudos to these Doctors for including this valuable information.

http://www.revisionrhinoplasty.com/RhinoplastyManual/index.html 

http://www.shahfacialplastics.com/grafts.html

http://www.seattlesinusdoctor.com/facial_procedures.html

http://www.rhinoplastyspecialistsurgeon.com/ethnic-rhinoplasty/grafts-sutures-in-rhinoplasty/

http://archfaci.ama-assn.org/content/5/4/291.full

http://www.glasgoldgroup.com/tipgrafts_theireffectsontipposition_contour-03.html

If any of the above links are broken, please don't hesitate to let me know. 

Alar Batten Graft (green area) and Different Shield grafts

FREQUENTLY USED GRAFTS IN RHINOPLASTY: NOMENCLATURE AND ANALYSIS

Author: Alan Landecker M.D. Co Authors: C.Spencer Cochran, Dr. Jack Gunter

Introduction Over the past several decades, numerous grafting techniques have been developed to sculpt the nasal framework in primary and secondary rhinoplasty. However, surgeons have been confused by the significant variability related to the nomenclature, exact anatomical position, and clinical indications of each graft. In this paper, the most commonly utilized grafts (a total of 24 grafts will be presented; below are 6 examples) in modern rhinoplasty are comprehensively analyzed according to the aforementioned factors.

http://www.hitechbrasil.com.br/sbcp/anais/42/paginas/285.htm#1355

The Butterfly Graft

The "Butterfly Graft" is a functional nasal procedure that Dr. J. Madison Clark has helped to develop and refine. Dr. Clark teaches the procedure to other nasal surgeons locally, regionally, and nationally. 

The simplest way to describe the procedure is as an internal "Breathe-Right" strip. The graft is taken from the ear but doesn't change the shape of the ear appreciably. It is usually intended that the graft not change the appearance of the nose, but it can be performed along with procedures that improve the aesthetic appearance of the nose (rhinoplasty).

The procedure is usually done under general anesthesia and takes about an hour to an hour and a half.

http://www.nc-faces.com/the-butterfly-graft/

Seagull Wing Graft

A technique for the replacement of the lower lateral cartilages

Fernando Pedroza, MD; Gustavo Coelho Anjos, MD; Lucas Gomes Patrocinio, MD; Jose M.Barreto, MD; Jorge Cortes, MD; Suad H. Quessep, MD

The seagull wing technique is indicated in cases in which there are severe signs of overresection of the lower lateral cartilages. 

We describe our 20-year experience with the seagull wing technique, which is designed to replace the lower lateral cartilages and to reconstruct the nasal tip. This technique has the advantages of almost completely rebuilding the structure of the nasal tip, restoring the function of the external nasal valve, and effectively correcting a great variety of aesthetic deformities. 

http://archfaci.ama-assn.org/content/8/6/396.full 

Structural Approach to Endonasal Rhinoplasty
Anil R. Shah, M.D. and Philip J. Miller, M.D.
Includes Information on Extended Tip graft and Columellar strut
Abstract
The marriage of endonasal rhinoplasty with structural grafting has resulted in more consistent rhinoplasty results. The nasal base can be stabilized by tongue-in-groove techniques, a columellar strut, or extended columellar strut. The middle vault can be addressed with spreader grafts or butterfly grafts. Lower lateral cartilage weakness can be supported with alar batten grafts or repositioning of the lower lateral cartilages.
http://www.drphilipmiller.com/Assets/Structuralapproach.pdf

Confused about what's the difference between Lateral crural strut grafts and alar strut grafts? Or rim grafts and Alar batten grafts?
Dr. Naderi explains in simple terms. Alar strut grafts and Lateral crural strut grafts are same.  But Alar batten grafts are not the same. A "rim graft" sits along the alar rim (right at the margin just like it sounds) whereas a "alar strut graft" site higher OVER the lateral aspect of the Lower Lateral Cartilage. The rim graft supports the soft tissue rim (nostril) while the strut graft supports the LLC laterally and thereby supports the entire nostril sidewall, not just the rim. An alar batten graft is a longer grafts that sits UNDER the lateral aspect of the Lower Lateral Cartilage and extends to the body pyriform apperture to prevent collapse of the nostrils during forceful inspiration.
Here's some other diagrams displaying nasal grafts. Click for larger view

Regenerative Medicine: Re-Growing Body Parts

This may seem futuristic, but it is happening today. Now imagine if we could apply this technology to those who suffer from empty nose syndrome, because of surgically removed turbinates, to burn victims, to cancer patients who are missing parts of their nose, if not most, to those like me suffering with nerve pain due to excessive removal of tissue in and around my nose tip and nostril area, even for those who need major reconstruction of the nose with grafts could benefit from this technology, since the surgeon wouldn't have to harvest the grafts from your own body which adds a lot of time to your surgery once shaped and put in place. You also wouldn't have to worry about warping, absorption, infection, or any of those downsides with grafting as performed today. It's an area that i hope some Plastic Surgeon or E.N.T. will explore. I think this is the future for nose reconstruction surgery/treatment as well as it is for all the other medical fields. One won't have to depend on donor body parts for transplants any longer. It's truly a transformational breakthrough.

More concerns when harvesting costal cartilage for use in nose surgery.

Image via Wikipedia

Two major concerns about, harvesting rib cartilage are: 1. the risk of  pneumothorax, a release of air from the lungs and 2. the concern about as we age rib cartilage tends to calcify therefore the cartilage becomes more like bone. 

According to Dr. Barry Eppley, a plastic surgeon in Indianapolis, his preference is the 7th, 8th, and free floater 9th rib for harvesting.  He claims it " is easier and provides plentiful options of shape and configurations. A small subcostal incision can be moved around to provide good visibiity and the underlying rectus muscle is split vertically for access rather than transecting it." See link below (exploreplasticsurgery).

He continues,  "One of the major concerns about rib harvesting is the risk of pneumothorax as the lung pleura  is close by underneath. But at the level of the 7^th ribs and lower, the lower apex of the lung is higher so this is not going to happen. In over 65 cases of rib harvest at this chest wall level, the pleura has never been violated. It becomes evident at the level of the 7^th and most certainly at the 6^th rib."  So for those seeking revision rhinoplasty and need rib grafts, don't forget to ask the surgeon at time of consult which rib he uses, how many has he done like that, and has he/she had any complications with it. 

Another nose revision surgeon , Dr. Anil Shah in Chicago prefers to use the 5th, and 6th rib. He says "either the 5th or 6th rib are most commonly used.  The 5th rib has the advantage of being straighter and not really connected to any of the other ribs.  The disadvantage is it tends to be smaller.  The 6th rib tends to be longer but more curved than the 5th rib.  In addition, it tends to connect to other ribs." See link below (shahfacial plastics).

How about calcification of the ribs as we age?

According to Dr. Shah,  "as we age, the cartilage portion of the rib cage becomes calcified and eventually actually turns to bone. This process is typically complete at age 55, but I operated on patients well over fifty who have had substantial cartilage remaining in their ribs".  When your over the age of 40 there is normally more calcification which makes the costal graft harder to shape, however the upside to this is there is less chance of warping over the years. 

Dr. Eppley mentions "one can always find enough cartilage to use. I have done rib grafts up to age 65 and adequate cartilage has always been found". 

http://exploreplasticsurgery.com/2010/04/10/rib-grafts-for-rhinoplasty 

http://www.shahfacialplastics.com/costal%20cartilage%20grafting.html

Irradiated cartilage (cadaver) grafts in nose surgery

So you need to have your nose built up but you don't have enough septal, or ear cartilage for support and you don't want synthetic implants in your nose, and your concerned about having your rib section operated on in order to harvest rib cartilage for nose grafting. Your option, Cadaver cartilage grafts. This is a controversial area, some nose surgeons say its much inferior to your own rib cartilage because of absorption problems, while others like Dr. Russell Kridel,  a facial plastics e.n.t. feels its a great option which shouldn't be overlooked and has shown studies (see medpagetoday link below) that support his view. Maybe it's a e.n.t. perspective vs the plastic surgeon's perspective. Most e.n.t.'s don't harvest rib cartilage for nose surgery (although this trend is changing) so it makes perfect sense they would be in favor of another option. But that's what makes things so interesting. The more options the better for the nose patient, however the debate between which is better can cause the patient to freeze in their tracks wondering who to believe and trust. Every surgeon has their own unique and favorite approach and so you have to consider what is best for you the patient and see if the surgeon has a lot of experience in the approach your seeking. What's right for one patient isn't right for another. Our general health, age, previous surgery's puts us all at a different place in time and has to be taken into consideration by the surgeon. It would be in the best interest of the surgeon to let the prospective patient know what options they provide and feel is appropriate. However they should not be afraid to also recommend another colleague to the patient, if that colleague does a procedure that they don't offer or specialize in yet is what  the patient is seeking. The surgeon will gain more respect from the patient this way, (meaning more referrals and positive internet forum comments) and therefore should not be afraid of losing the patient to someone else, since the patient will at the end go with who they feel is not only most qualified but with who can  offer what they want, making them feel more comfortable knowing they're on the same page with that particular surgeons view.

The Rate of Warping in Irradiated and Nonirradiated Homograft Rib Cartilage: A Controlled Comparison and Clinical Implication.      

In this study it was concluded that there was no difference in warping characteristics between irradiated and nonirradiated homograft (allograft) rib cartilage.  Make note:
The centrally cut pieces of cartilage in each group warped less than peripherally cut blocks in each group.

http://journals.lww.com/plasreconsurg/Abstract/1999/01000/The_Rate_of_Warping_in_Irradiated_and.42.aspx

http://archfaci.ama-assn.org/content/12/2/114.abstract

 Prevailing concerns with ICC and Costal AutoGrafts:
Homologous irradiated costal cartilage (ICC) has been shown to resorb on long-term follow-up and has the potential to warp but studies have shown contradictory results. In addition to problems with resorption, warping, and bacterial infection fear of viral transmission despite extensive sterilization has severely reduced its usage. However, irradiation of soft tissue allografts (ICC) with high dosage(>3Mrad) radiation can sterilize allograft tissue, destroying bacteria and viruses including HIV and hepatitis. [For more info. on risks of infection and transmitted diseases from allografts see my post Nov.25/10]  Costal cartilage autografts provides a large volume of graft material with excellent structural support.Autogenous rib grafts are known to warp,buckle and absorption can occur and be somewhat unpredictable, but there are techniques a well informed  or experienced surgeon will incorporate to limit warping capabilities in rib grafts. [See my post on techniques used to reduce warping - dated Nov 7/2010].  So the general disadvantages of Costal grafts are warping,  potential donor site morbidities, including pneumothorax, scar visibility, and chest wall deformity, but once again  keep in mind these can be avoided or be marginalized when performed by a surgeon who's well experienced in performing costal grafting. 

http://books.google.ca/books?id=2qq56LYomagC&pg=PA397&lpg=PA397&dq=RISK+OF+TRANSMITTED+DISEASE+WITH+ALLOGRAFTS&source=bl&ots=cU9MnbRoBB&sig=KSY91n5fKiD2lVksKSU6A8vG204&hl=en&ei=iqHuTMmwAcnFnAf0u5jwCg&sa=X&oi=book_result&ct=result&resnum=10&ved=0CFIQ6AEwCTge#v=onepage&q=RISK%20OF%20TRANSMITTED%20DISEASE%20WITH%20ALLOGRAFTS&f=false 

 http://www.entandallergy.com/afp/media/pdfs/lin_rhinoplasty_complications.pdf

Allograft vs. Autograft

  http://www.harthosp.org/TissueBank/HumanTissueGraftInformation/AllograftvsAutograft/default.aspx

A cadaveric analysis of the ideal costal cartilage graft for Asian rhinoplasty.

http://www.ncbi.nlm.nih.gov/pubmed/15277829

Rib Cartilage Safe for Rhinoplasty
http://www.medpagetoday.com/Surgery/PlasticSurgery/17037

Irradiated costal cartilage in augmentation rhinoplasty
http://www.optecoto.com/article/S1043-1810%2807%2900107-8/abstract

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Are synthetic nose implants a good idea?

Most nose revision nose experts would probably agree your own cartilage from your body is the preferred choice over synthetic implants to use when building up the nose. Here is a video by Dr. Naderi expressing his personal views on the subject. Cadaver cartilage is another option, i will discuss at a later time in another post.

http://onlinelibrary.wiley.com/doi/10.1097/00005537-200206000-00006/full

http://www.e-mjm.org/2008/v63n1/Rinoplasty.pdf

Removing Rib Grafts from the nose

Image via Wikipedia

If your considering a revision to remove rib grafts, you will have to consider the consequences. One of the consequences is that your nose grafts support your nose now, and some of your previous supporting structures may of been partially removed or reshaped.  A better solution if you feel your rib grafts are too large, is too have the grafts made smaller in thickness, however, warping can then become a problem.You will have to see your nose revision surgeon or a new surgeon if that isn't an option to discuss your options, and hopefully the operative report is complete and specific enough to guide the surgeon contemplating correcting this issue. Maybe a ct-scan of the nose would reveal more information before attempting to perform such a surgery.

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Is revision rhinoplasty the most expensive cosmetic/plastic surgical procedure?

Image via Wikipedia

The top 5 most expensive plastic surgery procedures in the 
world.
http://www.mostinterestingfacts.com/human/top-5-most-expensive-plastic-surgery-procedures-in-the-world.html

So there you have it, Revision rhinoplasty is in the top 5 (4th on above links list )  most expensive cosmetic/plastic surgical procedure out there.

   What's unfortunate is that the majority of the people needing revision rhinoplasty suffer from structural damage as a result of their primary or secondary surgery.  It is unique when compared to the other cosmetic procedures because it's a health issue for many in terms being able to breath normal.

For example, like what happened to me, as has happened with many others, the primary nose surgeon over-resected the bridge of the nose and by doing so removed too much of the supporting cartilage, leading to nasal valve collapse, which makes inspired (inward) breathing through the nostrils difficult to near impossible. Even more frustrating and disturbing, is that revision rhinoplasty is not normally covered by health care system in Canada, at least not in any significant or proportionate amounts. And the ent's and plastic surgeons don't even try to help their patients  with a out of province or out of Country referral , because they either don't understand the problem of nasal valve collapse &/or they figure its not worth the effort, since the government health care covers a nominal amount under Septoplasty. In the United States, some portion is recoverable if you have company or private insurance. The highest amount I read online was 50% of the surgery was covered. For Canada, I haven't heard or read any information about Insurance Coverage, I would suspect it would be the same as in the U.S. However If you have had nose surgery and problems with your breathing as a condition prior to you purchasing your Insurance I would pretty much guess most if not all the Insurance Company's wouldn't cover you. And I like many others had primary surgery when I was 18.

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Revision rhinoplasty: How to find the perfect nose surgeon

If your looking to have your nose operated to improve a cosmetic or functional problem that wasn't properly corrected or occurred from your primary surgery, then you are considering a revision rhinoplasty, or secondary rhinoplasty.

Some nose surgeons will correct a minor cosmetic defect at no charge if they did the surgery.  However if your problem is much more serious then being upset about a very minor cosmetic change then you will have to do a lot of research and see top specialists in determining what is the problem and how it can be corrected properly.

That is one of the reasons i put this blog together. As a resource and to pass on my experience as a nose patient.

In my first post, i mention revision nose surgeons who have experience with rib grafts. I also have listed different websites you can link to for more information.  There is no perfect nose surgeon, just have to find the right one who has experience correcting the problem you want corrected. If you need to travel outside your city or Country for someone who is more of an expert, then you should do so. Never settle for someone who simply say's they can do the surgery, and they can do what the other top experts promised you. Never underestimate the complexity of rhinoplasty especially revision rhinoplasty, its very challenging and specialized.  Never underestimate what could go wrong either. I would of never thought i could end up with neuropathic permanent pain from nose surgery, but i did. You could also end up with serious condition called Empty Nose Syndrome. I have this to mild degree on my left side nostril. This occurs from removal of too much turbinate tissue. Just because the nose is relatively a small part of your anatomy, doesn't mean a serious side effect  can't occur  from the surgery. Take the surgery very seriously, its your body and only trust someone you feel absolutely comfortable with and has the experience and /or knowledge to fix your specific problem. If your uncomfortable with the surgeon and you are not getting a clear outline about what the surgeon plans to do with  your nose  then you may want to  look elsewhere. If you are having doubts about their experience or approach to the surgery , that is a serious red flag. Don't  expect a surgeon to change their approach because its not in line with what you think is right for yourself. . It's not  likely going to happen, and it will likely lead to great disappointment after the surgery.

Neuropathy caused by Nose Surgery. It does happen!

Can a permanent neuropathic condition occur as a result of nose surgery?

Answer: YES.

After my second major revision nose surgery by a young inexperienced surgeon in Toronto, Ontario, i developed within 6 months time severe neuropathic pain around the tip, columella, and nostril regions. The pain was so excruciating it felt like someone was taking a scalpel to my nose and slashing it. Another phenomena in conjunction with this pain, is hyperesthesia and allodynia.  This means the pain could be triggered further, by light sensation to the nose by touch, blowing fan, cold temperature, rain, etc.. I finally realized normal pain medication doesn't take away the pain. The only thing that helped control the pain, was anti-convulsant pills such as neurontin (gabapentin) however even though that helped somewhat, my neurologist recommended Lyrica (Pregabalin). That worked far better then gabapentin and you don't have to take as many pills. It however does have side effects one being lack of concentration and making you lethargic.

So what caused this? My opinion is excessive cutting and removing of soft tissue and tip cartilage, all around tip and surrounding area's. I don't believe its a coincidence that where most of the scar tissue in my tip and columella area was removed with cartilage, is now where i have neuropathy. My reason for mentioning this is so you are aware of this as a future patient, and that surgeons should be aware of this as well, and will hopefully make future patients aware of this as a possible side effect from the surgery, even though its remote. In fact I am not aware of anyone else with this condition, however i have read forums where a couple people mentioned they experienced nerve pain after surgery, but they never mentioned they required to be medicated with special medications like i take, or that they have a permanent condition.

What have I done for my neuropathic pain, besides taking medication?
I first had to do a lot of research. I discovered a site which i have linked on this blog, endthepain.org which is a great site about facial neuropathic pain.  The section about Trigeminal nerve pain explains how this pain works. It's atypical however in my case, i have pain on both sides of my nose. I've had CT Scan to rule out Trigeminal Condition caused by pressure on a nerve in the brain.  I have had temporary nerve blocks, at a pain clinic, i almost had radio pulsed frequency-sphenopalatine block done, but after the pain specialist  after many appointments told me that the freezing injection could cause permanent loss of sight, i backed down from going ahead with that procedure. In fact the pain clinic in my city never performed radio pulse frequency until i mentioned it to them that it has been used as a treatment elsewhere for facial neuropathic pain. I have had botox injection in my tip area's, cortisteroid Kenalog, and inside my nose a sphenopalatine and ethmoid freezing block. I've tried cold lidocaine ointment and gabapentin cream and hot cayenne ointment cream. None had worked. The injections may of worked temporarily, but even that was inconclusive.

The Financial Burden of being a nose revision patient

What are all the financial costs of finding a good nose revision surgeon and cost of nose revision surgery?

Answer: A fortune

Costs:
1. Travel:
Travel costs of course vary for each individual. When finding a surgeon out of Country or State/Province your first cost is the cost to travel for a consultation. So you have flight, hotel, food, and Surgeons consult fee to incur here. Lets say you stay couple of nights within the city your surgeon works in, this with other costs then could cost about $600 for hotel, cab $75 back and forth, esp from airport to hotel, $125 food for 3 days, and consult fee of $200. Total = $ 1000.00 plus cost of flight, lets say $600 for a Total = $1600.00

That's if you see one nose doctor, if you see more then one in the same city then you just have to add consult fee of the other surgeon and maybe additional cab fair.

Now say your not happy with that surgeon and you need or want to see more nose surgeons which require you to travel to another city.  Well if your able to do that within the same trip lets say as your above trip, then cost of flight might be extra $250.00 and hotel for couple nights $475 with food, cab $60 and consult $200 for sub total of $985.  Cost of whole trip:  Total =$1600 + $985 = $2585.00

Now you decide to go with one of the surgeons you have seen, so now your costs will include the surgery cost, and hotel costs for 7 to 10 nights of stay, since you are not suppose to fly after nose surgery that amount of days.  So cost of secondary revision surgery lets say conservative figure today $12,000.  Now add hotel fee for lets say 8 nights at $200. for amount of $!600 plus food, $320 and flight $650.00. Total = $14,570
If your taking a companion with add cost of additional seat on flight, food, etc.

So total cost = $2585 + $14570 =$17,155.00


Remember you will need prescription medication which is however a nominal extra cost.

Now that's with one revision nose surgery. What if your outcome isn't successful and you require more surgery? Well again, you have to travel for the consult appointment, and then travel again for the surgery. Very rare will someone book surgery with the surgeon before the consult or be able to arrange it right after the consult all within one trip. So first off to heal properly it takes about good 2 years before having another surgery. Mentally it may take as long as 5 years until your ready to do this again. Well in 3-5 years time prices the surgeons charges goes up, and now that your coming to see surgeon with more history and problems the cost because of that goes up substantially. Lets leave the costs from above the same except for the surgery cost. Now your nose revision cost is $ 15,000 lets be again conservative. So adding that to all your other costs and you end up with $3000 more then above total, which then will be a total of $ 20,155.00

So cost of two revisions cost you total of $37,310.  Having two revisions would not be unusual.

Unfortunately, its at this point where one realizes if it has failed again, that seeking out the best revision nose surgeon is crucial. So your still having problems with your breathing the results of the cosmetic nose revision is showing poor results after couple years now what? A tertiary surgery, Oh damn! Why wasn't I more selective about who i chose from the very beginning. Well don't kick yourself even the best of the best have bad days.
But you need a 3rd revision and its not because your picky its because you didn't have the right surgeon perform the right procedure.  OK, here we go again, now the top revision specialists quotes you $20,000 to $30,000 with anesthesia costs. Lets agree on $25,000 to correct the mess, and add the extra costs using same figures as we used above, so the cost this time around totals=$30,155.00

Now assuming you didn't travel to other city's for consults which you decided not to go with that particular surgeon, your total costs for the 3 revisions now totals= $67,465 dollars.  Hopefully 3rd time was a charm. Oh but wait the surgeon requires for you to do a follow up with him/her. Some ask for more then 3 follow ups. Lets say you do one follow up in a year, so cost is lets say as above example $1400. no charge for follow up appointment. So new grand total of $ 68,865. Wow nearly $70,000. And most likely its not at all covered, so it's all coming out of your pocket. With a companion it would be at least that much. And the prices these surgeons are charging isn't slowing down anytime soon. It pay's to be rich, or becoming a revision nose surgeon.

Nose surgery a unique but questionable business

  What's unique but questionable in regards to nose surgery especially revision nose surgery for breathing issue's, is that it is the only surgery that i know of where you have to pay out of pocket (in full in some cases) in order to improve your health condition while being a citizen in a Country that offers Universal health care, like that in Canada.  For the few that are lucky enough to qualify in getting  insurance coverage in Canada, or the U.S.A,  they will still be out of pocket for the "cosmetic" component of the surgery which will likely end up being 50% or higher of the total fee.  In Canada, it would be very difficult to get any portion of nasal valve collapse surgery costs to be covered by the health care system and less likely to get coverage for empty nose syndrome corrective surgery, since most e.n.t. surgeons aren't aware or refuse to  recognize empty nose syndrome as a real serious condition and many don't know how to treat, let alone diagnose nasal valve collapse. Now as for Provincial or Federal Government financial assistance coverage don't expect a Plastic Surgeon to even help you apply. I had asked one Plastic Surgeon who is considered the best rhinoplasty surgeons in my city to see if I could get  provincial health coverage to help cover nominal amount towards the surgery I need, (since he and no one else in the province could correct the problem with my nose). He ended up giving me the run around. First he told me it wasn't going to be much money and then recommended that I should ask an e.n.t doctor. I think he was afraid his reputation would look bad, to admit to the government that he couldn't do the surgery which meant I would need to seek out a more qualified specialist. He agreed with me I should pursue finding a surgeon out of the country who specializes in revision nose surgery yet was still unwilling to be of any help. He couldn't even recommend a U.S. surgeon. In Canada, If you need to have surgery outside of  the country  you will not be eligible for any reimbursement, without a surgeon's referral stating that the level of care or procedure you need is not available in Canada. In my case, I already had 2 major revisions, which made my problems worse and one of the surgeons was considered a top nose revision surgeon in all of Canada. So  I need a highly skilled nose revision surgeon, like those in the United States, to correct my breathing issue's. This is a terribly unfair situation considering revision nose surgery for nasal valve collapse can cost upwards of $25,000 U.S. by a reputable experienced surgeon. The cost for empty nose syndrome surgery exceeds $10,000.  There's also the cost's of travel, hotel stay (you can't travel for 7-10 days after nose surgery) supervision by nurse for a day (if unaccompanied for the surgery), medication and food. If that isn't bad enough, some surgeons don't even offer financial payment plans. In these situations the person who needs the surgery may not be able to afford it.
  

     If you had unsuccessful eye surgery or ear surgery, and needed revision surgery because it made your sight or hearing worse, you most likely would be covered fully by the health care system in Canada , even if it was necessary to leave the country to get it done by a more qualified specialist. Unfortunately nose surgery is in a infamous league of its own when it comes to repairing a bad outcome that affected your breathing.  You are included in the "Cosmetic" category even though your major or full complaint is a "Functional" breathing issue. If you are insured then the the nose surgeon additionally bills you for the cosmetic portion which is above and beyond what the insurance company covers for the functional portion. Depending what the overall charges are some would venture to say it's a double billing system. If you have no insurance then you will end up paying the full amount out of your own pocket, since doctors in Canada seem uninterested in helping  you attain even a nominal amount of coverage through the Government. Many ent's  don't understand why you need to go out of the country for the surgery. Many don't realize the complexity of the surgery, with regards to proper nose grafting procedures and the expertise and experience that a surgeon needs to perform such complex revision nose surgery's with consistent successful results.

Nose revision surgeons in Canada, should also become active in recommending that the health care system cover a larger amount then the miniscule amount being offered now towards the revision surgical costs. An amount that is at least PROPORTIONAL to the SURGICAL TIME needed to correct the FUNCTION of the nose. We pay into the system through our taxes. We should expect equal and fair compensation like other surgery's would receive, especially when considering the fact that a nose surgeon within our own country was responsible for these breathings problems in the first place.   

There are also no set rules in how facial plastic surgeons (in general) divide up the fee's between the cosmetic and functional components. The nose revision surgeon arbitrarily decides what that breakdown will be. It seems to be that the portion the Government or Insurance company's covers (if you had prior nose surgery it may be very difficult to get any Insurance coverage) is the functional portion claimed and the balance is the cosmetic component.  If you don't have insurance or not able to qualify for it, and have the surgery in Canada as a citizen, the Gov't provincial health care portion claimed by the surgeon is considered the functional component.   

So how small an amount is this Gov't portion that is claimed for the functional surgery of the operation? Well very very small. There are different codes that are used by the surgeons when they make these claims, so it can be confusing to exactly what amount goes to the operation and what amount goes towards each consultation. With that in mind from my surgery in 2001 performed by a Plastic Surgeon the amount claimed for the operation was  $508.40. From my surgery performed in 2005 by an E.N.T/Facial Plastic surgeon the amount claimed was $307.75.  How much was I charged for the two surgery's? The Plastic Surgeon in 2001 charged me around $5500 for a 3-4 hour revision surgery. The E.N.T./FPS in 2005 charged me $7700 for a One and half hour revision surgery. So in other words the Functional component claimed in 2001 worked out to less then 10% of the total charges, and the Functional component claimed in 2005 worked out to less then 5% of the total charges. Note: My two only major complaints with each of those surgery's was 1) My problem with breathing due to collapsing of the nasal valve (a result of primary surgery) and 2) The projection and angle of my nose tip (also a result of primary surgery).

If the nose revision surgeons really care at all about these victims they would be addressing these issues with the health care system. Isn't being able to breath through your nose an important function??? The real irony is that nasal valve collapse is a condition that is primarily caused by poor primary nose surgery (iatrogenic). Empty nose syndrome which is more rare, is a result from over aggressive removal of the inferior turbinates and/or middle turbinates (also iatrogenic).

Many nose patients are unaware of these serious side effect before the surgery, and when it occurs, more often then not, the nose surgeon can't or will not correct the problem. The patient is now, not only out of pocket from the first surgery but has to pay out of pocket for the revision. Worse, like in my case, when you don't have a successful  secondary surgery  you are further out of pocket and the more nose surgery's you have, the higher the price a Nose Revision Specialist will charge you for another corrective procedure.

There's no question  greed and/or apathy has set in with some of the nose revision surgeons. They need to prove they care not just about the money but also about their patients health, by becoming vocal and active with helping them get some proportionate amount of coverage (either private or public) and offer a monthly payment plan. Its really in their best interest as well as the interest for their potential patients.  The ability for the nose revision surgeon to state that even if the surgery is for breathing issue's, it's still a cosmetic procedure, allows the surgeon free reign to charge whatever (s)he wants for the surgery. There's no limit, its a business based on the open market. But even the "cosmetic component" portion that some charge can be so exorbitant that many will have to shop around for a surgeon who charges a more reasonable and equitable amount. 

 

It's a serious problem, that won't make front page news and therefore not likely much if anything will be done to address these unjust situations. The revision nose victim falls within the cracks of the health care system and  therefore many may end up with serious financial consequences depending on their financial position. Some may end up having to take out a loan or second mortgage on their home or find someone that will borrow them the money. Some may even have to sell a valuable possession of theirs (i.e. Jewelry) to come up with the money.  For the  nose victims who just can't come up with the money for the surgery, they will have to suffer in silence and find alternatives to rely on such as; nose sprays, decongestant pills nose splints or possibly a  cheaper costing minor surgical procedure that may give some relief temporarily,  until they can afford the appropriate surgery. And  in the mean time the surgeons fee's, as well as hospital and clinic fee's will all continue to escalate.