Recon­structive nasal surgery.

Reconstructive nasal surgery goes beyond pure aesthetics: it reconstructs lost or damaged structures of the nose in order to restore both function (e.g. breathing) and appearance. It is frequently medically necessary and is combined with further treatments — for instance with the removal of tumours or the management of the consequences of accidents.

At the Kuzbari Centre these complex operations are carried out by our specialists — Univ.-Doz. Dr. Rafic Kuzbari, Dr. Christoph Grill and DDr. Jessica Wittmann. Thanks to modern techniques such as cartilage or skin grafts, flap techniques (flap) and, in selected cases, custom-made implants, we achieve results that look as natural as possible. The patient's own cartilage remains the gold standard. Our Vectra 3D simulation makes it possible to visualise, before the operation, how the reconstructed nose will look and function.

A nose consists of three layers that work together like a tent: the lining on the inside, the framework of cartilage and bone in the middle and the outer cover of skin on the outside. In a reconstruction one simple but unrelenting rule applies: every layer that is missing must be replaced. If one of them is skipped, the result will not hold.

The lining. It is the layer nobody thinks of — and the one on which reconstructions most often fail. Without inner lining the tissue contracts, the nasal opening narrows, and a framework that has been built up is drawn inwards. Depending on the size of the defect, it is replaced with mucous membrane from the nose itself, with a turn-in technique using neighbouring tissue or with a thin graft.

The framework. It gives the nose its shape and keeps the airway open. It is replaced with the patient's own cartilage — from the nasal septum, the ear or the rib area. Ear (conchal) cartilage is naturally curved and is particularly suitable for the alar rims and the nasal tip; rib cartilage provides volume and firmness for load-bearing parts. The body's own material is accepted as its own tissue and becomes incorporated — no foreign body remains under the skin.

The outer cover. Small defects can be closed directly or covered with a skin graft. Larger defects require tissue that brings its own blood supply with it — a flap. Here skin is moved from the neighbouring area without detaching it completely from its blood supply.

One detail that shapes the result: the skin of the nose is not the same everywhere. On the nose bridge it is thin and mobile; at the nasal tip and on the alar rims it is thick, rich in sebaceous glands and firmly attached. Replacement tissue is therefore chosen according to its similarity — skin from the forehead resembles the nasal tip more closely than skin from the neck. And that is why, wherever possible, reconstruction is carried out in whole aesthetic units rather than in patches: a scar running along the natural border of an alar rim is barely noticeable; the same scar in the middle of the alar rim is always noticeable.

Unlike an aesthetic rhinoplasty, one procedure is rarely enough in larger reconstructions. This is not a setback and not a sign that something has not worked — it is the method.

The reason lies in the blood supply. Transferred tissue needs weeks before it has built up its own vascular connections in its new location. If work continues too early, the very tissue on which the reconstruction is built is put at risk. The first step is therefore followed by a waiting period of usually several weeks before the next one is due.

A typical sequence for a larger defect looks like this: in the first step, the lining and the framework are built up and the outer cover is laid on. In the second step, a few weeks later, the tissue bridge through which the flap was initially supplied is divided, and the shape is roughly adjusted. In the third step comes the refinement: thinning, contouring, scar revision.

We discuss this path in full before the first procedure takes place — with all its stages, waiting periods and intermediate states. Knowing that the state after the first step is an intermediate one makes it considerably easier to bear. And throughout this entire time you have the mobile number of your surgeon.

Four in ten nose operations at the Kuzbari Centre are revision rhinoplasties on a nose that has already been operated on. These procedures require particular experience: the tissue is scarred, cartilage is sometimes missing, and the starting point is different for every patient. We deliberately take on such cases.

In a reconstructive context this means two things. On the one hand, there are noses in which structure is missing after an earlier procedure — a collapsed nose bridge, a retracted nasal tip, an alar rim that has been drawn inwards. Here the focus is on building up, not on reduction: the framework is restored, usually with cartilage from the ear or the rib area, because the nasal septum is often no longer available as a source.

On the other hand, the tissue behaves differently. Scars connect layers that ought to be separable from one another; exposing them takes longer and demands greater care, especially under thin skin. And scar tissue contracts — a reconstruction therefore has to be built more robustly than a first operation, because it has to withstand this pull.

Healing also takes more time. Here the final result is to be expected at twelve to eighteen months rather than at six. We say this before the operation, plan the follow-up appointments accordingly and monitor the course with photographic documentation.

A rhinoplasty with us takes one to four hours. This range is intentional: we operate in our own operating theatres and therefore without time pressure — for as long as it takes until every detail is right. How long a procedure takes is decided by the findings, not by the appointment schedule.

Reconstructive procedures regularly lie at the upper end of this range, and with extensive defects beyond it. There are three layers instead of one, there is tissue from several donor sites, and every suture determines the blood supply of the transferred tissue. Nothing here can be shortened without jeopardising the result.

That we are able to take this time is due to the fact that the operating theatres belong to us and that our team performs only nose and facial operations. Nobody is waiting for the room.

What is readily achievable: a nose that no longer stands out in the face. A restored contour, an open airway, scars that run along natural borders and fade over the years. For many patients the decisive point is not perfection, but that other people's eyes no longer linger on the nose.

There are limits too, and we name them. A reconstructed nose is not identical to the original one. Scars remain visible — they become inconspicuous, but not invisible. Transferred tissue partly retains the properties of its origin, for instance in colour and texture. Sensation in the reconstructed skin often remains permanently altered. And how much can be achieved over several steps depends on the size of the defect, on the blood supply, on any radiotherapy in your history and on smoking: nicotine considerably impairs the blood supply of transferred tissue — it is the most important point that you yourself can influence.

And the time frame. A reconstruction is a path over months, sometimes over a year. Anyone who knows this beforehand walks it differently from someone who had hoped for a single operation. That is why we set out the entire plan before the first procedure.

The Kuzbari Centre has its own state-of-the-art operating theatres — perfectly equipped for rhinoplasty, with the luxury of completely free scheduling. Our well-practised team of doctors, anaesthetists and assistants performs only nose and facial operations.

For a reconstruction this is more than comfort. A procedure that extends over several steps requires predictability: that the same surgeon, the same team and the same routines are available from the first to the last stage. And it requires time that is governed by the findings and not by a theatre schedule.

Congenital differences of the nose range from pronounced asymmetry to involvement of the nose in a cleft. What sets them apart from an accident or a tumour case: there is no earlier state to take as a reference — and there is a long shared history with one's own face.

Where the nose is involved in a cleft, one side is typically affected: the alar rim sits flatter and broader, the nasal tip deviates, the columella is tilted, and the nasal opening on this side is often narrower. Because the soft tissues, the cartilage and the bony base are all affected together, the work is done in several steps — matched to growth, to the situation at school and at work, and to what really needs to be done at each stage of life.

A final correction is usually carried out once facial growth is complete. It then generally combines several aims: the symmetry of the nasal tip, the position of the columella, the shape of the alar rim and the width of the airway on the affected side. In doing so we consistently stabilise the nasal tip in a cartilage-supported manner, because scar contraction is particularly pronounced in such noses.

And a correction is also readily possible in adulthood. Many patients come only then — because as adults they decide on it for themselves. That is a good moment.

The nose is one of the most common sites for non-melanoma skin cancer, because it is exposed to the sun throughout life. For those affected this means a double burden: the diagnosis itself and a defect in the middle of the face.

The order is unambiguous. First the tumour must be completely removed and the result of the tissue examination secured. Only then is the reconstruction carried out. This is not negotiable — a reconstruction over remaining tumour tissue would be a serious mistake. Sometimes this means leaving a defect open and dressed for a few days until the findings are available. We prepare you for this, so that this intermediate state does not come as a surprise.

Then it is planned, not improvised. The size and the position of the defect, the layers affected and the quality of the surrounding skin determine the concept. If the defect lies at the nasal tip or on the alar rim, reconstruction is often carried out in whole aesthetic units — because scars along natural borders are barely noticeable, and scars in the middle of a surface always are.

Working together. In the case of tumour disease we coordinate with the treating dermatologists and oncologists. Each of them contributes what they are responsible for — and the treatment plan is established jointly, not improvised one step after another.

And we take time for what lies behind the diagnosis. In this situation patients rarely come with a surgical question alone.

An initial consultation with three-dimensional simulation, a technique that suits your nose, and an operating time that follows the findings — this effort is the reason why rhinoplasty with us has its price. It is also the reason why the result is meant to hold: for a lifetime, not for a few years.