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Dr. Júlio Stédile, M.D.

Facial Plastic Surgery

Facial Plastic Surgery

Surgical Repair Of Nasal Septum Perforation



For over 20 years we have used the philosophy of Structured Rhinoplasty combined with CORRECTION OF SEPTAL PERFORATION. We prefer the approach by the CLOSED TECHNIQUE (Closed Rhinoplasty) because the surgery is performed without external incision and no scar on the columella. This CLOSED Approach ALLOWS FULL VIEW of the internal structures of the nose (tip, dorsum, septum, turbinates and sinuses), allowing to attach the cartilages and grafts, sutures, etc.. When full visualization is necessary we combine the technology of Video Endoscopic Surgery and Endonasal Microsurgery. Knowledge in the areas of OTOLARYNGOLOGY and FACIAL PLASTIC SURGERY, and the use of appropriate equipment enable us to perform PRIMARY Rhinoplasty, SECONDARY RHINOPLASTY and also CORRECTION OF SEPTAL PERFORATION without using an external incision. Training in OTOLARYNGOLOGY enables us to work in small and deep areas like the nose without resorting to external incision on the columella. We have honed and used the EXTENDED CLOSED TECHNIQUE in around 98% of our cases, thus avoiding external scars. The need to use the OPEN TECHNIQUE (Open Rhinoplasty) in our hands is restricted to only 2% of the operated cases.


correção da perfuração do septo nasal Greatest world authorities in this field and has the highest cure rates for this pathology throughout the world, currently 99% closure of perforations up to 3.5mm diameter in hundreds of patients operated on during a 16 year period (1989-2004). He has developed and perfected special technical-surgical details and equipment for treatment of this pathology.

Dr. Stédile has lectured to specialists in several parts of the world about the technical-surgical advances he has developed. He also runs annual courses for doctors in this field.

NASAL SEPTAL PERFORATION (a perforation of the membrane between the two nostrils) is becoming a more frequent complication due to the high number of nose injuries (arising from accidents, surgery, etc...) and also the use of cocaine, bringing patients many problems, such as frequent nose bleeding, bad-smelling nasal crusting, noise emission during breathing and nasal secretion (coryza).

Perforations larger than 1cm and located in the front part of the nasal septum tend to cause alterations to the aesthetic appearance of the nose, such as deepening of the nasal dorsum by destroying the nose support structure. IN THE GREAT MAJORITY OF CASES ASSOCIATED NASAL PLASTIC SURGERY IS NECESSARY to surgically correct perforations greater than 1 cm.

nasal_02The most frequent cause of septal perforation is previous nasal surgery (the consequence of an unsuccessful operation). We recommend that nasal septum perforation patients choose their surgeon wisely. It is fundamentally important that surgical correction is carried out in the first operation after detection of nasal septum perforation. Surgery performed by INEXPERIENCED HANDS AND INADEQUATE TECHNIQUES CAN PERMANENTLY PREVENT PERFORATION CORRECTION with further surgery. POORLY PERFORMED SURGERY can deplete natural stocks of grafts (ear cartilage and temporal fascia), can further damage the nose tissue, irreversibly harming the BLOOD FLOW in the nasal septum area, which is of vital importance for the success of the operation.

nasal_03 A pioneer in the application of an innovative method for Surgical Correction of Septal Perforation in Brazil, Dr. Júlio Stédile, who is a SPECIALIST IN DIFFICULT AND COMPLEX NASAL SURGERY CASES, has developed surgical equipment to provide greater precision in manipulation of nasal and facial tissue.

Septal perforation repair surgery is a highly complex procedure. Therefore CHOOSE YOUR SURGEON CAREFULLY. It is essential for the surgeon to have profound knowledge of otolaryngology and facial plastic surgery, as treatment of this pathology is highly complex.

nasal_04Using this new method, Dr. Stédile has achieved a 99% success rate of perforation closure compared with other described methods, which vary from 25-50% of usual techniques, with many of the methods described in medical literature not providing closure figures. This new technique of septal perforation closure has been applied by Dr. Júlio Stédile in Porto Alegre, Rio Grande do Sul, Brazil for about 16 years.

In addition to high rates of cure, this new technique can, and often MUST BE ASSOCIATED WITH CORRECTION OF THE AESTHETIC APPEARANCE OF THE NOSE DURING THE SAME SURGICAL PROCEDURE. Nasal Obstruction Correction Surgery and Endoscopic Sinus and Snoring Microsurgery can also be carried out at the same time. All those procedures are performed through internal incisions only.

The essence of the technique is based on the displacement of the submucoperichondrial, the submucoperiosteal from the entire nasal region (roof, floor) allowing extension of the displacement to the nasal cavity side walls. Care in handling of tissue is extremely important, as besides avoiding lesions it preserves the vascularisation of the nasal septum tissue.


Dr. Júlio Stédile has great experience in Otorhinolaryngological and Facial Plastic Surgery, being one of the global authorities in this area.

CHOOSE YOUR SURGEON WISELY. There is a significant difference between the quality of medical work, in much the same way as there is in other professions (lawyers, teachers, carpenters, baby-sitters, etc.).


• THE UNIVERSITY OF MIAMI SCHOOL OF MEDICINE, USA, conferred an award to Dr. Júlio Stédile Ribeiro and his team for Technical Innovations demonstrated in Septal Perforation Repair, in September 1997.

FAQ about Surgical Repair Of Nasal Septum Perforation

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1. How important is the selection of the surgeon to perform rhinoplasty or secondary rhinoplasty?

SELECTING THE SURGEON IS THE FIRST AND MOST IMPORTANT STEP. Often, information about surgeons are available on the Internet, where it is possible to see their curriculum and specializations. Obviously, any information obtained from the Internet should be checked out in loco. So, the patient should make an appointment with the physician in order to have his specific case evaluated, as lack of professional qualification may lead to disappointment at the results. In choosing the surgeon, the patient must be well aware that good nasal function is crucial for health and that for a surgery to be successful, it always must improve or preserve good nasal breathing and facial aesthetics. We breathe 24,000 times a day in average and ideally, ventilation through the nose should be normal.

The surgeon should have DEEP KNOWLEDGE IN RHINOLOGY, which is a subspecialty of OTOLARYNGOLOGY), because it is of huge importance for our physical and mental health to have good breathing through the nose, and he/she should be an EXPERT on FACIAL PLASTIC SURGERY, as the nose is at the center and is the most projected organ of the face.

2. What technical formation should a surgeon have to perform rhinoplasty or secondary rhinoplasty?

In RHINOPLASTY, and mainly in SECONDARY/REVISION RHINOPLASTY, it is extremely important for the professional to have deep knowledge in both the esthetic and the functional aspect of the nose. So, the professional should combine ESTHETIC KNOWLEDGE with great knowledge in OTOLARYNGOLOGY, as it is not enough to get an outcome that is purely esthetic in nature. It is crucial that the patient's nose function properly, fulfilling its role in the human cardiorespiratory system.

3. Is it possible to ensure a good result in rhinoplasty?

Surely, selecting a surgeon who is an EXPERT on Rhinoplasty, who has DEEP KNOWLEDGE IN BOTH OTOLARYNGOLOGY AND FACIAL PLASTIC SURGERY greatly increases the chances of good results.

Different surveys indicate that of every 100 Rhinoplasties PERFORMED, 20-40% need to be redone in new surgeries. It is worth mentioning that rhinoplasty is the third most performed cosmetic surgery in Brazil, but it is the leading one when it concerns the need for surgical re-intervention (Secondary Rhinoplasty). However, in the hands of high performance professionals, EXPERTS on Rhinoplasty, the consensus is that the need for reintervention does not exceed 5% of the total number of Rhinoplasties performed.

4. Is there a minimum age to undergo rhinoplasty?

An evaluation should be performed by the surgeon on an individual basis. Most often, however, Rhinoplasty can be performed on people from 15 (women) and 16 or 17 (men) years of age, when physical and cartilage and bone development are already complete.

5. What is the surgeon's commitment with the good outcome of rhinoplasty?

The patient's wishes should be considered. However, the surgeon should perform studies and simulations, together with the patient, to define the best alternative. It is important for the esthetic outcome to have spatial proportion. In practice, overall harmony must prevail, avoiding a certain trend to adopt "nose models" of famous people or actors, as it often happened in the recent past. This way, each patient has its own needs customized.

The surgeon's commitment will be to use the most appropriate techniques for each case. This includes the need for DEEP KNOWLEDGE in OTOLARYNGOLOGY and FACIAL PLASTIC SURGERY.

6. Does rhinoplasty have psychosocial effects?

We remind that RHINOPLASTY must always seek a positive outcome in both esthetics and function. In cases where Rhinoplasty is merely esthetic, the psychological effects are evident, specially among young people. A hooked or disproportional nose may generate some sort of complex. This way, restoration of self-esteem is an immediate side effect.

Similarly, Rhinoplasty will provide the patient with a "normal" facial aspect once corrected a deformity of the nose, which altered facial harmony.

Of course, correction of the nasal function generates effects in breathing and thus in the individual's quality of life and body performance. We may even speak of social insertion, as the individual whose nasal function is restored will feel physically fit.

7. What is expected from nose functionality and nasal aesthetics in a rhinoplasty?

Anyone undergoing Rhinoplasty should have full interaction with the surgeon. Such interaction is critical in the subsequent analysis of the results. The main effect is, of course, recovery of the nose function, allowing the correction or restoration of perfect breathing. Nasal breathing has fundamental importance for the harmonious development of the middle and lower third of the face, chest and entire body. In the second phase, and concurrently, anatomic correction of the nose is sought in order to establish an aesthetic standard suitable for the face as a whole, according to studies already conducted by the surgeon. Importantly, the results depend on variables that are not always fully under control. Among these variables is the postoperative care guidelines as defined by the surgeon and which must be strictly followed by the patient. This area includes drugs prescribed by the surgeon to the patient as well as physical care recommendations to be observed, particularly regarding healing. The patient should follow the guidelines strictly, avoiding alcohol, smoking, sun exposure and physical activity, among others.

8. Surgery in patients with psychological disturbances.

Sometimes the patient, besides presenting some sort of aesthetic or functional nasal problem that he wants corrected, can have some sort of psychological disturbance. Psychological disorders can pose a problem in the postoperative period. In some cases, even if the result is good the patient may feel unsatisfied with the aesthetic outcome, for he/she has acceptance issues with his own body, transferring to the surgeon some perceived "flaw" in the outcome. These patients should be treated with utmost care before surgery, when the surgeon should establish, in conjunction with the patient and even with the family, the postoperative procedures. Also, an assessment by a psychologist or psychiatrist, before surgery cannot be ruled out.

9. Do health insurance plans cover a Rhinoplasty?

Health insurance plans cover ​​Rhinoplasty costs when the case is purely functional. When the case is Aesthetic Rhinoplasty, health plans do not cover the costs. Very often there may be problems of functionality of the nose that must be corrected concomitantly with cosmetic correction.

10. What kind of tests are required before Rhinoplasty?

Preoperative tests are defined by the surgeon in light of the evaluation done in the office. Normally the battery of tests is composed of chest X-rays and CT of the sinuses, together with blood and cardiac tests. Depending on personal or family history, and also the physical condition of the patient, additional tests may be required, at the discretion of the surgeon.

11. What is the pre- and postoperative medication prescribed?

Before surgery, the patient should not take anticoagulant medications, like aspirin, Ginkgo biloba and anti-inflammatory drugs, to prevent postoperative bleeding. Any medication that the patient is using must be reported to the doctor well before surgery. Postoperatively, medications that provide adequate support to the patient are usually prescribed. In practice, the requirements of the surgeon should be strictly followed.

12. When to perform a Secondary Rhinoplasty?

Secondary, or Revision, Rhinoplasty is the surgery performed in patients who have already undergone one or more plastic surgeries of the nose and did not obtain satisfactory aesthetic and functional results. In these cases the nasal anatomy is altered requiring high Technical, Artistic and Scientific knowledge by the surgeon, which makes these highly complex cases. IN THESE CASES, THE SURGEON'S LARGE EXPERIENCE IN SURGICAL REVISIONS IS OF GREAT IMPORTANCE, with knowledge in OTOLARYNGOLOGY and FACIAL PLASTIC SURGERY being crucial. These are procedures that can require up to 5 hours of surgery, in which all of the functional and aesthetic aspects of the nose should be treated, the time needed for thorough tissue restructuring.

13. What is the best technique for Rhinoplasty?

The surgeon can perform rhinoplasty, whether primary or secondary, by selecting the option that best suits the case. Typically, options relate to the technique that must be used, which may be reductive or structured in nature. The two techniques, however, can be combined. FOR TWENTY YEARS WE HAVE USED THE PHILOSOPHY OF STRUCTURED TECHNIQUE WITH PREFERENCE FOR CLOSED APPROACH IN 98% OF OPERATED CASES, THUS AVOIDING A SCAR ON THE COLUMELLA. THE EXTENDED CLOSED TECHNIQUE THAT WE DEVELOPED AND IMPROVED OVER THE LAST 20 YEARS ALLOWS THE VISUALIZATION OF ALL NASAL STRUCTURES, GRAFT PLACEMENT , SUTURES. ETC.

We always recommend to perform the functional and aesthetic surgery at the same surgical act, when microsurgery for sinusitis, correction of nasal septum perforation, snoring surgery, sleep apnea, and tonsil surgery may be addressed as well. This will also require that the surgeon have knowledge in OTOLARYNGOLOGY and the patient is clinically fit to be submitted to these procedures.

However, over the years, time can change the aesthetic and even the functional outcome even when rhinoplasty was successful. Nasal breathing acts as an offending force, interacting with the new structures built by the surgeon. As a result, the nose may lose its support, causing some kind of deformity. Skin aging, gravity, smoking and some minor accidents can, in the medium and long term, compromise the result obtained in aesthetic and functional surgery. Thus, an accurate analysis of the problem presented by the patient in each case will determine the most appropriate technique and type of intervention so as to have a quality functional and aesthetic result, and one which extends in time.

14. When to re-operate?

SECONDARY RHINOPLASTY can be performed when the patient, the physician, or both, are dissatisfied, or because of functional problems referred to by the patient after surgery.

15. How long after the first surgery the patient should wait to perform a secondary rhinoplasty?

In general it is necessary to wait one year to re-operate the nose, because before one year there is much fibrosis and swelling, which are phenomena that hamper the surgical technique and withdraw, or do not offer valuable parameters for the doctor to "fix "the nose. Of course, in cases where there are serious functional problems or severe cosmetic deformities, it is interesting to operate the patient before one year so as not to induce the patient to psychological problems due to a possible cosmetic deformity or functional problems. In this situation, repair surgery can be performed before one year.

16. Why is Secondary Rhinoplasty considered complex?

Secondary rhinoplasty is much more difficult than primary rhinoplasty for several reasons: First, the patient who presents for a Secondary Rhinoplasty is emotionally shaken; a traumatized patient, who looks at the surgeon with some suspicion, wondering: will this professional fix my nose, will he get to operate my nose? Second, the physical aspect; that is, the tissues that the surgeon has on hand to work. Note that an operated nose has a distorted anatomy. Often it lacks or has only remnants of cartilage, and much fibrosis, facts that hinder dissection. Moreover, as they do not have native cartilage and what remains is inadequate or damaged, it is often necessary to remove cartilage from other parts of the body to perform the repair. These are factors that complicate the performance of surgery and increase the level of aggression to the patient. It is also important to remember that the surgeon will perform a Secondary Rhinoplasty without knowing exactly what was done by the surgeon before. Using soccer jargon, "it is a box of surprises." Thus, SECONDARY RHINOPLASTY should be performed by EXPERTS ON SURGICAL REVISIONS, with special attention, care and without haste, so as to make the surgery right and proper, in an effort to make it the last surgery to be made in the patient's nose. Deep knowledge in OTOLARYNGOLOGY and FACIAL PLASTIC SURGERY are indispensable for performing SECONDARY RHINOPLASTY. This is one of the areas that REQUIRE THE MOST EXPERIENCE, KNOWLEDGE AND DEDICATION BY THE SURGEON.

17. What is the chance of succeeding in Rhinoplasty?

The chance of success in Primary or Secondary Rhinoplasty depends on several factors. It depends on the physician's KNOWLEDGE, EXPERIENCE and ABILITY; it depends on the technique being performed and also on how the patient's tissues will respond to the surgical approach. It is obvious as well that success will depend on aspects that are in the patient's subjective sphere, because the patient has to be satisfied with the functional and aesthetic outcome. Although it is not possible to establish a success rate for this type of surgery, one can say that success rates are highly favorable when the patient selects A GOOD PHYSICIAN, AN EXPERT on Rhinoplasty, with knowledge in FACIAL PLASTIC SURGERY as well as on OTOLARYNGOLOGY – for the nasal function and aesthetics should always be addressed together – , and who uses the correct technique, explaining to the patient all the factors inherent to the surgery before performing it.

18. What are the main factors limiting a Secondary Rhinoplasty?

The main limiting factor of a SECONDARY rhinoplasty is the state of the skin and the cutaneous and mucous lining of the nose. Nasal lining is the skin and mucosa that is inside the nose overlying cartilage. If the nasal lining and external skin of the nose are compromised and without elasticity, the result of surgery may be compromised in the sense that it is impossible to get a good definition, and often there is a high risk of necrosis as this skin is lifted and dissected.

19. What are the main sources of graft?

The main sites for graft removal are the NASAL SEPTUM, which obviously is inside the nose, and this is the cartilage of first choice because it is naturally straight and very easy to find, having a consistency that is very similar to the cartilage of the nose. The EARS can be sources of both cartilage and composite grafts of skin and cartilage. But if the need for cartilage is very large, only the RIB CARTILAGE offers tissue enough to rebuild the nose in a reliable way. It is worth remembering that EAR CARTILAGE is naturally curve and requires much skill of the surgeon to shape it, being an excellent source of graft if the places of its removal are well planned according to the needs for correcting the nose. The RIB CARTILAGE is abundant. A major disadvantage of rib cartilage, however, is its tendency to "warp" after surgery. Thus, it is essential that the surgeon have proper training to handle and carve rib cartilage. With skilled hands, the risk is minimized, in which case the use of rib cartilage is quite reliable.

20. Must patients who underwent one or more rhinoplasties and want to perform another surgery using the structured technique have grafts taken from the rib cartilage?

The physician should attempt in all ways to reconstruct the patient's nose causing minimal discomfort, that is, using septum or ear cartilage. Often, however, there is not enough cartilage in the septum or ears, and only the rib cartilage provides the necessary amount for a correct and long lasting reconstruction. Remember that, currently, the mobility and level of aggression in these withdrawals of rib cartilage are performed through a small incision of 2.5 cm, located at 0.5 cm from the inframammary fold. If sutured carefully, this incision results in a small, usually unnoticeable scar.

21. Is it possible to use the ear cartilage graft to restructure the nose? What about rib cartilage?

Handling and use of EAR CARTILAGE requires skill of the surgeon as these cartilages are curved, but we can carve these cartilages to reconstruct the nose in cases of SECONDARY RHINOPLASTY without the need to resort to the RIB. The use of RIB cartilage is reserved for those cases in which there is a high need for structuring the nose, which are a minority of the patients who undergo Secondary Rhinoplasty. In the U.S. and even in BRAZIL, it is a bit trendy now to resort too often to the use of rib cartilage, which IN OUR VIEW IS UNNECESSARY IN A LARGE NUMBER OF CASES, because the appropriate, well planned, and thorough management of septal and ear cartilage (if any) is extremely useful in Secondary Rhinoplasty.

22. Is there any safe synthetic material that can be used instead of removed cartilage?

In terms of materials, it is very important to say that there is a global consensus that autogenous materials, i.e. from one's own body, are recommended for rhinoplasty. Foreign materials such as silicone, Porex, etc. are substances that should not to be used in the nose, because there is a greater risk of infection and expulsion, i.e. extrusion of the nose. Therefore, the utilization of material from the patient's own body, i.e. cartilage, is a worldwide consensus.

23. It is possible to ensure a successful outcome in Rhinoplasty?

Any type of promise in relation to a result is considered by the Conselho de Medicina (Medical Board) as unethical. What can be done is to explain to the patient that the best possible technique will be used, and the surgeon will only leave the operating room when it is not possible to improve the nose any further than what was obtained at surgery. Importantly, no physician is able to control the patient's body reactions after surgery. Thus, we cannot guarantee the outcome of surgical procedures in aesthetic character.

Surely choosing a surgeon who is an EXPERT on Rhinoplasty, who has DEEP KNOWLEDGE IN BOTH OTOLARYNGOLOGY AND FACIAL PLASTIC SURGERY, increases the chances of good results.

24. What are the most frequent difficulties encountered by the surgeon in Rhinoplasty?

Lack of control over HEALING is a huge difficulty, but fortunately cases with poor healing are rare. Furthermore, there is another major difficulty associated with the ANXIETY shown by patients over the end result. In the immediate postoperative, there is a swelling in the nose that will last about a year, after which the end result will be achieved. Often, so, it is difficult to manage the patient under the psychological point of view, so that he be patient and calm and wait the time required for the end of the swelling and the emergence of the result.

25. It is possible to combine other procedures with rhinoplasty?

Often the same surgical moment is used to perform associated procedures, which may include eyelids, Endoscopic Frontoplasty, among others, and even varied implants. These are combinations that must be determined together with the surgeon so that a feasibility study of the procedure is performed. Often patients have problems with nasal obstruction by SEPTAL DEVIATION - TURBINATE HYPERTROPHY, SINUSITIS, SNORING and SLEEP APNEA, procedures which can and should be done together to fix problems that are in the same area in a single surgical act. Surely some of these treatments require knowledge in the specialty of OTOLARYNGOLOGY.

26 What should be done to increase the chances of success in both primary and secondary rhinoplasty?

The chance of success in Primary or Secondary Rhinoplasty DEPENDS BASICALLY ON THE CHOICE OF THE SURGEON. The patient must choose a SPECIALIST, or even AN EXPERT WITH DEEP KNOWLEDGE IN OTOLARYNGOLOGY AND FACIAL PLASTIC SURGERY, seeking to obtain a perfect doctor-patient relationship in the medical visit concerning expectations and possible limitations of the procedure , i.e., what kind of results can be obtained in the particular case. We have the philosophy of STRUCTURING the nose using the CLOSED TECHNIQUE in 98% of Rhinoplasties, thus avoiding an external scar on the columella, which in some cases may have poor healing and leave a very visible scar. We use the OPEN TECHNIQUE in only 2% of our operated cases.

The CLOSED TECHNIQUE approach allows us to have FULL VIEW OF THE NOSE STRUCTURES, since we developed technical advances of the EXTENDED CLOSED TECHNIQUE which, with the aid of the equipment used in OTOLARYNGOLOGY, allow us to work easily in small and deep areas of the nose. Therefore, the commonly held notion that only through the OPEN TECHNIQUE it would be possible to have full view, place grafts, suture and restructure the nose IS NOT THE ONLY TRUTH, since IT IS POSSIBLE TO PERFORM both PRIMARY and SECONDARY RHINOPLASTY using the EXTENDED CLOSED TECHNIQUE with TOTAL VIEW OF STRUCTURES, as long as the surgeon has appropriate knowledge and training to work in cavities, and use the appropriate equipment for this approach. With the EXTENDED CLOSED TECHNIQUE, the risk of scar on the columella is totally eliminated.

27. Medical authorities through their societies recommend caution in the use of computer programs to simulate Rhinoplasty. What is your opinion about these programs?

These programs should be used in a very ethical way, and the patient should always be informed that the program is nothing more than one more way to communicate with the patient through the changes of the projected image on the computer screen and an idea of ​​how the surgery may be performed. Criticism is in the sense of misusing such programs to promise results. I believe it is very important to use these programs, since the projection of an imaging study helps patients to better express what they intend or want and helps physicians to determine what methods and techniques to use in each case, in accordance with the patient's wishes.

28. What is the best anesthesia for Rhinoplasty? What is the duration?

General anesthesia is safer for the patient. It protects the airways through the tube, and thus any bleeding which may move towards the airways is blocked, protecting the lung against breathing blood. In addition, this is the form of anesthesia that provides more control so that the patient will not move during surgery. As the patient will be unconscious, it will not be a traumatic experience for him/her. There are patients undergoing local anesthesia and sedation who wake up during surgery and have memories of the time of surgery. Furthermore, the drugs that are used for general anesthesia have an immediate metabolism by the liver. Thus, when the apparatus is turned off, the liver removes the medicines. In general anesthesia, patients wake up after a few minutes as if nothing had happened, and can even be discharged the same day. As we can see, the advantages of general anesthesia are much more significant. As for duration, the length of anesthesia will depend on the type of correction to be performed, but in a primary rhinoplasty average time is 01-03 hours, while in a secondary rhinoplasty, anesthesia time can vary between 02-06 hours depending on the complexity of the procedure.

29. When surgery does not work, why is it so difficult to fix?

First, because of the psychological state in which the patient seeks help. When the surgeon receives a patient who is traumatized because he put a lot of expectations in the first surgery, the surgeon's responsibility in relation to the case is greatly increased. On the other hand, it is technically much more difficult to perform corrective surgery because the surgeon will be working on an anatomy that is distorted and has been changed. It is a deconstruction of what was done previously, seeking the due aesthetic and functional corrections that are necessary.

30. Structured Rhinoplasty uses a number of grafts to strengthen the structure of the nose. May there be any complications with grafts?

Grafts may suffer infections, some degree of resorption, and loss of their structural strength. These complications, however, are extremely rare and the advantages of using these grafts granted to the surgeon through the structured philosophy are much more significant than the possible problems that could occur. Thus, it is better to run a philosophy of structured technique despite a small rate of complications than performing a philosophy of reductive rhinoplasty only without the use of structural grafts.

31. Is the philosophy of Structured Rhinoplasty recent in Brazil?

No, this philosophy is already being applied and spread in Brazil for over 20 years by DR. JULIO STEDILE. This way of working in Rhinoplasty began in the U.S. around 1990, and it was disseminated in South America by groups of otolaryngologists dedicated to Facial Plastic Surgery.

Dr. STEDILE has been using the EXTENDED CLOSED TECHNIQUE avoiding the external scar on the columella, which is necessary to perform the OPEN TECHNIQUE. It is important to highlight that it is possible to view and reconstruct all nasal structures by the EXTENDED CLOSED TECHNIQUE, but it will be necessary to HAVE THE SUITABLE KNOWLEDGE AND EQUIPMENT TO CARRY IT OUT THIS WAY. Knowledge in the specialty of OTOLARYNGOLOGY enables the surgeon to work in small and deep areas and the use of appropriate equipment enables him to have FULL VIEW OF NASAL STRUCTURES. Currently, we choose the OPEN TECHNIQUE approach only in 2% OF THE CASES.

32. In structured Rhinoplasty, why is the nose relatively hardened after surgery? And over time?

This is basically for two reasons. First, the philosophy involves a structural strengthening of the nose with supporting grafts, to prevent any distortion in the scar tissue post-operatively. So this structural strengthening by itself causes a certain hardening. In addition, there is a post-operative swelling that is due to these two factors. This hardening usually improves after some time with resorption of swelling and a slight loss of the structural strength of these grafts. In the first six months the nose is a bit hardened and gradually it gets a consistency very similar to that of an intact nose. This process can take up to three years depending on the degree of structuring that was necessary for surgical correction of the nose.

33. Why most repairs can only be performed one year after the last surgery? In selected cases, can adjustments be made before this period?

The problem of making a new intervention before one year is that there is much swelling between cartilage and skin. This influences the surgeon's parameter of assessment, because it is necessary to quantify an increase or decrease of the nose. Another issue concerns the scar tissue that forms between the cartilages and the skin in this surgery before one year.

34. What is the best technique for Rhinoplasty?

Consistency is immature, and this makes any kind of re-operation more complex and difficult as it is necessary to reopen the nose and dissect everything again. Therefore, it is preferable to wait until all this scar tissue is more mature and there is less swelling, so that we can perform this operation more accurately. In selected cases, however, it is possible to make these retouches before one year. A classic example are those noses that are obviously crooked or have an obvious deformity and are generating a major psychological or functional discomfort in the patient. In these selected cases it is possible, and even advisable, to intervene before, but as a general rule and considering a more precise approach, you must wait one year for repair surgery.

35. Is it possible to have the nose retouched without returning to the operating room?

Yes. There are cases of irregularities in the back where you can make small scrapings under local anesthesia using a needle. In these cases it is possible to perform the procedure on an outpatient basis or at a surgery center.

36. Is there something that can be done to accelerate resorption of swelling after surgery?

Generally not. Usually, compressive dressings, and sometimes, lymphatic drainage are performed to help reduce swelling. But in practice, the most important factor is a lot of patience when there are defined points or that are being caused by a proliferation of scar tissue or even excessive localized swelling. You can reduce this phenomenon using localized injections of cortisone, but these injections should always be conducted as a last resort, and by a highly specialized professional.

37. After surgery, why is it so important to return to the doctor frequently?

The healing process is gradual, usually taking up to 24 months depending on the procedure performed. Consequently, there is a need for periodic revisions during the gradual healing process, when there are TRANSFORMATIONS, RE-ADAPTATIONS AND RESTRUCTURING in tissues. No surgeon has full control over the effects of scar tissue, and therefore it is absolutely essential that the patient return to the doctor frequently so that he/she can assess how that nose is behaving in terms of healing. During the postoperative period, which may last for weeks or months, it is possible to guide and direct the healing tissues, acting in the foci of swelling or fibrosis. Thus, it is absolutely essential that the PATIENT HELP HIMSELF AND THE DOCTOR after surgery, always returning at the scheduled dates.

38 What are the technical innovations for the future of Rhinoplasty?

The association of knowledge in OTOLARYNGOLOGY, FACIAL PLASTIC SURGERY AND MAXILLOFACIAL SURGERY has allowed major advances in surgical techniques, even allowing to treat patients with nasal septum perforation along with FUNCTIONAL AND AESTHETIC RHINOPLASTY, SECONDARY RHINOPLASTY, ENDOSCOPIC SURGERY FOR SINUSITIS, SNORING AND SLEEP APNEA.

In the future, Rhinoplasty will not require major technical innovations as it will DEPEND MORE ON SURGEONS' BROADENING THEIR AREAS OF KNOWLEDGE IN OTOLARYNGOLOGY, ORAL AND MAXILLOFACIAL SURGERY, and FACIAL PLASTIC SURGERY, so as to master the many existing techniques, because in terms of new surgical techniques little can be improved. The difficulty in mastering these techniques is that it requires the surgeon to TRAIN IN VARIOUS SPECIALTIES and this takes many years of improvement and total devotion. Innovation will be around the development of new cartilage-like synthetic substances with very low infection rates that can be used to manufacture the grafts that are used in the STRUCTURED TECHNIQUE without having to seek distant body sites, such as a rib or ear. This will decrease the general aggressiveness of the procedure, and it is believed that this is one way, as today we have stem cells, cartilage banks, etc..

39. When to use the open or closed technique?

These two philosophies of approach will be determined by the surgeon, depending on the features of each case. Some surgeons prefer the open approach, although it is more invasive than the closed technique and can leave scars. We prefer the CLOSED APPROACH because the surgery is performed without external incision and no scar on the columella. This CLOSED approach allows full view of nose structures. Knowledge in the field of OTOLARYNGOLOGY AND FACIAL PLASTIC SURGERY, and the use of appropriate equipment enable us to perform both PRIMARY AND SECONDARY Rhinoplasty without using external incisions. We use the EXTENDED CLOSED TECHNIQUE in around 98% of our cases avoiding the scar on the columella. In our hands, the need to use the OPEN TECHNIQUE is restricted to only 2% of the operated cases.

40. What is the recovery time?

The more intense care will be in post-operative period, i.e. the first 10 days.

The healing process is gradual. It usually takes 24 months to be complete, depending on the surgical procedure performed. It is evident that healing also depends on factors inherent in the physiology and anatomy of each person and, of course, on the post-operative care recommended by the surgeon as well as correct use of medication. Monitoring by the surgeon in the office will help in the continual progress. There is a need for periodic assessments during the progressive healing process in which there are transformations, re-adaptations and restructuring of tissues.


Dr. Júlio Stédile M.D.
Av. Dr. Nilo Peçanha, 2825/1403 ZIP CODE 91330-001
Bairro Três Figueiras - Porto Alegre/Rio Grande do Sul - Brasil
Phone: +55 (51) 2111-1017 / +55 (51) 2111-1018


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