Questions to Dr. Bessler

Reply from Dr. Bessler

Dear Mr. Zahrwitter *

thank you very much for your good question. I am happy to explain the procedure for rib harvesting and why ear cartilage is not ideal for the revision of your nose.

For rib harvesting, I will make a 2 to 3 cm long incision below the right breast (see image). I will cut through the subcutaneous tissue and separate the muscle layer in the direction of the fibers without injuring the muscle. I will take a piece of muscle fascia to thicken the skin of your nasal bridge. I will remove a piece of rib cartilage approximately 3 cm long and 1 cm wide (see image).

Skin Incision for Rib Removal

Anatomy of Lung and Ribs with Removal Site
(Chest with ribs: the lungs are shown on the right-hand side of the image, and part of the musculature on the left-hand side.)

In the video „Nose Revision“ on Instagram, a patient shares her experiences during the first days after a nose operation with rib harvesting.

It is worth mentioning that there is a minimal risk of lung shrinkage after rib cartilage harvesting, which could require hospital admission. However, in my 30 years of practice, I have never experienced such a complication, and no cases are known in my professional circle.

Rib cartilage is very stable and can be cut very thin. In your case, stable and fine cartilage is necessary for the nasal reconstruction. Ear cartilage is not suitable for reconstructing your nose because it is too thick and soft and does not provide the required stability. Ear cartilage is rather used for reconstructing elastic nasal parts or filling in depressions.

I hope I was able to answer your questions clearly and send you my best regards,

Stephan Bessler

Answer from Dr. Bessler

Dear Mrs. Caspar *

Thank you very much for your fascinating question, which specialists frequently discuss.

A closed septorhinoplasty, also called the closed technique, is a nose operation without a columella incision. Open septorhinoplasty, also called open technique, refers to rhinoplasty with a columella incision, respectively.

Whether or not a rhinoplastic surgeon makes a columella incision is not a matter of technique (although it is said to be); it is simply a different surgical approach to the cartilaginous-bony nasal framework. When the rhinoplastic surgeon performs a columella incision, they can pull the nasal skin upward and have a good view of the cartilaginous-bony nasal framework.

If the nose surgeon makes the incisions inside the nose, i.e., does not make external incisions, the view is much more limited, and the surgical actions more demanding. There are only a few surgical techniques which can be performed exclusively with the open approach. Most of the surgical changes of the nose can be done with both approaches.

It is the case that closed septorhinoplasty is significantly more demanding for the surgeon. Often, less experienced nose surgeons operate with a columellar incision and experienced surgeons operate without a columellar incision. In addition, the surgeon's posture is much more bent in the closed approach than in the open approach with a columella incision. That is why surgeons with orthopedic back problems operate more often with a columella incision.

I operate almost exclusively with incisions inside the nose and therefore do not perform a columellar incision, even for nasal augmentations or revisions. This is because closed septorhinoplasty is advantageous for the patient in two ways: on one hand, no scar remains on the columella, and on the other hand, it shortens the swelling time after the nose surgery considerably.

I hope I have been able to answer your question and send you my best regards.

Stephan Bessler

Answer from Dr. Bessler

Dear Mr. Giesser *

Thank you for your interesting question, which I want to answer below.

Kind regards, Stephan Bessler

In which cases do you, as an experienced nose surgeon, advise against nose surgery?

Loan for Aesthetic Nose Surgery
If you must take out a loan for aesthetic nose surgery, you should refrain from having the nose surgery. It is better to save up for it than to pay off the nose surgery afterwards. You also must know that you might need follow-up surgery in the worst-case scenario.

Ambivalence towards Nose Surgery
If you are uncertain about having aesthetic nose surgery, you should wait for the nose correction. If you are sure to have your nose shape changed, I will offer you nose surgery. If a close person recommends or even imposes the nose surgery on you, a fortiori, you should not have the nose surgery.

Cocaine
If you take cocaine, nose surgery should not be performed because the supporting cartilage of the nose is weakened.

Mental Problems
You should discuss a planned rhinoplasty with a psychologically experienced professional if you have psychological problems. If in doubt, I recommend not having a nose job.

Ethnic Change
You should not have an aesthetic rhinoplasty if the planned aesthetic rhinoplasty could cause you to lose your ethnicity externally. Do not underestimate the reaction of your relatives.

Answer from Dr. Bessler

Dear Mrs Späth*,

I’m very sorry that you had to go through this bad experience with your nasal surgery in Germany. You are asking me about the earliest date of the operation.

Although you often read on the Internet that it’s necessary to wait a year between operations, I perform revision surgery sooner than that, providing there has been no infection or inflammation in the nose or a persisting swelling.

Revision surgery to restore your nose to something close to its original state is complex and challenging. I perform the incisions inside the nose.  The nasal cartilages will be separated and put back together in a new position with the external and internal nasal skin. The operation will be carried out under general anesthesia and lasts approximately four hours. If there is insufficient healthy cartilage in your nose, we must remove rib cartilage. The operation is laborious and complex, but the risks are justifiable.

I am convinced that we will achieve a pleasing result, although I will not be able to restore your nose to its original shape fully.

If you are physically healthy, you will probably be able to have the surgery as an outpatient, i.e., you will come in in the morning and return to your hotel in the evening. You would need to be picked up by a car, and a friend or relative should stay within calling distance for the first 24 hours after surgery. During the two days after the operation, you will have nasal tamponade (i.e., bandages inside the nose cavity) with a small tube inside to breathe through the nose. I remove the stitches and the dressing one week after the operation. It takes about two weeks to recover, so you need to take a holiday for that period.

In any case, I need to examine your nose personally. I recommend that you make an appointment on +41 44 201 76 22. We carry out a computer simulation of a possible surgical target. I will explain the rhinoplasty and its risks in detail. I am sure to be able to help you further on.

Sincerely, Dr. Stephan Bessler

Answer from Dr. Bessler

Dear Manuela (*),
Thank you very much for your inquiry. I am convinced we can improve the dimple on your nose tip caused by the post treatment scar.

There are basically two procedures to lift the depression due to the scar on your nose tip:

• Elevation of the depression with the placement of a small piece of cartilage taken from your ear. The harvest of the cartilage graft is possible without influencing or changing the shape of your ear.
• Injection with your own body fat.

Depending on the nature of your scar it might be possible that a combination of both procedures is needed. In this case this would be done in two procedures 6 months apart. Either surgery will be performed as an outpatient procedure using local anesthesia. It is important to keep in mind that German insurance companies will not cover your medical costs for the discussed procedures here in Switzerland, meaning, that you will have to pay for it “out of pocket”. Depending on the choice of the procedure(s) the costs will run between 1,500.- and 3,000.- CHF. Would you consider having the surgery(ies) done in my office I would suggest to schedule an initial consultation with myself and my staff. An initial consultation would cost 300.- CHF. If you choose to have the surgery done in my office the costs for the initial consultation will be deducted from the total costs mentioned above.

Please let me know if you have further questions.

With kind regards, SB

Answer from Dr. Bessler

Dear Alexandra (*),
Thank you very much for your inquiry. I read your email and carefully studied the enclosed facial photos:

Your nose
You feel uncomfortable with the shape of your nose. You dislike your nasal asymmetry and want to have your bump reshaped, straightened the nose and nasal tip by filler injections.

Assessment
Your photographs show that the nasal dorsal line differs in the oblique view from right to the left. Furthermore, there is a slight nasal hump noticeable.

Filler Treatment of the nasal shape
We offer two types of filler treatments for your nose; a) with hyaluronic acid and b) with your own body’s micro fat. A filler treatment with hyaluronic acid lasts for 6 to 8 months, while the treatment with micro fat stays long term (years).

Risks
I would like to point out that filler treatment of the nose area has not been officially approved and therefore is an ‘off-label-use’ for this type of treatment. In very rare cases necrosis of the nose or nose tissue has occurred. In rare cases the incidence of blindness as a consequence of nasal filler treatment has been described in world literature . We have adopted a very careful injection procedure to minimizes this risk.

Costs
In my practice the total cost for a nasal reshaping with hyaluronic acid is 1800.- Swiss Francs (CHF). It is an outpatient procedure and includes preliminary examinations, follow-up, and reinjection within 2 months if needed. We appreciate receiving payment before the intervention. The total cost for a treatment of the nasal shape with micro fat (fat transfer from your own body) costs CHF 4500.-. The fat will be taken from your lower abdomen. For this a small incision (less than 5mm) is made in your belly button.

Insurance
You should have an insurance that covers you for all cases of emergencies also in Switzerland.

Consultation
If you consider a filler treatment, we will be happy to arrange an initial consultation before treatment. A video conference is also possible. Each consultation will cost CHF 300.-. The costs for the consultation are charged against the cost of your treatment if you decide to go ahead with it.

I would be happy to advise you. Thank you for contacting us.

Sincerely
Stephan Bessler