Facial plastic and reconstructive surgery is a special form of reconstructive surgery. Patients who have defects and disfiguring scars as a result of accidents, congenital malformations or after the removal of malignant neoplasms (tumours), as well as associated functional disorders, are competently advised and treated here. Restoring the aesthetics and function of the face is crucial.

Very satisfactory results can usually be achieved through customised surgical procedures. As our face is unique and cannot be hidden, this form of surgery is based on great trust in the doctors treating us.

Our many years of experience are reflected in innovative treatment concepts and supra-regional patient referrals.

Obstructed nasal breathing is one of the most common reasons for consulting an ENT specialist, as it often affects the quality of life.

Surgery is a sensible option if the patient's symptoms can be explained by a change in the shape of the inner and/or outer nose. As there is a wide variety of nasal malformations (tension nose, crooked nose, saddle nose, split nose, etc.), it is crucial that the anatomical structures responsible for the impaired nasal breathing are recognised as part of a structured examination. Specific diagnostic examinations to objectify the nasal air passage in our Diagnostics Department (à Link) can additionally substantiate the indication for nasal surgery. The precise diagnosis, planning and performance of nasal surgery is one of the most demanding surgical activities. The motto is that form and function must be considered and treated with equal care in order to achieve an optimal result.

We have been performing a large number of nasal procedures of varying complexity for many years. Our experience is correspondingly high. This benefits our patients, because nasal surgery is "experience surgery".

Guideline for "Shape disorders of the inner and outer nose" (with functional and/or aesthetic impairment)

What is Osler's disease?

Osler's disease is a hereditary disease of the vascular connective tissue, also known as hereditary haemorrhagic telangiectasia (HHT). The disease is named after the Canadian physician Sir William Osler (1849 - 1919). The genetic changes lead to vascular dilatation, which can affect the entire body. This results in a wide range of mild to severe symptoms, which make holistic diagnosis and treatment essential.

Symptoms

As this is a systemic disease, the entire body can be affected. The severity of the symptoms varies greatly. The formation of so-called telangiectasias is typical. These are red, flat or raised changes in the skin and mucous membranes of the nose, mouth and gastrointestinal tract, which are also known as "Osler spots". These spots are mainly found in the nasal mucosa and lead to the main symptom of nosebleeds , which can be found in over 90% of patients. Less common are stomach or intestinal haemorrhages, which often go unnoticed and can lead to anaemia. As large amounts of blood can quickly accumulate in the gastrointestinal tract, unrecognised bleeding can be life-threatening.

• "Involvement of internal organs"
  Due to short circuits in the pulmonary circulation, part of the blood does not take part in the gas exchange. This can lead to a reduced oxygen concentration, although in most cases this does not restrict the patient's everyday life. In addition, bacteria or blood clots (e.g. as a result of an accident/injury) can be transported via the short-circuit connections, causing vascular blockages (infarcts) or accumulations of pus (abscesses). The very rare infestation of the arteries and veins supplying the brain can lead to cerebral haemorrhages and strokes. Depending on the size of the vascular dilatations and short circuits, infestation of the liver can lead to overloading of the heart.

Diagnosis

Four clinical criteria have been established for diagnosis (Curaçao criteria). In most cases, the disease can only be diagnosed through the patient interview (medical history) and clinical examination. If three or more of the following criteria are met, the diagnosis is confirmed:

1. Nosebleeds
2. Teleangiectasias (small vascular malformations) of the outer skin and mucous membrane
3. 1st degree relatives with a confirmed diagnosis of "Osler's disease"
4. Involvement of internal organs (lungs, brain, liver)

In order to find out whether the internal organs are involved, it is recommended that various screening examinations are carried out at the time of diagnosis. Imaging procedures such as ultrasound, magnetic resonance imaging (MRI) and computer tomography (CT) are used here. Knowledge of organ involvement is important in the event of potentially serious complications, as these can then either be treated or appropriate precautionary measures can be taken, e.g. during surgery.

In addition, a genetic test can be carried out to determine the exact type (see above).

Therapy

The treatment of the disease depends on the symptoms and must therefore be individualised for each patient. Co-operation with other specialist areas is essential. The aim of therapy is to control the symptoms so that they have as little impact as possible on everyday life. Unfortunately, a permanent cure is not possible with a hereditary disease.

There are various approaches to the treatment of nosebleeds. Regular care of the nasal mucosa with various moisturising ointments is essential.

Haemostatic ointment therapy

Various active ingredients are available to stop bleeding and reduce the number of bleeding events. However, the application depends on the clinical picture and must be discussed individually with the patient.

Laser therapy

In the case of recurrent bleeding and clearly visible Osler spots, laser treatment is mainly used to gently obliterate the Osler spots without causing mechanical damage. This is a good, quick and low-complication method and can be carried out under local anaesthetic in the outpatient clinic. However, as the spots form again and again, this treatment must be carried out more frequently.

Application of plastic film to the nasal septum

In the case of Osler spots with repeated bleeding from the nasal septum, a plastic film can be applied under a brief anaesthetic and attached using two sutures. This film compresses the mucous membrane and usually leads to an immediate stop of the bleeding. The film can remain in the nose for several months without affecting the patient.

Other surgical or medicinal approaches are also available. Each one has certain advantages and disadvantages. Your doctor can inform and advise you about the individual options.

• Laser treatments are generally performed in our clinic under local anaesthetic on an outpatient basis. Only in rare cases is a general anaesthetic necessary. A special procedure room is available in the outpatient clinic for the treatment. At the beginning, there is a short patient consultation. Here, particular emphasis is placed on the bleeding history (How often? How long? Which side?). This is followed by an examination of the nasal mucosa. Anaesthesia is achieved by inserting cotton swabs that have previously been soaked in anaesthetic. It is important to ensure that the anaesthetic is applied for a sufficient period of time. An anaesthetic injection is not normally necessary. A so-called diode laser is used for laser treatment. This enables treatment that is gentle on the mucous membrane.
• "Nosebleed diary"
  Keeping such a diary is very helpful as it can be used to measure the success of the treatment. It also helps to establish the "status quo" if you are presenting for the first time. This makes it easier to design a suitable therapy plan.

The following points should be documented:

1. Frequency (How many times a month? How many times a week? How many times a day?)
2. Duration (How long?)
3. Intensity (Dribbling? Running? Bubbling?)
4. Is medical help necessary? (Emergency visit to the ENT doctor? Emergency doctor?)

Links

Morbus Osler Selbsthilfe e.V.(http://www.morbus-osler.de/)

Morbus Osler Info Forum(http://forum.morbusosler.info/)

HHT Foundation USA(https://curehht.org/, English)

1 My ENT doctor says my nose is crooked. Do I have to have an operation?

• An obstructed nasal air passage in itself is not a disease in the true sense of the word. It cannot, for example, result in an undersupply of oxygen in the blood and the associated consequential damage. In many cases, however, the quality of life is severely restricted due to restricted nasal breathing, resulting in a high level of suffering for those affected. The increased mouth breathing, which is not intended by nature, also often leads to sore throats and dry mouth in the morning. Whether there is a diagnosis worthy of surgery must be determined in the course of a precise ENT examination with associated diagnostic measurements. For example, it is often sufficient to correct a curvature of the inner nose (deviated septum), but in some cases this is not enough and the outer bony nose must also be straightened. We will be happy to discuss this with you in person and inform you individually about the potential benefits of surgery.

2 What are the possible consequences of rhinoplasty?

• Swelling may occur in the facial area after the operation. Sometimes the eye area turns blue, both of which disappear within a few days. The nose can also become blocked after the operation due to swelling and crust formation. Intensive nasal care and daily nasal cleansing by the doctor will gradually clear the nose. Mucus mixed with old blood can run out of the nose. This is normal in the first few days after a nose operation. Wound infections or severe inflammation in the nose area are rare. They are characterised by significantly increased pain, redness and swelling, and fever may occur. If necessary, affected patients are given an antibiotic. In very rare cases, a haematoma can form between the mucous membrane leaves of the nasal septum, which must be surgically removed. Usually there is hardly any pain after a nose operation. However, if you do experience pain, please contact your ward team (doctor or nurse) at any time.

3. what should I do after a nose operation?

• Excessive rubbing with fingers or handkerchiefs and blowing your nose should be avoided for 14 days. We also advise you to refrain from excessive physical exertion such as weight training or lifting heavy loads for 14 days in order to avoid post-operative bleeding. Nasal decongestant drops can be used to temporarily relieve nasal congestion caused by swelling and crust formation; the duration of use should not exceed one week. You can make a significant contribution to the healing process by carrying out nasal rinses with saline solutions after discharge from hospital and treating the nose several times a day with soft ointment and nasal oil. You should refrain from smoking for the duration of your hospitalisation, as nicotine consumption interferes with wound healing.