Greater Manchester EUR Policy Statement on: Rhiniplasty / Septoplasty / Septo- Rhinoplasty GM Ref: GM024 Version: 2.

Transcription

1 Greater Manchester EUR Policy Statement on: Rhiniplasty / Septoplasty / Septo- Rhinoplasty GM Ref: GM024 Version: 2.3 (6 June 2016)

2 Commissioning Statement Rhiniplasty / Septoplasty / Septo-Rhinoplasty Policy Exclusions (Alternative commissioning arrangements apply) Rhinoplasty / Septo-Rhinoplasty to address the effects of facial trauma as part of the initial care pathway for that trauma are excluded from this policy Rhinoplasty / Septo-Rhinoplasty as part of the pathway of care for relevant cancers are excluded from this policy Treatment/procedures undertaken as part of an externally funded trial or as part of locally agreed contracts / or pathways of care are excluded from this policy, i.e. locally agreed pathways take precedent over this policy (the EUR Team should be informed of any local pathway for this exclusion to take effect). Fitness for Surgery Policy Inclusion Criteria NOTE: All patients should be assessed as fit for surgery before going ahead with treatment, even though funding has been approved. Rhinoplasty Rhinoplasty is considered an aesthetic procedure and is not routinely commissioned but may be considered in some cases of trauma where the initial reconstruction requires revision (NOTE: This requires a clinical opinion that the surgery needs revision). Surgery to correct a deformity of the nose following contact sports where there are no symptoms of nasal obstruction is not commissioned. Funding Mechanism Trauma where the initial reconstruction requires revision: Individual prior approval provided the patient meets the above criteria. Requests must be submitted with all relevant supporting evidence. Septoplasty Patients may be referred for a clinical assessment for septoplasty where the individual has: obstruction of one or both nostrils (NOTE: If the patient has a grossly deviated septum causing complete blockage of that nostril then the two bullet points below do not apply) AND tried conservative measures without success, e.g. medication to treat allergic rhinitis AND the overuse of nasal sprays has been excluded as a cause of the nasal congestions or has been treated prior to referral and the nasal congestion persists Prior to surgery the degree of obstruction and the likelihood of a positive outcome should be assessed by an ENT surgeon. Funding Mechanism Monitored approval: Referrals may be made in line with the criteria without seeking funding. NOTE: These referrals may be the subject of contract challenges and/or audit of cases against commissioned criteria. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 2 of 19

3 Septo-Rhinoplasty Septo-rhinoplasty may be considered only if deemed the most effective intervention for the patient s nasal obstruction. NOTE: The application must come from an ENT surgeon and include details of the reasons for this request with an assessment of the difference in likely outcome compared to septoplasty alone (this must be related to functional outcome and not appearance alone). Funding Mechanism Individual prior approval provided the patient meets the above criteria. Requests must be submitted with all relevant supporting evidence. Clinical Exceptionality Clinicians can submit an Individual Funding Request (IFR) outside of this guidance if they feel there is a good case for exceptionality. Exceptionality means a person to which the general rule is not applicable. Greater Manchester sets out the following guidance in terms of determining exceptionality; however the over-riding question which the IFR process must answer is whether each patient applying for exceptional funding has demonstrated that his/her circumstances are exceptional. A patient may be able to demonstrate exceptionality by showing that s/he is: Significantly different to the general population of patients with the condition in question. and as a result of that difference They are likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 3 of 19

4 Contents Commissioning Statement... 2 Policy Statement... 5 Equality & Equity Statement... 5 Governance Arrangements... 5 Aims and Objectives... 5 Rationale behind the policy statement... 6 Treatment / Procedure... 6 Epidemiology and Need... 7 Adherence to NICE Guidance... 7 Audit Requirements... 7 Date of Review... 7 Glossary... 8 References... 8 Governance Approvals... 9 Appendix 1 Evidence Review Appendix 2 Diagnostic and Procedure Codes Appendix 3 Version History GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 4 of 19

5 Policy Statement Greater Manchester Shared Services (GMSS) Effective Use of Resources (EUR) Policy Team, in conjunction with the GM EUR Steering Group, have developed this policy on behalf of Clinical Commissioning Groups (CCGs) within Greater Manchester, who will commission treatments/procedures in accordance with the criteria outlined in this document. In creating this policy GMSS/GM EUR Steering Group have reviewed this clinical condition and the options for its treatment. It has considered the place of this treatment in current clinical practice, whether scientific research has shown the treatment to be of benefit to patients, (including how any benefit is balanced against possible risks) and whether its use represents the best use of NHS resources. This policy document outlines the arrangements for funding of this treatment for the population of Greater Manchester. This policy follows the principles set out in the ethical framework that govern the commissioning of NHS healthcare and those policies dealing with the approach to experimental treatments and processes for the management of individual funding requests (IFR). Equality & Equity Statement GMSS/CCGs have a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved, as enshrined in the Health and Social Care Act GMSS/CCGs are committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, gender or sexual orientation. In carrying out its functions, GMSS/CCGs will have due regard to the different needs of protected characteristic groups, in line with the Equality Act This document is compliant with the NHS Constitution and the Human Rights Act This applies to all activities for which they are responsible, including policy development, review and implementation. In developing policy the GMSS EUR Policy Team will ensure that equity is considered as well as equality. Equity means providing greater resource for those groups of the population with greater needs without disadvantage to any vulnerable group. The Equality Act 2010 states that we must treat disabled people as more equal than any other protected characteristic group. This is because their starting point is considered to be further back than any other group. This will be reflected in GMSS evidencing taking due regard for fair access to healthcare information, services and premises. An Equality Analysis has been carried out on the policy. For more information about the Equality Analysis, please contact policyfeedback.gmscu@nhs.net. Governance Arrangements Greater Manchester EUR policy statements will be ratified by the Greater Manchester Association Governing Group (GMAGG) prior to formal ratification through CCG Governing Bodies. Further details of the governance arrangements can be found in the GM EUR Operational Policy. Aims and Objectives This policy document aims to ensure equity, consistency and clarity in the commissioning of treatments/procedures by CCGs in Greater Manchester by: reducing the variation in access to treatments/procedures. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 5 of 19

6 ensuring that treatments/procedures are commissioned where there is acceptable evidence of clinical benefit and cost-effectiveness. reducing unacceptable variation in the commissioning of treatments/procedures across Greater Manchester. promoting the cost-effective use of healthcare resources. Rationale behind the policy statement Aesthetic procedures are not routinely commissioned by the CCGs in Greater Manchester in order to target limited resources at those in most need. Septoplasty is recognised as a treatment to address a specific condition. This should be offered to those patients most likely to benefit from the procedure. Treatment / Procedure Nose Reshaping Surgery Most people who dislike their nose have concerns about the bridge or the tip. At the bridge, or dorsum, people often complain about having a hump. Meanwhile, people who want to change the tip often see this part of the nose as being too wide, round, blobby, beaked or lacking in definition. Some people also dislike the length of their nose. Nose operations are most commonly carried out to: alter the hump at the bridge of the nose reshape the tip of the nose alter the length of the nose alter the width of the nose alter the width of the nostrils restructure and reposition the nose after an injury open up the nasal airways to help breathing Medical reasons Other patients may opt for a rhinoplasty because of an injury to the nose, whereby the nose may be broken or bent following an accident of some kind. Others may have functional breathing problems relating to the nasal airways. In these cases, surgical interventions would be considered reconstructive, whereas for the majority of nose operations the surgery is classed as cosmetic. Rhinoplasty A nose reshaping operation is either performed from inside the nostrils this is referred to as a closed rhinoplasty; or else by making a small cut on the nose and elevating the skin known as an open rhinoplasty. The precise nature of the operation will vary depending on the area of the nose that is being treated. Bridge (or dorsum): If the bridge of the nose is being operated on, the surgeon removes the bone and cartilage that is causing the hump. The nose may then be broken to allow the remaining pieces of bone to be moved closer together, resulting in the narrowing of the nose. Tip: When the tip of the nose is operated on, the cartilage that makes up the tip-support needs to be partly removed or reshaped. This is done through the nostril, or by making a small cut in the bit between the nostrils (known as the columella) in an open rhinoplasty. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 6 of 19

7 Length: A surgeon can adjust and reduce the central structure of the nose, known as the septum, to help shrink the tip and reduce the overall length of the nose. Adjustment to the tip cartilages also helps adjust nasal length. Width: By breaking and repositioning the side nasal bone, a surgeon can also reduce the width of the nose and achieve a narrower appearance. Additional Rhinoplasty Surgeons can also add to the nose using cartilage grafts from the septum or, occasionally, silicone implants, in what is called an additional rhinoplasty. This type of operation is used to build up a flat bridge or tip. The above techniques can also be used to straighten and refine a nose that has been broken through injury, and to relieve breathing difficulties. Septoplasty Septoplasty is a surgical procedure to correct a deviated nasal septum, i.e. a displacement of the bone and cartilage that divides the two nostrils. During septoplasty, the nasal septum is straightened and repositioned in the middle of your nose. This may involve the surgeon cutting and removing parts of the septum before reinserting them in the proper position. Detail and expected outcome depend on the individual s symptoms, e.g. breathing difficulties and the physical structure of their nose. Septo-Rhinoplasty Septo-rhinoplasty is related to rhinoplasty but is carried out for patients who also have nasal obstruction. Septo-rhinoplasty not only improves the appearance of the nose, but it removes any internal obstructions that may be blocking breathing through the nose. Epidemiology and Need Nasal obstruction is a common complaint. In 1974, Vainio-Mattila 1 found a 33% incidence of nasal airway obstruction among randomly chosen adults. Septal deviation was found to be the most frequently encountered structural malformation causing nasal obstruction. Clinically significant septal deviation was found in 26% of patients with nasal obstruction in this study. It is difficult to provide epidemiological data for rhinoplasty as dissatisfaction with the appearance of the nose is affected by multiple factors and there is no standard definition of a normal nose; however, according to statistics released by the American Society of Plastic Surgeons in 2006, rhinoplasty is one of the most sought after aesthetic surgeries by ethnic patients and teenagers. It also is the most requested aesthetic operation by patients with body dysmorphic disorder. Adherence to NICE Guidance NICE have not currently issued guidance on this treatment. Audit Requirements There is currently no national database. Service providers will be expected to collect and provide audit data on request. Date of Review Three years from the date of the last review, unless new evidence or technology is available sooner. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 7 of 19

8 The evidence base for the policy will be reviewed and any recommendations within the policy will be checked against any new evidence. Any operational issues will also be considered at this time. All available additional data on outcomes will be included in the review and the policy updated accordingly. The policy will be continued, amended or withdrawn subject to the outcome of that review. Glossary Term Aesthetic Body Dysmorphic Disorder Cartilage Cartilage grafts Columella Conservative measures Cosmetic Deformity Deviated nasal septum / Septal deviation Nasal obstruction Nasal Septum Reconstructive Rhinoplasty Septoplasty Septo-Rhinoplasty Silicone implants Trauma Meaning Concerned with beauty or the appreciation of beauty. Or body dysmorphia, is an anxiety disorder that causes sufferers to spend a lot of time worrying about their appearance and to have a distorted view of how they look. Firm, flexible connective tissue. Cartilage from one part of the body is surgically removed and implanted in another. The tissue that links the nasal tip to the nasal base, and separates the nostrils It is the inferior margin of the nasal septum. Non-surgical interventions usually medication used to treat symptoms. Aesthetic (Concerned with beauty or the appreciation of beauty) The state of being deformed or misshapen. The septum has moved from the mid line of the nose toward one side. Blocked nose The dividing wall that runs down the middle of the nose, separating the two nasal 'cavities, each of which ends in a nostril. The nasal septum is composed of bone, cartilage, and 'membranes. Surgery to restore function or normal appearance by reconstructing defective organs or parts. Surgery performed to straighten or otherwise improve the appearance of the nose. Surgery to straighten the septum which has deviated from the midline - The nasal septum is the wall between the nostrils that separates the two nasal passages. It supports the nose and directs airflow. The septum is made of thin bone in the back and cartilage in the front. A surgical procedure performed to repair defects or deformities of both the nasal septum and the external nasal pyramid. A medical device composed primarily of silicone or silicone gel, which is meant to augment or substitute a non-essential part of the body. Physical injury due to external forces References 1. GM EUR Operational Policy GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 8 of 19

9 2. Vainio-Mattila J. Correlations of nasal symptoms and signs in random sampling study. Acta Otolaryngol Suppl. 1974;318:1-48. [Medline]. 3. ENT-UK website: Surgery on the nose Rhinoplasty Governance Approvals Name Date Approved Greater Manchester Effective Use of Resources Steering Group 19/11/2014 Greater Manchester Chief Finance Officers / Greater Manchester Directors of Commissioning May 2015 Greater Manchester Association Governing Group 02/06/2015 Bury Clinical Commissioning Group 01/07/2015 Bolton Clinical Commissioning Group 26/06/2015 Heywood, Middleton & Rochdale Clinical Commissioning Group 17/07/2015 Manchester Clinical Commissioning Group North: 08/07/2015 Central: 30/07/2015 South: 24/06/2015 Oldham Clinical Commissioning Group 02/06/2015 Salford Clinical Commissioning Group 02/06/2015 Stockport Clinical Commissioning Group 24/06/2015 Tameside & Glossop Clinical Commissioning Group 22/07/2015 Trafford Clinical Commissioning Group 21/07/2015 Wigan Borough Clinical Commissioning Group 30/06/2015 GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 9 of 19

10 Appendix 1 Evidence Review Rhiniplasty / Septoplasty / Septo-Rhinoplasty GM024 Search Strategy The following databases are routinely searched: NICE Clinical Guidance and full website search; NHS Evidence and NICE CKS; SIGN; Cochrane; York; and the relevant Royal College and any other relevant bespoke sites. A Medline / Open Athens search is undertaken where indicated and a general google search for key terms may also be undertaken. The results from these and any other sources are included in the table below. If nothing is found on a particular website it will not appear in the table below: Database NICE NHS Evidence and NICE CKS SIGN Cochrane York Result Nil specific to the procedures listed but there were IPGs related to specific techniques for nasal obstruction surgery (No s 113, 495 and 498) not cited here CRD review (see below) Citations related to specific techniques and for psychological impacts related to aesthetic surgery not cited here Nil found (private providers websites listed) Nil specific to the surgeries under review Evidence supporting functional rhinoplasty or nasal valve repair: a 25-year systematic Review, Rhee J S, Arganbright J M, McMullin B T, Hannley M., Otolaryngology - Head and Neck Surgery 2008; 139(1): Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review, Moore M, Eccles R., Clinical Otolaryngology 2011; 36(2): BMJ Clinical Evidence General Search (Google) Rhinoplasty related to cleft lip and palate (not cited here) ENT-UK website: Surgery on the nose - Rhinoplasty (not cited here) ENT-UK website: Surgery on the nose - Septal Surgery (not cited here) Medline / Open Athens Other Not done RCS and BAPRAAS websites searched. Summary of the evidence Nasal Septal Surgery: ENTUK position paper 2010 Patient information leaflet: Rhinoplasty (Augmentation), British Association of Aesthetic and Plastic Surgeons (BAAPS) (Added at review: Jul 2016) Patient information leaflet: Rhinoplasty (Reduction), British Association of Aesthetic and Plastic Surgeons (BAAPS) (Added at review: Jul 2016) Rhinoplasty is considered an aesthetic procedure and no evidence was found for its use in treating any underlying medical conditions. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 10 of 19

11 Septoplasty is an effective intervention in patients who have known septal deviation causing nasal obstruction. Outcomes are best where non-invasive interventions have failed and the nasal obstruction is having an impact on the individual s quality of mind. Where the obstruction is the result of trauma, septo-rhinoplasty may be indicated to get the best outcome for the patient The evidence Levels of evidence Level 1 Level 2 Level 3 Level 4 Level 5 Meta-analyses, systematic reviews of randomised controlled trials Randomised controlled trials Case-control or cohort studies Non-analytic studies e.g. case reports, case series Expert opinion 1. LEVEL 1: SYSTEMATIC REVIEW Evidence supporting functional rhinoplasty or nasal valve repair: a 25-year systematic Review, Rhee J S, Arganbright J M, McMullin B T, Hannley M., Otolaryngology - Head and Neck Surgery 2008; 139(1): The authors concluded that there was substantial support from case series that modern-day rhinoplasty techniques were effective for nasal obstruction due to nasal valve collapse. Evidence appeared to support the authors conclusions, but the limited search and reliance upon diverse and potentially biased observational studies that predominantly evaluated combinations of interventions undermined the strength of the evidence. 2. LEVEL 1: SYSTEMATIC REVIEW Objective evidence for the efficacy of surgical management of the deviated septum as a treatment for chronic nasal obstruction: a systematic review, Moore M, Eccles R., Clinical Otolaryngology 2011; 36(2): Background: Nasal septal surgery is a common procedure, but there are concerns that the benefits of this surgery are mainly cosmetic. Objective of Review: The primary aim is to identify any functional benefits of septal surgery and provide any evidence of a change in patency of the nasal airway, as assessed by objective methods such as rhinomanometry, acoustic rhinometry and peak nasal inspiratory flow. Search Strategy: A systematic search of the available literature was performed, using Pubmed, Medline (1950-November 2010), Embase (1947-November 2010) and the Cochrane Controlled Trials Register. Papers written in English that objectively compared pre- and post-surgical treatment of nasal obstruction in adults because of septal deviation were reviewed. Objective measurements of rhinomanometry, acoustic rhinometry and nasal peak inspiratory flow were specified within the search. Searches were restricted to surgery on the nasal septum, which included septoplasty, submucous resection and septal (deviation) corrective surgery. Results: Seven studies (460 participants) involving rhinomanometry, six studies (182 participants) with acoustic rhinometry and one study (22 participants) using nasal peak inspiratory flow were included in the review. All the studies reported an objective improvement in nasal patency after septal surgery. Mean unilateral nasal resistance (data from six studies) decreased from preoperative 1.19 Pa/cm(3) /s to postoperative 0.39 Pa/cm(3) /s, mean minimum cross-sectional area (data from five studies) increased GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 11 of 19

12 from preoperative 0.45 cm(2) to postoperative 0.61 cm(2), median peak nasal inspiratory flow (data from one study) increased by 35 L/min after surgery. Conclusions: There is sufficient evidence in the literature to conclude that septal surgery improves objective measures of nasal patency and that improved nasal airflow may have beneficial effects for the patient. 3. LEVEL 5: EXPERT OPINION Nasal Septal Surgery: ENTUK position paper 2010 A blocked nose is the one of the commonest presenting chronic symptoms in Ear Nose and Throat practice. One of the commonest causes of a blocked nose is a deviation of the midline nasal partition known as the nasal septum. This deviation may be congenital or acquired as the result of facial injury. Since this is a structural problem the only definitive treatment is surgical correction, referred to as septal surgery or septoplasty. Complications are uncommon, but include post-operative bleeding or infection and occasional septal perforation and external nasal deformity. The marked improvement often reported by patients is not always reflected in objective measures of nasal obstruction. This reflects the limitations of the objective tools, but has led to conflicting evidence for the efficacy of nasal septal surgery. This is sometimes mis interpreted by people outside of the specialty and has created a common misunderstanding that septal surgery is of limited effect, but this is far from the truth. Many of the studies in the past have been retrospective or used general quality of life questionnaires. However, prospective randomized studies using tools validated specifically for nasal obstruction corroborate the findings of these earlier studies. Long term results (up to 3 years post operatively) following nasal septal surgery show a significant improvement in nasal symptom scores. Conclusions Deviation of the nasal septal remains a common and important cause of nasal obstruction. Nasal endoscopy identifies other intranasal disease and has greatly enhanced the selection of patients who are listed for septoplasty. The evidence consistently supports the view that nasal septal surgery is highly effective in improving symptoms of nasal obstruction. Septoplasty is not only a very effective day case operation, but also one with a low complication rate. 4. LEVEL 5: EXPERT OPINION Patient information leaflet: Rhinoplasty (Augmentation), British Association of Aesthetic and Plastic Surgeons (BAAPS) Augmentation Rhinoplasty "nose jobs" to build up the shape of the nose Surgery to reshape the nose is a very common plastic surgery procedure and it can both increase or decrease the size of nose. The shape of the tip, the bridge and also the nostrils can be changed as can the angle between the nose and the upper lip. Sometimes breathing difficulties can be corrected at the same time. The nose is the central feature of the face, many people are self-conscious of shape which they may regard as too big, too small or have some other feature which they dislike. The characteristics of the nose are inherited from parents and develop during adolescent years. They continue until the age of 16, when the nose stops growing. It is, therefore, unwise to operate before this age. Injury to the nose is a common cause of flatness. Occasionally, it is a characteristic which is inherited. This can also develop after surgery to the interior framework of the nose (septoplasty to improve the breathing). The owner of a flat nose may acquire the reputation of the profession of a fighter as opposed to a sports person which may have an adverse effect to self-esteem. What can be done? To improve the appearance of a flattened nose it is necessary to introduce some additional framework underneath the skin to raise and straighten the bridge-line. The operation is called Augmentation GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 12 of 19

13 Rhinoplasty. Various materials are used for the additional framework such as bone, cartilage (gristle) and a range of manufactured materials which experience has shown are safe and well tolerated by the body. Each has its advantages and disadvantages which are too complex to discuss in this factsheet. The additional framework is usually introduced into the nose through a cut either inside the nostrils or in the strut of skin between the nostrils. If a bone graft is used for the additional frame it is taken either from the crest of the hip, from a rib, from the back of the elbow or from the outer surface of the skull without causing any weakness of the 'donor' bone. If cartilage is used, it is usually taken from the shell of one or both ears or from cartilage inside the nose, which is spare. When the nose has been flattened by injury, it is quite common for the plate of bone which separated the two halves of the nose to be buckled as well. This makes breathing difficult. It can often be corrected at the same time as an augmentation rhinoplasty by straightening the buckle out but sometimes it is advisable to have this done as a separate operation beforehand. In cases of severe collapse of the nose, skin grafts may also be necessary to achieve a satisfactory reconstruction. This is highly complex plastic surgery and outside the scope of this factsheet. What are the consequences? You can expect to have bruising and swelling of your face, particularly around the eyes, which will take up to three weeks to settle and during part of this time your nose is likely to be covered by a firm splint. Once the initial swelling has settled, you will find that your nose feels rather stiff and numb. The numbness will disappear slowly during the next few months but the stiffness is likely to be permanent. If it has been necessary to take a bone graft from another part of the body, you will be left with a scar which may be noticeable if it is on your hip or chest. What are the limitations? Although it is usually possible to make a substantial improvement to the appearance of the nose with the operation, the new frame may feel unnaturally hard. This is because it does not have the consistency and flexibility of the natural frame of the nose. You may also find that the additional frame can be moved about under the skin if it does not become fixed to the existing bony framework of your nose. These limitations need not worry you provided you bear in mind that the operation is done for the sake of your appearance. Particularly if a bone graft has been used, there is a tendency for it to gradually shrink in size during the first year or two after the operation. To help compensate for this, your surgeon is likely to put in more graft than you actually need so that to start with your nose may look over-bulky. There may be technical limitations to the perfection of appearance that can be achieved. For example, perfect symmetry may not be possible and it may not be possible to make the nose as large as might be desired. An experienced surgeon will be able to advise you what is possible in your own case. What are the risks? Like any operation that is carried out under a general anaesthetic, there is a small risk of chest infection, particularly among people who smoke. Very occasionally, the operation can be complicated by heavy nose bleeding either shortly afterwards or, after a week to 10 days which may require treatment in hospital. There is a small risk that infection could adversely affect the success of the operation. Were it to happen, it may be necessary to remove, temporarily, a manufactured implant if that has been used, or it may cause a graft of bone or cartilage to dissolve. In either event, it should be possible for you to have a further recontructive operation once the infection has cleared. Sometimes a manufactured implant will extrude through the skin of the nose or its lining and need to be removed. This can happen months or years later, and is more likely if a large implant has been used or if the nose is accidentally injured. Altogether, you can think in terms of there being about a 10% risk that you may need further surgical treatment for one or more of these complications were you to have this operation done. What you can expect at the time of your operation? If you need only a small implant, it may be possible to do the operation without a general anaesthetic, in which case you would have injections of local anaesthetic into your nose to make it numb and you would not need to stay in hospital. For larger reconstructions and if a bone graft from the hip or chest is needed, you would probably need a general anaesthetic and, maybe, up to a week in hospital. After the operation, you will probably have dressings in your nostrils for a day or so which will prevent you from breathing through your nose. You will also have a firm splint over your nose for the first week or two. There should be very little pain in your nose but, if you have a bone graft taken from your hip, you can GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 13 of 19

14 expect this to be quite painful for about 10 days, particularly when you walk. You will be given appropriate painkillers to help with this. What you should do when you go home? You can expect to have some minor bleeding from your nose for the first day or two and you can gently dab this away with a gauze swab or clean handkerchief. Unless you are advised otherwise, it is best for you to leave any crusts in your nostrils for the first week and then gently cleanse them away with cotton buds. You should keep your head up as much as possible and avoid having hot baths. Do not blow your nose and try your best not to sneeze through your nose. If you are going to sneeze, cough it out. It is safe to clear your nose by sniffing into the back of your throat. Stitches inside your nose will probably be of the dissolving type and do not need to be removed. If your stitches are outside your nose, your surgeon will advise you on their care and the time for their removal. You will also have a firm splint over your nose in order to protect the new frame and keep it stable whilst it is settling in. Once the splint has been removed, this protection is gone and you will have to be very careful in the way that you handle your nose for the first six weeks. You should avoid any activities where you might knock your nose and you should not move it from side to side between your finger and thumb. Try your best to sleep on your back. How long you would need off work will depend on the extent of your operation. The initial swelling and bruising will probably have disappeared within the first two weeks sufficiently for you to feel confident to show your face in public again. However, it will take at least three months for the reconstructed shape of your nose to mature and maybe a lot longer if you have had a lot done. Do not be too critical of your nose too early. Minor unevenness of contour is common during the first few months and usually settles with time. Conclusion: You should by now understand that this is a delicate and complex operation which needs to be designed for the needs of the individual patient. You should only consider having this operation for yourself if you are genuinely self-conscious of the nose you have at present. Do not think of having it done either for someone else s sake or if it is just a whim. If you do decide to go ahead, only go to a surgeon who is properly trained, and be guided by his or her advice as to what is possible in your own case. Cosmetic Surgery is carried out by members of several different organisations and therefore your general practitioner is the best person to advise you on whom you should see. DISCLAIMER: This document is designed to supply useful information but is not to be regarded as advice specific to any particular case. It does not replace the need for a thorough consultation and all prospective patients should seek the advice of a suitably qualified medical practitioner. The BAAPS accepts no liability for any decision taken by the reader in respect of the treatment they decide to undertake. 5. LEVEL 5: EXPERT OPINION Patient information leaflet: Rhinoplasty (Reduction), British Association of Aesthetic and Plastic Surgeons (BAAPS) Reduction Rhinoplasty "nose job" to reduce the size of the nose Surgery to reshape the nose is a very common plastic surgery procedure and it can both increase or decrease the size of nose. The shape of the tip, the bridge and also the nostrils can be changed as can the angle between the nose and the upper lip. Sometimes breathing difficulties can be corrected at the same time. The nose is the central feature of the face, many people are self-conscious of shape which they may regard as too big, too small or have some other feature which they dislike. The characteristics of the nose are inherited from parents and develop during adolescent years. It continues until the age of 16, when the nose stops growing. It is, therefore, unwise to operate before this age. What can be done? An operation called Reduction Rhinoplasty reduces the size of the framework of the nose over which the skin is draped. The skin itself is not touched. The frame of the nose which is made up of bone in its upper half and gristle (cartilage) in its lower half is approached from underneath the skin through cuts which are made inside the nostrils. Think of the frame of the nose as being like the roof of a house. In order to straighten the nose and bring its bridge closer to the face, its "ridge" is cut away. Then, to GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 14 of 19

15 restore a new ''ridge'' or bridge-line, the two sides of the nose are bought together by cutting the bones of the nose where they join onto the cheek bones. The elasticity of the overlying skin allows it to shrink down on the smaller frame. This operation effectively narrows the width of the nose. If doing so makes the nostrils seem too wide, it may be necessary to narrow them as well by cutting out a small piece of skin in the floor of the nostril which would leave a fine scar on each side. It is also possible to shorten the nose and to slim down a bulky tip by reducing the amount of cartilage which shapes the end of the nose. If you have some difficulty breathing through your nose, it may be possible to improve this at the same time by adjusting the lie of the plate of the bone which separates one half of your nose from the other. This is referred to as a Septoplasty. Sometimes the size of the nose as a feature of the face is influenced by the proportions of the other features, such as the chin and the cheek bones, and to ''normalise'' the appearance of the face it may be advisable to alter these features as well, either at the same time as the rhinoplasty, or during a separate operation. What are the consequences? There is always some bruising and swelling, particularly around the eyes, which can take up to three weeks to completely disappear and you would need to wear a firm splint over your nose during part of this time. By the end of three weeks, swelling will have settled sufficiently for you to look normal to others and as if you had not had recent surgery. Indeed, it is likely that you will be surprised by the absence of other people's reactions to the fact that you have a new nose. They, of course, have not been selfconscious of your nose as you have been. If you have any anxieties about family and friends noticing a change in your appearance, change your hairstyle at the same time and they will think it is that which accounts for your new looks. It is worth anticipating your own reaction to the first sight of yourself and your new nose. To start with, you will look rather strange in the mirror and not quite 'you' because of your different nose. Remember that it takes a few days for your mind's eye to adjust itself to your new appearance and to recognise it as 'you'. You should also bear in mind that it takes a good three months or more for all the swelling to settle out of the nose so, if there are any minor problems of shape soon after the operation, do not worry, they will almost certainly improve with time. Your nose will also feel rather numb and stiff for several months, particularly around the tip. What are the limitations? The object of the operation is to make your nose look right for your eyes so that you lose your selfconsciousness of it. It is, therefore, most important that you are clear in your mind what it is that you dislike about the appearance of your nose and that you are able to explain this to your surgeon. He or she will then be able to tell you what is surgically possible and what is not. For instance, if the skin on the tip of your nose is thick and oily, it may not be possible to reduce its bulky appearance as much as you might like because, generally speaking, it is not possible to thin the skin without leaving scars. If you are in middle age or if you have a very large nose, there may be a limit to the amount of reduction that can be achieved to the size of your nose within the limitations of the elasticity of your skin to shrink down on the smaller frame. If your nose is bent from previous injury, it may not be possible you make it perfectly straight. Large nostrils can be difficult to reduce without cutting the skin and leaving noticeable scars. What are the risks? Like any operation that is carried out under general anaesthetic, there is a small risk of chest infection, particularly among people who smoke. There is a small risk that infection could complicate the operation. You can minimise this risk by ensuring that you are free from cough, cold or sore throat at the time of your operation and, if you have any doubts, you should contact your surgeon. Occasionally, the operation is complicated by heavy nose bleeding either shortly afterwards or after a week to 10 days which may require treatment in hospital. It is quite common for there to be some difficulty with breathing through the nose during the first week after the operation which disappears as the swelling settles. occasionally, though, the difficulty persists and can be permanent. Sometimes (in about 10% of patients) the nose does not look right for the patient after all the swelling has settled. In these cases, it is usually possible for the surgeon to carry out a second operation to the residual problem of appearance but, not until all swelling has settled from the GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 15 of 19

16 first operation. Most surgeons wait for a year for this to happen. Secondary surgery like this may involve additional expense. What can you expect at the time of your operation? Most British surgeons prefer to do this operation under general anaesthetic and you will need to be in hospital at least overnight. The operation is remarkably painless and it is unlikely that you will need anything other than mild painkillers afterwards. It is, however, uncomfortable because you will probably have dressings in each nostril for a day or two which prevent you from breathing through your nose. You will also have a firm splint over your nose to hold the bones in their correct position. What you should do when you go home? You can expect to have some minor bleeding from your nose for the first day or two after your operation and you should dab this away gently with gauze squares or a clean handkerchief. Keep your head up as much as possible and avoid having hot baths. Do not blow your nose and try your best not to sneeze through your nose. If you are going to sneeze, cough it out. Once the dressings have been removed from the nostrils, you can clear your nose by sniffing into the back of your throat if you wish. Unless you are advised otherwise, it is better to leave any crusts in your nostrils until you see your surgeon for removal of the splint 1-2 weeks after the operation. Although there is no medical reason for you to stay away from work for more than a few days, you will probably feel more comfortable if you take two weeks off and go back when the bruising has gone. Cosmetic Surgery is carried out by members of several different organisations and therefore your general practitioner is the best person to advise you on whom you should see. DISCLAIMER: This document is designed to supply useful information but is not to be regarded as advice specific to any particular case. It does not replace the need for a thorough consultation and all prospective patients should seek the advice of a suitably qualified medical practitioner. The BAAPS accepts no liability for any decision taken by the reader in respect of the treatment they decide to undertake. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 16 of 19

17 Appendix 2 Diagnostic and Procedure Codes Rhiniplasty / Septoplasty / Septo-Rhinoplasty GM024 (All codes have been verified by Mersey Internal Audit s Clinical Coding Academy) GM024 Rhinoplasty / Septoplasty / Septo-rhinoplasty Reconstruction of nose NEC E02.2 Septorhinoplasty using implant E02.3 Septorhinoplasty using graft E02.4 Reduction rhinoplasty E02.5 Rhinoplasty NEC E02.6 Alar reconstruction with cartilage graft E02.7 Other specified plastic operations on nose E02.8 Unspecified plastic operations on nose E02.9 Septoplasty of nose NEC E03.6 Septal reconstruction with cartilage graft E03.7 Division of adhesions of turbinate of nose E04.4 Submucous diathermy of turbinate of nose E04.1 Cauterisation of turbinate of nose E04.6 Surgical outfracture of turbinate of nose E04.7 Correction of stenosis of nasal pyriform aperture E07.1 Septodermoplasty E07.2 Septorhinoplasty NEC E07.3 Other specified other plastic operations on nose E07.8 Unspecified other plastic operations on nose E07.9 With the following ICD-10 diagnosis code(s): Other plastic surgery for unacceptable cosmetic appearance Z41.1 Deviated nasal septum; (nothing to specify the degree of nasal obstruction/impairment) J34.2 GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 17 of 19

18 Appendix 3 Version History Rhiniplasty / Septoplasty / Septo-Rhinoplasty GM024 The latest version of this policy can be found here: GM Rhinoplasty / Septoplasty / Septo-Rhinoplasty policy Version Date Summary of Changes /09/2014 Initial draft /09/2014 Amendments made following discussion by the Greater Manchester EUR Steering Group on 17/09/2014: Amendment to 3 rd bullet point under Septoplasty in Section 4, Mandatory Criteria to make it clear that the overuse of nasal sprays should have been excluded/treated prior to referral. 17/09/2014 Policy approved for consultation by Greater Manchester EUR Steering Group subject to the agreed amendment /10/2014 Branding changed following creation of North West CSU on 01/10/ /12/2014 Amendment made following discussion of the Consultation feedback by the Greater Manchester EUR Steering Group on 19/11/2014: Criteria for Septoplasty made more explicit by including the use of AND to indicate that all three criteria need to be met. Policy approved by GM EUR Steering Group on 19/11/2014 subject to the above change being made /06/2015 Variance column removed and funding mechanism column added to table. Format of funding mechanism changed /04/2016 List of diagnostic and procedure codes in relation to this policy added as Appendix 2. Policy changed to Greater Manchester Shared Services template and references to North West Commissioning Support Unit changed to Greater Manchester Shared Services. Wording for date of review amended to read One year from the date of approval by Greater Manchester Association Governing Group thereafter at a date agreed by the Greater Manchester EUR Steering Group (unless stated this will be every 2 years) on Policy Statement and section 13. Date of Review /08/2016 Evidence reviewed June the new papers found do not affect the current policy as rhinoplasty alone is considered to be an aesthetic procedure. There was no new evidence for rhino-septoplasty or for septoplasty. GM EUR Steering Group agreed: Review date added to cover page and Policy Statement. The Date of Review on Policy Statement and in body of report changed to Three years from the date of last review unless new evidence warrants earlier review Section 4: Criteria for Commissioning: The word significant removed from the first bullet point under Septoplasty and the following added: (if the patient has a grossly deviated septum causing complete blockage of the nostril then the 2 bullet points below do not apply). New evidence added to the Evidence Review section of the policy. GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 18 of 19

19 2.1 30/09/2016 Funding Mechanism amended for clarification. Bolton CCG moved to Monitored Approval for Septoplasty from 1 October 2016 in line with rest of GM /12/2016 Appendix 2 - Procedure code E Total reconstruction of the nose removed /06/2018 Policy moved to new format and some wording rearranged and clarified. Appendix 2: o Procedure codes added: E04.1 Submucous diathermy of turbinate of nose; E04.4 Division of adhesions of turbinate of nose; E04.6 Cauterisation of turbinate of nose & E04.7 Surgical outfracture of turbinate of nose o Diagnostic code J34.2 Deviated nasal septum moved from policy exclusions GM Rhinoplasty Septoplasty Septo-Rhinoplasty Policy v2.3 FINAL Page 19 of 19