Cocaine damages the nose by destroying its lining. As a result, the septal cartilage becomes exposed, dries out, and eventually disintegrates, leaving a large hole (perforation) in the nasal septum. When you look into a nose damaged by cocaine, it’s like looking into a cavern. In addition, the external nose collapses around the damaged septum, which normally provides support to the nasal bridge and the airway.

What is interesting about cocaine-damaged noses is how different they can be. The reasons for these differences seem to be related to the individual patient, quantity of use, years of use, and strength of the cocaine, but there must be other variables that we haven’t identified. Some patients have noses that looked relatively normal, even though the septum has a perforation. Others are collapsed and sunken on the outside, the bridge concave, the nostrils collapsed, and the upper lip sunken.

Last week I operated on a woman with just this deformity. Her bridge was too low, her tip had lost its shape, and her nostrils had caved in so that she was breathing only through slits.

Even though her external nose looked abnormal, what bothered her most was her loss of airway. Fortunately, correcting the airway and the appearance go hand in hand in rhinoplasty. As I correct one, I correct the other.

The important principle in treating the cocaine nose is not to make incisions in the nasal lining, because the lining that remains is scarred and abnormal and will not heal normally. Instead, I make incisions in the internal nasal skin, just behind the nostrils. In this patient’s case, I used rolled cartilage from one of her ears to rebuild the bridge and re-create her tip shape; and grafts of cartilage and skin from the other ear, placed into pockets inside the nostrils, to open her airways and bring the nostril rims down to their appropriate height. It is very important to use the patient’s own rib or ear cartilage to rebuild the nose. Artificial implants provide, at best, only a temporary solution to the cocaine nose; and at worst, become infected and leave the patient with the worst deformity than he or she had originally.

This patient healed very well. As soon as I took the bandages off at six days, her breathing was instantly normal and better than it had been for decades. Her external nose already looks better but will continue to improve for months.

This is very gratifying surgery for me. Regardless of the cause of the deformity, is a privilege to care for patients.