Positioned between the eyes and the mouth, the nose is the aesthetic bulls-eye of the face. Because of its central location, both its size and shape can have great influence on the perceived appearance of the eyes, eyebrows, lips, and chin. Furthermore, the nose has an essential role in a process vital to human life – breathing. Thus, the nose holds considerable functional significance in addition to its aesthetic value. It is also the case that aesthetic concerns (cosmetic flaws) and functional problems (breathing difficulties) are inextricably interrelated. For this reason aesthetic nasal surgery, rhinoplasty, is often performed at the same time as functional nasal surgeries such as septoplasty, nasal vestibular stenosis correction, and inferior turbinate reduction. While rhinoplasty is done to improve shape and size and septoplasty and correction of nasal vestibular stenosis are employed to maximize breathing, these procedures can be synergistic with regard to their effect on appearance as well as function.
When a face is observed the gaze is focused on the eyes and mouth, shifting from one to the other. The explanation for this is that faces are observed for the purpose of communication. Eyes communicate non-verbal information and the mouth verbal information. Even though the nose holds a prominent position in the middle of the face, between the two features of communication, it is not natural for significant visual gaze to be focused on it. However, if a nose has an unusual or unbalanced shape or it is too large or too small it draws attention away from the two features of communication and is then perceived as unattractive. An attractive nose does not draw a lot of attention.
There are first tier (major) and second tier (minor) abnormalities of the nose. These both draw negative attention. Aesthetic abnormalities that fall into the first tier include: unbalanced size, dorsal shape, tip shape, alar shape, nostril shape, columellar shape, and nasal deviation. The complex structure of the nose opens the door for a myriad of other minor irregularities that round out the second tier. In the interest of clarity and simplicity, I will delve into the first tier only as the features that comprise it account for 90% of the aesthetic concerns that drive the desire to undergo rhinoplasty.
The characterization of size abnormalities is binary, either too small or too large. Both of these size irregularities can be corrected with rhinoplasty. Most people are interested in a reduction in the size of their nose or parts of their nose. Nonetheless, some people, fewer in number, have noses that are too small for their face or have portions of their nose that are diminutive and thus desire augmentation rhinoplasty (a rhinoplasty technique that adds cartilage to the structure in a strategic and precise fashion to make the nose bigger).
The most common deformity of the dorsal contour of the nose is a hump or bump, plastic surgeons refer to this as a dorsal convexity. The revision desired by people with this shape is removal of the hump in favor of a straight contour along the “bridge” of the nose from the nasal take off between the eyes to the tip. The importance and complexity of this is often overlooked. I prefer to perform this maneuver in a composite separation and incremental reduction technique followed by the use of spreader grafts or spreader flaps so as to avoid long-term inverted-V deformities and/or a scooped-out appearance.
The two most common tip shape forms that people want revised are a boxy or a bulbous tip. Calculated modifications of tip width and shape are performed to affect positive change in these two tip types. The goal in women is often to make the nose more refined and delicate and in men is to make the tip more distinguished. Tip projection (how far the tip extends from the base of the nose) and tip rotation (the angle the tip and the columella beneath it connects with the upper lip) are two additional characteristics that often require adjustment in precision rhinoplasty.
The final, and perhaps the most important, first tier aesthetic problem that is addressed in any premium rhinoplasty is crookedness. Crookedness is a deviation from the midline or a lack of straightness. People often say that their nose bends to one side of their face in a way that detracts from the overall appearance of both the nose and the face. Prior trauma, such as a broken nose, is sometimes an antecedent cause of this deformity and sometimes crookedness is congenital/developmental in origin. Independent of etiology, crookedness often relates to abnormalities of the septum and/or bone. As these elements are the structural core of the nose, correcting their form is paramount to improving shape.
It is extremely rare that the aesthetic abnormalities discussed above occur in isolation of one another. Due to the aesthetic, functional, and structural integration of the features, nose deformities occur in interrelated clusters. For that reason, precision rhinoplasty is designed and employed to address the composite aesthetic issues in a synergistic fashion. In my experience, it is relatively rare for someone to need a hump reduction or tip rhinoplasty alone. While these “minimalist” techniques might seem attractive, and may have marketing value, my personal perspective is that they can sometimes leave the nose internally imbalanced. That is to say, I believe procedures such as a “tip rhinoplasty” often create an operated look because they don’t modify the nose harmoniously. Precise interconnected changes throughout often lead to a more natural rhinoplasty. It is rare in life that comprehensive, but subtle, is not the best approach to a problem.
Rhinoplasty is a surgical procedure of the nose that is designed to reshape and/or resize the nose by precisely modifying its structure to bring about a more desirable appearance. It is commonly referred to in the lay media as a “nose job,” however I cringe at the utterance of that term. Please do not mistake objection to this nickname for arrogance. That is not the case, instead my opposition to the term “nose job” stems from my belief that the term utterly fails to capture and convey the importance and complexity of a high quality rhinoplasty. Plastic surgeons agree that rhinoplasty is one of the most complex cosmetic procedures performed. Think of it in these terms,referring to a Maserati or an Aston Martin as “wheels” fails to capture the elegance of the design and the complexity of the engineering of these vehicles.
Rhinoplasty is a procedure where success is measured in millimeters and minute angles. Furthermore, there is a very subtle but very definite line that segregates success from regret and natural appearance from a “done” look. Yet rhinoplasty is a very common procedure consistently topping the lists of the most frequent procedures requested by both men and women. The combination of frequency and complexity is likely an important factor contributing to a nation-wide revision rate of about 15% thus, rhinoplasty must be paid its due respect. My revision rate is far lower than that. To the best of my knowledge my revision rate is in the single digits, perhaps as low as 1%. Its complexity, its intricate nature, its importance in facial appearance must all be acknowledged and should be considered in every rhinoplasty plan. It is for this reason that I employ a technique designed to maximize finesse, precision, and customization. The goal is a nuanced transformation that yields a natural and balanced appearance to the nose and a synergistic and integrated connection with the composition of the face as a whole.
Patient, Precise, Analytical, Scientific, Systematic (PPASS) are the adjectives that define my approach to rhinoplasty and the demands of its successful execution.
Patient – I take as long as is required to provide a quality result, sometimes longer than other surgeons might spend on a given nose. I consider this a good thing. It is something of which I am proud.
Precise – Every maneuver is executed to high standards required to yield the desired result.
Analytical – Significant time is spent prior to surgery and during surgery to identify aesthetic flaws and determine the necessary interventions.
Scientific – I continually update and modify my techniques based on my continued self-directed education focused on the written literature and conference attendance.
Systematic – While every rhinoplasty I perform is customized to the patient and thus ultimately unique, I am very systematic in my approach to the procedure. For the most part I perform the many components of the procedure in the same order every time so as to yield predictable and reproducible results. Yet at the same time no procedure is performed the same way; every operation is customized to the patient’s needs and desires.
Central to my PPASS Rhinoplasty is the open approach to rhinoplasty. I use this technique in the majority of my cases. It is different from the closed approach.
Open -vs- Closed Rhinoplasty Techniques
Closed rhinoplasty is performed through incisions placed inside the nostrils only, whereas the open technique uses those incisions plus one additional incision across the columella. One of the consistent criticisms of the closed technique is the difficulty visualizing and controlling all of the important structures, both bone and cartilage, that contribute to the nose’s shape, size and appearance.
The open technique permits a significant improvement in visualization of the nose’s internal structure and enhances control of the modification of these structural elements during the course of the procedure. There are select cases in which I do use a closed technique. These include minor revision cases and minor augmentation rhinoplasties (rhinoplasties where the goal is to increase the size of the nose in a measured fashion).
It should be noted that additional scarring and prolonged swelling are stated disadvantages of the open approach, but in my experience, the scar is quite inconspicuous (to date I have never had a patient complain about the scar) and edema, or swelling, can be mitigated by a number of things such as a subperiostial/subperidchondrial dissection, dietary modification, pharmacologic nausea reduction (thus no wretching or vomiting), and careful collaboration with the anesthesiology staff to bring about precise intraoperative blood pressure control and a smooth emergence from general anesthesia. Systematic analytical principals are used both before and during the surgery to evaluate the nose in a paired problem-solution manner. A patient centric plan is generated to yield precise and customized results.
The Value of Cartilage Grafts
The PPASS approach used in my Austin, Texas Rhinoplasty practice is also characterized by the strategic use of structural cartilage grafts. A significant principal underlying a quality finesse rhinoplasty is goal oriented modification of the structure of the nose. In this sense, a rhinoplasty can be thought of as a renovation of a house. When a house is renovated, materials need to be brought and added to the structure and internal walls. This concept also holds true for rhinoplasty. In many cases, in order to create precise, predicable, and enduring change, “material” needs to be added to the nose. This “material” is cartilage and is usually borrowed from the septum but can also be gotten from the ears and ribs. The latter two sources are rarely required for primary rhinoplasties and thus a discussion of these materials is reserved for the revision rhinoplasty section.
Cartilage can be harvested from the septum without detriment to its structural integrity. This cartilage is invaluable to a modern rhinoplasty as it is used to create several grafts that I believe are of paramount importance. These grafts are alar rim grafts, spreader grafts, and columellar strut grafts. Alar rim grafts are used to prevent alar retraction, and an associated sneering appearance, that can occur following rhinoplasties if these grafts are not used. Spreader grafts help prevent an inverted-V deformity that can occur with hump reduction and also can be used to control dorsal width, dorsal aesthetic lines, and the correction of the crooked nose. A columellar strut graft is used to provide tip support thus improving the maintenance of tip projection and rotation in rhinoplasty. These are the most common grafts, but others are employed on a case-by-case basis depending on the indication.
In my practice, rhinoplasty is performed under general anesthesia and is an outpatient procedure. General anesthesia permits me to focus on the task at hand, achieving the best result, without having to attend to patient discomfort during the time of the procedure. There are some surgeons who will perform rhinoplasty under local anesthesia or with sedation – but I am not one of them. My goal is quality and patient satisfaction and I can only deliver this with a procedure performed under general anesthesia.
Discomfort (Often Minimal)
With regard to post-operative discomfort, many patients report that the discomfort is significantly less than they expected it to be, especially immediately after surgery. While the patient is asleep I administer two types of local anesthesia and often re-inject the longer acting one again prior to emergence from anesthesia so it is possible to wake up with little, and in some cases, no pain.
A small splint is sometimes placed on the outside of the nose over the bridge and soft plastic splints are often placed inside the nostrils along the walls of the septum. Both the external splint and the internal splints (inside the nostrils) are removed at about one week. On rare occasions the internal splints will be left in place for up to 10-14 days. Nasal packing is not routinely used.
Resumption of Activity
Patients generally return to work or school after one week. Normal strenuous activity can be resumed at 2-3 weeks. Discomfort often subsides after 3 days. Swelling is usually present for one week or less. Bruising is variable and dependent upon a number of factors. Some patients have very little bruising and that which is present lasts for less than a week. One week is typical. In some patients bruising may persist past one week. Cover up make-up to camouflage bruising is acceptable.
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