Rhinoplasty (Nose Surgery)

Rhinoplasty, nose reshaping, is a general term used to describe procedures that change the appearance of the nose. Although most commonly used for cosmetic reasons, functional nasal issues such as difficulty breathing can often also be addressed. Current rhinoplasty is very different from the past, when procedures were often very obvious. Today, rhinoplasty experts have otolaryngology training (ear, nose and throat) in addition to fellowships in facial plastic and reconstructive surgery (double board certified) and can offer much more advanced techniques. Not only are natural, predictable results the rule, but recovery is quicker both cosmetically and functionally.

Your surgeon’s philosophy is important. “If it looks like you had it, it’s not worth having”. Noses can be smaller, but do not have to be small to be beautiful and enhance one’s facial appearance. But philosophy alone cannot overcome the training and ability of a particular surgeon. Overall, our nose should not be noticed when someone views our face. The majority of one’s beauty is centered on their eyes, cheekbones and facial contour; our nose should fit our face, have aesthetically pleasing angles and most often go unnoticed on our face. Often great rhinoplasty causes the effect of bringing an observer’s gaze to our eyes and not our nose. Comments on the beauty of your eyes are often the most significant compliment in sophisticated rhinoplasty.

Noses are individualized procedures that are designed based on the specific imperfections in the nose as well as the degree of the nasal imperfection. This is then balanced with how the nose fits into the overall aesthetic of the face. One nose may look fine on one face and not another. A rhinoplasty specialist can be predictive, prior to any commitment to a procedure, of the degree of outcome that can be achieved, while still maintaining a natural, un-operated upon appearance.

We can classify degrees of imperfections in this manner:

In these cases, the attractiveness of the individual is clearly evident despite an imperfect nose. They may have both size and/or shape issues, but if they never chose to change their nose they will always be considered attractive. The goal in these cases is refinement of the facial feature. Their result creates the best version of their nose and will not make them look different, but will make them look much better. Often friends and family do not know the procedure was done, yet the before and after photos reveal a significant change.

In these cases, the individual may not appear attractive to themselves or others due to larger degrees of imperfections of their nose. Size and shape are both usually problems. The nose dominates the face and doesn’t allow the viewer to “see through” to their other attractive features. Refinement of the facial feature will not produce enough of a result to be considered satisfying to the individual. In these cases, the goal is eliminate the prominence and the attention created by the nose and bring out the “buried” facial features. In most situations by eliminating the aesthetic nasal issues, while respecting the shapes and angles of “natural nose”, the face becomes attractive based on the underlying, already existing facial features. Although the cosmetic results are often striking and very significant, if the nose retains natural angles, appearance and fits the face, new facial beauty is seen by others with the majority not knowing is was due to a rhinoplasty.

Revision Rhinoplasty:
In revision or secondary rhinoplasty (a person who has had a rhinoplasty before) being evaluated by a nose specialist carries the greatest importance. There are many reasons why a person may be dissatisfied with their rhinoplasty, and a nose expert can be predictive of whether the changes the person requests is consistent with the outcome that can be obtained. Noses can be imbalanced, over-done or under-done; each will have different solutions and levels of predictability. Commonly, improvement can predictively be made to their nose, in certain cases all issues can be reversed, and in some advice may be to not undergo further procedures. Face to face meetings are essential.

Open vs closed Technique:
The goal in rhinoplasty is to change the size and/or shape of the bone (upper third) and/or cartilage (lower 2/3 thirds) which constitute the infrastructure of the nose, creating its shape. In most situations the soft tissue (skin and underlying layers) are not effected or are minimally addressed. There are two techniques used in rhinoplasty to accomplish this, open and closed.

Understanding the difference is important. The older technique is closed rhinoplasty where all incisions are done internally. Since there are no external incisions the cartilage and bone cannot be appropriately visualized by the surgeon. When altering a segment of the nose, the cartilage must be distorted from its natural appearance in order to access it through the nostril. Predictions of symmetry and the details of how these internal structures relate to one another must be assumed since they cannot be seen. In addition, nasal asymmetries, not always apparent from the outside, were often made worse. This technique was most ineffective in noses with “tip” cosmetic issues and revision (secondary) rhinoplasties. Because the cartilage and bone cannot be visualized in its native state, often the same maneuvers were done regardless of the initial external appearance. This explains why for many decades rhinoplasty produced an unnatural, operated-upon appearance, as well as the “same nose” being produced over and over by a particular surgeon.

First used in revision or difficult rhinoplasties, open rhinoplasty adds one very small incision hidden in the base (columella) of the nose. The advantage of this incision is that now the nose can be “opened” and the internal structures, cartilage and bone, are visualized in their native state. Subtle differences between sides and how the structures interact, which are not seen from the outside, can be seen in their natural state and much more accurate changes can be made to predictably alter nasal shape and size. The small incision fades quickly and is not an issue but the advantage provided by actually seeing the structures you want to alter is invaluable. Once surgeons started “opening” noses the outcomes in rhinoplasties became much more natural appearing. Individual nose designs could be created and the “done”, “operated-upon” rhinoplasty began to disappear.

A useful analogy is to imagine needing to work on the engine of your car. In closed rhinoplasty you would need to reach through and under the grill and blindly feel around in order to make the adjustments to the engine. In open rhinoplasty you can open the hood of the car, see the engine and make accurate adjustments.

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