While a generation ago more surgeons created the identical "cookie cutter" nose at every operation, with little regard for the individual patient's facial features, today's surgeons do have a better sense of what looks natural and what is a good match with the other facial features. There is no reason to have artificial looking noses as today's surgeons have had the benefit of one or two generations of prior surgeons' experience. In fact, today's tastes call for less radical change, and a nose that would have none of the stigmata of having undergone surgery. The surgeon's highest compliment is always that his role remains incognito.
But, we are seeing too many of the dissatisfied patients with noses that are indeed not acceptable. When you can spot an obvious "nose job", two failures took place. One failure was that of the surgeon, obviously. An inability to conceptually or technically create that individualized unoperated appearing natural nose. The second failure was that on the part of the patient; poor surgeon selection. Not every plastic or cosmetic surgeon is an expert at nasal surgery. Not everyone can be a master rhinoplasty surgeon. Perhaps the patient did not do enough homework, too many questions were left unasked, or perhaps before and after photos were ignored, not requested, and not valued. An overdone, too pinched, too scooped, unnatural nose is the product of an inadequately trained doctor working on an unsuspecting patient. In addition, because of currently popular techniques whereby various tissues are grafted or transplanted to the nose from other parts of the body, there exists a greater possibility of unpredictability and therefore an unacceptable result and patient dissatisfaction.
Whatever technique is performed, a nose should look natural, well-proportioned to the face and so pleasing that it calls little attention to itself. Typically, the unsatisfactory outcomes tend to have significant asymmetries or look overdone; too upturned, too ski sloped, nostrils irregular and overly prominent or some dissatisfaction with breathing such as a deviated septum, which may have been the result of the surgery.
Nasal surgery takes unusual manual dexterity and superior eye/hand coordination. This is why the closed rhinoplasty approach, done entirely through the nostrils, is akin to operating through a keyhole. It is a challenging prospect, even for the most sophisticated surgeon and a re-do or revision rhinoplasty is even more challenging. All architectural changes are made inside the nose after tunneling under the skin and when previous surgery has been done, that tunneling is more difficult because of scar tissue and more apt to produce complications including perforation of the skin, and unanticipated damage to the cartilage and bone. Common to all operations is raising of the skin envelope of the nose so that there is room for the surgeon to work to shave or chisel down the bony bump, or to shave or sculpture a broader bulbous tip of the nose. In addition, following removal of the bump, the nasal bones need to be narrowed by a controlled "break" where the nasal bones join the cheek bones, allowing the surgeon to manipulate the bones closer together. Customized, miniaturized surgical instruments perform these sophisticated techniques and maneuvers. One eighth of an inch, more or less, can make a difference in the outcome. Even placing and tying stitches deep in the nasal interior is challenging. I recall as a resident-trainee, it took me over two hours to perform routine nasal surgery, and I didn't have much fun at it. Today, 4,000 nasal surgeries later, the operation may only take 35 to 40 minutes in my hands.
In many cases, the patient is unhappy with the appearance of their nose because it is crooked. Typically it is crooked because there has been an internal derangement of the support structures, including the critical nasal septum. The septum, which is a vertical partition made of cartilage in the front and bone in the back, should be ideally running straight back from its beginning between the nostrils. But, if there has been an accident or by some quirk of nature it is crooked, irregular, S shaped, or has been broken and displaced by an accident, the air flow will be diminished, and the nose may be crooked. Nasal surgeons all know the aphorism that "as the septum goes so goes the nose." Therefore, the crooked or deviated septum needs to be corrected if we are to be successful in straightening the externally crooked nose. Often, there are other issues including enlargement of the turbinates and even nasal polyps within the nose that are medical conditions that must be dealt with so that the patient comes through the operation with not only an improvement in appearance, but improvement in breathing too.
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