How to build a better nose

“Don’t make me look like celebrity X” or “I want to look like celebrity Y.”   …are probably the most common statements made by my patients before undergoing rhinoplasty surgery, otherwise known as a nose job. With no clear second place winner, Michael Jackson was the most public example for Rhinoplasty-gone-wrong. His transformation from heart-throb to “does he wear a prosthetic nose?” seems to be a timeless example for plastic surgery gone wrong.  I’ll tell you the same thing I tell my patients. Michael Jackson teaches us what can happen if you ignore a patient’s underlying anatomy and try to achieve an unrealistic result.   Rhinoplasty operations are different from traditional surgeries in many ways. Obviously, they lie in a highly visible part of the face and can not be covered with clothing or cosmetics. The nose is the second part (after the eyes) of your face that people focus on when they first see you. So, while good outcomes can result in a more positive self image and occasionally life altering personal motivation, bad outcomes can be debilitating.   And let’s not forget that you’re supposed to be able to breath through that thing. Someone with intricate knowledge of nasal airway mechanics is more likely to produce a nose that looks great AND still functions well. It is not always “better to look good than to feel good.”   The other unique factor about the nose is that each and every patient has different anatomy. These underlying differences can be very subtle or extremely drastic. In most other surgeries, anatomic variation is encountered rarely. So procedures are done almost like a recipe, in that the same steps are repeated over and over from patient to patient. In Rhinoplasty, variable anatomy is seen in every case and influences the steps of the operation, as well as the degree and scope of modification that is required to obtain a specific cosmetic alteration.   So, all noses are not created equal.   I have always believed that what you start with, in many ways, determines what can be and should be achieved with a Rhinoplasty. Some critical anatomical factors include:

• Skin thickness, which can range from crepe-paper-thin to thick and oily, is probably the most important factor in determining the degree of definition and narrowing that can be obtained. Trying to alter skin thickness during a nose job astronomically increases the risk profile of an operation.
• Cartilage Strength is a genetic and highly variable component of the operation. When you consider this, think about building a sky scraper. The foundation, the leveling of the ground underneath the foundation, the design, and the materials used in the project ultimately determine whether the building will stand for hundreds of years or collapse during or immediately after construction. The nose is no different. Patients with poor cartilage strength require either conservative operations (with less obvious changes) or extensive re-structuring employing grafts. Grafts increase the risk of immediate and long term complications from the surgery.
• The septum is, for all intent and purpose, the foundation of the nose. A deviated septum, while also having functional ramifications, may not provide the necessary support of the nasal tip, causing it to droop after an otherwise successful operation. This concept of Foundation Rhinoplasty is a new approach to nasal biomechanics that is only now being currently understood.
• The size of the nose is another critical factor. The taller the nose, the narrower it often appears, due to the increased shadowing along the sides of the nose. Making a smaller nose in height can make it look wider even though it is actually narrower. In the opposite situation (a patient with a broad nose), creating a markedly narrower appearing nose requires making it taller. Imagine the reaction of a patient when you tell them “in order to make your nose look smaller, I have to make it bigger.” However, most people are accepting of this after hearing the explanation.
• Ethnicity of a patient should never be forgotten. Not only does it often correlate directly with their specific anatomic variations, but it should help to guide the decisions you make regarding planned cosmetic interventions. Most people want to retain an ethnically appropriate appearance, because it looks more natural. From a surgeon’s perspective, when you try to create ethnically inappropriate noses, you are often doing things that put the overall surgical result at risk.

  These points and more are illustrated by a plastic surgeon that stopped practicing about 20 years ago. This highly regarded and successful surgeon would walk into his office after lunch, look around the waiting area and then say “I’ll do you…you…I won’t do you…” In many ways, he was doing the patients a great service by tailoring his patients to his particular operative method. Today, most surgeons agree that the operative method should, in fact, be tailored to the individual patient.   There are many other relevant factors to Rhinoplasty outcomes that lie outside the scope of this article. That is why a complete consultation is necessary in order to determine an individual surgeon’s opinion on the type of nose he or she can provide for you. You, as the consumer, will get different opinions and different projected results from each an every consultation. Multiple opinions are probably a good thing, but too many opinions will likely set you up for disappointment. If 9/10 surgeons say your aesthetic desires are not possible, then the 10th one that promises the moon is either really gifted (not likely) or providing you with really unrealistic expectations.   Building the perfect nose is not much different than turning Steve Austin into the 6 million dollar man. “Gentlemen, we can rebuild him. We have the technology. We have the capability to build the world's first bionic man. Steve Austin will be that man. Better than he was before. Better, stronger, faster.”   Most people, however, don’t want a six million dollar bionic nose.