Article by Daniel Reichner, MD
Newport Beach Plastic Surgeon
Everybody recognizes a beautiful nose, but just how do rhinoplasty surgeons create them? Rhinoplasty surgeons are artists that understand that beautiful noses must have certain proportions, ratios and characteristics for a natural and beautiful look.
I start the consultation by asking patients what they don't like about their noses. Most patients don't like the size of their nose, a hump or falling tip. Many describe what they don't want - the over-done rhinoplasty. They don't want the pinched tips or ski-slopes seen in many movie stars and some friends.
Highly visible clues of rhinoplasty include over reducing the top of the nose, known to rhinoplasty surgeons as the dorsum. This happens when the surgeon attempts to lower the dorsum to match a falling or under-projecting tip. Actually, a well done rhinoplasty respects the artistic proportions of the nose and may require an enhancement of the falling or under-projecting tip and just a subtle reduction of the dorsum to improve the nasal profile.
THE ART OF PRECISION RHINOPLASTY
Beautiful noses can be created through rhinoplasty with careful pre-operative planning, precise surgical technique, artistic talent and years of experience. Patients want a natural-looking nose with an appropriate size and shape that fits harmoniously with their face. Anybody glancing at the final results should think that the nose was created by nature - not the rhinoplasty surgeon's hand.
The perfect nose, according to classic proportions used by artists (the commonly seen standard in film, fashion and print) has a certain look. The dorsum is mostly straight or with a very subtle curve. As the dorsum meets the tip, it rises slightly to form the apex of the nose. The skin between the nostrils, known as the columella, should form an angle with the upper lip of between 95 and 100 degrees in women and 90 to 95 degrees in men. The height of the nose from the base to the tip should be 2/3 the length of the dorsum.
Precision rhinoplasty starts with a minimum of 6 photographs of the nose. I then "morph" these photographs in an artistic way to create the desired proportions. The morphing process must also respect the physical reality of what is surgically possible. My patients then review these morphed photographs to confirm that the changes meet their expectations for the final results. I explain to my patients that the morphed photographs represent our goal and that the actual results may vary depending on the healing process. Once the prospective patient approves the morphed photograph, it becomes the starting point for the rhinoplasty surgical plan - the blue-prints for the surgery.
The Rhinoplasty Surgical Plan - Designing a Beautiful Nose
The key element to precision rhinoplasty and creating a beautiful nose is the surgical plan. While planning may not be required when creating abstract art, it is essential when painting a portrait or building a house. Having a good plan saves time during the operation and achieves the desired results with greater consistency. The surgical plan will include all of the operative steps from the first incision to the final stitches. It includes the amount and location of cartilage to be removed or added, whether the nasal bones need to be narrowed and how much bone needs to be removed from the hump. I discuss these steps with each patient before surgery and explain some minor adjustments may be made during their surgery to match the morphed photograph as much as possible.
The Rhinoplasty Surgery - Creating a Beautiful Nose
When the moment of surgery is at hand, the surgeon’s planning, skill, artistic talent and experience all come into play. There are two types of incisions - endonasal (closed) and external (open). Both involve similar incisions on the inside of both nostrils with the external approach having an extra incision on the columella skin between the nostrils. I generally reserve the closed rhinoplasty for patients who need only minor adjustments to their noses - simple hump reduction and/or reducing a bulbous tip. More complicated cases require the open approach and the extra inverted "V" skin incision which is usually less than a 1/4 of an inch wide.
These incisions allow exposure of the nasal cartilage and bone that forms the framework or structure of the nose. This structure along with the skin and fat covering nose form the final shape. Precision rhinoplasty involves making precise changes in the structure - either by removing or adding these support elements- to match the morphed photographs. If additional structure is required, this is usually obtained by cartilage grafts. The cartilage grafts are usually harvested from nasal septum or ear cartilage. Some patients will need "spreader" grafts which may help straighten a deviated nose or help support the lateral nasal wall cartilage. Some patients will need tip grafts to help support a falling tip or add shape and definition. Many patients will require precise nasal bone fractures to narrow the width of the nose. Once the final shape is achieved the skin is closed with very fine stitches on the outside and dissolvable stitches on the inside. Finally, the internal and external splints are placed.
After the Operation
After the operation, patients usually have nasal swelling which is greatest in the tip and where the hump was removed. There may also be bruising around the nose or under the eyes, but this is temporary and improves daily. Most patients have an external splint on top of the nose and packing or silicone splint inside the nose. The internal splints and stitches will be removed at the first office visit. The external splint will stay on for 7 to 14 days after surgery to help control swelling. Patients should not blow or rub their noses or wear glasses for 3 weeks. Their nose may feel stuffy or congested during the healing process due to swelling. Most patients can go back to work in about week after the surgery. Most of the swelling will resolve in 3-6 weeks, however it may take up to one year for all the swelling to resolve.
Virtually all patients are thrilled with the new nasal shape and profile. They also receive a huge jump in self-confidence because they feel and look more attractive with a more balanced nasal appearance that brings out the natural beauty of their eyes and cheeks.